Between 60-80% of all patients with osteosarcomas of the pelvis and th
e extremities can now he safely treated with limb-sparing surgery. Res
ults (as defined by rates of local recurrence, overall survival, and f
unction) are equal to or better than those associated with amputation.
Successful use of limb-sparing procedures, however, depends on a well
-developed surgical plan. An understanding of the biologic behavior an
d growth patterns of these lesions is fundamental. Staging of the prim
ary tumor must involve a full complement of imaging modalities, includ
ing plain radiography, bone scintigraphy, computerized axial tomograph
y (CAT), magnetic resonance imaging (MRI), and angiography. The biopsy
must be well placed to reduce the possibility of tissue contamination
, which is a common reason for amputation. Restaging is necessary befo
re surgery for patients who have undergone neoadjuvant therapy; there
is recent evidence that preoperative therapy may make limb-sparing sur
gery possible in more than 50% of patients who otherwise would have re
quired amputation. Relative contraindications to limb-sparing surgery
include major involvement of the neurovascular bundle, pathologic frac
ture, inappropriate biopsy site, infection, immature skeletal age, and
extensive muscle involvement. Each of these factors is relative, and
patient selection decisions must be made on an individual basis. Limb-
sparing surgery consists of the following three phases: tumor resectio
n, skeletal reconstruction, and soft tissue and muscle transfers. The
range of reconstruction techniques has been broadened by developments
in bioengineering. Among the more commonly used techniques are custom
endoprostheses and allograft replacements. Future progress in inductio
n regimens and reconstructive techniques will undoubtedly enable limb-
sparing surgery to be a satisfactory alternative to amputation in even
more patients.