Edward A. Athanasian

Survival in Patients Operated on for Pathologic Fracture: Implications for End-of-Life Orthopedic Care

PURPOSE Life expectancy is routinely used as part of the decision-making process in deciding the value of surgery for the treatment of bone metastases. We sought to investigate the validity of frequently used indices in the prognostication of survival in patients with metastatic bone disease. METHODS The study prospectively assessed 191 patients who underwent surgery for metastatic bone disease. Diagnostic, staging, nutritional, and hematologic parameters cited to be related to life expectancy were evaluated. Preoperatively, the surgeon recorded an estimate of projected life expectancy for each patient. The time until death was recorded. RESULTS Kaplan-Meier survival analyses indicated that the survival estimate, primary diagnosis, use of systemic therapy, Eastern Cooperative Oncology Group (ECOG) performance status, number of bone metastases, presence of visceral metastases, and serum hemoglobin, albumin, and lymphocyte counts were significant for predicting survival (P < .004). Cox regression analysis indicated that the independently significant predictors of survival were diagnosis (P < .006), ECOG performance status (P < .04), number of bone metastases (P < .008), presence of visceral metastases (P < .03), hemoglobin count (P < .009), and survival estimate (P < .00005). Diagnosis, ECOG performance status, and visceral metastases covaried with surgeon survival estimate. Linear regression and receiver-operator characteristic assessment confirmed that clinician estimation was the most accurate predictor of survival, followed by hemoglobin count, number of visceral metastases, ECOG performance status, primary diagnosis, and number of bone metastases. Nevertheless, survival estimate was accurate in predicting actual survival in only 33 (18%) of 181 patients. CONCLUSION A better means of prognostication is needed. In this article, we present a sliding scale for this purpose.

A rotating-hinge knee replacement for malignant tumors of the femur and tibia

We evaluated the 2- to 7-year results of a rotating-hinge knee replacement after excision of malignant tumors of the knee joint. There were 25 distal femoral and 7 proximal tibial replacements. The 5-year prosthetic survival for distal femoral replacements was 88%, compared with 58% for proximal tibial replacements. Seven patients underwent prosthetic exchange: 1 for aseptic loosening, 2 for wound slough and perioperative infection, and 4 for articulating component failure. One patient underwent above-knee amputation owing to skin necrosis. The median functional scores at the latest follow-up were 27 by the International Society of Limb Salvage evaluation system and 80 by the Hospital for Special Surgery Knee Score system. This implant is a promising choice for joint reconstruction after excision of tumors at the knee joint.

Giant cell tumors of the bones of the hand

The cases of all patients with a diagnosis of giant cell tumor of bone occurring in the hand and seen at the Mayo Clinic during a 50-year period were reviewed to assess the results of treatment. There were 5 lesions in the phalanges, 7 in the metacarpals, and 1 in the scaphoid. The mean duration of symptoms and interval to recurrence were shorter than those seen in giant cell tumor of bone occurring in sites other than the hand. Radiographically advanced disease was common at presentation. Local recurrence was seen after 11 of 14 intralesional procedures (79%) involving curettage or curettage and bone grafting. Local recurrence was seen after 5 of 14 procedures (36%) involving local excision, wide excision, amputation, or ray resection. Lung metastases developed in 2 patients after or concurrent with local recurrence. Local control was most effectively achieved with wide excision or ray resection.

Relationship between magnitude of resection, complication, and prosthetic survival after prosthetic knee reconstructions for distal femoral tumors.

Limb‐sparing surgery has become the preferred surgical treatment of malignant bone tumors. The objective of this study was to evaluate factors that influence the morbidity and outcome of prosthetic knee replacement after resection of malignant tumors of the distal femur.

Osteonecrosis of the femoral condyle after arthroscopic reconstruction of a cruciate ligament. Report of two cases.

