"We're On The Same Team": A Qualitative Study On Communication And Care Coordination Surrounding The Requirement To Quit Smoking Prior To Elective Orthopaedic Surgery.

INTRODUCTION: Many surgeons require patients to quit smoking prior to elective surgeries to reduce the risk of postoperative complications. Our aim was to qualitatively evaluate the communication and care experiences of patients and clinicians involved in conversations about quitting smoking prior to elective orthopaedic surgery. METHODS: A qualitative interview study of rural-residing Veterans, primary care providers (PCPs), and Veterans Administration (VA) orthopaedic surgery staff and pharmacists, who care for rural Veterans. We performed a combination of deductive and inductive approaches to support conventional content analysis using a Patient-Centered Care framework. RESULTS: Patients appreciated a shared approach with their PCP on the plan and reasons for cessation. Despite not knowing if the motivation for elective surgeries served as a teachable moment to facilitate long-term abstinence, almost all clinicians believed it typically helped in the short-term. There was a lack of standardized workflow between primary care and surgery, especially when patients used care delivered outside of VA. CONCLUSIONS: While clinician-provided information about the reasons behind the requirement to quit smoking preoperatively was beneficial, patients appreciated the opportunity to collaborate with their care teams on developing a plan for cessation and abstinence. Other aspects of patient-centered care need to be leveraged, such as the therapeutic alliance or patient-as-person, to build trust and improve communication surrounding tobacco use treatment. System-level changes may need to be made to improve coordination and connection of clinicians within and across disciplines. IMPLICATIONS: This study included perspectives from patients, primary care teams, and surgical teams and found that, in addition to providing information, clinicians need to address other aspects of patient-centered care such as the therapeutic alliance and patient-as-person domains to promote patient engagement in tobacco use treatment. This, in turn, could enhance the potential of surgery as a teachable moment and patient success in quitting smoking.

Does Freehand, Patient-specific Instrumentation or Surgical Navigation Perform Better for Allograft Reconstruction After Tumor Resection? A Preclinical Synthetic Bone Study.

BACKGROUND: Joint-sparing resection of periarticular bone tumors can be challenging because of complex geometry. Successful reconstruction of periarticular bone defects after tumor resection is often performed with structural allografts to allow for joint preservation. However, achieving a size-matched allograft to fill the defect can be challenging because allograft sizes vary, they do not always match a patient's anatomy, and cutting the allograft to perfectly fit the defect is demanding. QUESTIONS/PURPOSES: (1) Is there a difference in mental workload among the freehand, patient-specific instrumentation, and surgical navigation approaches? (2) Is there a difference in conformance (quantitative measure of deviation from the ideal bone graft), elapsed time during reconstruction, and qualitative assessment of goodness-of-fit of the allograft reconstruction among the approaches? METHODS: Seven surgeons used three modalities in the same order (freehand, patient-specific instrumentation, and surgical navigation) to fashion synthetic bone to reconstruct a standardized bone defect. National Aeronautics and Space Administration (NASA) mental task load index questionnaires and procedure time were captured. Cone-beam CT images of the shaped allografts were used to measure conformance (quantitative measure of deviation from the ideal bone graft) to a computer-generated ideal bone graft model. Six additional (senior) surgeons blinded to modality scored the quality of fit of the allografts into the standardized tumor defect using a 10-point Likert scale. We measured conformance using the root-mean-square metric in mm and used ANOVA for multipaired comparisons (p < 0.05 was significant). RESULTS: There was no difference in mental NASA total task load scores among the freehand, patient-specific instrumentation, and surgical navigation techniques. We found no difference in conformance root-mean-square values (mean ± SD) between surgical navigation (2 ± 0 mm; mean values have been rounded to whole numbers) and patient-specific instrumentation (2 ± 1 mm), but both showed a small improvement compared with the freehand approach (3 ± 1 mm). For freehand versus surgical navigation, the mean difference was 1 mm (95% confidence interval [CI] 0.5 to 1.1; p = 0.01). For freehand versus patient-specific instrumentation, the mean difference was 1 mm (95% CI -0.1 to 0.9; p = 0.02). For patient-specific instrumentation versus surgical navigation, the mean difference was 0 mm (95% CI -0.5 to 0.2; p = 0.82). In evaluating the goodness of fit of the shaped grafts, we found no clinically important difference between surgical navigation (median [IQR] 7 [6 to 8]) and patient-specific instrumentation (median 6 [5 to 7.8]), although both techniques had higher scores than the freehand technique did (median 3 [2 to 4]). For freehand versus surgical navigation, the difference of medians was 4 (p < 0.001). For freehand versus patient-specific instrumentation, the difference of medians was 3 (p < 0.001). For patient-specific instrumentation versus surgical navigation, the difference of medians was 1 (p = 0.03). The mean ± procedural times for freehand was 16 ± 10 minutes, patient-specific instrumentation was 14 ± 9 minutes, and surgical navigation techniques was 24 ± 8 minutes. We found no differences in procedures times across three shaping modalities (freehand versus patient-specific instrumentation: mean difference 2 minutes [95% CI 0 to 7]; p = 0.92; freehand versus surgical navigation: mean difference 8 minutes [95% CI 0 to 20]; p = 0.23; patient-specific instrumentation versus surgical navigation: mean difference 10 minutes [95% CI 1 to 19]; p = 0.12). CONCLUSION: Based on surgical simulation to reconstruct a standardized periarticular bone defect after tumor resection, we found a possible small advantage to surgical navigation over patient-specific instrumentation based on qualitative fit, but both techniques provided slightly better conformance of the shaped graft for fit into the standardized post-tumor resection bone defect than the freehand technique did. To determine whether these differences are clinically meaningful requires further study. The surgical navigation system presented here is a product of laboratory research development, and although not ready to be widely deployed for clinical practice, it is currently being used in a research operating room setting for patient care. This new technology is associated with a learning curve, capital costs, and potential risk. The reported preliminary results are based on a preclinical synthetic bone tumor study, which is not as realistic as actual surgical scenarios. CLINICAL RELEVANCE: Surgical navigation systems are an emerging technology in orthopaedic and reconstruction surgery, and understanding their capabilities and limitations is paramount for clinical practice. Given our preliminary findings in a small cohort study with one scenario of standardized synthetic periarticular bone tumor defects, future investigations should include different surgical scenarios using allograft and cadaveric specimens in a more realistic surgical setting.

