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An amputation around, through or below the knee joint constitutes a "huge" change in a patient's life. In Orthopaedics, amputations are most frequently performed in cases with musculoskeletal tumours or failed total knee arthroplasty. A multidisciplinary team approach (surgeon, anaesthetist, pain specialists, orthotist, psychologist etc.) and patient-specific treatment regime from the outset as well as a meticulous surgical technique are of the outmost importance. Nowadays, prosthetic legs can be fitted for nearly any amputation level. The functional outcome of amputations below the knee is usually superior to amputations above or through the knee joint. Postoperative stump conditioning is paramount and the final prosthetic leg should not be fitted earlier than 4-6 months postoperatively. Problems with wound healing, muscle contractures and phantom limb pain represent common complications which might adversely affect patient outcomes.

PURPOSE The objective of this study was to investigate potential correlations between pathologic fractures (PFs) and prognosis of patients with primary central high-grade osteosarcoma of the extremities. METHODS We retrospectively analyzed 2,847 patients registered in the Consecutive Cooperative Osteosarcoma Study Group database with primary central high-grade osteosarcoma of the extremities, treated between 1980 and 2010. Intended treatment included pre- and postoperative chemotherapy and surgery. Univariable and multivariable survival analyses were performed for all patients and then differentiated for adult and pediatric (≤ 18 years at time of diagnosis) patients. RESULTS A total of 2,193 patients were ≤ 18 years of age; 11.3% of all patients had PFs. In the overall cohort, presence of PF correlated significantly with tumor site, histologic subtype, relative tumor size, and primary metastases, but not with body mass index or local surgical remission. In univariable analysis, 5-year overall survival (OAS) of patients with and without PF was 63% versus 71%, respectively ( P = .007), and 5-year event-free survival (EFS) was 51% versus 58% ( P = .026). In pediatric patients, OAS and EFS did not differ significantly between patients with and without PF. In adults, 5-year OAS in patients with and without PF was 46% versus 69% ( P < .001), and 5-year EFS was 36% versus 56% ( P < .001). In multivariable analysis, PF was not a statistically significant factor for OAS or EFS in the total cohort or in pediatric patients. In adult patients, PF remained an independent prognostic factor for OAS ( P = .013; hazard ratio [HR], 1.893). It was not a significant prognostic factor for EFS ( P = .263; HR, 1.312). CONCLUSION In this largest study to date with extremity osteosarcomas, we observed the occurrence of PF to correlate with inferior OAS expectancies in adult but not in pediatric patients.

Durch Fortschritte in der Diagnostik und Therapie primar maligner Knochentumoren kann heute in den allermeisten Fallen ein Extremitatenerhalt erreicht werden. Mithilfe moderner modularer Tumorprothesen konnen hierbei alle grosen Gelenke und sogar ganze Extremitatenabschnitte wie das Femur, der Humerus oder die Tibia endoprothetisch ersetzt werden. In diesem Beitrag werden die jeweils individuellen Voraussetzungen und Herausforderungen bei Durchfuhrung eines endoprothetischen Totalersatzes an vorgenannten anatomischen Lokalisationen herausgearbeitet. Des Weiteren wird ein Uberblick uber das zu erwartende Outcome sowie Probleme und Komplikationsraten gegeben.

An amputation around, through or below the knee joint constitutes a "huge" change in a patient's life. In Orthopaedics, amputations are most frequently performed in cases with musculoskeletal tumours or failed total knee arthroplasty. A multidisciplinary team approach (surgeon, anaesthetist, pain specialists, orthotist, psychologist etc.) and patient-specific treatment regime from the outset as well as a meticulous surgical technique are of the outmost importance. Nowadays, prosthetic legs can be fitted for nearly any amputation level. The functional outcome of amputations below the knee is usually superior to amputations above or through the knee joint. Postoperative stump conditioning is paramount and the final prosthetic leg should not be fitted earlier than 4-6 months postoperatively. Problems with wound healing, muscle contractures and phantom limb pain represent common complications which might adversely affect patient outcomes.

Die Rekonstruktion ausgedehnter ossarer Defekte nach Tumor, Trauma oder Infekt ist schwierig und unterliegt zumeist den individuellen Praferenzen des jeweiligen Operateurs. Freie autologe Fibulagrafts stellen eine verlassliche biologische Behandlungsoption dar, wobei die Transplantation grundsatzlich mit (vaskularisiert) oder ohne gleichzeitigen Gefasanschluss (nichtvaskularisiert) erfolgen kann. Beide Varianten weisen jeweils individuelle Vor- und Nachteile auf. Vaskularisierte Fibulatransplantate sind insbesondere zur Uberbruckung ausgedehnter segmentaler Knochendefekte und bei Patienten mit adjuvanter Chemo- oder Strahlentherapie geeignet. Nichtvaskularisierte Fibulae – welche den Vorteil eines Regenerationspotenzials an der Entnahmestelle sowie eine deutlich kurzere Operationszeit bieten – konnen hingegen gunstig zur Rekonstruktion hemikortikaler Defekte oder segmentaler Defekte im ersatzstarken Lager eingesetzt werden.

Prosthetic joint infection (PJI) is a severe complication for patients and represents an increasing health problem. At present, very limited data are available on the potential role of periodontopathogenic bacteria in PJI. The aim of this analysis was to compare the presence of periodontopathogenic bacteria in surgically treated patients diagnosed with PJI (study) to that of surgically treated infected orthopedic patients without PJI (controls).Patient records of all orthopedic surgical treatments performed between January 2009 and March 2014 were retrospectively screened. The study group consisted of 996 PJI patients, and the control group of 677 individuals, following surgical treatment of orthopedic infections. During surgery, microbiologic smears were taken and processed by standard procedures for microbiologic diagnosis.Periodontopathogenic bacteria were detected in both groups (4.3% study and 5.6% control group). Nine periodontal pathogenic species from the yellow, violet, and orange complex were identified, without any statistically significant difference between the two groups.Within their limits, the presented results indicate that periodontal bacteria may contribute similarly to PJI and other surgically treated orthopedic infections. The finding that periodontal pathogenic bacteria were identified in both groups highlights the importance of oral infection control prior to orthopedic surgery.

Background Patients with sarcoma are particularly vulnerable to psychosocial distress. The aim of this study was to collect preliminary data on the prevalence of psychosocial distress in such patients during follow-up care and identify risk factors associated with higher psycho-oncological stress levels. Patients and methods The study retrospectively enrolled 202 patients with bone or soft-tissue sarcomas who underwent routine psychosocial distress screening during their follow-up care. All patients were screened using an electronic cancer-specific questionnaire. Results Females and patients who underwent radiotherapy were more distressed. Psychosocial distress levels were markedly higher in the early postoperative phase, but approximately one-third of patients showed high psychosocial distress levels even more than 2 years postoperatively. Conclusion The results underscore the importance of routine psychosocial distress screenings in patients with sarcoma, which should be performed throughout the follow-up period.