CASE I. A twenty-eight-year-old man, who was a professional athlete. sustained an injury to the left knee when he was struck while playing football. He noted immediate pain and swelling in the knee and a subsequent sensation of instability. Physical examination of the knee revealed a positive posterior drawer at 90 degrees of flexion and a four-millimeter opening to valgus stress at 30 degrees of flexion. The initial radiographic evaluation revealed unremarkable findings. but magnetic resonance imaging demonstrated a total disruption of the posterior cruciate ligament along its attachment to the posterior aspect of the femoral condyle. The medial collateral ligament was disrupted in both the deep and superficial fibers. Two months after the injury. the patient had an arthroscopically assisted reconstruction of the posterior cruciate and medial collateral ligaments. The posterior cruciate ligament was reconstructed with use of a twelve-millimeter tunnel in the medial femoral condyle, through which a twelve-millimeter patellar-ligament graft was passed. The graft was secured with an interference screw while sutures through the proximal bone-plug were tied over a button overlying the supracond lar ridge of the distal medial cortex of the femur. The medial collateral ligament was reconstructed with an autologous semitendinosus tendon graft fixed. by means of a cancellous-bone screw and ligament washer. to the medial femoral condyle at the estimated center of rotation. Isometric femoral placement of the graft was estimated by examination of the position of the graft relative to a Kirschner wire placed transversely at the proposed site of fixation of the ligament while the knee was flexed to various degrees. Postoperative rehabilitation proceeded without incident. Seven months after the initial procedure. the screw and washer were removed and the patient resumed unrestricted activity. Ten months after the reconstruction. however. the patient noted discomfort in the left knee over the medial femoral condyle. Radiographs demonstrated faint suhchondral radiolucency surrounded by sclerosis in the medial femoral condyle and a clear defect in the articular surface of the medial femoral condyle ( Fig. 1-A). Magnetic resonance imaging (Figs. 1-B and 1-C) showed the lesion in the medial femoral condyle. and

Allograft-Prosthesis Composite Reconstruction of the Proximal Part of the Humerus Functional Outcome and Survivorship

BACKGROUND Limb salvage following resection of a tumor in the proximal part of the humerus poses many challenges. Reconstructive options are limited because of the loss of periarticular soft-tissue stabilizers of the glenohumeral joint in addition to the loss of bone and articular cartilage. The purpose of this study was to evaluate the functional outcome and survival of the reconstruction following use of a humeral allograft-prosthesis composite for limb salvage. METHODS An allograft-prosthesis composite was used to reconstruct a proximal humeral defect following tumor resection in thirty-six consecutive patients at one institution over a sixteen-year period. The reconstruction was performed at the time of a primary tumor resection in thirty cases, after a failure of a reconstruction following a previous tumor resection in five patients, and following excision of a local recurrence in one patient. The mean duration of follow-up of the living patients was five years. Glenohumeral stability, function, implant survival, fracture rate, and union rate following the reconstructions were measured. Functional outcome and implant survival were analyzed on the basis of the amount of deltoid resection, whether the glenohumeral resection had been extra-articular or intra-articular, and the length of the humerus that had been resected. RESULTS One patient sustained a glenohumeral dislocation. Deltoid resection (partial or complete) resulted in a reduced postoperative range of motion in flexion and abduction but had no effect on the mean Musculoskeletal Tumor Society score. Extra-articular resections were associated with lower Musculoskeletal Tumor Society scores. All patients had either mild or no pain and normal hand function at the time of final follow-up. The overall estimated rate of survival of the construct, with revision as the end point, was 88% at ten years. There were three failures due to progressive prosthetic loosening that necessitated removal of the construct. Four patients required an additional bone-grafting procedure to treat a delayed union of the osteosynthesis site. CONCLUSIONS An allograft-prosthesis composite used for limb salvage following tumor resection in the proximal part of the humerus is a durable construct associated with an acceptable complication rate. Deltoid preservation and intra-articular resection are associated with a greater range of shoulder motion and a superior functional outcome, respectively.

