Which Pre-Operative, Modifiable Risk Factors are Most Predictive of Complications in orthopedic Upper Extremity Surgery?

Objectives: Identification of modifiable comorbid conditions in the preoperative period is important in optimizing outcomes. We evaluate the association between such risk factors and postoperative outcomes after upper extremity surgery using a national database. Methods: The National Surgical Quality Improvement Program (NSQIP) 2006-2016 database was used to identify patients undergoing an upper extremity principle surgical procedure using CPT codes. Modifiable risk factors were defined as smoking status, use of alcohol, obesity, recent loss of >10% body weight, malnutrition, and anemia. Outcomes included discharge destination, major complications, bleeding complications, unplanned re-operation, sepsis, and prolonged length of stay. Chi square and multivariable logistic regressions were used to identify significant predictors of outcomes. Significance was defined as P<0.01. Results: After applying exclusion criteria, 53,780 patients were included in the final analysis. Preoperative malnutrition was significantly associated with non-routine discharge (OR=4.75), major complications (OR=7.27), bleeding complications (OR=7.43), unplanned re-operation (OR=2.44), sepsis (OR=10.22), and prolonged length of stay (OR=5.27). Anemia was associated with non-routine discharge (OR=2.67), bleeding complications (OR=13.27), and prolonged length of stay (OR=3.26). In patients who had a weight loss of greater than 10%, there was an increase of non-routine discharge (OR=2.77), major complications (OR=2.93), and sepsis (OR=3.7). Smoking, alcohol use, and obesity were not associated with these complications. Conclusion: Behavioral risk factors (smoking, alcohol use, and obesity) were not associated with increased complication rates. Malnutrition, weight loss, and anemia were associated with an increase in postoperative complication rates in patients undergoing upper limb orthopaedic procedures and should be addressed prior to surgery, suggesting nutrition labs should be part of the initial blood work.

Is surgical indication in multiple myeloma a poor prognosis sign? SEER database analysis

Aim This study aims to investigate demographic data, survival rates, and the relationship of these rates with surgery in a large case series including multiple myeloma (MM) patients. Method MM cases were analyzed retrospectively using the latest version of the SEER database published in April 2020. This version covers January 1975 to December 2017. Patients were classified according to gender, age, and race/ethnicity. Tumors were classified according to their localization, grade, year of diagnosis, and follow-up results. Results There were 60,239 patients diagnosed with Plasma Cell Myeloma. While 670 patients (1.2%) were operated on, 43,976 patients (76.7%) did not indicate operation, and 12,670 patients (22.1%) could not be operated on despite the recommendation. The mean survival was 62 months in those without an indication for surgery, and 42 months in patients with an indication but could not be operated on, and the difference was significant (p = 0.001). The mean survival was 58 months in the operated patients, and 42 months in the patients who could not be operated on despite the indication, and the difference was significant (p = 0.001). There was no difference between those who did not indicate surgery and those who were operated on with an indication (p = 0.243). Conclusion In multiple myeloma, the best prognosis is in the group of patients who received medical treatments without any indication for operation, while an indication for operation indicates a worse prognosis. A worse prognosis should be expected in patients who do not accept the operation or who cannot be operated on compared to the operated patients (AU)

Posterior Interosseous Neuropathy Related to a Loose Distal Biceps Cortical Button: A Case Series.

Posterior interosseous nerve (PIN) injury is an uncommon yet debilitating complication following distal bicep tendon repair. There are case reports of acute intraoperative PIN injury related to retractor placement, drill trajectory, and nerve incarceration. We report three cases of delayed PIN neuropathy in the setting of a loose cortical button. All patients had resolution of their pain with removal of the cortical button and decompression of the radial tunnel. The purpose of this case series is to: 1) highlight the possibility of a loose cortical bicep button as the cause of proximal forearm pain and PIN neuropathy in the early or late postoperative timeframe; and 2) emphasize the importance of proper surgical technique and use of intraoperative fluoroscopy to assure the cortical button is well-fixed and flush with the radial shaft. .

