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Vol 11, No 1, January/February 2003
25
Primary malignant bone tumors are
rare lesions, with fewer than 3,000
new cases per year in the United
States. Before the 1970s, manage-
ment routinely consisted of trans-
bone amputations or disarticula-
tions, with dismal survival rates
(10% to 20%). With the develop-
ment of more effective chemothera-
peutic agents and treatment proto-
cols in the 1970s and 1980s, survival
rates improved, which allowed the
focus of management to shift to
limb preservation.
1
Computed
tomography and magnetic reso-
nance imaging (MRI) allow the pre-
cise visualization of the anatomic
location of a tumor and its relation
to surrounding structures. Preop-
erative planning has been advanced
through the use of these modalities,
fostering better patient selection for
specific treatment strategies and
lowering the morbidity rates of
biopsy and subsequent resection.
2,3
Currently, 80% to 85% of patients

with primary malignant bone
tumors involving the extremities
(eg, osteosarcoma, Ewing’s sarco-
ma, and chondrosarcoma) can be
treated safely with wide resection
and limb preservation. Multi-
modality therapy has increased
long-term survival rates of patients
with chemotherapy-sensitive tumors
to 60% to 70%.
1,4
There are a num-
ber of options for skeletal recon-
struction after bone tumor resection,
and it is important to compare the
clinical and especially functional
outcomes based on type of recon-
struction, location of the tumor, and
limb-sparing versus ablative sur-
gery.
Limb-Sparing Surgery
Principles and Guidelines
There are four basic principles or
goals of limb-sparing procedures:
(1) Local recurrence should be no
greater and survival no worse than
with amputation. (2) The proce-
dure, or treatment of its complica-
tions, should not delay adjuvant
therapy. (3) Reconstruction should

be enduring and not associated with
a large number of local complica-
tions requiring secondary proce-
dures and frequent hospitalizations.
(4) Function of the limb should
approach that obtained by amputa-
tion, although body image, patient
preference, and lifestyle may influ-
ence the decision.
5
Before consideration of limb
preservation, the patient needs to be
appropriately staged and assessed
through a multidisciplinary ap-
proach. Some elements of the dis-
ease may warrant concern, includ-
Dr. DiCaprio is Resident, Department of
Orthopaedics and Rehabilitation, Yale Univer-
sity School of Medicine, New Haven, CT. Dr.
Friedlaender is Wayne O. Southwick Professor
and Chair, Department of Orthopaedics and
Rehabilitation, Yale University School of
Medicine.
Reprint requests: Dr. DiCaprio, PO Box
208071, New Haven, CT 06520-8071.
Copyright 2003 by the American Academy of
Orthopaedic Surgeons.
Abstract
Amputation, once the mainstay of treatment of malignant bone tumors, now
is used selectively and infrequently. Most patients are candidates for limb-

sparing procedures because of effective chemotherapeutic agents and regi-
mens, improved imaging modalities, and advances in reconstructive
surgery. Patient age as well as tumor location and extent of disease help
define the most appropriate surgical alternatives. Options for skeletal re-
construction include modular endoprostheses, osteoarticular or bulk allo-
grafts, allograft-prosthetic composites, vascularized bone grafts, arthrodesis,
expandable prostheses, rotationplasty, and limb-lengthening techniques.
Two key factors must be considered: survival rates should be no worse than
those associated with amputation, and the reconstructed limb must provide
satisfactory function. Functional outcome studies comparing limb-sparing
procedures and amputation have inherent limitations, including the inability
to randomize treatment and the subjective nature of important outcome
measures.
J Am Acad Orthop Surg 2003;11:25-37
Malignant Bone Tumors:
Limb Sparing Versus Amputation
Matthew R. DiCaprio, MD, and Gary E. Friedlaender, MD
ing relative contraindications to
such procedures (Table 1). Multi-
drug neoadjuvant chemotherapy,
popularized first for patients with
osteosarcoma by Rosen in the late
1970s, is usually initiated as appro-
priate after histologic diagnosis and
staging. Chemotherapy helps con-
trol systemic disease by attacking
micrometastases, dramatically
increasing overall survival rates.
1
Neoadjuvant therapy also “steril-

izes” the reactive zone around the
tumor by destroying microscopic
disease at the periphery of the pri-
mary lesion, thus facilitating resec-
tion. Additionally, in some patients
with a relative contraindication to
limb salvage, such as a pathologic
fracture in the upper extremity, the
use of chemotherapy with a favor-
able response may allow limb sal-
vage to be considered. However,
not all malignant bone tumors (and
especially chondrosarcomas) have a
viable and effective chemotherapy
regimen.
When appropriate, after 8 to 12
weeks of preoperative neoadjuvant
chemotherapy, wide tumor resec-
tion is performed to establish local
tumor control. Achieving tumor-
free resection margins is of para-
mount importance and remains the
primary goal in surgical oncology.
Most resections are performed
through an extensile longitudinal
incision, permitting access to the
major neurovascular bundle, with
complete removal of all biopsy
tracts. By definition, a wide resec-
tion will include a cuff of normal tis-

sue surrounding the resected speci-
men. Skeletal defects are large,
averaging 15 to 20 cm, reflecting the
size of these tumors and the need
for negative margins. After recon-
struction, muscle transfers may be
necessary to provide adequate motor
function. Finally, adequate, healthy
soft-tissue coverage is essential to
prevent early wound complications
and subsequent infection. Coverage
may require complex local flaps or
even free tissue grafts. When in-
dicated on the basis of histologic
diagnosis, adjuvant chemotherapy
consisting of multiple agents for
synergistic activity is continued for
6 to 12 months after wide tumor
resection.
After negative tumor margins are
obtained, there is often a large skele-
tal defect requiring reconstruction.
Several options are available.
6
Pa-
tient age, tumor location, and extent
of disease narrow the list of appro-
priate surgical alternatives.
Modular Endoprostheses
Indications and Advantages

