Surgical Margins in Musculoskeletal Sarcoma.

¼ Negative margin resection of musculoskeletal sarcomas is associated with reduced risk of local recurrence.¼ There is limited evidence to support an absolute margin width of soft tissue or bone that correlates with reduced risk of local recurrence.¼ Factors intrinsic to the tumor, including histologic subtype, grade, growth pattern and neurovascular involvement impact margin status and local recurrence, and should be considered when evaluating a patient's individual risk after positive margins.¼ Appropriate use of adjuvant therapy, critical analysis of preoperative advanced cross-sectional imaging, and the involvement of a multidisciplinary team are essential to obtain negative margins when resecting sarcomas.

3D Specimen Scanning and Mapping in Musculoskeletal Oncology: A Feasibility Study.

BACKGROUND: Surgical resection is the primary treatment for bone and soft tissue tumors. Negative margin status is a key factor in prognosis. Given the three-dimensional (3D) anatomic complexity of musculoskeletal tumor specimens, communication of margin results between surgeons and pathologists is challenging. We sought to perform ex vivo 3D scanning of musculoskeletal oncology specimens to enhance communication between surgeons and pathologists. METHODS: Immediately after surgical resection, 3D scanning of the fresh specimen is performed prior to frozen section analysis. During pathologic grossing, whether frozen or permanent, margin sampling sites are annotated on the virtual 3D model using computer-aided design (CAD) software. RESULTS: 3D scanning was performed in seven cases (six soft tissue, one bone), with specimen mapping on six cases. Intraoperative 3D scanning and mapping was performed in one case in which the location of margin sampling was shown virtually in real-time to the operating surgeon to help achieve a negative margin. In six cases, the 3D model was used to communicate final permanent section analysis. Soft tissue, cartilage, and bone (including lytic lesions within bone) showed acceptable resolution. CONCLUSIONS: Virtual 3D scanning and specimen mapping is feasible and may allow for enhanced documentation and communication. This protocol provides useful information for anatomically complex musculoskeletal tumor specimens. Future studies will evaluate the effect of the protocol on positive margin rates, likelihood that a re-resection contains additional malignancy, and exploration of targeted adjuvant radiation protocols using a patient-specific 3D specimen map.

Utility of iliac crest tetracycline-labelled bone biopsy in osteoporosis and metabolic bone disease: An evaluation of 95 cases over a period of 25 years.

Background: Metabolic bone diseases (MBD) are typically diagnosed by non-invasive imaging and clinical biomarkers. However, imaging does not provide structural information, and biomarkers can be transiently affected by many systemic factors. Bone biopsy and pathologic evaluation is the gold standard for diagnosis of MBD, however, it is rarely utilized. We describe our technique for iliac crest tetracycline-labelled bone using a cannulated drill and assess the utility of bone biopsies to provide diagnostic and therapeutic guidance. Methods: In the 25-year period between March 1998 and January 2023, a total of 95 bone biopsies were performed on 94 patients for an osteological indication at Vanderbilt University Medical Center (VUMC). Patient demographics, bone biopsy indications, complications, diagnostic utility, and subsequent therapeutic guidance were retrospectively reviewed and analyzed. Results: The procedure had minimal complications and was well tolerated by patients. This technique provided good quality specimens for pathology, which helped establish a diagnosis and treatment change in most patients. Patients that had biopsy-guided treatment alterations showed significant increases in Dual-Energy X-ray Absorptiometry (DEXA) bone mineral density (BMD) scores post-biopsy and subsequent treatment. Conclusion: Despite scientific and technological progress in non-invasive diagnostic imaging, clinical biomarkers, and procedures for MBD, there remains a small but significant subset of patients who may benefit from inclusion of tetracycline-labelled bone biopsy into the diagnostic and therapeutic picture. Future prospective comparison studies are warranted. Mini abstract: Tetracycline-labelled bone biopsies are under-utilized. Biopsy led to a histological diagnosis and ensuing treatment alteration in most patients with significant increases in bone mineral density. The biopsy procedure used herein provided good specimens with low pain/adverse events. Bone biopsy remains a valuable tool in a small, though significant, subset of patients.

