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Background: Instability is a common indication for revision after total knee arthroplasty. Replacement of multiple components is the current standard, but isolated polyethylene liner exchange (IPE) may present a less-morbid alternative. This study aims to determine (1) whether IPE results in similar rerevision frequency to component revision in select patients with symptomatic instability and (2) the effect of increasing constraint on the outcome., Methods: We retrospectively reviewed 117 patients revised for symptomatic total knee arthroplasty instability from January 2016 to December 2017. The component revision (60 patients) or IPE (57 patients) cohorts were further stratified based on whether constraint was increased or not. The primary objective was to compare rerevision rates 2 years after component revision vs IPE. The secondary objectives consisted of evaluating reasons for rerevision, preoperative and postoperative patient-reported outcome measures, and range of motion., Results: The rerevision rate was 18%, with no statistical difference between component and IPE cohorts. Cases where level of constraint increased due to revision, a significantly lower rate of rerevision was detected (9 of 77) (12%) than in cases where constraint did not increase (12 of 39) (31%) (P=0.012). This association was also noted in the component revision cohort but not in the IPE cohort (P=0.011)., Conclusions: Rerevision occurred at similar frequencies 2 years after IPE or component revision for total knee arthroplasty instability. For component revision, increased constraint was associated with significantly fewer rerevisions., (© 2023 The Authors.)

Background: The purpose of this study was to evaluate outcomes and complications because it relates to surgeon and hospital volume for patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) using the American Joint Replacement Registry from 2012 to 2017., Methods: A retrospective study was conducted on Medicare-eligible cases of primary elective THAs and TKAs reported to the American Joint Replacement Registry database and was linked with the available Centers of Medicaid and Medicare Services claims and the National Death Index data from 2012 to 2017. Surgeon and hospital volume were defined separately based on the median annual number of anatomic-specific total arthroplasty procedures performed on patients of any age per surgeon and per hospital. Values were aggregated into separate surgeon and hospital volume tertile groupings and combined to create pairwise comparison surgeon/hospital volume groupings for hip and knee., Results: Adjusted multivariable logistic regression analysis found low surgeon/low hospital volume to have the greatest association with all-cause revisions after THA (odds ratio [OR], 1.63, 95% confidence interval [CI], 1.41-1.89, P < 0.0001) and TKA (OR, 1.72, 95% CI, 1.44-2.06, P < 0.0001), early revisions because of periprosthetic joint infection after THA (OR, 2.50, 95% CI, 1.53-3.15, P < 0.0001) and TKA (OR, 2.18, 95% CI, 1.64-2.89, P < 0.0001), risk of early THA instability and dislocation (OR, 2.47, 95% CI, 1.77-3.46, P < 0.0001), and 90-day mortality after THA (OR, 1.72, 95% CI, 1.27-2.35, P = 0.0005) and TKA (OR, 1.47, 95% CI, 1.15-1.86, P = 0.002)., Conclusion: Our findings demonstrate considerably greater THA and TKA complications when performed at low-volume hospitals by low-volume surgeons. Given the data from previous literature including this study, a continued push through healthcare policies and healthcare systems is warranted to direct THA and TKA procedures to high-volume centers by high-volume surgeons because of the evident decrease in complications and considerable costs associated with all-cause revisions, periprosthetic joint infection, instability, and 90-day mortality., Level of Evidence: III., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Introduction: The role of bony fusion in influencing patient outcome and surgical revision rates in the treatment of metastatic spine disease is poorly defined. The goals of this study were, therefore, to evaluate the effect of fusion on revision surgery as well as on overall survival (OS) and functional status in patients with metastatic disease of the spine., Methods: A retrospective cohort study of a prospective database at a major cancer center was conducted. A total of 25 patients who met the inclusion criteria from January 2010 to December 2015 were included. Functional status, patient and tumor characteristics, fusion status, and survival were analyzed, and regression analyses were done. Bony fusion was classified as either present (seen across a minimum of three levels and crossing the tumor site) or absent as evidenced through CT images at minimum of 1-year postoperatively., Results: Twenty-five subjects with 28 surgical sites met the eligibility criteria to be included in this study cohort. Five surgical sites were found to have evidence of fusion on CT scans at 1 year after surgery, and 23 sites had no evidence of bridging fusion. No differences were found between the two groups in terms of OS, and ambulatory status (P > 0.10). Multivariate analysis did not reveal any specific factors affecting fusion. Mean follow-up was 23.7 months., Discussion: The lack of bony fusion is not an independent predictor of the need for revision surgery. The lack of bony fusion in patients with metastatic disease of the spine does not appear to negatively affect their OS or their ambulatory status. A discussion of factors affecting fusion is complex, and there are other factors that may also play a role. Large multicenter trials are needed to corroborate the preliminary findings seen in this complex patient cohort.

