Proximal radiolucent lines around fully hydroxyapatite-coated tapered femoral stems: should we be concerned?

INTRODUCTION

Radiolucent lines occasionally develop around the proximal aspect of fully hydroxyapatite (HA)-coated tapered femoral stems after total hip arthroplasty (THA). It was hypothesised that distal wedging of stems may predispose to proximal radiolucent line formation, which may negatively impact clinical outcome.

METHODS

All primary THA performed with a collarless fully HA-coated stem that had a minimum of 1 year of radiographic follow-up were identified in a surgical database (n = 244). Radiographic measures of proximal femoral morphology and femoral canal fill at the middle and distal thirds of the stem were analysed for association with the presence of proximal radiolucent lines. Linear regression was used to explore any association between radiolucent lines and patient reported outcome measures (PROMs), available in 61% of patients.

RESULTS

Proximal radiolucent lines developed in 31 cases (12.7%) at final follow-up. Dorr A femoral morphology and increased canal-fill at the distal ⅓ of the stem correlated with the development of radiolucent lines (p < 0.001). No correlation was observed between pain or PROMs and the presence of proximal radiolucent lines.

DISCUSSION

We observed an unexpectedly high incidence of proximal femoral radiolucent lines about collarless fully HA coated stems. Distal-only implant wedging in Dorr A bone may compromise proximal fixation. Although this finding did not correlate with short-term outcomes, the long-term clinical impact requires further study.

Traumatic Proximal Femoral Fractures during COVID-19 Pandemic in the US: An ACS NSQIP® Analysis

In order to determine the impact of COVID-19 on the treatment and outcomes in patients with proximal femoral fracture’s (PFF), we analyzed a national US sample. This is a retrospective review of American College of Surgery’s (ACS) National Surgical Quality Improvement Program (NSQIP) for patients with proximal femoral fractures. A total of 26,830 and 26,300 patients sustaining PFF and undergoing surgical treatment were sampled during 2019 and 2020, respectively. On multivariable logistic regression, patients were less likely to have ‘presence of non-healing wound’ (p < 0.001), functional status ‘independent’ (p = 0.012), undergo surgical procedures of ‘hemiarthroplasty’(p = 0.002) and ‘ORIF IT, Peritroch, Subtroch with plates and screws’ (p < 0.001) and to be ‘alive at 30-days post-op’ (p = 0.001) in 2020 as compared to 2019. Patients were more likely to have a case status ‘emergent’, ‘loss of ≥10% body weight’, discharge destination of ‘home’ (p < 0.001 for each) or ‘leaving against medical advice’ (p = 0.026), postoperative ‘acute renal failure (ARF)’ (p = 0.011), ‘myocardial infarction (MI)’ (p = 0.006), ‘pulmonary embolism (PE)’ (p = 0.047), and ‘deep venous thrombosis (DVT)’ (p = 0.049) in 2020 as compared to 2019. Patients sustaining PFF and undergoing surgical treatment during pandemic year 2020 differed significantly in preoperative characteristics and 30-day postoperative complications when compared to patients from the previous year.

Socioeconomic and insurance-related disparities in disease-specific survival among patients with metastatic bone disease

BACKGROUND

Approximately 5% of cancer patients in the United States presented with metastatic bone disease (MBD) at diagnosis. Current study explores the disparities in survival for patients with MBD.

METHODS

Patients with the diagnosis of MBD at presentation for the five most common primary anatomical sites were extracted from Surveillance, Epidemiology, and End Results Census tract-level dataset (2010-2016). Kaplan-Meier and Cox Proportional Hazard models were used to evaluate survival, and prognostic factors for each cohort. Prognostic significance of socioeconomic status (SES) and insurance status were ascertained.

RESULTS

The five most common anatomical-sites with MBD at presentation included "lung" (n = 59 739), "prostate" (n = 19 732), "breast" (n = 16 244), "renal and urothelium" (n = 7718) and "colon" (n= 3068). Lower SES was an independent risk factor for worse disease-specific survival (DSS) for patients with MBD originating from lung, prostate, breast and colon. Lack of insurance was an independent risk factor for worse DSS for MBD patients with primary tumors in lung and breast.

