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Orthopaedic Oncology
Radiation Therapy
Preoperative or Postoperative External Beam Radiation
Intraoperative Radiation Therapy (IORT)
Internal Radiation/Radiation Implants
Proton Beam Therapy
Common Questions About Surgery
and Recovery
Recovery
Growth and Development
Issues (Children and Adolescents)
TREATMENT PLAN
Once the diagnosis is confirmed by our pathologists and you are informed, treatment begins as soon as possible. Benign tumors are not life threatening, and most are just surgically removed. However, there are some 'aggressive' benign tumors that require closer follow-up once surgically removed. If your biopsy was positive for a malignancy, you will hear the word sarcoma or cancer. These tumors are life threatening if not treated and may require additional treatment such as chemotherapy and/or radiation therapy before, and sometimes after surgical removal. Malignancies are graded by the pathologist low to high grade (Grade 1/3, 2/3, or 3/3). The lower the grade the better the prognosis, and usually the smaller the tumor, the better the prognosis. All patients with sarcomas are discussed at our weekly Connective Tissue Oncology Center (CTOC) conference. Radiographic studies and pathology results are reviewed. Then the team establishes the best treatment plan for you. Treatment includes one or all of the following: radiation, chemotherapy and surgery.
There are four types of radiation therapy used for our patients which
are administered by the radiation oncologists in Radiation Oncology, Cox Building.
Preoperative or Postoperative External Beam Radiation:
Your first appointment in radiation oncology is called a simulation.
At this time, the radiation field (tumor bed and surrounding tissue) is marked
with indelible ink. This type of radiation delivers a calculated daily dose
of radiation to an area of tissue within a short period of time, usually once
or twice a day for 15 minutes or so. Duration is one to five weeks.
Intraoperative Radiation Therapy (IORT):
This type of radiation is given during your surgery. After your surgeon removes
the sarcoma, the tumor bed (area where the tumor was including surrounding
tissue) is directly radiated. Then your surgeon closes your wound.
Internal Radiation/Radiation Implants:
During surgery brachycatheters (small thin tubes) are placed at the
tumor site once the tumor is removed. Your surgeon closes your wound and you
are transferred to the recovery room, and eventually to a 'leaded room' on
the nursing floor. The radiation oncologists will place tiny radiation pellets
in the catheters which will stay in place for as many days as deemed necessary.
Visiting hours are limited during these treatments days. Check with the nurses
regarding specific instructions. Family and friends who 'are' or 'may think
they are pregnant' can not visit.
Proton Beam Therapy: Proton
beam therapy is a high technology form of radiation therapy used for treating
specialized types of sarcomas. Proton beam therapy offers an advantage in
that the depth of penetration of the radiation beam can be accurately controlled.
Special Note...
All types of radiation therapy can delay the wound healing process. Most often
the wounds heal without difficulty but you should be aware that your incision
may open and drain despite following all your doctor's restrictions on weightbearing
and range of motion. If your surgeon is concerned that would healing problems
are likely, a plastic surgeon may be asked to move a muscle or flap from elsewhere
to help with healing. If a wound problem develops, wet to dry packing of the
wound is done daily, or twice daily which begins the slow process of healing
(granulation). Many times wounds need a little clean-up job called an irrigation
and debridement (I&D). Dealing with chronic draining open wounds that
will not heal is mentally and physically exhausting. Some patients cope with
this problem one to two years after their original surgery. On a more positive
note, we have plenty of patients who will share with you their 'delayed wound
healing experiences' because they have finally healed and have resumed normal
daily activities.
CHEMOTHERAPY
Chemotherapy is drug treatment given in pill, injection and intravenous
forms to kill cancer cells. This may lead to shrinkage of the tumor, but chemotherapy
is primarily aimed at preventing the cancer from spreading. Since chemotherapy
can be harsh on the veins in your arm, most patients have a central venous
catheter (Broviac/Hickman or Portacath) placed in a large vein in their chest
through which the drugs are administered. Length of treatment depends on the
type of cancer and what research studies have shown to be the best time periods.
Common side effects include fatigue, hair loss, mouth sores, low blood counts
and fever.
Fatigue is very frustrating for our patients
because it prevents them from working, helping with household chores, or doing
activities they once enjoyed. Blood counts usually drop (nadir) seven to fourteen
days after a chemotherapy treatment. Some patients develop fever and are susceptible
to infection (neutropenia). Patients are usually admitted to the medical oncology
service for close monitoring when they are neutropenic and receive intravenous
antibiotics with possible blood transfusions (red cells, white cells or platelets).
Hair loss is traumatic for most of our patients.
