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Szapary HJ, Farid A, Desai V, Franco H, Ready JE, Chen AF, Lange JK. Predictors of reoperation and survival experience for primary total knee arthroplasty in young patients with degenerative and inflammatory arthritis. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05299-1. [PMID: 38613613 DOI: 10.1007/s00402-024-05299-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 03/24/2024] [Indexed: 04/15/2024]
Abstract
INTRODUCTION While total knee arthroplasty (TKA) is typically implemented in patients > 65 years old, young patients may need to undergo TKA for pain relief and functional improvement. Current data are limited by older cohorts and short-term survival rates. This study aimed to examine a large sample size of patients with degenerative and inflammatory conditions who underwent primary TKA at a young (≤ 40) age to identify predictors of reoperation, as well 15-year survivorship. MATERIALS AND METHODS A retrospective study was performed on 77 patients (92 surgeries) who underwent primary TKA at ≤ 40 years old, between January 1990 and January 2020. Patient charts were reviewed and a multivariable logistic regression model identified independent predictors of reoperation. Kaplan-Meier analysis was employed to build survival curves and log-rank tests analyzed survival between groups. RESULTS Of the 77 patients, the median age at the time of surgery was 35.7 years (IQR: 31.2-38.7) and median follow-up time was 6.88 years. Twenty-one (22.8%) primary TKAs underwent 24 reoperations, most commonly due to stiffness (n = 9, 32.1%) and infection (n = 13, 46.4%) more significantly in the OA group (p = 0.049). There were no independent predictors of reoperation in multivariable analysis, and 15-year revision-free survivorship after TKA did not differ by indication (77.3% for OA/PTOA vs. 96.7% for autoimmune, p = 0.09) or between ≤ 30 and 31-40 year age groups (94.7% vs. 83.6%, p = 0.55). CONCLUSIONS In this cohort of patients ≤ 40 years old, revision-free survival was comparable to that reported in the literature for older TKA patients with osteoarthritis/autoimmune conditions (81-94% at 15-years). Though nearly a quarter of TKAs required reoperation and causes of secondary surgery differed between degenerative and inflammatory arthritis patients, there were no significant predictors of increased reoperation rate. Very young patients ≤ 30 years old did not have an increased risk of revision compared to those aged 31-40 years.
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Affiliation(s)
- Hannah J Szapary
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA.
| | - Alexander Farid
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Vineet Desai
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Helena Franco
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - John E Ready
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Jeffrey K Lange
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
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Karczewski D, Gonzalez MR, Bedi A, Ready JE, Anderson ME, Lozano-Calderon SA. Giant cell-rich osteosarcoma: A match pair analysis of 11 new cases and literature review of 56 patients. J Surg Oncol 2023; 128:877-890. [PMID: 37292033 DOI: 10.1002/jso.27368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/23/2023] [Accepted: 05/26/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Limited remains known on giant cell-rich osteosarcoma (GCRO) with current studies being case reports or smaller series. This investigation compared GCRO and conventional osteoblastic osteosarcoma (OOS) with regard to demographics and survival. METHODS An institutional tumor registry was used to identify 11 patients (six males) treated for GCRO. Mean age was 43 years. Staging showed American Joint Committee on Cancer (AJCC) stages IIA in four and IIB in seven patients. Mean follow-up was 14 years. Study initiatives were: (1) Comparison of demographics between GCRO and 167 OOS from our institutional registry, (2) Differences in survival between GCRO and 33 OOS case controls (based on sex and AJCC stage), as well as 10 OOS using an age-based propensity match, and (3) Summary of all GCRO cases reported in the literature. RESULTS (1) Sex (p = 0.53), grading (p = 0.56), AJCC stage (p = 0.42), and chemotherapeutic response rate (p = 0.67) did not differ between groups. Age was significantly increased in GCRO (p = 0.001). (2) Case-control and propensity-matched groups revealed no difference in disease-free survival, local recurrence, and distant disease-free survival at 2 years (p > 0.05). (3) Mean age of 56 patients (50% males) reported in the literature was 26 years. After merging with our 11 cases, the 2-year disease-free survival was 66%. CONCLUSIONS GCRO remains a rare disease with high short-term mortality. Although affecting older patients more than conventional osteosarcoma, GCRO should not be viewed as a predictor of survival compared to OOS.
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Affiliation(s)
- Daniel Karczewski
- Department of Orthopedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcos R Gonzalez
- Department of Orthopedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Angad Bedi
- Department of Orthopedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - John E Ready
- Department of Orthopedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Brigham Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Megan E Anderson
- Department of Orthopedic Surgery, Musculoskeletal Oncology Service, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Santiago A Lozano-Calderon
- Department of Orthopedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Lozano-Calderón SA, Albergo JI, Groot OQ, Merchan NA, El Abiad JM, Salinas V, Gomez Mier LC, Montoya CS, Ferrone ML, Ready JE, Linares FJ, Levin AS, Peleteiro Pensado M, Pozo Kreilinger JJ, Ruiz IB, Ortiz-Cruz EJ, Gebhardt MC, Cote GM, Choy E, Spentzos D, Hung YP, Deshpande V, Chebib IA, McCulloch RA, Farfalli G, Aponte Tinao L, Morris CD, Petur Nielsen G, Anderson ME, Jeys LM. Complete tumor necrosis after neoadjuvant chemotherapy defines good responders in patients with Ewing sarcoma. Cancer 2023; 129:60-70. [PMID: 36305090 DOI: 10.1002/cncr.34506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Survival in patients who have Ewing sarcoma is correlated with postchemotherapy response (tumor necrosis). This treatment response has been categorized as the response rate, similar to what has been used in osteosarcoma. There is controversy regarding whether this is appropriate or whether it should be a dichotomy of complete versus incomplete response, given how important a complete response is for in overall survival of patients with Ewing sarcoma. The purpose of this study was to evaluate the impact that the amount of chemotherapy-induced necrosis has on (1) overall survival, (2) local recurrence-free survival, (3) metastasis-free survival, and (4) event-free survival in patients with Ewing sarcoma. METHODS In total, 427 patients who had Ewing sarcoma or tumors in the Ewing sarcoma family and received treatment with preoperative chemotherapy and surgery at 10 international institutions were included. Multivariate Cox proportional-hazards analyses were used to assess the associations between tumor necrosis and all four outcomes while controlling for clinical factors identified in bivariate analysis, including age, tumor volume, location, surgical margins, metastatic disease at presentation, and preoperative radiotherapy. RESULTS Patients who had a complete (100%) tumor response to chemotherapy had increased overall survival (hazard ratio [HR], 0.26; 95% CI, 0.14-0.48; p < .01), recurrence-free survival (HR, 0.40; 95% CI, 0.20-0.82; p = .01), metastasis-free survival (HR, 0.27; 95% CI, 0.15-0.46; p ≤ .01), and event-free survival (HR, 0.26; 95% CI, 0.16-0.41; p ≤ .01) compared with patients who had a partial (0%-99%) response. CONCLUSIONS Complete tumor necrosis should be the index parameter to grade response to treatment as satisfactory in patients with Ewing sarcoma. Any viable tumor in these patients after neoadjuvant treatment should be of oncologic concern. These findings can affect the design of new clinical trials and the risk-stratified application of conventional or novel treatments.