Accuracy of Time to Treatment Initiation Data in Musculoskeletal Soft Tissue Sarcoma.

Background: Time to treatment initiation (TTI) is a quality metric in cancer care. The purpose of this study is to determine the accuracy of TTI data from a single cancer center registry that reports to the National Cancer Database (NCDB) for sarcoma diagnoses. Methods: A retrospective analysis of a single Commission on Cancer (CoC)-accredited cancer center's tumor registry between 2006 and 2016 identified 402 patients who underwent treatment of a musculoskeletal soft tissue sarcoma and had TTI data available. Registry-reported TTI was extracted from the tumor registry. Effective TTI was manually calculated by medical record review as the number of days from the date of tissue diagnosis to initiation of first effective treatment. Effective treatment was defined as oncologic surgical excision or initiation of radiation therapy or chemotherapy. Registry-reported TTI and effective TTI values were compared for concordance in all patients. Results: In the entire cohort, 25% (99/402) of patients had TTI data discordance, all related to surgical treatment definition. For patients with a registry-reported value of TTI = 0 days, 74% (87/118) had a diagnostic surgical procedure coded as their first treatment event, with 73 unplanned incomplete excision procedures and 14 incisional biopsies. In these patients, effective TTI was on average 59 days (P < 0.001). For patients with a registry-reported value of TTI >0 days, only 4% (12/284) had discordant TTI values. Conclusions: Nearly three-fourths of patients with a registry-reported value of TTI = 0 days in a large, CoC-accredited cancer center registry had a diagnostic procedure coded as their first treatment event, though their effective treatment had not yet started. These data suggest that TTI is likely longer than what is reported to the NCDB. Redefinition of what constitutes surgical treatment should be considered to improve the accuracy of data used in measuring TTI in sarcoma.

Surgical Fixation Method in Lower Extremity Intercalary Allograft Reconstruction After Oncologic Resection: A Comparison of Plates and Nails.

INTRODUCTION: Fixation in intercalary allograft reconstruction includes plates and intramedullary nails. The purpose of this study was to examine rates of nonunion, fracture, the overall need for revision surgery, and allograft survival based on the surgical fixation method in lower extremity intercalary allografts. METHODS: A retrospective chart review was performed on 51 patients with intercalary allograft reconstruction in the lower extremity. Fixation methods compared were intramedullary fixation with nails (IMN) and extramedullary fixation with plates (EMP). Complications compared were nonunion, fracture, and wound complications. The alpha was set at 0.05 for statistical analysis. RESULTS: Nonunion incidence at all allograft-to-native bone junction sites was 21% (IMN) and 25% (EMP) ( P = 0.8). Fracture incidence was 24% (IMN) and 32% (EMP) ( P = 0.75). Median fracture-free allograft survival was 7.9 years (IMN) and 3.2 years (EMP) ( P = 0.04). Infection was seen in 18% (IMN) and 12% (EMP) ( P = 0.7). The overall need for revision surgery was 59% (IMN) and 71% (EMP) ( P = 0.53). Allograft survival at the final follow-up was 82% (IMN) and 65% (EMP) ( P = 0.33). When the EMP group was subdivided into single plate (SP) and multiple plate (MP) groups and compared with the IMN groups, fracture rates were 24% (IMN), 8% (SP), and 48% (MP) ( P = 0.04). Rates of revision surgery were 59% (IMN), 46% (SP), and 86% (MP) ( P = 0.04). Allograft survival at the final follow-up was 88% (IMN), 92% (SP), and 52% (MP) ( P = 0.05). DISCUSSION: Median fracture-free allograft survival was notably longer for the IMN group than the EMP group; otherwise, there were no notable differences between the intramedullary and extramedullary groups. When the EMP group was subdivided into the SP and MP groups, patients with MPs had higher rates of fracture, higher rates of revision surgery, and lower overall allograft survival. LEVEL OF EVIDENCE: III, Therapeutic Study, Retrospective Comparative Study.

Chronic Recurrent Multifocal Osteomyelitis: A Review of the Noninfectious Inflammatory Bone Disease and Lessons for More Timely Diagnosis.

