Upper Extremity Considerations for Oncologic Surgery

It was estimated that more than 3000 people would be diagnosed with a primary bone or joint malignancy and more than 11,000 people would be diagnosed with a soft tissue sarcoma in 2013. Although primary bone and soft tissue tumors of the upper extremity are infrequent, it is imperative that the clinician be familiar with a systematic approach to the diagnosis and treatment of these conditions to prevent inadvertently compromising patient outcome. With advances in chemotherapy, radiotherapy, tumor imaging, and surgical reconstructive options, limb salvage surgery is estimated to be feasible in 95% of extremity bone or soft tissue sarcomas.


  1. 1. In Howlader N., Noone A.M., and Krapcho M. (eds): SEER Cancer Statistics Review, 1975-2010. Bethesda (MD): National Cancer Institute, 2013.

  2. 2. Pisters P.W., Leung D.H., Woodruff J., et al: Analysis of prognostic factors in 1,041 patients with localized soft tissue sarcomas of the extremities. J Clin Oncol 1996; 14: pp. 1679-1689

  3. 3. Simon M.A., and Finn H.A.: Diagnostic strategy for bone and soft-tissue tumors. J Bone Joint Surg Am 1993; 75: pp. 622-631

  4. 4. Miller T.T.: Bone tumors and tumorlike conditions: analysis with conventional radiography. Radiology 2008; 246: pp. 662-674

  5. 5. Lodwick G.S., Wilson A.J., Farrell C., et al: Determining growth rates of focal lesions of bone from radiographs. Radiology 1980; 134: pp. 577-583

  6. 6. McNeil B.J.: Rationale for the use of bone scans in selected metastatic and primary bone tumors. Semin Nucl Med 1978; 8: pp. 336-345

  7. 7. Rougraff B.T., Kneisl J.S., and Simon M.A.: Skeletal metastases of unknown origin. A prospective study of a diagnostic strategy. J Bone Joint Surg Am 1993; 75: pp. 1276-1281

  8. 8. Bastiaanet E., Groen H., Jager P.L., et al: The value of FDG-PET in the detection, grading and response therapy of soft tissue and bone sarcomas; a systematic review and meta-analysis. Cancer Treat Rev 2004; 30: pp. 83-101

  9. 9. Mankin H.J., Lange T.A., and Spanier S.S.: The hazards of biopsy in patients with malignant primary bone and soft-tissue tumors. J Bone Joint Surg Am 1982; 64: pp. 1121-1127

  10. 10. Mankin H.J., Mankin C.J., and Simon M.A.: The hazards of biopsy, revisited. Members of the Musculoskeletal Tumor Society. J Bone Joint Surg Am 1996; 78: pp. 656-663

  11. 11. Styring E., Billing V., Hartman L., et al: Simple guidelines for efficient referral of soft-tissue sarcomas: a population-based evaluation of adherence to guidelines and referral patterns. J Bone Joint Surg Am 2012; 94: pp. 1291-1296

  12. 12. Scarborough M.T.: The biopsy. Instr Course Lect 2004; 53: pp. 639-644

  13. 13. Enneking W.F., Spanier S.S., and Goodman M.A.: A system for the surgical staging of musculoskeletal sarcoma. Clin Orthop Relat Res 1980; 153: pp. 106-120

  14. 14. Wunder J.S., Healey J.H., Davis A.M., et al: A comparison of staging systems for localized extremity soft tissue sarcoma. Cancer 2000; 88: pp. 2721-2730

  15. 15. Saddegh M.K., Lindholm J., Lundberg A., et al: Staging of soft-tissue sarcomas. Prognostic analysis of clinical and pathological features. J Bone Joint Surg Br 1992; 74: pp. 495-500

  16. 16. Fleming I.D., Cooper J.S., Henson D.E., et al: AJCC cancer staging manual. Philadelphia: Lippincott-Raven, 1997.