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Affiliation(s)
- Santiago A Lozano-Calderón
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jose Ignacio Albergo
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Hospital Italiano, Buenos Aires, Argentina
| | - Olivier Q Groot
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nelson A Merchan
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Boston Children's Hospital, Beth Israel Deaconess Medical Center, Dana-Farber Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jad M El Abiad
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, The Johns Hopkins Hospital, Johns Hopkins University, Baltimore, Maryland, USA
| | - Vanessa Salinas
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Instituto Nacional de Cancerología, Bogotá, Colombia
| | - Luis Carlos Gomez Mier
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Instituto Nacional de Cancerología, Bogotá, Colombia
| | - Camilo Soto Montoya
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Instituto Nacional de Cancerología, Bogotá, Colombia
| | - Marco L Ferrone
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Brigham and Women's Hospital, Dana-Farber Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - John E Ready
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Brigham and Women's Hospital, Dana-Farber Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Francisco J Linares
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Adam S Levin
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, The Johns Hopkins Hospital, Johns Hopkins University, Baltimore, Maryland, USA
| | - Manuel Peleteiro Pensado
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - José Juan Pozo Kreilinger
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Irene Barrientos Ruiz
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Eduardo J Ortiz-Cruz
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Mark C Gebhardt
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Boston Children's Hospital, Beth Israel Deaconess Medical Center, Dana-Farber Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory M Cote
- Division of Sarcoma and Connective Tissue Oncology, Department of Hematology and Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Edwin Choy
- Division of Sarcoma and Connective Tissue Oncology, Department of Hematology and Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Dimitrios Spentzos
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Yin P Hung
- Division of Bone and Soft Tissue Pathology, Department of Pathology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Vikram Deshpande
- Division of Bone and Soft Tissue Pathology, Department of Pathology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ivan A Chebib
- Division of Bone and Soft Tissue Pathology, Department of Pathology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Allan McCulloch
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Royal Orthopedic Hospital National Health Service Trust, Aston University, Birmingham, UK
| | - Germán Farfalli
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Hospital Italiano, Buenos Aires, Argentina
| | - Luis Aponte Tinao
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Hospital Italiano, Buenos Aires, Argentina
| | - Carol D Morris
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, The Johns Hopkins Hospital, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gunnlaugur Petur Nielsen
- Division of Bone and Soft Tissue Pathology, Department of Pathology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Megan E Anderson
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Boston Children's Hospital, Beth Israel Deaconess Medical Center, Dana-Farber Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lee M Jeys
- Musculoskeletal Oncology Service, Department of Orthopedic Surgery, Royal Orthopedic Hospital National Health Service Trust, Aston University, Birmingham, UK
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Hayden BL, Varady NH, Abdeen A, Lozano-Calderon SA, Chen AF, Ready JE. No Difference Between Hemiarthroplasty and Total Hip Arthroplasty in the Treatment of Pathologic Femoral Neck Fractures. J Arthroplasty 2021; 36:3662-3666. [PMID: 34419316 DOI: 10.1016/j.arth.2021.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 06/06/2021] [Accepted: 06/16/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Hemiarthroplasty (HA) and total hip arthroplasty (THA) have been widely discussed as treatment options for displaced osteoporotic femoral neck fractures. Pathologic femoral neck fractures from primary or metastatic tumors are comparatively rare and poorly investigated. The purpose of this study was to compare outcomes, complications, and perioperative survival for HA and THA in the treatment of pathologic femoral neck fractures of neoplastic etiology. METHODS A multicenter retrospective cohort study identified patients with pathologic femoral neck fractures treated with HA or THA from 2005 to 2018. Demographics, American Society of Anesthesiologists classification, Charlson comorbidity index, Dorr classification, histopathologic diagnosis, and surgical data were compared. The primary outcome was reoperation. Secondary outcomes included 90-day mortality, estimated blood loss, length of stay, periprosthetic fracture, periprosthetic joint infection, and Eastern Cooperative Oncology Group performance status. RESULTS There were 116 patients with HA and 48 patients with THA, with no differences between groups with regard to American Society of Anesthesiologists classification, Charlson comorbidity index, or Dorr classification. There were no differences between HA and THA in the primary outcome of reoperation (5.2% vs 4.2%, P = 1.00) or secondary outcomes of perioperative 90-day overall mortality (30.2% vs 25.0%, P = .51), estimated blood loss, transfusion rates, length of stay, discharge location, periprosthetic joint infection, periprosthetic fracture, or preoperative or postoperative Eastern Cooperative Oncology Group performance status. CONCLUSIONS Both HA and THA are viable options for the treatment of patients with pathologic femoral neck fractures and demonstrated no differences in reoperations, complications, perioperative 90-day mortality, or functional outcome scores. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Brett L Hayden
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA
| | - Ayesha Abdeen
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - John E Ready
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
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Newman ET, van Rein EAJ, Theyskens N, Ferrone ML, Ready JE, Raskin KA, Lozano Calderon SA. Diagnoses, treatment, and oncologic outcomes in patients with calcaneal malignances: Case series, systematic literature review, and pooled cohort analysis. J Surg Oncol 2020; 122:1731-1746. [PMID: 32974945 DOI: 10.1002/jso.26205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/26/2020] [Accepted: 08/24/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND OBJECTIVES Malignant tumors of the calcaneus are rare but pose a treatment challenge. AIMS (1) describe the demographics of calcaneal malignancies in a large cohort; (2) describe survival after amputation versus limb-salvage surgery for high-grade tumors. METHODS Study group: a "pooled" cohort of patients with primary calcaneal malignancies treated at two cancer centers (1984-2015) and systematic literature review. Kaplan-Meier analyses described survival across treatment and diagnostic groups; proportional hazards modeling assessed mortality after amputation versus limb salvage. RESULTS A total of 131 patients (11 treated at our centers and 120 patients from 53 published studies) with a median 36-month follow-up were included. Diagnoses included Ewing sarcoma (41%), osteosarcoma (30%), and chondrosarcoma (17%); 5-year survival rates were 43%, 73% (70%, high grade only), and 84% (60%, high grade only), respectively. Treatment involved amputation in 52%, limb salvage in 27%, and no surgery in 21%. There was no difference in mortality following limb salvage surgery (vs. amputation) for high-grade tumors (HR 0.38; 95% CI 0.14-1.05), after adjusting for Ewing sarcoma diagnosis (HR 5.15; 95% CI 1.55-17.14), metastatic disease at diagnosis (HR 3.88; 95% CI 1.29-11.64), and age (per-year HR 1.04; 95% CI 1.02-1.07). CONCLUSIONS Limb salvage is oncologically-feasible for calcaneal malignancies.
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Affiliation(s)
- Erik T Newman
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eveline A J van Rein
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nina Theyskens
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marco L Ferrone
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - John E Ready
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kevin A Raskin
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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Anoushiravani AA, Barnes CL, Bosco JA, Bozic KJ, Huddleston JI, Kang JD, Ready JE, Tornetta P, Iorio R. Reemergence of Multispecialty Inpatient Elective Orthopaedic Surgery During the COVID-19 Pandemic: Guidelines for a New Normal. J Bone Joint Surg Am 2020; 102:e79. [PMID: 32675667 DOI: 10.2106/jbjs.20.00829] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - C Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Joseph A Bosco
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY
| | - Kevin J Bozic
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - James I Huddleston
- Department of Orthopaedic Surgery, Stanford Healthcare, Stanford, California
| | - James D Kang
- Department of Orthopaedic Surgery, Brigham Health, Boston, Massachusetts
| | - John E Ready
- Department of Orthopaedic Surgery, Brigham Health, Boston, Massachusetts
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, Massachusetts
| | - Richard Iorio
- Department of Orthopaedic Surgery, Brigham Health, Boston, Massachusetts
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Bluman EM, Fury MS, Ready JE, Hornick JL, Weaver MJ. Orthopedic telemedicine encounter during the COVID-19 pandemic: A cautionary tale. Trauma Case Rep 2020; 28:100323. [PMID: 32685653 PMCID: PMC7320714 DOI: 10.1016/j.tcr.2020.100323] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2020] [Indexed: 11/29/2022] Open
Abstract
The COVID-19 pandemic has necessitated increased use of telemedicine for diagnosis and management of musculoskeletal disorders. We describe the virtual/telemedicine encounter and management of a patient with knee pain initially diagnosed as gonarthrosis but that actually resulted from an impending pathologic fracture of the femur. Definitive diagnosis and treatment occurred only after completion of the impending fracture. The multiple factors making telemedicine encounters challenging which contributed to this outcome are highlighted. Orthopedists need awareness of these challenges and must take steps to mitigate the risk of complications possible with continued increased utilization of telemedicine during this pandemic and beyond.
