Association between preoperative anaemia and blood transfusion with long-term functional and quality of life outcomes amongst patients undergoing primary total knee arthroplasty in Singapore: a single-centre retrospective study.

PURPOSE: Preoperative anaemia affects up to one-third of patients undergoing total knee arthroplasty (TKA) and is associated with increased blood transfusion and prolonged hospitalisation. Prior studies have associated preoperative anaemia with poorer functional recovery after total hip arthroplasty. However, the association between preoperative anaemia and functional outcomes following TKA is unknown. We aim to determine whether preoperative anaemia and perioperative blood transfusion affect health-related quality of life (HRQoL) and functional outcomes following TKA. METHODS: Retrospective analysis of 1994 patients who underwent primary unilateral TKA from 2013 to 2014 was performed. Anaemia was defined according to the World Health Organisation definition. Baseline and 6-month postoperative HRQoL was assessed with the 36-Item Short Form Survey (SF-36), while function was assessed with Oxford Knee Score (OKS) and Knee Society Function Score (KSFS). Physical function (PF), role physical (RP), bodily pain (BP), social function (SF) and role emotional (RE) domains of SF-36, OKS and KSFS demonstrated significant change greater than the minimal clinically important difference between baseline and 6 months. Analysis of covariance (ANCOVA) was performed to identify predictors of 6-month scores. RESULTS: The incidence of preoperative anaemia was 22.3%. 4.3% of patients received blood transfusions. Preoperative anaemia and perioperative blood transfusion did not significantly affect SF-36, KSFS and OKS scores at 6 months postoperatively. Poor baseline SF-36, KSS and OKS scores and high BMI ≥ 37.5 kg/m2 are consistently associated with lower scores at 6 months. CONCLUSION: Preoperative anaemia and perioperative blood transfusion did not significantly affect HRQoL and functional outcomes following primary TKA. Poor baseline and obesity were associated with poorer outcomes.

Predicting individual knee range of motion, knee pain, and walking limitation outcomes following total knee arthroplasty.

Background and purpose - Up to 20% of patients are dissatisfied after total knee arthroplasty (TKA), mainly because of pain and restricted physical function. We developed a prediction model for 6-month knee range of motion, knee pain, and walking limitations in patients undergoing TKA surgery. Patients and methods - We performed a prospective cohort study of 4,026 patients who underwent elective, primary TKA between July 2013 and July 2017. Candidate predictors included demographic, clinical, psychosocial, and preoperative outcome measures. The outcomes of interest were (i) knee extension and flexion range of motion, (ii) knee pain rated on a 5-point ordinal scale, and (iii) self-reported maximum walk time at 6 months post TKA. For each outcome, we fitted a multivariable proportional odds regression model with bootstrap internal validation. Results - At 6 months post TKA, around 5% to 20% of patients had a flexion contracture ³ 10°, range of motion < 90°, moderate to severe knee pain, or a maximum walk time £â€¯15 minutes. The model c-indices (the probabilities to correctly discriminate between 2 patients with different levels of follow-up TKA outcomes) when evaluating these patients were 0.71, 0.79, 0.65, and 0.76, respectively. Each postoperative outcome was strongly influenced by the same outcome measure obtained preoperatively (all p-values < 0.001). Additional statistically significant predictors were age, sex, race, education level, diabetes mellitus, preoperative use of gait aids, contralateral knee pain, and psychological distress (all p-values < 0.001). Interpretation - We have developed models to predict, for individual patients, their likely post-TKA levels of knee extension and flexion range of motion, knee pain, and walking limitations. After external validation, they can potentially be used preoperatively to identify at-risk patients and to help patients set more realistic expectations about surgical outcomes.

Sacral chordoma: clinical experience of a series of 11 patients over 18 years.