Survival and failure modes of the Compress® spindle and expandable distal femur endoprosthesis among pediatric patients: A multi-institutional study.

BACKGROUND: Expandable endoprostheses can be used to equalize limb length for pediatric patients requiring reconstruction following large bony oncologic resections. Outcomes of the Compress® Compliant Pre-Stress (CPS) spindle paired with an Orthopedic Salvage System expandable distal femur endoprosthesis have not been reported. METHODS: We conducted a multi-institutional retrospective study of pediatric patients with distal femoral bone sarcomas reconstructed with the above endoprostheses. Statistical analysis utilized Kaplan-Meier survival technique and competing risk analysis. RESULTS: Thirty-six patients were included from five institutions. Spindle survivorship was 86.3% (95% confidence interval [CI], 67.7-93.5) at 10 years. Two patients had a failure of osseointegration (5.7%), both within 12 months. Twenty-two (59%) patients had 70 lengthening procedures, with mean expansions of 3.2 cm (range: 1-9) over 3.4 surgeries. The expandable mechanism failed in eight patients with a cumulative incidence of 16.1% (95% CI, 5.6-31.5) at 5 years. Twenty-nine patients sustained International Society of Limb Salvage failures requiring 63 unplanned surgeries. Periprosthetic joint infection occurred in six patients (16.7%). Limb preservation rate was 91% at 10 years. CONCLUSIONS: There is a high rate of osseointegration of the Compress® spindle among pediatric patients when coupled with an expandable implant. However, there is a high rate of expansion mechanism failure and prosthetic joint infections requiring revision surgery. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Does "Hoarding" Impact Interview Distribution Among Orthopaedic Surgery Residency Applicants? A Modeling Study Based on a Large Database.

