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Biomedical subjects

K D Harrington

Publications and source records attributed to K D Harrington.

At least 19 recordsLinked to original sources
PubMed1999

Surgical management of neoplastic complications of Paget's disease.

Pagetic sarcoma is a rare anaplastic malignancy with a peak incidence in the seventh and eighth decades of life; it usually occurs in patients with polyostotic Paget's disease. The most common tumor type is osteosarcoma. In one-third of the cases, presentation is a spontaneous pathologic fracture of an affected long bone. Amputation is the most appropriate form of surgical management in most cases because of the aggressive behavior of the sarcoma and its usually late presentation in this elderly population. However, selected patients with extremity lesions may be managed by pre- and postoperative chemotherapy and wide curative resection with limb salvage reconstruction. It is essential to differentiate pagetic sarcoma from metastatic carcinoma in pagetic bone and from a benign giant cell tumor.

Aged↗
PubMed1997

Orthopedic surgical management of skeletal complications of malignancy.

Coincident with improved overall cancer palliation during the past 2 decades has been an increasing incidence of clinically apparent bone metastases, and from these metastases subsequent pathologic fractures of the long bones, spine, and pelvis. Current techniques for surgical management of these fractures are extremely effective in alleviating pain and allowing patients to resume an ambulatory status, often without the need of external support. This, in turn, has significantly improved the quality of the remaining months or years of these individuals' lives. In fact, the long term survival of patients after their first long bone pathologic fracture from malignancy has more than tripled for the most common cancers (breast carcinoma, prostate carcinoma, lymphomas, and myelomas) during the past 25 years. Surgical techniques for stabilizing pathologic or impending fractures must be individualized for the area of involvement, the particular qualities of the bone involved, and the potential for involvement of adjacent soft tissue structures. Long bone fractures most commonly occur in the femur and humerus and are typically internally fixed by intramedullary devices that control impaction, distraction, and torquing stresses by the use of proximal and distal interlocking fixation. Such fixation must be able to withstand weight-bearing stresses on lower extremity long bones. Upper extremity pathologic fractures are often subjected to distractive forces inherent in lifting and pulling, but they are also subjected to heavy compressive forces, particularly in patients who require crutches or other devices to assist them in walking. Fixation of upper or lower extremity long bone fractures ordinarily may be accomplished with minimal blood loss or morbidity. In contrast, fractures or impending fractures involving the acetabulum necessitate extensive joint reconstruction, with inherent increased potential for morbidity and complications. For this reason, the anticipated prognosis for survival and mobility should be greater preoperatively for patients with acetabular fractures than for patients with fractures of either upper or lower extremity long bones. Most spinal metastases can be managed conservatively. Those requiring surgical intervention present with progressive neurologic compromise, which requires decompression, or spinal instability, which requires stabilization. Constructs for internal stabilization of the spine must not be adversely affected by local postoperative irradiation. Ninety-six percent of patients experience good or excellent relief of pain after internal fixation of pathologic malignant long bone fractures. Eighty-four percent of patients with acetabular fractures experience good or excellent relief of pain after joint reconstruction. Eighty-two percent of patients with neurologic compromise secondary to vertebral malignancy improve at least one functional grade after decompression and stabilization, and 88% experience good or excellent relief of spinal pain with restoration of walking ability. Thirty-two percent survived for more than 2 years after spinal decompression and stabilization. Patients with pathologic fractures from metastatic carcinoma of the breast had a mean survival of 24.6 months after surgical management of their fractures. There was a similarly encouraging improvement in the survival statistics for patients with other primary tumor types. Most malignant pathologic fractures of the pelvis, long bones, or spine are amenable to effective stabilization by the techniques described in this article. These techniques allow resumption of weight-bearing ambulation in all but a few patients, good or excellent relief of pain in the vast majority, and an enhanced anticipation of survival and improvement in quality of life.

Arm Injuries↗
PubMed1995

Orthopaedic management of extremity and pelvic lesions.

Bony metastases are ubiquitous in patients with advanced cancer, and pathologic fractures may occur within either lytic or blastic foci. Approximately 90% of such fractures that require surgical intervention occur in the femur, humerus, or periacetabular pelvis. Techniques for internal fixation or prosthetic replacement have been designed with the realization that destructive bony lysis often extends well proximal and distal to the actual fracture site, and bony union will not occur after irradiation unless absolutely rigid fixation is achieved. Intramedullary fixation using some type of interlocking device, either proximally or distally, is preferable to extramedullary fixation of fractures. The mean postfracture survival for most patients is approximately 2 years.