  17. 17. Bednar M.S., Weiland A.J., and Light T.R.: Osteoid osteoma of the upper extremity. Hand Clin 1995; 11: pp. 211-221

  18. 18. Soong M., Jupiter J., and Rosenthal D.: Radiofrequency ablation of osteoid osteoma in the upper extremity. J Hand Surg Am 2006; 31: pp. 279-283

  19. 19. Ambrosia J.M., Wold L.E., and Amadio P.C.: Osteoid osteoma of the hand and wrist. J Hand Surg Am 1987; 12: pp. 794-800

  20. 20. Gibbs C.P., Weber K., and Scarborough M.T.: Malignant bone tumors. J Bone Joint Surg Am 2001; 83: pp. 1728-1745

  21. 21. Okada K., Wold L.E., Beabout J.W., et al: Osteosarcoma of the hand. A clinicopathologic study of 12 cases. Cancer 1993; 72: pp. 719-725

  22. 22. Sforzo C.R., Scarborough M.T., and Wright T.W.: Bone-forming tumors of the upper extremity and Ewing’s sarcoma. Hand Clin 2004; 20: pp. 303-315

  23. 23. Anninga J.K., Picci P., Flocco M., et al: Osteosarcoma of the hands and feet: a distinct clinco-pathological subgroup. Virchows Arch 2013; 462: pp. 109-120

  24. 24. Daecke W., Bielack S., Martini A.K., et al: Osteosarcoma of the hand and forearm: experience of the Cooperative Osteosarcoma Study Group. Ann Surg Oncol 2005; 12: pp. 322-331

  25. 25. Winkler K., Bielack S.S., Delling G., et al: Treatment of osteosarcoma: experience of the Cooperative Osteosarcoma Study Group (COSS). Cancer Treat Res 1993; 62: pp. 269-277

  26. 26. Bielack S.S., Kempf-Bielack B., Delling G., et al: Prognostic factors in high-grade osteosarcoma of the extremities or trunk: an analysis of 1,702 patients treated on neoadjuvant cooperative osteosarcoma study group protocols. J Clin Oncol 2002; 20: pp. 776-790

  27. 27. Meyers P.A., Heller G., Healey J., et al: Chemothterapy for nonmetastatic osteogenic sarcoma: the Memorial Sloan-Kettering experience. J Clin Oncol 1992; 10: pp. 5-15

  28. 28. Picci P., Sangiori L., Rougraff B.T., et al: Relationship of chemotherapy-induced necrosis and surgical margins to local recurrence in osteosarcoma. J Clin Oncol 1994; 12: pp. 2699-2705

  29. 29. Link M.P., Goorin A.M., Miser A.W., et al: The effect of adjuvant chemotherapy on relapse-free survival in patients with osteosarcoma of the extremity. N Engl J Med 1986; 314: pp. 1600-1616

  30. 30. O’Connor M.I., and Bancroft L.W.: Benign and malignant cartilage tumors of the hand. Hand Clin 2004; 20: pp. 317-323

  31. 31. Unni K.K., and Inwards C.Y.: Dahlin’s bone tumors: general aspects and data on 10,165 cases. Philadelphia: Lippincott Williams & Wilkins, 2010.

  32. 32. Sassoon A.A., Fitz-Gibbon P.D., Harmsen W.S., et al: Enchondromas of the hand: factors affecting recurrence, healing, motion and malignant transformation. J Hand Surg Am 2012; 37: pp. 1229-1234

  33. 33. Patil S., de Silva M.V., Crossan J., et al: Chondrosarcoma of small bones of the hand. J Hand Surg Br 2003; 28: pp. 602-608

  34. 34. Lee F.Y., Mankin H.J., Fondren G., et al: Chondrosarcoma of bone: an assessment of outcome. J Bone Joint Surg Am 1999; 81: pp. 326-338

  35. 35. Mourikis A., Mankin H.J., Hornicek F.J., et al: Treatment of proximal humeral chondrosarcoma with resection and allograft. J Shoulder Elbow Surg 2007; 16: pp. 519-524

  36. 36. Mittermayer F., Dominkus M., Krepler P., et al: Chondrosarcoma of the hand: is a wide surgical resection necessary? Clin Orthop Relat Res 2004; undefined: pp. 211-215

  37. 37. Athanasian E.A.: Aneurysmal bone cyst and giant cell tumor of bone of the hand and distal radius. Hand Clin 2004; 20: pp. 269-281