Loosing clumps of hair is physically annoying and overwhelming to look at.
Some patients shave their head to avoid the sporadic itchy clumps. Many patients
get wigs, others use hats or turbons, and many remain naturally bald. It is
important to remember that the hair will grow back after completion of the
chemotherapy.
We advise patients to talk with other patients receiving chemotherapy for
only they know what the experience is truly like. It is very important to
remember that each sarcoma has a personality of its own, behaving differently
in each patient, as do the side effects of chemotherapy treatment.
Chemotherapy protocols vary in length of treatment. Most protocols have an
outline (schema) of the treatment plan. Ask your oncologist for a copy so
that you have an idea about the schedule for hospitalizations or outpatient
clinic treatments.
An example of a protocol for bone cancer (osteosarcoma) is as follows: Combination Chemotherapy and Radiation: Large malignant soft tissue sarcomas greater than 8 centimeters in size are treated with both chemotherapy and radiation before they are surgically removed. This therapy is called the MAID protocol. Radiation is sandwiched in between cycles of chemotherapy to hopefully reduce the size of the tumor, cause death (necrosis) of tumor cells, and prevent spread of tumor cells (metastasis).
The treatment for bone and soft tissue sarcomas has improved and there
are many survivors. Previously, amputation was the only surgical option. Now
we have limb-sparing procedures which involve resection (surgical removal
of the tumor) and reconstruction with bone (allograft-cadaver bone), metal
prosthesis (rods, total knee and hip joints) and possible extensive muscle
and skin grafting. The primary goal of surgery is to completely and safely
remove the tumor. Resections or amputations must remove the entire bone or
soft tissue involved with the tumor, plus a certain amount of healthy tissue
around the tumor called a margin. The pathologist assists your surgeon to
determine if the margin is negative which means that it is likely that all
the local tumor has been removed. If margins are positive, postoperative radiation
therapy and/or a repeat excision is usually advised.
Surgery is usually scheduled one to three weeks after completion of preoperative
chemotherapy to allow time for your blood counts to get better, and about
two weeks after preoperative radiation therapy. Staging studies (plain films,
bone, MRI, and CT scans) will be scheduled again before surgery to determine
the effect of treatment on the tumor.
COMMON SURGICAL PROCEDURES
WITH PROJECTED LENGTH OF HOSPITAL STAY
BIOPSY (Bone or soft tissue)
The incisional or open biopsy is an inpatient procedure (usually home the
next day) because of concerns about spread of tumor, hematoma, pain control
and infection. Chemotherapy and other treatments may begin the next day. Needle
biopsies are out-patient procedures done either in the office or under CT
scan/ultrasound control.
SOFT TISSUE TUMORS
Resection of a benign soft tissue mass: one to two days in the hospital, three
days for larger masses.
Wide resection of a malignant soft tissue mass (sarcoma): three to five days depending on the tumor size, location and other type of treatment received before surgery, such as chemotherapy or radiation therapy. Larger sarcomas may require five to seven days in the hospital.
Tumor bed excision: Many patients are referred to us with an incomplete excision of a malignant soft tissue mass that was done at another hospital. They usually require radiation treatment and a re-excision of where the tumor was, called the tumor bed (or vice versa). Length of stay, three to five days in the hospital.
Wide resection of a soft tissue sarcoma with need for a plastic surgeon to do a muscle flap and/or split thickness skin graft: seven, ten or fourteen days depending on the tumor size, location, and type of flap/graft.
Wide resection of a soft tissue sarcoma with need for a vascular surgeon to repair an artery/vein because the tumor was wrapped around the vessels: seven to ten days in the hospital.
BONE TUMORS
Curettage (scraping out) of a benign bone tumor with cement or donor bone
(allograft) packing with or without metal fixation (plate, screws, wires):
two to four days in the hospital depending on the tumor size and extent of
curettage. If bone from your hip is used for packing, it may be longer (three
to five days).
Wide resection of a malignant bone tumor with (allograft) donor bone reconstruction: upper and lower extremities require about five to seven days in the hospital; pelvic and sacral procedures need seven, ten or fourteen days in the hospital depending on tumor size, location, and procedures done by other surgeons.
Wide resection of a malignant tumor bone with allograft
and/or metal prosthesis: same as above.
Amputations: above the knee (AKA) amputations, below the knee (BKA)
amputations, and upper extremity amputations need five to seven days in the
hospital. Amputation of the leg through the hip joint (hip disarticulation)
and amputation through the pelvis above the hip joint (external hemipelvectomy)
need about ten to fourteen hospital days.