BACKGROUND: "Interview hoarding" is commonly used to refer to the concentration of interview offers among a small number of high-performing residency applicants. Theoretically, if the same applicants interview at every program, fewer rank lists will be submitted than open residency positions, leading to a "match crisis" with unfilled positions after the match. There are no published studies we are aware of that describe the observed distribution of residency interview offers among orthopaedic surgery applicants or the potential impact of "hoarding" on that distribution. QUESTIONS/PURPOSES: We examined the distribution of interview invitations extended to orthopaedic surgery residency applicants in the 2020 to 2021 and 2021 to 2022 application cycles. The change in the shape of the interview invitation distribution was the primary outcome for two central questions: (1) Does the interview offer distribution curve among orthopaedic surgery applicants change meaningfully from baseline with implementation of an interview cap (Model 1)? (2) What is the impact on the distribution of invitations with a reduction in the number of applicants in the field (Model 2)? METHODS: This was a retrospective study of orthopaedic surgery interview invitations extended to applicants via the Thalamus interview management program during the 2020 to 2021 and 2021 to 2022 residency application cycles. The Thalamus database was chosen because it contains data on interview invitations for orthopaedic surgery residency positions and has the largest market share in orthopaedics compared with similar databases. Thalamus data represent 1565 applicants and 53 residency programs (90% and 25% of the national total, respectively) in 2021 to 2022 and 993 applicants and 46 programs (77% and 23%, respectively) in 2020 to 2021. It has been shown to contain a representative sample of orthopaedic residency programs. An interview cap (Model 1) was simulated by removing excess interviews held by applicants above the 75th and 95th percentiles, which were chosen to represent a formal cap and an informal cap, respectively. A reduction in the size of the applicant pool was similarly modeled by randomly removing 5% and 25% of applicants, chosen to simulate informal and formal application requirements, respectively. In both models, the excess interviews were redistributed among the remaining applicants. RESULTS: Applicants received a mean of 1.8 ± 2.2 Thalamus interview invitations in 2020 to 2021 and 1.7 ± 2.4 invitations in 2021 to 2022, with no change to the overall distribution curve. A total of 39% (606 of 1565) of applicants received no Thalamus interview invitations in 2021 to 2022, 75% (1176 of 1565) received two or fewer, and < 1% (14 of 1565) of applicants received 10 or more invitations. Redistributing excess interviews held by the top 5% of applicants resulted in 2% (61 of 2651) of interviews being redistributed (Model 1). Removing 5% of the total applicant pool resulted in a redistribution of 3% (87 of 2651) of the interview invitations (Model 2). CONCLUSION: Orthopaedic surgery interview data demonstrated an expected uneven distribution of interview invitations, with a small proportion of highly competitive applicants receiving a higher number of interview offers as well as a large group of applicants receiving no interview invitations in Thalamus. Concerns that "hoarding" would lead to a crisis resulting in many unmatched residency positions seemed unfounded, given the excess of applicants relative to positions and the minimal change in the distribution of interviews in the cap model. CLINICAL RELEVANCE: Medical students applying to orthopaedic residency should seek individual advising to improve their individual odds of matching, while understanding that interview hoarding does not seem to alter the distribution of interviews. Program directors and medical students' advisors should be cognizant that a small proportion of applicants are broadly interviewed and may benefit from steps taken to ensure applicants have genuine interest in the program.

Is the Addition of Anaerobic Coverage to Perioperative Antibiotic Prophylaxis During Soft Tissue Sarcoma Resection Associated With a Reduction in the Proportion of Wound Complications?

BACKGROUND: Wound complications are common after resection of soft tissue sarcomas, with published infection rates ranging from 10% to 35%. Multiple studies have reported on the atypical flora comprising these infections, which are often polymicrobial and contain anaerobic bacteria, and recent studies have noted the high prevalence of anaerobic bacterial infections after soft tissue sarcoma resection [ 26, 35 ]. Based on this, our institution changed clinical practice to include an antibiotic with anaerobic coverage in addition to the standard first-generation cephalosporin for prophylaxis during soft tissue sarcoma resections. The current study was undertaken to evaluate whether this change was associated with a change in major wound complications, and if the change should therefore be adopted for future patients. QUESTIONS/PURPOSES: (1) After controlling for potentially confounding variables, was the broadening of the prophylactic antibiotic spectrum to cover anaerobic bacteria associated with a lower odds of major wound complications after soft tissue sarcoma resection? (2) Was the broadening of the prophylactic antibiotic spectrum to cover anaerobic bacteria associated with a lower odds of surgical site infections with polymicrobial or anaerobic infections after soft tissue sarcoma resection? (3) What are the factors associated with major wound complications after soft tissue sarcoma resection? METHODS: We retrospectively identified 623 patients who underwent soft tissue sarcoma resection at a single center between January 2008 and January 2021 using procedural terminology codes. Of these, four (0.6%) pediatric patients were excluded, as were five (0.8%) patients with atypical lipomatous tumors and two (0.3%) patients with primary bone tumors; 5% (33 of 623) who were lost to follow-up, leaving 579 for final analysis. The prophylactic antibiotic regimen given at the resection and whether a wound complication occurred were recorded. Patients received the augmented regimen based on whether they underwent resection after the change in practice in July 2018. A total of 497 patients received a standard antibiotic regimen (usually a first-generation cephalosporin), and 82 patients received an augmented regimen with anaerobic coverage (most often metronidazole). Of the 579 patients, 53% (307) were male (53% [264 of 497] in the standard regimen and 52% [43 of 82] in the augmented regimen), and the mean age was 59 ± 17 years (59 ± 17 and 60 ±17 years in the standard and augmented groups, respectively). Wound complications were defined as any of the following within 120 days of the initial resection: formal wound debridement in the operating room, other interventions such as percutaneous drain placement, readmission for intravenous antibiotics, or deep wound packing for more than 120 days from the resection. Patients were considered to have a surgical site infection if positive cultures resulted from deep tissue cultures taken intraoperatively at the time of debridement. The proportion of patients with major wound complications was 26% (150 of 579); it was 27% (136 of 497) and 17% (14 of 82) in the standard and augmented antibiotic cohorts, respectively (p = 0.049). With the numbers we had, we could not document that the addition of antibiotics with anaerobic coverage was associated with lower odds of anaerobic (4% versus 6%; p = 0.51) or polymicrobial infections (9% versus 14%; p = 0.25). Patient, tumor, and treatment (surgical, radiotherapy, and chemotherapy) variables were collected to evaluate factors associated with overall infection and anaerobic or polymicrobial infection. Patient follow-up was 120 days to capture early wound complications. A multivariable analysis was performed for all variables found to be significant in the univariate analysis. A p value < 0.05 was used as the threshold for statistical significance for all analyses. No patients were found to have an adverse reaction to the augmented regimen, including allergic reactions or Clostridioides (formerly Clostridium) difficile infection. RESULTS: After controlling for other potentially confounding factors such as neoadjuvant radiation, tumor size and anatomic location, as well as patient BMI, anaerobic coverage was associated with smaller odds of wound complications (OR 0.36 [95% confidence interval (CI) 0.18 to 0.68]; p = 0.003). Other factors associated with major wound complications were preoperative radiation (versus no preoperative radiation) (OR 2.66 [95% CI 1.72 to 4.15]; p < 0.001), increasing tumor size (OR 1.04 [95% CI 1.00 to 1.07]; p = 0.03), patient BMI (OR 1.07 [95% CI 1.04 to 1.11]; p < 0.001), and tumor in the distal upper extremity (versus proximal upper extremity, pelvis/groin/hip, and lower extremity) (OR 0.18 [95% CI 0.04 to 0.62]; p = 0.01). CONCLUSION: The addition of anaerobic coverage to the standard prophylactic regimen during soft tissue sarcoma resection demonstrated an association with smaller odds of major wound complications and no documented adverse reactions. Treating physicians should consider these findings but note that they are preliminary, and that further work is needed to replicate them in a more controlled study design such as a prospective trial. LEVEL OF EVIDENCE: Level III, therapeutic study.

