Unplanned excision of soft tissue sarcoma: does it impact the accuracy of intra-operative pathologic assessment at time of re-excision?

PURPOSE: An "unplanned excision" refers to soft tissue sarcomas excised without planning imaging studies and a diagnostic biopsy, resulting in the presence of residual disease and usually necessitating a re-excision procedure. We aimed to assess the impact of previous unplanned excisions on the intra-operative pathologic assessment at the time of re-excision, in terms of need to perform repeat assessments and the accuracy to predict margin status of the final pathologic specimen. METHODS: Data was collected for all patients with extremity soft tissue sarcoma who had undergone wide local excision limb salvage surgery or amputation between 2012 and 2017. Intra-operative pathologic assessment with frozen sections was performed in all cases and was classified as negative, negative but close (< 1 mm), and positive. RESULTS: A total of 173 patients with extremity soft tissue sarcoma were included, 54 in the unplanned excision group and 119 in the planned excision group. The accuracy of intra-operative pathologic assessment to predict the margin status on final pathology was similar between groups (87% unplanned vs. 90.7% planned excisions). However, the need for repeat intra-operative pathologic assessment and subsequent resection due to microscopically positive margins was found to be higher within the unplanned excision group ((p = 0.04), OR = 3.2 (95% CI: 1.1-9.1, p = 0.048)). CONCLUSIONS: Intra-operative pathologic assessment of resection margins had a similar accuracy in planned and unplanned excisions; however, unplanned excisions showed a higher risk of re-resection during the same surgical setting.

Molecular profile of ultrastructure changes of the ligamentum flavum related to lumbar spinal canal stenosis.

Lumbar spinal canal stenosis (LSCS) is a degenerative disease observed by hypertrophy of the ligamentum flavum (LF) that cause compression of the lumbar neural content. Diabetes mellitus (DM) is a risk factor for the disease and we have shown previously that DM increases the fibrosis and elastic fiber loss in patients with LSCS. The purpose of this study was to find the proteins that play a role in the development of this clinical pathogenesis and the effect of DM on protein expression. LF tissue retrieved from patients diagnosed with LSCS, some were also diagnosed with DM, were compared with LF from patients diagnosed with herniated nucleus pulposus (HNP). The tissues were analyzed by mass spectrometry for proteins profile alteration. We found that LF of LSCS/DM patients exhibited significantly higher levels of proteoglycan proteins and latent transforming growth factor ß-binding protein (LTBP2 and LTBP4). Additionally, an increase of HTRA serine protease 1 and insulin-like growth factor binding protein-5 were noted. The higher fibrosis was also associated with proteins related to inflammation and slower tissue repair. Collagen 6 and transforming growth factor inhibitor are related to activation of the anti-inflammatory M2 pathway that is associated with tissue repair. The decrease of these proteins expression in LSCS/DM is associated with increased levels and activation of M1 pro-inflammatory pathways. Interestingly, C3 and C4b members of the complement complex and mannose receptor-like protein (CLEC18) paralogous proteins were detectable solely at the LSCS/DM patients' samples. Histology analysis shows that inflammatory was induced by the hyperglycemic conditions in diabetic patients involve in altering the matrix compositions. Thus, the protein profiles associated with inflammatory pathways affecting the LF suggested increasing susceptibility of developing the degeneration under hyperglycemic conditions.

Surgical treatment of low-grade chondrosarcoma involving the appendicular skeleton: long-term functional and oncological outcomes.