Sacral chordoma are rare low-to-intermediate grade malignant tumours that occur most commonly within the sacrum. Sacrectomy with wide resection margins seems to offer the best long-term prognosis.  This study aims to review the management of sacral chordomas including the duration of symptoms, features, treatment, complications and local recurrence rate following surgery at a tertiary centre. We retrospectively reviewed 11 patients treated at our institution between years 1999 and 2015. Patient data included age, sex, history, radiographs, surgical details, onset of recurrence, subsequent treatment, disease-free survival and overall survival were analyzed. Nine patients underwent surgical management with 1 through a sacral approach and eight patients through a combined abdominosacral approach. Despite wide resection in our series, sacral chordoma poses a major problem with approximately 60% of patients having local recurrence in their follow-up.

Accelerometer-Based and Computer-Assisted Navigation in Total Knee Arthroplasty: A Reduction in Mechanical Axis Outliers Does Not Lead to Improvement in Functional Outcomes or Quality of Life When Compared to Conventional Total Knee Arthroplasty.

BACKGROUND: Accelerometer-based navigation (ABN) is a novel navigation system that attempts to combine the accuracy of computer-assisted surgery (CAS) with the familiarity of conventional instrumentation (CON). No studies have compared the clinical outcomes of this new technology with existing techniques to date. METHODS: From July 2013 to April 2014, 152 consecutive patients (152 knees) underwent total knee arthroplasty using ABN (n = 38), CAS (n = 38), or CON (n = 76). We prospectively matched the groups in a 1:1:2 ratio for age, gender, body mass index, preoperative range of motion, Knee Society Score, Oxford Knee Score, Short-Form 36 Physical and Mental Component Scores, and preoperative deformity using preoperative data in isolation, thus controlling for potential confounding factors. All patients were prospectively followed for 2 years. RESULTS: The ABN and CAS groups had a significantly improved mean mechanical axis (P = .018), femoral (P = .050) and tibial component alignment (P = .008) compared to the CON group. There were significantly less mechanical axis outliers in the ABN and CAS groups (P = .034). The duration of surgery for the ABN group (83.9 ± 21 min) was significantly shorter than the CAS group (101 ± 11 min; P < .001) but similar to the CON group (76.6 ± 17 min; P = .131). There was no significant difference in functional outcomes, quality of life measures or satisfaction rates between the 3 groups at 2 years (P > .05). CONCLUSION: Although bone cuts were as accurate as CAS and operation time was similar to CON, the use of ABN failed to demonstrate any advantages in clinical outcomes following total knee arthroplasty at 2 years follow-up.

Accelerometer-Based Navigation Is as Accurate as Optical Computer Navigation in Restoring the Joint Line and Mechanical Axis After Total Knee Arthroplasty: A Prospective Matched Study.

The Zimmer iASSIST system is a novel accelerometer-based navigation system for TKA. 76 patients (76 knees) were prospectively matched for age, BMI, gender, diagnosis, and pre-operative scores, and underwent TKA using the iASSIST (n=38) or optical CAS (n=38). There were no significant differences in clinical outcomes or satisfaction rates at six months post-operatively (P>0.05). Mechanical axis was 1.8±1.3° in the iASSIST cohort versus 2.1±1.6° in the CAS cohort (P=0.543). There were no significant differences in number of outliers for mechanical axis (P=1.000), coronal femoral-component angle (P=0.693), coronal tibial-component angle (P=0.204) or joint line deviation (P=1.000). The duration of surgery was significantly longer in the CAS group (P<0.001), while the added cost of accelerometer-based navigation was approximately $1000 per operation.

Joint line changes in cruciate-retaining versus posterior-stabilized computer-navigated total knee arthroplasty.