CONCLUSIONS

MBD patients from the five most common primary sites demonstrated SES and insurance-related disparities in disease-specific survival. This is the first and largest study to explore SES and insurance-related disparities among patients specifically afflicted with MBD. Our findings highlight vulnerability of patients with MBD across multiple primary sites to financial toxicity.

Head and Neck Cutaneous Soft-Tissue Sarcoma Demonstrate Sex and Racial/Ethnic Disparities in Incidence and Socioeconomic Disparities in Survival

Background: Cutaneous soft-tissue sarcoma (CSTS) of the head and neck are rare and are known to have aggressive clinical course. The current study utilizes a population-based registry in the U.S. to characterize these malignancies and explore disparities. Methods: National Cancer Institute’s (NCI) Surveillance, Epidemiology and End Result (SEER) database from 2000 to 2018 was queried to report incidence and survival data in 4253 cases in the U.S. Results: Males were 5.37 times more likely and Non-Hispanic-White people (NHW) were 4.62 times more likely than females and Non-Hispanic-Black people (NHB) to develop CSTS of the head and neck. The overall incidence was 0.27 per 100,000 persons in 2018, with a significant increase since 2000. Advanced age and stage, histologic group other than ‘fibromatous sarcoma’ and lower SES groups were independent factors for worse overall survival. Conclusions: CSTS of the head and neck demonstrate sex and racial/ethnic disparities in incidence and socioeconomic disparities in overall survival. Level of evidence: II.

Impact of local treatment modality on overall- and disease-specific survival for nonmetastatic pelvic and sacral Ewing sarcoma

PURPOSE

The ideal local treatment modality for pelvic and sacral Ewing sarcoma (EWS) is controversial.

METHODS

We present the data from the American College of Surgeon's National Cancer Database (NCDB) and the National Cancer Institute's Surveillance, Epidemiology and End Result (SEER) database to investigate the impact of local treatment modalities on survival for nonmetastatic pelvic and sacral Ewing sarcoma. Local treatment includes "surgery," "radiation," and a combination of "surgery and radiation."

RESULTS

A total of 235 cases from SEER and 285 cases from NCDB were analyzed. Patients with "localized" stage (intraosseous) in the SEER database did not show any statistically significant difference in the disease-specific survival (DSS) for any of the local treatment modalities. Similar findings were observed for overall survival among patients with American Joint Committee on Cancer (AJCC) stage II and III in the NCDB database. However, patients with nonmetastatic disease, particularly regional disease (extraosseous), showed improved DSS with surgery only, in the SEER.

CONCLUSION

We found similar levels of efficacy for different treatment modalities for patients with intraosseous and AJCC II and III pelvic and sacral EWS. "Radiotherapy" is the most common local treatment modality employed in the United States. A prospective, randomized controlled trial with a direct head-to-head comparison is needed for a definitive conclusion.

Non-Private Health Insurance Predicts Advanced Stage at Presentation and Amputation in Lower Extremity High Grade Bone Sarcoma: A National Cancer Database Study : Amputation Predicts Survival: An Effect Most Pronounced in Pediatric and AYA Age Group

INTRODUCTION

Advances in diagnostic and treatment modalities for high grade bone sarcomas (HGBS) of lower extremity (LE) have enabled limb salvage resections as a feasible first-line surgical option. However, amputations are still performed. Impact of amputation on survival and predictive factors for amputation and the stage at presentation for HGBS of LE remain unknown.

METHODS

National Cancer Database was used to extract 5781 cases of high-grade bone sarcoma of the LE from 2004 to 2017. Kaplan-Meier and Cox regression were used to determine the impact of amputation on survival. Chi square test and logistic regression were used to assess the correlation of predictive factors with amputation and stage at presentation.

