Harold M. Dick

Massive allograft implantation following radical resection of high-grade tumors requiring adjuvant chemotherapy treatment

Since 1976, the authors have performed a total of 36 resections of malignant tumors of the limbs with reconstruction of these by implantation of allografts. All allografts have been supplied by the University of Miami Tissue Bank. Following resection of the long-bone tumor and obtaining acceptable margins, the allograft was inserted to the limb defect with three different techniques: (1) in addition to a custom prosthesis as a hemi-joint reconstruction, i.e., a custom Neer prosthesis and proximal humerus allograft; (2) an osteoarticular graft to replace an articular surface resected with the metaphyseal-diaphyseal portion of the tumor; and (3) an intercalary diaphyseal-metaphyseal graft replacing the resected tumor but preserving the recipient articular surface. Of the 36 tumors, one was in Stage III disease. The remainder were Stage II A or B by the System of Enneking. All of these patients had adjuvant chemotherapy. The follow-up time was 24 months to 96 months. The resection of tumors in 36 patients and treatment with postoperative chemotherapy resulted in a mortality of eight out of 36 and one amputation due to recurrence. Satisfactory results were obtained in 19 of 36 patients. If the tumor failures (eight deaths) and the amputation are subtracted from this number, the success rate is 70% (19/27). Intercalary grafts were more successful than osteoarticular grafts. Chemotherapy was started one to two weeks postoperation for all but four patients to whom it was also given preoperation. These patients were in a Childrens Cancer Study Group (CCSG) protocol for prospective study of the effects of preoperative chemotherapy. There was no apparent difference in the allograft success in these patients as compared to patients receiving only postoperative chemotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Adjuvant chemotherapy of malignant fibrous histiocytoma of bone

Malignant fibrous histiocytoma (MFH) is a pleomorphic sarcoma that is uncommon in children. It most frequently arises from the soft tissues; however, it has been recently established that primary bone MFH also exists. Surgical resection or amputation is the cornerstone of treatment for MFH of bone. But, with this modality of therapy alone the majority of patients develop either distant metastases or local recurrence. This study reports on three adolescent girls with MFH of bone who were successfully treated with radical resection and 18 months of adjuvant chemotherapy with vincristine, high dose methotrexate, Citrovorum Factor rescue, and Adriamycin. All three patients remain disease‐free for a follow‐up period of 42‐48 months. The current regimen was well tolerated. Morbidity was minimal, with no patient developing any significant drug‐related complications. The adjuvant chemotherapy regimen described appears to be effective in prolonging survival in patients with MFH of bone and appears to warrant further study in additional patients.

Synovial chondromatosis of the foot.

Synovial chondromatosis rarely occurs in the foot. Five patients with synovial chondromatosis in the foot were treated with excision. There were four men and one woman with a mean age of 37 years (range, 19–58 years). Mineral densities adjacent to the joint were seen on radiographs of all patients. Synovial chondromatosis occurred in the calcaneocuboid, tibiotalar, naviculocuneiform, and metatarsophalangeal joints. A painful mass was the common initial presentation in all patients. The patients were followed up for an average of 5 years (range, 3–16 years) after arthrotomy and excision. All patients were relieved of symptoms and retained normal function. There was no clinical or radiographic evidence of recurrence.

Treatment of Tibial Defects and Nonunions Using Ipsilateral Vascularized Fibular Transposition

Eight patients had nine ipsilateral vascularized fibular transpositions (IVFTs) in the period 1978-1987. The procedure, which involves no microvascular anastomosis, was done for difficult problems of the tibia including two long-standing posttraumatic nonunions, three allograft nonunions after tumor surgery, and four segmental tibial defects also after tumor surgery. The average duration of problems before surgery was 3.5 years, and the patients averaged 3.1 procedures before IVFT. The patients were followed for an average of 52.4 months. The average time to union was 4.2 months, and in all patients the grafts healed within six months. Late fracture of the graft developed in two patients after fixation removal; one required an additional procedure, and both eventually healed. Ipsilateral vascularized fibular grafting is a useful alternative to conventional, nonvascularized grafts for difficult tibial nonunions and segmental defects. It offers the advantages of a vascularized graft (early healing and hypertrophy), yet avoids the time-consuming microvascular anastomosis and distant donor site morbidity of free fibular grafts.

Novel translocation (9;12)(q22;q24) in secondardy chondrosarcoma arising from hereditary multiple exostosis

We report a new translocation in a patient with a history of hereditary multiple exostosis (HME) who developed a recurrent grade I chondrosarcoma involving the sacrum and retroperitoneum. Karyotypic analysis of the tumor revealed a sole chromosome abnormality t(9;12)(q22;q24.3). To our knowledge, this translocation has not been previously identified in either chondrosarcoma, HME, or related tumor types. Our novel translocation may be related to the sarcomatous degeneration of the pre-existing exostosis.

A curriculum for the ideal Orthopaedic residency

The Academic Orthopaedic Society met in April 1994 to discuss manpower issues in orthopaedics. The members developed an approach using the Delphi system to define and obtain consensus on the characteristics of the ideal residency. Six categories of educational attributes were included : General; Clinical Management; Skills and Technical Aspects; Rehabilitation; Basic Science and Research; and Educational Environment. The following year a questionnaire was scnt to more than 125 programs in an attempt to have residents and staff anonymously self score their residencies according to the standards defined by the Delphi panels. The results obtained from the 745 responders from 73 programs validate effectively the characteristics of the ideal program and also show the variation among the programs.

Osteoid-osteoma of the radius. Report of a case.

This case is a report of a 9-year-old boy with an osteoid osteoma in the distal radius, an unusual location. The tumor was remarkably large in size, and pain unrelieved by aspirin. Osteoid-osteomatat have been described in just about every bone in the skeleton. Lower extremity involvement is more frequent than upper in all series and incidence is much higher in males than in females. Pain is the major complaint, both night and day. The response to aspirin is variable. The diseases is most frequently encountered in the second decade of life.