BACKGROUND: The traditional treatment for chondrosarcoma is wide local excision (WLE), as these tumors are resistant to chemotherapy and radiation treatment. While achieving negative margins has traditionally been the goal of chondrosarcoma resection, multiple studies have demonstrated good short-term results after intralesional procedures for low-grade chondrosarcomas (LGCS) with curettage and adjuvant treatments (phenol application, cauterization or cryotherapy) followed by either cementation or bone grafting. Due to the rarity of this diagnosis and the recent application of this surgical treatment modality to chondrosarcoma, most of the information regarding treatment outcomes is retrospective, with short or intermediate-term follow-up. The aim of this study was to assess the long-term results of patients with LGCS of bone treated with intralesional curettage (IC) treatment versus WLE. This retrospective analysis aims to characterize the oncologic outcomes (local recurrence, metastases) and functional outcomes in these two treatment groups at a single institution. METHODS: Using an institutional musculoskeletal oncologic database, we retrospectively reviewed medical records of all patients with LGCS of the appendicular skeleton that underwent surgical treatment between 1985 and 2007. Thirty-two patients (33 tumors) were identified with LGCS; 17 treated with IC and 15 with WLE. RESULTS: Seventeen patients (18 tumors) with a minimum clinical and radiologic follow-up of 10 years were included. Nine patients were treated with IC (four with no adjuvant, three with additional phenol, one with liquid nitrogen and one with H2O2) with either bone graft or cement augmentation, and nine others were treated with WLE and reconstruction with intercalary/osteoarticular allograft or megaprosthesis. The mean age at surgery was 41 years (range 14-66 years) with no difference (p = 0.51) between treatment cohorts. There was a mean follow-up of 13.5 years in the intralesional cohort (range 10-19 years) and 15.9 years in the WLE cohort (range 10-28 years, p = 0.36). Tumor size varied significantly between groups and was larger in patients treated with WLE (8.2 ± 3.1 cm versus 5.4 ± 1.2 cm, at the greatest dimension, p = 0.021). There were two local recurrences (LR), one in the intralesional group and one in the wide local excision group, occurring at 3.5 months and 2.9 years, respectively, and both required revision. No further LR could be detected with long-term follow-up. The MSTS score at final follow-up was significantly higher for patients managed with intralesional procedures (28.7 ± 1.7 versus 25.7 ± 3.4, p = 0.033). There were less complications requiring reoperation in the intralesional group compared with the wide local excision group, although this difference was not found to be statistically significant (one versus four patients, respectively; p = 0.3). CONCLUSION: This series of low-grade chondrosarcoma, surgically treated with an intralesional procedures, with 10-year follow-up, demonstrates excellent local control (88.9%). Complications were infrequent and minor and MSTS functional scores were excellent. Wide resection of LGCS was associated with lower MSTS score and more complications. In our series, the LR in both groups were detected within the first 3.5 years following the index procedure, and none were detected in the late surveillance period.

Trochanteric Bursitis Following Primary Total Hip Arthroplasty: Incidence, Predictors, and Treatment.

BACKGROUND: Trochanteric bursitis (TB) remains a common complication after total hip arthroplasty (THA), with an incidence between 3% and 17%, depending on the surgical approach, with the posterior approach (PA) being relatively protective compared to the lateral approach. The purposes of this study were to determine the incidence of TB after primary THA, identify potential risk factors for TB, and examine the utility of different modes of treatment. METHODS: Retrospective cohort data of 990 primary THAs performed in a single institution, including 613 PAs and 377 direct anterior approaches (DAAs), were analyzed. Data abstracted included demographic data, operative diagnosis, comorbidities, radiographic assessment, and other specific predictors of interest that were compared between patients diagnosed with TB following THA and controls. RESULTS: The incidence of TB following primary THA was 5.4% (54/990) for the entire cohort. The incidence did not differ significantly between the PA and DAA (5% vs 6.1%, respectively; P = .47). Charlson comorbidity index and American Society of Anesthesiology did not differ significantly in the TB group. Lumbar spinal stenosis and history of past smoking were significantly more common in patients who developed TB (P = .03, P = .01, respectively), but did not continue to be significant risk factors on multivariate analysis. All patients were treated nonoperatively by the time of final follow-up. Seventy-four percent required a local steroid injection and 30% required treatment with more than one modality. CONCLUSION: The occurrence of TB is not influenced by the surgical approach (PA or DAA), and could not be predicted by specific comorbidities or radiographic measurements. However, it can be effectively treated conservatively in most cases.

