Biomedical subjects

David Zurakowski

Publications and source records attributed to David Zurakowski.

At least 163 records · Page 9Linked to original sources

PubMed2002

Bipolar hemiarthroplasty in juvenile rheumatoid arthritis: long-term survivorship and outcomes.

Because controversy surrounds the management of end-stage hip disease in juvenile rheumatoid arthritis (JRA), this study evaluated the long-term outcome of bipolar hemiarthroplasty as an alternative to conventional joint arthroplasty. A total of 24 JRA patients underwent 39 hemiarthroplasties; follow-up averaged 12 years (range, 3 to 15 years). There were 14 hips (36%) revised, and 25 hips (64%) maintained the original components. Mean Harris hip scores in surviving hips improved from 29 to 69 points (P<.001). Radiographs showed progressive bipolar superomedial migration (P<.01) despite attempted augmentation. Failure defined as revision to total hip arthroplasty or definite radiographic loosening occurred in 15 hips (38%). Ten-year Kaplan-Meier survivorship for all prostheses was 78%. Independent multivariate risk factors for failure included acetabular grafting (P =.006), prosthesis type (P<.001), and unilateral replacement (P<.001).

Adolescent↗

PubMed2002

Physical therapy and cognitive-behavioral treatment for complex regional pain syndromes.

Complex regional pain syndromes (CRPS; type 1, reflex sympathetic dystrophy, and type 2, causalgia) involve persistent pain, allodynia, and vasomotor signs. We conducted a prospective, randomized, single-blind trial of physical therapy (PT) and cognitive-behavioral treatment for children and adolescents with CRPS. Children 8 to 17 years of age (n = 28) were randomly assigned to either group A (PT once per week for 6 weeks) or group B (PT 3 times per week for 6 weeks). Both groups received 6 sessions of cognitive-behavioral treatment. Assessments of pain and function were repeated at two follow-up time periods. Outcomes were compared at the three time points through the use of parametric or nonparametric analysis of variance and post hoc tests. All five measures of pain and function improved significantly in both groups after treatment, with sustained benefit evident in the majority of patients at long-term follow-up. Recurrent episodes were reported in 50% of patients, and 10 patients eventually received sympathetic blockade. Most children with CRPS showed reduced pain and improved function with a noninvasive rehabilitative treatment approach. Long-term functional outcomes were also very good.

Adolescent↗

PubMed2002

Arterial switch operation with a single coronary artery.

OBJECTIVE: Our purpose was to evaluate the impact of coronary pattern on survival and reintervention in patients who underwent the arterial switch operation with a single coronary artery. METHODS: We conducted a retrospective analysis of 53 patients with a single coronary artery who underwent the arterial switch operation between 1983 and 2000 at Children's Hospital Boston. Recent follow-up information was obtained for 40 of the 46 long-term survivors (mean follow-up 7.3 +/- 4.5 years). RESULTS: Thirty-five patients had a single right coronary artery, with the left coronary artery posterior to the pulmonary artery in 27. Eighteen patients had a single left coronary artery (16 with the right coronary artery anterior to the aorta). Six of 7 total patients who died had a single right coronary artery; all died before 1992. There were 5 early deaths, all with a single right coronary artery, with 4 deaths due to coronary malperfusion. Survivals for all patients were 91% at 6 months and 87% at 1, 5, and 10 years after the arterial switch operation. Survival figures were lower for patients having a single right ostium with the left main coronary artery posterior to the pulmonary artery compared with all other subtypes (P =.02, log-rank test). Seven patients had reintervention, 4 because of right ventricular outflow tract obstruction, 1 for heart transplantation, 1 for mitral valve repair and 1 for pacemaker implantation. Freedom from reintervention for all patients was 96% at 6 months, 92% at 1 year, 86% at 5 years, and 82% at 10 years after the arterial switch operation, with lower rates for patients having a single left ostium with the right coronary artery anterior to the aorta (P =.0003, log-rank test). CONCLUSIONS: In the current era, the arterial switch operation with a single coronary artery can be performed safely irrespective of the coronary anatomy. Risk of reintervention is higher in patients having a single left ostium with the right coronary artery anterior to the aorta.