INTRODUCTION: This study compared joint line changes and functional outcomes between cruciate-retaining (CR) and posterior-stabilized (PS) computer-navigated total knee arthroplasties (TKAs). With the increased precision offered by computer navigation, we hypothesized that there should be minimal differences in the joint line changes between the groups and thus no significant differences in the clinical outcomes. MATERIALS AND METHODS: A retrospective study of 195 patients with a minimum of 2-year follow-up following primary surgery was conducted. The patients were stratified into two groups: the CR group and the PS group. The joint line changes of both groups were then compared using the Student t test. Multivariate analysis and regression modelling were then utilized to analyze the functional outcomes of both groups. RESULTS: CR knees had a significantly lesser mean joint line change of 1.70 mm as compared to 2.34 mm in PS knees (p = .04) but the absolute difference was only 0.64 mm. The PS group had significantly better final range of motion of 122° (±9.9°) as compared to 114° (±15.0°) in the CR group (p < .0001). There were no significant differences in the final outcome scores. CONCLUSION: Although there is a significant difference statistically in the joint line changes between the groups, this difference is less than 1 mm and probably has no significant clinical impact. This is further affirmed by the fact that there was no significant difference in the clinical outcomes. The increased range seen in PS knees is probably not related to joint line changes. LEVEL OF EVIDENCE: III.

Effect of implant length variations on stress shielding in proximal humeral replacement after tumor excision under torsion: Finite element study.

The proximal humerus is the most common site of occurrence of primary bone tumors in the upper limb. Endoprosthetic replacement is deemed as the preferred reconstructive option following primary resection of bone tumors. However, it has been also associated with complications such as stress shielding and aseptic loosening compromising prosthetic survival. Our objective was to conduct a finite element (FE) study to investigate the effect of varying endoprosthesis length on bone stresses as well as to quantify the extent of stress shielding across the bone length (BL) in a humerus-prosthesis assembly for proximal humeral replacement after tumor excision thereby allowing us to identify the optimal implant length with best biomechanical performance. FE models of the intact humerus and humerus-prosthesis assemblies were established where they were loaded at the elbow joint under torsion with the glenohumeral joint fixed to represent twisting. After dividing the bone into individual slices consisting of 5% BL, the maximum cortical and cancellous principal, von Mises and shear bone stresses were calculated. To measure the level of stress shielding, the percentage stress change from the intact state was evaluated across each slice. Similar stress patterns were observed between the intact state and shorter endoprosthesis compared to the longer endoprostheses. Our findings illustrated the possibility of stress shielding occurring under torsional forces with its effect increasing with implant lengthening. To conclude, we believe that using a shorter prosthesis may substantially diminish the risk of potential implant failure due to stress shielding.

Reduction of geometric misfit in straight antegrade humeral nailing by evaluating the effect of entry point angulation using a three-dimensional computational analysis.

BACKGROUND: Straight antegrade intramedullary nails are generally inserted utilising the apex as the surgical entry point in accordance with the mechanical axis of the bone. Our objective is to optimise the bone-nail fit in intramedullary nailing by subjecting the surgical entry point to varying angulations in both the mediolateral and anterior-posterior directions via a quantitative fit assessment in each configuration to identify the optimal angulation, defined as the angulation with the lowest occurrence of thin-out to improve nail fitting within the humerus. METHODS: Computed tomography (CT) scans from 10 cadaveric humeri models were used to generate three-dimensional bone models. The centreline profile of each humerus model was determined by dividing the humerus into multiple slices and identifying its respective centroid. The guidewire and nail models were then established and inserted into the humerus using the apex as the standard entry point. The bone-nail fit was measured utilising three fit quantification parameters: thin-out distance, nail protrusion volume into the cortical shell and deviation distance (top, middle, bottom) between the nail's longitudinal axis and medullary cavity centroid. FINDINGS: Results revealed a statistically significant association between angulation and occurrence of thin-out (p < .001) and showed that the optimally angulated entry point resulted in decreased cortical breach across the nail insertion depth compared to the standard entry point. INTERPRETATION: Our findings suggested that the current straight nail design may require further modifications to optimise the nail trajectory within the medullary canal by decreasing the bone-nail geometric mismatch to potentially maximise its working length.

Patterns of orthopaedic injury among hospitalised personal mobility device users and bicycle riders: a comparative study.

