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Background: This study reports the epidemiology of bone and soft-tissue tumors of the foot and ankle, presents therapy strategies, and evaluates mid-term clinicofunctional outcome after surgery for malignant tumors., Methods: Two hundred four patients with tumors of the foot and ankle were analyzed (163 benign and 41 malignant). Epidemiology and surgical therapy are reported., Results: The most frequent tumors were exostosis, bone cyst, and osteoid osteoma for benign tumors and metastases and chondrosarcoma and Ewing's sarcoma for malignant tumors. In more than 90% of the benign tumors, local resection could be carried out, whereas in malignant tumors, ablative procedures and arthrodeses were almost as common as limb- and joint-sparing techniques. However, follow-up revealed good functional results and a 5-year survival rate of 84% for patients with primary malignant tumors., Conclusion: Tumors of the foot and ankle require a thorough therapeutic strategy. Mid-term functional results and survival rate after surgical treatment are good, although a high percentage of ablative procedures or fusions could not be avoided in our patients.

Background: We describe the surgical treatment, outcome and long-term survival of patients with multiple myeloma (MM) in response to conventional (CC) or high-dose (HDT) chemotherapy., Patients and Methods: Eighty-four patients diagnosed with MM were recruited for the study (51 male, 33 female; median age 62 years) and consecutively surgically treated in a single institution during a 12-year period. The main end point of the study was overall survival after surgery. Cox regression analysis was used to estimate the effect of factors that may predict survival., Results: Spinal surgery was performed in 54 cases, and 30 patients were surgically treated at the extremities. The post-surgical complication rate was low (17%; 14/84 patients). The median overall survival time was 47 months. Patients receiving HDT had a longer 5-year overall survival rate than patients receiving CC (51% versus 33%). Univariate predictors of mortality included age >65 years [risk ratio (RR) 1.62; P=0.023], osteolyses in long weight-bearing bones (RR 2.23; P=0.007) and an elevated C-reactive protein level >5 mg/l (RR 1.82; P=0.016); the latter remained significant as a predictor in multivariate analysis (RR 2.66; P=0.0209)., Conclusions: Given the high number of patients reaching 5-year overall survival and the low post-surgery complication rate, surgery should pursue a long-term stable reconstruction of the affected bone.

Aims: This study reports outcome, functional results and quality of life of 45 elderly patients with age over 70 after surgery for primary malignant bone and soft tissue tumours., Methods: There were 24 primary malignant bone tumours and 21 soft tissue sarcomas. The most frequent diagnoses were: chondrosarcoma, malignant fibrous histiocytoma and liposarcoma. Local tumour resection with and without osteosynthesis, endoprostheses, and amputations had been performed for surgery. The patients were prospectively followed in a tumour register., Results: Complication and revision rate, functional outcome using the Musculoskeletal Tumor Society score, 5-year survival rate, median survival time and quality of life according to the Life Satisfaction Index A and the global health and quality-of-life scale of the QLQ-C30 revealed results that are only slightly inferior to those reported in younger tumour patients., Conclusions: The results of this study generally justify even extensive tumour surgery in the elderly patient over 70 although outcomes are not quite as good as those reported for younger adults. However, especially in the old patient indications like general condition and comorbidity should be given due consideration before any decision is made on whether surgery should be performed and if so what surgical technique should be applied.

Aim: To report the complication rates of limb-salvage reconstruction in the pelvis. Detailed analyses about the type, treatment and outcome of post-operative complications, various reconstruction options are presented., Methods: Factors that might influence the occurrence of complications were evaluated of 50 consecutive surgically treated patients., Results: The mean follow-up was 57 months. Limb-salvage procedures were used in 42/50 patients, amputations in 8/50 patients. After limb-salvage procedures complications occurred in 32/42 patients, after hemipelvectomy in 6/8 patients. The 1 and 5-year overall survival rate was 92 and 68%, respectively., Conclusion: There is a high complication rate in reconstructive techniques using hemipelvic autografts and/or allografts. These procedures are appropriate only in well selected patients. The complication rates following endoprosthetic reconstruction are comparably low.