Background: The ability to utilize magnetic resonance imaging (MRI) to assess bony fixation in 3 dimensions may allow a better understanding of the implant design and bony integration. We hypothesized that a new 3-dimensionally printed cementless highly porous acetabular component (Stryker Trident II Tritanium TM ) would show better fixation than an earlier cup from the same manufacturer as assessed by the noninvasive technique of multispectral MRI., Methods: Multiacquisition variable-resonance image combination selective metal suppression MRI was performed in 19 patients implanted with a new 3-dimensionally printed cup and 20 patients who had received a previous-generation cup from the same manufacturer at 1-year follow-up. Each cup was graded globally as well as by 9 specific zones. Integration grades were performed for each zone: 0, full bone integration; 1, fibrous membrane present; 2, osteolysis; and 3, fluid present. A mixed-effects logistic regression model was used to compare fixation between the 2 groups., Results: All cups in both cohorts showed greater than 90% estimated global bony integration (3-dimensionally printed cups, 99.4%; regular cups 91.6%) with no osteolysis or fluid observed in any cup. The 3-dimensionally printed cup had 1 of 171 zones (0.6%) graded as fibrous membrane present, while the 2-dimensional group had 15 of 180 zones (8.3%) graded as fibrous. Of note, screw hole regions were omitted but may be read as fibrous membrane areas., Conclusion: Using multiacquisition variable-resonance image combination selective MRI, our analysis showed greater osteointegration and less fibrous membrane formation in the 3-dimensionally printed cups than the control group at 1-year follow-up., (© 2020 The Authors.)

Objective: Opioids and benzodiazepines are commonly used for management of osteoarthritis, despite evidence-based recommendations to the contrary. This study aimed to quantify the prevalence of opioid and benzodiazepine prescribing for osteoarthritis. Additionally, we aimed to characterize risk factors for prescription drug misuse, abuse, and diversion among this population., Methods: We conducted a descriptive analysis of adult outpatient encounters with a primary diagnosis of osteoarthritis during a 1-year period at a large health care system, excluding cancer and outpatient procedures. Demographic data, prescription data, and patient-specific risk factors were collected. Descriptive analysis was conducted to characterize arthritis patients who received and did not receive prescription opioids., Results: During 1 year, our system had 31,123 outpatient encounters for osteoarthritis. Opioids and benzodiazepines were prescribed for nearly 27% of the encounters (n = 8,420). In all, 43% of the encounters involved patients age ≥65 years. Hydrocodone-acetaminophen was the most common medication prescribed (34.3%). Most prescriptions were written by pain specialists (53%). A total of 35.5% of patients had a risk factor for prescription misuse, the most prevalent being early refill and a history of receiving ≥3 prescriptions in the past month., Conclusion: Prescriptions for opioids and benzodiazepines continue to be written for osteoarthritis. These prescriptions may pose a risk for adverse outcomes since >1 in 5 patients receiving prescriptions had a risk factor for misuse. Continued efforts to improve compliance with evidence-based guidelines as well as multimodal and alternative pain management pathways are critical to help curb the use of opioids for management of osteoarthritis-related pain., Level of Evidence: level IV., (© 2019, American College of Rheumatology.)

Background: Research has become a key pillar of academic medicine and a cornerstone of residency training; however, there continues to be significant barriers to ensuring research productivity for residents. We implemented a novel tiered team approach which aimed to increase research productivity and promote collaboration during residency training., Methods: This was a retrospective study that evaluated the implementation of a novel tiered team research approach at a single institution between 2009 and 2013. Analytical software was used to visualize and display the research interconnections among the authors of the captured publications. In addition to using Gephi to determine the research interconnections, the growth in research capability of the tiered team and its individual members were also graphically depicted., Results: The research team produced a total of 77 publications during the study period (2009-2013). Significant and frequent collaboration and coauthorship was noted as the years progressed following implementation of tiered team research., Discussion: Tiered team research can be readily implemented at most institutions and can lead to increases in productivity of published research. It can also promote collaboration and peer mentorship among those involved., Competing Interests: None