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Affiliation(s)
- Eric M Bluman
- Dept. of Orthopedic Surgery, Brigham Health, 75 Francis St., Boston, MA, United States of America
| | - Matthew S Fury
- Dept. of Orthopedic Surgery, Brigham Health, 75 Francis St., Boston, MA, United States of America
| | - John E Ready
- Dept. of Orthopedic Surgery, Brigham Health, 75 Francis St., Boston, MA, United States of America
| | - Jason L Hornick
- Dept. of Pathology, Brigham Health, 75 Francis St., Boston, MA, United States of America
| | - Michael J Weaver
- Dept. of Orthopedic Surgery, Brigham Health, 75 Francis St., Boston, MA, United States of America
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Nakayama R, Jagannathan JP, Ramaiya N, Ferrone ML, Raut CP, Ready JE, Hornick JL, Wagner AJ. Clinical characteristics and treatment outcomes in six cases of malignant tenosynovial giant cell tumor: initial experience of molecularly targeted therapy. BMC Cancer 2018; 18:1296. [PMID: 30594158 PMCID: PMC6311045 DOI: 10.1186/s12885-018-5188-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 12/05/2018] [Indexed: 01/08/2023] Open
Abstract
Background Although tenosynovial giant cell tumor (TGCT) is classified as a benign tumor, it may undergo malignant transformation and metastasize in extremely rare occasions. High aberrant expression of CSF1 has been implicated in the development of TGCT and recent studies have shown promising activity of several CSF1R inhibitors against benign diffuse-type TGCT; however, little is known about their effects in malignant TGCT. Case presentation Information from six consenting patients (3 men, 3 women) with malignant TGCT presenting to Dana-Farber Cancer Institute for initial or subsequent consultation was collected. Median age at initial diagnosis of TGCT was 49.5 years (range 12–55), and median age at diagnosis of malignant TGCT was 50 years (range 34–55). Two patients developed malignant TGCT de novo, while four other cases showed metachronous malignant transformation. All tumors arose in the lower extremities (3 knee, 2 thigh, 1 hip). Five patients underwent surgery for the primary tumors, and four developed local recurrence. All six patients developed lung metastases, and four of five evaluable tumors developed inguinal and pelvic lymph node metastases. All six patients received systemic therapy. Five patients were treated with at least one tyrosine kinase inhibitor with inhibitory activity against CSF1R; however, only one patient showed clinical benefit (SD or PR). Five patients were treated with conventional cytotoxic agents. Doxorubicin-based treatment showed clinical benefit in all four evaluable patients, and gemcitabine/docetaxel showed clinical benefit in two patients. All six patients died of disease after a median of 21.5 months from diagnosis of malignant TGCT. Conclusions This study confirms that TGCT may transform into an aggressive malignant tumor. Lymph node and pulmonary metastases are common. Local recurrence rates are exceedingly high. Conventional cytotoxic chemotherapy showed clinical benefit, whereas tyrosine kinase inhibitors against CSF1R showed limited activity. Given its rarity, a prospective registry of malignant TGCT patients is needed to further understand the entity and to develop effective strategies for systemic treatment.
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Affiliation(s)
- Robert Nakayama
- Ludwig Center at Dana-Farber/Harvard and Center for Sarcoma and Bone Oncology, Department of Medical Oncology, Harvard Medical School, Boston, MA, USA.,Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan
| | | | - Nikhil Ramaiya
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Marco L Ferrone
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Chandrajit P Raut
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John E Ready
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jason L Hornick
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew J Wagner
- Ludwig Center at Dana-Farber/Harvard and Center for Sarcoma and Bone Oncology, Department of Medical Oncology, Harvard Medical School, Boston, MA, USA.
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Pretz JL, Barysauskas CM, George S, Hornick JL, Raut CP, Chen YLE, Marcus KJ, Choy E, Hornicek F, Ready JE, DeLaney TF, Baldini EH. Localized Adult Ewing Sarcoma: Favorable Outcomes with Alternating Vincristine, Doxorubicin, Cyclophosphamide, and Ifosfamide, Etoposide (VDC/IE)-Based Multimodality Therapy. Oncologist 2017; 22:1265-1270. [PMID: 28550026 PMCID: PMC5634761 DOI: 10.1634/theoncologist.2016-0463] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 03/10/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND In children with localized Ewing sarcoma (ES), addition of ifosfamide and etoposide to cyclophosphamide, doxorubicin, and vincristine (VDC/IE) improved 5-year overall survival (OS) to 70%-80%. Prior to delivery of VDC/IE in adults, 5-year OS was <50%. We reviewed our institutional outcomes for adults with ES who received VDC/IE-based treatment. MATERIALS AND METHODS Between 1997-2013, 67 adults with localized ES were treated with curative intent. Local recurrence-free survival (LRFS), progression-free survival (PFS), and OS were determined using Kaplan-Meier method; comparisons were assessed with log-rank. Proportional hazard models were used to determine predictive factors. RESULTS All patients received VDC/IE (median 14 cycles.) Local therapy was surgery for 33, radiation therapy for 17, or both for 17. Median follow-up for living patients was 5.2 years. Six patients had disease progression on therapy. Site of first failure was local for three, local and distant for two, and distant for ten. Five-year LRFS was 91%; 5-year LRFS was 96% for nonpelvic disease and 64% for pelvic disease (p = .003). Five-year PFS was 66%, and 5-year OS was 79%. On multivariate analysis, pelvic site had a 3.3 times increased risk of progression (p = .01). CONCLUSION Survival for adults with localized ES treated with VDC/IE-based multimodality therapy appears to be better than historical data and similar to excellent outcomes in children. Pelvic site of disease remains a predictor of worse outcome. Given the paucity of literature for adult ES, these data help validate VDC/IE-based therapy as an appropriate treatment approach for this rare disease in adults. IMPLICATIONS FOR PRACTICE Ewing sarcoma (ES) is rare in adults. Treatment approaches for adults have been extrapolated from the pediatric experience, and there is a sense that adults fare less well than children. We reviewed treatment outcomes in adults with localized ES treated with cyclophosphamide, doxorubicin, and vincristine in alternation with ifosfamide and etoposide (VDC/IE) as part of multimodality therapy. Survival outcomes appear to be better than historical data for adults and similar to the excellent outcomes for children. These data help validate VDC/IE-based therapy as an appropriate treatment approach for this rare disease in adults.
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Affiliation(s)
- Jennifer L Pretz
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Constance M Barysauskas
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Suzanne George
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Jason L Hornick
- Department of Pathology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Chandrajit P Raut
- Department of Surgical Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Yen-Lin E Chen
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Karen J Marcus
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Edwin Choy
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Francis Hornicek
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John E Ready
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Thomas F DeLaney
- Department of Surgical Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Elizabeth H Baldini
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, Massachusetts, USA
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Henderson ER, Keeney BJ, Pala E, Funovics PT, Eward WC, Groundland JS, Ehrlichman LK, Puchner SSE, Brigman BE, Ready JE, Temple HT, Ruggieri P, Windhager R, Letson GD, Hornicek FJ. The stability of the hip after the use of a proximal femoral endoprosthesis for oncological indications: analysis of variables relating to the patient and the surgical technique. Bone Joint J 2017; 99-B:531-537. [PMID: 28385944 DOI: 10.1302/0301-620x.99b4.bjj-2016-0960.r1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 12/29/2016] [Indexed: 11/05/2022]
Abstract
AIMS Instability of the hip is the most common mode of failure after reconstruction with a proximal femoral arthroplasty (PFA) using an endoprosthesis after excision of a tumour. Small studies report improved stability with capsular repair of the hip and other techniques, but these have not been investigated in a large series of patients. The aim of this study was to evaluate variables associated with the patient and the operation that affect post-operative stability. We hypothesised an association between capsular repair and stability. PATIENTS AND METHODS In a retrospective cohort study, we identified 527 adult patients who were treated with a PFA for tumours. Our data included demographics, the pathological diagnosis, the amount of resection of the abductor muscles, the techniques of reconstruction and the characteristics of the implant. We used regression analysis to compare patients with and without post-operative instability. RESULTS A total of 20 patients out of 527 (4%) had instability which presented at a mean of 35 days (3 to 131) post-operatively. Capsular repair was not associated with a reduced rate of instability. Bivariate analysis showed that a posterolateral surgical approach (odds ratio (OR) 0.11, 95% confidence interval (CI) 0.02 to 0.86) and the type of implant (p = 0.046) had a significant association with reduced instability; age > 60 years predicted instability (OR 3.17, 95% CI 1.00 to 9.98). Multivariate analysis showed age > 60 years (OR 5.09, 95% CI 1.23 to 21.07), female gender (OR 1.73, 95% CI 1.04 to 2.89), a malignant primary bone tumour (OR 2.04, 95% CI 1.06 to 3.95), and benign condition (OR 5.56, 95% CI 1.35 to 22.90), but not metastatic disease or soft-tissue tumours, predicted instability, while a posterolateral approach (OR 0.09, 95% CI 0.01 to 0.53) was protective against instability. No instability occurred when a synthetic graft was used in 70 patients. CONCLUSION Stability of the hip after PFA is influenced by variables associated with the patient, the pathology, the surgical technique and the implant. We did not find an association between capsular repair and improved stability. Extension of the tumour often dictates surgical technique; however, our results indicate that PFA using a posterolateral approach with a hemiarthroplasty and synthetic augment for soft-tissue repair confers the lowest risk of instability. Patients who are elderly, female, or with a primary benign or malignant bone tumour should be counselled about an increased risk of instability. Cite this article: Bone Joint J 2017;99-B:531-7.
