Reverse Fragility Index: Comparing Revision Rates Between Direct Anterior and Other Approaches in Total Hip Arthroplasty. A Systematic Review of Randomized Controlled Trials.

BACKGROUND: Despite increasing adoption of the direct anterior (DA) approach in total hip arthroplasty (THA), uncertainty persists regarding its outcomes beyond the 1-year mark in comparison to other approaches. We used the reverse fragility index (RFI) to evaluate the robustness of reported findings in the literature. METHODS: We conducted a systematic review of randomized controlled trials (RCTs) comparing implant revision rates between DA and other approaches in THA, defined as all those different from DA. Our primary outcome was the RFI, which gauges the number of events needed for a nonsignificant result to become significant, in the revision rate between DA and other approaches. We also calculated the reverse fragility quotient by dividing the RFI by each study's sample size. Median values and interquartile ranges (IQRs) were displayed. RESULTS: A total of 10 RCTs with a total of 971 patients were included. The median RFI was 5 (IQR, 4 to 5), indicating the study's results would be statistically significant if the outcomes of 5 patients in 1 treatment arm were reversed. The median reverse fragility quotient was 0.049 (IQR, 0.04 to 0.057), indicating that a change of outcome in 4.9% of patients would render the revision rate significant. The median number of patients lost to follow-up was 4 (IQR, 0 to 7). Of the 10 RCTs, 6 had more patients lost to follow-up than their respective RFI values. CONCLUSIONS: Notable fragility was evidenced in most studies comparing DA to other approaches for THA. Surgeons should not solely rely on the P value to determine clinical significance and instead use multiple metrics. LEVEL OF EVIDENCE: II.

Treatment and Outcomes of 4,973 Unicameral Bone Cysts: A Systematic Review and Meta-Analysis.

¼ Unicameral bone cysts (UBCs) can increase the risk of pathologic fractures of both long and short bones. Although multiple treatments exist, data are conflicting regarding optimal management.¼ We sought to analyze treatment strategies for UBCs and their rates of successful treatment.¼ Success rates were analyzed according to treatment modality, with emphasis on filling techniques and/or decompression associated with curettage, and injection compounds.¼ Curettage with bone substitute and cyst decompression was identified as a highly successful technique for UBC treatment.¼ Decompressing the cyst wall after injection, regardless of the specific compound used, had a greater potential to enhance healing rates.¼ The management decision should be individually guided within the patient's context.

Is Unplanned Excision of Soft Tissue Sarcomas Associated with Worse Oncological Outcomes?-A Systematic Review and Meta-Analysis.

BACKGROUND: Soft tissue sarcomas are a group of rare neoplasms which can be mistaken for benign masses and be excised in a non-oncologic fashion (unplanned excision). Whether unplanned excision (UE) is associated with worse outcomes is highly debated due to conflicting evidence. METHODS: We performed a systematic review and meta-analysis following PRISMA guidelines. Main outcomes analyzed were five-year overall survival (OS), five-year local recurrence-free survival (LRFS), amputation rate and plastic reconstruction surgery rate. Risk ratios were used to compare outcomes between patients treated with planned and unplanned excision. RESULTS: We included 16,946 patients with STS, 6017 (35.5%) with UE. UE was associated with worse five-year LRFS (RR 1.35, p = 0.019). Residual tumor on the tumor bed was associated with lower five-year LRFS (RR = 2.59, p < 0.001). Local recurrence was associated with worse five-year OS (RR = 1.82, p < 0.001). UE was not associated with a worse five-year OS (RR = 0.90, p = 0.16), higher amputation rate (RR = 0.77, p = 0.134), or a worse plastic reconstruction surgery rate (RR = 1.25, p = 0.244). CONCLUSIONS: Unplanned excision of Soft Tissue Sarcomas and the presence of disease in tumor bed after one were associated with worse five-year LRFS. Tumor bed excision should remain the standard approach, with special consideration to the presence of residual disease.

A Bibliometric Analysis of the 500 Most Cited Papers in Orthopaedic Oncology.

