Limb Salvage Surgery For Osteosarcoma Research Articles

Global Research Trends in Limb Salvage Surgery for Osteosarcoma: Findings from a Bibliometric and Visualized Analysis over 15Years.

Limb salvage surgery in osteosarcoma requires a multidisciplinary team of experts, due to which research interest has remained limited globally. This article analyzes research trends over 15years from 2007 to 2022. Publications on limb salvage surgery in osteosarcoma were retrieved using the Web of Science. Bibliometric analysis of the publication metadata was done using R software. VOS viewer software was used to analyze the bibliographic coupling, co-citation, co-authorship, and co-occurrence to report the current trends in global research on limb salvage surgery in osteosarcoma. A total of 693 articles were retrieved. On applying the inclusion and exclusion criteria, a publication metadata of 276 articles was analyzed using the methodology mentioned. Annual scientific production on the subject has shown a steady rising trend globally. China has the highest number of publications on the topic; however, the USA has the highest citations globally. The Journal "Clinical Orthopedics and Related Research" remains the pioneer in the topic with the highest number of publications and H index among all journals. Most of the research interest is generated in the developed countries of the USA, Europe, and China. Keyword analysis suggested 4 clusters of surgical reconstruction, Survival, Chemotherapy, and general management related. Newer keywords such as biological reconstructions, allograft, metastases, cell, and chemotherapy suggest future research topics in the field. Research interest in limb salvage surgery in osteosarcoma continues to grow with the introduction of concepts such as biological reconstructions and allografts. However, for more inclusive research on the topic, research interest must also be encouraged in underdeveloped and developing countries.

Comparative efficacy of intraoperative extracorporeal irradiated and alcohol-inactivated autograft reimplantation for the management of osteosarcomas\u2014a multicentre retrospective study

BackgroundBiologic bone reconstruction in limb salvage surgery for the treatment of malignant bone tumours has always been controversial. The various inactivation methods, their convenience and stability, the curative effects elicited and associated costs all need to be considered. This study aimed to compare the clinical efficacy of intraoperative extracorporeal irradiated reimplantation with alcohol-inactivated autograft reimplantation for limb salvage surgery in patients with osteosarcoma.MethodsWe retrospectively analysed 28 patients with osteosarcoma, 14 patients treated with intraoperative cobalt 60 irradiation and reimplantation (group A), and 14 patients treated by alcohol-inactivated autograft reimplantation (group B). The postoperative complications and clinical efficacy of each treatment method were compared by statistical analysis.ResultsThe local recurrence rate was 14.3% in each group. Complete bony union was achieved in 64.3% of patients in group A and 71.4% of patients in group B. The overall 5-year survival rate was 71.4% in group A and 78.6% in group B. The mean Musculoskeletal Tumor Society (MSTS) score was 25.33 ± 4.72 (range 15–30) in group A and 24.00 ± 5.85 (range 15–30) in group B, and the mean International Society of Limb Salvage (ISOLS) score was 25.79 ± 5.13 (range 20–36) in group A and 26.14 ± 5.33 (range 20–30) in group B. P < 0.05 was considered to indicate a significant difference. The results showed that the long-term clinical efficacy did not differ significantly between the two methods.ConclusionsIn limb salvage surgery for osteosarcoma, intraoperative extracorporeal irradiation and alcohol-inactivated autograft reimplantation yielded equivalent outcomes. The alcohol-inactivated method may be a much more convenient and inexpensive way to reconstruct bone defects. Additional studies as well as more case studies are needed to fully evaluate the clinical efficacy and safety of this treatment method.

Erratum: Life and limb after limb salvage surgery for osteosarcoma in an Indian tertiary cancer center

Erratum: Life and limb after limb salvage surgery for osteosarcoma in an Indian tertiary cancer center

Life and limb after limb salvage surgery for osteosarcoma in an Indian tertiary cancer center

