T. Yamamuro (Ed.)

New Developments for Limb Salvage in Musculoskeletal Tumors K yocera Orthopaedic Symposium

With 277 Figures

Springer-Verlag Tokyo Berlin Heidelberg New York London Paris

TAKAO YAMAMURO, M.D., D.M.Sc.

Professor and Chairman Department of Orthopaedic Surgery Faculty of Medicine Kyoto University Kyoto, 606 Japan

ISBN-13: 978-4-431-68074-1

DOl: lO.1 007/978-4-431-68072-7

e-ISBN-13: 978-4-431-68072-7

Library of Congress Cataloging-in-Publication Data New developments for limb salvage in musculoskeletal tumors. Papers presented at a symposium held in Kyoto in Oct. 1987. Includes bibliographies and indexes. 1. Limb salvage - Congresses. 2. Musculoskeletal system - Tumors - Treatment - Congresses. I. Yamamuro, T. (Takao), 1931- . [DNLM: 1. Bone Neoplasms-therapy-con­gresses. 2. Extremities - surgery - congresses. 3. Prosthesis - congresses. 4. Soft Tissue Neoplasms - therapy - congresses. WE 258 N532 1987] RD674.N49 1989 616.99'471059 89-5894

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© Springer-Verlag Tokyo 1989

Softcover reprint of the hardcover 1 st edition 1989

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Preface

Introduction of new diagnostic methods including various imaging techniques in the field of orthopaedic surgery has enabled us to make early and precise diagnoses of musculoskeletal tumors. In addition, recent progress in the chemotherapy and radiotherapy of malignant tumors has raised the five-year survival rate remarkably, although complete recovery from these treatments alone cannot be expected as yet. These medical advances naturally stimulate the search for ways of limb salvage even in malignant musculoskeletal oncology. To this pur­pose, not only oncologists, but orthopaedic surgeons, radiologists, engineers, and biomaterials scientists should work together to design suitable surgical procedures and prostheses using autograft, allograft and biomaterials.

The First International Workshop on the Design and Application of Tumor Prostheses for Bone and Joint Reconstruction was held in 1981 in Rochester, Minnesota. Participants were of an interdisciplinary nature in order to establish a basis for cooperative efforts, which have subsequently spread throughout the world. Since then, biennial inter­national symposia have been held successively in Vienna, Florida, and Kyoto. Previous gatherings of this prestigious series were open only to a small number of experts. However, since recent rapid progress in biomaterials, biomechanics, chemotherapy, radiotherapy, oncology, and surgical technique has brought about a substantial increase in the number of researchers involved in limb salvage, the Kyoto Symposium held in October, 1987, accepted some 300 participants with the expec­tation of young researchers exposed to highly advanced, intensive, and interdisciplinary fields being able to exchange opinions with experts on limb salvage. As a result, nearly 100 papers covering ten different topics were presented at the Kyoto Symposium. In addition to the functional evaluation of limb-saving operations performed earlier, many new approaches to limb salvage were discussed intensively.

This book records the new developments made after the Florida Symposium in the search for ways of complete limb salvage in mus­culoskeletal oncology. It is our hope that it will provide readers with useful ideas in planning surgery for limb salvage and that it wilJ stimu­late research on this difficult subject.

VI Preface

I wish to express my thanks to the contributors, who submitted their manuscripts in time. I am also grateful to the following members of the Planning Committee of the 4th International Symposium on Mus­culoskeletal Oncology for their tremendous help in making the Kyoto Symposium so successful: Dr. M. Campanacci, Dr. E.Y.S. Chao, Dr. R. Kotz, Dr. F. Langlais, Dr. U. Nilsonne, Dr. D.J. Pritchard, Dr. D. Springfield, Dr. S. Toriyama, and Dr. H.G. Willert. Finally, on behalf of the contributing authors, I would like to express our sincere gratitude to Kyocera Corporation, which sponsored this book for pub­lication by Springer-Verlag Tokyo.

