Analysis of the Effect of the Size and Grade of Soft Tissue Sarcoma on Rates of Unplanned Resection, Metastatic Disease, Mortality, and Morbid Re-Resection Over 20 Years.

Soft tissue sarcomas are rare malignancies that are often presumed to be benign and are resected without the typical preoperative workup, such as imaging or biopsy. These unplanned resections occur in approximately 30% of all cases and frequently require further morbid treatments, resulting in worse oncologic outcomes. A retrospective review was performed of all patients who presented to a tertiary sarcoma center with a diagnosis of sarcoma between 1996 and 2017. In-depth chart reviews were performed for the 2600 patients who were identified, with 836 having a primary diagnosis of soft tissue sarcoma in an upper or lower extremity. Data collected included histologic features, grade, size, resection status, demographic features, referral information, metastatic disease, morbid procedures, and mortality rate. Patients were divided into 2 groups based on whether the tumor size was greater or less than 5 cm. This classification was in keeping with the guideline of referring patients to a tertiary sarcoma center for workup for tumors "larger than a golf ball." The difference in the rate of unplanned resection for tumors measuring less than 5 cm (41.6%) and those measuring 5 cm or greater (18.8%) was statistically significant (P<.001), with smaller tumors more likely to undergo unplanned resection, in keeping with the success of the "golf ball rule." The rate of metastatic disease for unplanned resection for tumors measuring 5 cm or greater (50.7%) was significantly greater than that for tumors measuring less than 5 cm (19.7%) (P<.001). The authors found a great deal of morbidity associated with unplanned resection, regardless of tumor size. Before resection is planned, delineation is required beyond tumor size. [Orthopedics. 2021;44(3):166-171.].

Repair Surface Conditioning Measures Affect Enamel and Dentin Bond Strength.

CLINICAL RELEVANCE: Contamination of enamel and dentin with repair surface conditioning measures should be avoided. SUMMARY: Objectives: To analyze whether the contamination with different repair conditioning measures impairs the adhesive performance of a universal adhesive applied in etch-and-rinse mode (ER) or self-etch mode (SE).Methods and Materials: Bovine enamel and dentin surfaces (each subgroup n=16) were bonded with a universal adhesive in ER or SE after contamination with different repair conditioning measures (sandblasting, silica coating, hydrofluoric acid etching, self-etching ceramic primer). In half of the groups, sand-blasting, silica coating, and hydrofluoric acid etching was followed by the use of a universal primer. If the universal adhesive was applied in ER, contamination was performed either before or after phosphoric acid etching. If the universal adhesive was applied in SE, bonding was performed after contamination. In the control groups, no contamination was simulated. Shear bond strength (SBS) and failure modes of composite buildups were determined after thermal cycling (10,000 cycles, 5°C-55°C). Statistical analysis was performed using analyses of variance, Weibull statistics, and χ2 tests (p<0.05).Results: In ER, sandblasting and silica coating significantly reduced SBS (control: enamel =25.7±4.2 MPa; dentin = 22.0±5.3 MPa) only when performed after phosphoric acid etching. Contamination with hydrofluoric acid impaired SBS on enamel but not on dentin. The self-etching ceramic primer reduced SBS, but not significantly. The contamination with the universal primer had no significant effect. In SE, all repair conditioning measures except the universal primer reduced SBS (control: enamel = 20.3±5.5 MPa; dentin = 23.0±4.0 MPa).Conclusion: Contamination of enamel and dentin by repair conditioning measures potentially affects bond strength.

Childbearing Decisions in Residency: A Multicenter Survey of Female Residents.