Additional surgeries are rare, however in the unlikely event of infection,
fracture or bone nonunion (delayed healing), the following surgeries will
resolve the minor problems.
Irrigation and debridement (I &D) of wound/allograft
infections require five to fourteen days in the hospital or longer if infection
persists. Patients with wound infections are readmitted to the hospital for
the I&D and intravenous antibiotics. A PICC line is placed in your arm
before you go home so antibiotics can be given intravenously for about six
weeks. A PICC line is an intravenous catheter threaded up your arm to a major
central vein in your chest. This central vein can handle harsh antibiotics
better than the smaller veins in your hand. Daily dressing changes and packing
of an open wound may need to be done by the visiting nurses or the patient/family
member who has been taught the procedure. Sometimes allografts are removed
and replaced with antibiotic cement spacers to fight infection for a few months.
The patient receives intravenous antibiotics at home. Eventually the spacer
is removed and the extremity is reconstructed using a metallic prosthesis.
Open reduction with internal fixation (ORIF) for bone and allograft fractures requires a three to four day hospital stay.
Bone grafting procedures using the patient's hip bone (iliac crest-autologous) or donor bone (allograft) to nonunion sites (areas not healing) at the allograft-host junction sites require about three to four days in the hospital.
Hardware revision for broken plates, screws,
loose rods or total joints ranges from three to seven days in the hospital
depending on the extent of the revision.
PREOPERATIVE INFORMATION
Preoperative or Preadmission Testing
All patients must have preoperative testing which involves:
We are very careful not to repeat any testing you have had done. Your doctor's secretary will inform you of your testing date. We receive many requests to have testing done locally. We advise that it be done at Massachusetts General Hospital to ensure a smoother processing of all insurance information and paper work required for surgery. This will prevent surgery from being delayed or cancelled.
Blood Donation
Your physician or nurse practitioner will inform you whether or not you can
donate blood. Donating blood for yourself is called autologous blood donation.
Patients may donate at a local service, such as The American Red Cross or
at Massachusetts General Hospital, located on the first floor, just past the
Admissions Office. You can schedule an appointment by calling the Blood Transfusion
Service at 617-726-3718, Monday - Friday, 8:30 a.m. - 4:30 p.m.
If family or friends want to donate blood for you, they can do so only
at the Massachusetts General Hospital Blood Transfusion Service. Donations,
called designated donors, must be done two to six days before the surgery
date on Monday - Thursday 8:30 a.m. - 7:30 p.m., and Friday, 8:30 a.m. - 4:30
p.m.
For more information call 617-726-8164.
Medication
Aspirin, medication containing aspirin, and anti-inflammatory medications
(e.g., Motrin, Naprosyn, Advil, Aleve) must be stopped seven to ten days before
surgery. If you take Coumadin, please discuss upcoming surgery with the doctor
who prescribes your Coumadin and get specific instructions when to stop taking
it. On the morning of surgery, take your cardiac, seizure, thyroid, and heartburn/reflux
drugs or pain medication with a sip of water. Refer to the instructions given
to you during preadmission testing regarding other drugs such as insulin,
anxiety/depression drugs.
Surgery Time
Call your doctor's office the day before surgery, approximately 1-2 p.m. for
your surgery time. For Monday surgeries call on Friday because the office
is closed for the weekend. We apologize for any inconvenience this short notice
may cause you, but we are constantly adding patients and rearranging the schedule
due to urgent patient cases.
The main office number is (617) 724-3700.
The Night Before Surgery
Adult
Nothing to eat or drink after midnight. If you are to report later in the
day such as 11 a.m., you may have clear liquids until 3 hours before your
report time. For example, if you report at 11 a.m. you may drink clear liquids
until 8 a.m. (water, grape, apple, cranberry or other clear juices, black
coffee or tea if you do not have heartburn/reflux). NO cream, NO milk, NO
solids, NO grapefruit or orange juice with pulp, NO hard candy or gum.
Children 3 Years Old and Older
Same guidelines as adult.
Children Less than 3 Years Old
May eat soft solids until 6 hours before the surgery or procedure report time,
and may have clear liquids until 2 hours before the surgery or procedure report
time.
Infants Less than 6 Months Old
May nurse or have formula until 4 hours before the surgery or other procedure,
and may have clear liquids until 2 hours before the surgery or procedure.
The Day of Surgery
Report to the Surgical Day Care Unit, Wang Building, floor 3, room 309.
Gray Family Waiting Area
When you are in surgery, your family and friends can wait in the Gray Family
Waiting Area, located on the first floor, Gray Building, just past Admissions.
Your doctor will inform your family about your condition when surgery is over.