Low-Grade Myxofibrosarcoma: CT and MRI Patterns in Recurrent Disease

OBJECTIVE Low-grade myxofibrosarcoma often relentlessly recurs after surgical resection, with an unusual infiltrative growth pattern and sometimes without a discrete tumor nodule at pathologic examination. This study was undertaken to determine and show patterns of recurrent low-grade myxofibrosarcoma at CT and MRI. CONCLUSION Unlike in most other histologic types of low-grade soft-tissue sarcoma, recurrent low-grade myxofibrosarcoma often is infiltrative; shows a tapering, tail-like margin and superficial spreading configuration; and metastasizes to various distant sites, including lungs, pleura, bone, adrenal gland, soft tissue, and mesentery. Knowledge of these unusual characteristics is important in assessing the presence and extent of recurrent low-grade myxofibrosarcoma before surgical reexcision.

Experience with 31 sentinel lymph node biopsies for sarcomas and carcinomas in pediatric patients

Few data exist regarding techniques, indications, and outcomes for sentinel lymph node biopsy in pediatric patients with sarcomas and carcinomas.

Infiltrative MRI pattern and incomplete initial surgery compromise local control of myxofibrosarcoma.

Myxofibrosarcoma (MFS) has a high local failure rate of up to 79%. We conducted a retrospective analysis on all patients with the diagnosis of myxofibrosarcoma seen between 1990 and 2004 to assess whether improved imaging with MRI reduced local recurrence, increased survival, and whether radiotherapy following resection influenced outcome. Twenty-one patients were treated for MFS with a median followup of 52 months (range, 18-122). All patients were surgically treated, with 19 receiving limb-sparing surgery. All patients with high grade disease, positive margins, or a prereferral procedure received radiation therapy. The local recurrence rate was 57% for patients with a prior outside procedure (8 of 14), while patients with no prior surgery had a rate of 14% (1 of 7). Prior marginal excision and diffuse fascial spread on MRI predicted an increased local recurrence rate. The disease-free survival at 5 years was 43% (SE, 22%) for low-grade disease and 39% (SE, 18%) for high- grade disease. Magnetic resonance imaging observations suggest a unique pattern of diffuse spread along fascial planes that could be responsible for the high local recurrence. Radiation did not compensate for positive margins, nor did it reduce recurrence after negative margins.Level of Evidence: Therapeutic study, level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Proximal deep vein thrombosis after hip replacement for oncologic indications

BACKGROUND Patients with cancer who undergo surgery about the hip are at increased risk for the development of deep vein thrombosis. We implemented a program of chemical and mechanical prophylaxis to prevent this problem. This study was performed to assess the effectiveness of that program. METHODS Eighty-seven consecutive patients with an active malignant tumor who underwent hip replacement surgery at our institution over a two-year period were included in the study. All patients were treated with intermittent pneumatic compression devices. Seventy-eight patients received anticoagulants, and nine did not. Postoperative surveillance for proximal deep vein thrombosis was routinely performed on all patients with duplex Doppler ultrasonography. RESULTS Four patients had proximal deep vein thrombosis, and one patient, who did not receive anticoagulation, had a nonfatal pulmonary embolism. The use of prophylactic low-molecular-weight heparin (dalteparin) was associated with a 4% rate of proximal deep vein thrombosis (three of seventy-eight patients). Proximal deep vein thrombosis developed in three of eight patients with pelvic disease, one of nineteen patients with femoral disease, and zero of sixty patients with hip disease (p < 0.00001). The prevalence of proximal deep vein thrombosis was significantly higher (p < 0.02) following replacements in patients with sarcoma (three of twenty-one) than it was after replacements in patients with carcinoma (zero of fifty-seven) or hematologic malignant disease (one of nine). On multivariate analysis, only the location of the disease (the pelvis, femur, or hip) was found to be independently significant for an association with deep vein thrombosis. A wound complication developed in four of twenty-one patients with sarcoma and no patient with carcinoma or hematologic malignant disease (p < 0.001). The pathologic type was the only factor studied that was independently significant for an association with wound complications on multivariate analysis. CONCLUSIONS The rate of proximal deep vein thrombosis in patients who had undergone hip replacement for oncologic indications was low when the use of an intermittent pneumatic compression device was supplemented with prophylaxis with low-molecular-weight heparin.