Introduction: Personal mobility devices (PMDs), such as electronic scooters or motorised bicycles, are efficient modes of transportation. Their recent popularity has also resulted in an increase in PMD-related injuries. We aimed to characterise and compare the nature of injuries sustained by PMD users and bicycle riders. Methods: This retrospective study compared injury patterns among PMD and bicycle users. 140 patients were admitted between November 2013 and September 2018. Parameters studied included patients' demographics (e.g. age, gender and body mass index), type of PMD, nature of injury, surgical intervention required, duration of hospitalisation and time off work. Results: Of 140 patients, 46 (32.9%) patients required treatment at the department of orthopaedic surgery. 19 patients were PMD users while 27 were bicycle riders. 16 (84.2%) patients with PMD-related injuries were men. PMD users were significantly younger (mean age 45 ± 15 years) when compared to bicycle riders (mean age 56 ± 17 years; P <0.05). A quarter (n = 5, 26.3%) of PMD users sustained open fractures and over half (n = 10, 52.6%) required surgical intervention. Among 27 bicycle users, 7.4% (n = 2) of patients sustained open fractures and 70.4% (n = 19) required surgical intervention. Both groups had comparable inpatient stay duration and time off work. Conclusion: PMD-related orthopaedic traumas are high-energy injuries, with higher rates of open fractures, when compared to bicycle injuries. In addition, PMD users are significantly younger and of economically viable age. Prolonged hospitalisation and time off work have socioeconomic implications. Caution should be exercised when using PMDs.

Lower socioeconomic status is associated with increased co-morbidity burden and independently associated with time to surgery, length of hospitalisation, and readmission rates of hip fracture patients.

This study examines the relationship between socioeconomic status, comorbidities, and clinical outcomes of hip fracture patients. Lower socioeconomic status is not only associated with poorer comorbidities but is also independently impacting surgical access and outcomes. This can be considered a "double setback" in the management of hip fractures. PURPOSE: The effect of socioeconomic status on hip fracture outcomes remains controversial. We examine the relationship between SES and patient comorbidity, care access, and clinical outcomes of surgically managed hip fracture patients. METHODS: Using healthcare payor status as a surrogate for SES, patients operated for fragility hip fractures between 2013 and 2016 were dichotomised based on payor status, namely private healthcare (PRIV) versus subsidised healthcare (SUB). PRIV patients were compared with SUB patients in terms of demographic data, ASA scores, co-morbidity burden (Charlson comorbidity index, CCI), time to surgery, length of acute hospitalisation, and 90-day readmission rates. RESULTS: A total of 145 patients in group PRIV and 1146 patients in group SUB were included. SUB patients had a higher mean Charlson Co-morbidity Index (CCI) (p = 0.01), a longer length of hospitalisation (p = 0.001), an increased delay in surgery (p = 0.005), and higher 90-day readmission rates (p = 0.013). Lower SES (p = 0.01), older age (p = 0.01), higher CCI (p < 0.01), and a higher American Society of Anaesthesiologists score (ASA) (p = 0.03) were predictive of time to surgery. Lower SES (p = 0.02) and higher CCI (p < 0.001) were predictive of the length of hospitalisation. Lower SES (p = 0.04) and higher CCI (p < 0.001) were predictive of 90-day readmission rates. CONCLUSIONS: Low SES is associated with higher CCI in surgically treated hip fracture patients. However, it is independently associated with slower access to surgery, a longer hospital stay, and higher readmission rates. Hence, lower SES, with its associated higher CCI and independent impact on surgical access and outcomes, can be considered a "double setback" in the management of fragility hip fractures.

Higher Charlson Comorbidity Index Increases 90-Day Readmission Rate with Poorer Functional Outcomes in Surgically Treated Hip Fracture Patients.