Chronic recurrent multifocal osteomyelitis (CRMO) is an idiopathic autoinflammatory disease of the bone that typically occurs in children and adolescents. CRMO is characterized by recurrent periods of exacerbation and remission of symptomatic, osteolytic/sclerotic sterile bone lesions and is often a diagnosis of exclusion. Treatment consists of multimodal anti-inflammatory medication management by rheumatology and rarely involves surgery. This review summarizes the clinical presentation, pathophysiology, diagnosis, and management of this disease and highlights the role of the orthopedic surgeon. With increased familiarity with CRMO, clinicians will be able to diagnose and treat the condition in a more timely manner. [Orthopedics. 2023;46(3):e149-e155.].

Is the Number of National Database Research Studies in Musculoskeletal Sarcoma Increasing, and Are These Studies Reliable?

BACKGROUND: Large national databases have become a common source of information on patterns of cancer care in the United States, particularly for low-incidence diseases such as sarcoma. Although aggregating information from many hospitals can achieve statistical power, this may come at a cost when complex variables must be abstracted from the medical record. There is a current lack of understanding of the frequency of use of the Surveillance, Epidemiology, and End Results (SEER) database and the National Cancer Database (NCDB) over the last two decades in musculoskeletal sarcoma research and whether their use tends to produce papers with conflicting findings. QUESTIONS/PURPOSES: (1) Is the number of published studies using the SEER and NCDB databases in musculoskeletal sarcoma research increasing over time? (2) What are the author, journal, and content characteristics of these studies? (3) Do studies using the SEER and the NCDB databases for similar diagnoses and study questions report concordant or discordant key findings? (4) Are the administrative data reported by our institution to the SEER and the NCDB databases concordant with the data in our longitudinally maintained, physician-run orthopaedic oncology dataset? METHODS: To answer our first three questions, PubMed was searched from 2001 through 2020 for all studies using the SEER or the NCDB databases to evaluate sarcoma. Studies were excluded from the review if they did not use these databases or studied anatomic locations other than the extremities, nonretroperitoneal pelvis, trunk, chest wall, or spine. To answer our first question, the number of SEER and NCDB studies were counted by year. The publication rate over the 20-year span was assessed with simple linear regression modeling. The difference in the mean number of studies between 5-year intervals (2001-2005, 2006-2010, 2011-2015, 2016-2020) was also assessed with Student t-tests. To answer our second question, we recorded and summarized descriptive data regarding author, journal, and content for these studies. To answer our third question, we grouped all studies by diagnosis, and then identified studies that shared the same diagnosis and a similar major study question with at least one other study. We then categorized study questions (and their associated studies) as having concordant findings, discordant findings, or mixed findings. Proportions of studies with concordant, discordant, or mixed findings were compared. To answer our fourth question, a coding audit was performed assessing the concordance of nationally reported administrative data from our institution with data from our longitudinally maintained, physician-run orthopaedic oncology dataset in a series of patients during the past 3 years. Our orthopaedic oncology dataset is maintained on a weekly basis by the senior author who manually records data directly from the medical record and sarcoma tumor board consensus notes; this dataset served as the gold standard for data comparison. We compared date of birth, surgery date, margin status, tumor size, clinical stage, and adjuvant treatment. RESULTS: The number of musculoskeletal sarcoma studies using the SEER and the NCDB databases has steadily increased over time in a linear regression model (ß = 2.51; p < 0.001). The mean number of studies per year more than tripled during 2016-2020 compared with 2011-2015 (39 versus 13 studies; mean difference 26 ± 11; p = 0.03). Of the 299 studies in total, 56% (168 of 299) have been published since 2018. Nineteen institutions published more than five studies, and the most studies from one institution was 13. Orthopaedic surgeons authored 35% (104 of 299) of studies, and medical oncology journals published 44% (130 of 299). Of the 94 studies (31% of total [94 of 299]) that shared a major study question with at least one other study, 35% (33 of 94) reported discordant key findings, 29% (27 of 94) reported mixed key findings, and 44% (41 of 94) reported concordant key findings. Both concordant and discordant groups included papers on prognostic factors, demographic factors, and treatment strategies. When we compared nationally reported administrative data from our institution with our orthopaedic oncology dataset, we found clinically important discrepancies in adjuvant treatment (19% [15 of 77]), tumor size (21% [16 of 77]), surgery date (23% [18 of 77]), surgical margins (38% [29 of 77]), and clinical stage (77% [59 of 77]). CONCLUSION: Appropriate use of databases in musculoskeletal cancer research is essential to promote clear interpretation of findings, as almost two-thirds of studies we evaluated that asked similar study questions produced discordant or mixed key findings. Readers should be mindful of the differences in what each database seeks to convey because asking the same questions of different databases may result in different answers depending on what information each database captures. Likewise, differences in how studies determine which patients to include or exclude, how they handle missing data, and what they choose to emphasize may result in different messages getting drawn from large-database studies. Still, given the rarity and heterogeneity of sarcomas, these databases remain particularly useful in musculoskeletal cancer research for nationwide incidence estimations, risk factor/prognostic factor assessment, patient demographic and hospital-level variable assessment, patterns of care over time, and hypothesis generation for future prospective studies. LEVEL OF EVIDENCE: Level III, therapeutic study.