Kyoto, January 1989 T AKAO Y AMAMURO

Table of Contents

Chapter 1: Functional Evaluation of Reconstruction After Tumor Resection

Kinesiological Measurements in Patients with Various Limb Salvage or Amputation Procedures for Tumor Removal J.e. OTIS, J.M. LANE, M.A. KROLL, S.1. BACKUS, J.H. HEALEY ............................... 3

Gait Analysis in Patients with Osteosarcoma Treated by Limb Salvage Procedures: Compared with Those Treated by Amputation R. SUZUKI, T. HIRANO, M. FUJITA, N. MATSUSAKA 9

Limb Salvage in Malignant Pelvic Tumors: A Follow-up Study M.1. O'CONNOR, F.H. SIM .. . . . . . . . . . . . . . . . . . . . .. 17

Functional Evaluation of Limb Salvage Operation for Malignant Bone and Soft Tissue Tumors Using the Evaluation System of the Musculoskeletal Tumor Society K. AMINO, N. KAWAGUCHI, S. MATSUMOTO, J. MANABE, K. FURUYA, Y. ISOBE .......................... 27

Functional Results of Rotationplasty: Analysis and Commentary of the Enneking Evaluation System K. KNAHR, J. SEKERA, M. SALZER ................. 31

Modular Kotz Prosthesis: The Rizzoli Experience R. CAPANNA, e. LEONESSA, G. BETIELLI, B. BORGHI, R. DE CRISTOFARO, e. MARTELLI, P. RUGGIERI, M. CAMPANACCI ............................. 37

Functional Evaluation of Musculoskeletal Sarcomas by Hokkaido Orthopedic Oncology Group T. YAGI, T. MATSUNO, S. ISHII, M. USUI, T. SASAKI, S. YAMAWAKI, K. Isu . . . . . . . . . . . . . . . . . . . . . . . . .. 45

vm Table of Contents

Functional Evaluation of Reconstructed Extremities in Patients with Osteosarcoma After Limb Salvage Surgery N. TAKADA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 49

Overall Results and Functional Evaluation of Limb Salvage for Osteosarcoma: Assessment and Proposed Reorganization of Functional Evaluation System K. TOMITA, Y. AOTAKE, M. SUGIHARA, H. TSUCHIYA . . .. 53

Chapter 2: Influence of Limb Salvage on the Rate of Long Term Survival in Malignant Tumors

A Multi-Institutional Cooperative Study of Osteosarcoma: Partial Report with Emphasis on Survival After Limb Salvage J.e. IVINS, W.F. TAYLOR, H. GOLENZER ............. 61

Limb Salvage for Osteosarcoma M.A. SIMON ................................ 71

Limb Salvage Versus Amputation for Malignant Tumors Other Than Osteogenic Sarcoma J.J. ECKARDT, F.R. EILBER, G. ROSEN, M.H. KODY, J.M. MIRRA, F.J. DOREY ....................... 73

Surgical Margins Influencing Oncological Results in Osteosarcoma R. KOTZ, K. WINKLER, M. SALZER-KuNTSCHIK,

F. GOTTSAUNER-WOLF,W. KICKINGER, e. SCHILLER,

P. RITSCHL, U. HEISE, S. TORGGLER ............... 83

A Cooperative Study on Limb Salvage Treatment for Osteosarcoma K. FURUSE, S. MASUDA, S. YAMAWAKI, A. TATEISHI, Y. BEPPU, N. KAWAGUCHI ...................... 93

Long-Term Results of Limb Salvage and Amputation in Extremity Osteosarcoma: DFCIrrCH Results in Patients Receiving Postoperative Weekly High-Dose Methotrexate and Doxorubicin M.C. GEBHARDT, A.M. GOORIN, J. TRAINA, A. PEREZ-ATAYDE, J.W. ANDERSON, H.G. WATTS,

N. JAFFE .................................. 99

Surgical Management of Osteosarcoma in Extremities: Survival Between Limb Salvage and Amputation T. UEDA, A. UCHIDA, H. YOSHIKAWA, H. HAMADA,

H. HAYASHI, Y. AOKI, K. ONO ................... 111

Table of Contents IX

A Comparative Study of Amputation and Limb Salvage for Musculoskeletal Sarcoma: The EUSM Experience Before and After the Adoption of the Surgical Staging System T. SHIBATA, M. SASAKI, H. KUSHIBE, K. KOMI, M. NOJIMA . 115

European Osteosarcoma Intergroup: An Interim Analysis of Surgical Data J.W. VAN DER EUKEN ......................... 121

Extremity Soft Tissue Sarcomas Treated with Limb Salvage Surgery and Amputation: A Comparison of Survival O. BERLIN, B. STENER, L. ANGERVALL, L.-G. KINDBLOM, A. ODEN, B. GUNTERBERG ..................... 127