INTRODUCTION: The associated mortality and morbidity in hip fracture patients pose a major healthcare burden for ageing populations worldwide. We aim to analyse how an individual's comorbidity profile based on age-adjusted Charlson Comorbidity Index (CCI) may impact on functional outcomes and 90-day readmission rates after hip fracture surgery. MATERIALS AND METHODS: Surgically treated hip fracture patients between 2013 and 2016 were followed up for 1-year and assessed using Parker Mobility Score (PMS), EuroQol-5D (EQ-5D) and Physical and Mental Component Scores (PCS and MCS, respectively) of Short Form-36 (SF-36). Statistical analysis was done by categorising 444 patients into three groups based on their CCI: (1) CCI 0-3, (2) CCI 4-5 and (3) CCI ≥ 6. RESULTS: PMS, EQ-5D and SF-36 PCS were significantly different amongst the CCI groups pre-operatively and post-operatively at 3, 6 and 12 months (all P < 0.05), with CCI ≥ 6 predicting for poorer outcomes. In terms of 90-day readmission rates, patients who have been readmitted have poorer outcome scores. Multivariate analysis showed that high CCI scores and 90-day readmission rate both remained independent predictors of worse outcomes for SF-36 PCS, PMS and EQ-5D. DISCUSSION: CCI scores ≥6 predict for higher 90-day readmission rates, poorer quality of life and show poor potential for functional recovery 1-year post-operation in hip fracture patients. 90-day readmission rates are also independently associated with poorer functional outcomes. Peri-operatively, surgical teams should liaise with medical specialists to optimise patients' comorbidities and ensure their comorbidities remain well managed beyond hospital discharge to reduce readmission rates. With earlier identification of patient groups at risk of poorer functional outcomes, more planning can be directed towards appropriate management and subsequent rehabilitation. CONCLUSION: Further research should focus on development of a stratified, peri-operative multidisciplinary, hip-fracture care pathway treatment regime based on CCI scores to determine its effectiveness in improving functional outcomes.

Clinical and radiographic outcomes of computer-navigated total knee arthroplasty are not adversely affected by body mass index.

AIM: To study the effect of obesity on clinical and radiographic outcomes of computer-navigated knee arthroplasty. MATERIALS AND METHODS: 117 patients underwent primary computer-navigated total knee arthroplasty. Eight were lost to follow-up and 8 had incomplete data. RESULTS: Eighty-four (83.2%) female, 17 (16.8%) male patients age 65.3 ±â€¯6.9 years with a pre-operative BMI 27.2 ±â€¯4.1 (18.6-40.0) kg/m2, 7.3 ±â€¯0.98 years follow-up. Forty-two (41.6%) had a BMI>27.5 kg/m2 indicative of obesity in Singapore. Post-operative radiographic alignment, 2-year Oxford knee scores and ROM were not significantly associated with BMI. CONCLUSION: BMI is not a determinant of functional scores when computer navigation is used.

Serum albumin level predicts survival after surgical treatment of metastatic femur fractures: a retrospective study.

BACKGROUND: Surgical treatment for metastatic pathological femur fractures is associated with high mortality. Correct estimation of prognosis helps in determining the palliative value of surgical treatment and informs surgical decision. This study evaluates the risk factors for mortality in these patients who were surgically treated. METHODS: This is a retrospective study of 112 patients with surgical treatment of metastatic pathological femur fractures. Risk factors evaluated included age, ASA status, Charlson comorbidity index, preoperative serum albumin and haemoglobin, primary tumour site, presence of visceral metastases, presence of spinal metastases, time from diagnosis of cancer to occurrence of pathological fracture, type of surgical procedure performed, lesion and whether treatment was received for an actual or impending fracture. A Cox regression model was used to determine if these factors were independent significant factors for survival. RESULTS: Mortality at 2 years after surgical treatment of metastatic femoral fractures was 86%. Cox regression analysis of risk factors revealed that preoperative serum albumin and type primary tumour were independent risk factors for mortality. Presence of visceral metastases was strongly correlated to serum albumin levels. CONCLUSION: Preoperative serum albumin level and primary tumour site are independent risk factors of survival in patients treated for pathological femur fractures. Serum albumin level may be used as a prognostic tool to guide treatment in this cohort of patients with high mortality rates.

Side-to-side difference in joint position sense and kinesthesia in unilateral functional ankle instability.