Adjuvant Radiation after Primary Resection of Atypical Lipomatous Tumors of the Extremity Reduces Local Recurrence but Increases Complications: A Multicenter Evaluation.

Background: Radiation after resection of an atypical lipomatous tumor (ALT) is controversial. This study evaluates local control and complications after the first resection of ALTs of the extremity with or without adjuvant radiation. Methods: A dual institution, retrospective review of patients treated from 1995 to 2020 with first-time resection of an ALT in the extremity was performed. In total, 102 patients underwent adjuvant radiation (XRT group) and 68 patients were treated with surgery alone (no-XRT group). The median follow-up time was 4.6 years (interquartile range (IQR) 2.0-7.3 years). The median radiation dose was 60 Gy (IQR 55-66 Gy). Univariable and multivariable analyses evaluated the association of patient, tumor, and treatment variables with recurrence and complications. Kaplan-Meier analysis evaluated local recurrence-free survival (LRFS) and time to complication. Results: The overall incidence of local recurrence was 1% (1/102) in the XRT group and 24% (16/68) in the no-XRT group (p < 0.001). The median time-to-recurrence was 8.2 years (IQR 6.5-10.5 years). In the XRT and the no-XRT groups, 5-yr LRFS was 98% and 92% (p=0.21) and 10-yr LRFS was 98% and 41% (p < 0.001), respectively. The absence of radiation (HR = 23.63, 95% CI (3.09-180.48); p < 0.001) and R2 surgical resection margins (HR = 11.04, 95% CI (2.07-59.03); p < 0.001) incurred a 23-fold and 11-fold increased risk of local recurrence, respectively, while tumor size, depth, location, and neurovascular involvement were not found to be independent predictors of recurrence. The complication rate was 37% (38/102) in the XRT group and 10% (7/68) in the no-XRT group (p < 0.001). Eight patients (8/102, 8%) required surgical management for complication in the XRT group compared with two patients (2/68, 3%) in the no-XRT group (p=0.10). Higher radiation dose had a modest correlation with increased severity of complication (ρ=0.24; p=0.02). Conclusions: Adjuvant radiation after first-time resection of an ALT of the extremity was associated with a significantly reduced risk of local recurrence but a three-fold increase in complication rate. These data support a 10-year follow-up for these patients and inform a notable clinical trade-off if considering adjuvant radiation for this tumor with recurrent potential.

Telemedicine in Orthopedic Oncology During COVID-19: Patient Satisfaction, Reimbursement, and Physical Examination Competency.