Cardiac Surgical Procedures↗

PubMed2002

Outcome after reconstruction of discontinuous pulmonary arteries.

OBJECTIVE: This study was undertaken to determine outcomes of and optimal treatment strategies for reconstruction of congenital or acquired discontinuity of branch pulmonary arteries. METHODS: Between 1985 and 2000 pulmonary artery continuity was established in 102 patients with discontinuous central pulmonary arteries and normal peripheral arborization. Data were obtained retrospectively. RESULTS: Techniques to connect both pulmonary arteries included direct pulmonary artery-pulmonary artery anastomosis (n = 33), tube graft interposition (n = 47), or pulmonary arterial implantation in right ventricular-pulmonary arterial conduits (n = 22). Among patients with biventricular repair (n = 66), survival was 85% +/- 8% at 5 years, and freedom from surgical or interventional pulmonary arterioplasty was 31% +/- 11%. At most recent follow-up, mean branch pulmonary arterial z scores were -0.5 +/- 1.6 (right pulmonary artery) and -1.4 +/- 1.3 (left pulmonary artery). Mean right to left ventricular pressure ratio was 0.61 +/- 0.26, and this value was more than 0.75 in 13 of 58 cases. Fifteen of 51 had a lung perfusion mismatch of more than 75:25, and in 9 of 58 one branch pulmonary artery was occluded. Twenty-two patients who underwent primary establishment of antegrade pulmonary artery flow without previous shunt procedures had comparable survival and reintervention rates, with a tendency toward higher pulmonary arterial z scores and lower right to left ventricular pressure ratios. Among patients with single-ventricle repair (n = 33), 5-year survival was 93% +/- 8% and freedom from pulmonary arterioplasty was 39% +/- 9%. Ten of 19 patients had a lung perfusion mismatch, and one branch pulmonary artery was occluded in 4 of 31. Overall, a direct pulmonary artery anastomosis was associated with better survival (P =.006). The presence of aortopulmonary collaterals was a risk factor for pulmonary artery occlusion (P =.03). CONCLUSION: Good survival can be achieved for patients with pulmonary artery discontinuity, but this requires frequent reinterventions. Direct pulmonary artery- pulmonary artery anastomoses and control of all collateral vessels may further improve outcome.

Angioplasty↗

PubMed2002

Coagulation abnormalities in patients with single-ventricle physiology precede the Fontan procedure.

OBJECTIVE: Thromboembolic events in patients who have undergone the Fontan operation have been reported to be as high as 20% to 33%. A hypercoagulable state with deficiencies in proteins C and S has been implicated. Using age-matched control subjects, we evaluated whether an altered coagulation state is present earlier in the course of staged single-ventricle repair. METHODS: After informed consent had been obtained, coagulation factors were assayed in 36 infants (mean age, 7.7 +/- 3.6 months) with single-ventricle cardiac defects immediately before undergoing the bidirectional Glenn procedure; 34 infants (mean age, 8.4 +/- 2.6 months) without cardiac disease were assayed as control subjects. Concentration of factors II, V, VII, VIII, IX, and X; antithrombin III; plasminogen; proteins C and S; fibrinogen; serum albumin; and liver enzymes were measured. Normal reference intervals on the basis of the control subjects were determined by using 95% confidence limits. Patient demographic and hemodynamic variables were evaluated as possible predictors of coagulation abnormalities. RESULTS: Concentrations of protein C; factors II, V, VII, IX, and X; plasminogen; fibrinogen; and antithrombin III were significantly lower in the pre-Glenn infants compared with the age-matched control subjects (all P <.001, Student t test). On the basis of multiple logistic regression, no specific hemodynamic variables were predictive of a procoagulant or anticoagulant deficiency. Ventricular dysfunction did predict the presence of multiple coagulation abnormalities (P <.001). CONCLUSION: Procoagulant and anticoagulant factor abnormalities occur early in the course of single-ventricle repair and precede the cavopulmonary connection.