RESULTS

Amputation [hazard ratio (HR) 1.516; 95% confidence interval (CI) 1.259-1.826; p < 0.001] and advanced stage (HR 0.248; 95% CI 0.176-0.351; p < 0.001) were independent predictors of poor overall survival. The impact of amputation on survival was most pronounced for pediatric and adolescents and young adults (AYA) age groups (18% decrease in 10-year survival). Amputation was more likely to be performed among those with nonprivate insurance (HR 1.736; 95% CI 1.191-2.531; p = 0.004), a finding that was mirrored for advanced stage at presentation (HR 0.611; 95% CI 0.414-0.902; p = 0.013).

DISCUSSION

Amputation is an independent predictor of poor outcomes among patients with HGBS of LE. The impact of amputation on survival is the highest for the pediatric and AYA age group. Nonprivate insurance is associated with increased likelihood of amputation and an advanced stage at presentation among patients with high-grade bone sarcoma of the LE. This is the largest study highlighting insurance-related disparities in this cohort.

Sex, racial/ethnic and socioeconomic disparities in patients with metastatic bone disease

BACKGROUND

We have analyzed sex, race/ethnicity or socioeconomic disparities in the incidence of metastatic bone disease (MBD).

METHODS

Patients with the diagnosis of MBD at presentation for five most common primary anatomical sites was extracted from Surveillance, Epidemiology, and End Results Census tract-level dataset. Mean incidence of MBD for different sex, racial/ethnic and socioeconomic groups were compared.

RESULTS

The five most common anatomical sites with MBD at presentation include "lung: (n = 59 739), "prostate" (n = 19 732), "breast" (n = 16 244), "renal" (n = 7718) and "colon" (n = 3068). There was an increase in incidence of MBD among cancers originating from prostate (annual percentage change [APC] 4.94), renal (APC 2.55), and colon (APC 3.21) (p < 0.05 for all). Non-Hispanic Blacks had higher incidence of MBD for prostate and breast primary sites (p < 0.001). Non-Hispanic American Indian Alaskan Native had higher incidence of MBD for cancers originating from renal (p < 0.001) and colon (p = 0.049). A higher incidence of MBD was seen in lower socioeconomic status (SES) groups for the selected sites (p < 0.001).

CONCLUSIONS

These findings suggest that there are multiple sex-related, racial/ethnic and SES disparities in the incidence of MBD from the 5 most common primary sites. Higher incidence seen among lower SES suggests delay in diagnosis and limited access to screening modalities.

Prognostic factors, disparity, and equity variables impacting prognosis in bone sarcomas of the hand: SEER database review

BACKGROUND

Primary sarcomas originating from the bones of hand and wrist are rare but carry a significant burden of morbidity.

METHODS

National Cancer Institute's Surveillance, Epidemiology and End Result database from 1975 to 2017 was queried to report incidence and survival data in 237 patients in the United States. Kaplan-Meier and Cox regression were used to determine the prognostic factors affecting survival. χ² test was used to assess the correlation.

RESULTS

Incidence of hand and wrist sarcoma was 0.017 per 100 000 persons in 2017 and has not significantly changed since 1975 (p > 0.05). Disease-specific 5-year and 10-year survival for the entire cohort was 90% and 84%, respectively. On multivariate analysis race "others," histology other than "osteosarcoma," "undifferentiated" grade, and size "≥6 cm" were predictors of worse disease-specific survival. Cross-tabulation of race with other significant prognostic factors on univariate analysis revealed a significant correlation of race with every other significant prognostic factor except for grade.

CONCLUSIONS

The current study is an analysis of a population-based registry reporting incidence and survival data for patients with sarcoma of hand and wrist. Independent prognostic factors include race, histology, grade, and size. There is a lack of improvement in survival over the last four decades.

Malignant neoplasms originating from the bones of the foot: Predilection of hematological malignancies and sex-related and ethnic disparities in amputation

PURPOSE

Neoplasms originating from the "small bones of the lower limb and the overlapping joints" are rare but portend a serious prognosis. Current study utilizes a population-based registry in the United States to characterize the malignancies of the foot.

METHODS

National Cancer Institute's Surveillance, Epidemiology and End Result database from 1975 to 2017 was queried to report incidence and survival data in 514 patients in the Uited States. Kaplan-Meier and Cox Regression were used to determine the prognostic factors affecting survival. Chi square test was used to assess the correlation.

