Bone Tumor A tumor may be defined as an abnormal mass in the tissue the growth of which exceed and incoordinated

with surrounding normal tissue and remain in the same excessive manner even after the cessation of stimuli which evoked the change.

Neoplasm It may be defined as the new growth from preexisting tissue which is autonomous and not guided by the principle of natural growth and not serve any useful purpose and having an unknown etiology.

CLASSIFICATION OF BONE TUMOURS (W.H.O. 1972) WHO classification: a. Primary Bone Tumors
1.

Bone forming Tumor: They synthesize Osteoid matrix that becomes mineralized. I. Benign: a. Osteoma b. Osteotastoma c. Perosted ossifying fibroma. II. Malignant: a. osteogenic sarcoma III. Indeterminate: a. Aggressive osteobtastoma. Cartilage forming tumor: a. Benign: 1. Osteochondroma 2. Enchondroma 3. Chondroblastoma 4. Chondromyxoid fibroma b. Malignant: 1. Chondroamasarcoma

2.

3. Giant cell tumor: containing various types of giant cells of unknown origin and may be a. Benign b. Indeterminate c. Malignant 4. Marrow tumors: Arise from bone marrow. a. Malignant: 1. 2. 3. 4. Ewings sarcoma Multiple myeloma Chodoma or leukaemia of bone Histiocytic Lymphoma

5.Vascular tumors of bone: 1. Benign: Haemangioama Glomangioma 6.Other tumors of bone: a. Benign Neurilemmoma Neurofibroma b. Malignant: Malignant fibrous histocytoma Liposarcoma Undifferentiated sarcoma Adamantinoma
3

2. malignant Angiosarcoma

B.

Secondary tumors of bone :

75% bone tumors are secondary. Any bone tumors above the age 40 years are considered a secondary unless prove otherwise. 1. Metastatic: From the tumor of other organ or tissue to bone from bone. From other organs or tissue to bones a. Breast b. Prostate c. Thyroid d. Lung e. Kidney f. Gastrointestinal tract 2. by invasion or inclusion. a. Chordoma: Neoplasm of the embryonic remnants of the notochord persist in the nucleus palposus of intervertreval disc. b. Angioma , angiosarcoma c. Fibroma, fibrosarcoma d. Myosarcoma e. Synovioma

C. Tumor like Lesion of Bone 1. Bone cysts: a. Unicameral bone cyst b. Aneurysmal bone cyst c. Ganglion cyst of bone d. Epidermoid cyst 2. Fibrous lesions of bone: a. Fibrous cortical defect b. Non ossifying fibroma c. Fibrous dysplasia d. osteofibrous dysplasia / ossifying fibroma 3. Reparative giant cell granuloma 4. Eosinopilic granuloma 5. Diffuse osteitis fibrosa cystica.

Biological behavior of bone tumor.

A tumor may remain intracapsular or become extra capsular similarly it may remain within the compartment or may erode or destroy the bone cortex become extra compartmental Advanced trauma or excision may cause in compartmental lesion to spread outside the compartment of origin.

Benign tumors:
Behaviorally they are 3 categories
a.

Inactive benign tumor: (remain static or latent. )

completely

intracapsular Reactive zone minimum. Histologically benign, well differentiated. No hyperchromasia , Anaplasia or pleomorphism Usually asymphtomatic.

b.

Active benign tumor: Remain encapsulated with a fibrous tissue or trabecular ring But continue higher and inner side of the capsule may be irregular and the tumor becomes tabulated. Aggressive benign: Invasive in character

c.

Slowly penetrates the normal tissue with finger like projections.

Reactive zone forms pseudocapular but unable to prevent distribution or penetration into adjacent bone or compartment.

They have high cell to cell matrix ratio clearly differentiated bone matrix. Cytological feature offer symptomatic and cause pathological fracture.

Malignant tumors:
Ability to metastasis at a distal sides and form new foci. Behavior varies widely. Some are characterized by indolent local growth low incidence of metastasis and a protracted interval between primary tumors and metastasis. The other exhibit as aggressive destructive local growth, high indicidence of metastasis, and the primary tumor and metastasis recognize simultaneously. Aggressive behavior usually demonstrated by the Tumors histological activity Degree of cellular differentiation Degree of tissue necrosis.

