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Prolonged chemotherapy
1%
10/1341
Radiation therapy
0%
3/1341
Chemotherapy followed by en block resection and reconstruction
25%
336/1341
Radiation therapy followed by en block resection and reconstruction
7%
92/1341
Chemotherapy and amputation
66%
889/1341
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This patient had an unplanned biopsy of what ended up being high-grade osteosarcoma. Poor hemostasis intraoperatively led to a hematoma extending into the lower leg and contamination of numerous compartments in the lower leg and foot. Principles of biopsy are crucial in orthopedic oncology, and if done incorrectly, can have devastating results for the patient. Whenever possible, biopsies should be performed at the treatment center rather than a referring institution. Biopsy tracts are considered contaminated with tumor cells and must be resected during definitive treatment in the event of a malignant diagnosis. When performing incisional biopsies, important principles to remember are: (1) longitudinal incisions, (2) use an intramuscular plane to minimize the number of contaminated muscle compartments, (3) do not violate joints, (4) avoid dissection close to nerves/vessels, (5) avoid biopsy through the quadriceps whenever possible, (6) if using a drain bring it out in line with the incision, and (7) meticulous hemostasis must be maintained as an area of hematoma must also be resected in the event of a malignant diagnosis. Large post-biopsy hematomas can contaminate the entire extremity, making limb salvage impossible. Mankin et al. review the hazards of biopsies following bone and soft tissue tumors. They report on 597 patients who underwent biopsy for bone and soft tissue sarcomas, of which, major diagnostic errors occurred in 13.5%, complications in 15.9%, and unnecessary amputation in 3%. They conclude that biopsies should be carefully planned and performed by an orthopedic surgeon with experience in musculoskeletal oncology. Cirstoiu et al. review the current surgical management options for bone extremity sarcomas. They report a paradigm shift away from amputation and towards limb salvage, with the prevalence of amputation of <10% at the majority of cancer centers. They conclude that amputations should be reserved for patients in which limb-salvage is not an option, mainly due to the unresectable nature of the tumor or a significant expected loss of function following resection. Incorrect Answers: Answer 1: High-grade osteosarcoma is typically treated with chemotherapy and limb salvage resection. Answers 2 and 4: Osteosarcoma is radio-resistant and radiation therapy should not be used. Answer 3: The significant contamination of the lower leg and foot secondary to the hematoma makes limb salvage impossible.
4.3
(4)
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