Blood Coagulation Factors↗

PubMed2002

Ectopic ureteroceles in infants with prenatal hydronephrosis: use of renal cortical scintigraphy.

PURPOSE: This study assesses the contribution of renal cortical scintigraphy in the diagnostic evaluation of infants with ectopic ureteroceles. METHODS: The records of 20 infants (age range, 3 weeks to 4 months) who were referred for renal cortical scintigraphy after an ectopic ureterocele associated with a duplex kidney was found during follow-up of prenatal hydronephrosis were reviewed retrospectively. All infants underwent voiding cystourethrography, ultrasonography, and Tc-99m DMSA scintigraphy. RESULTS: All upper moieties showed absent or depressed Tc-99m DMSA uptake. Upper moiety functional impairment was associated with structural abnormalities shown by ultrasonography. The degree of functional impairment was reflective of ultrasonographically defined cortical thickness relative to pelvic diameter, but this relation varied. Eight of 20 (40%) lower moieties had diffusely depressed relative Tc-99m DMSA uptake. Focal defects were also present in three of these eight (38%) lower moieties. Lower moiety functional impairment was associated with higher degrees of pelvic dilatation and with vesicoureteral reflux. Ultrasonography revealed diffuse parenchymal thinning in four of the eight (50%) lower moieties with depressed uptake. Ultrasonography did not define focal parenchymal loss in any lower moiety. CONCLUSIONS: The degree to which function is impaired in the upper moieties of duplex kidneys with ureters terminating in ectopic ureteroceles is not highly predictable by ultrasonography. Lower moiety functional impairment and cortical defects are frequently present in these kidneys and often occur without ultrasonographic evidence of parenchymal damage. Use of renal cortical scintigraphy in the diagnostic evaluation of infants with ectopic ureteroceles is supported.

Female↗

PubMed2002

Complementary medicine use in children and young adults with inflammatory bowel disease.

OBJECTIVES: We examined the use of complementary alternative medicine (CAM) in children and young adults with inflammatory bowel disease. METHODS: After validation of a questionnaire and completion of a pilot survey, children and young adults with inflammatory bowel disease were enrolled in three centers of pediatric gastroenterology (Boston, Detroit, and London). RESULTS: Two hundred eight questionnaires were completed in total (Boston, 120; Detroit, 37; London, 51). Ages ranged from 3.8 to 23.0 yr, 58% were male, 57% had Crohn's disease, and 35% had ulcerative colitis. The frequency of CAM use was 41%. The most common CAMs were megavitamin therapy (19%), dietary supplements (17%), and herbal medicine (14%). Parental CAM use and the number of adverse effects from conventional medicines were predictors of CAM use (odds ratio = 1.9, 95% CI = 1.2-3.1, p = 0.02; odds ratio = 1.3, 95% CI = 1.2-1.5, p < 0.001, respectively). The most important reasons respondents gave for using CAM were side effects from prescribed medicines, prescribed medicines not working as well as they had hoped, and hoping for a cure. Fifty-nine percent of respondents not taking CAM were interested in learning more about it. CONCLUSIONS: In our survey over 40% of children with chronic inflammatory bowel disease used complementary medicine in addition to conventional therapies. Parental CAM use and number of adverse effects from conventional therapies were the only independent predictors of CAM use. Some complementary therapies have potential for adverse effects and for drug interactions with conventional treatments. Physicians should take a thorough history of CAM use in children with chronic inflammatory bowel disease.

Adolescent↗

PubMed2002

Testicular volume: comparison of orchidometer and US measurements in dogs.

