The surgical management of primary osteosarcoma.

Regrettably amputation remains to the present day an essential part of treatment in osteosarcoma of the limb bones. Only by its inclusion in the therapeutic regime can the present best level of about 20 per cent survival be achieved in any large group of patients. Preliminary biopsy is essential and there is no evidence that it is harmful even if followed by a delay of many days before definitive treatment. In patients treated initially by radiotherapy, selective amputation some 6 months later only in patients free of metastases, carries just as good a prognosis for the group as a whole as initial primary amputation in all patients. This method, first described by Cade, is widely practiced in the United Kingdom and spares many patients who develop early metastases following initial radiotherapy from unnecessary mutilating surgery shortly before inevitable death. Local recurrence may follow retention of a femoral stump following amputation for osteosarcoma at the most common site in the lower femoral metaphysis. There are cogent arguments in favor of hip disarticulation in such patients although they do not include evidence of greater survival. The balance between the two procedures is finely drawn but is weighted in favor of disarticulation.