Treatment Monitoring of a Patient with Synchronous Metastatic Angiosarcoma and Breast Cancer Using ctDNA.

Angiosarcoma is a rare and aggressive type of soft-tissue sarcoma with high propensity to metastasize. For patients with metastatic angiosarcoma, prognosis is dismal and treatment options are limited. To improve the outcomes, identifying patients with poor treatment response at an earlier stage is imperative, enabling alternative therapy. Consequently, there is a need for improved methods and biomarkers for treatment monitoring. Quantification of circulating tumor-DNA (ctDNA) is a promising approach for patient-specific monitoring of treatment response. In this case report, we demonstrate that quantification of ctDNA using SiMSen-Seq was successfully utilized to monitor a patient with metastatic angiosarcoma. By quantifying ctDNA levels using 25 patient-specific mutations in blood plasma throughout surgery and palliative chemotherapy, we predicted the outcome and monitored the clinical response to treatment. This was accomplished despite the additional complexity of the patient having a synchronous breast cancer. The levels of ctDNA showed a superior correlation to the clinical outcome compared with the radiological evaluations. Our data propose a promising approach for personalized biomarker analysis to monitor treatment in angiosarcomas, with potential applicability to other cancers and for patients with synchronous malignancies.

Incidence and Risk Factors for Surgical Site Infection in Ankle Fractures: An Observational Study of 480 Patients in Sweden.

INTRODUCTION: Surgical site infection (SSI) is a frequently reported complication after ankle fracture surgery. To our knowledge, no study has been conducted on its incidence in Sweden. The present study aimed to determine the incidence of, risk factors for, and most common causative pathogen of SSI. METHODS: Patients who underwent primary surgery for an ankle fracture between 1 September 2017 and 31 August 2019 at the Sahlgrenska University Hospital were identified. Data on potential SSI risk factors and clinical outcome (infected/non-infected) were retrieved from medical records. Cox regression analysis and descriptive statistics were used. RESULTS: Of the 480 reviewed patients, 49 developed SSI (10.2%), of which 35 (7.3%) were superficial and 14 (2.9%) were deep. Open fractures (p < 0.001) and age (p = 0.016) were statistically significant risk factors for SSI in the univariate analysis. In the multivariable analysis, only open fracture was statistically significant (HR = 3.0; 95% C.I. = 1.3-6.9, p = 0.013). Cases of Staphylococcus aureus (S. aureus) were most common (n = 12, 24.5%). Methicillin resistance was uncommon (n = 2, 4.1%). CONCLUSIONS: An incidence of 10.2% was established, which is comparable to international findings. Infection monitoring is an important part of tackling the global challenge of antibiotic resistance. Future prospective studies to further establish risk factors are warranted to decrease the incidence of SSI.

High Risk for Persistent Peri-Prosthetic Infection and Amputation in Mega-Prosthesis Reconstruction.

A peri-prosthetic joint infection is a feared complication after mega-prosthesis reconstruction of large bone defects. The current study investigates how patients operated with a mega-prosthesis due to sarcoma, metastasis, or trauma, are affected by a deep infection focusing on re-operations, risk for persistent infection, arthrodesis, or subsequent amputation. Time to infection, causative bacterial strains, mode of treatment and length of hospital stay are also reported. A total of 114 patients with 116 prostheses were evaluated, a median of 7.6 years (range 3.8-13.7) after surgery, of which 35 (30%) were re-operated due to a peri-prosthetic infection. Of the infected patients, the prosthesis was still in place in 51%, 37% were amputated, and 9% had an arthrodesis. The infection was persistent in 26% of the infected patients at follow-up. The mean total length of hospital stay was 68 (median 60) days and the mean number of reoperations was 8.9 (median 6.0). The mean length of antibiotic treatment was 340 days (median 183). Coagulase-negative staphylococci and Staphylococcus aureus were the most frequent bacterial agents isolated in deep cultures. No MRSA- or ESBL-producing Enterobacterales were found but vancomycin-resistant Enterococcus faecium was isolated in one patient. In summary, there is a high risk for peri-prosthetic infection in mega-prostheses, resulting in persistent infection or amputation relatively often.

Age, sex, primary tumor type and site are associated with mortality after pathological fractures: an observational study of 1453 patients from the Swedish Fracture Register.

BACKGROUND: Pathological fractures are challenging in orthopedic surgery and oncology, with implications for the patient's quality of life, mobility and mortality. The efficacy of oncological treatment on life expectancy for cancer patients has improved, but the metastatic pattern for bone metastases and survival is diverse for different tumor types. This study aimed to evaluate survival in relation to age, sex, primary tumor and site of the pathological fractures. METHODS: All pathological fractures due to cancer between 1 September 2014 and 31 December 2021 were included in this observational study from the Swedish Fracture Register (SFR). Data on age, sex, tumor type, fracture site and mortality were collected. RESULTS: A total of 1453 patients with pathological fractures were included (48% women, median age 73, range 18-100 years). Unknown primary tumors were the most common primary site (n = 308). The lower extremities were the most common site of pathological fractures. Lung cancer had the shortest median survival of 78 days (range 54-102), and multiple myeloma had the longest median survival of 432 days (range 232-629). The site at the lower extremity had the shortest (187 days, range 162-212), and the spine had the longest survival (386 days, range 211-561). Age, sex, primary type and site of the pathological fractures were all associated with mortality. INTERPRETATION: Age, sex, primary tumor type and site of pathological fractures were associated with survival. Survival time is short and correlated with primary tumor type, with lung cancer as the strongest negative predictor of survival.