Currently available metallic pros-
thetic systems offer a lightweight,
strong, inert means for skeletal
reconstruction. Modularity of pros-
thetic design allows intraoperative
flexibility based on the final amount
of tissue resected. A rigorous reha-
bilitation program can be initiated
immediately after implantation
(usually done with bone cement),
allowing early joint range of motion
and weight bearing. Prosthetic
reconstruction carries a lower risk of
deep infection than do allografts,
and nonunion is not a concern
because there are no osteosynthesis
sites. Endoprosthetic use also
avoids the risk of disease transmis-
sion and immune responses that
exists with allograft reconstruction.
Longevity, complications, and func-
tional outcome vary by anatomic
site, type of prosthesis, and fixation
technique.
Complications and
Clinical Results
Early complications associated
with the extensive nature of most
musculoskeletal oncology proce-
dures include wound necrosis/

dehiscence, infection, thromboem-
bolic disease, neurapraxia, and joint
instability. Meticulous surgical tech-
nique and attention to soft-tissue
handling and reconstruction can
significantly decrease the frequency
of these complications. Late compli-
cations include aseptic loosening,
infection, joint or prosthetic insta-
bility, fatigue fracture of the pros-
thesis, and wear or dissociation of
modular components. Late infec-
tion remains the most serious prob-
lem because most prosthesis-related
complications can be successfully
treated with revision surgery. Con-
cerns include the suboptimal attach-
ment of soft tissues to the metallic
components.
In an attempt to determine pros-
thesis and extremity survivorship,
Horowitz et al
7
reviewed their expe-
rience with 93 prosthetic reconstruc-
tions over 8 years: 16 proximal
femur, 61 distal femur, and 16 proxi-
mal tibia. Minimum follow-up was
Malignant Bone Tumors: Limb Sparing Versus Amputation
Journal of the American Academy of Orthopaedic Surgeons

26
Table 1
Relative Contraindications to Limb-Sparing Procedures
Major neurovascular structures encased by tumor when vascular bypass
is not feasible
Pathologic fracture with hematoma violating compartment boundary
Inappropriately performed biopsy or biopsy-site complications
Severe infection in the surgical field
Immature skeletal age with predicted leg-length discrepancy >8 cm
Extensive muscle or soft-tissue involvement
Poor response to preoperative chemotherapy
24 months (mean, 80 months).
Prosthesis survival at 5 years was
88%, 59%, and 54% for proximal
femur, distal femur, and proximal
tibia reconstructions, respectively.
The overall event-free prosthesis
survival was 63% at 5 years and 36%
at 10 years. Aseptic loosening was
cause for failure in approximately
20% at 5 years and 30% at 10 years.
Limb survival for the entire group
was 87% at 5 years and 81% at 10
years. Patients with lesions of the
proximal tibia had the longest sur-
vival rate, with 93% alive at 10 years.
(Histologies included 11 osteosarco-
mas, 4 malignant fibrous histiocy-
tomas, and 1 chondrosarcoma.) The
group as a whole had a survival rate

of 72% at 10 years and was com-
posed of a variety of histologies,
including 65 osteosarcomas, 13
chondrosarcomas, 10 malignant
fibrous histiocytomas, 3 Ewing’s sar-
comas, and 2 liposarcomas.
Aseptic loosening is the primary
long-term concern with this method
of reconstruction for tumors around
the knee. Whereas allografts success-
fully stabilize after 3 to 5 years, pros-
theses begin to exhibit their inherent
biomechanical limitations after 10
years. For the current rotating-hinge
knee design, reported follow-up is
limited to approximately 10 years.
Malawer and Chou
8
in 1995 showed
an 83% survival of prostheses at 5
years and 67% at 10 years. Of 52
patients who survived and were
available at 3-year follow-up, only 10
were available at the 10-year follow-
up. They had a revision rate of 15%,
infection rate of 13%, amputation rate
of 11%, and local recurrence rate of
6%. Overall, 44% of patients had at
least one complication. These sur-
vivorship data are limited because of

the small number of patients but may
represent an improvement from the
simple-hinge, custom-made prosthe-
ses, for which 5-year survival of 80%
drops to 53% at 20 years.
7,9-11
Of 1,001 patients treated with
cemented, custom-made endopros-
theses, aseptic loosening was the
principal mode of failure among the
210 requiring revision.
10
Seventy-
four revisions (35.2% of those re-
vised) were done for aseptic loosen-
ing. At 10 years, the rates of aseptic
loosening were 6.2%, 32.6%, and
42% for the proximal femur, distal
femur, and proximal tibia, respec-
tively. The poorest prognosis for
prosthesis survival without aseptic
loosening was in young patients
(<20 years) with distal femoral pros-
thetic reconstruction in whom a high
percentage of femur had been re-
placed. Experience to date indicates
that acetabular loosening rates have
been extremely high, simple-hinge
prostheses have a higher loosening
rate than do rotating-hinge designs,

and cemented fixation provides
the lowest rate of loosening.
9
Most
loose prostheses can be revised to
improve functioning.
Infection rates range from 0% to
13%.
8,9,11
Proximal tibial reconstruc-
tions carry the highest risk of infec-
tion, as do other regions where soft-
tissue coverage is tenuous. Infection
is the most serious complication as-
sociated with limb-sparing proce-
dures and is the most common reason
for amputation after attempted re-
construction. Rates have decreased,
however, with the more common use
of rotational or free flaps now readily
available through microsurgical tech-
niques.
Joint instability is a major concern
in reconstructions about the hip and
shoulder. Dislocation rates for the
hip range from 10% to 15%.
7-9,12,13
Reconstruction of the abductor
mechanism and the use of bipolar
components have improved stability

and function.
11
Fatigue fracture of intramedul-
lary stems has become extremely
uncommon with the increase in
stem diameters, improvements in
design, and current metallurgy used
during fabrication.
11
Dissociation
also is rare with modern prostheses;
most join with Morse tapers.
Regional Considerations
Prosthesis survival for proximal
femoral replacements is generally
reported as 77% to 100% at 10 years,
falling to 57% at 20 years.
9,11-13
Poor
abductor muscle function remains a
common reason for decreased func-
tional grades. Zehr et al
12
reviewed
their experience with 33 patients
after proximal femoral resection and
reconstruction with an allograft-
prosthetic composite (16 patients) or
a megaprosthesis (17 patients). The
primary mode of failure for compos-