Bone Neoplasms↗
PubMed1992

The use of hemipelvic allografts or autoclaved grafts for reconstruction after wide resections of malignant tumors of the pelvis.

Fourteen patients who had a malignant tumor of the pelvic bone, adjacent to the acetabulum, were managed with a wide en bloc resection that included most of the hemipelvis as well as the hip. Reconstruction was done with either a massive allograft or replacement of the resected bone after it had been autoclaved. The duration of follow-up ranged from four to eleven years, with a mean of seven years. One osteosarcoma recurred locally, and a repeat excision was done. Two patients who had had a solitary supra-acetabular metastasis preoperatively had systemic metastases much later, but no local recurrence. At the most recent follow-up examination, twelve patients had no evidence of tumor, and all had a functioning lower limb. After a minimum of two years, all grafts had healed and were structurally normal as seen roentgenographically. Later, however, three of the fourteen grafts had failed by fracture, and numerous other complications were evident. The described regimens offer superior functional results compared with other options for management, despite the complications.

Adult↗
PubMed1992

Long-term results for the McKeever patellar resurfacing prosthesis used as a salvage procedure for severe chondromalacia patellae.

From July 1972 until September 1985, 28 patients with a mean age of 36 years who had advanced arthritis of the patella were treated with a resurfacing arthroplasty using the McKeever prosthesis. The opposing articular surface of the femur appeared normal in 19 patients. The 28 patients had had a total of 50 previous operations on the patella (average, 1.8 operations per patient). These included 15 arthroscopic or open debridements, 14 lateral releases, six Maquet tibial tubercle elevations, six open patellar ligament transpositions, and seven open procedures for reduction and fixation of patellar fractures. Every case was observed postoperatively from a minimum of four years to a maximum of 16 years (mean, 8.1 years). Results were evaluated according to a patellar rating scale at five and eight years postoperatively. Seventeen of 24 were rated good or excellent at five years. Of the three poor results at five years, two were attributed to tricompartmental osteoarthrosis and were revised to total knee arthroplasties. There were no significant complications in the series. No patients had postoperative patellar instability or prosthetic loosening. Prolonged physical therapy rehabilitation (mean, 4.6 months) was necessary for patients to regain maximal ranges of motion, muscle strength, and endurance.

Adult↗
PubMed1988

Anterior decompression and stabilization of the spine as a treatment for vertebral collapse and spinal cord compression from metastatic malignancy.

During a ten-year period, 77 patients with spinal instability caused by metastatic pathologic fractures of one or more vertebrae were treated with anterior decompression and stabilization by replacement of the affected vertebral bodies with methylmethacrylate, polymerizing in situ, augmented by Knodt distraction rods positioned anteriorly. No postoperative external support was required, and the fixation achieved by this method was not affected adversely by subsequent irradiation at a mean of 4020 rads. Sixty-two patients had major neurologic impairments preoperatively and required spinal cord and/or nerve root decompression anteriorly prior to fixation. Of these, 26 had complete neurologic recovery postoperatively, 16 others improved significantly, 20 remained unchanged, and one patient deteriorated neurologically. Five patients suffered failures of fixation, although two were successfully restabilized after a second operation. The remaining 72 patients enjoyed good or excellent resolution of spine pain postoperatively, and, in patients surviving their underlying malignancies, stability did not deteriorate during the follow-up period ranging from 42 to 146 months. Six patients developed spinal instability from tumor lysis at a different level between five and 95 months postoperatively. All were treated with successful decompression and stabilization. There was one wound infection among the 83 anterior stabilization procedures. However, three of the six patients requiring secondary posterior stabilization suffered wound dehiscences, and three of these became infected.

Adult↗
PubMed1986

Limb salvage and prosthetic joint reconstruction for low-grade and selected high-grade sarcomas of bone after wide resection and replacement by autoclaved [corrected] autogeneic grafts.