MRI-based 3-dimensional volumetric assessment of fatty infiltration and muscle atrophy in rotator cuff tears.

BACKGROUND: The Goutallier and Warner Classification systems are useful in determining rotator cuff reparability. Data are limited on how accurately the scapular-Y view used in both systems reflects the 3-dimensional (3-D) changes in fatty infiltration (FI) and muscle atrophy (MA). Tendon retraction in the setting of a cuff tear may also influence the perception of these changes. This study's objectives were to (1) measure the 3-D volume of the supraspinatus muscle in intact rotator cuffs, and with varying magnitudes of retraction; (2) measure the 3-D volume of FI in the supraspinatus muscle in these conditions; and (3) determine the influence of tendon retraction on measured FI and MA using the Goutallier and Warner Classification Systems. METHODS: Between August 2015 and February 2016, all shoulder magnetic resonance images (MRIs) at the Portland VA Medical Center were standardized to include the medial scapular border. MRIs and charts were reviewed for inclusion/exclusion criteria. Included MRIs were categorized into 4 groups based on rotator cuff retraction. Supraspinatus muscle and fossa were traced to create 3-D volumes. FI and MA were measured within the supraspinatus. The supraspinatus muscle was graded among 6 physicians using the Goutallier and Warner classification systems. These grades were compared to 3-D measured FI and MA. The influence of tendon retraction on the measured grades were also evaluated. RESULTS: One hundred nine patients met inclusion/exclusion criteria. Ten MRIs for each group (N = 40) were included for image analysis. Supraspinatus volume tracings were highly reproducible and consistent between tracers. Supraspinatus muscle volumes decreased while global FI and MA increased with greater degrees of tendon retraction. In muscles with less than 10% global fat, fat concentrated in the lateral third of the muscle. In muscle with more than 10% global fat content, it distributed more diffusely throughout the muscle from medial to lateral. In comparing the scapular-Y to a medial cut, there was no consistent trend in FI whereas MA was more accurate at the medial cut. CONCLUSION: Parasagittal imaging location did not significantly influence the Goutallier score; however, assessment of MA using the Warner score leads readers to perceive less MA medially regardless of the magnitude of tendon retraction. The pattern of FI within the supraspinatus muscle changes from a laterally based location around the muscle-tendon junction to a more diffuse, global infiltration pattern when the whole muscle fat content exceeds 10%.

Thromboembolic risk in patients with lung cancer receiving systemic therapy.