This histological grade best reflects the biologic activity of tumor and best option for treatment and the ultimate prognosis. Assessment of histological type and grade is tem the key to successful treatment whether surgical or non surgical to alter the course of the disease.

Behaviorally malignant tumor are1.

Low grade sarcoma Slowly growing locally invasive low risk of metastasis. Anaplasia Plemorphism Hyperchromatism Modest number of mitosis Usually remain asymptomatic

2.High grade sarcoma Rapidly growing wide reactive zone but no psudocapsutation uninhibited by natural barriers and rapidly extends into adjacent tissues by destroying anatomical and compartmental barriers. Satellite nodules occur in the reactive tissue and Skip metastasis (Tumor nodules in ostensibly uninvolved areas of some bone) are found well outside the reactive zone usually in medullary canal. Histologic features:

High cell to cell matrix ratio Poor differentiation of immature matrixes Anaplasia Plemorphism Dyperchonmsia High atypical mylosis
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Staging of bone tumors:

TNM system TNM staging system is Tumor,Node & Metastasis staging designed by American Joint Commission on Cancer (AJCC) & adapted by International Union Against Cancer (IUAC) in 1987 for intramedullary tumor. T for Tumor: TX Cannot be assessed T1 Tumor confined with in the cortex. T2-Extend beyond the cortex. N- For lymph node NX- Cant be assessed. N1 Designates presence of metastasis. M for metastasis: MX- Indicates an unknown stratus of metastasis. M0- Indicates the absence of detectable distance metastasis. M1- Designates the presence of distant metastasis.

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Ennekings system was proposed in 1986 & adapted by AJCC & task force of bone tumors. This system may be applied to both bone & soft tissue tumors & based on the assessment of Biological aggressive ness & local extent of the disease based on the compartmentation concept of bone & soft tissue. The biologic & clinical aggressiveness is a combination of histologic grading & specific histologic types. The designation of this parameters G0- Benign lesions G1- Locally aggressive, low potential of metastasis e.g. Giant cell tumor of bone,Perosteal & periosteal osteosarcoma , Grade I & II osteosarcoma. G2- Aggressive with high metastatic potential Conventional osteosarcoma,Ewings sarcoma, Grade III Chondrosarcoma,,Malignant fibrous histocytoma.T1 Tumor involves only one compartment. T2- Tumor extend beyond the cortex, into adjacent soft tissue, joint or another bone.

11

TNM staging for Osseous neoplasm Stage Grade Tumor Node Stage I A Grade T1 N0 Stage Grade T2 N0 Stage Grade T1 N0 Stage Grade T2 N0 Stage Not defined Stage Any Any N1 Tumor Grade Stage Any Any Any Node Tumor Grade Ennekings staging system: Stage Stage Stage Stage Stage Stage Grade G1 Low G1 Low G2 High G2- High Metastasis Site T1 T1 T1 T2

Metastases M0 M0 M0 M0 M0 M1

IA IB II A II B III

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Osteoma Benign tumour forming mature bone; Commonly seen in adults and common sites are Mandible and Paranasal Sinuses. OSTEOID OSTEOMA: Def. A Benign Osteoblastic Lesion that occurs in Adolescents and Young Adults and affects the Long Bones.

Excruciating pain is the obvious Feature.

Etiology: Unknown Incidence: 10% of benign bone tumors. M : F: 2:1 Peak age 5 - 25 years (85% in this range) Rare >40 years Only occurs in bones formed by endochondral ossification Clinical features: Conspicuous pain often worse at night and relieved by aspirin. 10% occur in the spine and may -> scoliosis Other sites may -> joint effusion, LLD, synovitis

13

 Runs a self limiting course but usually -> surgery for pain relief Pain usually decreases as the lesion matures lasting 18 - 30 months Lesion heals by 3 - 7 years

Radiology

Lytic nidus surrounded by sclerotic bone (which may mask the nidus) Tomograms are useful Hot spot on bone scan

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Radiology: Lytic nidus surrounded by sclerotic bone (which may mask the nidus) Tomograms are useful Histopathology: Nidus- composed of vascular fibrous tissue in which there are small, irregular, but connected trabeculae of woven bone, demonstrating both prominent osteoblasts and prominent osteoclasts . Differential Diagnosis: 1. Idiopathic cortical sclerosis. 2. Brodies abscess 3. Benign bone cyst 4. Ch. Osteomyelitis with annular sequestrum Treatment: NSAIDs for pain relieve ( Salicylic acid) Surgical: Nidus excision -> no recurrence (need only intact rim of reactive bone around the nidus to ensure complete excision).