Your family and friends will not see you for at least 2 hours after the doctor
talks to them because you will be in the Recovery Room. Parents of children
and adolescents can often go to the Recovery Room. They should check with
the volunteer at the Gray Family Waiting Room desk. Once stable, you will
be transferred from the operating room to the orthopaedic nursing floors:
Ellison 6 or White 6 which are on the same floor as our office. Floor 6 connects
the Ellison, Gray/Bigelow and White building nursing floors. If you had a
complex surgery, you will be transferred from the operating room to an intensive
care unit. School age children and adolescents up to age 18 will go to Ellison
18. The preschool children, toddlers and infants will go to Ellison 17. Both
pediatric floors have 24 hour visiting for parents and accommodations for
one parent to stay overnight in the room with their child. Ask our office
staff for pediatric/adolescent specific information. We also have listings
for local housing accommodations (hotels, boarding houses, bed and breakfasts).
COMMON QUESTIONS ABOUT SURGERY AND RECOVERY
What day will I be operated on?
Dr. Gebhardt operates on Friday, occasionally on Thursday
Dr. Hornicek operates on Wednesday and Friday
What time is my surgery?
You need to call the office (617-724-3700) the day before your surgery about
1 - 2 p.m. If your surgery is on Monday, please call the office on the Friday
before your surgery because the office is closed for the weekend.
Will my doctor actually do my surgery?
YES. There will also be a surgical assistant, either the fellow or resident
to assist your doctor. Your surgical team involves your surgeon, the fellow
or resident, the anesthesiologist, and a scrub nurse who all remain sterile
and at your side at all times. A circulating nurse is also present to circulate
around the operating room and help with the needs of the team.
What type of anesthesia will I have?
You will meet an anesthesiologist during your pre-admission testing workup
or the morning of surgery to discuss the specifics of anesthesia and sign
the anesthesia consent form. For most of our major operations, general anesthesia
is given.
There are five types of anesthesia:
General Anesthesia: Your anesthesiologist uses
medications (given through your intravenous (IV) line and/or through a mask)
to put you into a controlled state of unconsciousness. Surgery takes place
while you are unconscious and you are awakened when the procedure has been
completed.
Regional Anesthesia: Your anesthesiologist
will numb a region or part of your body by injecting a local anesthetic in
the appropriate area This technique includes spinal, epidural, and several
types of nerve blocks. You may also receive medication to sedate you during
the procedure.
Monitored Anesthesia Care: Your anesthesiologist
will monitor your vital body functions and administer medicine through an
IV to make you drowsy. Your surgeon will inject local anesthesia to numb the
area of the operation.
IV Sedation: Your surgeon injects local
anesthesia without an anesthesiologist in attendance. There is a nurse with
you who may provide sedation.
Local The surgeon injects local anesthesia without an anesthesiologist in
attendance.
© Dept. of Anesthesia and Critical Care 4/97
What is a Bowel Prep and why do I need one?
Patients who are having major abdominal, pelvic, sacral or complicated pelvic
and hip surgery need a 'bowel prep'. When the bowel is empty of stool, it
is more manageable during the surgical procedure and the area being worked
on is more visible. Severe infection and complications can arise if stool
contaminates the surgical area. A bowel prep consists of a clear liquid diet
the entire day before surgery which limits you to broth, black tea or coffee,
jello, popsicles, apple/cranberry/ clear juices and gingerale. No cream, milk
or juice with pulp. No solid food at all which includes gum, candy and crackers.
Antibiotics taken by mouth will be ordered for you to take at 12 noon, 4 p.m.,
8 p.m. and 10 p.m. on the day before surgery. 'Go-lytely' is a drink that
you will take between 2 and 6 p.m. on the day before surgery which will cause
you to have several bowel movements to empty or 'clean out' your bowel. A
more gentle version of the bowel prep for less complicated surgery involves
the clear liquid diet, one bottle of Magnesium Citrate (the size of a soda)
and about 2 enemas on the afternoon and evening before surgery.
Years ago insurance companies would pay for a one day preoperative stay in
the hospital for the bowel prep. Now most preps are done at home and the patient
arrives at the hospital on the same day as surgery.
Why will I be in the Intensive Care Unit (ICU)
after surgery?
Patients who have complex surgery involving the pelvis, abdomen, sacrum or
hip usually go to the ICU for closer observation by the medical and nursing
staff until all of the major body systems are stable. Many times the endotracheal
or 'breathing tube' is left in your throat for a few days. If you wake up
with this tube, you will not be able to speak. The nurses will give you medication
to relax you and prevent you from pulling at the tube or 'fighting' the tube.