BACKGROUND: Impairment in proprioception has been suggested to be one of the causes of FAI. This study aimed to establish intra-session reliability of the Biodex System 2 in assessing joint position sense (JPS) and kinesthesia (K)~in addition to determining if there was any side to side difference in JPS and kinesthesia in people with unilateral functional ankle instability. MATERIALS AND METHODS: Both JPS and K were determined by means of the Biodex Systems 2. During evaluation of JPS, participants' ability to actively reproduce ankle joint position was tested three times in each of the two predetermined positions. During evaluation of K, data collection began with the foot placed in a starting position of 0 degrees (neutral position). RESULTS: A total of 25 participants (mean age 22.0 years, 95% confidence interval 19.9 to 24.1 years) were recruited into this study. No difference in JPS (p = 0.162 to 0.764) and K (p = 0.089 to 0.683) were found between the sprained and uninvolved ankle of subjects with unilateral functional ankle instability. There is moderate to good intra-session reliability in using the Biodex System 2 to assess JPS (ICC = 0.868 to 0.950, p < 0.01) and K (ICC = 0.825 to 0.893, p < 0.01). CONCLUSION: This study suggests that there is perhaps no difference in JPS and K between both ankles in people with unilateral FAI. Proprioceptive deficits may not always be present in every case of FAI. CLINICAL RELEVANCE: Proprioceptive training may not be beneficial in some patients with unilateral FAI.

Gap difference in navigated TKA: a measure of the imbalanced flexion-extension gap.

INTRODUCTION: The success of Total Knee Arthroplasty (TKA) hinges on balanced flexion-extension gaps. This paper aims to evaluate the correlation between imbalanced gaps and clinical outcomes, and hence help quantify the imbalanced gap in navigation-assisted total knee arthroplasty. METHODS: We studied 195 knees with an average follow-up of two years. Flexion-extension gaps were obtained from computer calculation upon cementation of implants in both flexion (90°) and extension. The gap difference (GD) was defined as the measured difference between the gaps in flexion and extension. RESULTS: At 2 years after surgery, the mean ROM in the balanced group, with GD less than or equal to 2 mm, was 115.1° ± 16.6° and the mean ROM in the imbalanced group was 116.7° ± 12.1°. This was not statistically significant with p-value 0.589. Balanced flexion-extension gaps also did not show significant difference in terms of mechanical alignment, with 0.29 ± 0.89 in the balanced group at 2 years, and 0.65 ± 1.51 in the imbalanced group with p-value 0.123. Balanced gaps however, were associated with improved outcomes in terms of physical functioning, bodily pain, social functioning, Oxford and Knee scores at 6 months and improved social functioning scores at 2 years. CONCLUSIONS: Computer navigation is a useful tool for assessing the gap balance in TKA. Balanced flexion-extension gaps, with gap differences of less than or equal to 2 mm, is associated with improved clinical outcomes at 6 months.

Treatment and outcomes of melanoma in Asia: Results from the National Cancer Centre Singapore.

BACKGROUND: Acral melanoma (AM) and mucosal melanoma (MM) make up more than half of melanomas in Asia but comprise only 5% of cases in Caucasians, where cutaneous melanoma (CM) predominates. AM and MM are thought to be genetically and biologically distinct from CM. We report the characteristics and outcomes of melanoma patients from the National Cancer Centre Singapore. METHODS: Case records of 210 patients treated between 2002 and 2014 were reviewed. RESULTS: Median follow-up was 2.5 years. CM, AM and MM made up of 37.6%, 33.8% and 16.2% of cases, respectively, with 6.2% each having ocular melanoma and unknown primary. Caucasians made up 16.2% of patients, accounting for 36.7% of CM but only 2.8 of AM and 2.9% of MM. Patients with MM (2.9% stage I, 14.7% stage IV) presented with higher American Joint Committee on Cancer (AJCC) stage than those with AM (16.9% stage I, 5.6% stage IV) or CM (24.1% stage I, 8.9% stage IV) (P = 0.01). Median overall survival (OS) was 5.7 years for all patients, and 1.0 year for metastatic disease. Considering stage I-III disease, multivariable Cox regression analysis demonstrated age ≥60 years and higher stage to be independent adverse prognostic factors for RFS and OS. Sentinel lymph node biopsy, undertaken for 56 stage I-III patients (25 AM, 31 CM) did not influence outcome. CONCLUSION: Our study reinforces the known unique clinicopathologic features of melanomas in Asians where AM and MM predominate. Age and stage remain the most critical prognostic factors across all subtypes.