In this retrospective study, we investigated the influence of chemotherapy and immunotherapy on thromboembolic risk among United States Veterans with lung cancer during their first 6 months (180 days) following initiation of systemic therapy. Included patients received treatment with common front-line agents that were divided into four groups: chemotherapy alone, immunotherapy alone, combination of chemo- and immunotherapies, and molecularly targeted therapies (control group). The cohort experienced a 7·4% overall incidence of thrombosis, but the analysis demonstrated significantly different rates among the different groups. We explored models incorporating multiple confounding variables as well as the competing risk of death, and these results indicated that both chemo- and immunotherapies were associated with an increased incidence of thrombosis, either alone or combined, compared with the control group (7·56%, P = 2.2 × 10-16 ; 10·2%, P = 2.2 × 10-16 ; and 7·87%, P = 2.4 × 10-14 respectively vs. 4·10%). The Khorana score was found to be associated with increased risk, as were vascular disease and metastases. We found an association between risk of thrombosis and the use of anticoagulation, accounting for several confounders, including history of thrombosis. Further study is warranted to better determine the drivers of thromboembolic risk and to identify ways to mitigate this risk for patients.

Is Reoperation Higher Than Expected after Below-the-knee Amputation? A Single-center Evaluation of Factors Associated with Reoperation at 1 Year.

BACKGROUND: Below-the-knee amputation (BKA) is relatively common among patients with vascular disease, infection, trauma, or neoplastic disease. Many BKAs are performed in patients with incompletely treated medical comorbidities, and some are performed in patients with acute high-energy trauma or crush injuries, malignant neoplasm undergoing time-sensitive limb removal, and diabetes with active infection or sepsis. Consequently, revision is common. Prior studies of outcomes after BKA, including several based on the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database, have follow-up periods that do not cover the entire at-risk period. QUESTIONS/PURPOSES: (1) What is the survivorship free from unplanned reoperation within 1 year of BKA? (2) What patient characteristics are associated with reoperation within 1 year of BKA? METHODS: We retrospectively studied all BKAs performed by the orthopaedic surgery service at a Level 1 trauma center from 2008 to 2018, as identified by Current Procedural Terminology (CPT) codes. Twenty-eight percent (38 of 138) underwent amputation as treatment for traumatic injury, 57% (79 of 138) for infection, and 15% (21 of 138) for malignancy. A total of 17% (23 of 138) had a final follow-up encounter before the 1-year study minimum, without differential loss to follow-up by surgical indication (p = 0.43) or hemoglobin A1c (p = 0.71). Median (range) follow-up was 570 days (6 to 3375). The primary outcome was survivorship from unplanned reoperation within 1 year of BKA index surgery or last planned reoperation, as determined by Kaplan-Meier estimation. Secondarily, we identified patient characteristics independently associated with reoperation within 1 year of BKA. Collected data included age, indication, BMI, diabetes, hemoglobin A1c level, closure method, and substance use. Unplanned reoperation was defined as irrigation and débridement, stump revision, or revision to a higher-level amputation; this did not include planned reoperations for BKAs closed in a staged manner. Factors associated with reoperation were determined using multivariate logistic regression analyses. All endpoints and variables related to patients and their surgical procedures were extracted from electronic medical records by someone other than the operating surgeon. RESULTS: Using Kaplan-Meier estimation, 38% of patients (95% confidence interval 29 to 46) who underwent BKA had an unplanned reoperation within 1 year of their index surgery. Twelve percent of patients (95% CI 7 to 17) who underwent BKA did not reach 30 days with the limb survivorship free from unplanned reoperation. The median (range) time between the initial surgery and reoperation was 54 days (6 to 315). After controlling for potential confounding variables like age, gender, platelet count, albumin, and the reason for undergoing amputation, a hemoglobin A1c level greater than 8.1% (relative to A1c ≤ 8.1%) was the only variable independently associated with increased odds of reoperation (odds ratio 4.6 [95% CI 1.3 to 18.1]; p = 0.02). CONCLUSION: BKA carries a higher risk for reoperation than currently reported in studies that use 30-day postoperative follow-up periods. Clinicians should critically assess whether BKA is necessary, especially in patients with uncontrolled diabetes assessed by hyperglycemia. Before planned BKA, patients should have documented glycemic control to minimize the odds of reoperation. Because many of this study's limitations were due to its retrospective single center design, we recommend that future work cover a clinically appropriate surveillance period using a larger cohort such as a national database and/or employ a prospective design. LEVEL OF EVIDENCE: Level III, therapeutic study.

Low-grade Osteosarcomatous Dedifferentiation of an Atypical Lipomatous Tumor in a Pediatric Patient.