Background/aim: Psycho-oncological distress is a relevant clinical problem. The aim of this study was to administer a standardized psycho-oncological distress screening for early identification and indication-based treatment of highly distressed orthopedic cancer patients as well as the evaluation of distress patterns. Patients and Methods: In total, 35 patients with cancer were psycho-oncologically screened using a cancer-specific expert rating scale (Basic Documentation for Psycho-Oncology Short Form) at three different time points (day of admission, day before discharge, 3 months postoperatively). Psycho-oncological support was offered to all patients whose distress exceeded a defined cut-off value. Results: Levels of distress in approximately 51% of patients exceeded the cut-off value at the time of admission and these patients received psycho-oncological support. The high distress levels decreased significantly over time. Patients whose distress did not exceed the cut-off value at the first assessment showed low distress levels at all time points. Conclusion: A relevant number of orthopedic tumor patients suffer from psychosocial distress. Standardized screening might help to identify and adequately treat those patients.

To evaluate utility of magnetic resonance (MR) imaging in local staging of soft-tissue sarcoma, with an emphasis on assessment of neurovascular encasement.Institutional review board approval was obtained; informed consent requirement was waived. Preoperative MR images in 174 patients with soft-tissue sarcoma were analyzed by two readers. Tumor staging according to the American Joint Committee on Cancer/Union International Contre le Cancer and Enneking staging systems and analysis of osseous and articular invasion were performed. To assess neurovascular encasement, contact between tumor and arteries, between tumor and veins, and between tumor and nerves was classified (no contact, contact ≤90°, 91°-180°, 181°-270°,271°). Interobserver agreement was determined; imaging findings were correlated with intraoperative findings and/or histopathologic findings (Pearson correlation coefficient [r] and Cohen κ coefficient).Intraoperative evaluation and/or histopathologic evaluation confirmed osseous, articular, and neurovascular invasion in 8.6%, 2.9%, and 25.3% of patients. Interobserver agreement was excellent for tumor staging (American Joint Committee on Cancer/Union International Contre le Cancer staging, κ = 0.811; Enneking staging, κ = 0.943) and osseous invasion (κ = 1.000). It was substantial for articular invasion (κ = 0.794). Sensitivity and specificity for osseous invasion were 100% and 98.7%, respectively (both readers). For articular invasion, sensitivity was 80% (both readers); specificities were 100% and 98.8% for readers 1 and 2, respectively. Interobserver agreement in quantifying contact between tumor and vessels and between tumor and nerves was excellent for arteries, veins, and nerves (κ = 0.845, 0.892, 0.893, respectively). Receiver operating characteristic analysis revealed optimal threshold of greater than 180° for prediction of arterial and venous encasement (both readers). For neural encasement, optimal threshold was greater than 180° (reader 1) and greater than 270° (reader 2). Sensitivities in diagnosing encasement for arteries, veins, and nerves were 84.6%, 84.6%, and 77.8% (reader 1) and 84.6%, 84.6%, and 72.2% (reader 2). Specificities for encasement of arteries, veins, and nerves, respectively, were 97.5%, 97.5%, and 93.2% (reader 1) and 93.8%, 94.7%, 97.3% (reader 2).MR imaging allows reliable and accurate local staging of soft-tissue sarcoma. Encasement of arteries, veins, and nerves should be diagnosed, if the contact between tumor and vascular or neural circumference exceeds 180°.

Background Soft tissue sarcomas are rare entities with over 50 histological subtypes. Liposarcoma (LS) is the most common neoplasm in this group; it is a complex neoplasm that is divided into different histological subtypes. Different therapy options, such as surgical resection, radiation, and chemotherapy, are available. Depending on the subtype, location, status of the resection margins and metastatic status, different therapy options are used. Therefore, the aim of this study was to determine the prognostic factors influencing the survival of patients affected by LS with consideration for the grading, histological subtype, state of the resection margin, size, location, metastases and local recurrence in a retrospective, single-centre analysis over 15 years. Methods We included 133 patients (male/female = 67/66) in this study. We recorded the histologic subtype, grade, TNM classification, localization, biopsy technique, tumour margins, number of operations, complications, radiation and dose, chemotherapy, survival, recrudescence, metastases and follow-up. Survivorship analysis was performed. Results We detected 56 (43%; 95%-CI 34.6–51.6%) atypical LS cases, 21 (16.2%; 95%-CI 9.8–22.5) dedifferentiated LS cases, 40 (30.8%; 95%-CI 22.8–38.7) myxoid LS cases and 12 (9.2%; 95%-CI 4.3–14.2) pleomorphic LS cases. G1 was the most common grade, which was followed by G3. Negative margins (R0) were detected in 67 cases (53.6%; 95%-CI 44.9–62.3) after surgical resection. Local recurrence was detected in 23.6% of cases. The presence of metastases and dedifferentiated LS subtype as well as negative margins, grade and tumour size are significant prognostic factors of the survival rates (p

Background: The purpose of this study was to investigate whether pathological fractures (PF) influence the prognosis of patients with osteosarcoma (OS) or Ewing tumor (ET) regarding 5-year survival, occurrence of metastases, and local recurrence. Methods: We retrospectively analyzed 205 patients with metastatic and nonmetastatic OS or ET. Survival analysis was performed for all patients and differentiated for patients with OS (n = 127) and ET (n = 78) as well as for adults (n = 101) and children (n = 104). Results: Patients with PF showed survival rates of 64% compared to 83% for those without PF (p = 0.023). Local recurrence occurred in 7% of the patients without and in 24% of those with PF (p = 0.023). In patients with ET and in children, survival analysis showed no significant difference between patients with and without PF in survival and local recurrence rates. In patients with OS, survival rate decreased from 83 to 59% (p = 0.024) and local recurrence rate increased from 13 to 30% (p = 0.042). In adults, survival rate decreased from 78 to 51% (p = 0.004) and local recurrence rate increased from 13 to 42% (p < 0.001). In multivariate analysis, age and PF were associated with inferior survival. Conclusion: This study suggests that the occurrence of PF has a negative impact on survival and implicates an increased risk of local recurrence. In children and in patients with ET, PF did not have a prognostic impact.