Intraoperative localization

bonescan,Tetracycline, CT
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 Percutaneous radiofrequency coagulation OSTEOSARCOMA The presence of malignant cells producing osteoid or bone osteosarcoma. identifies a neoplasia as an

Origin: Multipotential mesenchymal tissue.

Histological type:
1.

Osteogenic: osteoid tissue is predominant .

2.Collagenic 3.Chondrogenic.

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Etiological Classification: a. Primary Osteosarcoma (70%) 1. Sclerosing type Abundant formation. 2. Fibromatous type. 3. Chondromatous type. 4. Telangiectatic type or osteolytic type. 5. Periosteal type (arising from outer cortex). 6. Parosteal type (juxtacortical soft tissue). tumor bone

17

b. Secondary Osteosarcoma 1. Pagets disease. 2. Radiation induced. 3. Osteochondroma.

4.

Fibrous dysplasia.

C. On basis of dominant histopathology 1. Osteoblastic or sclerosing Osteosarcoma 2. Chondroblastic 3. Tetangiectatic 4. Fibroblastic

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Etiology Etiology exact unknown; 1. Predisposing factors: a. Age- peak incidence between 10-20 years rare below 10 years. b. Sex- male : female= 2:1 c. Race- white and black same ratio. d. Anatomical site 90% occurs in metaphysis of long bone. Deceasing order of frequency Lower end of femur upper end of tibia Upper end of humerus upper end of femur pelvis 2. Exciting factors: a. Virus * RNA virus: eg Meloney mouse sarcoma virus * DNA virus- eg polyoma virus b. Radiation: o Localized irradiation above 2000 rads can produce osteosarcoma o Radio nucleotide that localized in bone can produce tumor. c. Chemicals: 20- methylrcholanthrene Beryllium compounds.
19

20

CLINICAL PICTURE:
1. Age- Common second decade. 2. Location 3. Sex 4. Onset-- Metaphyseal region of long bones. -- More in males. Gradual & Spontaneous.

5. Symptoms -- Pain -- Swelling 6. Signs -- Tenderness - Consistency soft to hard. Lab findings : Hb% ESR Serum Alkaline phosphatase . Radiological finding: 1. Both osteoblastic & osteolytic lesion. 2. Destructive changes are represented by a) Irregular, poorly defined areas of radiolucency. b) Inner margin of cortex is eroded giving Moth-eaten appearance. 3. Sun-ray appearance.

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4. Codmans triangle due to reactive sub periosteal new bone formation.

Common variants are: Osteoblastic Osteolytic Telengiectatic Fibroblastic and Anaplastic types

Osteosarcoma - Histopathology
Parosteal Osteosarcoma A rare osteosarcoma arising from the external surface of bone. It has better prognosis than the usual osteosarcoma. Telangiectatic Osteosarcoma Pathology Irregularly distributed Gross appearance: 90% situated in the metaphysis Pleomorphic cells with 2 or pleomorphic malignant tumour knee tumor isMitotic figures of long bone and 70% of more nuclei. conventional cells with islands In osteoid of the metaphyseal region it appears as or medullary. and osteiod seen tissue tumor with destruction of inner cortex as it a large extends into subperiosteal space. Macroscopically Fibrous osteosarcoma- white Osseous - yellowish white Cortilanous bluish white
22

Periosteum act as a barrier and lifted away from the parent bone as the tumor tissue accumulate large amount within subperiosteal space the newly formed neoplastic bone becomes oriented perpendicularly to the surface of the cortex producing characteristic sunray appearance seen in roentgenograme. Reactive subperiosteal bone which is laid down is most pronounced at the proximal and distal osteo periosteal attachment producing codman's angles seen in roentogenous rarely it produce lamellar appearance under periosteum. Periosteum is penetrated as the tumor extends into the surrounding soft tissues. During active growth period when the epiphyseal plate is still intact act as a barrier to extend into epiphysis but after epiphyseal closure tumor reach epiphysis where articular cartilage act as a barrier to enter into the joint. Metastasis is early and haematogenous producing pulmonary deposit or to other bone suggest multi focal origin. Macroscopic appearance: Absolute - diagnostic criteria for osteogenic sarcoma are 1. sarcomatous stroma 2. Direct formation of neoplastic bone . Osteoid bone formed by the malignant connective tissue
23