PURPOSE: To compare the accuracy and precision of orchidometer and ultrasonographic (US) measurements of testicular volume in a canine model. MATERIALS AND METHODS: Volume measurements of 18 canine testes were obtained by using Prader and Rochester orchidometers. Testes were scanned with two linear-array US transducers with imaging frequencies of 6-13 MHz and 5-10 MHz. For each transducer, testicular volumes were calculated by using three formulas: length (L) x width (W) x height (H) x 0.52, L x W(2) x 0.52, and L x W x H x 0.71. Testes were weighed following bilateral orchiectomies. True testicular volume was determined by using the formula volume = weight/density. Paired t tests were used to assess whether mean measurement biases differed significantly from zero. The relationship between true and measured volume was evaluated with a linear regression model. RESULTS: US volume measurements demonstrated lower variability and better linear fit compared with orchidometry (R(2) = 0.75-0.90 vs R(2) = 0.14-0.38). The formula L x W x H x 0.71 had the smallest mean bias relative to true volume with use of either transducer over the entire volume range. CONCLUSION: US methods of testicular volume measurement are more accurate and precise than orchidometry. The formula L x W x H x 0.71 provides a superior estimate of testicular volume and should be used in clinical practice.

Animals↗

PubMed2002

Evolution of a protocol for ketamine-induced sedation as an alternative to general anesthesia for interventional radiologic procedures in pediatric patients.

PURPOSE: To establish a protocol for credentialed pediatric radiology nurses, with radiologist supervision, to administer ketamine to induce sedation and analgesia during interventional radiologic procedures. MATERIALS AND METHODS: This study was conducted in two phases. The goal of the first phase was to develop a sedation protocol to replace that of using general anesthesia for specified pediatric interventional procedures. Ketamine was administered intravenously (with intermittent bolus or continuous infusion) or intramuscularly. Sedation induction times, adverse events, doses, and sedation and recovery durations were recorded. In phase 2, the results of phase 1 were reviewed and a formal ketamine protocol was developed. RESULTS: Neither sedation failures nor substantial adverse events occurred in phase 1. Mean duration of all sedations was 52 minutes, and median recovery room time was 0 minutes. In phase 2, the results of phase 1 were reviewed and a sedation protocol was proposed to a hierarchy of hospital committees before final approval from the medical staff executive committee. Subsequently, standard order forms for radiology nurse administration of ketamine with radiologist supervision were prepared for exclusive use by the pediatric interventional radiology department. CONCLUSION: Ketamine-induced sedation may be a safe and effective alternative to general anesthesia for some interventional radiologic procedures in pediatric patients. Collaboration between anesthesia and radiology departments is important for development of a safe and successful ketamine sedation program. To the authors' knowledge, this is the first report describing the intravenous infusion of ketamine for sedation in pediatric patients and the only report describing the establishment of a protocol for ketamine administration by credentialed radiology nurses with radiologist supervision.

Adolescent↗

PubMed2002

Prediction of adverse outcome with cerebral lactate level and apparent diffusion coefficient in infants with perinatal asphyxia.