Is surgical indication in multiple myeloma a poor prognosis sign? SEER database analysis.

AIM: This study aims to investigate demographic data, survival rates, and the relationship of these rates with surgery in a large case series including multiple myeloma (MM) patients. METHOD: MM cases were analyzed retrospectively using the latest version of the SEER database published in April 2020. This version covers January 1975 to December 2017. Patients were classified according to gender, age, and race/ethnicity. Tumors were classified according to their localization, grade, year of diagnosis, and follow-up results. RESULTS: There were 60,239 patients diagnosed with Plasma Cell Myeloma. While 670 patients (1.2%) were operated on, 43,976 patients (76.7%) did not indicate operation, and 12,670 patients (22.1%) could not be operated on despite the recommendation. The mean survival was 62 months in those without an indication for surgery, and 42 months in patients with an indication but could not be operated on, and the difference was significant (p = 0.001). The mean survival was 58 months in the operated patients, and 42 months in the patients who could not be operated on despite the indication, and the difference was significant (p = 0.001). There was no difference between those who did not indicate surgery and those who were operated on with an indication (p = 0.243). CONCLUSION: In multiple myeloma, the best prognosis is in the group of patients who received medical treatments without any indication for operation, while an indication for operation indicates a worse prognosis. A worse prognosis should be expected in patients who do not accept the operation or who cannot be operated on compared to the operated patients.

Cephalomedullary Nailing has a Higher Reoperation Rate Compared to Sliding Hip Screw Fixation in the Treatment of Intertrochanteric Femur Fractures: A Systematic Literature Review and Meta-analysis.

Objectives: Intertrochanteric hip fractures are a common orthopaedic injury in the United States. Complications of surgical treatment include nonunion, lag screw cutout, implant failure, post-operative pain, risk of refracture or reoperation, and infection. The purpose of this study was to compare the rate of complications of sliding hip screw fixation (SHS) compared to cephalomedullary nailing (CMN) for the treatment of closed intertrochanteric femur fractures in adult patients. Methods: PubMed, CINAHL, and Cochrane Library databases were searched for studies comparing SHS to CMN in the treatment of closed intertrochanteric femur fractures in adults. Data were compiled to observe the rate of nonunion, cutout failure, infection, refracture, perioperative blood loss, reoperation, postoperative pain, pulmonary embolism/deep venous thrombosis (DVT), length of hospital stay, and mortality. Results: Seventeen studies were included comprising 1,500 patients treated with SHS and 1,890 patients treated with CMN. Treatment of intertrochanteric femur fractures with SHS demonstrated significantly fewer refractures and reoperations. There was no significant difference in other variables between SHS and CMN treated groups. Conclusion: This meta-analysis shows that the only notable difference in outcomes is patients treated with CMN have a higher rate of refracture and reoperation. With new advances in the development of both CMNs and SHS, further studies will be required to see if these differences persist in the coming years.

Comparison of Treatment Options for Chronic Scapholunate Interosseous Ligament (SLIL): A Systematic Literature Review and Meta-Analysis.

Background: The scapholunate interosseous ligament (SLIL) is an important contributor to wrist stability and functionality. SLIL injury is debilitating and therefore many surgical techniques have been proposed, but the optimal treatment modality remains debated.This meta-analysis reviews the available literature comparing surgical techniques used in the treatment of chronic SLIL to determine the best approach. Methods: An electronic search of the literature was conducted to identify all randomized controlled trials and cohort studies published before January 2019 that evaluated clinical outcomes of capsulodesis reconstruction, the modified Brunelli technique, and the reduction and association of the scaphoid and lunate (RASL) procedure for treatment of chronic SLIL. A chi-square analysis was performed to identify possible differences between each technique for several outcome measures. Results: A total 20 studies encompassing 409 patients met inclusion criteria. Average age among patients was 36.7 years, and 68.2% of patients were male. Reductions in visual analog scale pain scale; Disabilities of Arm, Shoulder, and Hand (DASH) scores; and increases in grip strength and range of motion were observed for all techniques. Capsulodesis was superior to the modified Brunelli technique regarding preserved range of motion. Conclusions: No significant differences were observed among any of the techniques for pain, DASH score, and grip strength outcomes. Capsulodesis, modified Brunelli, and RASL surgical techniques for the treatment of chronic SLIL injuries may all be seen as reliable methods of treatment of chronic SLIL injuries. While future trials directly comparing these methods are needed, this study suggests there is no superiority of one technique over another.

