The prognostic significance of surgical resection margins for local recurrence, distant metastasis, and overall survival in sarcoma.

BACKGROUND AND OBJECTIVES: Surgical resection with microscopically negative margins constitutes one of the key elements of a curative therapeutic approach for localized sarcomas. However, the prognostic value of quantitative margin width remains controversial. We sought to determine the prognostic significance of margin status and margin width for local recurrence (LR), distant recurrence (DR), and overall survival. METHODS: Retrospective analysis of 210 patients undergoing resection of localized sarcoma between 1997 and 2018 at a national sarcoma reference center. RESULTS: Logistic regression did not reveal an effect of metric margin width as a prognostic factor for LR (odds ratio [OR] = 0.98, p = 0.574), DR (OR = 1, p = 0.908), or overall survival (hazard ratio = 0.98, 95% confidence interval = 0.73-1.20, p = 0.609). Subgroup analysis revealed no differences between complete first resections (R0) and re-resections (re-R0) following unplanned R1-resections for LR (p = 0.727) and overall survival (p = 0.125), but a significantly higher DR-rate in re-R0 cases (p = 0.022). CONCLUSIONS: Achieving a negative margin is essential in sarcoma surgery, however, metric margin width was not associated with disease-specific outcomes. Re-resection of unplanned R1-resections should be performed to control for LR and overall survival rates. As re-R0 cases were at significantly higher risk of DR, these patients should be followed up closely in standardized surveillance protocols.

[Limb-sparing resection of axillary soft tissue sarcomas]. / Extremitätenerhaltende Resektion von Weichteilsarkomen in der Regio axillaris.

OBJECTIVE: For patients with soft tissue sarcoma, surgical resection is a key element of curative therapy. Surgery is performed as a wide resection with microscopically negative margins (R0 resection) and as limb-sparing procedure whenever possible to preserve maximum function. INDICATIONS: Soft tissue sarcoma, metastases. CONTRAINDICATIONS: Extensive disease with major neurovascular involvement, placement of biopsy tract necessitates extensive resection, palliative care. SURGICAL TECHNIQUE: Extended deltopectoral approach. Release of pectoralis major and minor tendons. Vascular and neurologic exploration, identification of the axillary vessels and brachial plexus, placing of loops around major structures. Mobilization of these structures to achieve adequate exposure. Clipping of vessels entering the tumor. Tumor resection, suture marking for histological analysis. Soft tissue reconstruction by transosseous reinsertion of the pectoralis minor to the coracoid process. Drill channel placement, transosseous refixation of the pectoralis major to the humerus. POSTOPERATIVE MANAGEMENT: Shoulder abduction brace for 6 weeks, passive mobilization for 6-12 weeks followed by active mobilization. Compression sleeve. Oncological follow-up. RESULTS: Between 2017 and 2022, wide resection was performed in 6 consecutive cases including 4 primary soft tissue sarcomas and 2 metastases. Primary R0 resection was achieved in 100%. Mean follow-up was 22.5 months (3-60 months). There were no local recurrences. Mean active shoulder abduction was 135.0 ± 41.4° (90-180°). Neurological deficits were not observed. Mean subjective shoulder function was 80.0 ± 21.0% (50-100%). The mean Musculoskeletal Tumor Society (MSTS) score was 89.5% (32-100%), indicating good functional outcome in the study cohort.

Robotic-assisted TKA reduces surgery duration, length of stay and 90-day complication rate of complex TKA to the level of noncomplex TKA.