  38. 38. Mankin H.J., Hornicek F.J., Ortiz-Crus E., et al: Aneurysmal bone cyst: a review of 150 patients. J Clin Oncol 2005; 23: pp. 6756-6762

  39. 39. Gibbs C.P., Hefele M.C., Peabody T.D., et al: Aneurysmal bone cyst of the extremities. Factors related to local recurrence after curettage with a high-speed burr. J Bone Joint Surg Am 1999; 81: pp. 1671-1678

  40. 40. Eckardt J.J., and Grogan T.J.: Giant cell tumor of bone. Clin Orthop Relat Res 1986; 204: pp. 45-58

  41. 41. Campanacci M., Baldini N., Boriani S., et al: Giant-cell tumor of bone. J Bone Joint Surg Am 1987; 69: pp. 106-114

  42. 42. Campanacci M.: Giant-cell tumor and chondrosarcomas: grading, treatment and results (studies of 209 and 131 cases). Recent Results Cancer Res 1976; undefined: pp. 257-261

  43. 43. Nijhuis P.H., Schaapveld M., Otter R., et al: Epidemiological aspects of soft tissue sarcomas (STS)–consequences for the design of clinical STS trials. Eur J Cancer 1999; 35: pp. 1705-1710

  44. 44. Talbot S.G., Mehrara B.J., Disa J.J., et al: Soft-tissue coverage of the hand following sarcoma resection. Plast Reconstr Surg 2008; 121: pp. 534-543

  45. 45. Murray P.M.: Soft tissue sarcoma of the upper extremity. Hand Clin 2004; 20: pp. 325-333

  46. 46. Riad S., Griffin A.M., Liberman B., et al: Lymph node metastasis in soft tissue sarcoma in an extremity. Clin Orthop Relat Res 2004; 426: pp. 129-134

  47. 47. Rosenberg S.A., Tepper J., Glatstein E., et al: The treatment of soft-tissue sarcomas of the extremities: prospective randomized evaluations of (1) limb-sparing surgery plus radiation therapy compared with amputation and (2) the role of adjuvant chemotherapy. Ann Surg 1982; 196: pp. 305-315

  48. 48. Keus R.B., Rutgers E.J., Ho G.H., et al: Limb-sparing therapy of extremity soft tissue sarcomas: treatment outcome and long-term functional results. Eur J Cancer 1994; 30A: pp. 1459-1463

  49. 49. Lin P.P., Guzel V.B., Pisters P.W., et al: Surgical management of soft tissue sarcomas of the hand and foot. Cancer 2002; 95: pp. 852-861

  50. 50. Pradhan A., Cheung Y.C., Grimer R.J., et al: Soft-tissue sarcomas of the hand: oncological outcome and prognostic factors. J Bone Joint Surg Br 2008; 90: pp. 209-214

  51. 51. Puhaindran M.E., Steensma M.R., and Athanasian E.A.: Partial hand preservation for large soft tissue sarcomas of the hand. J Hand Surg Am 2010; 35: pp. 291-295

  52. 52. Puhaindran M.E., Rohde R.S., Chou J., et al: Clinical outcomes for patients with soft tissue sarcoma of the hand. Cancer 2011; 117: pp. 175-179

  53. 53. Stojadinovic A., Leung D.H., Hoos A., et al: Analysis of the prognostic significance of microscopic margins in 2,084 localized primary adult soft tissue sarcomas. Ann Surg 2002; 235: pp. 424-434

  54. 54. Gronchi A., Casali P.G., Mariani L., et al: Status of surgical margins and prognosis in adult soft tissue sarcomas of the extremities: a series of patients treated at a single institution. J Clin Oncol 2005; 23: pp. 96-104

  55. 55. Gerrand C.H., Wunder J.S., Kandel R.A., et al: Classification of positive margins after resection of soft-tissue sarcoma of the limb predicts the risk of local recurrence. J Bone Joint Surg Br 2001; 83: pp. 1149-1155

  56. 56. Koskinen E.V., Visuri T.I., Holmström T., et al: Aneurysmal bone cyst: evaluation of resection and of curettage in 20 cases. Clin Orthop Relat Res 1976; 118: pp. 136-146

  57. 57. Biesecker J.L., Marcove R.C., Huvos A.G., et al: Aneurysmal bone cysts. A clinicopathologic study of 66 cases. Cancer 1970; 26: pp. 615-625