Your breathing and amount of circulating oxygen, hematology and chemistry
blood values, heart function, and incision are closely monitored. The breathing
tube will be removed as soon as the anesthesiologist or intensive care physician
feels you can safely breathe on your own. As soon as all of your systems are
stable, you will be transferred to the nursing floor. ICU visiting hours are
limited, as is the number of visitors allowed per patient due to the severe
surgical and medical conditions of all the patients in the ICU.
What type of pain control will I have postoperatively?
Most of our patients receive pain medication (narcotics) through the patient
controlled analgesia (PCA) pump. The narcotic is morphine or dilaudid. The
medication is placed in a syringe and locked into a pump. You are able to
push a button to receive your pain medication. You can not overdose because
the pump is calculated, set and locked at your correct dosage. If an epidural
catheter was placed to administer your anesthesia during surgery, pain medicine
will also be delivered through this catheter postoperatively. After a few
days, you will be weaned off the intravenous pain medication and given pain
medication pills. We usually discharge our patients with a small supply of
Percocet or Tylenol with Codeine for children and instruct them to wean off
this medication within a week or two. Eventually Tylenol Extra Strength or
anti-inflammatories such as Advil, Motrin or Aleve can be taken for minor
discomfort. Anti-inflammatories should not be taken if you are taking Coumadin.
Will I have a urinary catheter tube in place
after surgery?
Patients with pelvic, hip and thigh surgery will have a catheter placed after
they are asleep from anesthesia. The catheter remains in place for a few days
postoperatively.
How long will I be in the hospital?
Length of hospital stay depends on how complex surgery is and whether or not
other doctors assisted such as plastic, thoracic, or general surgeons. Refer
to the surgery section which gives you an idea about your length of stay in
the hospital based on the type of surgery. Clinical pathways are designed
to describe your hospital stay from preadmission testing through discharge
and the initial follow-up visit with your doctor.
What is Coumadin, and why do I need to take it?
Coumadin (Warfarin) belongs to a group of drugs called anticoagulants. Many
people refer to them as 'blood thinners'. They actually do not thin the blood,
rather lengthen the time it takes for blood to clot. If you take coumadin,
it makes it harder for a clot to form in your blood vessel, or it keeps an
existing clot in your vessel from getting bigger.
We put our patients on Coumadin after pelvic or lower extremity surgery. Since
you will not be out of bed right away or walking your normal pace, the circulation
in your pelvis and legs will be sluggish, can 'pool' and form a clot.
You will be on Coumadin for a total of six weeks from the date of surgery,
and about three months if you already have a blood clot. Patients who are
on 1 mg. of Coumadin to prevent a clot from blocking their portacath (central
line catheter used to administer chemotherapy) will receive a higher dose
for 6 weeks, then resume the 1 mg. plan. Coumadin is taken once a day, usually
in the evening.
The dose of Coumadin is determined by the results of blood tests (PT and
INR levels). Blood needs to be drawn twice a week until a stable dose can
keep your levels in the range we like to prevent a blood clot. Arrangements
will be made for your local primary care physician (PCP) or the nurses at
the Anticoagulant Therapy Clinic at Massachusetts General Hospital to monitor
your blood levels and Coumadin dose. Many times the Nurse Practitioner in
our office will monitor your blood levels and Coumadin doses.
The most serious side effect of Coumadin is excessive bleeding. It is very important that a physician or nurse monitor your blood work and tell you what dose to take. Making arrangements to have the blood drawn by a local visiting nurse or laboratory technician is the easy part. A physician or nurse must review your results. Call your physician's office if you are not notified about your Coumadin dose.
When can I be fitted for my prosthesis? (patients
who have had an amputation)
You may be fitted for a prosthesis before you are discharged. Usually patients
wait about four weeks before beginning prosthetic fittings. If you are experiencing
a lot of pain in your residual limb or have swelling, wearing the prosthesis
will only aggravate your symptoms. Proper wrapping must be done to decrease
swelling and the incision line must be healed. Your residual limb shrinks
when postoperative swelling decreases. Several fittings are necessary to get
your final prosthesis. You will develop a long term relationship with your
prosthetist because over the years the condition of your residual limb may
change requiring revisions of your prosthesis, or you may want a different
type of component for your prosthesis. Your prosthetist will revise your prosthesis
and meet all your needs. Usually a prescription is necessary for any prosthestic
revisions, so just call the office and we will send you one.
When should I see my doctor again?
