Osteosarcoma surgery

1. Biopsy and staging planned by an orthopedic oncology team
2. Chemotherapy before surgery for most conventional high-grade tumors
3. Wide surgical resection of the tumor, including a cuff of normal tissue
4. Reconstruction or amputation, depending on whether safe tumor-free margins can be achieved
5. Postoperative chemotherapy
   • Miller's Review of Orthopaedics, 9th ed., treatment section

Main surgical options

• Limb-salvage surgery: removes the tumor-bearing bone and involved soft tissue while retaining the limb. The defect may be reconstructed with a metal endoprosthesis, allograft, vascularized bone graft, or occasionally rotationplasty.
• Amputation: used when a wide, safe margin cannot be achieved while preserving a useful limb, such as extensive involvement of major nerves/vessels, uncontrolled infection, or inadequate margins after resection.
• Rotationplasty: mainly an option for selected children or adolescents with tumors around the knee. The ankle functions as a knee within a prosthesis.
• Pulmonary metastasectomy: if lung metastases are limited and completely removable, lung surgery can be considered as part of treatment.

Key principles

• The priority is a complete tumor removal with negative margins. An unplanned biopsy or poorly positioned biopsy scar can compromise later limb-salvage surgery.
• More than 80% of extremity osteosarcomas can often be managed with limb preservation when wide margins are feasible. Survival is generally similar for limb salvage and amputation, though amputation may provide better local control in selected high-risk cases. See the NCI osteosarcoma treatment guidance.
• A pathological fracture does not automatically require amputation if the surgical team can still achieve adequate margins.
• Surgery should be planned at a specialist bone sarcoma center, ideally before the biopsy.