Radial Head Arthroplasty for Fracture: Implant Survivorship and Outcomes at Mean Follow-up of 8 Years.

PURPOSE: The purpose of this study was to evaluate implant survivorship and clinical outcomes following radial head arthroplasty for fracture at long-term follow-ups. METHODS: A retrospective analysis was conducted on adult patients who underwent primary uncemented radial head arthroplasty for radial head or neck fractures between 2012 and 2015. Medical records were reviewed to collect information regarding demographics, injury characteristics, reoperations, and revisions requiring implant removal. A bivariate analysis was conducted to identify potential risk factors for reoperation. A Kaplan-Meier curve was created to determine implant survival rates. Eligible patients were contacted to confirm any reoperations and obtain Quick Disability of the Arm, Shoulder, and Hand scores at long-term follow-ups. RESULTS: A total of 89 patients were eligible for analysis and assessed at a mean of 97 months after surgery (range, 81-128). Reoperation rate was 16% (14 of 89 patients), including 5% of patients requiring implant removal or revision. However, 93% of reoperations occurred within the first 12 months of the index surgery. Fracture dislocations of the elbow had a higher rate of reoperation. A Kaplan-Meier curve demonstrated an implant survival rate of 96% at 10-year follow-up. Of the patients who responded, the mean Quick Disability of the Arm, Shoulder, and Hand score was 8.7 ± 10.3, with none requiring additional reoperations or revisions. There were otherwise similar outcome scores among patients requiring reoperation versus those who did not. CONCLUSIONS: Although radial head arthroplasty for fractures has a high potential for reoperation within the first year, survival rates with uncemented implants remain high at 10 years, and patients report excellent Quick Disability of the Arm, Shoulder, and Hand scores at long-term follow-ups, despite any need for reoperation. Fractures with associated elbow dislocation may be at a higher risk for reoperation, and it is important to provide this prognostic information to patients who are likely to require arthroplasty for more extensive injuries. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Characterization of Opioid Prescribing Tendencies Among Orthopaedic Surgeons: A National Perspective.

There has been increasing pressure on healthcare providers to exhibit restraint when prescribing opioids for pain control. However, data that characterizes the differences between orthopaedic providers and their accompanying prescription rates is not well developed. This study accessed Medicare Provider Utilization and Payment Data from 2015 to collect the number of prescriptions for opioid-based medications administered by orthopaedic surgeons across the country. A total of 19,410 orthopaedic providers were identified as opioid prescribers from the 2015 Medicare Part D Database. Providers averaged an opioid prescription every 10.9 days, with 94.7% of prescribers (18,387) having written more than 10 opioid prescriptions. Regionally, the Southern United States had the highest percentage of providers prescribing an opioid greater than 10 times at 96.4%. Female orthopaedic surgeons prescribed just over half the number of scripts that male surgeons did (79.4 vs. 154.2, p < 0.001). (Journal of Surgical Orthopaedic Advances 32(3):199-201, 2023).

Intraoperative Nerve Conduction Studies During Open Carpal Tunnel Release: A Pilot Study.