INTRODUCTION: Complex primary total knee arthroplasties (TKA) are reported to be associated with excessive episode of care (EOC) costs as compared to noncomplex procedures. The impact of robotic assistance (rTKA) on economic outcome parameters in greater case complexity has not been described yet. The purpose of this study was to investigate economic outcome parameters in the 90-days postoperative EOC in robotic-assisted complex versus noncomplex procedures. MATERIALS AND METHODS: This study is a retrospective, single-center review of 341 primary rTKAs performed between 2017 and 2020. Patient collective was stratified into complex (n = 218) and noncomplex TKA (n = 123) based on the presence of the following criteria: Obese BMI, coronal malalignment, flexion contracture > 10°, posttraumatic status, previous correction osteotomy, presence of hardware requiring removal during surgery, severe rheumatoid arthritis. Group comparison included surgery duration, length of stay (LOS), surgical site complications, readmissions, and revision procedures in the 90-days EOC following rTKA. RESULTS: The mean surgery duration was marginally longer in complex rTKA, but showed no significant difference (75.26 vs. 72.24 min, p = 0.258), neither did the mean LOS, which was 8 days in both groups (p = 0.605). No differences between complex and noncomplex procedures were observed regarding 90-days complication rates (7.34 vs. 4.07%, p = 0.227), readmission rates (3.67 vs. 3.25%, p = 0.841), and revision rates (2.29 vs. 0.81%, p = 0.318). CONCLUSIONS: Robotic-assisted primary TKA reduces the surgical time, inpatient length of stay as well as 90-days complication and readmission rates of complex TKA to the level of noncomplex TKA. Greater case complexity does not seem to have a negative impact on economic outcome parameters when surgery is performed with robotic assistance.

Drain fluid cultures can rule in but cannot rule out infection persistence after surgical treatment of periprosthetic joint infections.

BACKGROUND: Periprosthetic joint infection (PJI) is one of the most common reason for implant failure in arthroplasty. Surgical therapy is essential but there is no standardized guideline to determine infection eradication in multiple-step revision surgery. To date, clinical and laboratory inflammation markers and preoperative arthrocentesis are controversial to evaluate the infection status before reimplantation and therefore are often combined. Drain fluid cultures enable a microbiological analysis without need for further invasive procedure after revision surgery. This retrospective study evaluates the diagnostic performance of drain fluid cultures in diagnosing infection persistence according to the MSIS definition of PJI. METHODS: Drain samples have been taken after every revision surgery for microbiological testing. Afterwards, the results have been assigned to the infection status according to the diagnostic criteria of the MSIS definition of PJI. RESULTS: 1084 revision surgeries in 183 patients have been included, resulting in a total sample size of 1552 drain fluid cultures. Overall sensitivity was 36.0%, specificity was 90.7% and ROC-AUC was 0.63. CONCLUSION: Due to a high specificity and a low sensitivity drain fluid cultures can rule in but cannot rule out infection persistence in PJI.

Diagnostic Accuracy for Periprosthetic Joint Infection Does Not Improve by a Combined Use of Glucose and Leukocyte Esterase Strip Reading as Diagnostic Parameters.

The diagnosis of periprosthetic infections (PJI) can be challenging in clinical practice because the clinical presentations of aseptic loosening and low-grade infections are similar. Semiquantitative evaluation of leukocyte esterase (LE) in synovial fluid using a urine strip test has already established itself as a diagnostic method over the past decade. The analysis of LE in synovial fluid leads to a high number of false-positive test results. In the present study, the value of a combined semiquantitative determination of glucose and LE in synovial fluid to improve the diagnosis of PJI was investigated. Over a 4-year period, 145 synovial samples were collected from patients who developed joint effusion after arthroplasty. LE and glucose test strips were considered as an index test for the diagnosis of PJI. A ++ or +++ LE and a negative glucose test strip reading were considered as positive test results. Modified diagnostic criteria for PJI as recommended by the Musculoskeletal Infection Society (MSIS) served as the reference test, except that intraoperative findings were excluded. Forty-six out of 145 samples were classified as septic complication according to the reference test. In regard to PJI, our data showed that combined use of LE and glucose strip test reading displayed a 98.0% specificity (95% confidence interval (CI): 95.2% to 100%), a 50% sensitivity (95% CI: 35.6% to 64.4%), a 92% positive predictive value (95% CI: 81.4% to 100.0%), and an 80.3% negative predictive value (95% CI: 73.2% to 87.4%). In contrast, the exclusive analysis of LE on the urine strip to diagnose PJI demonstrated a 90.9% specificity (95% CI: 85.2% to 96.6%), a 67.4% sensitivity (95% CI: 53.8% to 80.9%), a 77.5% positive predictive value (95% CI: 64.6% to 90.4%), and an 85.7% negative predictive value (5% CI: 79.0% to 92.4%). A combination of LE and glucose test pad reading is considered superior as a potential "rule-in" method for the diagnosis of PJI compared with LE test pad analysis alone. However, combined LE and glucose synovial fluid testing also demonstrated lower test sensitivity and thus diagnostic accuracy compared with LE analysis alone. Therefore, combined glucose and LE test pad analysis does not represent a sufficient diagnostic standard to exclude PJI with certainty.