Atypical and malignant lipomatous tumors are infrequent in the pediatric population. Within this uncommon cohort, the morphologically and genetically related spectrum of atypical lipomatous tumor/well-differentiated liposarcoma/dedifferentiated liposarcoma (ALT/WDL/DDLS) is markedly rare. Their shared characteristic molecular aberration is a genomic amplicon of a region of chromosome 12q, including the oncogenes MDM2 and CDK4. We present an unusual case of a pediatric patient with an ALT, with recurrence after 2 years in the form of a bone-forming mass, radiologically and pathologically mimicking parosteal osteosarcoma, a tumor also molecularly characterized by amplification of MDM2 and CDK4. However, with ample histologic sampling, a single focus of lipogenic differentiation was identified, thus representing the first near complete low-grade osteosarcomatous dedififferentation reported within ALT/WDL/DDLS and the first ever in pediatric patient. The case serves a reminder of a diagnosis differential and pitfalls within MDM2-amplified tumors.

Advances in the Functional Assessment of Patients with Sarcoma.

Functional assessment of patients with osteosarcoma may yield unique insights into the guide and advance treatment. A range of patient-reported outcomes has been validated, including general health and condition-specific measures as well as computer adaptive testing. Health state utility measures, which facilitate comparative-effectiveness research, are also available. Beyond these surveys, and laboratory-dependent gait analyses, is the potential for real-world evaluation through research-oriented and consumer-oriented accelerometers. Initial studies have shown promising validity of these activity trackers and may also have implications for traditional oncologic outcomes.

Is There an Association Between Prophylactic Femur Stabilization and Survival in Patients with Metastatic Bone Disease?

BACKGROUND: The femur is the most common site of metastasis in the appendicular skeleton, and metastatic bone disease negatively influences quality of life. Orthopaedic surgeons are often faced with deciding whether to prophylactically stabilize an impending fracture, and it is unclear if prophylactic fixation increases the likelihood of survival. QUESTIONS/PURPOSES: Is prophylactic femur stabilization in patients with metastatic disease associated with different overall survival than fixation of a complete pathologic fracture? METHODS: We performed a retrospective, comparative study using the national Veterans Administration database. All patient records from September 30, 2010 to October 1, 2015 were queried. Only nonarthroplasty procedures were included. The final study sample included 950 patients (94% males); 362 (38%) received prophylactic stabilization of a femoral lesion, and 588 patients (62%) underwent fixation of a pathologic femur fracture. Mean followup duration was 2 years (range, 0-7 years). We created prophylactic stabilization and pathologic fracture fixation groups for comparison using Common Procedural Terminology and ICD-9 codes. The primary endpoint of the analysis was overall survival. Univariate survival was estimated using the Kaplan-Meier method; between-group differences were compared using the log-rank test. Covariate data were used to create a multivariate Cox proportional hazards model for survival to adjust for confounders in the two groups, including Gagne comorbidity score and cancer type. RESULTS: After adjusting for comorbidities and cancer type, we found that patients treated with prophylactic stabilization had a lower risk of death than did patients treated for pathologic femur fracture (hazard ratio = 0.75, 95% CI, 0.62-0.89; p = 0.002). CONCLUSIONS: In the national Veterans Administration database, we found greater overall survival between patients undergoing prophylactic stabilization of metastatic femoral lesions and those with fixation of complete pathologic fractures. We could not determine the cause of this association, and it is possible, if not likely, that patients treated for fracture had more aggressive disease causing the fracture than did those undergoing prophylactic stabilization. Currently, most orthopaedic surgeons who treat pathological fractures stabilize the fracture prophylactically when reasonable to do so. We may be improving survival in addition to preventing a pathological fracture; further study is needed to determine whether the association is cause-and-effect and whether additional efforts to identify and treat at-risk lesions improves patient outcomes. LEVEL OF EVIDENCE: Level III, therapeutic study.

Oncology Patients Are High Cost Outliers in Total Joint Replacement Bundled Payment Systems.

BACKGROUND: In 2016, the Centers for Medicare and Medicaid Services began its first mandatory bundled payment program, the Comprehensive Care for Joint Replacement (CJR) model, which covers a 90-day episode of care. This study determined whether oncology patients enrolled in the CJR bundle incur higher hospital costs than patients with osteoarthritis (OA). METHODS: A retrospective review of all patients enrolled in the CJR bundled payments system from April 1, 2016 to June 31, 2018 at a single academic medical center was conducted. To determine whether tumor patients had higher total episode costs, this group was compared to patients diagnosed with OA using a 2-tailed t-test. To adjust for moderators of total hospital costs, we used generalized linear regression with a log-link, including multiple variables abstracted from chart review. RESULTS: Three hundred fourteen patients met inclusion criteria (12 primary or metastatic tumors, 302 OA). Fifty-eight percent of tumor patients were over the target price vs 16% of OA patients. The mean tumor patient had $40,862 for total internal hospital costs compared to $16,356 in the OA group (P < .001). Length of stay was greater in the tumor group (6.75 vs 2.0 days, P < .001). A greater percentage of tumor patients were discharged to a skilled nursing facility (67% vs 27%, P = .006) with significantly higher skilled nursing facility episode costs ($18,852 vs $7731, P = .04). With adjustment for fracture status, tumor patients were 5.36 times more likely to exceed the CJR target price than OA patients (risk ratio 5.36, confidence interval 3.44-8.35, P < .001) and 50 times more likely to be outliers over the regional threshold than OA patients (risk ratio 50.33, confidence interval 16.33-155.19, P < .001). CONCLUSION: Oncology patients enrolled in the CJR bundled payment model incur significantly higher costs and have higher cost variability than patients with OA. We recommend that oncology patients be excluded from the CJR bundle.