Biological significance and prognostic relevance of peripheral blood neutrophil-to-lymphocyte ratio in soft tissue sarcoma.

Peripheral blood indices of systemic inflammation such as the neutrophil-lymphocyte ratio (NLR) have been shown to be prognostic in various cancers. We aim to investigate the clinical significance of these indices in patients with soft tissue sarcoma (STS). Seven hundred and twelve patients with available blood counts at diagnosis and/or metastatic relapse were retrospectively examined. An optimal cutoff for NLR-high (>2.5) in predicting overall survival (OS) was determined using receiver operating curve analyses. Survival analyses were performed using the Kaplan-Meier method and multivariate Cox proportional models. Our results show that NLR was significantly higher in patients with distant metastasis at diagnosis (n = 183) compared to those without (n = 529) (median: 4.36 vs 2.85, p < 0.0001). Progression of localized disease at diagnosis to metastatic relapse within the same patients was associated with an interval increase in NLR (median: 3.21 vs 3.74, p = 0.0003). In multivariate analysis, NLR-high was the only consistent factor independently associated with both worse OS (HR 1.53, 95% CI 1.10-2.13, p = 0.0112) and relapse-free survival (HR 1.41, 95% CI 1.08-1.85, p = 0.0125) in localized disease, as well as OS (HR 1.82, 95% CI 1.16-2.85, p = 0.0087) in metastatic/unresectable disease. In conclusion, high NLR is an independent marker of poor prognosis among patients with STS.

Association between preoperative anaemia with length of hospital stay among patients undergoing primary total knee arthroplasty in Singapore: a single-centre retrospective study.

OBJECTIVES: Studies in western healthcare settings suggest that preoperative anaemia is associated with poor outcomes after elective orthopaedic surgery. We investigated the prevalence of preoperative anaemia among patients with primary unilateral total knee arthroplasty (TKA) in Singapore and its association with length of hospital stay (LOS), perioperative blood transfusion and hospital readmission rates. METHODS: Retrospective cohort study performed in a tertiary academic medical centre in Singapore, involving patients who underwent primary unilateral TKA between January 2013 and June 2014. Demographics, comorbidities, preoperative haemoglobin (Hb) level, LOS and 30-day readmission data were collected. Anaemia was classified according to WHO definition. Prolonged LOS was defined as more than 6 days, which corresponds to >75th centile LOS of the data. RESULTS: We analysed 2394 patients. The prevalence of anaemia was 23.7%. 403 patients (16.8%) had mild anaemia and 164 patients (6.8%) had moderate to severe anaemia. Overall mean LOS was 5.4±4.8 days. Based on multivariate logistic regression, preoperative anaemia significantly increased LOS (mild anaemia, adjusted OR (aOR) 1.71, p<0.001; moderate/severe anaemia, aOR 2.29, p<0.001). Similar effects were seen when preoperative anaemia was defined by Hb level below 13 g/dL, regardless of gender. Transfusion proportionately increased prolonged LOS (1 unit: aOR 2.12, p=0.006; 2 or more units: aOR 6.71, p<0.001). Repeat operation during hospital stay, previous cerebrovascular accidents, general anaesthesia and age >70 years were associated with prolonged LOS. Our 30-day related readmission rate was 1.7% (42) cases. CONCLUSION: Anaemia is common among patients undergoing elective TKA in Singapore and is independently associated with prolonged LOS and increased perioperative blood transfusion. We suggest measures to correct anaemia prior to surgery, including the use of non-gender-based Hb cut-off for establishing diagnosis.