Wide resection is an acceptable alternative to amputation for the management of primary sarcomas of the long bones or pelvis. The resected bone can be debrided of gross tumor tissue, autoclaved, and then replaced over intramedullary fixation to reconstruct the limb anatomically. The procedure can be combined with prosthetic reconstruction of adjacent joints with sufficient strength to allow early unprotected weight-bearing. Resection and replacement for 28 low-grade (G1) and 14 selected high-grade (G2) sarcomas were performed in 42 patients. The hemipelvis was resected and replaced four times, the proximal or distal femur 28 times, the proximal or distal tibia eight times, and the proximal humerus two times. Replacement of an adjacent joint, most commonly using a long-stemmed hip or knee prosthesis, was accomplished in 33 patients. All patients had been followed for a minimum of two years, nine months after treatment. The mean follow-up period is four years, ten months. Six individuals, all with high-grade sarcomas, developed tumor-related complications. Two evidenced a local recurrence of tumor, and four developed distant metastases. None of the patients with low-grade sarcomas developed a recurrence or metastases. Fifteen patients suffered complications unrelated to tumor control; 13 required reoperation, including two who required amputations for persistent pseudoarthrosis and graft infection, respectively. There was one other infection, successfully eradicated by drainage followed by local and systemic antibiotics. Due to mechanical failure or loosening, six patients were treated by successful revision of their joint arthroplasties. Two years after initial surgery, five patients had failures of union at the graft-host junction. Four healed after cancellous grafting and one was revised to a custom prosthesis. There were no late fatigue fractures of the grafts. The technique does not compromise the margins for adequate tumor resection. It preserves a graft strong enough to support a joint arthroplasty and to allow early weight-bearing with a low risk of pseudarthrosis or late fatigue fracture.

Adolescent↗
PubMed1986

Impending pathologic fractures from metastatic malignancy: evaluation and management.

Both lytic and blastic long bone metastases are at risk to develop pathologic fractures in instances where more than 50% of the circumferential cortical bone has been destroyed or where the pain with weight-bearing stresses persists, increases, or recurs despite adequate local irradiation. Moreover, those most commonly encountered lesions of the proximal femur are at high risk to fracture if they are in excess of 2.5 cm in any dimension or if they are associated with avulsion of the lesser trochanter. Such lesions should be treated aggressively by prophylactic internal fixation. This will avoid the development of a secondary fracture with its concomitantly high risk that true bony healing will not occur even with adequate fixation. When internal fixation is chosen for a large metastasis with extensive cortical destruction, that fixation should be augmented by debulking of the lesion and by packing it with methylmethacrylate polymerizing in situ. Such an expedient not only improves the efficacy of subsequent radiotherapy but also prevents shortening of the bone with weight bearing while enhancing the torque capacity and sheer resistance inherent in the metal fixation device.

Adult↗
PubMed1984

Anterior cord decompression and spinal stabilization for patients with metastatic lesions of the spine.

Metastatic lesions involving the spine may cause vertebral body collapse, resulting in either spinal instability or neural compression, or both. Progressive destruction of the vertebral body by the tumor may cause increasing spinal instability, leading to a kyphotic deformity and further neural deficit. Anterior decompression allows direct excision of the tumor focus and direct neural decompression. Because of postoperative irradiation, conventional bone grafts are rarely incorporated. Over an 8-year period, 52 patients with spinal instability secondary to metastatic pathological fractures of one or more vertebrae underwent anterior decompression and stabilization by replacement of the affected vertebral bodies with methyl methacrylate, polymerizing in situ. No postoperative external support was required, and the acrylic fixation achieved by this method was not affected adversely by subsequent irradiation to a mean of 4020 rads. Forty patients had major neurological impairment preoperatively and required anterior spinal cord and/or nerve root decompression prior to fixation. Of these, 21 had complete neurological recovery postoperatively, 13 others were improved significantly, five remain unchanged, and one patient deteriorated neurologically. There were three cases with failure of fixation. Seven other patients did not benefit from the procedure because of specific complications or the advanced state of their disease. The remaining 42 patients had good relief of pain and restoration of spinal stability, which did not deteriorate during the follow-up period, ranging from 6 to 100 months postoperatively.

Adult↗
PubMed1982

New trends in the management of lower extremity metastases.