Radiographic parameter-driven decision tree reliably predicts aseptic mechanical failure of compressive osseointegration fixation.

Background and purpose - Compressive osseointegration fixation is an alternative to intramedullary fixation for endoprosthetic reconstruction. Mechanical failure of compressive osseointegration presents differently on radiographs than stemmed implants, therefore we aimed to develop a reliable radiographic method to determine stable integration.Patients and methods - 8 reviewers evaluated 11 radiographic parameters from 29 patients twice, 2 months apart. Interclass correlation coefficients (ICCs) were used to assess test-retest and inter-rater reliability. We constructed a fast and frugal decision tree using radiographic parameters with substantial test-retest agreement, and then tested using radiographs from a new cohort of 49 patients. The model's predictions were compared with clinical outcomes and a confusion matrix was generated.Results - 6 of 8 reviewers had non-significant intra-rater ICCs for ≥ one parameter; all inter-rater ICCs were highly reliable (p < 0.001). Change in length between the top of the spindle sleeve and bottom of the anchor plug (ICC 0.98), bone cortex hypertrophy (ICC 0.86), and bone pin hypertrophy (ICC 0.81) were used to create the decision tree. The sensitivity and specificity of the training cohort were 100% (95% CI 52-100) and 87% (CI 74-94) respectively. The decision tree demonstrated 100% (CI 40-100) sensitivity and 89% (CI 75-96) specificity with the test cohort.Interpretation - A stable spindle length and at least 3 cortices with bone hypertrophy at the implant interface predicts stable osseointegration; failure is predicted in the absence of bone hypertrophy at the implant interface if the pin sites show hypertrophy. Thus, our decision tree can guide clinicians as they follow patients with compressive osseo-integration implants.

Evaluation of Endoscopic Iliopsoas Tenotomy for Treatment of Iliopsoas Impingement After Total Hip Arthroplasty.

BACKGROUND: Iliopsoas impingement after total hip arthroplasty (THA) occurs in up to 4.3% of patients resulting in functional groin pain. Operative treatment historically has included open iliopsoas tenotomy or acetabulum revision. We present a large single surgeon series of patients treated with endoscopic iliopsoas tenotomy for iliopsoas impingement after THA to evaluate the effectiveness and risks. METHODS: A consecutive series of 60 patients with iliopsoas impingement after THA treated with endoscopic iliopsoas tenotomy was retrospectively evaluated. Outcomes assessed were resolution of pain, change in Hip Outcome Score (HOS), and complications. Radiographs were reviewed by a musculoskeletal radiologist to evaluate component positioning and to compare with a control cohort. RESULTS: At last follow-up (mean 5.5 months), 93.3% of patients had resolution of pain. The HOS activities of daily living (ADL) subscale mean was 57.5 (range 10.9-89.3, standard deviation [SD] 18.8) preoperatively and 71.6 (range 14.1-100, SD 26.1) postoperatively (P = .005). The HOS sports subscale mean was 37.3 (range 0-83.3, SD 24.0) preoperatively and 58.1 (range 0-100, SD 33.2) postoperatively (P = .002). One complication was reported, a postoperative hematoma managed conservatively. Body mass index and increased offset were associated with iliopsoas symptoms after THA in this series. CONCLUSION: Endoscopic iliopsoas tenotomy after THA had a 93.3% resolution of pain, clinically important improvements in HOS, and low rate of complications. Endoscopic tenotomy should be considered as a treatment option in patients with iliopsoas impingement after THA.

Treatment Modalities for Pathologic Fractures of the Proximal Femur Pertrochanteric Region: A Systematic Review and Meta-Analysis of Reoperation Rates.