PURPOSE: To compare the predictive value for adverse outcome of quantitative cerebral lactate level and of apparent diffusion coefficient (ADC) in infants with perinatal asphyxia in the early postnatal period. MATERIALS AND METHODS: Lactate-choline ratios determined with proton magnetic resonance (MR) spectroscopy and ADC determined with diffusion MR imaging in basal ganglia and thalami in 26 full-term neonates (age range, 1-10 days) were compared with severity of acute hypoxic-ischemic encephalopathy and long-term clinical outcome. Differences in metabolites between outcome groups were evaluated with the nonparametric Kruskal-Wallis test and the Dunn test. Logistic regression was performed to examine the predictive value of each metabolite for differentiating normal from abnormal or fatal clinical outcome. The likelihood ratio test was used to assess the statistical significance of each metabolite. RESULTS: Logistic regression confirmed that lactate-choline ratio could be used to differentiate normal (n = 5) from abnormal (n = 14) or fatal (n = 6) outcome (P <.001). The probability of an adverse outcome exceeded 95% for a lactate-choline ratio of 1.0. Even when analyses were restricted to the early postnatal period, lactate-choline ratio was still a significant predictor of adverse outcome (P =.001). Although ADC images were useful in clinical examination of these infants, quantitative ADCs were not predictive of outcome (P =.82). CONCLUSION: Higher lactate-choline ratios in basal ganglia and thalami of infants with perinatal asphyxia were predictive of worse clinical outcomes. Absolute ADC in the same brain regions did not indicate a statistically significant relationship with clinical outcome. Cerebral lactate level is useful in identifying infants who would benefit from early therapeutic intervention.

Asphyxia Neonatorum↗

PubMed2002

Outcomes of primary image-guided drainage of parapneumonic effusions in children.

OBJECTIVE: To assess the outcome of image-guided needle aspiration when compared with image-guided percutaneous catheter drainage in the management of parapneumonic effusions in children. METHODS: A retrospective chart review was conducted of the medical records, microbiology, and radiology reports of 67 children who presented with parapneumonic effusions and underwent primary image-guided drainage between April 1, 1995, and April 1, 2000. RESULTS: Thirty-four patients had aspiration only, and 33 patients had pigtail catheters placed. The 2 drainage methods had similar median length of stay and complication rates. The reintervention rate in this study was 27% (18 patients). Children who underwent primary aspiration without catheter placement had significantly higher rates of reintervention. Method of drainage, pH lower than 7.2, and loculation of the fluid collection were independent predictors of reintervention. A low glucose level was an additive predictor of reintervention when the pH was low. CONCLUSIONS: Aspiration and catheter drainage of parapneumonic effusions had similar complication rates and lengths of stay, but children who underwent primary aspiration had significantly higher reintervention rates, particularly when pH and glucose levels were low. Therefore, primary catheter placement for parapneumonic effusions should be considered in children who undergo diagnostic thoracentesis. The decision regarding tube placement could be facilitated by the on-site availability of a pH meter and a glucometer.

Adolescent↗

PubMed2002

Determinants of patient satisfaction with outcome after anterior cruciate ligament reconstruction.

BACKGROUND: The purpose of this study was to identify the determinants of patient satisfaction with the outcome after reconstruction of the anterior cruciate ligament. METHODS: A cohort of 201 patients undergoing primary reconstruction of the anterior cruciate ligament was studied prospectively. All patients were followed for a minimum of two years (mean, 35.9 months). The dependent variable was patient satisfaction with the outcome, graded ordinally on a scale of 1 to 10. Nonparametric univariate analysis and multivariable modeling were performed to identify determinants of satisfaction. RESULTS: The demographic variables were not found to have a significant association (p > 0.05) with patient satisfaction. The variables at surgery demonstrated a significant association (p < 0.05) with patient satisfaction only with respect to the status of the lateral meniscus, the presence of osteophytes, and concurrent plica excision. The objective variables at follow-up revealed that patients were significantly less satisfied (p < 0.05) if they had a flexion contracture, increased laxity of the involved leg on the manual maximum test as measured on a KT-1000 device, an abnormal result on the pivot-shift examination, effusion, or tenderness at the medial joint line or patella. With regard to the subjective symptoms at follow-up, patients were found to be significantly (p < 0.05) less satisfied with the outcome if they had symptoms of pain, swelling, partial giving-way, full giving-way, locking, noise, stiffness, or a limp. Analysis of the subjective function at follow-up demonstrated that patients were significantly less satisfied (p < 0.05) with the outcome if they had a lower level of activity, sports activity, strenuous work, activities of daily living, overall knee function, sports participation, or symptom-free activity; if they were unemployed; or if they had difficulty with walking, squatting, ascending or descending stairs, running, jumping, cutting, or twisting. Patient satisfaction was significantly associated (p < 0.05) with the Lysholm knee score, overall International Knee Documentation Committee (IKDC) knee score, IKDC subjective subscore, IKDC symptoms subscore, and IKDC range-of-motion subscore. The seven independent multivariate determinants (adjusted R (2) = 0.83, p < 0.001) of patient satisfaction included the Lysholm score, overall subjective knee function, IKDC range-of-motion subscale, patellar tenderness, full giving-way, flexion contracture, and swelling. CONCLUSIONS: Univariate and multivariate determinants of patient satisfaction with the outcome after reconstruction of the anterior cruciate ligament were established. Although some specific surgical and objective variables were important, subjective variables of symptoms and function had the most robust associations with patient satisfaction. In assessing the outcome of reconstruction from the perspective of patient satisfaction with the outcome, we should emphasize patient-derived subjective assessment of symptoms and function, particularly those involving issues of stiffness, giving-way, swelling, and patellofemoral symptoms.

