Table of Contents
- Key Points
- Background: Why This Research Matters
- What Is Joint Preservation Limb Salvage Surgery?
- How the Research Was Conducted
- Patient Characteristics and Tumor Locations
- Tumor Resection Techniques
- Bone Reconstruction Methods
- Complications After Surgery
- Cancer Outcomes: Recurrence and Survival
- Limb Function and Quality of Life
- What This Means for Patients
- Limitations of the Study
- Recommendations and Future Directions
- Frequently Asked Questions
- Source Information
Key Points
- In a review of 224 patients with osteosarcoma around the knee, joint preservation limb salvage achieved a 5-year survival of 83% and a 10-year survival of 77%.
- The local tumor recurrence rate was 5.4% in the reviewed patients, and recurrence was often linked to the resection margin rather than the reconstruction method.
- Common complications in the reviewed patients were bone graft fractures (12.9%), infections (9.4%), and bone nonunion (8.5%).
- The average MSTS limb function score was 26.7 points; patients who had complications tended to have lower scores.
- Reconstruction choices should be individualized based on defect size and location, patient growth status, material availability, and patient preferences.
Background: Why This Research Matters
Osteosarcoma (a type of bone cancer) is the most common primary malignant bone tumor in children and adolescents. This cancer primarily affects the metaphyses of long bones, which are the growing areas near the ends of bones. Despite significant advances in cancer treatment, osteosarcoma continues to pose major challenges for patients and their medical teams.
Current 5-year overall survival rates for osteosarcoma range from 60% to 70%. This means that about 6 to 7 out of every 10 patients survive at least five years after diagnosis. However, survival rates have plateaued in recent years, meaning they have stopped improving significantly. This has created an urgent need for new treatment strategies.
The main goals in treating osteosarcoma are to improve survival rates and preserve limb function for long-term survivors. While sustained improvement in limb function is achievable, it has become a critical focus for orthopedic surgeons who specialize in this field.
Joint preservation limb salvage (JPLS) surgery aims to remove the entire tumor while keeping as much healthy joint tissue as possible. This approach is gaining recognition within orthopedic oncology (the medical specialty focused on bone cancers). Traditionally viewed as high-risk and technically demanding, JPLS has benefited greatly from advancements in tumor imaging and precision surgical technologies.
These technological innovations include computer-aided navigation, 3D-printed surgical guides, and robotic surgery. These tools enhance the safety and precision of JPLS procedures, encouraging orthopedic oncologists to further explore and refine this approach.
In recent years, several reconstructive options for JPLS have emerged. However, variability among surgical techniques has led to confusion in clinical decision-making. Currently, there is no universally accepted gold standard for reconstruction in JPLS. There is also no clear clinical algorithm that accounts for individual patient needs when selecting a reconstructive technique.
This systematic review investigates developments in JPLS for osteosarcoma within long bone metaphyses over the last two decades. The review addresses four key questions:
- Does JPLS increase the risk of tumor recurrence and mortality?
- What are the optimal methods for bone tumor resection and defect reconstruction in JPLS?
- What is the functional outcome for patients undergoing JPLS?
- What are the common postoperative complications of JPLS, and how are they managed?
What Is Joint Preservation Limb Salvage Surgery?
Joint preservation limb salvage (JPLS) is a surgical approach that aims to completely remove a bone tumor while preserving as much healthy joint tissue as possible. This is different from traditional limb salvage surgery, which may remove more of the joint or require joint replacement.
The procedure strictly adheres to oncological surgical principles. This means the surgeon ensures complete excision of malignant tissue while maximizing joint function. Traditionally, surgeons required a 2 to 3 centimeter tumor-free margin (a buffer of healthy tissue around the tumor). However, advancements in precision surgery now suggest that narrower margins of approximately 1 centimeter may be acceptable.
These narrower margins are possible because of accurate MRI imaging and efficient neoadjuvant chemotherapy (chemotherapy given before surgery to shrink the tumor). JPLS is built upon these technological developments, which emphasize the preservation of adjacent joints.
Surgeons performing JPLS are understandably concerned about tumor recurrence and mortality. Survival analyses for osteosarcoma indicate a 5-year overall survival rate of 60% to 70%. This systematic review confirms that JPLS achieves comparable oncological outcomes to traditional limb salvage surgeries.