ites was infection, and for megapros-
theses, instability. The 10-year
prosthetic survival rate was 76% for
the composite group and 58% for the
megaprosthetic group. Instability
occurred in 0% and 28% of the com-
posite and megaprosthetic cohorts,
respectively; infection rates were
17% and 6%, respectively. Both
groups functioned well, with 87%
and 80% functional scores for the
respective cohorts. Allograft-pros-
thetic composites have been shown
to have a survival advantage over
megaprostheses used for proximal
femoral reconstructions.
12,14
Overall survival of a simple-
hinge distal femoral knee replace-
ment prosthesis at 5, 10, and 20
years is 80%, 65%, and 53%, respec-
tively.
9,10
Functional evaluation
reveals 69% to 93% good to excel-
lent results with less than 10 years
of follow-up.
7-11,15
Prosthetic sur-
vival analysis shows that a higher

percentage of femoral bone resected
distally is related to a higher risk of
prosthetic failure.
15
The extent of
soft-tissue resection is another im-
portant factor. The most common
cause of failure for distal femoral
prostheses is aseptic loosening. As
length of follow-up increases, the
rate of prosthetic survival diminishes.
Better long-term results are antici-
pated since simple-hinge designs
have given way to modular rotating-
hinge systems (Fig. 1).
Proximal tibial prosthetic replace-
ment survivorship has been poor
Matthew R. DiCaprio, MD, and Gary E. Friedlaender, MD
Vol 11, No 1, January/February 2003
27
because of tenuous soft-tissue cover-
age and unreliable extensor mecha-
nism reconstruction. Survival rates
vary from 45% to 74% at 5 years and
45% to 50% at 10 years.
9
Malawer
and Chou
8
found proximal tibial

replacements to have the highest
complication and revision rate
and worst Musculoskeletal Tumor
Society (MSTS) functional scores
(Table 2) for any region reconstruct-
ed. Wound problems and subse-
quent infections have decreased
with the routine use of flaps but
remain frequent problems for recon-
structions in this anatomic site.
Grimer et al
17
reported an initial
infection rate of 36% that was re-
duced to 12% by the use of a medial
gastrocnemius flap. Local recur-
rence was observed in 12.6% of
patients and was associated with
poor response to chemotherapy and
close margins of excision. They also
found that 70% of patients at 10
years required further surgical pro-
cedures and reported a 25% risk of
amputation at 10 years.
17
Many designs and techniques are
available for proximal humeral
replacements. The technique of
Malawer and Chou,
8

including
implantation of a large-segment
prosthesis stabilized by static recon-
struction with Dacron tape and
dynamic reconstruction by muscle
transfers, has yielded the best re-
ported results of any site of pros-
thetic replacement, with an average
MSTS functional score of 86.7%
(26/30) and no cases of instability.
However, there is a wide range of
results reported for this site, with in-
stability the primary reason for poor
functional outcome.
7,9,11
O’Connor
et al
18
reported on 11 patients who
underwent proximal humeral pros-
thetic reconstruction. Two demon-
strated evidence of stress shielding,
six had signs of instability, one had
a deep infection, and two had ce-
ramic prosthesis loosening or frac-
ture. Four of the 11 patients went
on to secondary arthrodesis. Those
Malignant Bone Tumors: Limb Sparing Versus Amputation
Journal of the American Academy of Orthopaedic Surgeons
28

A B C D
Figure 1 A 16-year-old boy presented with knee pain of 7 months’ duration and a history of bilateral retinoblastoma in infancy.
A, Anteroposterior radiograph of the knee shows an aggressive, eccentric, osteoblastic distal femoral metaphyseal lesion with extensive
periosteal reaction (Codman’s triangle, arrow). Coronal (B) and sagittal (C) T2-weighted MRI scans demonstrate the heterogeneous
lesion, periosteal reaction (white arrow), and soft-tissue extension (black arrow). Open biopsy confirmed the diagnosis of high-grade
osteosarcoma. Treatment included preoperative chemotherapy, wide tumor resection, skeletal reconstruction, and postoperative
chemotherapy. D, Anteroposterior radiograph after distal femoral reconstruction with a modular rotating-hinge knee prosthesis.
Table 2
Musculoskeletal Tumor Society Functional Evaluation
16
Lower Extremity Data
*
Upper Extremity Data
*
Pain Pain
Function Function
Emotional acceptance Emotional acceptance
Use of supports Hand positioning
Walking ability Manual dexterity
Gait Lifting ability
*
Within each category, each of the six factors is graded 0 to 5. The higher the number,
the greater the improvement in outcome. The sum total for the six categories can
equal a Maximum Extremity Score of 30 points (5 × 6). Outcome is reported as a per-
centage of the Maximum Extremity Score.
not converted to arthrodesis were
satisfied regarding pain, emotional
acceptance, and manual dexterity
and were dissatisfied regarding
function, positioning of the hand,

and lifting ability.
Osteoarticular or Bulk
Allografts
Indications and Advantages
Frozen allografts have been used
longer than any other tumor recon-
struction option. Allografts are
favored by some for their potential
for longevity because they function
as a biologic reconstruction. Incor-
poration of the allograft by the host
is a slow and incomplete process.
Osteoarticular allografts permit the
uninvolved portion of the joint to be
preserved; this approach allows the
strongest means of soft-tissue or
periarticular ligament reconstruc-
tion (Fig. 2). Although associated
with more early complications than
are endoprostheses, allograft recon-
structions stabilize after 3 to 5 years
and therefore do better in long-term
follow-up studies. Mankin et al
19
found that, after 3 years, approxi-
mately 75% of grafts are retained by
patients and remain successful for
more than 20 years. Seventy per-
cent to 80% of patients obtain a
good or excellent functional result

after allograft reconstruction,
although this varies with type of
graft, anatomic site, and stage of
disease.
19
The unpredictable early
outcomes with allografts and the
frequent need for multiple proce-
dures to obtain a successful end
result have led many orthopaedic
oncologists to favor modern endo-
prostheses. With their potential for
long-term stability, however, allo-
grafts play a key role in younger
patients (<20 years), in whom an
enduring reconstruction can limit
the additional revisions seen with
long-term follow-up of patients
with endoprosthetic constructs.
Complications and
Clinical Results
Allografts used for tumor recon-
struction have a high rate of early
complications. Cumulative compli-
cation rates approach 50% in some
series, with most patients requiring
additional surgery.
19
Infection, frac-
ture, joint instability, and nonunion

have vexed allograft reconstruction
for 30 years.
19-26
Immunologic com-
plications
27
and risk of disease trans-
mission
28
are of lesser concern but
do exist. With osteoarticular allo-
grafts, osteoarthritis becomes mani-
fest at 5 to 10 years in 15% of pa-
tients and is best treated with a
resurfacing arthroplasty.
19
Tumor
recurrence, infection, and fracture
are the most devastating complica-
tions and account for more than 85%
of allograft failures.
19
Most of the
clinical outcome studies pertaining
to the use of massive allografts come
from the Orthopaedic Oncology
Unit at Massachusetts General
Hospital, with a series of more than
1,100 allograft reconstructions.
19-24

