DISTAL (Distal tibia tumors treated with amputation versus limb Salvage): A systematic review and meta-analysis of oncologic, functional, and complication outcomes in malignant bone tumors.

Aims: Primary malignant bone tumors of the distal tibia are uncommon and constitute a distinctive surgical dilemma for musculoskeletal oncologist.The anatomical challenges enhance the probability of postoperative wound complications, infection, and soft-tissue necrosis following large tumor surgical excision. The management of primary malignant bone tumors of the distal tibia remains challenging as what is better treatment option for the patients limb salvage surgery or amputation.The aim of this systematic review and meta-analysis to find an answer for this question and compare the oncological and functional outcomes for patients with malignant bone tumors involving distal tibia treated with limb salvage and amputation surgery. Methods: The protocol was created in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations.A systematic review was performed and we finally obtained three eligible studies (Laitinen et al., 2005; Mavrogenis et al., 2012; Han et al., 2017). Data were extracted for survival, local recurrence, Musculoskeletal Tumor Society (MSTS) function, and complications.The primary objective was to compare differences in local recurrence, with secondary objectives including survival, functional outcomes, and comorbidities. A random-effects meta-analysis evaluated the odds of local recurrence between limb salvage and amputation. Results: A meta-analysis of 136 patients with chondrosarcoma (89 treated with limb-salvage surgery [LSS] and 47 with amputation [AMP]) compared oncological and functional outcomes.While overall survival rates were similar between LSS (80-84 %) and AMP (70-74 %), local recurrence was numerically higher in the limb-salvage group (10.1 % vs. 0 %). However, pooled statistical analysis found this difference was not statistically significant (Pooled OR: 2.66; 95 % CI 0.25-28.56), as the confidence interval spanned unity. The pooled mean MSTS score was 81 % for LSS compared to 69 % for amputation, representing a clinically meaningful advantage.This functional benefit was counterbalanced by a higher risk of surgical complications. The LSS group had a combined complication rate of 11.2 % (versus 6.4 % for AMP), including a critical 4.5 % rate of secondary amputation, primarily due to deep infection in earlier studies.Limb-salvage surgery provides a significant functional advantage over amputation but is associated with a non-significant trend toward higher local recurrence and a greater risk of post-operative complications, including a small but notable risk of ultimately requiring amputation. Conclusion: Malignant bone tumors involving distal tibia tumor treated with Limb-salvage surgery provides equivalent survival and local control compared with amputation when adequate margins and reconstruction are achieved according to the DISTAL (Distal Tibia Tumors Treated with Amputation versus Limb Salvage) metanalysis study. Overall, limb-salvage patients achieved higher functional scores compared to amputees across studies. The evidence remains limited by small sample sizes, retrospective design, and heterogeneous surgical techniques and we suggest multicentre studies for this rare bone tumors. Level of evidence: Level III, systematic review of retrospective comparative studies.