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BackgroundThe concept of complexity is used in palliative care (PC) to describe the nature of patients’ situations and the extent of resulting needs and care demands. However, the term or concept is not clearly defined and operationalised with respect to its particular application in PC. As a complex problem, a care situation in PC is characterized by reciprocal, nonlinear relations and uncertainties. Dealing with complex problems necessitates problem-solving methods tailored to specific situations. The theory of complex adaptive systems (CAS) provides a framework for locating problems and solutions.This study aims to describe criteria contributing to complexity of PC situations from the professionals’ view and to develop a conceptual framework to improve understanding of the concept of “complexity” and related elements of a PC situation by locating the complex problem “PC situation” in a CAS.MethodsQualitative interview study with 42 semi-structured expert (clinical/economical/political) interviews. Data was analysed using the framework method. The thematic framework was developed inductively. Categories were reviewed, subsumed and connected considering CAS theory.ResultsThe CAS of a PC situation consists of three subsystems: patient, social system, and team. Agents in the "system patient" are allocated to further subsystems on patient level: physical, psycho-spiritual, and socio-cultural. The "social system" and the "system team" are composed of social agents, who affect the CAS as carriers of characteristics, roles, and relationships. Environmental factors interact with the care situation from outside the system. Agents within subsystems and subsystems themselves interact on all hierarchical system levels and shape the system behaviour of a PC situation.ConclusionsThis paper provides a conceptual framework and comprehensive understanding of complexity in PC. The systemic view can help to understand and shape situations and dynamics of individual care situations; on higher hierarchical level, it can support an understanding and framework for the development of care structures and concepts. The framework provides a foundation for the development of a model to differentiate PC situations by complexity of patients and care needs. To enable an operationalisation and classification of complexity, relevant outcome measures mirroring the identified system elements should be identified and implemented in clinical practice.Electronic supplementary materialThe online version of this article (10.1186/s12913-019-3961-0) contains supplementary material, which is available to authorized users.

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Between 1980 and 1997, we treated 39 patients (mean age 39 (16-66) years, 24 men) with megaprosthetic replacement of a large bone defect (> 10 cm) of the pelvis. The bone resection was necessary in 38 cases due to malignant bone and soft tissue tumors and in 1 case due to hydatid disease. Polyacetal hemipelvic replacement was performed in 29 cases, CAD hemipelvic replacement in 8 cases, and a saddle prosthesis was inserted in 2 cases. All patients were followed clinically and radiographically. The mean follow-up was 58 (15-110) months. 20 patients have died of their tumor. 10 local infections occurred, in 2 cases necessitating hemipelvectomy. Hip dislocation occurred in 6 cases. 13 of the remaining 17 survivors had good or excellent clinical results according to the Enneking evaluation (MSTS). In 6 of the 17 survivors, radiographs revealed implant loosening.

Purpose. Chondrosarcoma (CS) most commonly involves the pelvis. The factors that influence local and systemic control of pelvic CS and the functional outcome should be evaluated.Patients. Fifty-one patients (37 males and 14 females; mean age, 39.4 years) with pelvic CS were included in this retrospective study.Methods. The tumor stage, surgical treatment, surgical margin achieved, complications, incidence of local recurrence (LR), incidence of distant metastases, and the oncologic and functional status were evaluated. Oncologic outcome was estimated by the method of Kaplan and Meier, and the functional status was scored according to Musculoskeleral Tumor Society (MSTS) criteria. Analysis of variance was used to determine the factors that influence the oncologic and functional outcome.Results. Surgical stages were IA in three cases, IB in 23, IIB in 23, and III in two. Hemipelvectomy (H) was performed in 13 cases, internal hemipelvectomy (IH) with endoprosthetic replacement in 17, and continuity resection (CR) in 23.Two patients received IH and CR, one due to LR, and one due to instability. Radical or wide margins were achieved in 27 cases, marginal margins in 16, and intralesional margins in eight. Local complication required additional surgery in 10 cases due to local infections and/or hematomas.Two patients died perioperatively. In 48 out of the 49 remaining patients, follow-up was available with a mean duration of 73.4 months (range, 4-229 months).Twenty patients died of the disease, two patients are alive with metastases, four patients are disease free after LR, and 22 patients show no evidence of the disease. LR occurred in 10 cases (20.4%), and 17 patients (34.6%) developed distant metastases. Functional evaluation of the 28 survivors revealed good and excellent results in 19 cases, fair in three and poor in six.The mean MSTS score of all survivors was 69.2%, after H it was 37.6%, after IH was 61.4%, and after CR was 79.5%.Conclusion. In pelvic chondrosarcoma, survival was determined by the tumor stage and the surgical margin achieved.The incidence of LR was influenced by the surgical margin achieved, whereas the incidence of distant metastases was influenced by the tumor stage. The best oncologic results in chondrosarcoma involving the innominate bone could be found in low-grade tumors, and the best functional results after continuity resection and restoration of the pelvic girdle.