Analysis of margin classification systems for assessing the risk of local recurrence after soft tissue sarcoma resection

Purpose: To compare the ability of margin classification systems to determine local recurrence (LR) risk after soft tissue sarcoma (STS) resection. Methods: Two thousand two hundred seventeen patients with nonmetastatic extremity and truncal STS treated with surgical resection and multidisciplinary consideration of perioperative radiotherapy were retrospectively reviewed. Margins were coded by residual tumor (R) classification (in which microscopic tumor at inked margin defines R1), the R+1mm classification (in which microscopic tumor within 1 mm of ink defines R1), and the Toronto Margin Context Classification (TMCC; in which positive margins are separated into planned close but positive at critical structures, positive after whoops re-excision, and inadvertent positive margins). Multivariate competing risk regression models were created. Results: By R classification, LR rates at 10-year follow-up were 8%, 21%, and 44% in R0, R1, and R2, respectively. R+1mm classification resulted in increased R1 margins (726 v 278, P < .001), but led to decreased LR for R1 margins without changing R0 LR; for R0, the 10-year LR rate was 8% (range, 7% to 10%); for R1, the 10-year LR rate was 12% (10% to 15%) . The TMCC also showed various LR rates among its tiers (P < .001). LR rates for positive margins on critical structures were not different from R0 at 10 years (11% v 8%, P = .18), whereas inadvertent positive margins had high LR (5-year, 28% [95% CI, 19% to 37%]; 10-year, 35% [95% CI, 25% to 46%]; P < .001). Conclusion: The R classification identified three distinct risk levels for LR in STS. An R+1mm classification reduced LR differences between R1 and R0, suggesting that a negative but < 1-mm margin may be adequate with multidisciplinary treatment. The TMCC provides additional stratification of positive margins that may aid in surgical planning and patient education

Assessment of Objective Ambulation in Lower Extremity Sarcoma Patients with a Continuous Activity Monitor: Rationale and Validation

In addition to patient reported outcome measures, accelerometers may provide useful information on the outcome of sarcoma patients treated with limb salvage. The StepWatch (SW) Activity Monitor (SAM) is a two-dimensional accelerometer worn on the ankle that records an objective measure of walking performance. The purpose of this study was to validate the SW in a cross-sectional population of adult patients with lower extremity sarcoma treated with limb salvage. The main outcome was correlation of total steps with the Toronto Extremity Salvage Score (TESS). In a sample of 29 patients, a mean of 12 days of SW data was collected per patient (range 6–16), with 2767 average total steps (S.D. 1867; range 406–7437). There was a moderate positive correlation between total steps and TESS (r=0.56,  P=0.002). Patients with osseous tumors walked significantly less than those with soft tissue sarcoma (1882 versus 3715, P<0.01). This study supports the validity of the SAM as an activity monitor for the objective assessment of real world physical function in sarcoma patients

'To prove this is the industry's best hope': big tobacco's support of research on the genetics of nicotine addiction.

New molecular techniques focus a genetic lens upon nicotine addiction. Given the medical and economic costs associated with smoking, innovative approaches to smoking cessation and prevention must be pursued; but can sound research be manipulated by the tobacco industry?http://dx.doi.org/10.1111/j.1360-0443.2010.02940.

Portland Pivot Kick Study: Can a novel physical exam maneuver for medial meniscus tears predict improvement after partial medial meniscectomy? v1

Specific Aims/Purpose This study aims to evaluate patients with symptomatic medial meniscus tear verified by MRI using a novel physical exam maneuver, the Portland Pivot Kick (PPK). The goal is to assess whether patients with symptomatic medical meniscus tears have a change in the PPK before and after arthroscopic partial medial meniscectomy. This physical exam maneuver may help predict the potential benefit of arthroscopic partial medial meniscectomy in treating mechanical symptoms, even in the setting of degenerative joint disease. Hypothesis: Patients with a positive preoperative PPK will have improvement of mechanical symptoms and significantly improved subjective outcomes scores following arthroscopic partial medial meniscectomy. Scientific Rationale and Significance Medial meniscal tears are common and they are often associated with osteoarthritis in elderly patients presenting with knee pain. One study reported a prevalence of 86% of medial meniscal tears in patients with symptomatic osteoarthritis. Management of medial meniscal tears include structured physical therapy and arthroscopic partial meniscectomy, with 700,000 partial meniscectomies performed annually in the United States. Multiple randomized control trials have evaluated the efficacy of partial meniscectomies in patients with osteoarthritis by comparing surgery to physical therapy. Three of the 4 studies found no benefit to partial meniscectomy, while one study found a significant benefit to surgical treatment. However, up to one third of patients in the randomized control trials crossed over from physical therapy to arthroscopic partial meniscectomy. A follow up analysis found that patients who crossed over to surgery after starting a course of physical therapy had a higher acute level of pain and similar outcome scores to patients who initially underwent surgery. These findings suggest that a subset of patients with meniscal tears and osteoarthritis elect for surgery even after physical therapy, leading to an improvement in symptoms. Mechanical symptoms of catching or locking are often attributed to meniscal tears and used as evidence to recommend partial meniscectomy. However, there is no consensus on what exactly are mechanical symptoms specific to meniscal tears. Prior studies have evaluated mechanical symptoms solely based on subjective patient reports of knee catching and/or locking. There is a paucity of objective measures of mechanical symptoms of meniscal tears. This study will investigate the efficacy of the PPK in identifying medial meniscal tears that may improve with surgical intervention. Medial meniscal tears are a common finding amongst the veteran population with knee pain, with a prevalence approaching 50% in older patients. This study will help provide a more objective measurement of symptomatic medial meniscal tears for both veterans and the general population. </p

Reflections in a time of transition: orthopaedic faculty and resident understanding of accreditation schemes and opinions on surgical skills feedback

Introduction: Orthopaedic surgery is one of the first seven specialties that began collecting Milestone data as part of the Accreditation Council for Graduate Medical Education's Next Accreditation System (NAS) rollout. This transition from process-based advancement to outcome-based education is an opportunity to assess resident and faculty understanding of changing paradigms, and opinions about technical skill evaluation. Methods: In a large academic orthopaedic surgery residency program, residents and faculty were anonymously surveyed. A total of 31/32 (97%) residents and 29/53 (55%) faculty responded to Likert scale assessments and provided open-ended responses. An internal end-of-rotation audit was conducted to assess timeliness of evaluations. A mixed-method analysis was utilized, with nonparametric statistical testing and a constant-comparative qualitative method. Results: There was greater familiarity with the six core competencies than with Milestones or the NAS (p<0.05). A majority of faculty and residents felt that end-of-rotation evaluations were not adequate for surgical skills feedback. Fifty-eight per cent of residents reported that end-of-rotation evaluations were rarely or never filled out in a timely fashion. An internal audit demonstrated that more than 30% of evaluations were completed over a month after rotation end. Qualitative analysis included themes of resident desire for more face-to-face feedback on technical skills after operative cases, and several barriers to more frequent feedback. Discussion: The NAS and outcome-based education have arrived. Residents and faculty need to be educated on this changing paradigm. This transition period is also a window of opportunity to address methods of evaluation and feedback. In our orthopaedic residency, trainees were significantly less satisfied than faculty with the amount of technical and surgical skills feedback being provided to trainees. The quantitative and qualitative analyses converge on one theme: a desire for frequent, explicit, timely feedback after operative cases. To overcome the time-limited clinical environment, feedback tools need to be easily integrated and efficient. Creative solutions may be needed to truly achieve outcome-based graduate medical education