Principles of Tumour Surgery



Tumour removal to gain local control and minimize recurrence while maintaining functional limb 




1.  Intralesional


Within lesion

- macroscopic tumour remains


2.  Marginal


Within reactive zone

- microscopic tumour remains


3.  Wide 


Intra-compartmental and outside of reactive zone

- remove tumour and cuff of normal tissue


4.  Radical



- removal of all compartments that contain tumour

- at least two compartments

- limb salvage possible with radical resection

- however, amputation may be only practical method


Limb Salvage




Must have same survival rates

Must not delay adjuvant treatment

Reconstruction should be enduring with minimal complications

Function should approach that achieved by amputation


Absolute and Relative Contraindications



- Pathological fracture

- Infection

- NV bundle involvement

- LLD > 8 cm

- Extensive muscle loss

- Good v poor biopsy




1.  Can't obtain wide margins

2.  Major NV bundle involvement

3.  Infection




1.  Pathological fracture

- hematoma spreads tumour beyond accurately defined limits

- may necessitate amputation


2.  Inappropriate previous biopsy

- contamination of other compartment


3.  Significant skeletal immaturity

- predicted LLD > 8cm

- adjustable / growing joint replacements available


4.  Extensive muscle involvement

- resection leaves leg non functional


5.  Medically unfit


Technique principles


Radical or wide resection

- extra-articular resection is preferred if a tumour is adjacent to or involves a joint

- prophylactic antibiotics

- no tourniquet if possible

- biopsy site excised

- tumour and/or pseudocapsule not visualised during procedure.

- distant flaps should not be developed until the tumour has been removed

- all dead space should be eliminated and hematoma formation should be prevented

- surgical wound marked with clips for later radiotherapy

- regional muscle transfer

- adequate soft tissue coverage


Reconstruction Options


Modular Endoprosthesis

Allograft reconstruction

Autograft reconstruction


Modular Endoprosthesis 


Proximal Femoral Replacement




Early weight bear and rehabilitation

No risk of non union like allograft


Massive Allograft 


Massive Femoral Allograft0002Massive Femoral Allograft0001



- biological reconstruction

- intercalary

- osteochondral



- incorporation is a slow and incomplete process

- risk of nonunion / fracture


Autograft / Vascularised fibula graft


Advantage over allografts

- more rapid incorporation

- stronger initial construct secondary to graft hypertrophy



- increased surgical time

- surgical site morbidity

- size limitations

- stress fractures




Rosenberg et al, Ann Surg 1982

- Landmark article

- 43 sarcomas randomised to amputation vs salvage

- Salvage had more recurrence, but 5y disease-free and overall survival the same