This study investigated quality of life (QoL) and function of 124 patients with lower extremity sarcoma who underwent either amputation or limb-salvage surgery (LSS) in order to assess potential differences in subjective treatment outcome. The results reflect similar QoL in both treatment groups. However, in contrast to patients with LSS, who described QoL in terms of a high physical performance status with sports and recreational activities, amputees' QoL was strongly associated with their social acceptability. High QoL in amputees brings into question the expectations held with time-consuming advanced technical skills for LSS by physicians.

In 13 patients with primary malignant bone tumors (10 Ewing's sarcoma, 1 parosteal osteosarcoma, 1 adamantinoma recurrence, and 1 MFH) local therapy was performed as intraoperative extracorporeal irradiation and replantation (IEIR) of the involved bone segment (5 tibia, 2 femur, and 6 pelvis). Of the 13 patients (69%), 9 are alive at the time of the follow-up (5 CDF, 4 AWM(treated)) and 4 patients died of disease (DOD). Up to now during the follow-up of 32 months (6-57), no local recurrence was observed in the replanted bone segments. The complication rate was very high (18 complications in 11 of the 13 patients, including 6 cases with complication V degrees according to Ruggieri with loss of the reconstruction). The typical complication is severe local infection necessitating removal of the replant. In cases of mechanical failure, the replanted segment could mostly be preserved by surgical revision and autologous bone grafting. If serious complications can be managed or avoided, functional results can be achieved. IEIR must be seen as an extraordinary reconstruction procedure in cases where established procedures such as endoprosthesis, biological reconstructions, or rotationplasties cannot be used or are refused by the patient.

The purpose of this study was to compare quality of life and subjective well-being between patients who underwent either amputation or limb-salvage procedures for lower extremity sarcomas in order to determine if this aspect can be considered in the decision on the type of surgery. Sixty-six patients were evaluated at least 1 year after surgery and systemic therapy for lower extremity sarcomas. Self-report questionnaires such as the Quality of Life Questionnaire (QLQ-C30), the Life Satisfaction Questionnaire (FLZ), and the Enneking Score (MSTS) were used. There were no differences in quality of life and subjective well-being between the two groups. Scores of the symptom scale (14.1 vs 13.2), the global quality of life (70.9 vs 71.0) as well as scores of the function scale (51.7 vs 50.3) were similar. Small differences in scores were found in social functioning but not in scores of physical, cognitive, and emotional functioning. Global subjective well-being in both groups was also similar (219.5 vs 223.7). High satisfaction was found in marital life and partnership as well as in self-assessment. The least satisfaction was found in finances. Results in functional outcome after limb-salvage procedures (77% vs 65%) were better. Although more complications were reported after limb-salvage procedures, they did not seem to have any impact on quality of life ( p=0.235, r(p)=0.112) and subjective well-being ( p=0.856, r(p)=0.140) of the patients whereas a correlation to function could be shown ( p<0.001, r(p)=0.595; p=0.015, r(p)=0.304). Additionally, a correlation between subjective well-being and the location of either amputation or reconstruction ( p=0.039, r(p)=- 0.309) could be shown. These findings demonstrate that the type of surgery has no influence on quality of life and subjective well-being after lower extremity sarcomas. Thus the decision for either limb-salvage procedures or amputation cannot be based on quality of life and subjective well-being but must be determined by oncological criteria.

To bridge large bone defects after resection of primary malignant bone tumors, an autologous free vascularized fibular graft was used in 31 patients (15 x upper limb, 16 x lower limb). The median bone defect measured 16 cm (7-29.5 cm). At the lower extremity the vascularized fibular transplant was reinforced with an allograft and different osteosyntheses. At the upper limb stabilization of the transplant was obtained exclusively by plate osteosynthesis or condylar plate. Applications and the authors' experiences are described and discussed in terms of clinical outcome, graft union, functional outcome, and complications for each localization. After a median of 48 months, ten complications at the upper limb and eight complications at the lower limb, respectively, were seen requiring secondary surgical revision. Major complications such as perioperative deaths or secondary amputations were not observed. Functional evaluation showed better results for the lower than for the upper extremity, due mainly to en bloc resection of proportionally large amounts of soft tissues around the shoulder girdle for local tumor control. Despite the demanding operative procedure and a large number of controllable complications, the good functional outcome and high patient satisfaction indicate that the free vascularized fibular graft is an option for limb-sparing surgery of primary malignant bone tumors.