The coronavirus disease 2019 (COVID-19) pandemic forced many institutions to implement telemedicine to facilitate continued patient care at a distance. The quality of patient care with telemedicine in orthopedic oncology has not been assessed. Between March and June 2020, a telephone survey of 64 patients was conducted in an academic orthopedic oncology practice. Patient satisfaction was assessed with a Likert scale metric, open-ended feedback, and direct comparisons between telemedicine and in-office visits. Billing and collection financial data of the telemedicine cohort and of a separate cohort of in-office visits during the same time period were compared. The clinical competency of telemedicine visits was measured by delayed or missed diagnoses and surgical site infections that may be attributable to lack of an in-person physical examination. Overall, patients were largely satisfied with their telemedicine experience. More than 90% of patients described telemedicine as equal to or better than in-office visits regarding convenience, time, privacy, and overall quality. Patients reported that better assessment of their physical condition may be indicated, particularly in early postoperative and early sarcoma surveillance visits. Two of 64 patients had adverse events (both local recurrences) potentially attributable to lack of an in-person physical examination. Institutional financial reimbursement of telemedicine visits was comparable to that of in-office visits. These findings have supported continued use of telemedicine in our practice, particularly for patients traveling significant distance and those returning for sarcoma surveillance. However, the limitations of lack of an in-person physical examination should be considered on a case-by-case basis. [Orthopedics. 2021;44(5):274-279.].

Does PET/CT Aid in Detecting Primary Carcinoma in Patients with Skeletal Metastases of Unknown Primary?

BACKGROUND: Patients older than 40 years presenting with osteolytic bone lesions are likely to have a diagnosis of carcinoma, even if they had no prior cancer diagnosis. For patients with no prior cancer diagnosis, there is a well-accepted algorithm to determine a potential primary site. That algorithm, however, leaves approximately 15% of people without a detectable primary tumor site, making treatment decisions extremely difficult. Positron emission tomography (PET) fused with CT, more commonly known as PET/CT, has emerged as an important staging modality for many other malignancies but has been used in a very limited fashion in musculoskeletal oncology. QUESTIONS/PURPOSES: We asked (1) What is the ability of PET/CT to detect the source of the primary tumor in patients with a skeletal metastasis of unknown primary? (2) How does PET/CT perform in detecting metastases in other sites in patients with a skeletal metastasis of unknown primary? METHODS: A retrospective analysis between 2006 and 2016 of the pathology database of a single tertiary center identified 35 patients with a biopsy-proven skeletal metastasis (histologically confirmed carcinoma or adenocarcinoma) and a PET/CT scan that was performed after the standard diagnostic evaluation of the primary cancer site. Patients were identified through use of our pathology database to identify all biopsy-proven bone carcinomas. This was then cross referenced with our imaging database to identify all patients who were at any time evaluated with PET/CT. During this time, we identified 1075 patients with biopsy-proven metastatic bone disease through our pathology database. Any indication for a PET/CT was included, and was most often done for staging of the identified malignancy or evaluation for the unknown source. Data regarding the ability of PET/CT to find or confirm the primary cancer and all metastatic sites were evaluated. The standard diagnostic evaluation (history and physical, laboratory evaluation, CT of the chest/abdomen/pelvis and whole body bone scan) identified the primary cancer in 22 of the 35 patients. Among the 35 patients, there were a total of 176 metastatic sites of disease identified, with 115 identified with the standard diagnostic evaluation (before PET/CT). RESULTS: Among patients with a skeletal metastasis of unknown primary, PET/CT was unable to identify the primary cancer in 12 of 13 patients. PET/CT confirmed the site of the known primary cancer in all 22 patients. There were 176 total metastatic sites. Of the 115 metastases known before PET/CT, PET/CT failed to identify three of 115 (3% false-negative rate). CONCLUSIONS: PET/CT may not provide any additional benefit over the standard evaluation for identification of the primary cancer in patients with a skeletal metastasis of unknown primary, although it may have efficacy as a screening tool equivalent or superior to the standard diagnostic algorithm for evaluation of the overall metastatic burden in these patients. LEVEL OF EVIDENCE: Level III, diagnostic study.

Time to Treatment Initiation and Survival in Adult Localized High-Grade Bone Sarcoma.