RESULTS

Hematological malignancies constituted 14.8% of the entire cohort. Incidence of the foot neoplasms was 0.024 per 100 000 persons in 2017 and has not significantly changed since 1975 (p > 0.05). Disease-specific-5-year survival for the entire cohort was 73%. On multivariate analysis younger age groups, "localized" stage and extent of surgical resection were predictors of improved outcomes. A significant correlation was found between amputation with male sex and Hispanic ethnicity.

CONCLUSIONS

The current study analyzes data from population-based registry reporting incidence and survival data for patients with neoplasms of the foot. Independent prognostic factors include age, stage and extent of surgical resection. Amputation was found to be associated with male sex and Hispanic ethnicity.

Proximal femoral reconstruction with a constrained acetabulum in oncologic patients

Metallic endoprostheses are used for oncological reconstruction around the proximal femur and hip joint. Common modes of failure with hemiarthroplasty or standard hip arthroplasty after proximal femoral replacement include dislocation, late hip pain, and infection. The authors reviewed hospital records to identify patients undergoing constrained tripolar hip arthroplasty for oncological reasons between 2002 and 2012. Inclusion criterion was at least 12-cm proximal femoral resection, including patients with total femur reconstruction. A total of 33 patients were reviewed. Information regarding demographics, length of follow-up, treatment characteristics, and patient outcomes was extracted. Average follow-up for all patients was 912.33 days (30.4 months). Average follow-up was 1396.1 days for living patients and 428.6 days for deceased patients. Average estimated blood loss was 462.12 cc: an average of 1080 cc for patients undergoing total femoral resection and replacement and 315.8 cc for patients undergoing proximal femoral resection and replacement. Average operative time was 137.7 minutes: an average of 205 minutes for patients undergoing total femoral resection and replacement and 119.1 minutes for patients undergoing proximal femoral resection and replacement. Average Musculoskeletal Tumor Society score was 21.7. There were no dislocations in the cohort. A constrained tripolar device can be safely used for oncological proximal femoral reconstructions while minimizing the risk of dislocation. Positioning of the acetabular implant in neutral anatomic version in conjunction with a neutral-placed femoral component provides the greatest range of motion, reduction of liner impingement, and improved hip stability.

MC3T3-E1 osteoprogenitor cells systemically migrate to a bone defect and enhance bone healing

Although iliac crest autologous bone graft remains the gold standard for treatment of bone defects, delayed- and nonunions, and arthrodeses, several alternative strategies have been attempted, including the use of mesenchymal stem cells. Whether cells from the osteoblast lineage demonstrate systemic recruitment to an acute bone defect or fracture, and whether these cells directly participate in bone healing is controversial. This study tests two hypotheses: (1) that exogenous murine MC3T3-E1 osteoprogenitor cells with a high propensity for osteoblast differentiation are able to systemically migrate to a bone defect and (2) that the migrated MC3T3-E1 cells enhance bone healing. Two groups of nude mice were used; a bone defect was drilled in the left femoral shaft in both groups. MC3T3-E1 were used as reporter cells and injected in the left ventricle of the heart, to avoid sequestration in the lungs. Injection of saline served as a control. We used bioluminescence and microCT to assay cell recruitment and bone mineral density (BMD). Immunohistochemical staining was used to confirm the migration of reporter cells. MC3T3-E1 cells were found to systemically migrate to the bone defect. Further, BMD at the defect was significantly increased when cells were injected. Systemic cell therapy using osteoprogenitor cells may be a potential strategy to enhance bone healing.