How the Research Was Conducted
This systematic review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. These guidelines ensure that the review is conducted in a standardized and transparent manner.
The researchers conducted a systematic search across three major medical databases: MEDLINE, Embase, and the Cochrane Library. The search covered publications from January 1, 2003, to December 31, 2023. The search utilized the following keywords: "osteosarcoma," "bone tumor," "limb salvage surgery," "surgery," "operation," and "knee."
Two independent investigators reviewed the titles and abstracts of all retrieved articles. When disagreements occurred, a full-text evaluation was performed to reach consensus. Studies qualified for inclusion if they met three criteria:
- Original studies published in English
- Clinical research pertaining to JPLS
- Studies providing detailed individual patient information
Reviews, expert opinions, and conference articles were excluded from the analysis.
The researchers extracted essential attributes from the included studies. These attributes included references, patient ages, genders, tumor locations, reconstruction methods, complications, and knee functional scoring. Two independent researchers conducted patient data extraction, with any disputes resolved through discussions among three members of the research team.
The researchers noted concerns regarding potential biases in the studies reviewed. However, assessing this was challenging due to the rarity of osteosarcoma and the uniqueness of surgical methods. The included studies were not randomized controlled trials. While a meta-analysis was considered, the available data did not support its application.
A subgroup analysis was conducted to investigate the incidence of complications associated with different reconstruction methods. All analyses were performed using IBM SPSS Version 21. A p-value of less than 0.05 was considered indicative of a significant association.
The initial search identified 740 unique studies, of which 228 were duplicates. After removing duplicates, 380 references were eliminated based on title and abstract screening. An additional 50 studies were excluded following a full-text review. Ultimately, 25 retrospective clinical studies published between 2003 and 2023 were included, comprising a total of 224 patients for systematic analysis.
All included studies were observational and retrospective. The researchers honestly noted that the methodological quality of this study is generally considered average.
Patient Characteristics and Tumor Locations
The age of patients ranged from 2 to 59 years, with a notable concentration between 9 and 18 years. Approximately two-thirds of patients belonged to this 9 to 18-year age group. The mean age at diagnosis was 16.8 years.
Male patients predominated, with a male-to-female ratio of 1.46 to 1. This is consistent with typical demographics for osteosarcoma, which affects more males than females.
Osteosarcomas were primarily located in two areas around the knee:
- Distal femur (the lower end of the thigh bone): 170 cases
- Proximal tibia (the upper end of the shin bone): 54 cases
The average follow-up duration was 78.6 months, with a range of 5 to 313 months. This means patients were followed for an average of about 6.5 years after surgery.
Tumor Resection Techniques
Accurate bone resection is fundamental to the success of JPLS. The goal is to remove the entire tumor while preserving as much healthy tissue as possible.
Accurate bone resection lengths were documented for 152 patients. The average resection length was 167.6 mm, with a range of 55 to 396 mm. The choice of resection length influenced which reconstruction method was used.
Several specialized techniques were employed to remove tumors while preserving joint tissue:
- Epiphyseal distraction: 8 patients underwent this procedure, which involves gradually separating the growth plate from the tumor
- Marginal microwave ablation: 11 patients received this treatment prior to tumor segment resection, which uses heat to destroy tumor cells
- Pedicle-freezing technique: 5 patients had partial tumor segment resection using this method, which preserves cortical continuity on one side
Navigation techniques facilitated precise tumor segment osteotomy (bone cutting). These techniques included:
- Fused CT-MR image guidance: 20 patients
- 3D-printed guide plates: 18 patients
These advanced technologies enhance procedural precision and safety. While implementing JPLS requires more energy and financial resources than traditional limb salvage surgery, recent years have seen increasing integration of these technologies into clinical practice.
Bone Reconstruction Methods
Following tumor resection, methods for bone defect repair and reconstruction among the 224 patients were categorized into four main types. The reconstruction method chosen depended on various factors, including the size and location of the bone defect.
Allograft bone repair was performed in 76 patients. Allograft bone comes from a donor rather than from the patient's own body. Of these patients, 25 cases were combined with autograft (the patient's own bone), primarily used alone in 51 cases. The advantage of allogeneic bone reconstruction is that it is unaffected by repair length limitations. However, it presents challenges such as allogeneic bone resorption, non-healing, fractures, and the risk of infections.