Background: Operative management of carpal tunnel syndrome (CTS) involves release of the transverse carpal ligament (TCL) and often the volar antebrachial fascia (VAF). Evidence of a difference between TCL and TCL+VAF release is limited. We conducted a pilot study to measure changes of intraoperative nerve conduction velocity (NCV) after CTS surgery and compared outcomes of variable degrees of decompression. Methods: Patients aged 18 to 65 years diagnosed with idiopathic CTS that failed to respond to conservative management were included in this study. Patients were excluded if they had prior surgical release, diabetes, acute CTS, trauma, or cervical spine radiculopathy. Outcomes included motor and sensory amplitude and latency. Electrodes were placed on the skin intraoperatively along the abductor pollicis brevis, index finger, and forearm. Outcome data were recorded at baseline, after TCL release, and after TCL+VAF release. Data were compared using a single-tail t test. Results: A total of 10 patients were included in this study. There were no significant changes in mean motor or sensory amplitude and latency from baseline to TCL release, TCL to VAF release, or from baseline to TCL+VAF release measured intraoperatively. Conclusions: This pilot study shows there is no immediate detectable difference in NCV following release of TCL or TCL+VAF. This suggests that NCV may not be useful for assessing intraoperative improvement. We highlight the need for future research in the form of case-control studies to determine the utility of intraoperative NCV. These studies should be conducted with larger numbers of patients and involve multiple hand specialists.

Intramedullary Nailing Versus Plate Fixation for Humeral Shaft Fractures: A Systematic Review and Meta-Analysis.

Background: The two techniques most utilized in the surgical treatment of humeral shaft fractures are open reduction internal fixation (ORIF) and intramedullary nailing (IMN). Although there have been multiple comparative clinical studies comparing outcomes for these two treatments, studies have not suggested one approach to be superior to the other. The purpose of this study is to perform a systematic literature review and meta-analysis of studies that evaluated the treatment of humeral shaft fractures with either ORIF or intramedullary nail. Methods: We conducted this meta-analysis utilizing stricter inclusion and broader exclusion criteria to examine these two common approaches. We examined those articles which have compared first-time, closed fractures of the humeral diaphysis in adults in fracture patterns that could be treated equivalently by intramedullary nail or plate fixation. The primary outcome of interest was nonunion, and studies that did not report nonunion rates were excluded. Results: There were a total of 1,926 abstracts reviewed and a total of three articles were included in the final analysis after screening. There was no significant difference in the incidence of nonunion between plating (2/111, 1.8%) and nailing (4/104, 3.9%) (P>0.05). The mean difference in average time to union for plated fractures and nailed fractures was 1.11 weeks (95% CI 0.82 to 1.40) which was statistically significant (P<0.05). There was a significant difference in the incidence of radial nerve palsy (12/111, 10.8%) for plating compared to nailing (0/104, 0%) (P=0.0004). There was no difference in incidence of post-operative infection between the two groups intramedullary nailing (P>0.05). Conclusion: The results of this analysis demonstrate an increased risk of iatrogenic radial nerve injury, and a significantly shorter time to union when treating humeral shaft fractures with plating as compared to intramedullary nailing. There was no difference in the rates of nonunion or delayed union. Based on the evidence, both plating and nailing can achieve a similar treatment effect on humeral shaft fractures.

Hand Tumors: An Individual Surgeon's Retrospective Review.

Background: Tumors of the hand are encountered frequently and represent a variety of pathologic diagnoses, both benign and malignant. Even within a single pathologic type, presentation can vary. This study reviews hand tumors encountered by an individual surgeon and described presenting features to better aid in clinical decision making. Methods: A retrospective chart review of patients presenting with a hand tumor between January 2005 and December 2017 from an individual surgeon's perspective was performed. Pertinent data were extracted by researchers and statistical analysis was completed with GraphPad Prism (GraphPad Software, Inc). Results: A total of 101 patients aged 14 months to 87 years (mean age, 40.52 years) were included. Within this patient group, soft tissue tumors accounted for 97%, malignant neoplasm 2%, and bone tumors 1%. Ganglion cysts were most common (54.5%) followed by hemangiomas (9.9%), giant cell tumors (6.9%), granulomas (5.9%), and fibromas (5%). A total of 54.5% of patients reported pain and 43.5% reported decreased range of motion (ROM). Conclusions: In this patient cohort, ganglion cyst was the most common tumor type and presented with pain and deficits in ROM. This is contrary to the asymptomatic presentation of such cases in the literature. Other common tumors were hemangiomas, giant cell tumors, granulomas, and fibromas. Malignant tumors were rare, as expected, and both cases presented without pain or tenderness.

