Introduction:Complications of pediatric limb salvage surgery (LSS) for malignant bone tumors can be classified and treated as age-dependent and age-independent. We aimed to review the complication profile and management strategies in the skeletally immature.

Methods:Retrospective analysis was done on 163 patients (M/F:83/80) who underwent LSS for osteosarcoma or Ewing's sarcoma (126/37 respectively) between 1990-2017. Mean age was 12 (1-16) years and mean follow-up was 59,5 (2-290) months. The most common anatomical sites were femur (86) and tibia (51). All patients received preoperative chemotherapy and underwent surgery with the intent of wide resection. Osseous reconstruction was biological in 94 and non-biological in 69 while 60 (37%) underwent soft tissue reconstruction in the index procedure.

Results:The most common complication was limb length discrepancy (LLD) with a mean of 2,4 (0,0-15,0) cm. LLD was observed in 76 (47%) patients. Bone healing problems and graft fractures were observed in 35 (21%), wound problems in 26 (16%), mechanical prosthesis failure in 26(16%), deep infection in 9 (6%), local recurrence (LR) in 13 (8%), and compartment syndrome in 3(2%). The patients underwent a mean of 0,8 (0-6) major additional surgical intervention for complications. Ten patients underwent lengthening surgery with either external fixator or magnetic motorized intramedullary nail. Shoe lift was used for all remaining LLD. Amputation was required in 3 patients due to LR while the remaining was treated with radiotherapy and local resection. Pseudoarthrosis was accepted as sequela in 3. Complications associated with all age groups were treated similar to adult patients. Mean MSTS was 22(5-30) and the oncological status was NED in 69, DOD in 40 and CDF in 30.

Conclusion:LLD remains the most important age-dependent pediatric LSS complication while LR is the most devastating yet age-independent complication. Management starts preoperatively and varies from simple conservative measures to extremely complicated and sophisticated surgical procedures.