Im multimodalen Therapiekonzept bei Knochensarkomen ist die Tumorresektion einer der entscheidenden Faktoren. Moderne Verfahren der Bildgebung haben die praoperative Planung wesentlich vereinfacht und erlauben prazise die Festlegung von Tumorgrenzen. Nachdem in den letzten Jahrzehnten klar belegt wurde, dass Kompartmentresektionen gegenuber einer weiten Resektion sowohl hinsichtlich der Lokalrezidivrate, wie auch des Gesamtuberlebens keine signifikanten Verbesserungen bringen, bleibt unklar, wie „weit“ tatsachlich eine „weite Resektion“ erfolgen sollte. Auswertung der Literatur der letzten 15 Jahre, Diskussion von Grundlagenarbeiten und multidisziplinare Expertenempfehlungen aus relevanten multinationalen Studien. Eine intralasionale Resektion (R1) ist lediglich bei hochdifferenzierten (G1) Chondrosarkomen zulassig. Sowohl bei Osteosarkomen, wie auch bei Ewing-Sarkomen ist die R0-Resektion anzustreben. Gelingt diese nicht, finden sich beim Osteosarkom Belege, die in diesen selektiven Fallen eine adjuvante Strahlentherapie rechtfertigen, sollte eine Nachresektion nicht moglich sein. Bei Patienten mit Ewing-Sarkomen sollte in Erwartung einer R1-Resektion (z. B. in kritischen Lokalisationen wie dem Becken) besser auf eine solche verzichtet werden und stattdessen die alleinige Strahlentherapie erfolgen als sich von der Kombination beider Verfahren eine „Heilung“ des kontaminierten Resektionsrandes zu versprechen. Hinsichtlich der notwendigen Sicherheitsabstande bei einer klaren R0-Resektion sind die Empfehlungen der Literatur heterogen. Letztlich kommt neben der reinen Distanzmessung naturlich auch der anatomischen Qualitat des Resektionsrandes (z. B. Faszie) grose Bedeutung zu. Eine eindeutige Empfehlung im Sinne mindestens x Millimeter oder Zentimeter ist mit aktuell vorliegenden Daten nicht zu begrunden. Ziel der Resektion eines Knochensarkoms sollte bis auf die Ausnahme Chondrosarkom (G1) eine weite Resektion sein. Ultraradikale Resektionen unter Mitnahme von vitalen Strukturen zur Vergroserung eines absehbar bereits im Gesunden (R0) verlaufenden Resektionsrandes zeigen keine belegbaren Vorteile. Kann eine Resektion mit ggf. Nachresektion nicht in Sano (also nur R1) durchgefuhrt werden, sollte bei Osteosarkomen eine zusatzliche Strahlentherapie erfolgen. Patienten mit Ewing-Sarkomen sollten unter dieser Bedingung gar nicht reseziert werden. Bei Chondrosarkomen sind die vorliegenden Daten, z. B. aus dem Beckenbereich, widerspruchlich und erlauben keine klare Festlegung.

Die chirurgische Therapie muskuloskelettaler Tumoren wird masgeblich von der Dignitat sowie Faktoren wie anatomische Lage, Beziehung zu neurovaskularen Strukturen, Patientenalter, Lebenserwartung und Funktionsanspruch beeinflusst. Die Defektrekonstruktion kann in biologische und endoprothetische Rekonstruktionen unterteilt werden. Modulare Endoprothesen finden aufgrund ihrer freien Verfugbarkeit, Kosteneffektivitat und der relativ kurzen Rehabilitationsdauer breite Anwendung, jedoch bei hohen Komplikationsraten. Zu den biologischen Rekonstruktionstechniken, die jeweils individuelle Vor- und Nachteile aufweisen, zahlen Allografts bzw. vaskularisierte/nicht vaskularisierte Autografts, Explantation-Replantation (mit Devitalisierung des tumortragenden Segments), Masquelet-Technik und Kallusdistraktion. Indikationsspektrum, mogliche Versagensgrunde der einzelnen Methoden sowie Grundsatzen der Behandlung muskuloskelettaler Tumoren werden erlautert.

Surgery in metastatic bone disease is currently the most frequent type of surgery in orthopedic oncology. Improved survival rates and an increasing incidence of bone metastasis have led to an increase in complications caused by metastatic disease, such as pathological fractures or hardware failure after operative treatment. Although surgery of metastatic lesions remains a palliative therapy concept, because of sufficient therapy for the primary carcinomas, tumor-specific-oriented follow-up protocols and a variation in the prognosis for the individual entities, an individually adapted treatment strategy is necessary. Depending on the life expectancy, more aggressive surgical procedures with the goal of adequate local tumor control have come into focus. Therefore, prognosis-tailored treatment requires an experienced team and should be performed in a multidisciplinary tumor center. The current article provides an overview of recent therapy concepts for the surgical treatment including endoprosthetic reconstruction, internal fixation with either intramedullary nailing or plate fixation devices, often augmented with bone cement.

Studienziel Die Biopsie stellt in der Diagnostik maligner Tumoren des Bewegungsapparats einen wesentlichen Schritt dar. Ziel ist immer die Gewinnung einer reprasentativen Gewebeprobe unter Beachtung des spateren Zugangswegs fur die definitive Operation. Ziel dieser Studie war es daher, die Vorgehensweisen der tumororthopadischen Kliniken in Deutschland im Rahmen einer anonymisierten Umfrage zu erfassen und so die aktuellen Versorgungsmoglichkeiten aufzuzeigen.

Die Hirnschadigung bei der Zerebralparese ist nicht progredient, die peripheren Auswirkungen am Skelettsystem sind aber durch die Einwirkung des Wachstums und der Schwerkraft wechselnd. Bei der Analyse spastischer Fusdeformitaten mussen die unterschiedlichen Mechanismen, die zur jeweiligen Deformitat fuhren, berucksichtigt werden. Operative Verfahren haben zum Ziel, Deformitaten zu korrigieren und ausreichend Kraft und Stabilitat wiederherzustellen, funktionelle Beweglichkeit zu erhalten und ein Muskelgleichgewicht zu schaffen. Die haufigsten spastischen Fusdeformitaten sind der Spitzfus, der Knick-Plattfus, der Klumpfus und der Hackenfus. Fur die Therapie kommen Weichteiloperationen wie Muskelverlangerungen und -verlagerungen und knocherne Operationsverfahren wie Osteotomien und Arthrodesen zum Einsatz. Oft sind Kombinationen dieser Verfahren erforderlich. Postoperativ erfolgt zunachst eine Ruhigstellung im Unterschenkelgips. Anschliesend sind temporar Funktions- und Lagerungsorthesen notwendig, um das erreichte Ergebnis zu schutzen.

Tumore des Bewegungsapparates sind sehr seltene Erkrankungen Je nach biologischem Verhalten werden (vereinfacht) unterschieden (Tab. 5.1) Benigne: Lokal expansives Wachstum, keine Metastasierungstendenz Semimaligne (Synonym: Intermediare, ungewisse Dignitat, Borderline-Lasionen): Lokal aggressives Wachstum mit seltener, in der Regel erst nach mehrfachen Rezidiven auftretender, Metastasierungstendenz Maligne: Lokal aggressives Wachstum, Metastasierungstendenz. Unterschiedliche Graduierungen sind beschrieben Die Prognose von Knochen- und Weichteilsarkomen hangt wesentlich vom Grading ab: 5-Jahres-Uberlebensrate (JUR) bei G1-Tumore ca. 75 %, G2-Tumore ca. 50 %, G3/4-Tumore 25 % Benigne Knochentumore sind haufig Zufallsbefunde, oft ohne therapeutische Konsequenz. Die Inzidenz ist deshalb fur viele Lasionen nicht bekannt Knochensarkome: Auftreten gehauft in 2.-3. Lebensdekade Inzidenz: 0,8–4/100.000/Jahr 0,2 % aller Neoplasien Haufigstes primares Knochensarkom (Gesamtanteil von 40 % an allen malignen Knochentumoren): Osteosarkom (ca. 150 Falle pro Jahr in Deutschland) Weichteilsarkome: Auftreten gehauft ab 50. Lebensjahr, wobei 40 % der Patienten alter als 55 Jahre sind Inzidenz: 1-2/100.000/Jahr < 1 % aller malignen Neoplasien 1–15 % aller Weichteiltumore sind maligne Knochensarkome:Weichteilsarkome = 1:10

Operationsziel Behandlung von Tumoren des Beckenrings durch Resektion eines Teils oder des gesamten Os innominatum unter Erhalt der Extremitat (innere Hemipelvektomie). Implantation und stabile Verankerung einer „Custom-made“-Megaprothese zur Wiederherstellung einer schmerzfreien Gelenkfunktion und Belastbarkeit. Moglichst weite Resektion und lokale Tumorkontrolle.