Metastases involving the pelvis and lower extremities are common among the large population of cancer patients presently treated by hormonal or chemotherapy. The use of methylmethacrylate as an adjunct to conventional fracture fixation has improved markedly the results of pathological fracture management. Intertrochanteric femoral fractures should be internally fixed by a combination of a compression hip screw and methylmethacrylate. Subtrochanteric pathological fractures should be internally fixed using a Zickel nail and methylmethacrylate. Pathologic fractures of the femoral neck should be treated by replacement with a long-stem proximal femoral prosthesis. Fractures of the acetabulum must be analyzed as to the extent of medial wall or superior wall osteolysis. Prosthetic hip replacement is appropriate for these fractures but must be augmented by specialized fixation devices, depending on the extent of tumor osteolysis. The indications for prophylactic fixation of lytic lesions of the femur include: (1) a lesion 2.5 cm or larger in size; (2) a lesion destroying 50% or more of the femoral cortex; and (3) a lesion causing local pain with weight-bearing despite adequate radiotherapy. Local radiotherapy can be administered in an abbreviated interval and with much lower dosage than has been accepted conventionally, and the results with regard to tumor control, fracture healing, and cost to the patient will be much improved.

Acetabulum↗
PubMed1981

The use of methylmethacrylate for vertebral-body replacement and anterior stabilization of pathological fracture-dislocations of the spine due to metastatic malignant disease.

Metastatic malignant lesions involving the spine occasionally cause severe enough vertebral-body collapse to result in either spinal instability or neural compression, or both. Conventional decompressive laminectomy in such cases rarely results in neural improvement. It may, however, cause local instability of the spine, leading to a progressive kyphotic deformity and an increasing neural deficit. Anterior decompression allows excision of the focus of tumor and direct neural decompression. However, anterior stabilization by bone grafts usually does not succeed, as postoperative irradiation in dosages sufficient for tumor control may interfere with incorporation of the graft. Over a four and one-half-year period, fourteen patients with spinal instability secondary to metastatic pathological fractures of one or more vertebrae received anterior stabilization by replacement of the affected vertebral bodies with methylmethacrylate polymerized in situ. No postoperative external support was required, and the acrylic fixation achieved by this method was not affected adversely by subsequent irradiation averaging 4375 rads. There was only one soft-tissue infection, which did not involve the anterior stabilization. Twelve patients had major neural impairment preoperatively and required spinal cord or nerve-root decompression anteriorly prior to fixation. Nine had complete neural recovery postoperatively, two others were improved significantly, and one remained unchanged. None deteriorated neurologically. Five patients had undergone decompressive laminectomy before the anterior stabilization was attempted. None had improved neurologically, and all had increased spinal instability. There was one failure of fixation. The remaining thirteen patients had excellent relief of pain and restoration of spinal stability which did not deteriorate during the follow-up period, ranging from thirteen to forty-five months postoperatively.

Adult↗
PubMed1979

Degenerative arthritis of the ankle secondary to long-standing lateral ligament instability.

Long-standing lateral ligament instability of the ankle results in unbalanced loading of the medial joint space and the possible development of degenerative arthritis. Thirty-six patients who had had lateral ankle instability for at least ten years and complaints of increasing ankle pain evidence degenerative changes of the articular cartilage over the medial half of the talar and tibial surfaces of the ankle joint. These changes were minimally apparent on roentgenograms unless weight-bearing roentgenograms were made, but arthroscopy of the joint accurately revealed the extent of degeneration. After reconstruction of the lateral ankle ligaments, fourteen of twenty-two patients with mild to moderate arthritic changes showed both symptomatic improvement and demonstrable widening of the medial joint space on weight-bearing roentgenograms. Four of five patients with severe degenerative arthritis subsequently had a total ankle replacement.

Adult↗
PubMed1976

Methylmethacrylate as an adjunct in internal fixation of pathological fractures. Experience with three hundred and seventy-five cases.

In 323 patients with 375 pathological fractures or impending fractures, local tumor resection and internal fixation supplemented by intramedullary methylmethacrylate proved highly successful. One hundred and thirty-nine patients had metastases from breast carcinoma; 142, metastases from other tumors; and forty-two, myeloma or lymphoma. The mean survival for the 210 patients who had undergone operation two years or more before final evaluation was 15.4 months. Ninety-four per cent of the patients who were ambulatory before fracture regained the ability to walk. Eighty-five per cent had excellent or good pain relief and in only five was pain relief rated poor. There were four failures of fixation and six functionally poor results. Twenty patients died within four weeks of operation, but the remaining patients benefited from the procedure in terms of pain relief, improved mobility, and ease of nursing care.

Acetabulum↗