OBJECTIVE: Few studies have evaluated the prognostic implication of the length of time from diagnosis to treatment initiation in bone sarcoma. The purpose of this study is to determine if time to treatment initiation (TTI) influences overall survival in adults diagnosed with primary bone sarcoma. METHODS: A retrospective analysis of the National Cancer Database identified 2,122 patients who met inclusion criteria with localized, high-grade bone sarcoma diagnosed between 2004 and 2012. TTI was defined as length of time in days from diagnosis to initiation of treatment. Patient, disease-specific, and healthcare-related factors were also assessed for their association with overall survival. Kruskal-Wallis analysis was utilized for univariate analysis, and Cox regression modeling identified covariates associated with overall survival. RESULTS: Any 10-day increase in TTI was not associated with decreased overall survival (hazard ratio (HR) = 1.00; P=0.72). No differences in survival were detected at 1 year, 5 years, and 10 years, when comparing patients with TTI = 14, 30, 60, 90, and 150 days. Decreased survival was significantly associated (P < 0.05) with patient ages of 51-70 years (HR = 1.66; P=0.004) and > 71 years (HR = 2.89; P < 0.001), Charlson/Deyo score ≥2 (HR = 2.02; P < 0.001), pelvic tumor site (HR = 1.58; P < 0.001), tumor size >8 cm (HR = 1.52; P < 0.001), radiation (HR = 1.81; P < 0.001) as index treatment, and residing a distance of 51-100 miles from the treatment center (HR = 1.30; P=0.012). Increased survival was significantly associated (P < 0.05) with chordoma (HR = 0.27; P=0.010), chondrosarcoma (HR = 0.75; P=0.002), treatment at an academic center (HR = 0.64; P=0.039), and a private (HR = 0.67; P=0.006) or Medicare (HR = 0.71; P=0.043) insurer. A transition in care was not associated with a survival disadvantage (HR = 0.90; P=0.14). CONCLUSIONS: Longer TTI was not associated with decreased overall survival in localized, high-grade primary bone sarcoma in adults. This is important in counseling patients, who may delay treatment to receive a second opinion or seek referral to a higher volume sarcoma center.

Osteoid Osteoma Masquerading as Cholelithiasis: A Case Report.

CASE: We present a case report of an 18-year-old woman who presented to a general surgeon with a several month history of intermittent right upper quadrant pain, strongly suggestive of symptomatic cholelithiasis and underwent a laparoscopic cholecystectomy. She was eventually found to have an osteoid osteoma (OO) of the right eighth rib. She was treated with radiofrequency ablation with complete resolution of symptoms 1 month after treatment. CONCLUSIONS: In cases where a patient's age and risk factors would make the diagnosis of cholelithiasis less likely, OO should be added to the differential diagnosis of symptomatic right upper quadrant pain.

Immediate Versus Staged Soft Tissue Reconstruction After Soft Tissue Sarcoma Resection Has Similar Wound and Oncologic Outcomes.

BACKGROUND: The aim of this study was to compare the wound complication rate and oncologic outcome in patients undergoing immediate versus staged soft tissue reconstruction after soft tissue sarcoma (STS) resection. METHODS: This is a retrospective analysis of a single sarcoma referral center between 2006 and 2016 which identified a cohort that underwent resection of an extremity or trunk STS with reconstruction surgery (split thickness skin graft or flap coverage). Patients were divided into 2 groups based on the reconstruction timing: immediate (same day) versus staged (later date). Demographic characteristics, wound complications, and oncologic outcomes were compared. RESULTS: Of the 491 patients who underwent resection of an extremity or trunk STS, 81 (16%) received reconstructive surgery, with 26 patients undergoing immediate reconstruction and 55 patients undergoing staged reconstruction. Overall wound complication (58% vs 45%, P = 0.347) and infection rates (35% vs 25%, P = 0.602) were similar between immediate and staged groups, respectively. Likewise, local recurrence (8% vs 7%, P = 1.000), metastasis (19% vs 20%, P = 0.755), and all-cause mortality (27% vs 27%, P = 1.000) rates after reconstruction was similar. Patients in the staged group with positive margins after resection were re-excised before definitive reconstruction, whereas those in the immediate group were not. The staged group required fewer surgical intensive care unit stays after resection surgery (22% vs 58%, P = 0.006). The mean ± SD final follow-up was 38 ± 33 months. CONCLUSIONS: Wound complication rates and oncologic outcomes remain similar, regardless of timing for reconstruction. Staged reconstructions were associated with fewer surgical intensive care unit stays, while also affording opportunity for reintervention after positive margins with little additional morbidity.