Chapter 3: Limiting Factors for Limb Salvage Operation

The Impact of MRI on Staging Malignant Musculoskeletal Tumors: A Prospective Study of 65 Patients A.H.M. TAMINIAU, J.L. BLOEM .................. 133

Limiting Factors of Limb Salvage Operation for Musculoskeletal Sarcoma N. KAWAGUCHI, K. AMINO, S. MATSUMOTO, J. MANABE, K. PuRUY A, Y. ISOBE ......................... 137

Results of Multidisciplinary Limb Salvage in 272 Consecutive Sarcomas: Is Amputation Still Indicated in 1987? G. DELEPINE, N. DELEPINE, C. JASMIN,

L. SCHWARZENBERG, G. MATHE, M. RICCI ......... 143

Role of Vascular Resection and Reconstruction in Rotationplasty A.H.M. TAMINIAU, J.W. VAN DER EUKEN, J.H. VAN BOCKEL, M.R. SOBOTKA, W.R. OBERMANN, W.K. TACONIS .............................. 149

Rotationplasty for Malignant Tumors of the Femur and Tibia W. WINKELMANN ............................ 153

Chapter 4: Rationales of Adjuvant Therapies for Limb Salvage

Local Hyperthermia Reinforced by Thermotherapy As an Adjuvant Therapy for Limb Salvage: An Experimental Study Y. OGIHARA, Y. TACHI, T. NARITANI .............. 161

Limb Salvage Treatment for Osteosarcoma Based on Clinicopathological Studies of Preoperative Chemotherapy K. FURUSE, K. YAMAMOTO ..................... 169

x Table of Contents

Results of Combination Treatment of Osteogenic Sarcoma Patients N.N. TRAPEZNIKOV, L.A. YEREMINA, A.T. AMIRASLANOV, P.A. SINUKOV .............................. 175

Neoadjuvant Chemotherapy for Osteosarcoma: Results in 126 Consecutive Patients P. PICCI, G. BACCI, R. CAPANNA, E. MADON, G. PAOLUCCI, M. AVELLA, N. BALDINI, M. MERCURI, M. CAMPANACCI ............................. 183

The Effects of Preoperative Cis-Platinum (COOP) Therapy for the Purpose of Limb Salvage of Osteosarcoma Evaluated by Multifactor Evaluation Method: Japanese Intergroup Study of Osteosarcoma A. TATEISHI, H. MIKI, S. TAKEYAMA, S. ISHII, S. YAMAWAKI, T. YAGI, H. KAKIZAKI, M. CHIGIRA, N. TAKADA, F. ENDO, H. KAWANO, S. OSAKA, S. HIGAKI, Y. HAMADA, S. TAKEUCHI, K. TOMITA, H. MATSUI, K. SHINJO, H. OAISAKU, O. INOUE ......... -....... 189

The Influence of Intra-Arterial Chemotherapy on Local Control of Bone Sarcoma W.W. MARSDEN, F.O. STEPHENS, M.H.N. TATIERSALL, S.W. MCCARTHY, R. WAUGH .................... 193

Osteosarcoma in Children: Preoperative Chemotherapy with Intra-Arterial Cis-Oiamminedichloroplatinum-II (COP) Followed by Tumor Resection, Biological Reconstruction and Postoperative Adjuvant Chemotherapy N. JAFFE, J. MURRAY, K. SASAKI, H. CARRASCO, S. WALLACE, A.K. RAYMOND, A. AYALA ............ 199

Neoadjuvant Chemotherapy by Intra-Arterial Infusion for Osteosarcoma H. KAWANO, S. TORIYAMA ...................... 207

Clinical Experience with Preoperative Continuous Intra-Arterial Chemotherapy As Part of a Combined Modality Treatment for Osteosarcoma of the Extremities S. TAKEUCHI, A.C.W. WONG, C. KASAl, Y. KUSHIDA, M. SATOH, Y. NISHIMOTO, Y. AKAHOSHI ............ 211

A Monoclonal Antibody Against a Subgroup of Malignant Round Cell Tumors: Cytochemical, Immunological Findings and Chromosomal Analysis E.J. FELLINGER, G. HAMILTON, I. SCHRATIER, P.F. AMBROS, P. RITSCHL, R. KOTZ, M. SALZER-KuNTSCHIK . . . . . . . . . . . . . . . . . . . . . . . .. 219