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Affiliation(s)
- E R Henderson
- The Geisel School of Medicine at Dartmouth College, One Medical Center Drive, Lebanon, NH 03756, USA
| | - B J Keeney
- The Geisel School of Medicine at Dartmouth College, One Medical Center Drive, Lebanon, NH 03756, USA
| | - E Pala
- University of Padova, Via Giustiniani 3, 35128 Padova, Italy
| | - P T Funovics
- Medical University of Vienna, Waehringer Gürtel 18-20, 1090 Vienna, Austria
| | - W C Eward
- Duke Medical School, 20 Duke Medicine Circle, Durham NC 27710, USA
| | - J S Groundland
- University of South Florida, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - L K Ehrlichman
- Naval Hospital Beaufort, 1 Pinckney Boulevard, Beaufort, SC 29902, USA
| | - S S E Puchner
- Medical University of Vienna, Waehringer Gürtel 18-20, 1090 Vienna, Austria
| | - B E Brigman
- Duke Medical School, 20 Duke Medicine Circle, Durham NC 27710, USA
| | - J E Ready
- Brigham & Women's Hospital, 75 Frances Street, Boston MA 02115, USA
| | - H T Temple
- Nova Southeastern University, 3301 College Avenue, Ft Lauderdale, FL 33314, USA
| | - P Ruggieri
- University of Padova, Via Giustiniani 3, 35128 Padova, Italy
| | - R Windhager
- Medical University of Vienna, Waehringer Gürtel 18-20, 1090 Vienna, Austria
| | - G D Letson
- Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - F J Hornicek
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Janssen SJ, van Dijke M, Lozano-Calderón SA, Ready JE, Raskin KA, Ferrone ML, Hornicek FJ, Schwab JH. Complications after surgery for metastatic humeral lesions. J Shoulder Elbow Surg 2016; 25:207-15. [PMID: 26547526 DOI: 10.1016/j.jse.2015.08.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 08/06/2015] [Accepted: 08/09/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Knowledge of surgical outcome and its predictors helps inform patients and aids in surgical decision-making. We aimed to assess the outcome-reoperation and systemic complication rate-of surgery for humeral metastases, myeloma, or lymphoma. Our null hypothesis was that there are no factors associated with these outcomes. METHODS We included 295 consecutive patients in this retrospective study: 134 (45%) proximal, 131 (44%) diaphyseal, and 30 (10%) distal impending or pathologic fractures. Proximal lesions were treated by intramedullary nailing (43%, n = 57), prosthesis (34%, n = 46), plate-screw fixation (22%, n = 30), and a combination (n = 1). Diaphyseal lesions were treated by intramedullary nailing (69%, n = 91), plate-screw fixation (30%, n = 39), and a combination (n = 1). Distal lesions were treated by plate-screw fixation (97%, n = 29) and intramedullary nailing (3.3%, n = 1). RESULTS We found 25 (8.5%) reoperations, and 17 (5.8%) patients had 18 systemic complications: pneumonia (3.7%, n = 11), pulmonary embolism (1.3%, n = 4), sepsis (0.68%, n = 2), and fat embolism (0.34%, n = 1). No factors were independently associated with reoperation. Logistic regression analysis demonstrated that favorable cancer status (i.e., a higher modified Bauer score: odds ratio, 0.48; 95% confidence interval, 0.29-0.80; P = .005) was independently associated with a decreased systemic complication rate. CONCLUSION Poor cancer status was an independent predictor of postoperative systemic complications. This could help inform the patient and anticipate postoperative problems.
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Affiliation(s)
- Stein J Janssen
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA.
| | - Maarten van Dijke
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA
| | - Santiago A Lozano-Calderón
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA
| | - John E Ready
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Brigham and Women's Hospital, Boston, MA, USA
| | - Kevin A Raskin
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA
| | - Marco L Ferrone
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Brigham and Women's Hospital, Boston, MA, USA
| | - Francis J Hornicek
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA
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12
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Najafzadeh M, Kim SC, Patterson C, Schneeweiss S, Katz JN, Brick GW, Ready JE, Polinski JM, Patorno E. Patients' perception about risks and benefits of antithrombotic treatment for the prevention of venous thromboembolism (VTE) after orthopedic surgery: a qualitative study. BMC Musculoskelet Disord 2015; 16:319. [PMID: 26503220 PMCID: PMC4624375 DOI: 10.1186/s12891-015-0777-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/15/2015] [Indexed: 11/24/2022] Open
Abstract
Background The 9th edition of the American College of Chest Physicians’ Antithrombotic Therapy and Prevention of Thrombosis guidelines emphasize the importance of considering the risk–benefit ratio of “patient-important” outcomes. However, little is known about patients’ perception and understanding regarding the different outcomes of antithrombotic treatment after orthopedic surgery, and the factors that influence their decision to use these treatments. Using a series of semi-structured interviews, we explored patients’ understanding and perception concerning the benefits and risks of antithrombotic treatment for the prevention of venous thromboembolism (VTE) after joint replacement surgery. Methods A series of semi-structured interviews were conducted with patients who had undergone knee or hip replacement surgery at a tertiary care hospital (Brigham and Women’s Hospital, Boston, MA) in 2014. Discussions were recorded and transcribed. Two investigators independently coded and analyzed the data to identify important themes and concepts using the constant comparative method. Results Of 64 patients who were invited, 12 patients (19 %) completed the interviews. The majority of patients (92 %) were aware of the benefits of antithrombotic therapy for reducing the risk of blood clots, while less than half of them had a clear understanding of deep vein thrombosis and pulmonary embolism. While all patients were aware of risk of minor bleeding, only 6 patients (50 %) considered the risk of major bleeding as a possible side effect of antithrombotic treatment. Overall, patients perceived bleeding as a less important outcome than a thrombotic event. The lack of awareness about the risk of major bleeding, the assumption that a short-term exposure would not meaningfully affect bleeding risk, and the assumption that bleeding is a controllable event influenced their perception. Most patients (83 %) stated that their decision to use antithrombotic medications was mainly based on the trust in their physician’s expertise. Conclusions Patients perceived thrombotic events as more important outcomes than bleeding events. Patients’ understanding of thrombotic and bleeding events varies and may play a key role in their preferences. The majority of patients stated that trust in their physician’s expertise had a large influence on their decision to use antithrombotic medications.