Background: Limb salvage surgery (LSS) is the current surgical standard for malignant bone tumors. The advancements in imaging, surgical techniques, chemotherapy, and biomedical engineering have made LSS oncologically safe and with improved functional outcome. In this retrospective study, we report our experience with LSS and perioperative chemotherapy for osteosarcoma in a tertiary cancer center in India. Materials and Methods: A total of 41 LSS were performed from January 2009 to January 2015. Perioperative chemotherapy was administered to all patients after histopathological confirmation of osteosarcoma. The functional outcome of the patients was evaluated using the musculoskeletal tumor society (MSTS) scoring system at regular intervals. Statistical analysis involved the use of descriptive and inferential statistics for data analysis. Kaplan–Meier method was used for calculating the recurrence free and overall survival (OS) and log-rank test for comparing survival functions. Spearman and Karl Pearson's methods were used for correlation analysis. Results: The mean age was 19.3 years (range, 8–49 years). Twenty-five (61%) patients were males. Thirty-six (88%) patients had conventional high-grade osteosarcoma. Five-year relapse-free survival and OS were 56.1% ± 7.8% (95% confidence interval [CI], 53.7–58.5) and 58.5% ± 7.7% (95% CI, 56.1–60.9), respectively. The mean MSTS scores at 1 year for tumors of the upper tibia and distal femur were 64 and 75.9, respectively. Patients with high rate of chemotherapy-induced tumor necrosis (>99%) had significantly better median OS (85.70 ± 8.22 months) compared to those with less ( Conclusion: The oncological and functional outcomes in osteosarcoma patients in the present study are comparable to those from the world literature. Chemotherapy-induced tumor necrosis is a favorable prognostic factor for patients treated for osteosarcoma with curative intent.

Study on the efficacy of neoadjuvant chemotherapy on limb salvage surgery for osteosarcoma

In this study, 32 osteosarcoma patients admitted in the department of orthopedics from 2008 to 2016 were selected as subjects. Percutaneous intra-arterial chemotherapy was performed on 17 patients on the day before admission, and then the general chemotherapy was carried out on next day. After limb salvage surgery, the previous chemotherapy was repeated for 4 times. Before limb salvage surgery, the remaining 15 patients were treated with intravenous systemic chemotherapy. Fourteen days later, amputation was performed. Both the treatment strategies were compared and it was concluded that patients can adapt better to the method of limb salvage treatment after arterial and venous chemotherapy, thus the application of which is more promising.

Clinico-pathological Study of Limb Salvage Surgery for Osteosarcoma: Experience in a Rural Cancer Center.

Although recent multimodality therapeutic protocols have led to improved survival in osteosarcoma (OS), the outcome still remains dismal. Ongoing international multicentric trials on OS aim to randomize patients for optimum management, based on histological response to NACT. The pathologic response to neoadjuvant chemotherapy (NACT) is the most important factor predicting prognosis. In this study of 23 cases of limb salvage surgery post neoadjuvant chemotherapy, mean age was 18.3years, with male predominance. 65.5% cases were conventional OS. Histologic assessment of chemotherapeutic effect done by Huvos grading revealed good response (Huvos lll and lV) in 15 (65.2%) and poor response (Huvos l and ll) in eight (34.8%). A scoring based on MRI with a scale of 1-6 was compared with histologic response. Five (62.5%) of poor responders showed score of >3 and 73.3% of good responders showed ≤3. Dose intensity of NACT was calculated and correlated with the histological response. 53.3% of good responders showed ARDI>0.9. Five (21.7%) developed local recurrence and 10(43.4%) had pulmonary metastasis. Adoption of more aggressive treatment modalities may ensure better histologic response and longer event free survival.

'Broken-heart syndrome'… Be aware..

Takotsubo cardiomyopathy (TCM), also known by various other names such as broken-heart syndrome, stress-induced cardiomyopathy and apical ballooning syndrome, is an acute, reversible, transient left ventricular dysfunction that was first described by a Japanese cardiologist in 22 patients in the year 1990. The Japanese word ‘takotsubo’ means an octopus trap, used to describe the shape of the left ventricle in this condition during systole. Since its original publication, there have been several case reports describing its occurrence in patients in the periprocedural and perioperative periods, underscoring the importance of the need for awareness about this rare syndrome among anaesthesiologists. There are several case reports published from India too. In this issue of the Indian Journal of Anaesthesia, a case of this entity is reported after thyroidectomy and also one describing its occurrence in a young patient who developed anaphylaxis to cephalosporin intraoperatively during limb salvage surgery for osteosarcoma of the tibia.[1,2] TCM is more common in elderly postmenopausal women, although presentations have been reported in young men and women also. A systematic review of this syndrome has recently been published by Ono and Falcao.[3] The triggering factor for this cardiomyopathy seems to be the elevated levels of plasma catecholamines due to physical or emotional stress, which leads to coronary spasm, direct myocardial toxicity or microvascular impairment. Iatrogenic administration of catecholamines can also be a trigger of this syndrome.[4] Lyon et al. have described a novel pathophysiological hypothesis to explain the myocardial stunning due to catecholamine excess.[5] It has been proposed that apical ballooning could be due to the abundance of beta receptors in this region that can lead to negative inotropy due to change in the intracellular signal trafficking. The Heart Failure Association of the European Society of Cardiology has recently published a position statement on takotsubo syndrome that includes a diagnostic algorithm comprising seven criteria including anatomic features, electrocardiogram (ECG) changes, cardiac biomarkers and reversibility of the ventricular dysfunction.[6]

Takotsubo cardiomyopathy due to cephalosporin anaphylaxis under general anaesthesia.