Aims: Prosthetic joint infection (PJI) remains a serious complication that is associated with high morbidity and costs. The aim of this study was to prepare a systematic review to examine patient-related and perioperative risk factors that can be modified in an attempt to reduce the rate of PJI., Materials and Methods: A search of PubMed and MEDLINE was conducted for articles published between January 1990 and February 2018 with a combination of search terms to identify studies that dealt with modifiable risk factors for reducing the rate of PJI. An evidence-based review was performed on 12 specific risk factors: glycaemic control, obesity, malnutrition, smoking, vitamin D levels, preoperative Staphylococcus aureus screening, the management of anti-rheumatic medication, perioperative antibiotic prophylaxis, presurgical skin preparation, the operating room environment, irrigant options, and anticoagulation., Results: Poor glycaemic control, obesity, malnutrition, and smoking are all associated with increased rates of PJI. Vitamin D replacement has been shown in preliminary animal studies to decrease rates of PJI. Preoperative Staphylococcus aureus screening and appropriate treatment results in decreased rates of PJI. Perioperative variables, such as timely and appropriate dosage of prophylactic antibiotics, skin preparation with chlorohexidine-based solution, and irrigation with dilute betadine at the conclusion of the operation, have all been associated with reduced rates of PJI. Similarly, aggressive anticoagulation and increased operating room traffic should be avoided to help minimize risk of PJI., Conclusion: PJI remains a serious complication of arthroplasty. Surgeons should be vigilant of the modifiable risk factors that can be addressed in an attempt to reduce the risk of PJI.

Study Design: This was a retrospective cohort study., Objective: The primary goal was to evaluate risk factors related to increased blood loss in adolescent idiopathic surgery (AIS) surgery with the secondary goal being to evaluate the financial implications around the use of intraoperative cell salvage (ICS) and the routine preallocation of autogenous blood products., Summary of Background Data: Deformity correction for AIS is a complex procedure and can be associated with significant blood loss., Methods: A retrospective cohort study was conducted on consecutive patients between the ages of 10 and 18 years who underwent posterior spinal fusion of 7-12 levels over a 3-year period between January 2013 and December 2015. Demographic information and surgical characteristics were recorded. All patients had a preoperative type and cross of 2 units and ICS was used in all cases. Charges for preoperative type and cross and ICS were also measured. Univariate and multivariable analyses were performed to identify pertinent variables affecting blood loss., Results: In total, 134 patients met inclusion criteria. ICS was used in all cases. In total, 51 patients were transfused cell saver blood intraoperatively/postoperatively at the discretion of the surgeon. On average 133 mL were returned to the patient. No complications related to ICS were observed. Multivariable analysis identified male sex, lower body mass index and higher surgical time to be associated with increased blood loss (P<0.05). All 134 patients had a preoperative type and cross, with an average charge to patient of $311. Patients were charged $1037 for intraoperative use of ICS and $242 for centrifugation. Patients who had allogeneic transfusion were charged $1047., Conclusions: Several blood conservation strategies, including use of ICS, exist to minimize the consequences of blood loss. Routine use of preoperative type and cross may be avoided except in cases where significant blood loss is anticipated-that is adolescent male individuals, those with a lower body mass index and in whom a longer surgical time is anticipated.

Purpose of Review: Periprosthetic joint infection (PJI) remains a complication that is associated with high morbidity as well as high healthcare expenses. The purpose of this review is to examine patient and perioperative modifiable risk factors that can be altered to help improve rates of PJI., Recent Findings: Evidence-based review of literature shows that improved control of post-operative glycemia, appropriate management of obesity, malnutrition, metabolic syndrome, preoperative anemia, and smoking cessation can help minimize risk of PJI. Additionally, use of Staphylococcus aureus screening, preoperative evaluation of vitamin D levels, screening for urinary tract infection, and examination of dental hygiene can help with improving rates of PJI; similarly, appropriate management of perioperative variables such as limiting operating room traffic, appropriate timing, and selection of prophylactic antibiotics and surgical site preparation can help to decrease rates of PJI. In summary, PJI is a morbid complication of total joint arthroplasty. Surgeons should be vigilant of modifiable risk factors that can be improved upon to help minimize the risk of PJI.

Study Design: Retrospective review of a prospective database., Objective: Certain subset of patients undergoing surgical treatment for spinal metastasis will require a revision surgery in their disease course; however, factors predictive of revision surgery and survival outcomes are largely unknown. The goal of this study is to report on survival outcomes as well as factors predictive of revision surgery in this unique patient population., Methods: A total of 55 patients who met the inclusion criteria were included from January 2010 to December 2015. Twelve (22%) of these patients underwent a revision surgery. Patient and tumor characteristics were summarized and survival outcomes were evaluated using Kaplan-Meier methods and Cox proportional hazards regression., Results: Both the revision and the nonrevision groups were similarly matched with respect to spine disease burden, neurological status at time of initial presentation, primary malignancy types, and the use of adjuvant treatment modalities. Tumor progression (66.7%) was the most common reason for necessitating a revision followed by nonunion (16.7%), wound dehiscence (8.3%), and construct failure (8.3%). Following multivariate model selection procedures, smokers were found to have 3.5 times increased odds of undergoing revision compared to nonsmokers ( p = 0.05). Analysis of survival curves showed that the median survival in the revision group was 3.0 years (95% CI: 1.5, 4.1), while the median survival in the nonrevision group was 1.5 years (95% CI: 1.1, 2.3; log-rank test, p = 0.105)., Conclusion: Despite aggressive treatment, tumor progression is the most common reason for revision surgery. Smoking is an independent risk factor for revision. Revision surgery should be considered in patients when indicated as it does not appear to detrimentally affect survival.