Ziel der Operation ist die onkologisch adaquate Resektion von Tumoren der proximalen Tibia unter Erhalt der Extremitat. Durch die Implantation einer Spezialprothese mit Scharniergelenk und die alloplastische Augmentation des Streckapparats mit einem textilen Kunstband konnen Funktion und Stabilitat des Kniegelenks wiederhergestellt werden. Primare Knochen- oder Weichteilsarkome. Aggressiv wachsende benigne oder semimaligne Lasionen oder Metastasen (bei Strahlenresistenz und/oder guter Prognose). Schlechter Allgemeinzustand mit eingeschrankter Operationsfahigkeit. Ausgedehnte Metastasierung mit Lebenserwartung unter 6 Monaten. Weitflachige Tumorpenetration durch die Haut. Lokaler Infekt oder therapieresistente Osteomyelitis. Mangelnde Kooperationsbereitschaft. Groser poplitealer extraossarer Tumoranteil mit Befall der neurovaskularen Strukturen. Der Hautschnitt reicht vom anteromedialen Aspekt des distalen Oberschenkels bis etwa zum distalen Drittel des medialen Unterschenkels. Es erfolgt zunachst die Praparation eines medialen und lateralen fasziokutanen Lappens. Die poplitealen Gefase werden durch einen medialen Zugang dargestellt. Es erfolgt ein Release des Pes anserinus und der Sehne des M. semimembranosus. Der mediale Kopf des M. gastrocnemius wird mobilisiert und der M. soleus von der Tibiahinterflache abgelost. Ligatur der A. und V. tibialis anterior. Ist das Kniegelenk nicht vom Tumor befallen, folgt die zirkumferentielle Eroffnung der Gelenkkapsel. Nach Ablosung des Lig. patellae erfolgt die Osteotomie des Tibiaschafts entsprechend der praoperativen Planung. Um adaquate Resektionsrander zu erreichen, muss in einigen Fallen eine En-bloc-Resektion des Tibiofibulargelenks erfolgen. Hierzu wird – abhangig von der Resektionshohe der Fibula – der N. peroneus dargestellt. Teile des M. tibialis anterior und M. soleus sowie der M. popliteus verbleiben am Resektat. Vorbereiten der femoralen Oberflachenresektion. Nach Implantation der Prothese erfolgen die Kopplung des femoralen und tibialen Gelenkteils sowie die Rekonstruktion des Streckapparats mit einem Kunstband. Dieses wird transversal durch das distale Ende der Quadrizepssehne als Schlinge um die Patellabasis gefuhrt und durch das mediale und laterale Retinakulum subsynovial nach distal geleitet. Beide Enden des Bands werden im Klemmblock des Tibiateils unter Vorspannung fixiert. Die abgelosten Sehnen und verbleibende Bandstrukturen konnen an vorgefertigten Osen der Prothese refixiert werden. Zur Weichteildeckung der tibialen Prothese kommt ein medialer Gastrocnemiusmuskellappen zum Einsatz. Postoperative Bettruhe und strikte Hochlagerung des operierten Beins fur 5 Tage, dann Lappentraining. Mobilisierung in einer Kniegelenkschiene in Streckstellung mit Entlastung der Extremitat fur 6 Wochen. Wahrend dieser Zeit schrittweise Zunahme der aktiven Flexion bis 90°, isometrisches Quadrizepstraining. Danach Beginn mit aktiver Extension, schrittweise Freigabe des Bewegungsumfangs der Schiene um 30° jede 2. Woche. Aufbelastung um 10 kg pro Woche. Thromboseprophylaxe bis zur Vollbelastung. Regelmasige Nachuntersuchungen mit Anamnese, korperlicher Untersuchung und radiologischer Befunderhebung. Ausschluss eines Lokalrezidivs und Metastasensuche. Zwischen 1988 und 2009 erfolgte bei 17 konsekutiven Patienten (9 Frauen, 8 Manner) mit einem Durchschnittsalter von 31,1 Jahren (11–65 Jahre) eine endoprothetische Versorgung und alloplastische Rekonstruktion des Streckapparats nach Resektion eines Tumors der proximalen Tibia. Im postoperativen Verlauf kam es zu keinem Lokalrezidiv. Bis zum Nachuntersuchungszeitpunkt verstarben 5 Patienten aufgrund des Tumorleidens. Bei 53,9% der Patienten waren im Verlauf ein oder mehrere operative Revisionseingriffe notig. Nach Kaplan-Meier lag das Implantatsurvival mit dem Endpunkt Prothesenteilwechsel bzw. distaler Oberschenkelamputation nach 5 Jahren bei 53,6% bzw. nach 10 Jahren bei 35,7%. In 2 Fallen erfolgte aufgrund einer tiefen Infektion eine distale Oberschenkelamputation. Bei 3 Patienten musste der Tibiastiel infolge Materialbruchs bzw. aseptischer Lockerung gewechselt werden. In 3 weiteren Fallen war ein Gelenkteilwechsel notig. Weitere Komplikationen waren 2 oberflachliche Wundheilungsstorungen. In 3 Fallen kam es zu einer postoperativen Peroneusparese, die bei einem Patienten im Verlauf rucklaufig war. Der durchschnittliche Oxford-Knee-Score von 9 der insgesamt 12 noch lebenden Patienten lag bei 30,7 ± 7,5 Punkten (24–36 Punkte). Bei keinem Patienten konnte ein klinisch relevantes Streckdefizit beobachtet werden. Das durchschnittliche Bewegungsausmas zum Zeitpunkt der Nachuntersuchung lag bei 90,2 ± 26,7° (35–130°). Alle Patienten waren mit dem postoperativen Ergebnis zufrieden.

Osteosarcomas are aggressive bone tumours with a high degree of genetic heterogeneity, which has historically complicated driver gene discovery. Here we sequence exomes of 31 tumours and decipher their evolutionary landscape by inferring clonality of the individual mutation events. Exome findings are interpreted in the context of mutation and SNP array data from a replication set of 92 tumours. We identify 14 genes as the main drivers, of which some were formerly unknown in the context of osteosarcoma. None of the drivers is clearly responsible for the majority of tumours and even TP53 mutations are frequently mapped into subclones. However, >80% of osteosarcomas exhibit a specific combination of single-base substitutions, LOH, or large-scale genome instability signatures characteristic of BRCA1/2-deficient tumours. Our findings imply that multiple oncogenic pathways drive chromosomal instability during osteosarcoma evolution and result in the acquisition of BRCA-like traits, which could be therapeutically exploited., Osteosarcomas are a heterogenous group of tumours and little is known about how these tumours evolve. Here, Kovac et al. use exome sequencing and discover that although no driver gene explains the majority of these tumours, they are characterized by specific mutation signatures and genomic instability typical of BRCA1/2-deficient tumours.