Sir, Cephalosporin anaphylaxis is a known but rare entity with an incidence of 0.0001-0.1%[1] We report an unusual case of anaphylaxis during general anaesthesia which resulted in transient stress-induced cardiomyopathy in the absence of coronary disease. A 27-year-old female was posted for limb-salvage surgery for osteosarcoma of the left proximal tibia. She had received three cycles of chemotherapy containing Adriamycin. She was active pre-operatively and did not have any comorbidity. All her laboratory investigations were normal including echocardiography which showed an ejection fraction of 62%. On arrival in the operation theatre, she was provided general anaesthesia with standard monitoring. After an intravenous dose of injection cefuroxime, the patient developed bradycardia followed by multifocal ventricular extrasystoles and ventricular tachycardia. The arrhythmia resolved spontaneously but the patient became haemodynamically unstable. All anaesthetic agents were discontinued and 100% oxygen was administered. Patient's radial artery was catheterized and arterial blood gas analysis was done. The patient was administered injection hydrocortisone and an infusion of noradrenaline was started. Trans-oesophageal echocardiography showed global left ventricular hypokinesia, dyskinesia and regional wall abnormality beyond the territory of the single epicardial vessel with an ejection fraction of 35%. Cardiac enzymes (creatine kinase-MB and TROP-T) were mildly raised. She was shifted to Intensive Care Unit for monitoring and further management. A 12 lead electrocardiogram (ECG) showed diffuse ST segment elevation in leads I, II, aVL and V3–V 6. She was extubated the following day and follow-up echocardiography on the 3rd post-operative day showed an ejection fraction of 45% with improved left ventricular contractility. She was posted for incision and drainage of pus 6 weeks later but this time, she had an uneventful perioperative period. A skin prick test performed during pre-anaesthetic check-up was positive for cefuroxime and negative for other drugs, including atracurium, propofol and midazolam. Echocardiography showed an ejection fraction of 60%. The temporal relationship between drug administration and cardiovascular collapse and positive results in the skin prick test in the present case suggest that cefuroxime, a second-generation cephalosporin, was the most likely cause of the reaction. The negative results of pre-operative intradermal tests can be explained by the lower sensitivity of the tests. We did not obtain serum tryptase levels as it is not routinely done in our hospital. Serial mast cell tryptase[2] levels as early as feasible may be useful for diagnosis. During anaphylaxis, compensatory release of catecholamines by renin-angiotensin system and histamine results in excessive activation of catecholamine receptors in the left ventricle; catecholamine-induced transient left ventricular dysfunction is known as takotsubo cardiomyopathy.[3,4,5] Our patient fulfilled all the criteria (Mayo clinic) of takotsubo cardiomyopathy, which are; left ventricular hypokinesia, dyskinesia extending beyond a single epicardial distribution; absence of chronic obstructive pulmonary disease and coronary disease; new ECG changes with elevated cardiac enzymes and absence of pheochromocytoma and myocarditis. Kurisu et al.[6] suggested multivessel coronary spasm at microscopic level as a cause of cardiomyopathy. Lymphodepletion and profound suppression and alteration of antigen-specific IgG antibody response by the chemotherapeutic agents and the pre-operative dexamethasone were possibly the factors due to which our patient did not have any other respiratory and cutaneous manifestation of anaphylaxis. Treatment of stress-induced cardiomyopathy relies on standard supportive measures. The prognosis is generally favourable, provided the patient survives the initial complications. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Functional outcomes and quality of life in patients with osteosarcoma treated with amputation versus limb-salvage surgery: a systematic review and meta-analysis.