Inactivated tumor bone replantation was performed in 90 patients. This technique involves removing the tumor-containing bone, treating it to destroy cancer cells, and then reimplanting it. The methods used included:
- Pasteurization: 56 patients (49 cases combined with fibula, predominantly vascularized in 43 cases)
- Irradiation: 16 patients
- Freezing: 13 patients (2 cases combined with allograft and 1 case with fibula)
- Alcohol inactivation: 5 patients
The advantage of inactivated bone reconstruction is that it eliminates the need to consider bone source and compatibility. However, its drawbacks include inappropriateness for patients with severe bone destruction, an increased risk of tumor recurrence, and potential complications such as fractures and non-healing of the inactivated bone.
Autograft reconstruction was performed in 23 patients following tumor resection. This included 12 patients with bone transport, 6 with vascularized fibula, and 5 without additional methods. The advantage of autogenous bone reconstruction is its ability to promote effective bone healing. However, this method is associated with increased trauma and limited repair length.
Prosthetic reconstruction was performed in 35 patients. This included 17 patients with traditionally manufactured customized prostheses and 18 with 3D-printed customized prostheses. The advent of 3D printing for metal prostheses enhances both surgical precision and bone integration. Customized 3D-printed prostheses and guide plates improve the accuracy of resections and defect reconstructions. Additionally, the superior bone integration capabilities of 3D-printed prostheses rapidly fulfill patients' functional needs.
However, ongoing concerns regarding internal stress in 3D-printed prostheses, such as fatigue strength, warrant further investigation.
Complications After Surgery
Complications were significant among patients who underwent JPLS. The overall incidence rates for fractures, infections, and nonunion were 12.9%, 9.4%, and 8.5%, respectively.
Bone graft fractures occurred in 29 patients postoperatively. These fractures primarily occurred in cases involving allograft reconstructions (15 cases) and inactivation (12 cases). In the allograft group, 12 patients who underwent simple allograft reconstructions and 3 patients who received allograft combined with autograft experienced fractures.
Additional fractures occurred in:
- 4 patients with pasteurization combined with fibular reconstructions
- 3 patients with alcohol inactivation
- 3 patients with freezing inactivation
- 2 patients with irradiation inactivation
- 1 bone transport patient
- 1 fibula transplant patient
The incidence of fractures following autogenous bone reconstruction was 8.7%. This compared to 19.1% for allogeneic bone and 13.3% for inactivated bone. However, these differences were not statistically significant (p = 0.334).
Infections were reported in a total of 21 cases. These included:
- 6 cases associated with allogeneic bone (7.9%)
- 9 cases with inactivated bone (10.0%)
- 2 cases with autogenous bone (8.7%)
- 4 cases involving prostheses (11.4%)
The differences among these groups were also not statistically significant (p = 0.935). Notably, infection was the only complication observed in patients who underwent prosthetic reconstruction.
Bone nonunion (failure of the bone to heal) was identified in 19 cases:
- 8 cases with allogeneic bone (10.5%)
- 9 cases with inactivated bone (10.0%)
- 2 cases with autogenous bone (8.7%)
Again, no statistically significant difference was observed (p = 0.968).
Limb shortening was observed variably, although detailed statistical analysis was not conducted. Managing limb length discrepancies post-surgery is particularly critical for pediatric patients. This can be addressed with limb lengthening techniques. Some JPLS patients retain limb growth capability because tumors are situated distant from the epiphyseal plate (growth plate), preserving its function. Others experience compromised growth due to the resection of both the tumor and epiphyseal plate.
Non-oncological complications included abnormal knee joint force lines, knee instability, knee degeneration, bone resorption, and failed internal fixation.
Surgical complications, including bone graft fractures and nonunion, are prevalent and often interrelated. They are managed with techniques such as POP fixation (plaster of Paris cast fixation). The pedicle-freezing method shows promise in treating non-healing bones, although its technical complexities hinder broader implementation.
Notably, 3D-printed prostheses in JPLS exhibit lower complication rates than traditional methods. Infections remain a significant challenge, necessitating focused efforts in the management of large bone defects. Deep infections can be particularly challenging to treat, potentially requiring multiple surgeries or amputations. Effective integration of soft tissue, adequate drainage, and the avoidance of dead space formation are recognized strategies for reducing infection rates. The porous structure of 3D-printed prostheses promotes improved soft tissue integration compared to traditional machined prostheses, contributing to their increasing acceptance among surgeons.