Circulating microRNAs in Symptomatic and Asymptomatic Carotid Stenosis.

Background: Specific microRNAs (miRs) have been implicated in the pathophysiology of atherosclerosis and may represent interesting diagnostic and therapeutic targets in carotid stenosis. We hypothesized that the levels of specific circulating miRs are altered in patients with symptomatic carotid stenosis (sCS) in comparison to those in patients with asymptomatic carotid stenosis (aCS) planned to undergo carotid endarterectomy (CEA). We also studied whether miR levels are associated with plaque vulnerability and stability over time after CEA. Methods: Circulating levels of vascular-enriched miR-92a, miR-126, miR-143, miR-145, miR-155, miR-210, miR-221, miR-222, and miR-342-3p were determined in 21 patients with sCS and 23 patients with aCS before CEA and at a 90-day follow-up. Transcranial Doppler ultrasound for detection of microembolic signals (MES) in the ipsilateral middle cerebral artery was performed prior to CEA. Carotid plaques were histologically analyzed. Results: Mean levels of miRs were not considerably different between groups and were only marginally higher in sCS than aCS concerning miR-92a, miR-210, miR-145, and miR-143 with the best evidence concerning miR-92a. After adjustment for vascular risk factors and statin pre-treatment, the effect sizes remained essentially unchanged. At follow-up, however, these modest differences remained uncorroborated. There were no relevant associations between miR-levels and MES or histological plaque vulnerability features. Conclusions: This study does not provide evidence for strong associations between specific circulating miRs and symptomatic state in a collective of comprehensively characterized patients with carotid stenosis. Further work is needed to elucidate the role of circulating miRs as targets in advanced carotid atherosclerosis.

Distinct systemic cytokine networks in symptomatic and asymptomatic carotid stenosis.

Inflammatory processes are crucial in atherosclerosis and atherothrombosis. This study aimed to identify a cytokine-pattern that is associated with plaque-vulnerability or symptomatic state in comprehensively investigated patients with symptomatic (sCS) and asymptomatic carotid stenosis (aCS). Twenty-two patients with sCS and twenty-four patients with aCS undergoing carotid endarterectomy (CEA) were considered. A cytokine-panel was measured in plasma-specimens prior to surgery and at a 90 day follow-up. Doppler-ultrasound detecting microembolic signals (MES) in the ipsilateral middle cerebral artery was performed. Carotid plaques were analysed regarding histopathological criteria of plaque-vulnerability and presence of chemokine receptor CXCR4. Correction for multiple comparisons and logistic regression analysis adjusting for vascular risk factors, grade of stenosis, antithrombotic and statin pretreatment were applied. In sCS-patients higher plasma-levels of Fractalkine (CX3CL1), IFN-α2, IL-1ß, IL-2, IL-3, IL-7 were found compared to aCS-patients. CXCR4-expression on inflammatory cells was more evident in sCS- compared to aCS-plaques and was associated with vulnerability-criteria. In contrast, plasma-cytokine-levels were not related to CXCR4-expression or other vulnerability-criteria or MES. However, in both groups distinct inter-cytokine correlation patterns, which persisted at follow-up and were more pronounced in the sCS-group could be detected. In conclusion, we identified a distinct cytokine/chemokine-network in sCS-patients with elevated and closely correlated mediators of diverse functions.