Acetabular morphometry and prevalence of hip dysplasia in the South Asian population

We carried out a cross-sectional study to measure the association of the seven acetabular parameters with pelvic morphometry and prevalence of hip dysplasia in our population. Convenience sampling was carried out and 250 consecutive patients who came to AKUH for intravenous pyelogram and had no complaints in the region of the hip joint were enrolled in the study. Post-micturition standardized plain antero-posterior pelvic radiographs of 250 asymptomatic adults (500 hip joints) was studied. There were 136 males (54.4%) and 114 females (45.6%). Mean age of our study population was 38 years (15–78 years). The average center edge angle was 35.5±6.6° standard deviation (SD), acetabular angle was 37.76±4.37°, depth to width ratio was 0.31±4.6°, roof obliquity was 10.6±6.2°, extrusion index was 0.1±5.8, lateral subluxation 8.9±2.7 mm, and peak to edge distance 17±3.98 mm. There was significant influence (p<0.05) of age in all angles except depth to width ratio. A total of seven hip joints (1.4%) were dysplastic with CE angle <25° while four of the seven hips were severely dysplastic with CE angle <20°. In the dysplastic group there was significant correlation (p<0.05) of CE angle with acetabular angle, depth to width ratio, extrusion index and peak to edge distance. Prevalence of hip dysplasia was found to be very low in our population. These results are consistent with the findings of studies carried out in other Asian countries.

Matrix metalloproteinase 1: role in sarcoma biology

In carcinomas stromal cells participate in cancer progression by producing proteases such as MMPs. The expression MMP1 is a prognostic factor in human chondrosarcoma, however the role in tumor progression is unknown. Laser capture microdissection and In Situ hybridization were used to determine cellular origin of MMP1 in human sarcomas. A xenogenic model of tumor progression was then used and mice were divided in two groups: each harboring either the control or a stably MMP1 silenced cell line. Animals were sacrificed; the neovascularization, primary tumor volumes, and metastatic burden were assessed. LCM and RNA-ISH analysis revealed MMP1 expression was predominantly localized to the tumor cells in all samples of sarcoma (p = 0.05). The percentage lung metastatic volume at 5 weeks (p = 0.08) and number of spontaneous deaths secondary to systemic tumor burden were lower in MMP1 silenced cell bearing mice. Interestingly, this group also demonstrated a larger primary tumor size (p<0.04) and increased angiogenesis (p<0.01). These findings were found to be consistent when experiment was repeated using a second independent MMP1 silencing sequence. Prior clinical trials employing MMP1 inhibitors failed because of a poor understanding of the role of MMPs in tumor progression. The current findings indicating tumor cell production of MMP1 by sarcoma cells is novel and highlights the fundamental differences in MMP biology between carcinomas and sarcomas. The results also emphasize the complex roles of MMP in tumor progression of sarcomas. Not only does metastasis seem to be affected by MMP1 silencing, but also local tumor growth and angiogenesis are affected inversely.

Morphology of the proximal femur in a Pakistani population

PURPOSE

To measure the morphology of the proximal femur in a Pakistani population.

METHODS

Standardised anteroposterior pelvic radiographs of 116 male and 20 female healthy volunteers aged 20 to 50 (mean, 33) years were taken. Morphologic dimensions of the proximal femur were measured, including canal flare index (CFI), morphological cortical index (MCI), femoral head offset, femoral head diameter, and femoral head position.

RESULTS

Based on the CFI, 67% of the subjects had normal canal shapes (CFI, 3.0-4.7), whereas 1% and 33% of the subjects had stovepipe shapes (CFI, <3) and champagne-flute shapes (CFI, 4.7-6.5), respectively. Based on the MCI, 29% of the subjects had cylindrical shapes (MCI, <2.7) and 71% had trumpet shapes (MCI, >2.7).

CONCLUSION

Morphology of the proximal femur in our study population differed significantly from those in western populations, indicating regional variation. It could also be due to the younger age of our population.

Malignant sarcoma of the pelvic bones: treatment outcomes and prognostic factors vary by histopathology

BACKGROUND

Treatment of malignant sarcomas of the pelvis poses a challenge for local disease control and oncologic outcome. Many reports have described the dismal outcomes. Most studies are retrospective series coming out of single centers, thus biased toward patient selection and are of limited statistical power.

METHODS

The authors used the Surveillance, Epidemiology, and End Results database to analyze 1185 pelvic sarcoma cases from 1987 to 2006. Kaplan-Meier and Cox regression were used to analyze the significance of prognostic factors. The analysis was repeated for different histopathological subtypes to determine specific prognostic factors in each case.