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Affiliation(s)
- M Najafzadeh
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - S C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. .,Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.
| | - C Patterson
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - S Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - J N Katz
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA. .,Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.
| | - G W Brick
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.
| | - J E Ready
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.
| | - J M Polinski
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - E Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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13
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Janssen SJ, van der Heijden AS, van Dijke M, Ready JE, Raskin KA, Ferrone ML, Hornicek FJ, Schwab JH. 2015 Marshall Urist Young Investigator Award: Prognostication in Patients With Long Bone Metastases: Does a Boosting Algorithm Improve Survival Estimates? Clin Orthop Relat Res 2015; 473:3112-21. [PMID: 26155769 PMCID: PMC4562931 DOI: 10.1007/s11999-015-4446-z] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 06/30/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Survival estimation guides surgical decision-making in metastatic bone disease. Traditionally, classic scoring systems, such as the Bauer score, provide survival estimates based on a summary score of prognostic factors. Identification of new factors might improve the accuracy of these models. Additionally, the use of different algorithms--nomograms or boosting algorithms--could further improve accuracy of prognostication relative to classic scoring systems. A nomogram is an extension of a classic scoring system and generates a more-individualized survival probability based on a patient's set of characteristics using a figure. Boosting is a method that automatically trains to classify outcomes by applying classifiers (variables) in a sequential way and subsequently combines them. A boosting algorithm provides survival probabilities based on every possible combination of variables. QUESTIONS/PURPOSES We wished to (1) assess factors independently associated with decreased survival in patients with metastatic long bone fractures and (2) compare the accuracy of a classic scoring system, nomogram, and boosting algorithms in predicting 30-, 90-, and 365-day survival. METHODS We included all 927 patients in our retrospective study who underwent surgery for a metastatic long bone fracture at two institutions between January 1999 and December 2013. We included only the first procedure if patients underwent multiple surgical procedures or had more than one fracture. Median followup was 8 months (interquartile range, 3-25 months); 369 of 412 (90%) patients who where alive at 1 year were still in followup. Multivariable Cox regression analysis was used to identify clinical and laboratory factors independently associated with decreased survival. We created a classic scoring system, nomogram, and boosting algorithms based on identified variables. Accuracy of the algorithms was assessed using area under the curve analysis through fivefold cross validation. RESULTS The following factors were associated with a decreased likelihood of survival after surgical treatment of a metastatic long bone fracture, after controlling for relevant confounding variables: older age (hazard ratio [HR], 1.0; 95% CI, 1.0-1.0; p < 0.001), additional comorbidity (HR, 1.2; 95% CI, 1.0-1.4; p = 0.034), BMI less than 18.5 kg/m(2) (HR, 2.0; 95% CI, 1.2-3.5; p = 0.011), tumor type with poor prognosis (HR, 1.8; 95% CI, 1.6-2.2; p < 0.001), multiple bone metastases (HR, 1.3; 95% CI, 1.1-1.6; p = 0.008), visceral metastases (HR, 1.6; 95% CI, 1.4-1.9; p < 0.001), and lower hemoglobin level (HR, 0.91; 95% CI, 0.87-0.96; p < 0.001). The survival estimates by the nomogram were moderately accurate for predicting 30-day (area under the curve [AUC], 0.72), 90-day (AUC, 0.75), and 365-day (AUC, 0.73) survival and remained stable after correcting for optimism through fivefold cross validation. Boosting algorithms were better predictors of survival on the training datasets, but decreased to a performance level comparable to the nomogram when applied on testing datasets for 30-day (AUC, 0.69), 90-day (AUC, 0.75), and 365-day (AUC, 0.72) survival prediction. Performance of the classic scoring system was lowest for all prediction periods. CONCLUSIONS Comorbidity status and BMI are newly identified factors associated with decreased survival and should be taken into account when estimating survival. Performance of the boosting algorithms and nomogram were comparable on the testing datasets. However, the nomogram is easier to apply and therefore more useful to aid surgical decision making in clinical practice. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Stein J. Janssen
- />Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital–Harvard Medical School, Boston, MA USA , />Massachusetts General Hospital, Room 3.946, Yawkey Building, 55 Fruit Street, Boston, MA 02114 USA
| | - Andrea S. van der Heijden
- />Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital–Harvard Medical School, Boston, MA USA
| | - Maarten van Dijke
- />Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital–Harvard Medical School, Boston, MA USA
| | - John E. Ready
- />Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Brigham and Women’s Hospital–Harvard Medical School, Boston, MA USA
| | - Kevin A. Raskin
- />Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital–Harvard Medical School, Boston, MA USA
| | - Marco L. Ferrone
- />Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Brigham and Women’s Hospital–Harvard Medical School, Boston, MA USA
| | - Francis J. Hornicek
- />Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital–Harvard Medical School, Boston, MA USA
| | - Joseph H. Schwab
- />Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital–Harvard Medical School, Boston, MA USA
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14
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Janssen SJ, Braun Y, Ready JE, Raskin KA, Ferrone ML, Hornicek FJ, Schwab JH. Are Allogeneic Blood Transfusions Associated With Decreased Survival After Surgery for Long-bone Metastatic Fractures? Clin Orthop Relat Res 2015; 473:2343-51. [PMID: 25637400 PMCID: PMC4457741 DOI: 10.1007/s11999-015-4167-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 01/21/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies have shown that perioperative blood transfusion increases cancer recurrence and decreases patient survival after resection of primary malignancies. The question arises whether this association also exists in patients with already disseminated disease undergoing surgery for metastatic long-bone fractures. PURPOSES We sought to determine whether perioperative allogeneic blood transfusion is associated with decreased survival after operative treatment of long-bone metastatic fractures after accounting for clinical, laboratory, and treatment factors. Secondarily, we aimed to identify potential factors that are associated with decreased survival. METHODS We included 789 patients in our retrospective study who underwent surgery at two institutions for a pathologic or impending metastatic long-bone fracture. We used multivariable Cox proportional hazards regression model analysis to assess the relationship of perioperative allogeneic blood transfusion with survival, and accounted for patient age, sex, comorbidities, BMI, tumor type, fracture type and location, presence of other bone and visceral metastases, previous radiotherapy and systemic therapy, preoperative embolization, preoperative hemoglobin level, treatment type, anesthesia time, blood loss, duration of hospital admission, year of surgery, and hospital. RESULTS Considering transfusion as an "exposure," and comparing patients who received transfusions with those who did not, we found that blood transfusion was not associated with decreased survival after accounting for all explanatory variables (hazard ratio [HR] 1.06; 95% CI, 0.87-1.30; p = 0.57). Evaluating transfusion in terms of dose-response, we found that patients who received more transfusions had lower survival compared with those who had fewer transfusions after accounting for all explanatory variables (HR per unit of blood transfused, 1.07; 95% CI, 1.02-1.12; p = 0.005). We found that age (HR, 1.02; 95% CI, 1.01-1.02; p < 0.001), comorbidity status (HR, 1.06; 95% CI, 1.01-1.10; p = 0.014), duration of hospital stay (HR, 1.02; 95% CI 1.00-1.03; p = 0.021), tumor type (HR, 1.71; 95% CI, 1.44-2.03; p < 0.001), and visceral metastases (HR, 1.59; 95% CI, 1.34-1.88; p < 0.001) were independently associated with survival. CONCLUSION We found that exposure to perioperative allogeneic blood transfusion does not decrease survival, with the numbers available. However, our sample size might have been insufficient to reveal a small but potentially relevant effect. Our results do suggest a dose-response relationship; patients who received more transfusions had lower survival compared with those with fewer transfusions. Risk of death increased by 7% per unit of blood transfused. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Stein J. Janssen
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital – Harvard Medical School, Room 3.946, Yawkey Building, 55 Fruit Street, Boston, MA 02114 USA
| | - Yvonne Braun
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital – Harvard Medical School, Room 3.946, Yawkey Building, 55 Fruit Street, Boston, MA 02114 USA
| | - John E. Ready
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Brigham and Women’s Hospital, Boston, MA USA
| | - Kevin A. Raskin
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital – Harvard Medical School, Room 3.946, Yawkey Building, 55 Fruit Street, Boston, MA 02114 USA
| | - Marco L. Ferrone
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Brigham and Women’s Hospital, Boston, MA USA
| | - Francis J. Hornicek
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital – Harvard Medical School, Room 3.946, Yawkey Building, 55 Fruit Street, Boston, MA 02114 USA
| | - Joseph H. Schwab
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital – Harvard Medical School, Room 3.946, Yawkey Building, 55 Fruit Street, Boston, MA 02114 USA
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Fairweather M, Wang J, Devlin PM, Hansen J, Baldini EH, Ready JE, Sugarbaker DJ, Bertagnolli MM, Raut CP. Safety and efficacy of radiation dose delivered via iodine-125 brachytherapy mesh implantation for deep cavity sarcomas. Ann Surg Oncol 2014; 22:1455-63. [PMID: 25341749 DOI: 10.1245/s10434-014-4171-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Radiation delivered as brachytherapy (BRT) via catheters placed during extremity soft tissue sarcoma (STS) resection results in acceptable local control rates; however, there are limitations in deep cavities. (125)I seeds embedded in mesh provide a flexible BRT platform that may be contoured to irregular deep cavities surfaces, but the risks and benefits are unknown. METHODS Patients with thoracic, abdominal, pelvic, retroperitoneal, and deep truncal STS undergoing resection and implantation of permanent (125)I mesh BRT at our institution were reviewed. Local recurrence rates within the tumor bed covered by mesh (in field) and postoperative complications were analyzed. RESULTS Between 2000 and 2010, a total of 46 patients were treated for primary (n = 8, 17 %) or recurrent (n = 38, 83 %) deep cavity STS (median follow-up 34.8 months); 74 % received external-beam radiotherapy for this or a prior presentation. In-field recurrences were observed in 9 patients (19.5 %). Crude cumulative incidences of in-field, regional, and distant recurrences at 5 years were 26.3, 54.2, and 54.1 %, respectively. 5-year overall survival rate was 47.2 %; median survival was 44.0 months. Twenty-two patients (48 %) experienced complications, half of whom (24 %) developed grade III/IV complications requiring percutaneous intervention (n = 6) or reoperation (n = 5) at a median of 35.5 days. There were no postoperative deaths. CONCLUSIONS To our knowledge, this is the first study to report safety and efficacy for permanent (125)I mesh BRT implantation after resection of deep cavity STS. Local in-field recurrence rates were relatively low in this high-risk population. However, 24 % developed complications requiring intervention. (125)I mesh BRT appears effective, but it should be used with caution.