PURPOSE: To characterize how female residents make decisions about childbearing, factors associated with the decision to delay childbearing, and satisfaction with these decisions. METHOD: In 2017, the authors sent a voluntary, anonymous survey to 1,537 female residents enrolled across 78 graduate medical education programs, consisting of 25 unique specialties, at 6 U.S. academic medical centers. Survey items included personal, partner, and institutional characteristics, whether the respondent was delaying childbearing during residency, and the respondent's satisfaction with this decision. RESULTS: The survey response rate was 52% (n = 804). Among the 447 (56%) respondents who were married or partnered, 274 (61%) were delaying childbearing. Residents delaying childbearing were significantly more likely to be younger (P < .001), not currently a parent (P < .001), in a specialty with an uncontrollable lifestyle (P = .001), or in a large program (P = .004). Among self-reported reasons for delaying childbearing, which were not mutually exclusive, the majority cited a busy work schedule (n = 255; 93%) and desire not to extend residency training (n = 145; 53%). Many cited lack of access to childcare (n = 126; 46%), financial concerns (n = 116; 42%), fear of burdening colleagues (n = 96; 35%), and concern for pregnancy complications (n = 74; 27%). Only 38% (n = 103) of respondents delaying childbearing were satisfied with this decision, with satisfaction decreasing with increasing age. CONCLUSIONS: Decisions to delay childbearing are more common in certain specialties, and many residents who delay childbearing are not satisfied with that decision. These findings suggest that greater attention is needed overall, and particularly in certain specialties, to promote policies and cultures that both anticipate and normalize parenthood in residency, thus minimizing the conflict between biological and professional choices for female residents.

Maternity Leave in Residency: A Multicenter Study of Determinants and Wellness Outcomes.

PURPOSE: To characterize determinants of resident maternity leave and the effect of length of leave on maternal well-being. METHOD: In 2017, the authors sent a voluntary, anonymous survey to female residents at 78 programs, in 25 unique specialties, at 6 institutions. Survey items included personal, partner, and child demographics, and logistics of leave, including whether leave was paid or vacation or sick leave was used. Outcomes were maternity leave length; duration of breastfeeding; burnout and postpartum depression screens; perceptions of support; and satisfaction with length of leave, breastfeeding, and childbearing during residency. RESULTS: Fifty-two percent (804/1,537) of residents responded. Among 16% (126) of respondents who were mothers, 50% (63) had their first child during residency. Seventy-seven maternity leaves were reported (range, 2-40 weeks), with most taking 6 weeks (32% of leaves; 25) and including vacation (81%; 62) or sick leave (64%; 49). Length of leave was associated with institution, use of sick leave or vacation, and amount of paid leave. The most frequently self-reported determinant of leave was the desire not to extend residency training (27%; 59). Training was not extended for 53% (41) of mothers; 9% (7) were unsure. Longer breastfeeding duration and perceptions of logistical support from program administration were associated with longer maternity leaves. Burnout affected approximately 50% (38) of mothers regardless of leave length. CONCLUSIONS: This study illustrates variability in administration of resident maternity leaves. Targets for intervention include policy clarification, improving program support, and consideration of parent wellness upon return to work.

Differential Outcomes and Biologic Markers of Radiation-Associated vs. Sporadic Osteosarcoma: A Single-Institution Experience.

Background: Radiation-associated osteosarcoma (RAO) is a rare, life-threatening complication from radiation. Many physicians presume RAO has a worse prognosis than sporadic osteosarcoma (SO), although limited objective data exist. We conducted a retrospective study comparing these entities. Methods: We identified adults treated at our institution with osteosarcoma (1990-2016) and categorized tumors as SO or RAO based on location within a prior radiation field. We extracted data on demographics, treatment and primary malignancy and examined available tumor samples for MTA-1 and ezrin using immunohistochemistry (IHC). Results: Of 159 identified patients, 28 had RAO, diagnosed at a median interval from radiation of 11.5 years (1.5-28 years). Median follow-up was 2.8 years (0.1-19.6 years). Median progression free survival (PFS) and overall survival (OS) were not significantly different in the small population of patients with metastases, SO (n = 20) vs. RAO (n = 6): PFS 10.3 months vs. 4.8 months (p = 0.45) and OS 15.6 months vs. 6.1 months (p = 0.96), respectively. For the larger group with localized disease, median relapse-free survival (RFS) and OS were significantly different, NR vs. 12.2 months (p < 0.001) and NR vs. 27.6 months (p = 0.001) in SO (n = 111) vs. RAO (n = 22), respectively. On IHC, there were significant differences in distribution of high, intermediate or low MTA-1 (p = 0.015) and ezrin (p = 0.002) between RAO and SO tumors. Conclusions: Patients with metastases at diagnosis fared poorly irrespective of prior radiation. RAO patients with localized disease had worse outcomes without detectable differences in therapy rendered or treatment effect in resected specimens. Higher expression of MTA-1 in RAO patients may suggest an underlying difference in tumor biology to explain differences in outcomes.