BACKGROUND: The proximal femur represents the most common site of metastatic bone disease in the appendicular skeleton, and associated pathologic pertrochanteric femur fractures contribute to cancer-related morbidity and mortality. Controversy exists as to whether these injuries are best managed with intramedullary nailing (IMN) or with arthroplasty. METHODS: A systematic review of the literature was performed using a PubMed search following PRISMA guidelines to identify studies performed within the last 20 years regarding treatment of proximal femur metastatic lesions with either nailing or arthroplasty with a reported reoperation rate. Sixteen studies were selected for inclusion containing 1414 patients. Pooled estimates and 95% confidence intervals (CIs) for reoperation rates associated with IMN and endoprosthetic reconstruction (EPR) were separately calculated. RESULTS: The pooled estimate for reoperation for IMN was a median of 9% (95% CI, 5%-14%) and the pooled estimate for reoperation for EPR was a median of 7% (95% CI, 5%-11%). Significant heterogeneity was present in studies reporting on both treatment modalities: for IMN, I2 = 55%, and for EPR, I2 = 51%. CONCLUSION: This systematic literature review identified 16 eligible, nonrandomized, retrospective studies that reported on the results of surgical treatment for proximal femur metastatic disease. The pooled estimate of reoperation was similar between patients treated with IMN and EPR. Inconsistencies among follow-up and the study designs used limited evidence-based conclusions. As the oncologic care of patients with metastatic disease continues to evolve and improve, patient-specific needs must be carefully considered when selecting an optimal treatment strategy. LEVEL OF EVIDENCE: Level III.

An Analysis of Tumor- and Surgery-Related Factors that Contribute to Inadvertent Positive Margins Following Soft Tissue Sarcoma Resection.

BACKGROUND: The risk of local recurrence (LR) after soft tissue sarcoma (STS) resection is higher in the setting of inadvertent positive margins (IPMs). This study assessed whether both tumor- and surgery-related factors contribute to IPMs, and whether tumor- versus surgery-related IPMs differ in LR or overall survival (OS). METHODS: Retrospective review of a tertiary center database identified patients with IPMs following STS resection between 1989 and 2014. Of 2234 resected STSs, 309 (13%) had positive margins; 89 (4%) were IPMs. Mean follow-up was 52 months, mean tumor size was 9.2 cm, and 55% were high grade. Cases were categorized as surgery-related (67, 75%) or tumor-related (22, 25%). RESULTS: There was a significant difference in positive margin location, with the deep margin commonly involved in surgery-related IPMs (55% vs. 9%; p < 0.001). Tissue type also differed (p = 0.01), with surgery-related IPMs frequently in muscle (33%), while tumor-related IPMs favored subcutaneous tissues (41%). STSs with surgery-related IPMs were larger (p = 0.01). Histologic subtypes differed (p = 0.02), with myxofibrosarcoma and undifferentiated pleomorphic sarcoma/malignant fibrous histiocytoma predominating in tumor-related IPMs (82%). The cumulative probability of LR after IPMs, with death as a competing risk, was 28% (95% confidence interval [CI] 18-35) at 5 years and 37% (95% CI 24-45) at 10 years. Mortality was 28% (95% CI 18-38) at 5 years and 38% (26-50) at 10 years. There was no difference in LR (p = 0.91) or OS (p = 0.44) between surgery- and tumor-related IPMS. CONCLUSIONS: IPMs after STS resection results in substantial LR risk. While demonstrating distinct surgery- and tumor-related contributions, there was no between-group difference in LR or OS. These results may aid in avoiding IPMs. LEVEL OF EVIDENCE: Therapeutic Level III, retrospective comparative study.

Can a Made-for-Consumer Activity Monitor Assess Physical Activity in Adolescents and Young Adults After Lower Extremity Limb Salvage for Osseous Tumors?

BACKGROUND: The purpose of this study was to test the validity of a consumer-oriented activity monitor in adolescents and young adults undergoing limb salvage for primary bone malignancies. METHODS: A cross-sectional population of participants with an average age of 16 (range 12 to 22) years produced 472 days of activity monitoring during 25 evaluations periods alongside patient-reported outcome measures. RESULTS: Average daily steps ranged from 557 to 12,756 (mean=4711) and was moderately associated with the short-form (SF) 36 physical component subscale (r=0.46, P=0.04) as well as the SF6D health state utility measure (r=0.48, P=0.04), but not the SF36 mental component subscale (P=0.66) or Toronto extremity salvage score (P=0.07). Time from surgery was strongly correlated with average daily steps (r=0.7, P<0.001). CONCLUSIONS: A made-for-consumer activity monitor provided real-world data regarding the outcome of adolescent and young adult limb salvage, and evidence of validity in this population. Such lower cost, user-friendly devices may facilitate assessment of free-living activity and allow novel comparisons of treatment strategies. LEVEL OF EVIDENCE: Level II-diagnostic.