Lord et al
20
reported on the inci-
dence, nature, and treatment of
infections in bone allografts. A ret-
rospective review of 283 patients
with more than 2 years of follow-up
revealed an infection rate of 11.7%
(33/283). Gram-positive organisms,
particularly Staphylococcus epider-
midis, were the most common patho-
gens. Risk factors reflected those of
a population treated by wide resec-
tion of soft tissue and bone, chemo-
therapy, and radiation therapy.
Wound complications are the most
common problem and were associ-
ated with early infection; additional
surgical intervention is the most
common risk factor for late infection.
Eighty-two percent of infected cases
(27/33) were considered failures
and required amputation or removal
of the allograft to control infection.
Salvage is sometimes possible, but it
requires an aggressive approach
involving resection of the infected
allograft, implantation of a spacer or
external fixation, intravenous antibi-
otics, oral antibiotics for extended

periods, and reimplantation of a
new allograft or conversion to a
metallic endoprosthesis.
In a retrospective review of 274
allograft recipients after limb-spar-
ing tumor resections with a mini-
mum follow-up of 4 years, Berrey et
al
21
reported a fracture incidence of
16% (43/274). There were no major
distinguishing or predictive features
in the allograft group between
patients who had a fracture of the
Matthew R. DiCaprio, MD, and Gary E. Friedlaender, MD
Vol 11, No 1, January/February 2003
29
A B
Figure 2 A 17-year-old boy presented
with knee pain of 2 months’ duration.
Radiographs, MRI, and biopsy confirmed
osteosarcoma. A, Initial postoperative
anteroposterior radiograph demonstrates
distal femoral reconstruction with an
osteoarticular allograft stabilized with two
orthogonal dynamic compression plates.
The patient underwent a bone-graft proce-
dure 1 year later to treat an allograft-to-
host bone nonunion. B, Anteroposterior
radiograph 2 years after reconstruction

demonstrates solid union of the osteosyn-
thesis site.
allograft and those who did not.
There was a trend toward a higher
incidence of nonunion in patients
with fractures, but it was not statisti-
cally significant. The mean time to
fracture was 28.6 months after the
index surgery, with more than 70%
of fractures occurring within 3 years.
The results in this population after
treatment approached those of pa-
tients who had never had a fracture.
The mean time to union was 7.4
months (range, 4 to 14 months), with
all but four fractures treated with an
operation and most involving autog-
enous bone grafting. Weight bear-
ing was restricted until radiographic
union. The 43 patients underwent a
total of 59 operations. The authors
concluded that 9.3% of allograft
shaft fractures (4/43) may heal with
immobilization, but many require
treatment with internal fixation and
bone grafting. Several attempts may
be necessary, and sometimes ex-
change of the allograft or conversion
to a metallic endoprosthesis is neces-
sary.

Berrey et al
21
classified the frac-
tures into three patterns. Type I
fractures (2/43) were seen soon after
surgery, with almost complete dis-
solution of the graft. These were
thought to be secondary to an im-
mune reaction to the allograft. Type
II fractures (22/43) were through the
shaft of the allograft, with a mean
time to fracture of 27.6 months.
Type III fractures (19/43) occurred
at the articular surface of osteoartic-
ular allografts at a mean of 31.6
months from surgery. These are
best treated with a standard resur-
facing total knee arthroplasty, when
feasible.
In a larger series of allograft re-
constructions,
22
fractures occurred
at a rate of 17.7% (185/1,046). Mean
time to fracture was 3.2 years.
There were 8 Berrey type I fractures,
114 type II, and 63 type III. Sixty-
one fractures (33%) involved a screw
hole at the end of the plate. Neither
adjuvant chemotherapy nor radia-

tion influenced the rate of allograft
fracture.
Nonunion is another common
complication in the postoperative
course of allograft reconstructions.
All allografts have at least one os-
teosynthesis site that, until healed,
limits the amount of weight bearing
permitted through the reconstructed
limb. The location of the osteosyn-
thesis affects the healing potential.
Diaphyseal-to-diaphyseal osteosyn-
thesis sites have a higher risk of
delayed union or nonunion than do
metaphyseal-to-metaphyseal sites.
Supplemental autograft and stronger
internal fixation are recommended
at osteosynthesis sites in an effort to
decrease the rate of nonunion. In
the future, bone morphogenetic pro-
teins may play a similar role when
allograft reconstruction is per-
formed. Hornicek et al
23
evaluated
factors affecting nonunion of the
allograft-host junction. Of 945 pa-
tients, 163 (17.3%) had a nonunion.
Those receiving chemotherapy had
twice the rate of nonunion. Two

hundred sixty-nine additional sur-
geries were performed on these 163
patients. In 114 patients, treatment
led to successful union. The per-
centage of failure increased as the
number of surgical procedures in-
creased. Despite treatment, 49 pa-
tients failed to demonstrate union of
the osteosynthesis site.
In comparing different types of
allografts, intercalary allografts have
better clinical outcomes than do
osteoarticular allografts, allograft-
prosthetic composites, and allografts
used for arthrodesis
6,19,24
(Fig. 3).
Ortiz-Cruz et al
24
reviewed 104 in-
tercalary allografts done over an 18-
year period (median follow-up, 5.6
years). Eighty-four percent (87/104)
were considered successful, with
retention of allograft and normal
extremity function. Infection, frac-
ture, stage of disease, and adjuvant
therapy all had adverse effects on
graft survival. Fifteen reconstruc-
tions failed, most within 3 to 4 years.