Table of Contents

Chapter 5: Biomaterial and Biomechanical Evaluation of Tumor Prostheses

Histomorphological Evaluation of the Diaphyseal Anchorage in KMFTR-Type Tumor Prostheses F. GOTISAUNER-WOLF, H. PLENK,JR., K. KNAHR,

XI

R. KOTZ ................................... 227

The HSS Modular Linked System for Segmental Replacement J.e. OTIS, A.H. BURSTEIN, J.M. LANE, T.M. WRIGHT, R.W. KLEIN ................................ 233

Biological and Biomechanical Justification of Porous-Coated Modular Segmental Bone/Joint Prostheses E.Y.S. CHAO, F.H. SIM ........................ 237

Porous-Coated Segmental Prosthesis for Large Tumor Defects: A Prosthesis Based upon Immediate Fixation (PMMA) and Extracortical Bone Fixation M.M. MALAWER, D. CANFIELD, I. MELLER ........... 247

The Use of Extracortical Implant Fixation to Reconstruct Large Bony Defects B.W. WIPPERMANN, F.H. SIM, D.J. PRITCHARD,

T.C. SHIVES, E.y'S. CHAO ...................... 257

Experience in the Use of a Custom Modular Titanium Intramedullary Rod in Resection/Arthrodesis of the Knee J.R. NEFF .................................. 263

Demineralized Bone Powder: Use in Bone Tumor Surgery R.M. WILKINS ............................... 271

Thermal Aspects of the Use of Polymethylmethacrylate in Large Metaphyseal Defects in Bone: A Clinical Review and Laboratory Study M.e. LEESON, S.B. LIPPITI, J.T. MAKLEY ............ 277

The Use of Methylmethacrylate As a Hyperthermia Agent for the Treatment of Giant Cell Tumors: Experience of 78 Cases in a Long-Term Appraisal (1974-1987) O.P. DE CAMARGO ........................... 289

Chapter 6: The Use of Ceramic Prostheses for Replacement of Bone Tumors

Long-Term Results with Ceramic Tumor Prostheses K. KNAHR, M. SALZER, H. PLENK, JR., M. BOHLER. . . . .. 295

XII Table of Contents

New Technique for Providing Ligamentous Stability in Prosthetic Replacement of the Knee for Tumors Y. YANASE, S. TANAKA, M. TOMIHARA, S. SOEN,

H. YAMASAKI ............................... 305

Results of Alumina-Ceramic Endoprostheses Used for Bone Tumor Cases S. MATSUMOTO, N. KAWAGUCHI, K. AMINO, J. MANABE,

K. FURUYA, Y. ISOBE ................ . . . . . . . . .. 309

Results of Replacement with Ceramic Prostheses for Bone Tumors H. HAYASHI, Y. AOKI, Y. KOMATSUBARA ............ 313

Clinical Application of Ceramics in Bone Tumors A. UCHIDA, H. YOSHIKAWA, Y. AOKI, H. HAMADA,

E. KURISAKI, K. ONO .......................... 321

Intraoperative Radiotherapy and Ceramic Prosthesis Replacement for Osteosarcoma T. YAMAMURO,Y. KOTOURA,K. KASAHARA,

M. TAKAHASHI, M. ABE ........................ 327

Moderator's Comment T.YAMAMURO .............................. 335

Chapter 7: Prosthesis vs. Osteochondral Graft, Alternative Substitute for Bone Tumor

A Comparison of Vascularized and Conventional Bone Grafts for Bridging Large Bone Defects K.L.B. BROWN, 1.F. WELTER .................... 339

Vascularized Bone Graft for Limb Salvage Surgery of Malignant Bone Tumor K. TOMITA, K. IKEDA, H. TSUCHIYA, S. NOMURA . . . . . .. 347

Limb Saving Surgery Without Endoprosthesis on Malignant Bone Tumors O. INOUE, K. IBARAKI, H. NORIMATSU, M. KAYO,

M. TAKEUCHI, A. ARAKAKI ..................... 353

Chondrocyte Viability and Cryopreservation of Frozen Osteochondral Allografts M.G. ROCK ................................ 359

Limb Salvage and Massive Segmental Allograft Replacement for Malignant or Aggressive Bone Tumors After Wide Resection S. MASUDA, Y. SUGIOKA, M. USHIJIMA, N. SHINOHARA ., 369

