Clinical Orthopaedics and Related Research®

, Volume 471, Issue 3, pp 762–773

Joint-preserving Tumor Resection and Reconstruction Using Image-guided Computer Navigation

Symposium: Papers Presented at the 2011 ISOLS Meeting in Beijing, China



Joint-preserving surgery is performed in select patients with bone sarcomas of extremities and allows patients to retain the native joint with better joint function. However, recurrences may relate to achieving adequate margins and there is frequently little room for error in tumors close to the joint surface. Further, the tumor margin on preoperative CT and/or MR images is difficult to transpose to the actual extent of tumor in the bone in the operating room.


We therefore determined whether joint-preserving tumor surgery could be performed accurately under image-guided computer navigation and determined local recurrences, function, and complications.


We retrospectively studied eight patients with bone sarcoma of extremities treated surgically by navigation with fused CT-MR images. We assessed the accuracy of resection in six patients by comparing the cross sections at the resection plane with complementary prosthesis templates. Mean age was 17 years (range, 6–46 years). Minimum followup was 25 months (mean, 41 months; range, 25–60 months).


The achieved resection was accurate, with a difference of 2 mm or less in any dimension compared to that planned in patients with custom prostheses. We noted no local recurrence at latest followup. The mean Musculoskeletal Tumor Society score was 29 (range, 28–30). There were no complications related to navigation planning and procedures. There was no failure of fixation at the remaining epiphysis.


In selected patients, the computer-assisted approach facilitates precise planning and execution of joint-preserving tumor resection and reconstruction. Further followup assessment in a larger study population is required in these patients.

Level of Evidence

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Supplementary material

Supplementary material 1 (MPG 34935 kb)

Supplementary material 2 (MPG 4491 kb)


  1. 1.
    Agarwal M, Puri A, Anchan C, Shah M, Jambhekar N. Hemicortical excision for low-grade selected surface sarcomas of bone. Clin Orthop Relat Res. 2007;459:161–166.PubMedCrossRefGoogle Scholar
  2. 2.
    Agarwal M, Puri A, Gulia A, Reddy K. Joint-sparing or physeal-sparing diaphyseal resections: the challenge of holding small fragments. Clin Orthop Relat Res. 2010;468:2924–2932.PubMedCrossRefGoogle Scholar
  3. 3.
    Avedian RS, Haydon RC, Peabody TD. Multiplanar osteotomy with limited wide margins: a tissue preserving surgical technique for high-grade bone sarcomas. Clin Orthop Relat Res. 2010;468:2754–2764.PubMedCrossRefGoogle Scholar
  4. 4.
    Cho HS, Oh JH, Han I, Kim HS. Joint-preserving limb salvage surgery under navigation guidance. J Surg Oncol. 2009;100:227–232.PubMedCrossRefGoogle Scholar
  5. 5.
    Deijkers RL, Bloem RM, Hogendoorn PC, Verlaan JJ, Kroon HM, Taminiau AH. Hemicortical allograft reconstruction after resection of low-grade malignant bone tumours. J Bone Joint Surg Br. 2002;84:1009–1014.PubMedCrossRefGoogle Scholar
  6. 6.
    Deijkers RL, Bloem RM, Kroon HM, Van Lent JB, Brand R, Taminiau AH. Epidiaphyseal versus other intercalary allografts for tumors of the lower limb. Clin Orthop Relat Res. 2005;439:151–160.PubMedCrossRefGoogle Scholar
  7. 7.
    Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res. 1993;286:241–246.PubMedGoogle Scholar
  8. 8.
    Gillespy T, Manfrini M, Ruggieri P, Spanier SS, Pettersson H, Springfield DS. Staging of intraosseous extent of osteosarcoma: correlation of preoperative CT and MR imaging with pathologic macroslides. Radiology. 1988;167:765–767.PubMedGoogle Scholar
  9. 9.
    Gupta A, Pollock R, Cannon SR, Briggs TW, Skinner J, Blunn G. A knee-sparing distal femoral endoprosthesis using hydroxyapatite-coated extracortical plates: preliminary results. J Bone Joint Surg Br. 2006;88:1367–1372.PubMedCrossRefGoogle Scholar
  10. 10.
    Kumta SM, Chow TC, Griffith J, Li CK, Kew J, Leung PC. Classifying the location of osteosarcoma with reference to the epiphyseal plate helps determine the optimal skeletal resection in limb salvage procedures. Arch Orthop Trauma Surg. 1999;119:327–331.PubMedCrossRefGoogle Scholar
  11. 11.
    Muscolo DL, Ayerza MA, Aponte-Tinao LA, Ranalletta M. Partial epiphyseal preservation and intercalary allograft reconstruction in high-grade metaphyseal osteosarcoma of the knee. J Bone Joint Surg Am. 2005; 87(suppl 1 pt 2):226–236.PubMedGoogle Scholar
  12. 12.
    Picci P, Sangiorgi L, Rougraff BT, Neff JR, Casadei R, Campanacci M. Relationship of chemotherapy-induced necrosis and surgical margins to local recurrence in osteosarcoma. J Clin Oncol. 1994;12:2699–2705.PubMedGoogle Scholar
  13. 13.
    Scapinelli R. Vascular anatomy of the human cruciate ligaments and surrounding structures. Clin Anat. 1997;10:151–162.PubMedCrossRefGoogle Scholar
  14. 14.
    So TY, Lam YL, Mak KL. Computer-assisted navigation in bone tumor surgery: seamless workflow model and evolution of technique. Clin Orthop Relat Res. 2010;468:2985–2991.PubMedCrossRefGoogle Scholar
  15. 15.
    Tsuchiya H, Abdel-Wanis ME, Sakurakichi K, Yamashiro T, Tomita K. Osteosarcoma around the knee: intraepiphyseal excision and biological reconstruction with distraction osteogenesis. J Bone Joint Surg Br. 2002;84:1162–1166.PubMedCrossRefGoogle Scholar
  16. 16.
    Wong KC, Kumta SM, Antonio GE, Tse LF. Image fusion for computer-assisted bone tumor surgery. Clin Orthop Relat Res. 2008;466:2533–2541.PubMedCrossRefGoogle Scholar
  17. 17.
    Wong KC, Kumta SM, Chiu KH, Antonio GE, Unwin P, Leung KS. Precision tumour resection and reconstruction using image-guided computer navigation. J Bone Joint Surg Br. 2007;89:943–947.PubMedCrossRefGoogle Scholar
  18. 18.
    Wong KC, Kumta SM, Chiu KH, Cheung KW, Leung KS, Unwin P, Wong MC. Computer assisted pelvic tumor resection and reconstruction with a custom-made prosthesis using an innovative adaptation and its validation. Comput Aided Surg. 2007;12:225–232.PubMedGoogle Scholar
  19. 19.
    Wong KC, Kumta SM, Leung KS, Ng KW, Ng EW, Lee KS. Integration of CAD/CAM planning into computer assisted orthopaedic surgery. Comput Aided Surg. 2010;15:65–74.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2012

Authors and Affiliations

  1. 1.Department of Orthopaedics and Traumatology, Prince of Wales HospitalThe Chinese University of Hong KongShatinHong Kong

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