Association of Bacterial Etiology With Rates of Reoperation in Patients With Septic Tenosynovitis of the Hand.

Background: The anatomy of the hand makes it uniquely sensitive to complications after bacterial infection. The causative organism has been implicated as a predictor of complications after surgery. We hypothesize that bacterial etiology is associated with different operation and reoperation rates in patients with flexor tenosynovitis. Methods: The Nationwide Inpatient Sample 2001-2013 database was queried for cases of tenosynovitis by using International Classification of Diseases, 9th Revision (ICD-9) diagnostic codes 727.04 and 727.05. The pathogen cultured was also identified with ICD-9 codes, and surgical intervention was determined using ICD-9 procedural codes. χ2 analysis and logistic regression were used to determine predictors of outcomes. Outcomes included initial surgery and the need for additional surgery, which was defined as records having ICD-9 procedural codes repeated for the same patient. Results: A total of 17,476 cases were included. The most common bacterial etiology was methicillin-sensitive Staphylococcus aureus followed by Streptococcus species. Infections with gram-positive organisms, including methicillin-sensitive and methicillin-resistant S aureus, unspecified Staphylococcus, and Streptococcus species were significantly associated with higher rates of initial surgery for tenosynovitis. Patients receiving Medicaid and Hispanic patients had a statistically significant lower likelihood of surgery. Higher rates of reoperation were reported in patients aged 30 to 50 years, 51 to 60 years, 61 to 79 years, and ≥80 years; other factors associated with higher reoperation rates were Streptococcus and Staphylococcus infections and use of Medicare. Conclusions: The data show that cultures of Streptococcus and certain species of Staphylococcus in patients with septic tenosynovitis are predictive of operation and reoperation rates. Patients with these infectious etiologies may have more severe presentations that warrant operative intervention. This data may allow for more informed decision-making in the preoperative period.

Cemented-augmented fixation of metastatic humeral lesions without segmental bone loss results in reliable outcomes.

Background: Treatment of metastatic lesions to the humerus is dependent on patient's pain, lesion size and location, and post-operative functional goals. Surgical options include plate or nail fixation [open reduction internal fixation (ORIF)], or endoprosthetic replacement (EPR), with cement augmentation. The objective of this study was to perform a single institution retrospective analysis of outcomes by method of reconstruction, tumor volume, and pathologic diagnosis. Methods: The records of 229 consecutive patients treated surgically for appendicular metastatic disease from 2005-2018 at our musculoskeletal oncology center were retrospectively reviewed following institutional review board (IRB) approval. Indications for surgical treatment at the humerus included patients who presented with impending and displaced pathologic fractures. Results: Sixty patients (34 male, 26 female) with a mean age of 62.9±12.2 were identified who were treated surgically at the proximal (n=21), diaphyseal (n=29), or distal (n=10) humerus. Forty-nine (82%) patients presented with displaced pathologic fractures. The remaining eleven patients had a mean Mirels score of 9.5. There was no difference in overall complication rate between EPR or ORIF [4/36 (11%) versus 2/24 (8%); P=0.725]. Mean Musculoskeletal Tumor Society (MSTS) scores were 83% for both EPR and ORIF, with no differences in subgroup analyses at the proximal, diaphyseal, or distal humerus. Patients with cortical destruction on anterior posterior (AP) and lateral imaging were at increased risk for mechanical failure [2/6 (33%) versus 0/18 (0%), P=0.015]. Conclusions: In conclusion, when pathologic pattern permits, cement-augmented fixation allows for stabilization of pathologic bone, while minimizing risk of soft-tissue detachment, while EPR resulted in similar outcomes in patients with more extensive bone destruction. Increased tumor volume was associated with lower MSTS scores.