Adolescent↗

PubMed2002

Treatment of advanced primary and recurrent diffuse pigmented villonodular synovitis of the knee.

BACKGROUND: Diffuse pigmented villonodular synovitis of the knee is a difficult tumor to eradicate. We report our experience with a combined open posterior and anterior synovectomy with and without adjuvant postoperative radiation therapy in patients with advanced extracapsular disease. METHODS: A single surgeon operated on forty patients, with an average age of thirty-five years (range, fourteen to sixty-eight years), who had diffuse pigmented villonodular synovitis of the knee. All patients had been referred to us after having initially undergone arthroscopic or open surgical procedures without eradication of the disease. Patients were retrospectively placed into one of three groups: Group I received surgery alone (five patients), Group II had surgery and intra-articular radiation synovectomy with use of dysprosium-165 (thirty patients), and Group III had surgery and external beam radiation (five patients). Adjuvant radiation was performed three months postoperatively. Magnetic resonance imaging was used for all patients for preoperative staging and postoperative follow-up. RESULTS: The average Knee Society score for the entire series improved from 61 points preoperatively to 92 points at the time of follow-up, at an average of five years (range, 1.5 to eight years) (p < 0.001). There was also a significant (p < 0.001) increase in the average range of motion of the knees across all groups. On the basis of the Knee Society scores, thirty-seven patients (93%) had a good or excellent result, two patients had a fair result, and one patient had a poor result. Complications included stiffness requiring manipulation in three knees, one case of reflex sympathetic dystrophy, advanced osteoarthritis leading to a total knee replacement in four patients, and seven recurrences (a prevalence of 18%) after operative treatment and radiation therapy. CONCLUSIONS: This surgical technique allows excellent visualization and removal of intra-articular and extra-articular diffuse pigmented villonodular tissue and yields excellent functional results and a low prevalence of knee stiffness. However, the rate of recurrence detected by magnetic resonance imaging was 18%. Adjuvant intra-articular radiation therapy may be beneficial for eradication of small foci of residual disease, but complete resection of all pigmented villonodular tissue appears to be the key to preventing recurrence. Magnetic resonance imaging was essential for accurate preoperative staging of the tumor and for follow-up since the presence of residual disease did not reliably correlate with the clinical findings. Patients with minimal degenerative arthritis and primary or recurrent extra-articular disease will benefit most from this approach.

Adolescent↗

PubMed2002

Biochemical characterization of pediatric brain tumors by using in vivo and ex vivo magnetic resonance spectroscopy.