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Affiliation(s)
- Mark Fairweather
- Division of Surgical Oncology, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA,
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Schwarzkopf R, Shah J, Ahmad AQ, Ready JE. WITHDRAWN: Porous Metal Augments Show Excellent Mid-to-Long Term Survival in Complex Acetabular Reconstruction. J Arthroplasty 2014:S0883-5403(14)00188-0. [PMID: 24768546 DOI: 10.1016/j.arth.2014.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 03/16/2014] [Accepted: 03/18/2014] [Indexed: 02/01/2023] Open
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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Affiliation(s)
- Ran Schwarzkopf
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - Jinesh Shah
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Asim Q Ahmad
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - John E Ready
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Affiliation(s)
- Flávia A Sakamoto
- Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, A21, Cleveland, OH, 44195, USA
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Cheriyan T, Ready JE, Brick GW, Martin SD, Martin TL, Schmid TM, Padera RF, Spector M. Lubricin and smooth muscle α-actin-containing myofibroblasts in the pseudomembranes around loose hip and knee prostheses. Acta Biomater 2013; 9:5751-8. [PMID: 23174700 DOI: 10.1016/j.actbio.2012.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 10/24/2012] [Accepted: 11/09/2012] [Indexed: 11/17/2022]
Abstract
The objective was to evaluate the presence and distribution of the lubricating and anti-adhesion glycoprotein lubricin and cells containing the contractile isoform smooth muscle α-actin (SMA) in pseudomembranes around loose hip prostheses. Periprosthetic tissue was obtained at revision arthroplasty of eight aseptic, loose hip implants, and for comparison three loose knee prostheses. Immunohistochemical analysis was performed in 3 zones: zone 1, within 300μm of the edge of the implant-tissue interface; zone 2, between zones 1 and 3; zone 3, within 300μm of the resected/trimmed edge. The presence of lubricin was extensive in all samples: (1) as a discrete layer at the implant-tissue interface; (2) within the extracellular matrix (ECM); (3) intracellularly. There was significantly more high grade (>50%) lubricin surface staining at the implant-tissue interface compared with the resected edge. While there was also a significant effect of location of high grade ECM lubricin staining, there was no significant effect of implant type (i.e. hip versus knee). All but two hip pseudomembrane samples showed the presence of many SMA-containing cells. There was a significant effect of location on the number of SMA-expressing cells, but not of implant type. These findings might explain why the management of loose prosthesis is so challenging.
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Baldini EH, Lapidus MR, Wang Q, Manola J, Orgill DP, Pomahac B, Marcus KJ, Bertagnolli MM, Devlin PM, George S, Abraham J, Ferrone ML, Ready JE, Raut CP. Predictors for major wound complications following preoperative radiotherapy and surgery for soft-tissue sarcoma of the extremities and trunk: importance of tumor proximity to skin surface. Ann Surg Oncol 2012; 20:1494-9. [PMID: 23242820 DOI: 10.1245/s10434-012-2797-1] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Indexed: 12/20/2022]
Abstract
PURPOSE Preoperative and postoperative RT for the treatment of high-grade soft-tissue sarcoma result in similar local control and overall survival rates, but morbidities differ. Postoperative RT is associated with a higher rate of long-term fibrosis, edema, and joint stiffness. Preoperative RT is associated with higher rates of wound complications. It is important to identify predictors for major wound complications (MWC) and to develop strategies to minimize this outcome. We reviewed our experience to determine predictors for MWC following preoperative radiotherapy (RT) and surgery for soft-tissue sarcoma. METHODS Between January 2006 and May 2011, 103 patients with soft-tissue sarcoma of the extremities and trunk were treated with preoperative RT followed by surgery. MWCs were defined as those requiring operative or prolonged nonoperative management. Fisher's exact test was used to compare rates. Logistic regression was used for multivariable analysis of factors potentially associated with MWCs. RESULTS Median tumor size was 8.4 cm (range 2-25). All patients had wide or radical resections. Wound closures were primary in 70 %, a vascularized flap in 27 %, and split-thickness skin graft (STSG) in 3 %. There were 36 MWCs (35 %). Significant predictors for MWCs on univariate analysis included diabetes, tumors >10 cm, tumors <3 mm from skin surface, and vascularized flap/STSG closure. The same four variables were significant predictors on multivariable analysis. CONCLUSIONS MWCs following preoperative RT and surgery were common. Tumor proximity to skin surface <3 mm is a previously unreported independent predictor, and further strategies to minimize wound complications are needed.
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Affiliation(s)
- Elizabeth H Baldini
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA.
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20
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Abraham JA, Weaver MJ, Hornick JL, Zurakowski D, Ready JE. Outcomes and prognostic factors for a consecutive case series of 115 patients with somatic leiomyosarcoma. J Bone Joint Surg Am 2012; 94:736-44. [PMID: 22517390 DOI: 10.2106/jbjs.k.00460] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Leiomyosarcoma is an uncommon tumor that affects 500 to 1000 patients in the United States annually. The purpose of our study was to further define survival rates as well as to identify multivariable predictors of disease-specific mortality, local recurrence, and development of distant metastasis following surgical resection. METHODS We studied a consecutive series of patients treated for leiomyosarcoma at our institution (a tertiary-care referral center) over a ten-year period. Only patients with leiomyosarcoma of soft tissues, vasculature, or bone were included. Those with uterine, gastrointestinal, or cutaneous forms of the disease were excluded. This yielded a cohort of 115 patients with complete follow-up data on which statistical analysis was performed. RESULTS One-year, five-year, and ten-year disease-specific survival rates were 87%, 57%, and 19%, respectively. Tumor depth (p < 0.01), histological grade (p < 0.01), and metastasis at presentation (p = 0.03) were found to be multivariable predictors of mortality. Both retroperitoneal location (p = 0.01) and mitotic rate (p < 0.001) were predictive of distant metastasis. Resection margin was the only multivariable significant predictor of local recurrence in the group treated with surgical resection (p < 0.001). CONCLUSIONS Leiomyosarcoma is an aggressive disease, with a generally poor prognosis. Depth of tumor and high histological grade are indicators of a poor prognosis. Retroperitoneal tumors have a particularly high potential to metastasize.