To perform a meta-analysis for comparing the functional outcomes and quality of life (QOL) of osteosarcoma patients receiving amputation or limb-salvage surgeries. A search was conducted of the Medline, Cochrane, EMBASE, and Google Scholar on September 30, 2013. Studies were included in the analysis if there were patients who underwent amputation and limb-salvage surgery for osteosarcoma or Ewing's sarcoma, and for whom postoperative functional outcomes and QOL were evaluated. Outcomes were compared between participants who underwent limb-salvage operation and those who underwent amputation. The methodological quality of non-randomized comparative studies was assessed using the Newcastle-Ottawa Scale. A total of 121 studies were identified and 6 were included in the meta-analysis. Quality assessment indicated that all six studies were of high quality. The mean age of the participants ranged from 17 to 37years, and among them 118 underwent amputations and 138 underwent limb-salvage procedures. The mean length of follow-up ranged from 28 to 145months. The meta-analysis indicated that functional outcomes and QOL were similar between patients who underwent amputation and those who underwent a limb-salvage procedure. This meta-analysis including six high-quality studies indicates that amputation and limb-salvage surgery provide similar functional outcomes and quality of life for patients with osteosarcomas.

Limb salvage surgery for osteosarcoma: Early results in Indian patients.

Background:While limb salvage surgery has long been established as the standard of care for osteosarcoma, large studies from Indian centers are few. Given the diverse socio economic milieu of our patients, it becomes significant to determine the feasibility and outcome of management of osteosarcoma in our population. We analyzed the early outcome of limb salvage surgery with multimodality treatment of osteosarcoma of the extremity/girdle bones at a tertiary North Indian Cancer Centre.Materials and Methods:A total of 51 limb salvage surgeries performed during the months between November 2008 and November 2012 were studied. Neoadjuvant/adjuvant chemotherapy was given by the pediatric/adult medical oncology teams as applicable. The mean followup was 19.45 months (range 2-50 months). The oncological outcome was correlated with age, sex, size of tumor, stage at presentation, site, histological subtype, type of chemotherapy protocol followed and necrosis seen on postoperative examination of resected specimen. The functional outcome of the patients was evaluated using the musculoskeletal tumor society (MSTS) scoring system.Results:Out of a total of 37 males and 14 females with an average age of 18.8 years, the 3 year overall survival was 66% and 3 year event free survival was 61.8%. In this group of patients with a short followup, a better oncological outcome was associated with good postoperative tumor necrosis, nonchondroblastic histology and age <14 years. The average MSTS score was highest in patients with proximal or distal femur prosthesis and the lowest in patients undergoing a knee arthrodesis.Conclusion:The present study shows oncological and functional outcomes of limb salvage combined with chemotherapy in Indian patients with osteosarcoma comparable to those in world literature. Larger studies on Indian population with longer followup are recommended.

A Preliminary Evaluation of Limb Salvage Surgery for Osteosarcoma around Knee Joint

ObjectiveTo evaluate the effectiveness and drawbacks of diversified procedures of limb salvage surgery (LSS), providing a reference of rational surgical criterion of LSS.MethodsFifty eight patients with stage IIB extremity osteosarcoma around knee joint area between 1992 and 2002 were studied retrospectively. Among them, 43 patients were treated by LSS followed by reconstruction. Reconstruction approaches included re-implantation of irradiation-devitalized tumor bone (n = 12), autoclaving-devitalized tumor bone (n = 8), prosthetic replacement (n = 11), allograft transplantation (n = 8) and vascularized fibula autograft implantation (n = 4). Amputations were performed in 15 patients. Patients were followed up for 6–16 years.ResultsThere were no significant difference between LSS and amputation groups regarding disease free survival and local recurrence rates. The actuarial 5-year continuous disease free survival and local recurrence rate were 30.0% and 25.0% in patients of devitalized LSS group, whereas those were 56.5% and 8.7% in patients of non-devitalized reconstruction group. The complication rate was significantly higher in LSS group compared to amputation group (P = 0.003).ConclusionLSS with non-devitalized procedures is the optimal treatment for osteosarcoma around knee joint area. Prosthesis implantation is the preferred option for bone reconstruction following LSS. Prevention and treatment of post-operative complications should be paid more attention to get good long-term outcomes of surgery.

Pulmonary toxocariasis masquerading as metastatic tumor nodules in a child with osteosarcoma

A 14-year-old male, who completed chemotherapy following limb salvage surgery for osteosarcoma approximately 2 years ago, was seen for routine follow-up. A CT scan revealed new scattered multifocal nodular lesions. An ultrasonography-guided percutaneous needle biopsy was done to confirm pulmonary metastasis of the underlying osteosarcoma. The lung biopsy showed findings of eosinophilic pneumonia with no evidence of malignancy. Peripheral eosinophilia was also noted. When a more thorough history revealed frequent intake of raw cow liver, we diagnosed pulmonary toxocariasis by ELISA for specific serum IgG antibody.