OBJECT: Magnetic resonance (MR) spectroscopy provides biochemical information about tumors. The authors sought to determine the relationship between in vivo and ex vivo biochemical characterization of pediatric brain tumors by using MR spectroscopy. Their hypothesis was that ex vivo MR spectroscopy provides a link between in vivo MR spectroscopy and neuropathological analysis. METHODS: In vivo proton MR spectroscopy was performed before surgery in 11 patients with neuroepithelial tumors. During resection, a total of 40 tumor biopsy samples were obtained from within the volume of interest identified on in vivo MR spectroscopy and were frozen immediately in liquid nitrogen. High-Resolution Magic Angle Spinning (HRMAS) was used to perform ex vivo MR spectroscopy in these 40 tumor biopsy samples. Neuropathological analysis was performed using the same biopsy samples, and the tumors were classified as ependymoma, choroid plexus carcinoma, pineoblastoma (one each), and pilocytic astrocytoma, medullobastoma, low-grade glioma, and glioblastoma multiforme (two each). Ex vivo HRMAS MR spectroscopy improved line widths and line shapes in the spectra, compared with in vivo MR spectroscopy. Choline (Cho) detected in vivo corresponded to three different peaks ex vivo (glycerophosphocholine, phosphocholine [PCho], and Cho). Metabolite ratios from in vivo spectra correlated with ratios from ex vivo spectra (Pearson correlation coefficient range r = 0.72-0.91; p < or = 0.01). Metabolite ratios from ex vivo spectra, such as PCho/ total creatine (tCr) and lipid/tCr, correlated with the percentage of cancerous tissue and percentage of tumor necrosis, respectively (r = 0.84; p < 0.001). CONCLUSIONS: Agreement between in vivo and ex vivo MR spectroscopy indicates that ex vivo HRMAS MR spectroscopy can improve resolution of this modality and provide a link between in vivo MR spectroscopy and neuropathological analysis.

Adolescent↗

PubMed2002

Spondylolysis: returning the athlete to sports participation with brace treatment.

Between 1988 and 1995, 73 adolescent athletes treated with the Boston Overlap Brace for spondylolysis were reviewed to evaluate improvement in pain score and activity level. A favorable clinical outcome was achieved in 80%. Girls and boys who participated in high-risk sports were five times more likely to have an unfavorable clinical outcome than those who participated in low-risk sports (odds ratio = 5, 95% confidence interval = 2.4-7.5, P = .003). In addition, acute onset of pain and hamstring tightness were associated with a worse outcome. Athletes with symptomatic spondylolysis treated with an antilordotic brace can expect improvement in their clinical course and return to sports participation in 4-6 weeks.

Adolescent↗

PubMed2002

Pathologic fracture in osteosarcoma : prognostic importance and treatment implications.

BACKGROUND: The presence of a pathologic fracture in an osteosarcoma has been considered a poor prognostic factor and an indication for immediate amputation. The purpose of the present study was to determine, in the current era of neoadjuvant chemotherapy, whether a pathologic fracture in an osteosarcoma has prognostic importance and whether limb salvage can be safely performed in such patients without compromising clinical outcome. METHODS: In a cooperative effort of the Musculoskeletal Tumor Society, members from eight institutions provided retrospective data on fifty-two patients with osteosarcoma who had a pathologic fracture and on fifty-five patients with osteosarcoma who had not had a pathologic fracture and had been followed for at least two years or until disease recurrence, metastasis, or death. The two groups were matched for patient age and tumor location. Outcomes examined were survival and local recurrence. A subgroup analysis was performed to assess differences in outcome within the group with the pathologic fracture. RESULTS: The five-year estimated survival rates were 55% for the group with a pathologic fracture and 77% for the group without a fracture (p = 0.02). The rate of survival without a local recurrence at five years was 75% for the group with a fracture and 96% for the group without a fracture (p = 0.007). In the group with a fracture, seven (23%) of the thirty patients managed with limb salvage and four (18%) of the twenty-two managed with an amputation had a local recurrence (p = 0.75). Eleven (37%) of the thirty patients with a fracture who were managed with limb salvage and ten (45%) of the twenty-two patients with a fracture who were managed with an amputation died of the disease (p = 0.50). Five patients underwent open reduction and internal fixation followed by limb-salvage surgery. Two of them had a local recurrence and died at an average of eight months postoperatively. The remaining three patients were alive at an average of 6.1 years postoperatively. Local disease control and the survival of these patients were not significantly different from those for the thirty-three patients who were treated with nonoperative immobilization of the fracture followed by limb-salvage surgery. CONCLUSIONS: Patients with osteosarcoma who present with a pathologic fracture or sustain one during preoperative chemotherapy have an increased risk of local recurrence and a decreased rate of survival compared with patients who have not sustained a pathologic fracture. The performance of a limb-salvage procedure in carefully selected patients with a pathologic fracture does not significantly increase the risk of local recurrence or death. Factors predictive of improved outcome, such as the response to chemotherapy and union of the fracture, should be taken into account when limb salvage is being considered.