Inadvertent Inguinal Sarcoma Excision during Hernia Surgery: Outcomes, Gender Analysis, and Prevention.

INTRODUCTION: Inadvertent excision of a soft tissue sarcoma during hernia surgery is a preventable clinical scenario that leads to unnecessary patient morbidity. Prior series are few, which only include male patients with little focus on prevention. The purpose of this study is to report the presenting features and outcomes of both male and female patients who underwent inadvertent inguinal sarcoma excision during hernia surgery. METHODS: A retrospective analysis of a single sarcoma referral center identified 33 patients who were referred for definitive treatment. Patients were divided into three clinically relevant groups based on intraoperative diagnosis, sex, and location of the mass relative to the inguinal ligament. T-tests and Fisher's exact tests were performed to compare continuous and categorical variables, respectively. Kaplan-Meier modeling was performed to assess sarcoma-specific survival. RESULTS: Females were younger (47 years vs. 61 years, p=0.003) and had smaller sarcomas (6.7 cm vs. 11 cm, p=0.012) compared to males. Only two sarcomas (2/33, 6%) were <4 cm in size. The majority of sarcomas in females were above the inguinal ligament (12/14, 86%). Twenty-nine (88%) underwent definitive R0 excision. The mean number of surgeries per patient was three (range 1-13), with nineteen (58%) patients requiring flap reconstruction and six (18%) requiring vascular bypass. Five patients locally recurred (15%) at a mean of 38 months after definitive excision (range 5-128 months). Overall sarcoma-specific disease-free survival was 64%, with no difference between males (80 ± 11%) and females (59 ± 17%) (p=0.885). Mean follow-up was 75 months (range 5-212). CONCLUSION: This is the second largest study regarding inadvertent inguinal sarcoma excision and the first to include females. When a suspected hernia is >4 cm, irreducible, firm, and is growing, especially in females, consider obtaining preoperative advanced three-dimensional imaging (CT or MRI) that can differentiate a neoplasm from a hernia.

Time to treatment initiation and survival in adult localized, high-grade soft tissue sarcoma.

BACKGROUND: Although shorter delays in soft tissue sarcoma (STS) diagnosis may improve overall survival (OS), the influence of time to treatment initiation (TTI) on OS in STS has not been determined. OBJECTIVE: To determine if TTI influences OS in localized, high-grade STS. METHODS: An analysis of the National Cancer Database identified 8648 patients meeting criteria with localized, high-grade STS diagnosed between 2004 and 2012. TTI and secondary variable associations with OS were determined using Kruskal-Wallis tests in univariate analyses, and a Cox regression multivariable model. RESULTS: In a multivariable Cox regression, TTI was associated with OS in a nonlinear fashion with a minimum hazard ratio (HR) demonstrated at 42 days. Secondary variables significantly associated (P < .05) with decreased OS included, advanced age, increased Charlson/Deyo score, nonprivate insurance, axial tumor location, tumor size more than 5 cm, stage III disease, and a nonsurgical treatment modality. CONCLUSIONS: Minimum HR was observed at a TTI of 42 days, with HR = 0.64, when compared with TTI = 1 day. Appropriate referrals to a higher volume sarcoma centers may account for these delays and explain a potential OS advantage. This is important in counseling patients, who may seek referral to a higher volume treatment center.

Positive "Surprise" Broth Cultures in Nonunion Surgery Do Not Require Antibiotic Treatment.