RESULTS

Incidence of pelvic sarcoma in 2006 was 89 per 100,000 persons; it has significantly increased since 1973 (P < .05). The overall 5-year survival for all the patients with pelvic sarcoma was 47%, with osteosarcoma having the worst 5-year survival at 19% and patients with chordoma having the best 5-year survival at 60%. Independent prognostic factors included age, stage, grade, size of primary lesion, histopathology, and treatment-related factors. Comparing the patients only with high-grade lesions, patients with Ewing sarcoma have the best prognosis.

CONCLUSIONS

This is an analysis of patients with pelvic sarcomas derived from a population-based registry. Survival and prognostics vary with histopathological diagnoses. Although surgical resection was associated with superior outcomes for osteosarcoma and chondrosarcoma, there was no significant difference in outcomes of patients with Ewing sarcoma treated with surgery and/or radiotherapy.

Osteosarcoma: improvement in survival limited to high-grade patients only

BACKGROUND

We sought to identify the significant prognostic parameters of patients with osteosarcoma over the past three decades using a population-based registry.

METHODS

A total of 3765 patients with osteosarcoma were identified in the SEER database. Information regarding patient demographics, clinical and treatment characteristics, cause of death and survival were extracted. Kaplan-Meier, Log-Rank, and Cox regression were used for analysis.

RESULTS

On multivariate analysis only age group '<25 years', 'local' stage and 'low' grade, 'appendicular skeleton' and employment of 'surgical resection' showed a disease-specific survival benefit with a P value < 0.001. The long-term survival improved in the interval from 1973 to 1985 from approximately 55 to 65% but subsequent improvement has been limited only to patients with high-grade disease.

CONCLUSION

When comparing survival rates by decade of diagnosis, it appears that improvement in survival since 1985 is limited to patients with high-grade disease only.

LEVEL OF EVIDENCE

The level of evidence for this article is 2.

Prognostic factors for survival in patients with epithelioid sarcoma: 441 cases from the SEER database

Current stratification of prognosis in patients with epithelioid sarcoma (ES) is based largely on data reported by individual centers with a limited number of patients. We sought to identify the important prognostic parameters using the Surveillance, Epidemiology, and End Results (SEER) database. We identified 441 patients with ES in the database and extracted information regarding patient demographics and clinical characteristics. Kaplan-Meier, log-rank, and Cox regression were used for analysis. Disease-specific survival declined until 100 months after diagnosis after which survival was unrelated to epithelioid sarcoma. The overall incidence of ES during 2005 was 0.041 per 100,000. The reported incidence has increased since 1973, with an annual percentage change of 5.217%. On multivariate analysis, only age younger than 16 years, local stage of disease, or negative nodes and surgical resection of the tumor predicted better disease-specific survival. We observed no increase in survival by comparing decades of diagnosis since 1986. The SEER database shows only age younger than 16 years, negative nodes, or local stage of disease and operability of primary disease independently predict survival in patients with ES.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Skeletal Plasmacytoma: progression of disease and impact of local treatment; an analysis of SEER database

BACKGROUND

Previous reports suggest an as yet unidentifiable subset of patients with plasmacytoma will progress to myeloma. The current study sought to establish the risk of developing myeloma and determine the prognostic factors affecting the progression of disease.

METHODS

Patients with plasmacytoma diagnosed between 1973 and 2005 were identified in the SEER database(1164 patients). Patient demographics and clinical characteristics, treatment(s), cause of death, and survival were extracted. Kaplan-Meier, log-rank, and Cox regression were used to analyze prognostic factors.

RESULTS

The five year survival among patients initially diagnosed with plasmacytoma that later progressed to multiple myeloma and those initially diagnosed with multiple myeloma were almost identical (25% and 23%; respectively). Five year survival for patients with plasmacytoma that did not progress to multiple myeloma was significantly better (72%). Age > 60 years was the only factor that correlated with progression of disease (p = 0.027).

DISCUSSION

Plasmacytoma consists of two cohorts of patients with different overall survival; those patients that do not progress to systemic disease and those that develop myeloma. Age > 60 years is associated with disease progression. Identifying patients with systemic disease early in the treatment will permit aggressive and novel treatment strategies to be implemented.