Background: Retrospective review of a prospective database. Spine metastasis has been shown to occur in 40% of cancer patients with an annual incidence of over 18,000 cases in North America alone. In this study, we sought to explore the functional and survival outcomes of patients undergoing surgical treatment for metastatic disease of the spine., Methods: A retrospective cohort study of a prospective database at a major cancer center was conducted. A total of 55 patients who met the inclusion criteria from January 2010 to December 2015 were included. Functional status was assessed through patient's ambulatory status. Patient and tumor characteristics were analyzed and regression analyses were performed., Results: Renal cell carcinoma (RCC) was the most common subtype encountered (27.3%). Excluding patients who had spinal metastasis at time of diagnosis, the median time to spinal metastasis from cancer diagnosis was 2.5 years. Median overall survival (OS) time was 1.8 years post diagnosis and 1.6 years post-surgical intervention. Age and tumor subtype were independent predictors of death (P<0.05). Post-surgical intervention, only 3.6% of patients were unable to ambulate-an improvement from 12.7% seen in the immediate preoperative period, P=0.0253. However, at the time of final follow-up, this number had risen to nearly 37%, P<0.0001., Conclusions: Spinal metastasis portends a debilitating prognosis. Ambulatory status is improved or maintained in the post-surgical period. However, long-term outlook remains dismal with median survival at only 1.8 years following diagnosis of spinal metastasis and ambulatory status declining precipitously at the time of final follow-up., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: Racial disparities in access and survival have been reported in a variety of cancers. These issues, however, have yet to be explored in detail in patients with soft-tissue sarcomas (STS). The purpose of this paper was to investigate the independent role of race with respect to survival outcomes in STS., Methods: A total of 7601 patients were evaluated in this study. A SEER registry query for patients over 20 years old with extremity STS diagnosed between 2004 and 2009 (n=7225) was performed. Survival outcomes were analyzed after patients were stratified by race. Multivariable survival models were used to identify independent predictors of sarcoma-specific death. The Wilcoxon rank-sum test was used to compare continuous variables. Statistical significance was maintained at P<0.05., Results: This study showed that African American patients were more likely to die of their STS. They were younger at presentation (P=0.001), had larger tumors (P<0.001), had less surgery (P=0.002), received radiotherapy less frequently (P=0.024), had higher family income (P<0.001), and were less likely to be married (P<0.001). African American race by itself was not an independent predictor of death., Conclusions: African Americans encounter death due to STS at a much larger proportion and faster rate than their respective white counterparts. African Americans frequently present with a larger size tumor, do not undergo surgical resection, or receive radiation therapy as frequently as compared with their white peers. Barriers to timely and appropriate care should be further investigated in this group of at-risk patients.

Background: Among surgical patients, follow-up visits are essential for monitoring post-operative recovery and determining ongoing treatment plans. Non-adherence to clinic follow-up appointments has been associated with poorer outcomes in many different patient populations. We sought to identify factors associated with non-attendance at follow-up appointments for orthopedic trauma patients., Materials and Methods: A retrospective chart review at a level I trauma center identified 2,165 patients who underwent orthopedic trauma surgery from 2008 to 2009. Demographic data including age, sex, race, tobacco use, American Society of Anesthesiologist (ASA) score, insurance status, distance from the hospital, and follow-up time were collected. Injury characteristics including fracture type, anatomic location of the operation, length of hospital stay, living situation and employment status were recorded. Attendance at the first scheduled follow-up visit was recorded. Multivariable log-binomial regression analyses were used with statistical significance maintained at p < 0.05., Results: Of the 2,165 patients included in the analysis, 1,449 (66.9 %) attended their first scheduled post-operative clinic visit. 33.1 % (717) were not compliant with keeping their first clinic appointment after surgery. Patients who used tobacco, lived more than 100 miles from the clinic site, did not have private insurance, had an ASA score >2, or had a fracture of the hip or pelvis were significantly less likely to follow-up. Age, sex, and race were not significantly associated with failure to follow-up., Discussion: Follow-up appointments are essential for preventing complications among orthopedic trauma patients. By identifying patients at risk of failure to follow-up, orthopedic surgeons can appropriately design and implement long-term treatment plans specifically targeted for high-risk patients.