Unter der Vielzahl moglicher Tumorerkrankungen sind primare Neoplasien des Skeletts vergleichsweise selten. Primar maligne Knochentumoren zeigen eine jahrliche Inzidenz von knapp 10 Erkrankungen pro 1 Mio. Einwohner. Im Kindesalter ist der Anteil maligner Knochentumoren mit 6% aller kindlichen Malignome groser als der entsprechende Anteil bei Erwachsenen. Der Altersgipfel der Gesamtheit aller Knochentumoren liegt zwischen 15 und 19 Jahren. Am haufigsten sind das Osteo- (35%), das Chondro- (25%) und das Ewing-Sarkom (16%). Seltener (≤ 5%) folgen Entitaten wie das Chordom, das primare maligne fibrose Histiozytom (MFH) des Knochens und das Fibrosarkom des Knochens. Vaskulare primare maligne Knochentumoren und das Adamantinom sind sehr selten. Das fur eine systematische Therapieableitung notwendige Staging beinhaltet eine vollstandige bildgebende Diagnostik und die histopathologische Diagnosesicherung der Entitat, welche im Fall von malignen Knochentumoren meist uber eine Probebiopsie erfolgt. Darauf basierend muss in einer interdisziplinaren Tumorkonferenz das individuelle therapeutische Vorgehen festgelegt werden. Die operative Therapie beinhaltet dabei zumeist die weite Tumorresektion und anschliesende Rekonstruktion. Die engmaschige, kontinuierliche Tumornachsorge ist von essenzieller Bedeutung fur die Prognose und sollte ublicherweise im behandlungsfuhrenden Tumorzentrum fortgefuhrt werden.

Primary sarcoma of bone is a rare entity but nevertheless a significant cause of mortality in children and adolescents. The focus of the preoperative evaluation is to set up a histological diagnosis, define local tumor extent and develop a therapy regimen. In addition to patient history and clinical findings a radiograph in two orthogonal planes is still of great importance. MRI plays a major role in the further clarification of the diagnosis, while CT is valuable in the diagnosis of tumors of the axial skeleton as well as in systemic staging. A PET-CT can be performed to obtain an overview of further tumor sites. Open bone biopsy is the final diagnostic step and should be carried out at the institution where the definitive treatment will be performed. Complications such as fracture, neural lesions and spread of tumor cells are relatively rare if the biopsy is performed appropriately; however, patients should be instructed to strictly avoid weight-bearing on the affected extremity.

Out of all skeletal metastases 30% are located in the spine as are 10% of primary bone tumors, whereby 52% of metastases occur in the lumbar region, 36% in the thoracic spine and 12% in the cervical spine. Patients suffer from local pain caused by irritation of the periosteum due to rapid growth of the tumor or subsequent pathologic fractures which may lead to compression and neurological impairment with paresthesia, paresis and paraplegia. If the diagnosis cannot be confirmed exactly by radiological imaging and laboratory tests, a biopsy should be performed. A precise diagnosis of the tumor entity as well as an estimation of the prognosis provides an important basis for further decision-making. The aim of therapy is pain relief and stabilization by operative and non-operative measures. Therapy is palliative with the aim of pain relief and preservation of mobility. In cases of solitary metastasis a curative operative treatment should be performed.

We report the case of a young female patient who received a total hip replacement due to pain in her left hip joint, misdiagnosed as degenerative arthritis. A clear cell chondrosarcoma (CCCS) in the femoral head had initially not been detected. Seven years later, a periprosthetic recurrence of CCCS close to the former femoral osteotomy occurred. Although a sample of the periprosthetic tumour had been taken for histologic analysis, the recurrence of CCCS remained misdiagnosed for almost 2 years until this rare histopathologic morphology was examined in a specialised multidisciplinary tumour centre. Finally, revision surgery with wide tumour resection margins had to be performed requiring the removal of the total hip replacement and its reconstruction using a modular megaimplant (proximal femoral replacement). Relevant facts of the CCCS as a rare entity regarding histology, treatment and differential diagnoses are discussed.

Extensive bone loss, as encountered in both revision arthroplasty of the hip and after resection of malignant tumors of the pelvis, is a major challenge for the surgeon as well as for the revision implant. The aims are, despite extensive acetabular defects, to achieve a primary and load-stable fixation of the revision prosthesis in the pelvic bone as well as restoring the physiological joint biomechanics. At present, a large number of different alloarthroplastic revision implants and complex techniques are available for reconstruction of acetabular deficiencies. According to D'Antonio's classification of acetabular defects, particularly high-grade defects with loss of the posterior column or a pelvic discontinuity require special attention regarding implant selection and surgical planning. The object of this paper is to highlight the most important tools and techniques of endoprosthetic reconstruction for grade III and IV defects (D'Antonio) of the acetabulum by means of a classification-oriented therapeutic concept and to discuss the pros and cons of the particular implant.

Treatment of soft tissue sarcomas requires an individual plan which considers interdisciplinary recommendations and the various clinical situations. Anatomical region, histological grading and typing, and tumor size necessitate adjusted methods of reconstruction. The biopsy should be performed at the institution where the patient is treated. In general surgical resection of the tumor will be the treatment of choice. Adjuvant therapies are applied according to anatomical region and size and grading of the tumor. Surgery alone is recommended only in small (

Der endoprothetische Ersatz des Huftgelenks ist bei Patienten der alteren Altersgruppe sehr effektiv. Patienten unter 55 Jahren weisen jedoch eine hohere Lockerungsrate auf, weshalb der Oberflachenersatz des Huftgelenks als Alternative fur den jungen aktiven Patienten mit degenerativer Huftgelenkerkrankung entwickelt wurde. Weitere Vorteile liegen in der Erhaltung von Knochensubstanz und Optimierung der Kraftubertragung im Bereich des proximalen Femurs, sowie der besseren Gelenkstabilitat und -beweglichkeit der Hufte. Das Scheitern der ersten Generation des Oberflachenersatzes war weitgehend eine Konsequenz aus der Verwendung ungeeigneter Materialien, schlechtem Implantatdesign und Operationstechnik und nicht ausgereiftem Implantationsinstrumentarium. Dass es nicht ein Problem des Verfahrens selbst war, lasst sich unschwer an den positiven, aktuellen Fruhergebnissen erkennen, bei denen im Vergleich zu den 1970er und 1980er Jahren Fruhlockerungen und Schenkelhalsfrakturen nicht mehr im gleichen Ausmas auftreten. Obwohl Fruhergebnisse immer mit groser Vorsicht interpretiert werden mussen, geben doch die neuen Implantatdesigns mit Metall-Metall-Gleitpaarung bei kritischer Patientenauswahl die Moglichkeit, die Anatomie bestmoglichst zu erhalten und die Funktion wiederherzustellen. Um Implantate fur den Oberflachenersatz mit konstant guten, tribologischen Eigenschaften herzustellen, bedarf es eines hohen technischen Standards. Die Technologie scheint sich im Vergleich zu den fruheren Implantaten erheblich verbessert zu haben, jedoch bleiben nach wie vor Unklarheiten bezuglich der moglichen biologischen Effekte erhohter Serumspiegel von Metallionen bei Patienten mit Metall-Metall-Gleitpaarung. Negative Berichte sind diesbezuglich bisher nicht publiziert. Nur Langzeitergebnisse und die weitere Verbreitung dieser Implantatform werden zeigen, ob der Oberflachenersatz eine dauerhafte Losung fur das arthrotische Huftgelenk ist oder ob es sich um eine moglichst knochenerhaltende Technik vor der Notwendigkeit eines konventionellen Huftgelenkersatzes handelt.