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Affiliation(s)
- John A Abraham
- Brigham and Women's Hospital, Boston, Massachusetts, USA.
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21
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Banffy MB, Vrahas MS, Ready JE, Abraham JA. Nonoperative versus prophylactic treatment of bisphosphonate-associated femoral stress fractures. Clin Orthop Relat Res 2011; 469:2028-34. [PMID: 21350886 PMCID: PMC3111775 DOI: 10.1007/s11999-011-1828-8] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2010] [Accepted: 02/15/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Several studies have identified a specific fracture in the proximal diaphysis of the femur in patients treated with bisphosphonates. The fractures typically are sustained after a low-energy mechanism with the presence of an existing characteristic stress fracture. However, it is unclear whether these patients are best treated nonoperatively or operatively. QUESTIONS/PURPOSES What is the likelihood of nonoperatively treated bisphosphonate-associated femoral stress fractures progressing to completion and during what time period? If prophylactic fixation is performed, do patients have a shorter hospital length-of-stay compared with patients having surgical fixation after fracture completion? PATIENTS AND METHODS We retrospectively searched for patients older than 50 years receiving bisphosphonate therapy, with either incomplete, nondisplaced stress fractures or completed, displaced fractures in the proximal diaphysis of the femur between July 2002 and April 2009. After applying exclusion criteria, we identified 34 patients with a total of 40 bisphosphonate-associated fractures. The average duration of bisphosphonate use was 77 months. Twenty-eight of 40 (70%) fractures were completed, displaced fractures. Six of the 12 nondisplaced stress fractures initially were treated nonoperatively. The remaining six stress fractures were treated with prophylactic cephalomedullary nail fixation. The minimum followup was 12 months (mean, 36.5 months; range, 12-72 months). RESULTS Five of the six stress fractures treated nonoperatively progressed to fracture completion and displacement at an average of 10 months (range, 3-18 months). The average hospital stay was 3.7 days for patients treated prophylactically and 6.0 days for patients treated after fracture completion. CONCLUSIONS Our data suggest nonoperative treatment of bisphosphonate-related femoral stress fractures is not a reliable way to treat these fractures as the majority progress to fracture completion. Prophylactic fixation of femoral stress fractures also reduces total hospital admission time. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michael B. Banffy
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA USA ,Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street WHT 535, Boston, MA 02114 USA
| | - Mark S. Vrahas
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA USA ,Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street WHT 535, Boston, MA 02114 USA
| | - John E. Ready
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA USA
| | - John A. Abraham
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA USA
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Abstract
BACKGROUND Bone, soft-tissue, and articular lesions are often well visualized by magnetic resonance imaging. Our goal was to evaluate the diagnostic performance of magnetic resonance imaging-guided biopsies of selected musculoskeletal lesions. METHODS In this retrospective case series, forty-five consecutive biopsies were performed in an open mid-field 0.5-T interventional magnetic resonance imaging unit with a real-time guidance system. The biopsies were performed at twenty bone, eighteen extra-articular soft-tissue, and seven intra-articular soft-tissue sites. The main reasons for using magnetic resonance imaging guidance were the need to improve lesion conspicuity compared with that provided by other imaging modalities, the need for site-specific targeting within the lesion, and the need for real-time guidance. Samples were obtained with fine-needle aspiration, core-needle biopsy, or a combination of these techniques. An independent reference standard was used to confirm the final diagnosis. Diagnostic performance was evaluated on the basis of the diagnostic yield (the proportion of biopsies yielding sufficient material for pathological evaluation) and diagnostic accuracy (sensitivity, specificity, positive predictive value, and negative predictive value). Complications were identified as well. RESULTS The diagnostic yield was 91% (forty-one of forty-five biopsies yielded sufficient material for a diagnosis) overall, 95% (nineteen of twenty) for the bone lesions, 94% (seventeen of eighteen) for the extra-articular soft-tissue lesions, and 71% (five of seven) for the intra-articular soft-tissue lesions. With regard to the diagnostic accuracy, the sensitivity was 0.86, the specificity was 1.00, the positive predictive value was 1.00, and the negative predictive value was 0.76 in the overall group. The respective values were 0.92, 1.00, 1.00, and 0.86 for the bone lesions; 0.77, 1.00, 1.00, and 0.57 for the extra-articular soft-tissue lesions; and 1.00, 1.00, 1.00, and 1.00 for the intra-articular soft-tissue lesions. There was one complication: exacerbation of neuropathic pain related to a biopsy of a peripheral nerve sheath tumor. CONCLUSIONS Magnetic resonance imaging-guided percutaneous biopsies of musculoskeletal lesions for which other imaging modalities might be inadequate have a good diagnostic performance overall. The performance can be very good for bone lesions, moderate for extra-articular soft-tissue lesions, and fair for intra-articular soft-tissue lesions.
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Affiliation(s)
- John A Carrino
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA.
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Tuncali K, Morrison PR, Winalski CS, Carrino JA, Shankar S, Ready JE, vanSonnenberg E, Silverman SG. MRI-Guided Percutaneous Cryotherapy for Soft-Tissue and Bone Metastases: Initial Experience. AJR Am J Roentgenol 2007; 189:232-9. [PMID: 17579176 DOI: 10.2214/ajr.06.0588] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE We sought to determine the safety and feasibility of percutaneous MRI-guided cryotherapy in the care of patients with refractory or painful metastatic lesions of soft tissue and bone adjacent to critical structures. MATERIALS AND METHODS Twenty-seven biopsy-proven metastatic lesions of soft tissue (n = 17) and bone (n = 10) in 22 patients (15 men, seven women; age range, 24-85 years) were managed with MRI-guided percutaneous cryotherapy. The mean lesion diameter was 5.2 cm. Each lesion was adjacent to or encasing one or more critical structures, including bowel, bladder, and major blood vessels. A 0.5-T open interventional MRI system was used for cryoprobe placement and ice-ball monitoring. Complications were assessed for all treatments. CT or MRI was used to determine local control of 21 tumors. Pain palliation was assessed clinically in 19 cases. The mean follow-up period was 19.5 weeks. RESULTS Twenty-two (81%) of 27 tumors were managed without injury to adjacent critical structures. Two patients had transient lower extremity numbness, and two had both urinary retention and transient lower extremity paresthesia. One patient had chronic serous vaginal discharge, and one sustained a femoral neck fracture at the ablation site 6 weeks after treatment. Thirteen (62%) of the 21 tumors for which follow-up information was available either remained the same size as before treatment or regressed. Eight tumors progressed (mean local progression-free interval, 5.6 months; range, 3-18 months). Pain was palliated in 17 of 19 patients; six of the 17 experienced complete relief, and 11 had partial relief. CONCLUSION MRI-guided percutaneous cryotherapy for metastatic lesions of soft tissue and bone adjacent to critical structures is safe and can provide local tumor control and pain relief in most patients.
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Affiliation(s)
- Kemal Tuncali
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA.