There fore the tumor which contain neoplastic osteo blastic area are qualified as osteogenic sarcoma. Sometimes malignant cartilage and fibrous tissue present in variable amount even may predominate . But the findings of minute foci of neoplastic osteoid and bone directly formed the anaplastic cellular stroma categories the tumor as an osteosarcoma The stromal cells are large resemble osteoblast and their malignant characteristics include. b. Anisocytosis( Variable size) c. Poikilocytosis ( Variable shape) d. Nuclear pyknosis e. Pleomorphism f. Polyhadral contours tending toward a spindle shape g. Frequent mitosis Central portion of the tumor is sclerotic with neoplastic bone. As the anaplastic cells become enclosed in new bone , they become smaller rounded and unsuitable for diagnosis. So the peripheral zones are most satisfactory for diagnosis.

Sclerosing osteosarcoma Grayish white tumor central portion continue neoplastic bone, peripheral part contain cell and stroma so consistency soft.

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Develop in metaphysic, erode the inner cortex and spread through medullary canal, not reach epiphysis except epiphyseal union. Advanced stage erode the outer cortex & cause periosteal elevation, subperiosteal new bone formation . Late stage invades the surrounding soft tissue Metastasis is through haematogenous route. MicroscopicallyExtensive irregular sheet of new osteoid and bone. Peripherally hypercellular stroma with direct formation of osteoid from the anaplastic cells. Biopsy should performed from the peripherally of the tumor. Osteolytic osteosarcoma Destructive tumor arise in central metaphysic usually cause pathological fracture. Grosssly- tumor consists of soft friable bloody tissue interspersed with fibrous tissue that enclose the necrotic haemorrhagic cavities Macroscopically- blood containing cavities without indothelial living composed mainly abundant spindle cells and anaplastic osteoblastic hypochromatic nucleus and frequent mitoses. Slow growing tumor contain foreign body giant cell and rapid growing tumor contain tumor giant cells.

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Differential diagnosis finding of osteosarcoma Osteosarcoma contain any one or all the three element of osteogenesis 1. osteoblast 2. osteoid (neoplastic ) 3. bone (neoplastic ) 4. calcifying cartilage which eventually replace by bone Osteosarcoma varies in appearance depending upon the predominating component. The osteoblast is analplastic characterised by large size large hyperchromatic nuclei, frequent mitosis. Osteoid irregular bone intermingled with partially absorbed bone trabeculi and cortical lamella . The main criteria for diagnosis of osteosarcoma is1. Sarcomatous stroma 2. Formating of neoplastic osteo.. and bone by the sarcomatous stroma. CLINICAL FEATURE Symptoms: 1. Children adolescent or young adult male or female present with a gradual or spontaneous onset of pain in the metaphyseal region of long bone , that at first become intermittent and latter become continuous & incapacitating the
26

pain is due to increased tension or neurovascular compression. 2. Swelling may present for several months. 3. Constitutional symptoms present. Local examination: 1. Early stage : A tender palpable mass at the end of a long bone, soft to free or hard in consisting with normal overlying skin, rapid growing tumor becomes lobular. 2. Letter stage: The overlying tissue become immobile , skin stretched, thin & glossy & exhibit distended nevus, but never ulcerates. Involvement of joint cause limitation of motion. General examination: 1. Weight loss in children 2. Moderate anemia Cause: 80% case develop progressive pulmonary metastasis in early stage but remain undetected before months . The process usually total within 2 years.

Treatment:

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Before treatment is instituted the first consideration is to establish a definite diagnosis. This can only be ascertained by biopsy. To prevent metastasis the biopsy a frozen section, and the ablative surgery should be carried out at the same time. After diagnosis has established we are to find out whether the patient can any pulmonary deposit or not. By the time the patient seen medical attention. Local tumor extension and haemoatogenous metastasis spread, usually to the long have already occurred in most instances . Although at the early date tumor micro emboli are not demonstrable but must be considered in the treatment protocol. The principles of treatment are1. complete control of primary tumor: by early and radical amputation. 2. Prevention of metastasis or their control. Once they are established : this can be accomplished locally by preoperative moderate and post operative chemotherapy as some possible after ablation of primary tumor not before healing of amputation stump otherwise interfering with soft tissue healing. Level of amputation: a. Tumor upper and of tibia- above knee amputation. b. Tumor distal end of femur28