Background and Objectives: In 2002, with the advent of better classification techniques, the World Health Organization declassified malignant fibrous histiocytoma (MFH) as a distinct histological entity in favor of the reclassified entity high-grade undifferentiated pleomorphic sarcoma (HGUPS). To date, no study has evaluated comparative outcomes between patients designated historically in the MFH group and those classified in the new HGUPS classification. Our goal was to determine the presence of clinical prognostic implications that have evolved with this new nomenclature., Methods: Sixty-eight patients were retrospectively evaluated between January 1998 and December 2007. Forty-five patients diagnosed with MFH between 1998 and 2003 were compared to 23 patients in the HGUPS group, from 2004 to 2007. Primary prognostic outcomes assessed included overall survival, metastatic-free, and local recurrence-free survival., Results: Five-year survivorship between MFH and HGUPS populations, using Kaplan-Meier or competing risk methods, did not show statistical difference for overall survival (60% vs. 74%, P=0.36), 5-year metastasis-free survival (31% vs. 26%, P=0.67), or local recurrence-free survival (13% vs. 16%, P=0.62)., Conclusion: Despite new classification nomenclature, there appears to be no identifiable prognostic implications for sarcomas that remain in the unclassifiable HGUPS group, as compared to the previously accepted MFH group., (© 2014 Wiley Periodicals, Inc.)

Background and Objective. Sarcopenia is associated with decreased survival and increased complications in carcinoma patients. We hypothesized that sarcopenic soft-tissue sarcoma (STS) patients would have decreased survival, increased incidence of wound complications, and increased length of postresection hospital stay (LOS). Methods. A retrospective, single-center review of 137 patients treated surgically for STS was conducted. Sarcopenia was assessed by measuring the cross-sectional area of bilateral psoas muscles (total psoas muscle area, TPA) at the level of the third lumbar vertebrae on a pretreatment axial computed tomography scan. TPA was then adjusted for height (cm(2)/m(2)). The association between height-adjusted TPA and survival was assessed using Cox proportional hazard model. A logistical model was used to assess the association between height-adjusted TPA and wound complications. A linear model was used to assess the association between height-adjusted TPA and LOS. Results. Height-adjusted TPA was not an independent predictor of overall survival (p = 0.746). Patient age (p = 0.02) and tumor size (p = 0.009) and grade (p = 0.001) were independent predictors of overall survival. Height-adjusted TPA was not a predictor of increased hospital LOS (p = 0.66), greater incidence of postoperative infection (p = 0.56), or other wound complications (p = 0.14). Conclusions. Sarcopenia does not appear to impact overall survival, LOS, or wound complications in patients with STS.

Introduction: The standard of care for extremity soft tissue sarcomas continues to be negative-margin limb salvage surgery. Radiotherapy is frequently used as an adjunct to decrease local recurrence. No differences in survival have been found between preoperative and postoperative radiotherapy regimens. However, it is uncertain if the use of a postoperative boost in addition to preoperative radiotherapy reduces local recurrence rates., Methods: This retrospective review evaluated patients who received preoperative radiotherapy (n = 49) and patients who received preoperative radiotherapy with a postoperative boost (n = 45). The primary endpoint analysed was local recurrence, with distant metastasis and death due to sarcoma analysed as secondary endpoints. Wilcoxon rank-sum test and either χ(2) or Fisher's exact test were used to compare variables. Multivariable regression analyses were used to take into account potential confounders and identify variables that affected outcomes., Results: No differences in the proportion or rate of local recurrence, distant metastasis or death due to sarcoma were observed between the two groups (P > 0.05). The two groups were similarly matched with respect to demographics such as age, race and sex and tumour characteristics including excision status, tumour site, size, depth, grade, American Joint Committee on Cancer stage, chemotherapy receipt and histological subtype (P > 0.05). The postoperative boost group had a larger proportion of patients with positive microscopic margins (62% vs 10%; P < 0.001)., Conclusion: No differences in rates of local recurrence, distant metastasis or death due to sarcoma were found in patients who received both pre- and postoperative radiotherapy when compared with those who received only preoperative radiotherapy., (© 2014 The Royal Australian and New Zealand College of Radiologists.)