We treated 11 patients with primary sarcoma and 1 patient with enchondroma of the femur or tibia. Bridging the osseus defect we used an intercalary allograft shell and contralateral fibula as described by Capanna et al. [7]. The median bone defect after resection of the tumor was 15.7 (9.0-28.5) cm, average follow up was 29.2 (13-56) month. Anastomosis of the autologous fibula was successful in 8 cases. There were 3 cases necessitating later amputation. The other cases showed good clinical (Enneking-score) and radiological (ISOLS-score) results. These results indicate the described technique as a suitable method for defect reconstruction with good functional outcome.

Low-grade central osteosarcoma is a well-differentiated subtype of osteosarcoma, which is often confused with benign lesions. Males and females were affected about equally in our study. The tibia and femur were most commonly involved. Three case reports demonstrate the distinct features of the tumor. Excision of the tumor almost invariably led to recurrences. Wide resection was almost never followed by recurrence and seems to be the treatment of choice for this very rare variant of osteosarcoma.

Retrospective analysis of 30 patients with pathological fracture out of 336 patients with primary malignant bone tumors should demonstrate the influence a pathologic fracture and the form of surgical therapy have on the survival rate. In 25 out of 30 patients a fracture led to diagnosis of the disease. Pathological fractures occurred cumulatively by malignant fibrous histiocytoma of the bone and in tumor stages IIb and III. Surgery was performed on 26 out of 30 patients (12 ablative therapies, 14 reconstructive therapies). The mortality risk for patients with pathological fractures was more than double the risk for patients without pathological fractures (P = 0.0062). When performed correctly, reconstructive therapy does not influence the survival rate.

In 6 patients with primary malignant bone tumors (4 Ewing, 1 recurrent Adamantinoma, 1 maligne Haemangioperizytoma) the local therapy was performed as intraoperative extracorporeal irradiation and replantation. During the follow-up 10 (6-24) months no local recurrence in the replanted segment occurred. One recurrence occurred in the host bed; in two cases the replanted segment had to be removed because of severe infection. The other cases showed good functional and radiological results. These clinical findings and the reports in the literature seem to allow the application of the intraoperative extracorporeal irradiation and replantation procedure for defect reconstruction in cases of chemo- and radiotherapy-sensitive bone tumors.

Operations on skeletal metastases of the extremities represent the most frequent surgical treatment in orthopedic oncology. From 1970 to 1997, 340 patients were operated on in 383 surgical procedures in the Orthopedic Department of the University of Heidelberg. Carcinoma of the breast and renal cell carcinoma were the most common primary tumors. Operations concerned mainly the femur with acetabulum (55%) and the humerus with glenoid (25%). A pathologic fracture occurred in 51%. While in these cases surgical treatment is absolutely necessary, it is contraindicated in preterminal patients. In imminent fractures or peripheral compression syndromes, the indication is relative and has to be justified on a multidisciplinary basis. Marginal resection of the tumor is allowed because of the limited life expectancy of most patients. Only in patients with solitary metastases and a better prognosis the resection of metastasis margin can be more extensive. Intensification of local therapy by adjuvant irradiation is indicated in an R2 situation, depending on the patient's prognosis. An analysis of our cases from 1994 to 1996 exemplifies the increasing use of modular tumor endoprostheses (52%). In meta-diaphyseal and diaphyseal cases, cement-augmented osteosynthesis is mainly used (34%). The application of these established reconstruction techniques after metastasis resection in cases with adjuvant radiotherapy assures a pain-free extremity capable of weight bearing.

An analysis of indications and operative techniques was carried out in 166 patients with skeletal metastases of the proximal femur and acetabulum. Complications as well as functional and oncological results clearly show advantages and disadvantages of different methods such as osteosyntheses, standard hip prostheses and tumour prostheses referring to the tumour's localization and extent.