Use of Intra-Arterial Chemotherapy and Embolization Before Limb Salvage Surgery for Osteosarcoma of the Lower Extremity

We report our experience with the use of intra-arterial chemotherapy and embolization before limb salvage surgery in patients with osteosarcoma of the lower extremity. We evaluated the effect of this procedure on the degree of tumor necrosis and on the amount of blood loss during surgery. We reviewed the medical records of all patients who received intra-arterial chemotherapy and embolization before undergoing limb salvage surgery for osteosarcoma of the lower extremity at our institution between January 2003 and April 2008. Patient demographic, tumor characteristics, treatment details, postembolization complications, and surgical and pathological findings were recorded for each patient. We evaluated the operative time, estimated blood loss (EBL), and volume of blood transfusion during surgery and in the postoperative period in all patients in the study group. The same parameters were recorded for 65 other patients with lower extremity osteosarcoma who underwent limb salvage operation at our institution without undergoing preoperative intervention. The study included 47 patients (25 males and 22 females). Angiography showed that the tumors were hypervascular. Intra-arterial chemotherapy and embolization were performed successfully, resulting in a substantial reduction or complete disappearance of tumor stain in all patients. No major complications were encountered. At the time of surgery, performed 3-7 days after embolization, a fibrous edematous band around the tumor was observed in 43 of the 47 patients, facilitating surgery. The goal of limb salvage was achieved successfully in all cases. Percentage tumor necrosis induced by treatment ranged from 70.2% to 94.2% (average, 82.9%). EBL during surgery, EBL from drains in the postoperative period, total EBL, and transfusion volumes were significantly lower in the 47 study patients compared to the 65 patients who underwent surgery without preoperative treatment with intra-arterial chemotherapy and embolization. The mean operative time was also significantly less in the intervention group compared to the nonintervention group (73.2 vs. 88.5 min; p < 0.05). In conclusion, intra-arterial chemotherapy and embolization performed 3 to 7 days before limb salvage surgery in patients with lower extremity osteosarcomas can cause substantial tumor necrosis, reduce the EBL and transfusion requirements during surgery, and induce formation of a false capsule around the tumor, thus facilitating surgical excision of the tumors.

Reconstructive Arthrodesis using a Non-living Fibular Graft with an Attached Periosteal Sleeve for Osteosarcoma of the Distal Tibia - A Case Report -

According to previous reports, ankle arthrodesis is regarded as the best reconstructive procedure after limb salvage surgery for osteosarcoma of the distal tibia. Of the many arthrodesis options, vascularized fibular graft (VFG) is widely accepted as the most successful method. However, reconstruction using VFG is not always possible, because VFG is a complicated surgical procedure and is associated with high rates of morbidity at donor sites. The authors devised a novel reconstructive surgical procedure that exploits the osteogenic potential of the periosteum. A 10-year-old female patient with osteosarcoma of the distal tibia underwent limb salvage surgery and the ipsilateral distal fibula and periosteal sleeve were transported to the defect for ankle arthrodesis. The transported fibula and periosteal new bone formation acted as a dual strut bone graft providing better stronger stability than fibula alone transfer. The authors believe the proposed procedure is an easier alternative to the surgically demanding VFG method.

Limb Salvage Surgery for Osteosarcoma: Effective Low-cost Treatment

Limb Salvage Surgery for Osteosarcoma: Effective Low-cost Treatment

Limb salvage surgery for osteosarcoma of extremity

化疗在骨肉瘤治疗中地位的确立,提高了骨肉瘤患者5年生存率,促进了保肢技术的发展,瘤段灭活再植、异体骨、复合人工关节、肿瘤型假体等替代了截肢,但目前还没有一个完美的方案,儿童保肢还面临着巨大的挑战。

Limb salvage surgery for osteosarcoma around the knee in children and adolescent patients