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24
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Pezeshk P, Sadow CA, Winalski CS, Lang PK, Ready JE, Carrino JA. Usefulness of 18F-FDG PET-directed skeletal biopsy for metastatic neoplasm. Acad Radiol 2006; 13:1011-5. [PMID: 16843854 DOI: 10.1016/j.acra.2006.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2006] [Revised: 05/10/2006] [Accepted: 05/10/2006] [Indexed: 10/24/2022]
Abstract
RATIONALE AND OBJECTIVES Technium-99m methylene diphosphonate (99mTc-MDP) bone scintigraphy and 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) are useful imaging modalities to detect skeletal metastases. Several other conditions such as infection, fractures, and arthritis can cause false-positive results with either modality. However, PET is felt to be more specific than bone scintigraphy for malignancy. Our objective was to investigate the value of PET scan compared with bone scintigraphy for directing biopsies in patients with suspected metastatic bone lesions. MATERIALS AND METHODS Retrospective case series of subjects with undergoing skeletal biopsy of suspected metastases detected by 99mTc-MDP scintigraphy or 18F-FDG PET scan. Reference standards were pathologic reports and follow-up for 6 months. The diagnostic test performance measures of true positive (TP), false positive (FP), and positive predictive value (PPV) were calculated for each group. The PPV with 95% confidence intervals (CI) was compared using the Fisher exact test. RESULTS There were a total of 68 subjects. PET-directed skeletal biopsies (n = 39) showed 35 TP, 4 FP, and an 89.7% PPV (95% CI: 75.7-97.1%). Bone scintigraphy directed biopsies (n = 29) had 21 TP, 8 FP, and 72.4 % PPV (95% CI: 52.7-82.7%). The PPV was not significantly different between the groups (P = .10). CONCLUSION This study supports that PET can be used to effectively direct bone biopsies to confirm metastatic neoplasm and suggests that PET may provide incremental improvement to diagnostic yield over bone scintigraphy. The role of PET compared with bone scintigraphy for directing skeletal biopsies warrants further verification.
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Affiliation(s)
- Parham Pezeshk
- Department of Radiology, Harvard Medical School, Boston, MA 02115, USA
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25
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Kocher MS, Erens G, Thornhill TS, Ready JE. Cost and effectiveness of routine pathological examination of operative specimens obtained during primary total hip and knee replacement in patients with osteoarthritis. J Bone Joint Surg Am 2000; 82:1531-5. [PMID: 11097439 DOI: 10.2106/00004623-200011000-00002] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The challenge of cost-efficiency is maintaining the quality of medical care while reducing costs and eliminating unnecessary practices. The purpose of this investigation was to evaluate the cost and effectiveness of routine pathological examination of surgical specimens from patients undergoing primary total hip or knee replacement for the treatment of osteoarthritis. METHODS Effectiveness was assessed by comparing clinical and pathological diagnoses associated with 1,234 consecutive primary total joint replacements (471 hip and 763 knee replacements) performed between 1992 and 1995 in one hospital in patients with the clinical diagnosis of osteoarthritis. Clinical and pathological diagnoses were considered concordant if they agreed, discrepant if they differed without a resultant change in patient management, and discordant if they differed with a resultant change in patient management. Cost identification was performed by determining charges, reimbursement, and costs in 1998-adjusted American dollars for both total hip and total knee replacement. The cost per health-effect was determined by calculating the cost per discrepant and discordant diagnosis. RESULTS The prevalence of concordant diagnoses was 97.6 percent (1,205 of 1,234) (95 percent confidence interval, 96.6 to 98.4 percent), the prevalence of discrepant diagnoses was 2.3 percent (twenty-eight of 1,234) (95 percent confidence interval, 1.4 to 3.1 percent), and the prevalence of discordant diagnoses was 0.1 percent (one of 1,234) (95 percent confidence interval, 0.1 to 0.3 percent). The cost per discrepant diagnosis was $4,383, and the cost per discordant diagnosis was $122,728. CONCLUSIONS Routine pathological examination of surgical specimens from patients undergoing primary total hip or knee replacement because of the clinical diagnosis of osteoarthritis had limited cost-effectiveness at our hospital due to the low prevalence of findings that altered patient management.
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MESH Headings
- Aged
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Knee/economics
- Cost-Benefit Analysis
- Costs and Cost Analysis
- Diagnostic Tests, Routine/economics
- Female
- Hip Joint/pathology
- Hospital Charges
- Humans
- Insurance, Health, Reimbursement/economics
- Knee Joint/pathology
- Male
- Medicare/economics
- Osteoarthritis, Hip/pathology
- Osteoarthritis, Hip/surgery
- Osteoarthritis, Knee/pathology
- Osteoarthritis, Knee/surgery
- Retrospective Studies
- United States
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Affiliation(s)
- M S Kocher
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, and the Harvard School of Public Health, Boston, Massachusetts 02115, USA.
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26
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O'Donnell RJ, Springfield DS, Motwani HK, Ready JE, Gebhardt MC, Mankin HJ. Recurrence of giant-cell tumors of the long bones after curettage and packing with cement. J Bone Joint Surg Am 1994; 76:1827-33. [PMID: 7989388 DOI: 10.2106/00004623-199412000-00009] [Citation(s) in RCA: 271] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The nine-year experience with sixty patients who had had a giant-cell tumor of a long bone was reviewed to determine the rate of recurrence after treatment with curettage and packing with polymethylmethacrylate cement. The demographic characteristics, including the age and sex of the patient and the site of the tumor, were similar to those that have been reported for other large series. An average of four years (range, two to ten years) after the operation, the over-all rate of initial local recurrence was 25 per cent (fifteen of sixty patients). Patients who had had a tumor of the distal aspect of the radius had a higher rate of recurrence (five of ten) than those who had had a tumor of the proximal aspect of the tibia (seven [28 per cent] of twenty-five) or of the distal part of the femur (three [13 per cent] of twenty-three). Higher rates of recurrence were also noted for patients who had had a pathological fracture (three of six), those who had had a Stage-III tumor according to the classification of Campanacci et al. (six of sixteen), and those who had not had adjuvant treatment with either a high-speed burr or phenol (eight of nineteen). Patients who had had an initial recurrence after packing with cement had a low rate of secondary recurrence when the initial recurrence had been treated with a wide resection or a second intralesional procedure (zero of ten and one of five patients, respectively), after an average of three years (range, ten months to eight years). No patient had a multicentric tumor or metastasis.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R J O'Donnell
- Orthopaedic Oncology Unit, Massachusetts General Hospital, Boston 02114
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Coppolelli BG, Ready JE, Awbrey BJ, Smith LS. Polydactyly of the foot in adults: literature review and unusual case presentation with diagnostic and treatment recommendations. J Foot Surg 1991; 30:12-8. [PMID: 2002180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The authors present an unusual case of polydactyly of the foot in an otherwise healthy adult male. The modern literature describing polydactyly of the foot is reviewed, as well as a review and critique of various classification schemes for foot polydactyly deformities. The authors applied the classification criteria of Blauth and Olason to an atypical case and to other varied, yet typical, presentations of polydactyly of the foot in adults. Nonsurgical and surgical treatment options are reviewed, and a rational treatment plan is proposed based upon use of the classification scheme. They then apply the management plan for symptomatic polydactyly of the foot to the unusual case, and make recommendations for surgical management of this deformity.
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Affiliation(s)
- B G Coppolelli
- Department of Podiatry, Cambridge Hospital, Massachusetts
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28
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Gebhardt MC, Ready JE, Mankin HJ. Tumors about the knee in children. Clin Orthop Relat Res 1990:86-110. [PMID: 2189635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Tumors are rare causes of knee symptoms in children but must be considered in the differential diagnosis of pediatric knee pain in order to avoid errors in treatment that could result in loss of limb or even life. Experience with 199 bone and soft-tissue tumors about the knee in children are reviewed. The majority of lesions were benign bone tumors (n = 101), with osteocartilaginous exostoses, nonossifying fibromas, and chondroblastomas predominating. Malignant bone tumors (n = 59) were less frequent, and osteosarcoma (n = 48) was by far the most common sarcoma. Soft-tissue lesions (n = 31) were much less frequent and included rhabdomyosarcoma, synovial sarcoma, fibrosarcoma, and desmoid tumors. A careful history, physical examination, and review of roentgenograms are essential to avoid errors in diagnosis. Malignant tumors require roentgenograms and laboratory studies in sequence to stage the patient. A properly performed biopsy established the diagnosis in most instances. Popliteal cysts, stress fractures, infection, myositis ossificans, histiocytosis, and other lesions can mimic tumors and delay correct diagnosis.
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Affiliation(s)
- M C Gebhardt
- Harvard Medical School, Massachusetts General Hospital, Boston 02114
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