Four were salvaged with a second
allograft, three by another recon-
struction technique; eight required
amputation (two for local recur-
rence). With two osteosynthesis
sites, nonunions might be expected
to be a common concern with inter-
calary allografts. Thirty-one of the
104 allografts (30%) failed to unite at
one or both junctions within 1 year,
but only seven remained ununited
(and were considered failures) after
additional surgical intervention.
Eighty-one additional surgical pro-
cedures were needed to achieve sat-
isfactory function in 92% of these
patients. Different modes of internal
fixation were used; plate fixation
spanning both osteosynthesis sites
was found to be superior to the use
of two shorter plates at either end of
the allograft.
Mankin et al
19
found similar re-
sults in their review of 718 allograft
transplantations (mean follow-up,
78 months). Intercalary allografts
yielded the greatest satisfaction,
with excellent or good outcomes in

84% of cases. Osteoarticular allo-
grafts, allograft-prosthetic compos-
ites, and allograft arthrodeses had
excellent and good outcome rates of
73%, 77%, and 54%, respectively,
although they often required addi-
tional surgical procedures to achieve
these outcomes.
Regional Considerations
Most allograft reconstructions
are for the femur, and the results of
large studies primarily reflect the
outcome for this region. Hornicek
et al
25
reviewed the largest series to
date of proximal tibial osteoarticular
allografts, consisting of 38 recon-
structions (38 patients) in 15 years.
Fifty-five percent of the patients
experienced one or more complica-
tions, which were managed with
multiple subsequent procedures.
Three amputations were done for
deep infections. About one third of
the patients required removal of the
original allograft and reconstruction
Malignant Bone Tumors: Limb Sparing Versus Amputation
Journal of the American Academy of Orthopaedic Surgeons
30

with a new allograft or conversion
to metallic prosthesis. Ultimately,
66% had a good or excellent func-
tional result. The study also com-
pared outcomes and complications
between the subset of patients treat-
ed with chemotherapy, radiation
therapy, or both to those without
adjuvant therapy. The only signifi-
cant (P < 0.05) difference observed
between the groups was the higher
incidence of fracture in the patients
treated with chemotherapy.
Proximal humeral osteoarticular
allografts are an attractive option be-
cause of their potential for soft-tissue
reconstruction, healing, and func-
tion. O’Connor et al
18
reported on
eight patients treated with this tech-
nique, a subset of 57 patients who
underwent limb-sparing tumor re-
sections and various forms of recon-
struction. There was no nonunion
or cases of instability, but half of the
patients experienced subchondral
fractures and collapse of the articu-
lar surface. Three of these four pa-
tients were asymptomatic; the other

was treated with conversion to a
prosthesis. Functional rating aver-
aged 71% by the MSTS system, with
patients least satisfied with function
and positioning of the hand. Com-
pared with endoprosthetic recon-
struction, osteoarticular allografts
resulted in superior function after
intra-articular resection of the proxi-
mal humerus. Shoulder arthrodesis
using an intercalary allograft com-
bined with plate fixation and vascu-
larized fibular grafting is an excel-
lent method of reconstruction after
extra-articular resection of the proxi-
mal humerus.
Getty and Peabody
26
reported
similar results in 16 patients who
underwent osteoarticular allograft
reconstruction after intra-articular
resection of the proximal humerus.
At a mean follow-up of 47 months,
the mean MSTS functional evalua-
tion score was 70%. Deterioration
was noted to continue with time
from surgery. The authors have
stopped doing the procedure
because of the unacceptable rates

of epiphyseal fragmentation (4/16),
instability (11/16), fracture (4/16),
and infection (1/16).
Allograft-Prosthetic Composites
Clearly there are benefits and
inherent drawbacks to either allo-
graft or endoprosthetic reconstruc-
tion. By combining the two meth-
ods or using an allograft-prosthetic
composite, the surgeon can tailor
the procedure to help diminish the
inherent risks encountered when
either reconstruction is used alone.
The composite helps restore as
much bone stock as possible and
offers joint stability that is often
difficult to obtain with osteoarticu-
lar allograft reconstruction. By
Matthew R. DiCaprio, MD, and Gary E. Friedlaender, MD
Vol 11, No 1, January/February 2003
31
Figure 3 A 21-year-old man presented with thigh pain. Anteroposterior (A) and lateral (B) radiographs of the femur show a permeative
diaphyseal lesion with cortical erosion (white arrows). C, Coronal T2-weighted MRI scan demonstrates the diaphyseal lesion (black
arrow). Open biopsy confirmed Ewing’s sarcoma. D, Postoperative anteroposterior radiograph of the femur after wide tumor resection
and intercalary allograft reconstruction stabilized with a statically locked intramedullary nail.
A B C D
resurfacing the allograft bone with
an implant, cartilage degradation
is no longer a potential problem 5
to 10 years after reconstruction

(Fig. 4).
Gitelis and Piasecki
14
performed
11 hip and 10 knee reconstructions
and 1 elbow reconstruction in 22 pa-
tients (mean follow-up, 45 months).
Mean MSTS functional score was
94.3%. Five patients had a non-
union, four of which healed after
bone grafting; one was converted to
a megaprosthesis. There were no
dislocations. Graft resorption did
not occur in this small number of pa-
tients, and no revisions were done
for implant loosening.
Techniques With Special
Indications
Vascularized Bone Grafts
Vascularized bone grafts can be
taken from the iliac crest, rib, scapula,
or fibula. Of these options, only vas-
cularized fibular grafts are suited for
the large skeletal defects left after
wide resection of a malignant bone
tumor. Compared with allografts,
vascularized autografts offer a more
rapid incorporation, stronger initial
construct secondary to graft hyper-
trophy, and absence of immunologic

problems. Vascular grafts change
not the pattern of bony repair but
rather the rate of repair. Final matu-
ration and hypertrophy of grafts
is consistent with Wolff’s law.
29
External fixation is preferable to
plate fixation because it maximizes
these stresses and allows for greater
hypertrophy and ultimate strength
of the graft. Ideally suited for chil-
dren and young adults, this method
of biologic reconstruction has the
potential to be enduring without
need for revision surgery later in life.
Vascularized autografts also are used
with the poorly vascularized tumor
bed commonly found in previously
irradiated tissue and when a delay in
osteosynthesis healing is anticipated
secondary to adjuvant therapy with
radiation, chemotherapy, or both.
The main disadvantages of vascular-
ized autograft are the increased
surgery time, surgical site morbidity,
and size limitations.
Few published reports focus on
vascularized autograft in tumor
reconstruction, and long-term out-
come data are lacking.