Surgical Approach to Bone Metastases.

PURPOSE OF REVIEW: The purpose of this review was to examine the recent changes in the surgical treatment of bone metastases and how the treatment paradigm has shifted with the improvement of adjuvant therapies. How surgery fits into the local and systemic treatment was reviewed for bone metastases in different areas. RECENT FINDINGS: The more common use of targeted chemotherapies and focused high-dose radiation have altered the treatment paradigm of bone metastases. Overall changes in the surgical treatment of bone metastases have been driven by an increased multidisciplinary approach to metastatic cancer and the awareness that one type of surgery does not work for all patients. The individual patient treatment goals dictate the surgical procedures used to achieve these goals. Advancements in adjuvant therapy-like radiation and more targeted chemotherapies have allowed for less invasive surgical approaches and therefore faster recoveries and reduced surgical morbidity for patients.

NCCN Guidelines Insights: Multiple Myeloma, Version 3.2018.

The NCCN Guidelines for Multiple Myeloma provide recommendations for diagnosis, evaluation, treatment, including supportive-care, and follow-up for patients with myeloma. These NCCN Guidelines Insights highlight the important updates/changes specific to the myeloma therapy options in the 2018 version of the NCCN Guidelines.

Early diastolic septal movement in patients with myocarditis.

AIM: To evaluate early diastolic septal relaxation as a parameter in the diagnostic workup via cardiovascular magnetic resonance imaging (CMRI) in patients with myocarditis. MATERIALS AND METHODS: Early diastolic septal movement was evaluated (EDS) prospectively via frame-by-frame analysis in 255 consecutive patients with presenting signs of myocarditis and in 64 controls matched 4:1 for gender and age. ECG-triggered, T2-weighted, fast spin echo triple inversion recovery sequences and late gadolinium enhancement were obtained, as well as left ventricular (LV) function and dimensions in patients and controls. RESULTS: EDS was detected in 66.7% of the patients and 18.7% of the controls (p<0.001). Sensitivity was 69.4% and specificity 79.7%. Patients with EDS had a significant lower LV ejection fraction (LV-EF) of 61.1±0.6% and significant higher end-diastolic volume (EDV) of 158.5±2.7 ml than in patients without EDS (LV-EF 65.3±0.9%, p=0.0001; EDV 148.4±3.9 ml, p=0.04). A significant negative correlation was observed between LV-EF and EDS in patients, and a lower LV-EF correlated with a more frequent occurrence of EDS (r=-0.24, p=0.0001). Scar tissue was also more frequent in patients than controls (63.1% and 7.8%, p=0.007). CONCLUSIONS: EDS is a parameter obtained non-invasively by CMRI and is present in a high percentage of patients with myocarditis. Cardiac functional parameters are significantly altered in patients with EDS. EDS is a feasible parameter that can play an important role in the diagnosis of myocarditis.

Role of Bone-Modifying Agents in Metastatic Breast Cancer: An American Society of Clinical Oncology-Cancer Care Ontario Focused Guideline Update.

Purpose To update, in collaboration with Cancer Care Ontario (CCO), key recommendations of the American Society of Clinical Oncology (ASCO) guideline on the role of bone-modifying agents (BMAs) in metastatic breast cancer. This focused update addressed the new data on intervals between dosing and the role of BMAs in control of bone pain. Methods A joint ASCO-CCO Update Committee conducted targeted systematic literature reviews to identify relevant studies. Results The Update Committee reviewed three phase III noninferiority trials of dosing intervals, one systematic review and meta-analysis of studies of de-escalation of BMAs, and two randomized trials of BMAs in control of pain secondary to bone metastases. Recommendations Patients with breast cancer who have evidence of bone metastases should be treated with BMAs. Options include denosumab, 120 mg subcutaneously, every 4 weeks; pamidronate, 90 mg intravenously, every 3 to 4 weeks; or zoledronic acid, 4 mg intravenously every 12 weeks or every 3 to 4 weeks. The analgesic effects of BMAs are modest, and they should not be used alone for bone pain. The Update Committee recommends that the current standard of care for supportive care and pain management-analgesia, adjunct therapies, radiotherapy, surgery, systemic anticancer therapy, and referral to supportive care and pain management-be applied. Evidence is insufficient to support the use of one BMA over another. Additional information is available at www.asco.org/breast-cancer-guidelines and www.asco.org/guidelineswiki .