The objective of this study was to review the efficacy of a treatment approach for patients with positive intraoperative cultures during fracture nonunion surgery. The authors performed a retrospective case series at a level I trauma center. In this series, 60 patients without preoperative concern for infection were surgically treated for fracture nonunion. The treatment course of patients after fracture nonunion surgery, including culture results, antibiotic administration, and the presence of clinical infection and radiographic union, was studied. Sixty patients underwent fracture nonunion surgery. Twenty-four patients had a positive intraoperative culture. Fourteen patients had only a positive broth culture, 6 had only a positive routine culture, and 4 had positive mixed (routine and broth) cultures. The most common bacteria was coagulase-negative staphylococci, isolated in 19 of 24 patients, and the only isolated organism in 13 of 24 patients. Patients with a positive broth culture were not treated with antibiotics. Four of 10 patients with either a positive routine or mixed culture grown within 3 days of surgery were treated with antibiotics. All patients achieved clinical healing without signs of infection, and all but 2 patients achieved radiographic union at a mean follow-up of approximately 5 years. In the setting of fracture nonunion surgery, patients with only a positive broth culture and those with only a positive routine or mixed cultures that grew in a delayed fashion (>3 days postoperatively) did not require antibiotic treatment to achieve healing. [Orthopedics. 2019; 42(6):e532-e538.].

The utility of the angled blade plate in hip fracture nonunion treatment: A report of three cases and review of the literature.

OBJECTIVES: We report the radiographic and clinical outcome of patients treated with an angled blade plate (ABP) for hip fracture nonunion. We also provide a review of the literature on joint preserving treatment approaches to hip fracture nonunions. DESIGN: Retrospective, case series. SETTING: Tertiary academic hospital. PATIENTS/PARTICIPANTS: Three. INTERVENTION: We treated three patients with varied hip fracture nonunions using a joint preserving approach with an ABP. MAIN OUTCOME MEASUREMENTS: Radiographic union and clinical outcome. RESULTS: All three patients achieved radiographic union, and were ambulating without pain at final follow-up. CONCLUSIONS: The treatment approach to hip fracture nonunions is either restorative (joint preserving) or reconstructive (joint replacing). The primary restorative approach to nonunions around the hip consists of revision open reduction and internal fixation with or without bone grafting. Though a variety of implants and treatment techniques have demonstrated excellent success in this setting, revision open reduction and internal fixation with an ABP remains an efficacious implant selection in hip nonunion surgery.

Adult Primary Bone Sarcoma and Time to Treatment Initiation: An Analysis of the National Cancer Database.

OBJECTIVE: The time to treatment interval (TTI), defined as the period from diagnosis to first definitive treatment, has very limited descriptions toward understanding delays in primary bone sarcoma (PBS) care. Our primary goal was to determine the national standard for time to treatment initiation (TTI) in PBS in adults and to identify characteristics associated with TTI variability. METHODS: An analysis of the National Cancer Database identified 15,083 adult patients with PBS diagnosed from 2004 to 2013. Kruskal-Wallis analysis identified differences between covariates regarding TTI and regression modeling identified covariates that independently influenced TTI. RESULTS: The median TTI was 22 days. Approximately 60% of patients were definitively treated in the same center where the index diagnosis was made. Increased TTI was correlated with a transition in care institution (incidence rate ratio (IRR) = 1.89; P < 0.001), being uninsured (IRR = 1.36; P < 0.001), primary tumor site in the pelvis (IRR = 1.26; P < 0.001), Medicaid insurance status (IRR = 1.22; P < 0.001), care at an academic center (IRR = 1.14; P < 0.001), non-white race (IRR = 1.12; P=0.002), and Medicare insurance status (IRR = 1.08; P=0.017). Decreased TTI was correlated with a diagnosis of chondrosarcoma (IRR = 0.85; P < 0.001), having surgery as the index treatment (IRR = 0.88; P < 0.001), a primary tumor site of the lower (IRR = 0.91; P=0.001) or upper extremity (IRR = 0.92; P=0.023), and stage II or stage III disease (IRR = 0.91; P=0.010). CONCLUSIONS: TTI is associated with tumor, treatment, and socioeconomic and healthcare system characteristics. Transitions in care between institutions are responsible for the greatest increase in TTI. As TTI is more commonly used as a quality metric, physicians need to be aware of the causes for prolonged TTI, as we work to improve national delays in diagnosis and treatment initiation.