F-18 FDG PET differentiation of benign from malignant chondroid neoplasms: a systematic review of the literature.

INTRODUCTION: Discriminating among benign chondroid tumors, low-grade chondrosarcomas, and grade 2/3 chondrosarcomas is frequently difficult with standard imaging modalities. We systematically reviewed the literature to determine the performance of PET-CT in making this distinction. METHODS: A systematic review was performed identifying 811 PubMed- and Embase-indexed articles containing combinations of "chondrosarcoma," "enchondroma," "chondroid," "cartilage" and "PET/CT," "PET," "positron." Eight articles including 166 lesions were included. Age, gender, tumor size, histologic grade, and SUVmax values were extracted for individual lesions when possible and otherwise recorded as aggregated data. Comparisons in SUVmax among benign, low-grade, and intermediate-/high-grade chondroid neoplasms were made. RESULTS: Individual SUVs were available for 101 lesions; 65 additional lesions were reported as aggregated data. There were 101 malignant and 65 benign tumors. Benign tumors were seen more frequently in females (p = 0.04, Fischer's exact test), but malignancy was not associated with age or lesion size. SUVmax was lower for benign (1.6 ± 0.7) than malignant tumors (4.4 ± 2.5) (p < 0.0001, t-test). SUVmax was lower for grade 0/1 (2.0 ± 0.7) than grade 2/3 (6.0 ± 3.2) (p < 0.0001, t-test). Increasing SUVmax correlated with higher grade chondroid tumors (Spearman's rank, ρ = 0.78). SUVmax ≥4.4 was 99% specific for grade 2/3 chondrosarcoma. CONCLUSIONS: SUVmax correlates with histologic grade in intraosseous chondroid neoplasms; very low SUVmax supports a diagnosis of benign tumor, while elevated SUVmax is suggestive of higher grade chondrosarcoma.

The Accuracy of Digital Templating for Primary Total Hip Arthroplasty: Is There a Difference Between Direct Anterior and Posterior Approaches?

BACKGROUND: The direct anterior approach (DAA) has gained recent popularity for total hip arthroplasty (THA), as it provides immediate feedback on cup position and limb length using fluoroscopy. The purpose of this study is to evaluate any differences in the accuracy of digital templating for preoperative planning of THA, performed with 2 different surgical approaches: DAA using a radiolucent table with intraoperative fluoroscopy and the posterior approach (PA). METHODS: One hundred thirty-one consecutive patients (148 hips) underwent a THA by a single surgeon, using the same cup and stem designs. Seventy-five hips were performed using the DAA using a fracture table and fluoroscopy. Seventy-three hips were performed using the PA with the patient positioned in lateral decubitus using standard positioners without fluoroscopy. Preoperative radiographs were digitally templated by the same surgeon. RESULTS: The PA patients had a higher mean body mass index and were more likely to have a preoperative diagnosis of avascular necrosis. The accuracy of templating for predicting the cup size to be within 2 mm was 91% for DAA vs 88% for PA (P = .61). For stem size, the accuracy was 85% (to within 1 size) for the DAA vs 77% for the PA (P = .71). Likewise, there was no significant difference in predicting the final stem's neck angle or femoral offset. CONCLUSION: Digital templating was found to be a reliable and highly accurate method for predicting component sizes and offset for THA, regardless of using either the PA or the DAA with fluoroscopy.

Computer-assisted total knee arthroplasty marketing and patient education: an evaluation of quality, content and accuracy of related websites.

BACKGROUND: The internet is increasingly being used as a resource for health-related information by the general public. We sought to establish the authorship, content and accuracy of the information available online regarding computer-assisted total knee arthroplasty (CA-TKA). METHODS: One hundred fifty search results from three leading search engines available online (Google, Yahoo!, Bing) from ten different countries worldwide were reviewed. RESULTS: While private physicians/groups authored 50.7 % of the websites, only 17.3 % were authored by a hospital/university. As compared to traditional TKA, 59.3 % of the websites claimed that navigated TKA offers better longevity, 46.6 % claimed accelerated recovery and 26 % claimed fewer complications. Only 11.3 % mentioned the prolonged operating room time required, and only 15.3 % noted the current lack of long-term evidence in support of this technology. CONCLUSIONS: Patients seeking information regarding CA-TKA through the major search engines are likely to encounter websites presenting a narrow, unscientific, viewpoint of the present technology, putting emphasis on unsubstantiated benefits while disregarding potential drawbacks. LEVEL OF EVIDENCE: Survey of Materials-Internet.