  58. 58. Vergel De Deios A.M., Bond J.R., Shives T.C., et al: Aneurysmal bone cyst. A clinicopathologic study of 238 cases. Cancer 1992; 69: pp. 2921-2931

  59. 59. Marcove R.C., Sheth D.S., Takemoto S., et al: The treatment of aneurysmal bone cyst. Clin Orthop Relat Res 1995; 311: pp. 157-163

  60. 60. Peeters S.P., Van der Geest I.C., de Rooy J.W., et al: Aneurysmal bone cyst: the role of cryosurgery as local adjuvant treatment. J Surg Oncol 2009; 100: pp. 719-724

  61. 61. Puhaindran M.E., Chou J., Forsberg J.A., et al: Major upper-limb amputations for malignant tumors. J Hand Surg Am 2012; 37: pp. 1235-1241

  62. 62. Malawer M., and Wittig J.: Overview of resections around the shoulder girdle: anatomy, surgical considerations and classification. In Malawer M., and Sugarbaker P.H. (eds): Musculoskeletal cancer surgery: treatment of sarcomas and allied diseases. Boston: Kluwer Academic, 2001. pp. 179-202

  63. 63. Clarkson P.W., Griffin A.M., Catton C.N., et al: Epineural dissection is a safe technique that facilitates limb salvage surgery. Clin Orthop Relat Res 2005; 438: pp. 92-96

  64. 64. Ferguson P.C., Kulidjian A.A., Jones K.B., et al: Peripheral nerve considerations in the management of extremity soft tissue sarcomas. Recent Results Cancer Res 2009; 179: pp. 243-256

  65. 65. Windhager R., Millesi H., and Kotz R.: Resection-replantation for primary malignant tumours of the arm. An alternative to fore-quarter amputation. J Bone Joint Surg Br 1995; 77: pp. 176-184

  66. 66. Hahn S.B., Choi Y.R., Kang H.J., et al: Segmental resection and replantation have a role for selected advanced sarcomas in the upper limb. Clin Orthop Relat Res 2009; 467: pp. 2918-2924

  67. 67. Krajbich J.I., and Carroll N.C.: Van Nes rotationplasty with segmental limb resection. Clin Orthop Relat Res 1990; undefined: pp. 7-13

  68. 68. Mahendra A., Gortzak Y., Ferguson P.C., et al: Management of vascular involvement in extremity of soft tissue sarcoma. Recent Results Cancer Res 2009; 179: pp. 285-299

  69. 69. Ghert M.A., Davis A.M., Griffin A.M., et al: The surgical and functional outcome of limb-salvage surgery with vascular reconstruction for soft tissue sarcoma of the extremity. Ann Surg Oncol 2005; 12: pp. 1102-1110

  70. 70. Lee S.K., and Wolfe S.W.: Nerve transfers for the upper extremity: new horizons in nerve reconstruction. J Am Acad Orthop Surg 2012; 20: pp. 506-517

  71. 71. Ozkan T., Ozer K., and Gülgönen A.: Restoration of sensibility in irreparable ulnar and median nerve lesions with use of sensory nerve transfer: long-term follow-up of 20 cases. J Hand Surg Am 2001; 26: pp. 44-51

  72. 72. Ratner J.A., Peljovich A., and Kozin S.H.: Update on tendon transfers for peripheral nerve injuries. J Hand Surg Am 2010; 35: pp. 1371-1381

  73. 73. Gebert C., Hillmann A., Schwappach A., et al: Free vascularized fibular grafting for reconstruction after tumor resection in the upper extremity. J Surg Oncol 2006; 94: pp. 114-127

  74. 74. Rashid S., Zia ul Islam M., Rizvi S.T., et al: Limb salvage in malignant tumours of the upper limb using vascularized fibula. J Plast Reconstr Aesthet Surg 2008; 61: pp. 648-661

  75. 75. Murray P.M.: Free vascularized bone transfer in limb salvage surgery of the upper extremity. Hand Clin 2004; 20: pp. 203-211

  76. 76. Mack G.R., Licthman D.M., and MacDonald R.I.: Fibular autografts for distal defects of the radius. J Hand Surg Am 1979; 4: pp. 576-583