Background: Obesity is a growing epidemic and has been associated with an increased frequency of complications after various surgical procedures. Studies also have shown adipose tissue to promote a microenvironment favorable for tumor growth. Additionally, the relationship between obesity and prognosis of soft tissue sarcomas has yet to be evaluated., Questions/purposes: We sought to assess if (1) obesity affects survival outcomes (local recurrence, distant metastasis, and death attributable to disease) in patients with extremity soft tissue sarcomas; and (2) whether obesity affected wound healing and other surgical complications after treatment., Methods: A BMI of 30 kg/m(2) or greater was used to define obesity. Querying our prospective database between 2001 and 2008, we identified 397 patients for the study; 154 were obese and 243 were not obese. Mean followup was 4.5 years (SD, 3.1 years) in the obese group and 3.9 years (SD, 3.2 years) in the nonobese group; the group with a BMI of 30 kg/m(2) or greater had a higher proportion of patients with followups of at least 2 years compared with the group with a BMI less than 30 kg/m(2) (76% versus 62%). Outcomes, including local recurrence, distant metastasis, and overall survival, were analyzed after patients were stratified by BMI. Multivariable survival models were used to identify independent predictors of survival outcomes. Wilcoxon rank sum test was used to compare continuous variables. Based on the accrual interval of 8 years, the additional followup of 5 years after data collection, and the median survival time for the patients with a BMI less than 30 kg/m(2) of 3 years, we were able to detect true median survival times in the patients with a BMI of 30 kg/m(2) of 2.2 years or less with 80% power and type I error rate of 0.05., Results: Patients who were obese had similar survival outcomes and wound complication rates when compared with their nonobese counterparts. Patients who were obese were more likely to have lower-grade tumors (31% versus 20%; p = 0.021) and additional comorbidities including diabetes mellitus (26% versus 7%; p < 0.001), hypertension (63% versus 38%; p < 0.001), and smoking (49% versus 37%; p = 0.027). Regression analysis confirmed that even after accounting for certain tumor characteristics and comorbidities, obesity did not serve as an independent risk factor in affecting survival outcomes., Conclusions: Although the prevalence of obesity continues to increase and lead to many negative health consequences, it does not appear to adversely affect survival, local recurrence, or wound complication rates for patients with extremity soft tissue sarcomas., Level of Evidence: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Background and Objectives: Prior studies have demonstrated postoperative infection may confer a survival benefit after osteosarcoma resection. Our aim was to determine whether infection after soft tissue sarcoma resection has similar effects on metastasis, recurrence and survival., Methods: A retrospective review was conducted; 396 patients treated surgically for a soft tissue sarcoma between 2000 and 2008 were identified. Relevant oncologic data were collected. Fifty-six patients with a postoperative infection were compared with 340 patients without infection. Hazard ratios and overall cumulative risk were evaluated., Results: There was no difference in survival, local recurrence or metastasis between patients with or without a postoperative infection. Patients were evenly matched for age at diagnosis, gender, smoking status, and diabetes status. Tumor characteristics did not differ between groups in tumor size, location, depth, grade, margin status, stage, and histologic subtype. There was no difference in utilization of chemotherapy or radiation therapy between groups. From our competing risk model, only positive margin status significantly impacted the risk of local recurrence. An increase in tumor size corresponded to an increased risk of metastasis and death., Conclusions: Postoperative infection neither conferred a protective effect, nor increased the risk of adverse oncologic outcomes after soft tissue sarcoma resection., (© 2013 Wiley Periodicals, Inc.)

Background: Spousal support has been hypothesized as providing important psychosocial support for patients and as such has been noted to provide a survival advantage in a number of chronic diseases and cancers. However, the specific effect of marital status on survival in soft tissue sarcomas (STSs) of the extremity has not been explored in detail., Patients and Methods: A total of 7384 patients were evaluated for this study using a Surveillance, Epidemiology, and End Results (SEER) registry query for patients over 20 years old with extremity STS diagnosed between 2004 and 2009. Survival outcomes were analyzed using Gray's test after patients were stratified by marital status. The Fine and Gray model, a multivariable regression model, was used to assess whether marital status was an independent predictor of sarcoma specific death. Statistical significance was maintained at P < 0.05., Results: Analysis of the SEER database showed that single patients were more likely to die of their STS and at a faster rate than married patients. No differences were noted in tumor size and tumor site on presentation between married and single patients. However, single patients presented with higher grade tumors more frequently (P = 0.013), received less radiotherapy (P < 0.001), and had less surgery carried out (P < 0.001), compared with their married peers. Regression analysis showed that after accounting for tumor size, grade, site, histology, use of radiotherapy, age, gender, region where the patients were from, and income, being single continued to serve as an independent predictor of sarcoma-specific death; P < 0.0001., Conclusion: Overall survival is worse for single patients, when compared with married patients, with STS. Single patients do not undergo surgical resection or receive radiation therapy as frequently as their married counterparts. Social support systems and barriers to care should be evaluated at time of diagnosis and addressed in single patients to potentially improve survival outcomes.