Table of Contents xm

Megaprosthesis-Massive Osteochondral Allograft D. POITOUT ................................ 377

The Use of Proximal Femoral Allografts in the Treatment of Bone Tumors M.H. JOFE, M.e. GEBHARDT, H.J. MANKIN . . . . . . . . . .. 387

Titanium Long-Stem Prosthesis Combined with Bone Allografts in Reconstructive Surgery of High-Grade Bone Sarcomas G. DELEPINE, N. DELEPINE ...................... 395

Chapter 8: Reconstruction After Resection of Large Bone Tumors About the Hip and Pelvis

Long-Term Performance of Custom Prosthetic Replacement for Neoplastic Disease of the Proximal Femur K.-S. KHONG, E.Y.S. CHAO, F.H. SIM .............. 403

Total Massive Hip Prosthesis for Tumors of Upper Femur: Analysis of Twenty Cases J.P. COURPIED, B. TOMENO . . . . . . . . . . . . . . . . . . . . .. 413

Resection of Tumors of the Pelvis and Proximal Femur: Evaluation of Survival, Local Recurrence and Function R.P.H. VETH, H.K.L. NIELSEN, J. OLDHOFF, H. SCHRAFFORDT Koops, D. MEHTA, L. POSTMA, L.N.H. GOEKEN, J.W. OOSTERHUIS, B. VERKERKE ...... 419

Reconstruction After Resection of Bone Tumors About the Hip G. ZAFIROSKI, B. MISEV, P. GEORGIEV, I. STEFANOSKA, G. ZOGRAFSKI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 425

Bone Reconstruction Using Vascularised Bone Grafts: A 7-Year Review P.-e. LEUNG ................................ 431

The Use of Bateman Bipolar Proximal Femoral Replacement in the Management of Proximal Femoral Metastatic Disease M.G. ROCK

Resection and Reconstruction of Peri acetabular Malignant and Aggressive Tumors J.H. HEALEY, J.M. LANE, R.e. MARCOVE, K. DUANE, J.e. OTIS ..................................

Surgical Treatment of Bone Tumors Arising from Pelvic Ring A. UCHIDA, H. HAMADA, H. YOSHIKAWA, Y. AOKI,

437

443

S. EBARA, K. ONO ............................ 451

XIV Table of Contents

Innominate Bone Resection for Tumors with Limb Preservation: A Report of 36 Cases B. TOMENO, A. LANGUEPIN . . . . . . . . . . . . . . . . . . . . .. 459

Results of Treatment After Resection of Large Bone Tumors of the Pelvic Girdle W. WINKELMANN, K.P. SCHULITZ 465

Reconstruction After Resection of Pelvic Bone Tumors T. SAWAGUCHI, K. TOMITA, S. AKAGAWA, S. NOMURA 469

A Custom-Made Adaptable Pelvic Prosthesis R. GRADINGER, E. HIPP ........................ 475

The Saddle Prosthesis Mark II, Endo-Modell® E. NIEDER, A. KELLER ......................... 481

Pelvic and Sacrum Resections: Surgical Procedure and Outcome P. RITSCHL, W. KICKINGER, H. FELDNER-BusZTIN,

R. WINDHAGER, R. KOTZ ....................... 491

Reconstruction of Pelvis and Sacrum After Resection of Bulky Tumors S. INOUE, N. TAKADA, H. KITAHARA ............... 503

Hemipelvis Allograft: Technical Aspects of Three Cases After Tumor Resection F. LANGLAIS, e. VIELPEAU ...................... 507

Chapter 9: Functional Results Following Resection of Tumor in the Proximal Humerus and Tibia

Shoulder Girdle Resections for Bone and Soft Tissue Tumors: Analysis of 38 Patients and Presentation of a Unified Classification System M.M. MALAWER, I. MELLER, W.K. DUNHAM . . . . . . . . .. 519

Functional Results Following Resection of Tumor in the Proximal Humerus: Excluding Arthrodesis and Massive Allografts J.P. COURPIED, B. TOMENO, F. LANGLAIS, B. AUGEREAU,

J.H. AUBRIOT, S. BABIN, D. MOULIEs, B. PECOUT ...... 531

The Role of Limb Salvage Procedures in Patients with Bone Tumors of the Shoulder Girdle A.T. AMIRASLANOV ........................... 537