Preoperative Pain Catastrophizing and Neuropathic Pain Do Not Predict Length of Stay and Early Post-Operative Complications following Total Joint Arthroplasty.

BACKGROUND: Both pain catastrophizing and neuropathic pain have been suggested as prospective risk factors for poor postoperative pain outcomes in total joint arthroplasty (TJA). OBJECTIVE: We hypothesized that pain catastrophizers, as well as patients with pain characterized as neuropathic, would exhibit higher pain scores, higher early complication rates and longer lengths of stay following primary TJA. METHODS: A prospective, observational study in a single academic institution included 100 patients with end-stage hip or knee osteoarthritis scheduled for TJA. In pre-surgery, measures of health status, socio-demographics, opioid use, neuropathic pain (PainDETECT), pain catastrophizing (PCS), pain at rest and pain during activity (WOMAC pain items) were collected. The primary outcome measure was the length of stay (LOS) and secondary measures were the discharge destinations, early postoperative complications, readmissions, visual analog scale (VAS) levels and distances walked during the hospital stay. RESULTS: The prevalence of pain catastrophizing (PCS ≥ 30) and neuropathic pain (PainDETECT ≥ 19) was 45% and 20.4%, respectively. Preoperative PCS correlated positively with PainDETECT (rs = 0.501, p = 0.001). The WOMAC positively correlated more strongly with PCS (rs = 0.512 p = 0.01) than with PainDETECT (rs = 0.329 p = 0.038). Neither PCS nor PainDETECT correlated with the LOS. Using multivariate regression analysis, a history of chronic pain medication use was found to predict early postoperative complications (OR 38.1, p = 0.47, CI 1.047-1386.1). There were no differences in the remaining secondary outcomes. CONCLUSIONS: Both PCS and PainDETECT were found to be poor predictors of postoperative pain, LOS and other immediate postoperative outcomes following TJA.

Novel technique for intraoperative sciatic nerve assessment in complex primary total hip arthroplasty: a pilot study.

INTRODUCTION: Sciatic nerve injury (SNI) is a potentially devastating complication after total hip arthroplasty (THA). Intraoperative neural monitoring has been found in several studies to be useful in preventing SNI, but can be difficult to implement. In this study, we examine the results of using a handheld nerve stimulator for intraoperative sciatic nerve (SN) monitoring during complex THA requiring limb lengthening and/or significant manipulation of the SN. METHODS: A consecutive series of 11 cases (9 patients, 11 hips) with either severe developmental dysplasia of the hip (Crowe 3-4) or other underlying conditions requiring complex hip reconstruction involving significant leg lengthening and/or nerve manipulation. SN function was monitored intraoperatively by obtaining pre- and post-reduction thresholds during component trialing. The results of nerve stimulation were then used to influence intraoperative decision-making. RESULTS: No permanent postoperative SN complications occurred, with an average increase of 28.5 mm in limb length, range (6-51 mm). In 2 out of 11 cases, a change in nerve response was identified after trial reduction, which resulted in an alternate surgical plan (femoral shortening osteotomy and downsizing femoral head). In the remaining cases, the stimulator demonstrated a response consistent with the baseline assessment, assuring that the appropriate lengthening was achieved without SNI. 1 patient had a transient motor and sensory peroneal nerve palsy, which resolved within 2 weeks. CONCLUSIONS: The intraoperative use of a handheld nerve stimulator facilitates surgical decision-making and can potentially prevent SNI. The real-time assessment of nerve function allows immediate corrective action to be taken before nerve injury occurs.