[Indications and technique for transconjunctival optic nerve sheath fenestration : Video article]. / Indikation und Technik der transkonjunktivalen Optikusscheidenfensterung : Videobeitrag.

BACKGROUND: Placement of a ventricular shunt is the primary surgical procedure for lowering intracranial pressure in pseudotumor cerebri syndrome; however, if ophthalmological symptoms prevail over neurological symptoms or if there are no neurological symptoms at all, optic nerve sheath fenestration may be a valuable option for relief of pressure on the retrobulbar optic nerve when papilledema caused by pseudotumor cerebri syndrome threatens vision despite previous conservative measures. METHODS: This review covers the indications, technique and results of optic nerve sheath fenestration compared to competing procedures based on a systematic literature search, analysis of own cases and a documentation of the surgical technique. SURGICAL TECHNIQUE: After performing a medial transconjunctival orbitotomy the medial rectus muscle tendon is temporarily detached and the eye abducted by traction sutures. Using confocal illumination under a surgical microscope, the optic nerve can be visualized using orbital spatulas and the sheath can be punctured with a microscalpel. A video of this operation is available online. CONCLUSION: Transconjunctival optic nerve sheath fenestration is a relatively safe method to reduce the rate of visual loss in pseudotumor cerebri syndrome. In selected cases it can be a useful alternative to ventriculoperitoneal/atrial shunts or venous stents.

Implantation of CARILLON® Mitral Contour System with transvenous left ventricular lead in place.

BACKGROUND: Cardiac resynchronisation therapy (CRT) is an established treatment option for chronic heart failure patients with left bundle branch block. Although a concomitant functional mitral regurgitation is often reduced by CRT, many patients need additional mitral valve repair. Placing a CARILLON® Mitral Contour System (CMCS) over a transvenous CRT lead is currently not recommended, since both of them are implanted in the coronary sinus (CS). The aim of this study was to investigate the feasibility of sequential implantation of a transvenous LV lead followed by CMCS implantation, and to assess LV lead performance and possibility of extraction. METHODS AND RESULTS: Standard transvenous LV leads were implanted in the CS of five female sheep. After establishing regular anatomical position with stable electrical parameters of the LV lead, a CMCS was additionally implanted in the CS. After an observation period of 100 days, lead performance and positions of lead and CMCS were studied. Sequential implantation of the two components was feasible in sheep. After 100 days, all leads showed regular measurements of impedance, threshold, and sensing. There was no migration of either the LV lead or the CMCS. In all cases, the LV lead could be completely extracted without migration of the CMCS. There were no acute or long-term complications. CONCLUSIONS: In an animal model of healthy adult sheep, implantation of CMCS with a transvenous LV lead already in place was feasible and without major problems with either the CMCS or the LV lead. Electrical performance of the LV leads was excellent. All LV leads could be extracted without migration of the CMCS.

Root Cause Analysis and Actions for the Prevention of Medical Errors: Quality Improvement and Resident Education.

The quality of care delivered by orthopedic surgeons continues to grow in importance. Multiple orthopedic programs, organizations, and committees have been created to measure the quality of surgical care and reduce the incidence of medical adverse events. Structured root cause analysis and actions (RCA2) has become an area of interest. If performed thoroughly, RCA2 has been shown to reduce surgical errors across many subspecialties. The Accreditation Council for Graduate Medical Education has a new mandate for programs to involve residents in quality improvement processes. Resident engagement in the RCA2 process has the dual benefit of educating trainees in patient safety and producing meaningful changes to patient care that may not occur with traditional quality improvement initiatives. The RCA2 process described in this article can provide a model for the development of quality improvement programs. In this article, the authors discuss the history and methods of the RCA2 process, provide a stepwise approach, and give a case example. [Orthopedics. 2017; 40(4):e628-e635.].

NCCN Guidelines Insights: Bone Cancer, Version 2.2017.