* Disarticulation of Hip * 7 cm above the area of increased uptake seen in bone scan if modern chemotherapy & ` megavoltage irradiation instituted earlier. c. Tumor of the midshaft of femur* Disarticulation of hip * 7cm above the maximum of dye if stump size is 10cm d. Tumor at the upper end of femur or of innominate bone hind quarter amputation. * But done after local growth control has been established by radiotherapy and adjuvant chemotherapy along. a. Tumor upper end of the humerus -- fore quarter amputation. 3. Treatment of pulmonary metastasis: During diagnosis micro emboli in lung are present in most of the areas. But opacities of solitary or multiple ling metastasis not become radiologically apparent for several months or year when the patient treated with chemotherapy. When large masses developed in the ling can be removed by lobectomy or wedge resection. After ablation of primary tumor whole lung tomogram are taking every 3 months as appearance of metastasis require early pulmonary resection. Contra indication of pulmonary resection:
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1. Wide spread metaststic disease beyond the lung 2. Extensive pulmonary involvement 3. Inability of the patient to tolerate such surgery. 4. Megavoltage Radiotherapy

Chemotherapy &Radiotherapy Methotrexate -> 80% response. T10 regimen (methotrexate, vincristine, adriamycin)-> 60-75% survival . Regimen continued post operatively or changed to cisplatin depending on histology -> 92% disease free at 2 years Chemotherapy continues for 12 months in 4/52 cycles Intra-arterial chemotherapy used in some centres -> increased dose to the site of the lesion but no evidence that this changes the outcome as if multiple feeding vessels some of tumour may be missed.

Radiotherapy palliation of local pain and to treat surgically inaccessible lesions and painful metastatic deposits. Relatively radio-resistant tumour but radiotherapy may also be used pre30

operatively to decrease the size and vascularity of the tumour. Prophylactic irradiation of the chest has not been shown to be effective Survival beyond 10 years = cure Surgery: Wide resection / Amputation Limb salvage requires ability to: 1. Preserve nerves. 2. Preserve or reconstruct vessels 3. Preserve sufficient muscle for functional motor power & soft tissue coverage 4. Achieve safe, tumour-free margins (wide) Reconstruction options: 1. Allografts 2. Endoprosthesis 3. Expendable bone (fibula, ilium)

Prognosis Typical OS.

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 Untreated -> 95% death in 2 years. 10% have macro-metastases at presentation; 90% have micro-metastases Even with metastatic (Stage 3) disease 5 year survival rate is now 30 - 40%. Prognostic Factors: 1. Age - adults do worse ,Location (proximal worse than distal) 2. Type -Parosteal - tend to be more low grade tumours , Intra osseous (classical) osteosarcoma -> good prognosis 3. Stage 4. Origin of tumour in pre-existing lesion -> worse prognosis

Response to chemotherapy 80 - 90% 5 year disease free survival in good response patients. 60% 5 year disease free survival in patients with poor response. more than 16 metastatic deposits -> poor prognosis Pathological fracture does not affect prognosis

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Biopsy of Bone Tumours-Principles Should know probable diagnosis and stage of tumour before biopsy - last step in the staging. Performed by the surgeon who will perform the definitive surgery Biopsy tract orientation & location is critical Meticulous haemostasis Microbiological analysis Open Biopsy Aim for excisional biopsy when possible . Incisional biopsy preferable in malignant lesions. After consultation with the pathologist and radiologist. Longitudinal incision Incision through muscle not between muscle planes. Windows in bone - small and oval to avoid stress risers and pathological fracture . Haemostasis
33

 Close with a subcutaneous stitch. Drains should come out through the wound If proceed following biopsy -> new instruments and drapes to stop seeding Needle Biopsy Place the biopsy tract where it can be excised Fine needle biopsy: accuracy = 65 to 95% . Core needle biopsy: Accuracy = 75 to 95% allows for immuno-histochemical analysis. Disadvantage of needle biopsy Tissue obtained may be from necrotic portion of tumor and therefore not suitable for diagnosis, or tissue may be reactive in nature and not representative of actual tumor. Frozen section may benefit. Frozen section- Can determine if specimen is adequate or representative,needs culture,any more tests required, immediate diagnosis & can proceed to definitive surgery.