Critical evaluation of contemporary management in a new Pelvic Exenteration Unit: The first 25 consecutive cases.

AIM: To critically appraise short-term outcomes in patients treated in a new Pelvic Exenteration (PE) Unit. METHODS: This retrospective observational study was conducted by analysing prospectively collected data for the first 25 patients (16 males, 9 females) who underwent PE for advanced pelvic tumours in our PE Unit between January 2012 and October 2016. Data evaluated included age, co-morbidities, American Society of Anesthesiologists (ASA) score, Eastern Cooperative Oncology Group (ECOG) status, preoperative adjuvant treatment, intra-operative blood loss, procedural duration, perioperative adverse event, lengths of intensive care unit (ICU) stay and hospital stay, and oncological outcome. Quantitative data were summarized as percentage or median and range, and statistically assessed by the χ2 test or Fisher's exact test, as applicable. RESULTS: All 25 patients received comprehensive preoperative assessment via our dedicated multidisciplinary team approach. Long-course neoadjuvant chemoradiotherapy was provided, if indicated. The median age of the patients was 61.9-year-old. The median ASA and ECOG scores were 2 and 0, respectively. The indications for PE were locally invasive rectal adenocarcinoma (n = 13), advanced colonic adenocarcinoma (n = 5), recurrent cervical carcinoma (n = 3) and malignant sacral chordoma (n = 3). The procedures comprised 10 total PEs, 4 anterior PEs, 7 posterior PEs and 4 isolated lateral PEs. The median follow-up period was 17.6 mo. The median operative time was 11.5 h. The median volume of blood loss was 3306 mL, and the median volume of red cell transfusion was 1475 mL. The median lengths of ICU stay and of hospital stay were 1 d and 21 d, respectively. There was no case of mortality related to surgery. There were a total of 20 surgical morbidities, which occurred in 12 patients. The majority of the complications were grade 2 Clavien-Dindo. Only 2 patients experienced grade 3 Clavien-Dindo complications, and both required procedural interventions. One patient experienced grade 4a Clavien-Dindo complication, requiring temporary renal dialysis without long-term disability. The R0 resection rate was 64%. There were 7 post-exenteration recurrences during the follow-up period. No statistically significant relationship was found among histological origin of tumour, microscopic resection margin status and postoperative recurrence (P = 0.67). Four patients died from sequelae of recurrent disease during follow-up. CONCLUSION: By utilizing modern assessment and surgical techniques, our PE Unit can manage complex pelvic cancers with acceptable morbidities, zero-rate mortality and equivalent oncologic outcomes.

Germline Mutations in Cancer Predisposition Genes are Frequent in Sporadic Sarcomas.

Associations of sarcoma with inherited cancer syndromes implicate genetic predisposition in sarcoma development. However, due to the apparently sporadic nature of sarcomas, little attention has been paid to the role genetic susceptibility in sporadic sarcoma. To address this, we performed targeted-genomic sequencing to investigate the prevalence of germline mutations in known cancer-associated genes within an Asian cohort of sporadic sarcoma patients younger than 50 years old. We observed 13.6% (n = 9) amongst 66 patients harbour at least one predicted pathogenic germline mutation in 10 cancer-associated genes including ATM, BRCA2, ERCC4, FANCC, FANCE, FANCI, MSH6, POLE, SDHA and TP53. The most frequently affected genes are involved in the DNA damage repair pathway, with a germline mutation prevalence of 10.6%. Our findings suggests that genetic predisposition plays a larger role than expected in our Asian cohort of sporadic sarcoma, therefore clinicians should be aware of the possibility that young sarcoma patients may be carriers of inherited mutations in cancer genes and should be considered for genetic testing, regardless of family history. The prevalence of germline mutations in DNA damage repair genes imply that therapeutic strategies exploiting the vulnerabilities resulting from impaired DNA repair may be promising areas for translational research.