Because of an often excessive tumor extension, radical surgical resection of malignant tumors of the pelvis was possible in only half of our patients. Until now we refused to perform hemicorporectomy. In view of a temporary improvement of the quality of life it seems reasonable to perform these radical and palliative operations, even if a high recurrence rate can be anticipated. As for the survivor-rate, no exact conclusions can be drawn from our results. The possibility of a radical resection is largely dependent upon the tumor's localisation (I, III) i.e. most of the periacetabular tumors additionally involve several regions of the pelvis (II + III + I). In the region of the sacrum (IV) a radical resection could not be achieved in our patients. Functionally, type I and III resections show the best results. These days there is a good chance of achieving a satisfying result with endoprosthetic reconstruction of the pelvis following resection of periacetabular tumors--however a high complication rate has to be taken into account.

The aim of this study was to analyse the gait pattern, muscle force and functional outcome of patients who had undergone replacement of the proximal tibia for tumour and alloplastic reconstruction of the extensor mechanism using the patellar-loop technique. Between February 1998 and December 2009, we carried out wide local excision of a primary sarcoma of the proximal tibia, proximal tibial replacement and reconstruction of the extensor mechanism using the patellar-loop technique in 18 patients. Of these, nine were available for evaluation after a mean of 11.6 years (0.5 to 21.6). The strength of the knee extensors was measured using an Isobex machine and gait analysis was undertaken in our gait assessment laboratory. Functional outcome was assessed using the American Knee Society (AKS) and Musculoskeletal Tumor Society (MSTS) scores. The gait pattern of the patients differed in ground contact time, flexion heel strike, maximal flexion loading response and total sagittal plane excursion. The mean maximum active flexion was 91° (30° to 110°). The overall mean extensor lag was 1° (0° to 5°). The mean extensor muscle strength was 25.8% (8.3% to 90.3%) of that in the non-operated leg (p < 0.001). The mean functional scores were 68.7% (43.4% to 83.3%) (MSTS) and 71.1 (30 to 90) (AKS functional score). In summary, the results show that reconstruction of the extensor mechanism using this technique gives good biomechanical and functional results. The patients’ gait pattern is close to normal, except for a somewhat stiff knee gait pattern. The strength of the extensor mechanism is reduced, but sufficient for walking. Cite this article: Bone Joint J 2015;97-B:1063–9.

Background The aim of the trial is to demonstrate that with the use of modern IMRT/IGRT and reduction of safety margins postoperative wound complications can be reduced. Methods/ Design The trial is designed as a prospective, monocentric clinical phase II trial. The treatment is performed with helical IMRT on the Tomotherapy HiArt System© or with RapidArc© IMRT as available. All treatments are performed with 6 MV photons and daily online CT-based IGRT. A dose of 50 Gy in 2 Gy single fractions (5 fractions per week) is prescribed. Restaging including MRI of the primary tumor site as well as CT of the thorax/abdomen is planned 4 weeks after RT. PET-examinations or any other imaging can be performed as required clinically. In cases of R1 resection, brachytherapy is anticipated in the 2nd postoperative week. Brachytherapy catheters are implanted into the tumor bed depending on the size and location of the lesion. Surgery is planned 5–6 weeks after completion of neoadjuvant RT. All patients are seen for a first follow-up visit 2 weeks after wound healing is completed, thereafter every 3 months during the first 2 years. The endpoints of the study are evaluated in detail during the first (2 weeks) and second (3 months) follow-up. Functional outcome and QOL are documented prior to treatment and at year 1 and 2. Treatment response and efficacy will be scored according to the RECIST 1.1 criteria. A total patient number of 50 with an expected 20 % rate of wound complications were calculated for the study, which translates into a 95 % confidence interval of 10.0-33.7 % for wound complication rate in a binomial distribution. Discussion The present study protocol prospectively evaluates the use of IMRT/IGRT for neoadjuvant RT in patients with soft tissue sarcomas of the extremity with the primary endpoint wound complications, which is the major concern with this treatment sequence. Besides complications rates, local control rates and survival rates, as well as QOL, functional outcome and treatment response parameters (imaging and pathology) are part of the protocol. The data of the present PREMISS study will enhance the current literature and support the hypothesis that neoadjuvant RT with IMRT/IGRT offers an excellent risk-benefit ratio in this patient population. Trial registration NCT01552239

The aim of this study was to analyze the inter- and intra-observer variability regarding biopsy technique in bone and soft tissue sarcoma based on magnetic resonance imaging (MRI).Thirty-seven MRI scans of bone and soft tissue sarcomas treated in our clinic were randomly selected. Six observers with three different expertise levels were assigned to analyze the scans for suspected entity and preferred biopsy technique at 2 time points with a delay of 8 weeks.The differentiation between bone and soft tissue sarcomas in MRI seemed closely related to the observer's level of experience. Regarding biopsy technique, no inter-observer accordance could be identified in either group.We observed an association of inter- and intra-observer agreement regarding suspected tumor entity and the observer's level of experience. The decision for either biopsy technique showed a low inter-observer but high intra-observer variability. These findings suggest that the decision for incisional or core needle biopsy is, even in the expert group, frequently based on personal predilection.

Die Behandlung von Weichteilsarkomen erfordert wegen der hohen Variabilitat der klinischen Situationen eine individuell zugeschnittene, multimodale Therapie. Generell ist fur Patienten mit oberflachlichen Low-Grade-Tumoren 5 cm Durchmesser kann lokale Kontrolle durch Resektion und Strahlentherapie erzielt werden. Jedoch entwickelt mindestens jeder 2. dieser Patienten Metastasen. Bei Patienten mit Lokalrezidiv sollte die Nachresektion diskutiert bzw. durchgefuhrt werden. Die Strahlentherapie ist umso effektiver, je geringer die postoperativ verbliebene Tumorzelllast ist.

Weichteilsarkome sind relativ selten. Doch wenn sich einmal ein maligner Befund bestatigt, dann ist die Prognose des Patienten ganz entscheidend davon abhangig, welche diagnostischen und therapeutischen Masnahmen im Vorfeld stattfanden. Wurde voreilig und unsachgemas operiert, weil „sowas ja fast immer harmlos ist“, kann der Preis fur den Patienten eine viel grosere Folge operation sein, im Extremfall die Amputation oder der Tod.