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ADJUVANT CHEMOTHERAPY Neo-adjuvant chemotherapy Immediate action against tumour. Reduces mass and vascularity of the tumour prior to definitive surgery Buys time for operative planning Want 90% kill rate and if < 90% -> change agents Commence adjuvant treatment once the wound has healed May persist for 2 months to 2 years depending on the response Localised disease = 60-70% long-term diseasefree survival

SURGICAL PROCEDURES Principles of surgical management: The surgical procedure for removing the tumor is classified by the type of surrounding tissue removed with the tumor .Therefore basic surgical margins are for definitive surgery. 1. Intracapsular ( Intralesional ) margin 2. Marginal margin 3. Wide margin
35

4. Radical margin 1. Intracapsular margin: The surgical dissection extents the reactive zone and psudocapsule or capsule into the tumor itself. Surgical procedures can be done are1. Incisional biopsy 2. Debulking of the tumor 3. Curettage 4. Piece meal removal 5. Intracapsular excision. Amputation. Surgical procedure through this margin is not good procedure. 100% chance of recurrence due to incomplete removal, disturbing or dissimination of tumor. 1. Marginal margin ( excisoinal margin): Recurrence rate 25- 50 %. Here the flame of dissection is through the reactive zone at side the pseudocapsule or capsular. It is also not a ideal procedure but has some indications such as1. Benign tumor with no chance or very title chance or propensity to recurrence.This procedure is not suitable for 1. Benign tumor with chance of reccurence 2. Benign tumor with recurrence 3. Potentially malignant tumor
36

4. Frankly malignant tumor 5. Frank malignant tumor metastasis. 3. Wide margin : The plane of dissection is through normal tissue outside the reactive zone. The tumor and its reactive zone are removed enblci along with an intact cuff of normal tissue surgical procedure done or, a. wide excision or b. wide amputation But this is not a suitable procedure becomes of micrometastasis or skipped metastasis. Recurrence rate > 10% The procedure is indicated 1. Benign tumor 2. Benign tumor with propensity to recurrence 3. Potentially malignant tumor 4. Some malignant tumor. Actually this level is 7cm above the maximum concentration of dye seen in radioisotopic scanning. 5. Radical margin: The tumor and the enteric bone or muscle compartment that contained it are removed. Procedure named ash. Radical excision or i. Radical amputation. Radical excision or radical margin achieved in two ways37

j. Ablative type- wide excision with removal of whole limb k. Non ablative type- wide excision without removing normal foot tissue. Compartmental extent of tumor invation eg. CT. sufficient scope excision an also be done. But the is determined by sophisticated For this reason there must be and the surgeon must be experience.

ADJUVANT THERAPY 1. Chemotherapy 2. Radiation therapy Antineoplastic 1. Antimetabolities : ad by inter.. l. Methotieatel m. 6- mercaptopureni n. 6- Thioguanine o. 5- Fluroural p. Cytosine arabinoside q. Azathioprine 2. Alkylothing agents: act by . * Nitrogen mustard *Cyclophosphomide *Chloranmbual * Busulphan
38

* Melphalan * Iphosphamide 3. Plant alkatoids: * Vincristen *Vin blastin * Vincrintine * Vp 16-213 * VM- 26 4. Antibiotics: * Doxorubicin * Actinomycin- D * Mitomycin-C

Radiation therapy This necrotizes primary tumor therapy facilities limb salvage stage I and II malignant tumors and selected stage 3 benign lesions responds well to radiation therapy . It is most effective in controlling tumor that originate from bone marrow. Tumors of connective tissue origin do not respond as well. Complication of chemotherapy 1. Aplastic anaemia 2. Bone marrow depression 3. Alopecia During chemotherapy 1. Blood count
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2. Platedls count 3. Alkaline phosphatase 4. Bone marrow examination

Limb Salvage. Criteria for limb salvage: local control of the lesion. Saved limb must be functional. Types of osseous resection Inter calary (between joints) Intra articular (one side of joint) Extra articular (both sides of the joint) . Various methods of salvage eg, endoprosthesis, allograft, composite, arthrodesis (allograft). Relative contraindications Pathological fractures Skeletal immaturity The presence of distal metastasis is not a contraindication.

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