30
Hsu et al
31
reviewed a consecutive series of 30
patients who underwent skeletal
reconstruction by vascularized fibu-
lar transfer after resection of primary
bone tumors. Mean follow-up was
36 months (range, 24 to 85 months),
with union achieved in 90% (27/30)
at an average of 7.6 months. The
mean fibular graft length was 18.9
cm (range, 10 to 30 cm). Functional
results were evaluated in 24 patients,
with 9 excellent, 7 good, 6 fair, and 2
poor results. When used for inter-
calary grafts (14 patients), the func-
tional results were better than those
seen with arthrodesis procedures (10
patients). There was a high compli-
cation rate (50%), but many were
managed nonsurgically and resolved
without greatly affecting the final
outcome. Complications included
three nonunions, three deep infec-
tions, three stress fractures, two local
recurrences, and an assortment of
soft-tissue complications.
Arthrodesis
Arthrodesis creates a stable,

painless, durable limb. Indications
for arthrodesis are extra-articular
joint resection or extensive muscle
resection with lack of remaining
muscle to power the joint, or when
the desire for joint stability is para-
mount. The two most common re-
gions for this technique are the knee
and shoulder.
Knee arthrodesis can be accom-
plished with allografts, nonvascu-
larized autografts, vascularized
rotational fibular grafts, external fix-
ation with bone transport, or some
combination of these techniques.
Fixation is achieved with either
compression plating or intramedul-
lary nailing. Intramedullary fixa-
tion is favored for arthrodesis be-
cause of a decreased rate of graft
Malignant Bone Tumors: Limb Sparing Versus Amputation
Journal of the American Academy of Orthopaedic Surgeons
32
Figure 4 A 14-year-old boy presented with knee pain of 3 months’ duration and an
enlarging mass. A, Anteroposterior radiograph of the knee demonstrates an eccentric lytic
proximal tibial metaphyseal lesion with cortical destruction and soft-tissue extension
(arrow). Biopsy confirmed osteosarcoma. Anteroposterior (B) and lateral (C) radiographs
demonstrate skeletal reconstruction with a rotating-hinge knee prosthesis and proximal
tibial allograft-prosthetic composite stabilized with a dynamic compression plate.
A B C

fracture and nonunions. The knee is
aligned in 10° to 15° of flexion and
0° to 5° of valgus. In the skeletally
mature individual, the limb is short-
ened 1 to 2 cm to allow for foot
clearance during the gait cycle. In
skeletally immature patients, the
limb may be lengthened with the
grafting technique; the expectation
is that the contralateral normal limb
will continue to grow, with the
result that limb length at skeletal
maturity on the operated side will
be equal or slightly shorter. The
procedure is associated with a high
rate of complications (approximate-
ly 50%), including all of the inherent
risks of allograft reconstruction.
Despite this complication rate, how-
ever, most patients achieve success-
ful union and have a durable, func-
tional limb.
32-34
The shoulder joint is challenging
to reconstruct, given the extreme
range of motion and lack of inherent
static stability. The few published
reports that discuss shoulder
arthrodesis in tumor reconstruction
have small numbers of patients (5 to

10). Notable rates of infection, frac-
ture, and nonunion exist, as with
knee arthrodesis.
32
Most patients
obtain stable fusion, allowing satis-
factory function of the upper ex-
tremity.
18,32
Wolf et al
33
reviewed the long-
term results in 73 patients who,
from 1967 to 1985, underwent resec-
tion arthrodesis of the knee with
autogenous grafts. Forty patients
followed for more than 10 years
formed the basis of the evaluation.
Intramedullary rods were used to
stabilize hemicortical femoral or tib-
ial allografts and nonvascularized
autogenous fibular grafts to the
native femur and tibia. A high inci-
dence of complications (52%) was
evident, yet most patients eventual-
ly achieved a successful outcome
with preservation of the limb, and
86% were independent ambulators
at long-term follow-up. The most
common complications were graft

fatigue fracture (51%), delayed
union (23%), rod migration or rod
fracture (25%), peroneal nerve palsy
(8%), and infection and wound
problems (23%). Thirty-seven of the
40 patients (93%) achieved a solid
reconstruction. Two patients
required an above-knee amputation,
one for infection and the other for
local tumor recurrence. One addi-
tional patient sustained a commi-
nuted traumatic fracture of the
fusion and was treated with an
allograft arthrodesis. The recon-
structions proved to be durable,
and patient satisfaction and func-
tion remained high for decades,
with an average MSTS functional
score of 77%.
Weiner et al
34
evaluated 39 pa-
tients treated with resection arthrod-
esis done with an intercalary allo-
graft fixed with an intramedullary
nail. In 31 patients, this procedure
was the index reconstruction; in
eight, it was done after failure of a
different type of tumor reconstruc-
tion. Proximal and distal osteosyn-

thesis sites both healed, and function
was satisfactory in 32 patients.
Nonunion occurred in seven pa-
tients (one junction in six patients,
both junctions in one). The non-
union was healed in five of the
seven treated with bone grafting,
repeat internal fixation, or exchange
allografting; two patients went on to
above-knee amputation. An addi-
tional patient from the study under-
went above-knee amputation for
local recurrence. Fatigue fracture of
the allograft occurred in five pa-
tients, all within metaphyseal bone.
Overall, the rate of complication
was lower than that experienced
with autograft arthrodesis.
Expandable Prostheses
Expandable prostheses were
developed in an attempt to over-
come anticipated limb-length dis-
crepancies in the growing child
treated with limb-sparing surgery.
The first approach includes the
Lewis Expandable Adjustable
Prosthesis (LEAP).
35
Expansion of
the LEAP is achieved by a modified