Epidemiology of more than 50,000 ankle fractures in the Swedish Fracture Register during a period of 10 years.

BACKGROUND: Despite being one of the most common types of fracture, there is a lack of epidemiological studies involving ankle fractures of all kinds. Since 2012, the Swedish Fracture Register (SFR) has prospectively collected data on surgically and non-surgically treated ankle fractures. The aim of this study is to describe the epidemiology of ankle fractures between 2012 and 2022. METHODS: All ankle fractures registered in the SFR between 1 April 2012 and 31 March 2022 in patients aged 16 years or older were included. Information on age, sex, mechanism of injury, fracture classification according to AO/OTA and high- or low-energy trauma was retrieved from the SFR. RESULTS: During the study period, 56,439 patients sustained 57,443 ankle fractures. Women (61%) were more commonly affected than men (39%). The mean age at the time of injury was 55 years. Men were found to be younger at the time of injury compared with women. Women were found to sustain open fractures more frequently, whereas the men more frequently sustained high-energy trauma. The most common mechanism of injury for all ankle fractures and for each AO/OTA44 fracture group separately was a simple fall. A seasonal variation in ankle fractures was found, where the number of ankle fractures peaked during the between November and March. CONCLUSIONS: This study presents the epidemiology of all AO/OTA types of ankle fractures. We have demonstrated that most ankle fractures are caused by a simple fall and occur during wintertime. Women are more commonly affected than men and are older at the time of injury. These findings indicate that age-related skeletal fragility, as well as an increasing risk of simple falls in the elderly, may be risk factors for ankle fractures. This study will contribute to the planning of primary prevention for ankle fractures.

The Swedish Fracture Register - ten years of experience and 600,000 fractures collected in a National Quality Register.

BACKGROUND: Before the creation of the Swedish Fracture Register (SFR), there was no national quality register that prospectively collects data regarding all types of fractures regardless of treatment in an emergency setting. Observational data on fractures registered in a sustainable way may provide invaluable tools for quality improvements in health care and research. DESCRIPTION: Ten years after its implementation, the Swedish Fracture Register has 100% coverage among orthopaedic and trauma departments in Sweden. The completeness of registrations reached in 2020 69-96% for hip fractures at the different departments, with the majority reporting a completeness above 85%. The Swedish Fracture Register is a fully web-based national quality register created and run by orthopaedic professionals, with financial support from public healthcare providers and the government. All users have full access to both the registration platform and all aggregated statistics in real time. The web-based platform was created for use in health quality registers and it has easily gained acceptance among users. The register has gradually developed by the addition of more fracture types and skeletal parts. Research activity is high and 31 scientific publications have been published since 2016. The strategy from the start was to publish validation data and basic epidemiological data. However, over the past few years, publications on outcomes, such as re-operations and mortality, have been published and four register-based, randomised, controlled trials are ongoing. CONCLUSION: It is possible to create a fracture register, to gain professional acceptance and to collect fracture data in a sustainable way on a national level if the platform is easy to use. Such a platform can also be used as a randomisation platform for prospective studies.

The risk for complications and reoperations with the use of mega prostheses in bone reconstructions.

BACKGROUND: Despite a relatively high risk for complications and reoperations, mega prostheses are considered a useful method for reconstruction of bone defects after tumour resections. The total number of reoperations has not previously been described, and little is known about the complication rate of mega prostheses used for other indications than primary bone tumours. QUESTIONS/PURPOSES: The current retrospective observational study aimed to describe the patient population treated with mega prostheses at Sahlgrenska University Hospital, Sweden, during 14 consecutive years, reports the complications leading to reoperation and the number and type of reoperations for different kinds of complications, and reports on implant survival. METHODS: All patients treated with a mega prosthesis, regardless of surgical indication and anatomical location, at Sahlgrenska University Hospital during the period 2006-2019 were identified. The medical records for all patients were reviewed. Data regarding age, sex, diagnosis, site of disease, bone resection length, chemotherapeutical treatment and postoperative complications including infections and oncological outcome, were collected and evaluated. RESULTS: One hundred and fourteen patients treated with 116 mega prostheses were included in the study. The predominant indication for primary surgery with a mega prosthesis was sarcoma of either bone or soft tissue (53.5% of the patients). In total 51 prostheses (44%) did not require any reoperation after the primary surgery. The most common reason for reoperation was infection (22%) followed by soft tissue failure (13%). The risk for prosthetic infection was significantly higher in the group of patients operated due to sarcoma compared with all other indications for surgery regardless of surgical site (p = 0.004). CONCLUSION: The study reveals a total reoperation rate of 56% after reconstructive surgery using mega prostheses. Despite the high reoperation rates, at the end of the study period, 83% of the patients had still a functioning prosthesis. Therefore, the use of mega prostheses can be considered a reliable method for reconstruction of large bone defects in selected patients. LEVEL OF EVIDENCE: Level IV, therapeutic study.