Clavicle fractures: Associated trauma and morbidity.

BACKGROUND: Clavicle fractures are frequently associated with trauma to regions beyond the immediate zone of injury. In order to provide surgeons with information on injury prevalence to prevent delays in diagnosis and management, we describe the epidemiology of concomitant injuries in patients with clavicle fractures and identify differences between those with open and closed fractures. Methods:The Nationwide Inpatient Sample (NIS) 2001-2013 database was queried for adult patients discharged with a diagnosis of a clavicle fracture using ICD-9 codes. A "common" injury was defined as prevalence ≥4.0% in our study population. We analyzed data for injury locations associated with open vs. closed clavicle fractures with chi square and independent samples t-tests. RESULTS: A total of 41,1612 patients were included in our study population. The majority of patients had closed clavicle fractures (98.2%). The most common concomitant fracture was that of the rib, followed by the spine. The most common non-vascular, non-nervous injury was a hemo/pneumothorax followed by a lung, bronchus, or diaphragm injury. Fractures of the humerus, rib, scapula, pelvis, tibia or fibula, and facial bones as well as concussion, pneumo/hemothorax, other pulmonary, and splenic injuries were more common in patients with open clavicle fractures. Patients with open clavicle fractures were, on average, 11.8 years younger than those with closed fractures. CONCLUSION: There is a significant association between clavicle fractures and concussion, splenic, and thoracic injuries, as well as increased rate of complications with open fractures. Clinicians may use this information to perform risk assessments prevent delays in diagnosis.

A simplified preoperative risk assessment tool as a predictor of complications in the surgical management of forearm fractures.

PURPOSE: Frailty is a well-known predictor of adverse postoperative outcomes and is often considered in the preoperative planning stage of surgery. In recent years, the modified frailty index (mFI), a novel metric used to quantify frailty, has become increasingly used in the orthopedic literature as a risk assessment tool. In this study, we analyze the utility of the mFI in predicting unplanned repeat operations and morbidity in the surgical treatment forearm fractures. METHODS: We used the American College of Surgeons National Surgical Quality Improvement Program 2006-2014 dataset to identify patients undergoing open fixation of forearm fractures. The mFI was calculated based on 5 possible comorbid conditions. Demographic and predictor variables were analyzed for associations with each outcome. In order to assess frailty in both the general and elderly population, two analyses were completed: one for the entire population and one for a population of age 65 or older. The primary outcome of interest was unplanned repeat operation. Secondary outcomes included discharge destination and major post-operative complications. Chi square and logistic regression analyses were used to identify associations. RESULTS: A total of 4641 patients were included in our final analysis. There was a higher prevalence of females and patients between the ages of 61 and 80 compared to other age groups. An mFI score ≥2 was a positively associated with unplanned repeat operation in the general population. An mFI score ≥2 was also positively associated with a discharge destination other than home and major post-operative complications. In the elderly population, mFI ≥2 was similarly associated with a discharge destination other than the patient's home. CONCLUSIONS: Patients undergoing open treatment of forearm fractures were at an increased likelihood of having an unplanned repeat operation and having major complications as frailty score increased, demonstrating that the mFI may be clinically applicable risk assessment tool for these patients.

Differences in the Predictive value of Elixhauser Comorbidity Index and the Charlson Comorbidity indices in patients with hand infections.

