Multiple myeloma may be associated with extensive bone destruction, impending or present pathological fracture, and intractable pain. Chemotherapy and radiotherapy are usually effective, but surgical intervention may sometimes be required.

We analyzed the surgical technique and the functional and oncological outcomes of patients with multiple myeloma who underwent surgery in our services between 1993-2004.

There were 19 males and 15 females (age range 49– 75 years) who had destructive bone lesions located at the humerus (n=17), acetabulum (n=5), femur (n=5), or tibia (n=7). Indications for surgery included pathological fracture (n=20), impending pathological fracture (n=11), and intractable pain (n=3). Nineteen patients underwent marginal tumor resection, reconstruction with cemented hardware, and adjuvant radiation therapy and 15 patients underwent wide tumor resection with endoprosthetic reconstruction. All patients reported immediate and substantial postoperative pain relief. Function was good/excellent in 23 patients (68%), moderate in eight (23%), and poor in three (9%). Two patients (5.9%) had local tumor recurrence treated with local excision and adjuvant radiotherapy, with no evidence of further recurrence at 21 and 26 months, respectively. Thirty one (91%) patients survived > 1 year, 23 (68%) > 2 years, and 15 (44%) > 3 years postoperatively. All reconstructions remained stable at the most recent follow-ups.

The relatively prolonged survival of patients with multiple myeloma justifies an aggressive surgical approach, which is safe and associated with good local tumor control and functional outcome.

Introduction: Metastatic bone disease of the humerus may be associated with disabling pain and loss of function. Surgery must provide good local tumor control, immediate mechanical stability, and a short rehabilitation period. Between 1980 and 2000, the authors operated 59 patients with metastatic disease of the humerus. The current study summarizes the principles of the surgical technique and functional and oncological outcomes.

Materials and Methods: There were 33 females and 26 males. Indications for surgery included pathological fracture (40), impending fracture (11), and intractable pain (6). Anatomic locations of humeral metastases included: around the proximal humeral metaphysic and head (Type I) – 18, humeral diaphysis (Type II) – 39, and humeral condyles (Type III) – 2. Types I and III metastases were treated with resection and endoprosthetic reconstruction. Type II metastases were treated with intralesional tumor removal and cemented nailing. Postoperatively, 31 patients were treated with radiation therapy, 35 with chemotherapy, and 14 with immunotherapy.

Follow-up of the study patients included physical examination, radiological evaluation and functional evaluation according to the American Musculoskeletal Tumor Society system.

Results: Patients who had cemented nailing had better overall function, emotional acceptance, hand positioning, and lifting ability than patients who underwent endoprosthetic reconstruction. Pain alleviation and dexterity were comparable in both groups. All patients had a stable extremity and overall function of 56 patients (95%) was > 68% of normal upper extremity function. Only two patients (3%) had a local tumor recurrence.

Conclusions: An aggressive surgical approach in patients who have humeral metastases and meet the criteria for surgical intervention is beneficial; it provides durable reconstruction and is associated with good function and local tumor control in most patients.

Multiple myeloma may be associated with extensive bone destruction, impending or present pathological fracture, and intractable pain. However, surgical intervention is rarely indicated since local bone crises are effectively managed with chemotherapy and radiotherapy in the majority of the patients. The current retrospective analysis of patients who eventually required surgical intervention emphasized indications for surgery, surgical technique, and functional and oncological outcomes.

Materials and Methods: Between 1982 and 2000, the authors operated on 18 patients with multiple myeloma. There were 11 females and 7 males whose age ranged from 4 to 67 years (median, 59 years). Anatomic locations: proximal humerus – 5, proximal femur – 4, distal femur – 5, proximal tibia – 3. One patient had total femur involvement. Preoperatively, 11 patients were treated with chemotherapy and 4 received radiotherapy. Seven patients were referred with a bone lesion as their initial presentation and, therefore, did not receive pre-operative treatment.

Indications for surgery: pathological fractures – 11 patients, impending pathological fractures – 5 patients, and intractable pain in 2 patients. Surgeries included 12 marginal resections with cryosurgery and 6 wide resections with endoprosthetic reconstructions. Postoperative radiotherapy was given to three patients and chemotherapy to 11. Follow-up included physical and radiological evaluation and functional evaluation according to the American Musculoskeletal Tumor Society System.

