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.

The Impact of the COVID-19 2020 Pandemic on Hospital Length of Stay Following Fragility Hip Fracture Surgery.

BACKGROUND: Hip fractures in elderly patients are a major cause of morbidity and mortality. Variability in length of hospital stay (LOS) was evident in this population. The coronavirus disease-2019 (COVID-19) pandemic led to prompt discharge of effected patients in order to reduce contagion risk. LOS and discharge destination in COVID-19 negative patients has not been studied. OBJECTIVES: To evaluate the LOS and discharge destination during the COVID-19 outbreak and compare it with a similar cohort in preceding years. METHODS: A retrospective study was conducted comparing a total of 182 consecutive fragility hip fracture patients operated on during the first COVID-19 outbreak to patients operated on in 2 preceding years. Data regarding demographic, co-morbidities, surgical management, hospitalization, as well as surgical and medical complications were retrieved from electronic charts. RESULTS: During the pandemic 67 fragility hip fracture patients were admitted (COVID group); 55 and 60 patients were admitted during the same time periods in 2017 and 2018, respectively (control groups). All groups were of similar age and gender. Patients in the COVID group had significantly shorter LOS (7.2 ± 3.3 vs. 8.9 ± 4.9 days, P = 0.008) and waiting time for a rehabilitation facility (7.2 ± 3.1 vs. 9.3 ± 4.9 days, P = 0.003), but greater prevalence of delirium (17.9% vs. 7% of patients, P = 0.028). In hospital mortality did not differ among groups. CONCLUSIONS: LOS and time to rehabilitation were significantly shorter in the COVID group. Delirium was more common in this group, possibly due to negative effects of social distancing.

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.

The Association Between Scholarly Impact and National Institutes of Health Funding in Orthopaedic Surgery.

The assessment of scholarly productivity assumes a strong role in evaluating faculty in academic orthopaedic surgery. The investigators examine the association between scholarly impact, as measured by the h-index, and National Institutes of Health (NIH) funding in orthopaedic surgery. Orthopaedic surgery faculty from 20 randomly chosen departments that received NIH-funding were compared to non-NIH funded faculty from the same departments. Faculty members in orthopaedic surgery departments who received NIH funding had higher scholarly impact as measured by h-index than their non-funded peers (h = 11.98 versus 4.45; p < 0.0001). This relationship holds across academic ranks, terminal degrees, and institutions. Investigators with higher academic rank had higher scholarly impact (h = assistant 3.29 versus associate 5.12 versus full professor 7.94; p < 1 x 10-7) as well as higher NIH-funding (assistant $16,580 versus associate $26,368 versus full professor $113,129; p < 1 x 10-7). Increasing individual NIH funding is correlated with elevated scholarly impact (ß = 4.64; p < 0.0001). Increasing total departmental NIH funding is correlated to increased departmental scholarly impact (ß = 1.04; p < 0.0001). The h-index is strongly associated with NIH funding, academic rank, and sole PhD holding faculty. Increasing scholarly impact is also correlated with higher NIH funding. The h-index is an objective and easily calculable measure of assessing individual research productivity.