Your first postoperative visit should be scheduled between two to three weeks
after surgery. If you go to a rehabilitation hospital, you should see us once
you are discharged from that facility. If you are from another state, we request
that you make an initial postoperative visit with us. Your referring orthopedic
doctor can monitor your care from then on. We keep close communication with
primary care physicians and referring orthopedists to inform them of your
surgery, progress, and any future x-rays that are needed.
Do I need x-rays for my next office visit?
If you had bone surgery, every follow-up office visit (except the first post-operative
visit for a wound check) will require an x-ray of the body part that was operated
on. If the bone tumor was malignant, a chest x-ray will always be required
in addition to the body part x-ray. If you had a benign soft tissue mass,
no x-ray is needed. However, if your soft tissue mass was malignant, you will
always need a chest x-ray at all your follow-up appointments except the first
postoperative wound check visit.
When do my sutures/staples come out?
They usually come out two to three weeks after surgery. If you have had chemotherapy
or radiation therapy, staples may be left in place for almost one month, since
both of those treatments tend to delay the healing process.
Can my local doctor or visiting nurse take out
my sutures/staples?
It is always best to return to us to remove your sutures/staples because your
doctor who performed the surgery knows your body and medical condition very
well. If financial or transportation difficulties prevent you from doing so,
just call the office and ask to speak to the doctor or nurse, and special
arrangements will be made for you.
When can I shower?
You should not shower if you have any open wound, or any drainage coming from
your incision. Otherwise, if you can cover the incision or cast with a plastic
wrap (Saran or Handi-wrap) or a garbage bag and shower safely, you can do
so. If the incision gets wet, just pat it dry. If the cast gets wet, it must
be changed.
How often do I need to change my dressing?
Most of the time, patients are discharged from the hospital with a dry sterile
dressing. The incision area should be checked at least daily, if not twice,
for any redness, swelling or drainage. If your incision is dry there is no
need for the sterile dressing, unless the sutures/staples are pricking on
your clothing and you desire a dressing for comfort. There are occasions when
our patients are discharged with a bulky dressing or some type of splint with
bulky dressing that was applied in the operating room. This dressing should
remain intact until you see your doctor in the office. Of course, if you notice
any drainage coming through the dressing, please contact the office immediately.
When will I resume chemotherapy and/or radiation
after surgery?
The decision to resume your postoperative chemotherapy and/or radiation is
made after the doctor checks your wound in approximately two to three weeks
after surgery. If healed, treatment resumes.
I have a lot of insurance forms/disability forms
to complete, what do I do?
We will complete any insurance, disability or transportation forms for you.
Please complete and sign the patient portion and send the form to the office
for the physician's portion to be completed.
When can I go back to work/school?
If your surgery was not that serious, you should give yourself at least two
weeks to heal and recover from the stress of having surgery. It is advised
that you wait until your first postoperative visit so your doctor can see
how your incision is healing. Even though you feel good, it takes about four
to six weeks for soft tissues to adequately heal, and about eight to twelve
weeks for bone healing to take place. If you had an allograft (donor bone)
reconstruction, bone healing can take nine to twelve months to occur.
If you have a sedentary (sit down) job, you may return to work sooner than
someone who has a very physical job. As long as you can maintain the activity
restrictions that are set by your doctor and ambulate safely with whatever
aids were prescribed (crutches, long leg brace, cast) you may return to work
with restrictions on your activity. In general after upper extremity surgery,
we restrict our patients from overhead lifting, repetitive use of the arm
and no heavy lifting, pushing, or pulling objects. For lower extremity surgery,
we restrict our patients from contact sports, prolonged standing, walking,
climbing, bending, lifting or pushing heavy objects.
Before returning to work or school think about your transportation to and
from, the distance from the parking lot to your office or classroom, the number
of stairs you have to deal with, the accessibility of an elevator and whether
you can manage a crowd of people without falling or being bumped.
When can I go back to gym class?
The answer to this question is almost the same as returning to work or school.
You will be restricted from gym class until adequate bone and/or soft tissue
healing takes place. We will fill out any school form necessary to excuse
you from gym class. Some schools have non-contact sports and academic-type
activities, such as writing a report on health or sports, that can be done
to fulfill the gym requirements to graduate. Most of our allograft patients
must refrain from contact sports forever.
When can I drive?
Answering the question about driving is complicated because it involves more
than your doctor's medical clearance which is based on your safety and your
healing progress. It involves the policies of the Registry of Motor Vehicles
and your insurance company. Just think, if you get into an accident and you
are wearing a long leg brace or cast and have crutches in the car, the situation
may appear that you are the one to blame for the accident. Once your doctor
gives you medical clearance to resume driving, the rest is up to you.
Can I apply for a handicap placard or license
plate?