Results: Fifteen patients (83%) survived more than 1 year and 12 patients (66%) survived more than 2 years after surgery. There were no postoperative deep wound infections, thromboembolic complications, or local tumor recurrences. Functional outcome was good to excellent in 14 patients (78%), moderate in 3 (16%), and poor in one patient (6%).

Conclusions: Multiple myeloma rarely may require surgical intervention because of impending or present pathological fracture or intractable pain. The relatively prolonged survival of patients with multiple myeloma justifies an aggressive surgical approach. Resection of these tumors was shown to be safe, reliable, and associated with good local tumor control and functional outcome.

Introduction: Tumors of the axilla impose a surgical difficulty because they are usually large at presentation and in close proximity to the major neurovascular bundle of the upper extremity. Attempted tumor resection via the base of the axilla is difficult because of limited exposure of the axillary content and neurovascular bundle. The authors have used a safe and reliable exposure for these situations.

Methods: Between 1980 and 1997, 35 patients underwent extensile exposure of an axillary tumor. Diagnoses included 19 primary and 16 metastatic tumors of the axilla. The axillary cavity was fully exposed via the deltopectoral groove after detachment and reflection of two layers of muscles: first, the pectoralis major and, second, the coracoid origin of the pectoralis minor, cora-cobrachialis, and the short head of the biceps muscle. This surgical approach allowed full tumor visualization and determination of the exact anatomic relation of the tumor to the neurovascular bundle and as a result, tumor respectability. Following resection, the pectoralis minor and conjoined tendons were reattached to the coracoid process with a nonabsorbable suture, and the pectoralis major was reattached to its insertion site on the proximal humerus in the same manner.

Results: Exposure revealed a safe plane of dissection between the tumor and the major neurovascular bundle in 23 patients and invasion of the major neurovascular bundle in 12 patients who subsequently underwent a forequarter amputation. At the most recent follow-up, none of these patients had functional limitation, which could be attributed to the extensile approach itself. All patients gained their presurgical pectoralis major and biceps function.

Complications in the group of patients that underwent tumor resection included three (13%) superficial wound infections. Due to intended enbloc resection of an involved nerve with the tumor, two nerve palsies (8.7%) were documented. None of the remaining 21 patients had numbness, paresthesias, or nerve pain. There were three (13%) local recurrences; two were managed with wide excision and adjuvant radiation therapy and one necessitated amputation.

Conclusions: The extensile exposure of the axilla allows full visualization of axillary tumors. It allows determination of tumor respectability and safe and reliable resection, when indicated. This exposure is associated with good functional outcome and an acceptable morbidity and is recommended in the management of axillary tumors.

Introduction: Surgical removal by means of curettage is the mainstay of treatment of enchondromas of the hand. Methods of reconstruction after tumor removal usually entail no reconstruction or filling of the tumor cavity with a bone graft. These techniques necessitate a prolonged period of protected activity until bone healing of the tumor cavity occurs. The authors have utilized hardware and bone cement for the purpose of reconstruction of the tumor cavity. This technique provides immediate mechanical stability and allows early mobilization.

Methods: Between 1986 and 1999 the authors treated 13 patients (8 females, 4 males) who ranged in age from 23 to 58 years (median, 32 years) and diagnosed with enchondroma of the hand. Eight patients presented with a pathological fracture. Anatomic locations included: metacarpal bones – 5, proximal phalanx – 4, and middle phalanx – 4. Tumors were approached through the retained thinned or destroyed cortex to minimize additional bone loss. Surgery included removal of all gross tumor with hand curettes; this was followed by high speed burr drilling of the inner reactive bone shell. Reconstruction included intramedullary metal wire along the longitudinal axis of the cavity and polyme-hylmethacrylate (PMMA). Full activity as tolerated was allowed immediately after surgery. All patients were followed for more than 2 years.

Follow-up included physical and radiological evaluation and functional evaluation.

Results: Following surgery, all patients returned to their presurgical functional capability within two weeks. At the last follow-up, none of the patients had local tumor recurrence and although three patients had 15° to 20° decrease in flexion of the metacarpophalangeal joint, none reported a functional limitation. There were no postoperative infections or fractures.

Conclusions: Reconstruction of the tumor cavity, remaining after curettage of enchondroma of the hand, with intramedullary hardware and PMMA provides immediate mechanical stability and allows early mobilization. This technique is associated with good short- and long-term functional outcomes.