Adolescent↗

PubMed2002

Neuroimaging in pediatric brain tumors: Gd-DTPA-enhanced, hemodynamic, and diffusion MR imaging compared with MR spectroscopic imaging.

BACKGROUND AND PURPOSE: Gadolinium-enhanced MR images assist in defining tumor borders; however, the relation between tumor cell extent and contrast-enhanced regions is unclear. Our aim was to improve conventional neuroimaging of pediatric brain tumors with hemodynamic, diffusion, and spectroscopic MR imaging. METHODS: We performed conventional MR and MR spectroscopic imaging in 31 children with neuroglial brain tumors. Hemodynamic MR imaging was performed in 16 patients with a first-pass intravenous bolus of gadolinium diethylenetriaminepentaacetic acid (Gd-DTPA); apparent diffusion coefficients (ADCs) were measured in 12 patients. To account for multiple measurements in a patient, we used a nested analysis of variance. RESULTS: At MR spectroscopy, choline (Cho)-containing compounds (indicating tumor) and lipid levels (indicating necrosis) did not correlate with percent Gd-DTPA enhancement on MR images. Percent enhancement was positively correlated with relative cerebral blood volumes (rCBVs) (P =.05) and negatively correlated with ADCs (P <.001). Stepwise multiple linear regression revealed that rCBV (P =.008), ADC (P =.022), and lipid (P <.001) levels were significant independent predictors of percent enhancement. Tumor spectral patterns were detected in tumor regions and outside enhancing tumor beds in patients with clinical progression; these were confirmed at neuropathologic analysis. CONCLUSION: MR spectroscopic imaging improves the assessment of pediatric brain tumors by adding biochemical information regarding tumor involvement and by depicting residual or recurrent tumor outside the Gd-DTPA-enhanced tumor bed. rCBV and ADC mapping complemented MR spectroscopic imaging. We recommend the use of MR spectroscopic imaging in addition to conventional MR imaging in assessing pediatric brain tumors.

Adolescent↗

PubMed2002

Intraoperative measurements of male and female distal femurs during primary total knee arthroplasty.

The anteroposterior (AP) and medial-lateral (ML) dimensions of 200 consecutive osteoarthritic knees (100 males and 100 females) undergoing unilateral primary total knee arthroplasty were compared. For all patients, the mean AP dimension was 57.3 mm (range: 49-66 mm) and the dimension was 10.5% taller in height in men than women. The mean ML dimension was 71.6 mm (range: 56-85 mm), and the dimension was 13.7% wider in men than women. The mean AP/ML ratio was 0.8 for all patients, 0.82 (range: 0.73-0.93) for females and 0.79 (range: 0.70-0.89) for males (P<.001). The data suggest that for any given AP femoral dimension, women tend to have a narrower ML dimension than men, independent of AP height, and an AP/ML ratio of 0.80 most closely approximates a standard-sized distal femur across gender. This report documents important gender differences that may serve as a reference for femoral implant designers and knee surgeons.

Adult↗