Yes, you can apply by calling the Registry of Motor Vehicles (RMV) and request
a disabled placard/plate form. Please complete the patient information section.
We will gladly fill out any form you give us. Lately, the Registry of Motor
Vehicles is trying to stop the abuse of disabled placards. Sometimes the Registry
rejects temporary orthopaedic conditions, requests that you retake the Registry
driver's test, or ask that you purchase disabled equipment to modify your
car before they grant a disable placard or plate.
How long do I have to use my crutches?
Your doctor will determine when you can stop using your crutches. For simple
soft tissue surgery that does not involve the bone, you use crutches just
to keep excess weight off the extremity for a few days. You may then increase
your weightbearing as tolerated. Excessive weight-bearing or activity too
soon after surgery can lead to complications such as a collection of blood
at your incision area called a hematoma. For more serious soft tissue surgery,
such as removing a large tumor mass, you may need crutches for four to eight
weeks. Bone surgery, such as an allograft reconstruction, requires crutches
for almost one year.
When can I bear more weight?
After bone surgery your bone x-rays must show signs of healing before you
can increase your weight-bearing status. You will be informed of your progress
at every office visit. For simple soft tissue surgery you may increase your
weight-bearing status as tolerated. For more extensive soft tissue surgery
or if you have had radiation or chemotherapy, you will be given specific instructions
about how much weight or how many 'pounds of pressure' you can bear. You will
hear words like 'touchdown weight-bearing' or 'toe touch only'. If you are
given specific pounds like 20, 30, 40 pounds, step gently on your bathroom
scale and 'feel' the pressure you need to exert to have the scale's needle
stop on 20, 30, or 40 pounds. Partial weight-bearing usually means half of
your total body weight. You will eventually achieve full weight-bearing status.
Increasing your weight-bearing status is a slow, gradual process which totally
depends on adequate soft tissue and bone healing.
How often do I return to see the doctor?
If you are diagnosed with a malignant sarcoma, the routine oncology follow-up
protocol involves getting an x-ray of the affected body part to rule out local
recurrence and a chest x-ray to rule out distant metastases every three months
for two years, then every six months for three years, and yearly for five
years which equals a total of ten years. For benign tumors, you will return
to the office in about two weeks after surgery. Visits then gradually decrease,
for example, four weeks, six weeks, two months, four months, and so on.
Do I need to take antibiotics before I go to
the dentist?
It is necessary to take antibiotics before any dental work or any invasive
procedure like an endoscopy or colonoscopy to prevent infection if you have
had a joint replacement with a metal prosthesis or an allograft (donor bone)
reconstruction. Infection in the area of your total joint would require intravenous
antibiotics, possible surgery to irrigate and debride the area or remove the
prosthesis. Infection is easily preventable by taking your oral antibiotic
before any invasive medical or dental procedure. The following chart explains
what oral antibiotic you should take:
Adults
If you are not allergic to Penicillin, you will take Amoxicillin 500
mg as follows:
Amoxicillin 3 grams (6 pills) orally one hour before the procedure, then 1.5
grams (3 pills) 6 hours after the initial dose.
If you are allergic to Penicillin/Amoxicillin/Ampicillin, you will take Clindamycin
600 mg as follows:
Clindamycin 600 mg orally one hour before the procedure OR
Cephalexin (Keflex) 500 mg as follows: 2 grams orally one hour before the
procedure
OR Azithromycin 500 mg orally one hour before the procedure
Children
Initial pediatric doses given orally one hour before the procedure are
listed below. The follow-up dose (taken 6 hours after administration) should
be one-half the initial dose. Total pediatric dose should not exceed total
adult dose.
If the child is not allergic to Penicillin give:
Amoxicillin 50 mg/kg
If allergic to Amoxicillin/Penicillin/Ampicillin give Clindamycin 20 mg/kg
OR Cephalexin (Keflex) 50 mg/kg OR Azithromycin 15 mg/kg
Note: The American Heart and American Dental Associations changed
the pre-procedure antibiotic protocol in June 1997. The pre-procedure dose
has been decreased and the post-procedure dose eliminated. Due to the complex
nature of our surgeries, we continure to prescribe the old protocol. If you
have concerns, discuss the issue with your surgeon.
RECOVERY
Most of our patients undergo very complex surgeries which involve removal
of bones and muscles. Healing takes time, usually months, sometimes an entire
year. Regaining muscle and motor function requires tiring physical therapy.
If you are frustrated with slow progress or upset that you still need crutches
and a brace, be comforted in knowing that most of our patients feel the same
way. It is difficult to put into words how slow and gradual your recovery
will be. Before surgery, most patients focus their energy on 'getting through'
the surgery. Although recovery is explained preoperatively and discharge needs
are discussed, the anxiety of surgery blocks one's ability to understand the
lengthy recovery period.