Background To date, the pathomechanism of soft tissue sarcomas such as synovial sarcoma remains unclear whereas even a viral etiology was suspected. Aim of this study was to analyze whether EBV, HHV-8 or HPV play a role in the development of synovial sarcomas. Findings In total 41 synovial sarcomas were included in this retrospective study. For detection of EBV 1/2 and HHV-8, resection specimens were analyzed with regard to virus-specific sequences using a SingleStep PCR. HPV analysis was carried out by an HPV-specific multiplex-PCR and subsequent array-hybridization for HPV-typing. No virus-specific DNA of EBV, HHV-8 or HPV was detected. Conclusion An involvement of these viruses in the etiology of synovial sarcoma was not detected but further studies are needed with different virus types and sarcoma entities.

Die Behandlung von chronischen Ruckenschmerzen mit radikularer Symptomatik ist ein bis heute nicht gelostes klinisches Problem. Die von Gabor Racz beschriebene Neurolyse in perkutaner minimal-invasiver Technik wird zunehmend zur Behandlung der chronischen Radikulopathien eingesetzt und kontrovers diskutiert. Ein Wirksamkeitsnachweis oder prospektiv randomisiert kontrollierte Studien, die eine Wirksamkeit zeigen, fehlen bisher. In einer prospektiven Pilotstudie wurden 25 Patienten nach erfolgloser konservativer Therapie mit monosegmentalen chronischen Radikulopathien im Bereich der Lendenwirbelsaule mit der minimal-invasiven perkutanen epiduralen Neurolyse in der Kathetertechnik nach Racz behandelt. Die Ursache der Beschwerden waren Bandscheibenvorfalle oder ein Postnukleotomiesyndrom mit Nervenwurzelbeteiligung. Das mittlere Alter der Patienten lag bei 51±16 Jahren,die durchschnittliche Schmerzanamnese betrug 28 Monate. 12 Wochen nach perkutaner minimal-invasiver epiduraler Neurolyse kam es zu einer deutlichen klinischen Verbesserung. Der Oswestry-Score verbesserte sich nach 12 Wochen von praoperativ 64±17 auf 22±12 Punkte. Auch die subjektive Schmerzempfindung, quantifiziert nach dem McNab-Score,zeigte eine deutliche Verbesserung. In keinem Fall kam es zu einer Verschlechterung im Vergleich zum Ausgangsbefund. Es traten keine klinisch relevanten Komplikationen auf. Die vorliegenden Ergebnisse wurden zur Planung einer Studie zum Wirksamkeitsnachweis verwendet. Die Kathetertechnik nach Racz bleibt weiter eine klinisch experimentelle Behandlungsmethode, deren Einsatz jedoch aufgrund der geringen Nebenwirkungswahrscheinlichkeit und den bislang vorliegenden guten Ergebnissen anderer Studien zur Behandlung der chronischen und konservativ therapieresistenten Radikulopathie gerechtfertig ist.

Carbon fiber-reinforced plastics have been used clinically as an implant material for different applications for over 20 years.A review of technical basics of the composite materials (carbon fibers and matrix systems), fields of application,advantages (e.g., postoperative visualization without distortion in computed and magnetic resonance tomography), and disadvantages with use as an implant material is given. The question of the biocompatibility of carbon fiber-reinforced plastics is discussed on the basis of experimental and clinical studies. Selected implant systems made of carbon composite materials for treatments in orthopedic surgery such as joint replacement, tumor surgery, and spinal operations are presented and assessed. Present applications for carbon fiber reinforced plastics are seen in the field of spinal surgery, both as cages for interbody fusion and vertebral body replacement.

Seit uber 20 Jahren wird die extrakorporale Stoswellentherapie (ESWT) in grosen Zahlen angewendet. Trotz guter und zahlreicher klinischer und experimenteller Arbeiten ist uber den Wirkmechanismus wenig bekannt. Mittels verbesserter messtechnischer Verfahren konnten zunehmend einzelne technische Parameter festgestellt und quantifiziert werden. Inwieweit diese unter Laborbedingungen gefundenen Parameter auf In-vivo-Bedingungen ubertragen werden konnen, ist bislang unklar.

Bei der interkorporellen Fusion von Wirbelsaulensegmenten werden als Platzhalter neben autogenem und allogenem Knochen zunehmend sog. Cages aus Metall oder Kunststoff eingesetzt. Ziel dieser Studie war die mechanische Testung von Cages zur anterioren lumbalen interkorporellen Fusion aus kohlenstoffaserverstarktem Kunststoff (CFRP). In Anlehnung an ASTM-Normen wurden mittels spezieller Prufvorrichtungen die mechanischen Implantateigenschaften unter 4 verschiedenen Lastbedingungen ermittelt. Die Implantate (UNION Cages, Medtronic Sofamor Danek) zeigten seitens des Grundkorpers eine hinreichende Kompressions-, Scher- und Torsionsfestigkeit. Die axiale Bruchlast der Fuhrungsleisten ist jedoch niedriger als physiologische Druckbelastungen in Lumbalsegmenten. Deswegen mussen intraoperativ in adaquater Technik parallele Ausfrasungen (Rinnen) entsprechend der Fuhrungsleisten-Geometrie in die Wirbelkorper-Endplatten eingebracht werden. Die Druckkrafte werden dann vom Grundkorper aufgenommen, und die Fuhrungsleisten sind vor schadlichen Belastungen geschutzt. Unter Verwendung einer zusatzlichen ventralen bzw. dorsalen Stabilisierung ist ein In-vivo-Versagen der Fuhrungsleisten infolge physiologischer Scher- und Torsionsbelastungen nicht zu erwarten. Aufgrund spezifischer Komplikationen autogener und allogener Knochenspane sind Cages aus Metall oder faserverstarkten Kunststoffen eine wichtige Implantat-Alternative bei interkorporellen Fusionseingriffen.

Therapies targeting programmed death 1-(PD-1) or its ligand (PD-L1), promoting antitumor T-cell activity have been successfully introduced into clinical practice. Clinical response correlates with PD-L1 expression by tumor cells or immune cells within the tumor microenvironment. The PD-L1/PD-1 axis and tumor microenvironment has been rarely studied in high-grade sarcomas of soft tissue (hSTS), a group of rare, genetically heterogenous and clinically aggressive tumors. We examined PD-L1 protein and CD274/PD-L1 gene copy number variations in 128 primary resected, therapy-naive hSTS using immunohistochemistry and fluorescence-in-situ hybridization. Frequency of tumoral PD-L1 expression varied widely in different disease subentities, with highest rates of positivity (40%) seen in undifferentiated pleomorphic sarcomas (UPS) and rare positivity detected in synovial sarcomas (6%). Amplification of the CD274/PD-L1 gene occurred in 14% of UPS and was rare in other subtypes. PD-L1 protein expression was significantly more frequent in CD274/PD-L1 amplified cases (p = 0.015). The subgroup of UPS was further characterized regarding the interaction between PD-L1 and the immunologic tumor microenvironment. High density of CD3+ and CD8+ tumor infiltrating lymphocytes (TILs) was significantly correlated with the presence of PD-L1 expression and seen more frequently in tumors with lower TNM stage (p = 0.024). Both, PD-L1 expression and high density lymphocytic infiltration were independent prognostic factors for a favorable overall (p = 0.001, HR 6.105 (2.041–8.258)), disease-specific (p = 0.003, HR 10.536 (2.186–50.774)) and disease-free survival (p = 0.020, HR 3.317 (1.209–9.106); values for CD8) in this particular subgroup of hSTS, whereas PD-L1 expression in TILs or CD274/PD-L1 gene amplification were not associated with outcome. These findings represent novel insights into the immune landscape of soft tissue sarcomas, in particular UPS and strengthen the rationale for immunotherapy, including targeting the PD-1/PD-L1 axis in these tumors.