Jacob’s chuck mechanism. Rotation
of the outer sleeve of the prosthesis
engages the threads on the inner
shaft, thereby increasing the length
of the prosthetic shaft with each rev-
olution. An average lengthening is
1.5 to 2 cm; the average overall
extension capability of a LEAP is 6
to 9 cm. Collapse of the expansion
mechanism, observed early in its
use, has been addressed with the use
of spacer rings. Problems with tita-
nium debris and fatigue failure of
expandable prostheses led to the
alternative use of modular systems.
These systems use a Morse taper
locking system to connect segmental
parts. Exchange of intercalary seg-
ments can be performed as the
patient grows, adding 2 cm to the
length of the segment replaced.
When extremity length discrep-
ancy reaches approximately 2 cm or
more, an expansion procedure is in-
dicated. The original incision is used,
and the pseudocapsule around the
prosthesis is excised to prevent
problems with joint stiffness after
lengthening and to relieve tension on
the neurovascular bundle. Eckardt

et al
36
reported on their 14-year ex-
perience with 32 expandable pros-
theses. Nineteen of the 32 patients
(59%) survived, with a median fol-
low-up of 105 months. Sixteen of
the patients (50%) did not undergo
an expansion because of death, am-
putation, or short duration of follow-
up. The remaining 16 patients un-
derwent 32 expansion procedures,
to a maximum of 9 cm, without
infection. The average time from
implantation to the first lengthening
was 19 months. Most of the length-
enings were 1.5 to 2 cm. More than
50% of the patients had at least
one complication, most frequently
aseptic loosening or failure of the
prosthesis, collapse of the LEAP, tem-
porary nerve palsy, or flexion con-
tractures. The average MSTS ratings
Matthew R. DiCaprio, MD, and Gary E. Friedlaender, MD
Vol 11, No 1, January/February 2003
33
were good to excellent at the knee,
fair to good at the hip, and fair about
the shoulder. The authors concluded
that, in children and the skeletally

immature, rehabilitation can be
problematic; early loss of joint mo-
tion and fixed flexion contractures
can occur. With advances in tech-
nology, a noninvasive prosthetic
lenghtening mechanism is now
being evaluated clinically.
Rotationplasty
Rotationplasty, another recon-
struction option in the skeletally im-
mature patient, can be done after
wide resection about the knee when
the sciatic nerve can be preserved.
The tibia is rotated 180° and fused
to the femur, with the ankle joint
placed at the level of the contralateral
knee. The procedure creates a func-
tional below-knee amputation; out-
come far exceeds that associated
with above-knee ablation. The main
indication for this technique is in a
very young child with an extensive
malignant bone tumor and several
years of growth remaining. Rotation-
plasty also may be used in adults
when soft-tissue coverage is inade-
quate after extensive tumor resec-
tion. In general, the procedure is
associated with a low incidence of
complications and a highly func-

tional and durable extremity recon-
struction.
37
Advantages include the
maintenance of growth and a func-
tioning “knee” joint, the ability to
tailor the procedure to obtain limb-
length equality at skeletal maturity
without further operations, an energy-
efficient gait pattern, and avoidance
of the problems of neuromas and
stump breakdown seen with ampu-
tations. With the advent of expand-
able prostheses in the late 1980s,
however, the indications for rota-
tionplasty have narrowed. A full
presurgical discussion is essential so
that the patient and family under-
stand the advantages and cosmetic
appearance of the reconstructed
limb, thus limiting postoperative
dissatisfaction or psychological
problems. Meetings with other pa-
tients who have had the procedure
are beneficial.
Kotz
37
reviewed the results of 40
patients treated with rotationplasty
between 1976 and 1988. Thirty were

followed for more than 3 years. No
patient developed local recurrence;
six died from metastatic disease, and
the remaining 24 were tumor free.
All patients were prosthetic ambula-
tors without additional supports,
and most participated in sports.
Functional evaluation revealed 68%
excellent, 28.5% good, 3.5% fair, and
no poor results according to the
system of Enneking et al.
38
Compli-
cations of rotationplasty include
postoperative vascular occlusion,
pseudarthrosis between femur and
tibia, nerve palsies, rotational mal-
alignment, and diffuse osteopenia in
the distal limb bones. The high level
of function achieved by most pa-
tients far outweighs the appearance
of the limb, limiting the psychologi-
cal problems associated with rota-
tionplasty.
37,39
Long-term follow-up
studies have shown the high durabil-
ity of rotationplasty, with continued
excellent or good results at 8 years.
39

Limb Lengthening
The Ilizarov bone transport pro-
cedure and other techniques of limb
lengthening can be used to regain
bone length after resection and re-
construction. Limb lengthening by
distraction osteogenesis or bony
transport has limited utility after
resection of malignant bone tumors
when used as the primary recon-
struction technique. The large os-
seous defect is difficult to replace
and requires extended periods of
treatment, which are associated
with significant complications. Fre-
quently, the final functional result
with this technique is poor.
40
Limb-
lengthening procedures are better
suited as adjuncts to other methods
of reconstruction or for smaller
defects.
Limb-Sparing Procedures
Compared With
Amputation
Survival and Local
Recurrence Rates
In comparing limb-sparing proce-
dures with amputation, the points

selected as outcome measures are
important. The primary goal of any
oncologic procedure is local tumor
control to diminish local recurrence
and improve overall survival.
Limb-preserving procedures have
not decreased overall survival
rates
4,5,11,19,41,42
(Table 3). Local recur-
rence associated with limb-sparing
resection and reconstruction is
slightly greater than it is after ampu-
tation or joint disarticulation, but
this has not been found ultimately to
affect patient survival.
4,41
In the
largest series to date comparing
limb-sparing surgery with amputa-
tion in 227 patients with osteosarco-
ma of the distal femur, Rougraff et
al
41
found local recurrence in 8 of 73
patients treated with limb preserva-
tion, in 9 of 115 patients treated with
above-knee amputation, and in none
of 39 patients treated with hip disar-
ticulation.

Functional Outcome
The MSTS system for assessing
the function of reconstructive pro-
cedures (Table 2) is designed to
allow for comparison of results.
16
Functional outcome studies com-
paring limb preservation and
amputation have inherent limi-
tations, however, including the
inability to randomize treatment
and the subjective nature of impor-
tant outcome measures. Most func-
tional outcome measures favor
nonarthrodesis procedures because
range of motion is measured. Most
of the studies designed to assess
functional outcome focus on pa-
tients with perigeniculate tumor
resections. Good and bad out-
comes occur with whatever proce-
dure is used, and there is little dif-
Malignant Bone Tumors: Limb Sparing Versus Amputation
Journal of the American Academy of Orthopaedic Surgeons
34
ference in quality-of-life outcomes
between limb-sparing and amputa-
tive surgeries.
43
Rougraff et al