  77. 77. Maruthainar N., Zambakidis C., Harper G., et al: Functional outcome following excision of tumors of the distal radius and reconstruction by autologous non-vascularized osteoarticular fibula grafting. J Hand Surg Br 2002; 27: pp. 171-174

  78. 78. Kiss J., Sztrinkai G., Antal I., et al: Functional results and quality of life after shoulder girdle resections in musculoskeletal tumors. J Shoulder Elbow Surg 2007; 16: pp. 273-279

  79. 79. Hsu R.W., Wood M.B., Sim F.H., et al: Free vascularized fibular grafting for reconstruction after tumour resection. J Bone Joint Surg Br 1997; 79: pp. 36-42

  80. 80. Talbot S.G., Athanasian E.A., Cordeiro P.G., et al: Soft tissue reconstruction following tumor resection in the hand. Hand Clin 2004; 20: pp. 181-202

  81. 81. Lohman R.F., Nabawi A.S., Reece G.P., et al: Soft tissue sarcoma of the upper extremity: a 5-year experience at two institutions emphasizing the role of soft tissue flap reconstruction. Cancer 2002; 94: pp. 2256-2264

  82. 82. Schwab J.H., Healey J.H., and Athanasian E.A.: Wide en bloc extra-articular excision of the elbow for sarcoma with complex reconstruction. J Bone Joint Surg Br 2008; 90: pp. 78-83

  83. 83. Muramatsu K., Ihara K., and Taguchi T.: Selection of myocutaneous flaps for reconstruction following oncologic resection of sarcoma. Ann Plast Surg 2010; 64: pp. 307-310

  84. 84. Grinsell D., Di Bella C., and Choong P.F.: Functional reconstruction of sarcoma defects using innervated free flaps. Sarcoma 2012; 2012: pp. 315190

  85. 85. Malawer M.M.: Tumors of the shoulder girdle. Technique of resection and description of a surgical classification. Orthop Clin North Am 1991; 22: pp. 7-35

  86. 86. O’Connor M.I., Sim F.H., and Chao E.Y.: Limb salvage for neoplasms of the shoulder girdle. Intermediate reconstructive and functional results. J Bone Joint Surg Am 1996; 78: pp. 1872-1888

  87. 87. Probyn L.J., Wunder J.S., Bell R.S., et al: A comparison of outcome of osteoarticular allograft reconstruction and shoulder arthrodesis following resection of primary tumours of the proximal humerus. Sarcoma 1998; 2: pp. 163-170

  88. 88. Rödl R.W., Gosheger G., Gebert C., et al: Reconstruction of the proximal humerus after wide resection of tumours. J Bone Joint Surg Br 2002; 84: pp. 1004-1008

  89. 89. Getty P.J., and Peabody T.D.: Complications and functional outcomes of reconstruction with an osteoarticular allograft after intra-articular resection of the proximal aspect of the humerus. J Bone Joint Surg Am 1999; 81: pp. 1138-1146

  90. 90. Potter B.K., Adams S.C., Pitcher J.D., et al: Proximal humerus reconstructions for tumors. Clin Orthop Relat Res 2009; 467: pp. 1035-1041

  91. 91. van de Sande M.A., Dijkstra P.D., and Taminau A.H.: Proximal humerus reconstruction after tumour resection: biological versus endoprosthetic reconstruction. Int Orthop 2011; 35: pp. 1375-1380

  92. 92. Tsukushi S., Nishida Y., Takahashi M., et al: Clavicula pro humero reconstruction after wide resection of the proximal humerus. Clin Orthop Relat Res 2006; 447: pp. 132-137

  93. 93. Marulanda G.A., Henderseon E., Cheong D., et al: Proximal and total humerus reconstruction with the use of an aortograft mesh. Clin Orthop Relat Res 2010; 468: pp. 2896-2903

  94. 94. Wittig J.C., Bickels J., Kellar-Graney K.L., et al: Osteosarcoma of the proximal humerus: long-term results with limb-sparing surgery. Clin Orthop Relat Res 2002; 397: pp. 156-176