Background: Soft tissue sarcomas (STS) continue to be excised inappropriately without proper preoperative planning. The reasons for this remain elusive. The role of insurance status and patient distance from sarcoma center in influencing such inappropriate excisions were examined in this study., Methods: This retrospective review of a single institution prospective database evaluated 400 patients treated for STS of the extremities between January 2000 and December 2008. Two hundred fifty three patients had a primary excision while 147 patients underwent re-excision. Wilcoxon rank sum test and either χ(2) or Fisher's exact were used to compare variables. Multivariable regression analyses were used to take into account potential confounders and identify variables that affected excision status., Results: Tumor size, site, depth, stage, margins, and histology were significantly different between the primary excision and re-excision groups; P < 0.05. Insurance status and patient distance from the treatment center were not statistically different between the two groups. Large and deep tumors and certain histology types predicted appropriate referral., Conclusions: Inappropriate excision of STS is not influenced by patient distance from a sarcoma center or by a patient's insurance status. In this study, tumor size, depth, and certain histology types predicted the appropriate referral of a STS to a sarcoma center., (© 2013 Wiley Periodicals, Inc.)

Background: Although survival outcomes have been evaluated between those undergoing a planned primary excision and those undergoing a reexcision following an unplanned resection, the financial implications associated with a reexcision have yet to be elucidated., Methods: A query for financial data (professional, technical, indirect charges) for soft tissue sarcoma excisions from 2005 to 2008 was performed. A total of 304 patients (200 primary excisions and 104 reexcisions) were identified. Wilcoxon rank sum tests and χ2 or Fisher's exact tests were used to compare differences in demographics and tumor characteristics. Multivariable linear regression analyses were performed with bootstrapping techniques., Results: The average professional charge for a primary excision was $9,694 and $12,896 for a reexcision (p<.001). After adjusting for tumor size, American Society of Anesthesiologists status, grade, and site, patients undergoing reexcision saw an increase of $3,699 in professional charges more than those with a primary excision (p<.001). Although every 1-cm increase in size of the tumor results in an increase of $148 for a primary excision (p=.006), size was not an independent factor in affecting reexcision charges. The grade of the tumor was positively associated with professional charges of both groups such that higher-grade tumors resulted in higher charges compared to lower-grade tumors (p<.05)., Conclusions: Reexcision of an incompletely excised sarcoma results in significantly higher professional charges when compared to a single, planned complete excision. Additionally, when the cost of the primary unplanned surgery is considered, the financial burden nearly doubles.

Ganglion cysts, soft-tissue masses that commonly occur about the wrist, are often excised without imaging or biopsy. In this article, we report a series of incompletely excised soft-tissue sarcomas about the wrist and offer an algorithm for their evaluation. We describe a series of 4 consecutive patients who each presented after incomplete resection of a soft-tissue sarcoma mistakenly diagnosed as a ganglion cyst. We also retrospectively review the cases of 7 patients with incompletely excised sarcomas of the wrist. Three of the 4 patients with sarcomas mistaken for ganglion cysts did not have prior magnetic resonance imaging (MRI), 3 of the 4 did not have an attempted aspiration, and all 4 did not have transillumination. Common atypical characteristics included ulna-based lesions (3/4), symptoms for less than 6 months (3/4), and no appreciable fluctuation in size (3/4). Functional outcomes for all patients were poor because of multiple surgical procedures, re-excisions requiring flaps, and need for additional adjuvant therapies. Dorsal wrist masses with atypical characteristics should be approached with caution. Transillumination and aspiration are 2 accessible, cost-efficient methods for evaluating these masses. If either test is abnormal, an MRI should be performed.

Background and Objectives: Administration of preoperative radiotherapy for extremity soft tissue sarcoma improves local control, while allowing for a more conservative surgical resection. During radiation treatment tumor size typically decreases or remains constant. In a subset of patients, however, a size increase in the tumor occurs. Our goal was to investigate the prognosis of patients who had a size increase of at least 20% over the course of preoperative radiotherapy versus those who did not., Methods: This retrospective study evaluated 70 patients treated for localized primary STS of the extremities between January 2000 and December 2008. Kaplan-Meier curves for disease-specific and metastasis-free survival were calculated for both groups., Results: Sixty-one patients had stable or decrease local tumor size following preoperative radiotherapy and nine patients had an increase of at least 20% in tumor size. There were no statistically significant differences found in disease-specific survival and metastasis-free survival (Gray's test, P = 0.93 and P = 0.68, respectively) among the two groups., Conclusion: Our results indicate that a 20% increase in tumor size following preoperative radiotherapy did not result in a worse outcome for patients when compared to those who had stable or decrease local tumor size following preoperative radiotherapy., (Copyright © 2013 Wiley Periodicals, Inc.)