PURPOSE: Hand infections are a common source of potentially debilitating morbidity, particularly in patients with comorbid disease. We hypothesize that there is a difference in predictive value between two commonly used comorbidity indices for the prognosis of hand infections, which may have clinical implications in the management of these conditions. METHODS: The Nationwide Inpatient Sample 2001-2013 database was queried for hand infections using International Classification of Diseases, Ninth Revision codes. The Elixhauser (ECI) and Charlson (CCI) comorbidity scores were calculated based on validated sets of ICD-9 codes. Primary outcomes included mortality, prolonged length of stay (LOS, defined as >95 percentile), discharge destination, and postoperative complications. Indices were compared using receiver operating characteristic (ROC) curves and the areas under the curve (AUC). If confidence intervals overlapped, significance was determined using the DeLong method for correlated ROC curves. This is a validated, non-parametric comparison used for the calculation of the difference between two AUCs. RESULTS: A weighted total of 1,511,057 patients were included in this study. The majority were Caucasian (57.1%) males (61.4%). Complication rates included 0.9% mortality, 5.3% prolonged length of stay, 25.3% discharges to non-home destinations, and 5.3% post-operative complications. The ECI and CCI each demonstrated good predictive value for mortality, but poor predictive value for non-routine discharge, prolonged LOS, and post-operative complications. There was a significantly increased likelihood of each complication with increasing comorbidity score for both indices, with the greatest odds ratio in the ECI ≥4 cohort. CONCLUSIONS: The CCI was superior in predicting mortality while the ECI was superior in predicting non-routine discharge, prolonged length of stay, and postoperative complications, but these indices may not be clinically relevant. While both represent good predictive models, a score specifically designed for patients with hand infections may have superior prognostic value. LEVEL OF EVIDENCE: Level IV.

Epidemiology and survival of liposarcoma and its subtypes: A dual database analysis.

PURPOSE: Liposarcoma (LPS) is a one of the most commonly diagnosed soft tissue sarcomas. Little is known about the epidemiology and prognosis of each subtype. We present an analysis of epidemiology and survival of the subtypes of LPS using a national database. METHODS: We queried the Survival Epidemiology, and End Results (SEER) and the Canadian Institute for Clinical Evaluative Sciences (ICES) databases for data on 7 types of LPS. Pearson's chi square was used to determine associations between variables and subtypes. Kaplan-Meier and Cox Regression analyses were performed for two tests: one using SEER data and the other using variables common to both SEER and ICES. RESULTS: The well-differentiated subtype was the most common subtype identified. Metastatic disease was associated with decreased survival across all subtypes and age >35 was associated with decreased survival in well-differentiated and myxoid subtypes. Tumor grade was associated with decreased survival in the well-differentiated, myxoid, mixed, and round cell subtypes. In the secondary analysis, age >35 was associated with decreased survival in the myxoid subtype. CONCLUSIONS: The prognosis of liposarcoma differs greatly by subtype. Clinicians should account for patient factors at the time of diagnosis to best navigate treatment of their patients.

Patient frailty as a risk assessment tool in surgical management of long bone fractures.

BACKGROUND: Frailty is an important predictor of surgical outcomes and has been quantified by several models. The modified frailty index (mFI) has recently been adapted from an 11-item index to a 5-item index and has promise to be a valuable risk assessment tool in orthopedic trauma patients. We perform a retrospective analysis of the 5-item mFI and evaluate its effectiveness in predicting outcomes in patients with long bone fractures. METHODS: The National Surgery Quality Improvement Program (NSQIP) 2006-2016 database was queried for surgical procedures in the treatment of long bone fractures by current procedural terminology (CPT) codes, excluding those performed on metacarpals and metatarsals. Cases were excluded if they were missing demographic, frailty, and variable data. The 5-item frailty index was calculated based on the sum of presence of 5 conditions: COPD/pneumonia, congestive heart failure, diabetes, hypertension, and impaired functional status. Chi square was used to determine variables significantly associated with each outcome. The significant variables were included in multivariate logistic regression along with the mFI. Significance was defined as p < 0.05. RESULTS: Of the 140,249 fixation procedures performed on long bone fractures in NSQIP, 109,423 cases remained after exclusion criteria were applied. The majority of patients were between the ages of 61 and 80 (34.0%), were female (65.6%) and Caucasian (86.3%). Multivariate analysis revealed that mFI scores ≥3 were predictive of unplanned reoperation (OR = 1.57), wound disruption (OR = 2.83), unplanned readmission (OR = 2.12), surgical site infection (OR = 1.90), major complications (OR = 3.04), and discharge destination (OR = 3.06). CONCLUSIONS: Our study analyzed the relationship of frailty and postoperative complications in patients with long bone fractures. Patients had increased likelihood of morbidity, independent of other comorbidities and demographic factors. The mFI may have a role as a simple, easy to use risk assessment tool in cases of orthopedic trauma.