Cancer Outcomes: Recurrence and Survival
Oncological outcomes related to tumor recurrence and metastasis revealed that 12 patients experienced local recurrences. This represents a local recurrence rate of 5.4%.
Among these recurrences:
- 7 patients who underwent inactivation had local recurrences that were not associated with the inactivated autografts
- Recurrences were identified in the surrounding soft tissues in 6 cases
- Recurrences were identified within the residual host bone in 1 case
In the allograft group, no local recurrences occurred in the remaining bony epiphysis. However, 3 patients developed local recurrences in adjacent soft tissues. Additionally, 2 patients who received autogenous bone transplantation had ambiguous sites of tumor recurrence.
These findings suggest that there is no clear relationship between tumor recurrence and the choice of reconstruction method. Rather, recurrence is often linked to the resection margin.
During the follow-up period, 39 patients died as a result of tumor progression. The 5-year survival rate was 83%, while the 10-year survival rate was 77%. This means that 83 out of every 100 patients survived at least five years after surgery, and 77 out of every 100 survived at least ten years.
Limb Function and Quality of Life
JPLS aims to preserve postoperative limb function, enhancing proprioception (the sense of body position and movement) and maintaining knee functionality.
The average Musculoskeletal Tumor Society (MSTS) score for limb function was 26.7 points. The MSTS score is a standardized system for evaluating limb function after tumor surgery, with higher scores indicating better function.
Among the studied patients, 10 patients scored below 20 on the MSTS scale. All of these patients experienced postoperative complications, some leading to limb loss. In contrast, patients who did not experience complications generally achieved normal limb function post-JPLS. These patients restored levels of physical activity typically limited by other surgical approaches.
What This Means for Patients
This systematic review confirms that JPLS achieves comparable oncological outcomes to traditional limb salvage surgeries. The tumor recurrence rate of 5.4% and 10-year survival rate of 77% are encouraging results for patients considering this approach.
For patients with osteosarcoma around the knee, JPLS offers the potential to preserve joint function while effectively treating the cancer. The average MSTS score of 26.7 points indicates that most patients achieve good limb function after surgery.
However, patients should be aware that complications can occur. The most common complications are bone graft fractures (12.9%), infections (9.4%), and bone nonunion (8.5%). Patients who experience complications tend to have lower limb function scores.
The choice of reconstruction method should be individualized based on each patient's specific situation. Factors to consider include:
- The size and location of the bone defect
- Whether the patient is still growing
- The availability of different reconstruction materials
- The patient's overall health and preferences
Newer technologies, such as 3D-printed prostheses, show promise for reducing complication rates and improving outcomes. However, more research is needed to fully understand their long-term benefits and risks.
Limitations of the Study
The present study acknowledges several limitations. First, there were challenges in determining the validity of some included studies. The methodological quality of this study is generally considered average.
Second, the included studies were not randomized controlled trials. All studies were observational and retrospective, meaning they looked back at patient records rather than randomly assigning patients to different treatments.
Third, while a meta-analysis was considered, the available data did not support its application. This limited the researchers' ability to combine data from multiple studies statistically.
Fourth, assessing potential biases in the studies reviewed was challenging due to the rarity of osteosarcoma and the uniqueness of surgical methods. The small number of patients in each study and the variety of surgical techniques used make it difficult to draw definitive conclusions.
Fifth, the study did not include cases involving microwave ablation for osteosarcoma. Concerns remain regarding the absence of standardized procedures for such techniques.
Finally, the follow-up durations varied widely among studies, ranging from 5 to 313 months. This variability could affect the reported outcomes.
Recommendations and Future Directions
Based on this systematic review, several recommendations emerge for patients and healthcare providers:
- Consider JPLS as a viable option: For patients with osteosarcoma around the knee, JPLS offers comparable cancer outcomes to traditional limb salvage surgery while potentially preserving better joint function.
- Individualize reconstruction choices: The choice of reconstruction method should be tailored to each patient's specific circumstances, including tumor size, location, and patient age.
- Discuss complication risks: Patients should be fully informed about the risks of fractures, infections, and nonunion, as well as strategies to manage these complications if they occur.
- Consider newer technologies: 3D-printed prostheses and navigation techniques show promise for improving outcomes, though more research is needed.
- Monitor limb length in pediatric patients: For growing children, regular monitoring of limb length and appropriate interventions when needed are essential.