The NCCN Guidelines for Bone Cancer provide interdisciplinary recommendations for treating chordoma, chondrosarcoma, giant cell tumor of bone, Ewing sarcoma, and osteosarcoma. These NCCN Guidelines Insights summarize the NCCN Bone Cancer Panel's guideline recommendations for treating Ewing sarcoma. The data underlying these treatment recommendations are also discussed.

Multiple Myeloma, Version 3.2017, NCCN Clinical Practice Guidelines in Oncology.

Multiple myeloma (MM) is caused by the neoplastic proliferation of plasma cells. These neoplastic plasma cells proliferate and produce monoclonal immunoglobulin in the bone marrow causing skeletal damage, a hallmark of multiple myeloma. Other MM-related complications include hypercalcemia, renal insufficiency, anemia, and infections. The NCCN Multiple Myeloma Panel members have developed guidelines for the management of patients with various plasma cell dyscrasias, including solitary plasmacytoma, smoldering myeloma, multiple myeloma, systemic light chain amyloidosis, and Waldenström's macroglobulinemia. The recommendations specific to the diagnosis and treatment of patients with newly diagnosed MM are discussed in this article.

Implementation of a Service-Specific Template Integrating Objective Structured Clinical Examination and Accreditation Council for Graduate Medical Education Milestones: One Institution's Experience.

The Accreditation Council for Graduate Medical Education (ACGME) orthopaedic milestones require detailed, frequent resident evaluations. This institution desired a cost-effective objective structured clinical examination (OSCE) to facilitate these evaluations. Data were collected as a prospective, uncontrolled observational study. The OSCE was completed by residents entering and exiting the foot and ankle rotation during postgraduate years 2 and 4. Physician assistants functioned as standardized patients. Statistical analyses were performed using paired and independent t tests. The OSCE was implemented using reliable, low-cost modalities and has facilitated milestones evaluations. Preliminary data show 4th-year residents performed higher in prerotation global assessment with a standardized patient and written exam (p < .03). Second-year residents showed improvement in the written exam on rotation completion (p = .03). Using this methodology, institutions may establish similar cost-effective OSCEs as feasible evaluative solutions to satisfy milestone requirements. The authors believe this tool may be modified for any specialty. (Journal of Surgical Orthopaedic Advances 26(4):257-261, 2017).

How to perform a root cause analysis for workup and future prevention of medical errors: a review.

Providing quality patient care is a basic tenant of medical and surgical practice. Multiple orthopaedic programs, including The Patient Safety Committee of the American Academy of Orthopaedic Surgeons (AAOS), have been implemented to measure quality of surgical care, as well as reduce the incidence of medical errors. Structured Root Cause Analysis (RCA) has become a recent area of interest and, if performed thoroughly, has been shown to reduce surgical errors across many subspecialties. There is a paucity of literature on how the process of a RCA can be effectively implemented. The current review was designed to provide a structured approach on how to conduct a formal root cause analysis. Utilization of this methodology may be effective in the prevention of medical errors.

Staged Soft Tissue Reconstruction Following Sarcoma Excision with Anticipated Large Cutaneous Defects: An Oncologically Safe Alternative.

BACKGROUND: We hypothesized that select patients undergoing planned soft tissue sarcoma (STS) excision with anticipated skin and soft tissue deficits could be treated with a two stage surgical procedure which would allow some flexibility in coverage options while not significantly increasing local recurrence rate or wound complication rate. METHODS: A retrospective review was undertaken in a series of consecutive patients with a minimum 2-year follow-up treated by a single orthopedic oncologist and a single reconstructive plastic surgeon who were managed with a staged approach STS excision and reconstruction. RESULTS: There were 73 patients identified over a ten-year period that underwent staged STS excision and soft tissue reconstruction. There were 12 (16%) initial positive margins resected to negative final margins, and a variety of coverage procedures performed. Wound complication rate was 21%. Local recurrence rate was 11%. CONCLUSION: Staged STS excision and reconstruction is an acceptable tool in the armamentarium of the orthopedic oncologist for managing major soft tissue deficits without an increase in local recurrence rates.

NCCN Guidelines Insights: Multiple Myeloma, Version 3.2016.

These NCCN Guidelines Insights highlight the important updates/changes specific to the 2016 version of the NCCN Clinical Practice Guidelines in Oncology for Multiple Myeloma. These changes include updated recommendations to the overall management of multiple myeloma from diagnosis and staging to new treatment options.