BACKGROUND: Despite notable progress over time, broad insight into the scientific landscape of orthopaedic oncology is lacking. We conducted a bibliometric analysis of the 500 most cited papers in the field. METHODS: We searched the Science Citation Index Expanded database of the Web of Science Core Collection to find the 500 most cited articles in the field. RESULTS: Citation count ranged from 81 to 1,808. Articles were published from 1965 to 2018. Over half of all articles were published in the United States (53.6%). The 2000s was the most productive decade with 170 (34%) articles. All articles were written in English and were published across 29 journals. Female participation as first authors significantly increased from the 1960s to the 2010s (0% vs 14.6%, P = 0.0434). Similarly, female involvement as senior authors grew from the 1960s to the 2010s (0% vs 12.2%, P = 0.0607). Primary bone sarcomas were the most cited topic among articles from the 1970s to the 1980s. From studies produced in the 1990s up until the 2010s, reconstruction procedures were the most cited topic. CONCLUSION: Trends over the years have resulted in an emphasis on a surgical technique. Notable progress has been made regarding gender diversity, yet disparities still exist.

Postoperative Outcomes of Total Femur Replacement in Oncologic and Nononcologic Patients: A Systematic Review of the Literature.

BACKGROUND: Total femur replacement (TFR) is used for primary reconstruction after extensive tumor resection or as a revision surgery due to prosthetic failure. Studies on TFR rates of failure and functional outcomes are scarce. The purpose of our study was to compare the modes of failure, amputation rates, and functional outcomes after TFR between oncologic and nononcologic patients. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were for this manuscript. Our study was registered on PROSPERO (413582). Quality assessment of all studies was performed using Strengthening the Reporting of Observational Studies in Epidemiology checklist. Endoprosthesis failure was assessed using the Henderson classification and functional outcomes using the Musculoskeletal Tumor Society score. Weighted means and standard deviations were calculated. RESULTS: Overall failure rate was similar between groups. Henderson type 4 failures were more common within the nononcologic group, while the others were more frequently found in the oncologic group. Overall amputation rate was higher in the oncologic group mainly due to type 5 failure. Amputations occurred mainly after type 4 and type 5 failures. Functional outcome was better within the oncologic group (70.5 versus 61.7, respectively; P < .001). CONCLUSIONS: Total femoral replacement in the oncologic and nononcologic group is associated with a high rate of failure (31% and 32.5%, respectively). Overall amputation rate was higher in the oncologic group mainly due to type 5 failure. Functional outcome was better within the oncologic group. LEVEL OF EVIDENCE: Level III.

Foot and Ankle Soft Tissue Sarcomas-Treatment and Oncologic Outcomes: A Systematic Review of the Literature.

BACKGROUND: Foot and ankle soft tissue sarcomas (STSs) are rare neoplasms associated with a high risk of local recurrence and metastasis. Although amputation is often performed, its impact on prognosis remains unknown. The aims of our systematic review were identifying risk factors for (1) disease-specific death, (2) local recurrence, (3) metastasis, and assessing (4) whether the type of surgery (amputation or limb-salvage) affected disease-specific survival. METHODS: This systematic review was conducted following PRISMA guidelines. The PubMed, Embase, and Scopus databases were searched. Our study was registered in PROSPERO (ID: 415624). Quality appraisal was done using STROBE guidelines. RESULTS: A total of 7 studies and 123 patients were included. Metastasis was the only risk factor for disease-specific death (OR = 107.85, P< .001). Previous unplanned excision (OR = 22.29, P = .009) and positive margins (OR = 64.48, P = .011) were associated with higher risk of local recurrence. Patients with high-grade tumors (OR = 13.22, P = .023) and tumors ≥6 cm (OR = 7.40, P = .022) were more likely to develop metastases. After adjusting for confounders (age, sex, and presence of metastasis), amputation was not associated with poorer disease-specific survival. CONCLUSION: Metastasis was the single most important risk factor for death with foot and ankle soft tissue sarcoma. Positive margins and history of previous unplanned excision are risk factors for local recurrence. The most important risk factors for metastasis are tumor grade and size ≥6 cm. Amputation was not associated with poorer disease-specific survival.