Ongoing clinical applications of these technologies hold the potential for further improvements in oncological outcomes and patient recovery post-surgery. Future research should focus on standardized procedures, longer follow-up periods, and prospective study designs to better understand the optimal approaches for JPLS in osteosarcoma patients.
Frequently Asked Questions
What is joint preservation limb salvage surgery for osteosarcoma around the knee?
It is a surgical approach that removes the entire bone tumor while keeping as much healthy joint tissue as possible. Unlike traditional limb salvage, which may remove more of the joint or require joint replacement, this method follows strict cancer surgery principles. It aims to completely remove malignant tissue while maximizing joint function, and it relies on precise imaging and chemotherapy given before surgery.
Who might be eligible for joint preservation limb salvage surgery?
In a review of 224 patients, those with osteosarcoma around the knee were mostly between 9 and 18 years old, with an average age of 16.8 years. Tumors were in the lower thigh bone or upper shin bone. Eligibility depends on tumor size, location, whether the patient is still growing, available reconstruction materials, and overall health.
What are the cancer outcomes after joint preservation limb salvage surgery?
In a review of 224 patients, the 5-year survival rate was 83% and the 10-year survival rate was 77%. The local tumor recurrence rate was 5.4%. These outcomes are comparable to traditional limb salvage surgeries. Recurrence was often linked to the resection margin rather than the choice of reconstruction method.
What complications can occur after joint preservation limb salvage surgery?
In a review of 224 patients, the most common complications were bone graft fractures (12.9%), infections (9.4%), and bone nonunion (8.5%). Other issues included limb shortening, knee instability, and failed internal fixation. Patients who experienced complications tended to have lower limb function scores. Deep infections can be challenging and may require multiple surgeries.
What does an MSTS score of 26.7 mean for limb function?
The Musculoskeletal Tumor Society (MSTS) score measures limb function after tumor surgery, with higher scores indicating better function. In a review of 224 patients, the average score was 26.7 points. Ten patients scored below 20, and all of them had postoperative complications. Patients without complications generally achieved normal limb function.
How is the bone defect reconstructed after tumor removal?
In a review of 224 patients, reconstruction methods included allograft bone (76 patients), inactivated tumor bone replantation (90 patients), autograft (23 patients), and prostheses (35 patients). The choice depends on the size and location of the defect, whether the patient is still growing, material availability, and patient preferences. Each method has specific advantages and risks.
What should patients know about recovery and follow-up after surgery?
In a review of 224 patients, the average follow-up was 78.6 months (about 6.5 years). Complications such as fractures and nonunion are managed with techniques like plaster casts. For growing children, limb length should be monitored regularly. Patients should discuss complication risks and individualized reconstruction choices with their care team.
My child has osteosarcoma around the knee and the surgeon recommends joint preservation limb salvage surgery — should we get a second opinion on whether this is the right operation?
Joint preservation limb salvage removes the tumor while keeping as much healthy joint tissue as possible, and it achieves comparable cancer outcomes to traditional limb salvage, with a 5.4% local recurrence rate, 83% five-year and 77% ten-year survival, and an average MSTS limb function score of 26.7 points. Because no universally accepted standard exists for reconstruction, and the choice among allograft, inactivated bone, autograft, or prosthetic methods should be individualized to defect size, location, growth status, and patient preferences, an independent review of the imaging, pathology, and proposed reconstruction can help confirm the plan fits your child's situation. Diagnostic Detectives Network provides independent expert second opinions.
Source Information
Original Article Title: Systematic Review of joint preservation limb salvage in osteosarcoma around the knee.
DOI: 10.3389/fonc.2025.1554799
License: CC BY (open access)
Authors: Zheng K, Yu X, Xu M, Cui H, Chen Q.
Affiliation: Department of Orthopedics, 960th Hospital of the People's Liberation Army (PLA), Jinan, China
Journal: Frontiers in Oncology, Volume 15, Article 1554799
Publication Date: May 15, 2025
DOI: 10.3389/fonc.2025.1554799
Funding: This work was supported by a grant from the Youth Talent Support Project of Shandong Medical Association (2023_LC_0077).
This patient-friendly article is based on peer-reviewed research. The original study was a systematic review of 25 retrospective clinical studies involving 224 patients who underwent joint preservation limb salvage surgery for osteosarcoma around the knee between 2003 and 2023.