To discuss the reconstruction methods and treatment effects of osteosarcoma around the knee in skeletal immature children and adolescent patients. Between October 1996 and December 2005, 89 children and adolescent patients with osteosarcoma around the knee received limb salvage surgery. The average age was 13 years old. Tumor involved distal femur in 52 cases, proximal tibia in 36 cases, and both parts in one patient. Different limb salvage methods, including tumor recycle bone reimplantation (n = 20), partial endoprosthesis (n = 19) and total knee megaprosthesis replacement (n = 50) were chosen according to both the age of the patient and the skeletal. Expandable and special designed pediatric prosthesis some times might also be considered. After average follow up of 42 months, 4 cases of local recurrence and 11 of metastasis occurred in tumor recycle bone group; 1 case of local recurrence and 4 of metastasis in partial endoprosthesis group; another 4 cases of local recurrence and 9 patients died of disease in total knee megaprosthesis group. The five-year survival rate was 47.1%, 71.7% and 68.2% in 3 groups respectively. There were 3 deep infections in all the cases, 2 subluxations and 1 amputation after operation for limb ischemia in partial endoprosthesis group. The average functional score of MSTS 93 was 21.43 point, 23.40 point and 25.32 point; and the average leg length discrepancy was 5.48, 4.50 and 3.12 cm in 3 groups respectively. Partial-joint prosthesis or other methods which can avoid injury of the opposite epiphysis should be used to decrease the possibility of limb length discrepancy and ease the following revised arthroplasty. For patient with almost mature skeletal, total knee megaprosthesis may be a proper choice for better function result.

Improved Survival Associated With Postoperative Wound Infection in Dogs Treated With Limb-Salvage Surgery for Osteosarcoma

Limb-salvage surgery and adjuvant chemotherapy are performed as a treatment of appendicular osteosarcoma in dogs. Approximately 50% of dogs that undergo limb-salvage surgery develop postoperative surgical wound infections. Postoperative surgical infections may affect survival in cancer patients. The purposes of this study were to examine the effect of surgical wound infection on survival, local recurrence, and metastasis in relation to other prognostic factors for dogs with spontaneous osteosarcoma treated with limb-salvage surgery. Forty-seven client-owned dogs with osteosarcoma of the distal radius were treated with limb-salvage surgery and adjuvant chemotherapy--either carboplatin or carboplatin and doxorubicin. Hazard ratios were estimated by using the Cox proportional hazard model, and survival functions were estimated by using the Kaplan-Meier product-limit life-table method. Of the 47 dogs in this study, 32 (68%) developed a postoperative wound infection. Infection, dog weight, and extent of the primary tumor (percentage of length) significantly affected survival, and infection and percentage of length significantly affected time to metastasis. None of the variables considered in this study affected local recurrence. Dogs that were diagnosed with an infection were less likely to die (hazard ratio, .446), and dogs with greater body weight and greater percentage length involvement were more likely to die (hazard ratios of 3.37 and 3.66, respectively). In dogs with osteosarcoma treated with limb-salvage surgery, infection has a positive influence on survival, as does a smaller initial length of radius involved and lower body weight.

Treatment of shortening of the lower limb after the limb salvage surgery for osteosarcoma

Treatment of shortening of the lower limb after the limb salvage surgery for osteosarcoma

Marginal Excision for Osteosarcoma With Caffeine Assisted Chemotherapy

The authors report on intentional marginal excision for osteosarcoma in conjunction with caffeine assisted chemotherapy for the purpose of preservation of good limb function. Twenty-seven patients with osteosarcoma (22 patients with Stage IIB and five with Stage IIIB) preoperatively were given three-to-five courses of intraarterial cisplatin and caffeine without or with doxorubicin. For 26 (96%) responders to the chemotherapy, limb salvage surgery was conducted by means of an intentional marginal procedure, which led to the preservation of important structures such as major neurovascular bundles, tendons, ligaments, muscles, and the epiphysis. Tumors were located in the distal femur in 11 patients, the proximal tibia in eight, the proximal fibula in four, the proximal humerus in two, and the proximal femur in one patient. The histologic response of these 26 patients to the preoperative chemotherapy showed no viable cells in 19 patients with Stage IIB osteosarcoma and only scattered foci of viable cells in two patients with Stage IIB and five patients with Stage IIIB osteosarcoma. As for reconstruction, distraction osteogenesis was performed in eight patients, allograft or autoclaved bone and prosthesis composite in four, autoclaved bone in two, osteochondral allograft in two, megaprosthesis in six, and resection alone in four patients. The average functional evaluation of the 26 patients was 91% of normal. Local tumor recurrence was seen in one patient, whereas 18 patients with Stage IIB osteosarcoma remain diseasefree with a mean followup of 61 months. Two patients with Stage IIB osteosarcoma and four patients with osteosarcoma Stage IIIB died of the disease. Intentional marginal excision for osteosarcoma in conjunction with caffeine assisted chemotherapy is advantageous because it results in the preservation of healthy important structures, with joint preservation possible in selected cases. This approach should help to improve the success rate of limb salvage surgery for osteosarcoma and to preserve the function of the affected limb.