41
found that their
limb-preservation group had higher
functional scores than did the group
treated with amputation but that
the limb-preservation patients fre-
quently required additional surgical
procedures to reach peak function.
Renard et al
42
found functional re-
sults to be significantly (P = 0.0001)
better after limb-saving surgery
compared with ablative therapy;
however, complications were three
times more common in the limb-
saving cohort.
Otis et al
44
studied the energy
cost during gait by measuring oxy-
gen consumption in 14 patients with
custom-made knee prostheses and
12 patients who had had above-
knee amputations and been fitted
with an artificial limb. They con-
cluded that prosthetic reconstruc-
tion provides superior function
because these patients had a lower
energy cost during gait. In contrast,

the patients studied by Harris et al
45
functioned similarly and walked
with comparable velocity, efficien-
cy, and rate of oxygen consumption
whether they had had an amputa-
tion, arthrodesis, or arthroplasty.
The patients treated with endopros-
theses lived more sedentary lives
and were the most protective of the
limb.
Kawai et al
46
evaluated clinical
outcomes, length of resection, and
energy cost of walking after pros-
thetic knee replacement for malig-
nant tumors of the distal femur. The
mean free-walking velocity was 79%
of normal, reflecting a decrease in
both cadence and stride length.
Also, mean energy cost during walk-
ing was 35% greater than that of
normal control subjects and correlat-
ed with the percentage of femur that
had been resected. Hillmann et al
47
reported on 67 patients with malig-
nant tumors of the distal femur or
proximal tibia who were treated by

rotationplasty or endoprosthetic
reconstruction. Patients with a rota-
tionplasty had a mean MSTS func-
tional score of 80% (24/30) com-
pared with 83.3% (25/30) for patients
treated with an endoprosthesis.
Those with a rotationplasty had
fewer restrictions in their daily activ-
ities and required ambulatory assis-
tive devices less frequently than did
those reconstructed with a prosthe-
sis. Finally, McClenaghan et al
48
compared oxygen consumption in
patients treated with above-knee
amputation, arthrodesis, or rota-
tionplasty. Patients treated by ro-
tationplasty walked the most effi-
ciently.
Psychological Factors
Whether limb-sparing surgery
offers a psychological outcome ad-
vantage compared with amputation
for extremity sarcomas has yet to be
demonstrated because no long-term
prospective or comparative studies
have been done.
5,49
In a small, retro-
spective, one-time psychological

assessment of patients treated for
lower extremity sarcomas, no differ-
ences between amputation and limb
sparing were found regarding cog-
nitive capacity, mood, body image,
global physical functioning, global
adjustment to illness and surgery,
and lifetime prevalence of psycho-
logical disorders before or after
surgery.
49
Most patients adjust well
to both the disease and the required
surgical treatment if they have no
premorbid psychological disorders.
5
Costs
Grimer et al
43
demonstrated that
endoprosthetic reconstruction is less
expensive than amputation, based
on a 1997 cost analysis and 20-year
follow-up. Their formula takes into
account the projected need for revi-
sion surgery, based on rates of asep-
tic loosening of 2.5% per year and
on rates of other causes of early fail-
ure (eg, infection, implant failure) of
1.5% per year.

Future Directions
As experience is gained, the abili-
ty to amend methods of treatment
to improve outcomes will increase.
Endoprostheses continue to be
improved. Long-term results of
modular rotating-hinge knee com-
ponents are anticipated to yield
better results than those of simple-
hinge knee prostheses. A few insti-
tutions have had experience with an
endoprosthesis that is lengthened
noninvasively by the application of
external electromagnetic force, and
development continues. Soft-tissue
reattachment and ligament recon-
struction are easier to perform be-
cause of the use of osteoarticular
Matthew R. DiCaprio, MD, and Gary E. Friedlaender, MD
Vol 11, No 1, January/February 2003
35
Table 3
Limb Sparing Versus Amputation for Extremity Bone Sarcomas
Management
Outcome Measure Limb Sparing
*
Amputation
†
Local recurrence
4,5,11,19,41,42

5% to 10% 5%
Survival
4,5,11,19,41,42
70% 70%
Functional outcome
41,42,44-47
Good Good
Initial cost
43
High Low
Long-term cost
43
Less than amputation More than limb-
sparing procedure
*
85% to 90% of patients with extremity bone sarcomas can be managed with
limb-sparing surgery.
†
Only 10% to 15% of patients require ablative surgery as initial management.
allografts. With the development of
tendon-attachment devices or en-
hanced tendon-anchorage devices
for prostheses, the indications and
outcomes for proximal tibial pros-
theses are likely to broaden and im-
prove.
3
Better stability around the
hip and shoulder after prosthetic
reconstructions fit with these special

devices should improve functional
results in these regions. Extracor-
tical bone-bridging fixation will
likely improve the longevity of
prostheses by walling off the pros-
thesis-bone interface and adding
additional points of fixation to
improve construct strength.
3,9
For reconstructions using allo-
grafts, bone morphogenetic proteins
may decrease nonunion rates. A
better understanding of allograft
biology, as well as either closer
matching of allografts to recipients
or modulation of immune respons-
es, may decrease the presumed con-
sequences of allograft reconstruc-
tion. Using more vascularized bone
grafts and combining them with
allografts may help reduce or
address rates of nonunion and frac-
ture. The continued vigilant use of
adequate soft-tissue coverage in
reconstruction procedures, which
reduced early postoperative wound
complications, likely will decrease
the incidence of late deep wounds.
Summary
The surgical management of malig-

nant bone tumors of the extremities
presents many challenges. With
advances in chemotherapy, radio-
graphic imaging, and reconstructive
surgery, most patients with these
rare tumors now can be offered
limb-sparing surgery. Osteoarticular
allografts, modular prostheses, or
composites of these two approaches
form the basis for most current
reconstruction efforts. However,
amputation still plays an important
role and offers a standard to which
other approaches must be com-
pared. Functional outcome and
patient satisfaction appear to be at
least as good, and probably better,
after skeletal reconstruction than
after amputation. However, the sur-
gical treatment regimen associated
with limb-sparing procedures is also
associated with significant complica-
tions and requires extensive rehabili-
tation. Outcomes should continue
to improve as advances are made in
surgical technique, implant design,
autogenous bone allograft biology,
and postoperative management.
Malignant Bone Tumors: Limb Sparing Versus Amputation
Journal of the American Academy of Orthopaedic Surgeons

36
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Matthew R. DiCaprio, MD, and Gary E. Friedlaender, MD
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