No change in reoperation rates despite shifting treatment trends: a population-based study of 4,070 proximal humeral fractures.

Background and purpose - Clear and acknowledged treatment algorithms for proximal humeral fractures (PHFs) are lacking. Nevertheless, a change in treatment trends, including a change towards more reversed shoulder arthroplasties (RSA), has been observed during recent years. We examined the effect of these changes on reoperation rates.Patients and methods - Between 2011 and 2017, 4,070 PHFs treated at Sahlgrenska University Hospital were registered prospectively in the Swedish Fracture Register (SFR) and followed up until 2019 (mean follow-up of 4.5 years). Data on all reoperations were gathered from the SFR and from medical records.Results - The majority of PHFs were treated non-surgically and the proportion increased slightly, but not statistically significantly, during the study period (from 76% to 79%). Of the surgically treated fractures, the proportion fixed with a plate decreased from 47% to 25%, while the use of RSA increased 9-fold (from 2.0% to 19%). 221 patients underwent 302 reoperations. For those primarily treated surgically, the reoperation rate was 17%. Among treatment modalities, plate fixation was associated with the highest reoperation rate (21%). Rate of reoperations remained constant during the study period, both for the entire study cohort and for the surgically treated patientsInterpretation - During the study period, treatment changes that are in accordance with recently published treatment recommendations were observed. However, these treatment changes did not affect the reoperation rate. Treatment with a plate, intramedullary nail, or hemiarthroplasty was associated with the highest reoperation rates. The fact that almost every 4th surgical procedure was a reoperation indicates a need for further improvement of modern treatment concepts for PHFs.

Treatment and re-operation rates in one thousand and three hundred tibial fractures from the Swedish Fracture Register.

PURPOSE: Approximately, 50 persons per 100,000 per year sustain a tibial fracture. There is, however, a lack of large cohort studies that describe the treatment and re-operation frequencies of tibial fractures. The aim of this study was to describe the treatment and re-operation rates of tibial fractures in all segments of the tibia. METHODS: Data related to all patients aged 16 and above treated for tibial fractures (ICD-10 S82.10-31) at Sahlgrenska University Hospital in 2011-2015 were extracted from the Swedish Fracture Register. To make sure all re-operations were included in the study, the operation planning system was checked for all patients included in the study. RESULTS: The study comprised 1371 tibial fractures - 712 proximal, 417 diaphyseal and 242 distal tibial fractures. Among the proximal and distal tibial fractures, plate fixation was the most commonly used surgical method, whereas among tibial shaft fractures, an intramedullary nail was the most commonly used surgical method. Almost 30% (29.8%) of all surgically treated tibial fractures underwent re-operation. Among proximal tibial fractures, 24.0% underwent re-operation; tibial shaft fractures 37.0% and distal tibial fractures 26.8%. Re-operations due to infection were more or less equally common in all segments (3.9-5.4%). CONCLUSION: This study describes the treatment and re-operation rates after tibial fractures in a cohort of 1371 tibial fractures at Sahlgrenska University Hospital during a period of 5 years. The study shows an overall re-operation rate of 29.8% for fractures in all segments of the tibia.

The Swedish fracture register: 103,000 fractures registered.

BACKGROUND: Although fractures consume large social and financial resources, little is known about their actual numbers, treatment methods or outcomes. The scarcity of data calls for a high-quality, population-based register. No previous registers have prospectively collected data and patient-reported outcome measures (PROMs) on fractures of all types. The Swedish Fracture Register was recently created to fill this gap in knowledge. Its purpose is to provide information on fractures of all types, whether treated by surgery or otherwise. The aim of this article is to describe how the register was developed and its current use. DESCRIPTION: The Swedish Fracture Register was developed during a 4-year period, 2007-2010. Data collection started in 2011. The register currently collects data on all extremity, pelvic and spine fractures in adults who have been diagnosed or treated at the affiliated departments. Data entry is fully web based, including date, cause of injury, classification and treatment. It is performed by the attending physician. Patients fill out PROMs - EQ-5D-3L and the Short Musculoskeletal Function Assessment (SMFA) - relating to health status and level of functioning before the fracture and one year later. Surgeon-reported outcome measures are registered as reoperation rates. The Swedish Fracture Register is now functioning effectively and is used in clinical routine. From January 2011 to September 2015, more than 103,000 fractures have been entered at 26 Swedish orthopedic departments. CONCLUSIONS: The Swedish Fracture Register is already a well-functioning, population-based fracture register that covers fractures of all types, regardless of treatment, and collects both surgeon- and patient-reported outcome measures. In the future the Swedish Fracture Register will be able to present both results of fracture treatment and valuable epidemiological data.