Radiation therapy plays an essential part in modern treatment regimes of musculoskeletal tumors. Nevertheless damage to the surrounding tissue does occur inevitably. Postradiogenic changes of bone are associated with decreased stability and an increased fracture rate. The orthopedic surgeon therefore faces a challenging situation with altered bone metabolism, changes in perfusion and soft tissue problems.We present 3 cases of radiation induced fractures during the treatment of soft tissue tumors, all of which received radiation doses of58 Gy. All fractures occurred over 1 year after the exposure to radiation in otherwise uneventful follow ups.Postoperative follow up showed fracture healing or in the case of the arthroplasty, osseous integration without further complications.Radiation doses of ≥ 58 Gy are a major risk factor for pathological fractures in long bones. Regardless of their low incidence, fracture rates between 1,2 and 6,4 % prove their importance. Local tumor control has therefore to be weighed against the resulting decrease in bone quality and stability. Treatment options should always take into consideration the increased risk for complications such as infection, pseudarthroses and wound healing disorders. Our results show that substitution of vitamin D and calcium as well as the the use of reamed intramedullary implants benefits the outcome.

Background In recent years, scientific research has increasingly focused on malignancies during pregnancy. However, the development of musculoskeletal tumors during pregnancy has only been the subject of a few studies so far. The primary aim of this study was to identify the incidence of sarcomas during pregnancy at our musculoskeletal tumor center (MSTC). Secondarily we intended to analyze these cases and discuss possible recommendations regarding diagnostic work-up as well as therapy on the basis of the literature. Methods All female patients who had been treated for soft tissue or bone sarcoma at our academic MSTC in the period between the years 2002 and 2010 were screened retrospectively for anamnestic annotations of pregnancy or records of pregnancy in the obstetrical database of our university hospital. The patients who met the criteria for inclusion (diagnosed sarcoma and pregnancy) were enrolled. For every pregnant patient two age-matched female control patients that suffered from tumors with the same histologic type were included. Results In the period between 2002 and 2010, 240 female patients between the age of 16 and 45 were treated for sarcoma. In eight out of the 240 cases the tumor disease developed or progressed during pregnancy. The delay in diagnosis was approximately eight months and turned out to be significantly higher for pregnant patients compared to non- pregnant controls. Each woman’s tumor was misdiagnosed at least once. Conclusions Diagnostic follow-up of pregnant women presenting with a growing or painful mass, which is suspected to be a musculoskeletal tumor, should be performed at a specialized tumor center. We recommend a multidisciplinary approach and discussing all possible consequences for mother and child intensively in accordance with the available literature.

We sought to analyse clinical and oncological outcomes of patients after guided resection of periacetabular tumours and endoprosthetic reconstruction of the remaining defect.From 1988 to 2008, we treated 56 consecutive patients (mean age 52.5 years, 41.1 % women). Patients were followed up either until death or February 2011 (mean follow up 5.5 years, range 0.1-22.5, standard deviation ± 5.3). Kaplan-Meier analysis was used to estimate survival rates.Disease-specific survival was 59.9 % at five years and 49.7 % at ten and 20 years, respectively. Wide resection margins were achieved in 38 patients, whereas 11 patients underwent marginal and seven intralesional resection. Survival was significantly better in patients with wide or marginal resection than in patients with intralesional resection (p = 0.022). Survival for patients with secondary tumours was significantly worse than for patients with primary tumours (p = 0.003). In 29 patients (51.8 %), at least one reoperation was necessary, resulting in a revision-free survival of 50.5 % at five years, 41.1 % at ten years and 30.6 % at 20 years. Implant survival was 77.0 % at five years, 68.6 % at ten years and 51.8 % at 20 years. A total of 35 patients (62.5 %) experienced one or more complications after surgery. Ten of 56 patients (17.9 %) experienced local recurrence after a mean of 8.9 months. The mean postoperative Musculoskeletal Tumor Society (MSTS) score was 18.1 (60.1 %).The surgical approach assessed in this study simplifies the process of tumour resection and prosthesis implantation and leads to acceptable clinical and oncological outcomes.

To evaluate magnetic resonance (MR) perfusion and diffusion imaging characteristics in patients with transient bone marrow edema (TBME), avascular necrosis (AVN), or subchondral insufficiency fractures (SIF) of the proximal femur.29 patients with painful hip and bone marrow edema pattern of the proximal femur on non-contrast MR imaging were examined using diffusion-weighted and dynamic gadolinium-enhanced sequences. Apparent diffusion coefficients (ADCs) and perfusion parameters were calculated for different regions of the proximal femur. Regional distribution and differences in ADC values and perfusion parameters were evaluated.Seven patients presented with TBME, 15 with AVN and seven with SIF of the proximal femur. Perfusion imaging showed significant differences for maximum enhancement values (Emax), slope (Eslope) and time to peak (TTP) between the three patient groups (p0.05). In contrast, no significant differences for ADC values were calculated when comparing TBME, AVN, and SIF patients.Diffusion weighted imaging of bone marrow of the proximal femur did not show significant differences between patients with TBME, AVN or SIF. In contrast, MR perfusion imaging demonstrated significant differences for the different patient groups and may as a complementary imaging technique add information to the understanding of the pathophysiology of diseases associated with bone marrow edema.

To test the hypothesis that bone marrow oedema (BME) observed on MRI in patients with avascular necrosis (AVN) of the femoral head represents an indicator of subchondral fracture.Thirty-seven symptomatic hips of 27 consecutive patients (53% women, mean age 49.2) with AVN of the femoral head and associated BME on magnetic resonance (MR) imaging were included. MR findings were correlated with computed tomography (CT) of the hip and confirmed by histopathological examination of the resected femoral head. Imaging studies were analysed by two radiologists with use of the ARCO classification.On MR imaging a fracture line could be identified in 19/37 (51%) cases, which were classified as ARCO stage 3 (n = 15) and stage 4 (n = 4). The remaining 18/37 (49%) cases were classified as ARCO stage 2. However, in all 37/37 (100%) cases a subchondral fracture was identified on CT, indicating ARCO stage 3/4 disease. The extent of subchondral fractures and the femoral head collapse was graded higher on CT as compared to MRI (P 0.05). Histopathological analysis confirmed bone necrosis and subchondral fractures.In patients with AVN, BME of the femoral head represents a secondary sign of subchondral fracture and thus indicates ARCO stage 3 disease.BME on MRI in AVN of femoral head indicates a subchondral fracture. BME in AVN of the femoral head represents ARCO stage 3/4 disease. CT identifies subchondral fractures and femoral head collapse better than MR imaging. This knowledge helps to avoid understaging and to trigger adequate treatment.