Multiple ipsilateral lower extremity masses in a 46-year-old man. Schwannomatosis.
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Humans↗
Biomedical subjects
Carol D Morris
Publications and source records attributed to Carol D Morris.
Treatment algorithm for locally recurrent osteosarcoma based on local disease-free interval and the presence of lung metastasis.
BACKGROUND: Local recurrence in osteosarcoma is clinically distinct from metastasis, although associated with a similar reduction in survival. The prognostic factors in locally recurrent osteosarcoma were investigated and these factors were translated into a management strategy. METHODS: In all, 407 consecutive patients with skeletal osteosarcoma between 1977 and 2002 were analyzed. Twenty-three patients with resectable local recurrence were analyzed. Clinical and tumor-related factors were assessed for significance in relation to survival and a management strategy was formulated based on factors found to be independently significant for survival. RESULTS: Seventeen of the 23 patients underwent primary resections and initial treatment, yielding an overall local recurrence rate of 4.2% for resectable cancer. Median time to local recurrence was 13 months (95% confidence interval, 9-16 months). The 5-year and 10-year survival rates in the recurrent cases were 29% and 10%, respectively. All patients received chemotherapy both for their primary and recurrent disease. Increased risk of local recurrence (P < .0001) was strongly correlated with positive margins of resection. The rate of local recurrence was not related to chemotherapy-associated necrosis in the primary tumor. Nevertheless, neoadjuvant therapy halved the risk of local recurrence (odds ratio, 1.92; P = .3, power 10%). The strongest correlate with poor survival was local recurrence within the first year after primary resection (P = .001), followed by metastasis at the time of first local recurrence (P = .04) and failure to achieve clinical remission after disease recurrence (P = .04). Chemotherapy-associated necrosis and margins of resection of the primary tumor were not significant prognostic variables for survival. Survival differed significantly among patients defined by local disease-free interval and lung metastasis (P = .0001). They required an individualized approach as captured in the management algorithm. CONCLUSION: There is a residual risk of local recurrence in patients despite favorable chemotherapy-associated necrosis and negative margins of resection. A treatment strategy emphasizing clinical remission at all identifiable sites offers the highest likelihood of survival in this patient population.
Adolescent↗
Function correlates with deltoid preservation in patients having scapular replacement.
Advocates of scapular replacement suggest sparing the deltoid should be a prerequisite for use of a scapular prosthesis. We evaluated the importance of a functioning deltoid in scapular replacement for malignant tumors. We retrospectively reviewed 19 patients who received scapular prostheses after resection of a malignant tumor. The median followup was 18 months (range, 12-124 months). The axillary nerve was resected in eight patients and spared in 11 patients. The average International Society of Limb Salvage score was 25 of 30 points (range, 21-27 points). The average scores for patients with and without axillary nerve resection were 24 points (range, 21-25 points) and 26 points (range, 23-27 points), respectively. There was a difference between the two groups in hand positioning, overall function, and pain. However, there were no differences in emotional acceptance, lifting ability, or hand dexterity. We favor using a scapular prosthesis if there is a functioning deltoid; however resection of the deltoid should not be considered an absolute contraindication for scapular replacement.
Adolescent↗
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.
Aged, 80 and over↗
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.
Aged↗
De novo osteogenic sarcoma in patients older than forty: benefit of multimodality therapy.
UNLABELLED: The treatment of primary osteogenic sarcoma is well established in younger patients; however, controversy surrounds the treatment of this disease in the older population. To confirm multimodality therapy results in longer survival than surgery alone, 58 patients older than 40 years with primary osteogenic sarcoma were assessed retrospectively for the benefits of multimodality treatment versus surgery alone. We then asked whether specific patient and tumor characteristics and treatment modalities affected the rates of survival. Finally, we questioned whether pulmonary metastatectomy increased survival. The 5-year and 10-year overall survival for the group was 58% and 44%, respectively. Multimodality therapy increased survival compared with surgery alone in patients with high-grade disease. On multivariate analysis, considerable prognostic factors for improved overall survival for the entire group were age younger than 60 years, volume less than 100 cm, normal alkaline phosphatase, localized disease, negative surgical margins, and absence of recurrence. Pulmonary metastatectomy improved survival in selected patients. LEVEL OF EVIDENCE: Therapeutic study, Level III-1 (retrospective cohort study). See the Guidelines for Authors for a complete description of levels of evidence.
Adult↗
Bisphosphonates in orthopaedic surgery.
Bisphosphonates are the most clinically important class of antiresorptive agents available to treat diseases characterized by osteoclast-mediated bone resorption. Currently, seven bisphosphonates have the approval of the United States Food and Drug Administration. The most common adult diseases treated with bisphosphonates include osteoporosis, Paget disease, and metastatic bone disease. The treatment of pediatric disorders such as osteogenesis imperfecta and fibrous dysplasia with bisphosphonates has gained momentum, and initial investigations have demonstrated an acceptable safety profile. Currently, there is a lack of long-term follow-up data, which will be necessary for the development of responsible guidelines for therapy.
Adult↗
Lower extremity swelling after treatment for thigh synovial sarcoma.
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Adult↗
Prospective identification of risk factors for wound infection after lower extremity oncologic surgery.
BACKGROUND: Surgical site infections (SSI) are frequent causes of morbidity and mortality after orthopaedic oncologic procedures. This study was conducted to identify the surgical site infection rate following a lower extremity or pelvic procedure and assess the risk factors for acquiring SSI by direct observation of orthopaedic oncology patients' wounds at a comprehensive cancer center. METHODS: One hundred ten consecutive patients were prospectively studied. The surveillance of surgical site infections was carried out by a surgeon-trained nurse from the Infectious Disease Service. Nineteen variables were analyzed as risk factors. RESULTS: The overall SSI rate was 13.6% (15 of 110). Excluding those patients with known preoperative infections, the SSI rate was 9.5% (10 of 105). Two statistically significant risk factors for surgical site infection in these patients emerged in the multivariate analysis: blood transfusion (P =.007) and obesity (P =.016). Procedure category was significant in univariate analysis only. Preoperative length of stay, length of procedure, prior adjuvant treatment (chemotherapy or radiotherapy), prior surgery, and use of an implant or allograft were not statistically significant risk factors for wound infection. Antibiotic usage patterns did not influence SSI rate. CONCLUSIONS: Blood transfusion and obesity should be considered individual risk factors for the development of wound infection in patients having orthopaedic oncologic procedures.
Blood Transfusion↗
Leg length inequality and epiphysiodesis: review of 96 cases.
A retrospective analysis of 96 patients who underwent an epiphysiodesis procedure for leg length discrepancy was performed. Forty patients were identified who had an open Phemister-type epiphysiodesis. Fifty-six patients underwent a percutaneous epiphysiodesis procedure. All patients' medical records and radiographs were reviewed for complications. No angular deformities or epiphysiodesis failures occurred in the open group; however, one deep infection requiring intravenous antibiotics and serial surgical debridement was successfully treated. Five complications occurred in the percutaneous group. The complications included two superficial infections, two failures of physeal arrest, and one postoperative angular deformity. The occurrence of complications in the two groups was not statistically significant. Regular follow-up and radiographic evaluation of patients who have undergone a percutaneous epiphysiodesis is essential. Failure of physeal arrest and angular deformities are rare in this patient population, but they can occur.
Child↗