Background: Limb salvage surgery (LSS) has gained widespread acceptance as the current treatment for treating extremity soft tissue sarcoma (STS) and has been greatly refined since its inception. Combined with improved adjuvant treatment modalities, rates of local relapse have greatly decreased. Nonetheless, local recurrence still occurs and identifying the cause and the subsequent effects of local recurrence can provide valuable insights as LSS continues to evolve., Methods: This retrospective study evaluated 278 patients treated for STS of the extremities between 2000 and 2006. Of these, 41 patients developed a local recurrence while 247 did not. Tumor characteristics and prognostic outcomes were analyzed. Wilcoxon rank sum test and either χ(2) or Fisher's exact was used to compare variables. Kaplan Meier and Gray's test for cumulative risk were also performed., Results: Patients who had a positive margin were 3.76 times more likely to develop local recurrence when compared to those with negative margins. This corresponds to a 38% risk of local recurrence if the margins were positive after six years vs. 12% if the margins were negative. In patients who underwent a re-excision, the presence or absence of residual disease upon re-excision did not have any bearing on local recurrence (p = 0.27). In comparing patients with and without local recurrence, there was no statistically significant difference in the rate and the proportion encountering distant metastasis and death due to sarcoma (p > 0.05)., Conclusions: Despite advancements in surgery, radiation and imaging, positive margins still occur, and the presence of positive margins following definitive treatment continues to remain as a strong predictor for local recurrence. While local recurrence represents a negative outcome for a patient, its impact on future prognosis is influenced by a variety of factors such as time to local recurrence as well as the tumor's inherent biological characteristics.

Background. One-third of all extremity soft tissue sarcomas are misdiagnosed and inappropriately excised without proper preoperative diagnosis and planning. This study aimed at examining the clinical judgment of residents in both general and orthopaedic surgery and at determining whether resident education plays a role in appropriately managing unknown soft tissue masses. Methods. A case-based survey was used to assess clinical decisions, practice patterns, and demographics. Aggregate response for all of the clinical cases by each respondent was correlated with the selections made for practice patterns and demographic data. Results. A total of 381 responses were returned. A higher percentage of respondents from the orthopaedic group (84.2%) noted having a dedicated STS rotation as compared to the general surgery group (35.8%) P < 0.001. Depth, size, and location of the mass, rate of growth, and imaging characteristics were considered to be important factors. Each additional year of training resulted in 10% increased odds of selecting the correct clinical decision for both groups. Conclusion. Our study showed that current residents in both orthopaedic surgery and general surgery are able to appropriately identify patients with suspicious masses. Continuing education in sarcoma care should be implemented beyond the years of residency training.

To determine if amputation increases survival when compared to limb salvage surgery in patients with a soft tissue sarcoma (STS) of the extremity when there is often a misconception among physicians and patients that ablative surgery eliminates local recurrence and increases overall survival. This retrospective cohort study assessed 278 patients with STS and compared 18 patients who had undergone amputations for soft tissue sarcomas of the extremities to a comparative cohort of 260 patients who underwent limb salvage surgery during the same time period. Our limb salvage surgery (LSS) rate was 94% overall for soft tissue sarcomas with a median follow-up of 3.1 years. Patients undergoing amputations either had tumors that involved a critical neurovascular bundle (in particular nerve rather than vessel resection was more responsible for a decision toward ablation), or underlying bone or had neoplasms whose large size would require such an enormous resection that a functional limb would not remain. In comparing prognostic effects, mainly death due to sarcoma, distant metastasis and local recurrence, it was found that there was no statistically significant difference between patients undergoing amputation to those undergoing limb salvage surgery (p > 0.05). While amputations do not increase overall survival in soft tissue sarcomas of the extremity as compared to LSS, they are still a valuable option in a surgeon's arsenal. In particular, amputations can provide improved local control and symptomatic treatment in patients who might not be candidates for limb salvage surgery., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Soft tissue sarcomas (STS) are rare and are commonly excised outside of a sarcoma center without appropriate preoperative planning. Studies have shown varying results in survival and outcome when comparing patients undergoing re-excision to patients undergoing a single, planned excision., Methods: This retrospective study evaluated 278 patients treated for STS of the extremities between January 2000 and July 2006. One hundred seventy-two patients had a primary excision while 106 patients had a sarcoma re-excised. Survival curves for disease-free survival, metastasis-free survival, and local recurrence-free survival were calculated using competing risk analysis for both groups., Results: After adjusting for high-risk variables, our results indicate that re-excision is a proxy for smaller, low-grade tumors which tend to have a better survival profile. Death due to sarcoma and distant metastases were correlated with high-grade and large tumors. The presence of positive microscopic margins was the strongest predictor of local recurrence (P < 0.05)., Conclusions: There were no differences in death, metastases, or local recurrence between the two groups after adjusting for high-risk variables. Survival advantages previously reported with STS re-excision serve as proxy for tumors that have a better survival profile., (Copyright © 2011 Wiley Periodicals, Inc.)