Epidemiological Study of Adamantinoma from US Surveillance, Epidemiology, and End Results Program: III Retrospective Analysis.

OBJECTIVE: Adamantinomas are rare low-grade malignant bone tumors. This study aims to describe the demographic characteristics and survival rates of patients suffering from adamantinomas. METHODS: The National Institute of Cancer Surveillance, Epidemiology, and Recent Results (SEER) database was used, and patients diagnosed with adamantinoma between 1973 and 2016 were screened. Patients were classified according to sex, age, race/ethnicity, and marital status, and also tumors were classified according to year of diagnosis, laterality, type of treatment, and follow-up. RESULTS: The mean age of patients was 30.8 ± 16.7 (range: 4-75). A total of 92 patients were identified; of these, 43 were females and 49 were males. The mean follow-up period was 138.1 ± 90.3 (range: 1-156) months. Mean survival duration was 287.8 ± 15.4 (95% CI: 257.7-317.9) months. Five- and ten-year survival rates were 98.8% and 91.5%, respectively. Besides, survival time was also observed to be independent of gender, age groups, race, marital status, tumor location, and year of diagnosis. CONCLUSION: Adamantinoma is a very rare bone tumor that affects the long bones in lower extremities and is more common in men. Five- and 10-year survival prognoses are reasonably satisfactory. Also, survival time is independent of variables such as gender, age, and tumor location.

Epidemiology, incidence, and survival of synovial sarcoma subtypes: SEER database analysis.

BACKGROUND: Synovial sarcoma (SyS) is a rare malignancy that is typically located on the limbs and occurs predominantly in adolescents. A study in a large population for SyS comparing subtypes has not yet been reported. METHODS: National Cancer Institute's Surveillance, Epidemiology, and End Results database was queried for patients diagnosed with SyS between January 1975 and December 2016. Patients were classified demographically according to gender, age, race/ethnicity, and marital status, and they were also classified by tumors, subtypes, localization, grade, year of diagnosis, laterality, type of treatment, and follow-up results. RESULTS: A total of 3228 patients were included, with a mean age of 39.3 ± 18.8 (range: 1-94), of which 1521 (47.1%) were females and 1707 (52.9%) were males. According to its subtypes, 47.2% were SyS not otherwise specified, 32.3% were spindle cell, 19.9% were biphasic, and 0.6% were epithelioid type. The overall survival period is 138.0 (95% confidence interval: 113.2-162.8) months. Survival duration was found to be significantly different between groups according to gender (log-rank test; p < 0.001), age groups (log-rank test; p < 0.001), race (log-rank test; p = 0.001), marital status (log-rank test; p < 0.001), tumor subtypes (log-rank test; p < 0.001), tumor location (log-rank test; p < 0.001), tumor laterality (log-rank test; p < 0.001), date of diagnosis (log-rank test; p = 0.025), tumor grade (log-rank test; p < 0.001), historic stage (log-rank test; p < 0.001), state of chemotherapy (log-rank test; p < 0.001), state of radiotherapy (log-rank test; p < 0.001), presence of metastasis (log-rank test; p < 0.001), and total number of malignant tumors (log-rank test; p < 0.001). CONCLUSION: Male gender, being colored individual, being over 35 years at the time of diagnosis, epithelioid type, non-head and neck region localization is associated with poor prognosis. While radiotherapy improves survival, benefit of chemotherapy is unclear. LEVEL OF EVIDENCE: III retrospective analysis.