Progress is determined by evidence of bone and soft tissue healing. Bone healing
is determined by evidence seen on x-rays. Soft tissue healing is determined
by examining the wound for redness, openings, drainage, hardness or swelling
at the incision area. If recovery is 'rushed' that is, if the weight-bearing
status is too great or the exercises too strenuous, complications can arise
which will only compound the healing process and length of recovery period.
Hematomas (collection of blood), wound dehiscence (wound openings), bone fractures
and hardware loosening are a few problems that can arise. Coping with slow,
gradual progress is difficult, but once healing occurs, a sense of normalcy
will return to you and your family's life.
Your first postoperative visit is usually two to three weeks after surgery.
This visit is usually for a wound check. If you are discharged to a rehabilitation
hospital, make an appointment with us at the end of your rehabilitation stay.
During the office visit, sutures or staples will be removed unless you have
had chemotherapy or radiation therapy (adjuvant therapy). Since those treatments
can delay the healing process, your sutures or staples may be left in place
for up to one month. If your incision is healing well, your surgeon will clear
you to resume chemotherapy and/or radiation.
The first bone x-rays following surgery are taken at four to six weeks postoperatively.
Office visits gradually become more spaced out. Once stable, routine oncology
office visits for malignant tumors take place every three months for two years,
then every six months for three years, and then yearly for five years to equal
a total of ten years of follow-up care. Follow-up care for benign tumors will
eventually stop.
GROWTH AND DEVELOPMENT ISSUES
Since we care for children and adolescents with benign and malignant bone and soft tissue tumors, it is important to discuss growth and development issues. Many people ask us how we tell a child or adolescent that he has a tumor (cancer) which will require chemotherapy and surgery. Knowledge of the child's growth and development level allows us to communicate openly and honestly. Children in each stage of development have their own communication style, fears and stressors of hospitalization. Thus, we communicate based on their cognitive level of understanding. For example, an 8 day old infant with a bone tumor was referred to us. Since an infant's needs are basic at this stage of development requiring security, comfort and nutrition, we had the parents present at all times. We provided up-to-date information enabling the parents a sense of control, assessed the mother's postpartum needs, assessed the father's needs, medicated the child for comfort and provided privacy for the mother to breastfeed. Both parents and family members were with the infant as much as possible, participating in all aspects of care, including the stressful cast removal and application. The major stressors that we address with children and adolescents are pain, altered body image, fear of death, interruption of daily routines with family, school, friends, work and sports, isolation and loneliness.
In addition to the psychological issues related to caring for children,
adolescents and their families we need to address the anatomical differences
between caring for children and adults. Relative to the orthopaedic surgeries
we perform, growth plate injury causing limb length discrepancies is the major
concern depending on the child's skeletal maturity.
In patients near or at skeletal maturity (>12 years old in girls and >14
years old in boys) with lesions in the lower extremity, or for lesions in
the upper extremity at any age, growth considerations are not a major concern.
Osteoarticular allografts, arthrodeses, metallic implants or at times, vascularized
bone grafts may be used to reconstruct the defects. In children with lower
extremity lesions in younger ages, the consideration of growth remaining becomes
a major concern. For example a 6-8 year old patient with a distal femoral
osteosarcoma presents a major reconstruction challenge. The most logical option
is rotationplasty or amputation, but patients and their families are refusing
such an approach more often. The surgeon is left with the option of reconstructing
with allografts (if one of an appropriate size can be obtained) and performing
standard limb equalizing procedures at a later date, or employing metallic
prostheses which can be lengthened. Neither approach is ideal, and long term
studies of outcome in this age group are limited. Children are not as cooperative
with rehabilitation protocols, nor are they willing to limit their sports
activities. Our preference has been to recommend rotationplasty for the very
young patient with a lesion about the knee, and osteoarticular allografts
for those at or near skeletal maturity. We believe that this biological approach
is advantageous in this young age, and prefer to restrict metallic prosthesis
for adults or those who fail allograft treatment. Limb length can usually
be equalized by a combination of timed epiphysiodeses, using a graft which
is 1-2 centimeters longer than the resected bone, and on occasions lengthening
or shortening procedures.
Epiphysiodesis is a surgical procedure that can
be done percutaneously or through an incision depending on the situation.
It is done to stop the growth of the extremity by destroying the growth cartilage
cells. This is done by drilling or curretting the cells from the physeal growth
plate. Afterwards the child is kept immobilized until the bone heals.
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