Introduction: Total scapular resection causes a significant functional loss because of the sacrifice of the glenoid, which serves as a stable base for shoulder motion. The authors analyze their experience with two types of reconstructions following total scapular resection; suspension of the humeral head from the clavicle without endoprosthetic reconstruction of the scapula and endoprosthetic scapular reconstruction.

Materials and Methods: Between 1979 and 1997, the authors treated 23 patients with scapular tumors that required total scapular resection. Patients were diagnosed with 14 bone and 9 soft-tissue tumors. Resection included total scapulectomy in 12 patients and enbloc resection of the scapula and humeral head in 11 patients.

Reconstruction: All eleven patients who had resection of their humeral head underwent reconstruction of the humerus with endoprosthesis. Scapular endoprosthesis was further installed in 7 patients and suspension of the humeral head from the clavicle with a Dacron tape was performed in 16 patients (Suspension of the prosthetic humeral head from the clavicle – 4 patients; suspension of the native humeral head from the clavicle – 12 patients). Endoprosthetic reconstruction of the scapula was feasible only when the periscapular musculature was sufficient for endoprosthetic attachment and coverage. The scapular prosthesis was attached to the prosthetic humeral head with a Goretex® sleeve, which served as an artificial joint capsule. All patients were followed for a minimum of 2 years; follow-up included physical examination, radiological evaluation and functional evaluation according to the American Musculoskeletal Tumor Society system.

Results: Elbow range-of-motion and hand dexterity were similar in the two groups of patients. However, compared with patients who undergone humeral suspension, those who had scapular endoprosthesis had better abduction (60°–90° vs. 10°–20°) of the shoulder joint. Moreover, these patients had better cosmetic appearance of the shoulder girdle. There were no deep wound infections, prosthetic failures, or secondary amputations. Overall, 6 patients who had scapular prosthesis (86%) and 10 patients who had humeral suspension (62%) had a good-to-excellent functional outcome.

Conclusions: The number of patients who underwent a scapular endoprosthetic reconstruction is small and does not allow a valid statistical analysis; however, the authors feel that scapular endoprosthesis reconstruction is associated with better functional and cosmetic outcomes, when compared to humeral suspension. The authors recommend reconstruction of the scapula with endoprosthesis when periscapular musculature, remaining after tumor resection allows attachment and coverage of the prosthesis.

Introduction: Despite advances in limb-sparing techniques, the proximal tibia remains a difficult area in which to perform a wide resection of extensive bone tumors due to the intimate relationship to the nerves and blood vessels, inadequate soft-tissue coverage, and the need to reconstruct the extensor mechanism. The current long-term follow-up study, based on the experience with 55 patients who underwent proximal tibia endoprosthetic reconstruction emphasizes reconstruction of the extensor mechanism.

Materials and Methods: Between 1980 and 1997, 55 patients underwent proximal tibia resection with endoprosthetic reconstruction. There were 34 males and 21 females whose age ranged from 8 to 56 years (median, 27 years. Diagnoses were: primary bone sarcomas – 48, benign aggressive lesions – 6, and failure of previous osteoarticular allograft reconstruction – 1. Intra-articular resection with en bloc removal of the tibial tuberosity was performed in all cases. Endoprosthetic reconstruction was performed with 39 modular, 16 custom-made prostheses. Reconstruction of the extensor mechanism included reattachment of the patellar tendon to the prosthesis with a Dacron tape and reinforcement with a gastrocnemius flap and bone grafting of the patellar tendon-prosthesis interface. Rehabilitation emphasized prolonged immobilization of knee joint in full extension.

Results: All patients were followed for a minimum of 2 years (range 24–235 months, median – 75.5 months). Full extension to extension lag of 20° was achieved in 44 patients (78%), extension lag of 20° to 30° was found in 10 patients (19%), and extension lag of 40° was found in 1 patient (3%). Eight patients required an additional procedure which involved reinforcement of the patellar tendon with either combined quadriceps tendon and Goretex graft construct (seven patients) or simple plication of the tendon (one patient). Seven of these patients gained an extension lag of less than 20°. Overall, function was estimated to be good to excellent in 48 patients, fair in 6, and poor in one patient.

Discussion: Extension lag of up to 20° is considered compatible with activities of daily living. Emphasis on reattachment of the patellar tendon to the prosthesis and its reinforcement with a gastrocnemius flap and bone graft achieved that goal in the majority of the patients.

Secondary reinforcement of the patellar tendon is recommended for extension lag of more than 20°.