Proximal Humeral Osteoarticular Allograft Transplantation for Musculoskeletal Tumors of the Shoulder Region M.e. GEBHARDT, Y.F. ROTH, H.l. MANKIN .......... 541

Table of Contents

Limb Salvage Procedures for Primary Sarcomas of the Humerus J.O. JOHNSTON

Modular Endoprosthesis for Humerus and Tikhoff-Linberg Resection R. CAP ANNA , A. GlUNT!, R. BIAGINI, A. FERRUZZI,

A. FERRARO, R. CASADEI, P. PICCI, M. CAMPANACCI

Reconstruction of the Upper Limb by Arthrodesis in Cases of Tumors of the Proximal Humerus: Six Cases of Limb Salvage Procedure of Shoulder Girdle H. KYOGOKU, T. OGINO, A. MINAMI, K. FUKUDA,

T. MATSUNO, M. MINAMI ...................... .

Guidelines to Upper Humerus Resections F. LANGLAIS, J.F. DUBOUSSET, J. DUNOYER, A. TRIFAUD

Functional Results Following Resection Arthrodesis About the Knee E.Y.S. CHAO, F.H. SIM ....................... .

The Use of Proximal Tibial Allografts in the Reconstruction of Tumors and Other Defects

xv

543

547

557

563

567

M.e. GEBHARDT, H.l. MANKIN ................... 573

Operative Methods in Functional Reconstruction of Massive Giant Cell Tumors of the Proximal End of the Tibia N. AKAMATSU ............................... 587

Total Knee Prosthesis After Upper Tibia Resection for Tumors: Report of 42 French Cases G. MISSENARD, B. TOMENO, F. LANGLAIS, J.F. DUBOUSSET,

B. AUGEREAU, E. SCHVINGT, F. BONNEL, P. DENAYER, P. GROULIER, A. TRIFAUD, J. VIDAL ............... 591

Uncemented Hinge Prostheses with Reinsertion of the Ligamentum Patellae R. KOTZ, N. PONGRACZ, E.l. FELLINGER, P. RITSCHL ... 605

Techniques of Limb-Sparing Resection and Extensor Mechanism Reconstruction for High-Grade Malignant Tumors of the Proximal Tibia M. MALAWER, K.A. McHALE .................... 611

Moderator's Comment F. LANGLAIS ................................ 619

XVI Table of Contents

Chapter 10: Innovative Techniques

Cytostatic Bone Cement: Experimental Studies and First Clinical Experience H.-U. LANGENDORFF .......................... 623

The Effect of Bone Cement Containing Methotrexate on the Canine Osteosarcoma: A Preliminary Report L. Hovy, B. TELLHELM, E. DINGELDEIN, H. WAHLIG,

A. ENDERLE ................................ 633

Casted Femur-Knee Endoprosthesis with Spongy Metal Surface and Length Adaption In Situ E.J. HENSSGE, E. HIPP, H. GRUNDEI, T. BIEHL, P. DUFEK,

R. GRADINGER .............................. 643

The Development of a Connection Between the Modules of a Modular Femur Endoprosthesis G.J. VERKERKE, F.M. VAN KRIEKEN, H.K.L. NIELSEN,

J. OLDHOFF, H. SCHRAFFORDT Koops, R.P.H. VETH, A. POSTMA, L.N.H. GOEKEN, H.H. VAN DEN KROONENBERG, H.J. GROOTENBOER .......................... 649

Amputoresection: An Innovative Technique in Limb Salvage Procedure for Malignant Bone Tumors F.S. SANTORI, S. GHERA, M. MANILI, G. MONTICELLI .... 653

Microsurgical Reconstructions Following Wide Resection of Bone and Soft Tissue Sarcomas in the Extremities M. USUI, S. ISHII, T. MATSUYAMA, S. ASANO, S. YAMAWAKI, K. Isu, A. MINAMI ................. 661

Adipose Venolymphatic Transfer for Management of Postradiation Lymphedema R.W.H. PHO, P. BAYON, L. TAN .................. 667

Ceramic Tricalcium Phosphate As a Bone-Graft Substitute for Benign Bone Tumors T.A. LANGE ................................ 675

Autotransfusion with Recovery of Blood Loss in Conservative Surgery for Tumors of Lower Limbs B. BORGHI, S. LARI, R. CAPANNA, M. CAMPANACCI 681

Author Index ................................ 687

Key Word Index .............................. 691