  95. 95. Abdeen A., Hoang B.H., Athanasian E.A., et al: Allograft-prosthesis composite reconstruction of the proximal part of the humerus: functional outcome and survivorship. J Bone Joint Surg Am 2009; 91: pp. 2406-2415

  96. 96. Aponte-Tinao L.A., Ayerza M.A., Muscolo D.L., et al: Allograft reconstruction for the treatment of musculoskeletal tumors of the upper extremity. Sarcoma 2013; 2013: pp. 925413

  97. 97. Gebhardt M.C., Roth Y.F., and Mankin H.J.: Osteoarticular allografts for reconstruction in the proximal part of the humerus after excision of a musculoskeletal tumor. J Bone Joint Surg Am 1990; 72: pp. 334-345

  98. 98. De Wilde L.F., Plasschaert F.S., Audenaert E.A., et al: Functional recovery after a reverse prosthesis for reconstruction of the proximal humerus in tumor surgery. Clin Orthop Relat Res 2005; 430: pp. 156-162

  99. 99. Pritchard D.J., and Dahlin D.C.: Neoplasms of the elbow. In Morrey B.F. (eds): The elbow and its disorders. Philadelphia: WB Saunders, 1985. pp. 713-735

  100. 100. Athwal G.S., Chin P.Y., Adams R.A., et al: Coonrad-Morrey total elbow arthroplasty for tumours of the distal humerus and elbow. J Bone Joint Surg Br 2005; 87: pp. 1369-1374

  101. 101. Weber K.L., Linn P.P., and Yasko A.W.: Complex segmental elbow reconstruction after tumor resection. Clin Orthop Relat Res 2003; 415: pp. 31-44

  102. 102. Dean G.S., Holliger E.H., and Urbaniak J.R.: Elbow allograft for reconstruction of the elbow with massive bone loss. Long term results. Clin Orthop Relat Res 1997; 341: pp. 12-22

  103. 103. Kocher M.S., Gebhardt M.C., and Mankin H.J.: Reconstruction of the distal aspect of the radius with use of an osteoarticular allograft after excision of a skeletal tumor. J Bone Joint Surg Am 1998; 80: pp. 407-419

  104. 104. Scoccianti G., Campanacci D.A., Beltrami G., et al: The use of osteo-articular allografts for reconstruction after resection of the distal radius tumour. J Bone Joint Surg Br 2010; 92: pp. 1690-1694

  105. 105. Lackman R.D., McDonald D.J., Beckenbaugh R.D., et al: Fibular reconstruction for giant cell tumor of the distal radius. Clin Orthop Relat Res 1987; undefined: pp. 232-238

  106. 106. Bickert B., Heitmann Ch, and Germann G.: Fibulo-scapho-lunate arthrodesis as a motion-preserving procedure after tumour resection of the distal radius. J Hand Surg Br 2002; 27: pp. 573-576

  107. 107. Natarajan M.V., Chandra Bose J., Viswanath J., et al: Custom prosthetic replacement for distal radial tumours. Int Orthop 2009; 33: pp. 1081-1084

  108. 108. Hatano H., Morita T., Kobayashi H., et al: A ceramic prosthesis for the treatment of tumours of the distal radius. J Bone Joint Surg Br 2006; 88: pp. 1656-1658

  109. 109. Seradge H.: Distal ulnar translocation in the treatment of giant-cell tumors of the distal radius. J Bone Joint Surg Am 1982; 64: pp. 67-73

  110. 110. Minami A., Kato H., and Iwasaki N.: Vascularized fibular graft after excision of giant-cell tumor of the distal radius: wrist arthroplasty versus partial wrist arthrodesis. Plast Reconstr Surg 2002; 110: pp. 112-117

  111. 111. Pho R.W.: Malignant giant-cell tumor of the distal end of the radius treated by a free vascularized fibular transplant. J Bone Joint Surg Am 1981; 63: pp. 877-884

  112. 112. Campbell C.J., and Akbarnia B.A.: Giant-cell tumor of the radius treated by massive resection and tibial bone graft. J Bone Joint Surg Am 1975; 57: pp. 982-986

  113. 113. Athanasian W.A.: Bone and soft tissue tumors. In (eds): , 6th edition. New York: Churchill Livingstone, 2010. pp. 2142-2195

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