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Schelling G, Heesen P, Tautermann B, Wepf M, Di Federico B, Frei A, van Oudenaarde K, Giovanoli P, Bode-Lesniewska B, Studer G, Fuchs B. Impact of Institutional Practices and Surgical Complexity on Sarcoma Surgery Costs: Driving Efficiency in Value-Based Healthcare. Cancers (Basel) 2024; 16:2209. [PMID: 38927915 PMCID: PMC11201775 DOI: 10.3390/cancers16122209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/10/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Sarcomas present a unique challenge within healthcare systems due to their rarity and complex treatment requirements. This study explores the economic impact of sarcoma surgeries across three Swiss tertiary healthcare institutions, utilizing a consistent surgical approach by a single surgeon to eliminate variability in surgical expertise as a confounding factor. METHODS By analyzing data from 356 surgeries recorded in a real-world-time data warehouse, this study assesses surgical and hospital costs relative to institutional characteristics and surgical complexity. RESULTS Our findings reveal significant cost variations driven more by institutional resource management and pricing strategies than by surgical techniques. Surgical and total hospitalization costs were analyzed in relation to tumor dignity and complexity scores, showing that higher complexity and malignancy significantly increase costs. Interestingly, it was found that surgical costs accounted for only one-third of the total hospitalization costs, highlighting the substantial impact of non-surgical factors on the overall cost of care. CONCLUSIONS The study underscores the need for standardized cost assessment practices and highlights the potential of predictive models in enhancing resource allocation and surgical planning. By advocating for value-based healthcare models and standardized treatment guidelines, this research contributes to more equitable and sustainable healthcare delivery for sarcoma patients. These insights affirm the necessity of including a full spectrum of care costs in value-based models to truly optimize healthcare delivery. These insights prompt a reevaluation of current policies and encourage further research across diverse geographical settings to refine cost management strategies in sarcoma treatment.
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Affiliation(s)
- Georg Schelling
- Faculty of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, 6002 Luzern, Switzerland
- Sarcoma Center & Department of Orthopedics & Trauma, LUKS University Hospital, 6000 Lucerne, Switzerland
| | - Philip Heesen
- Sarcoma Center & Department of Orthopedics & Trauma, LUKS University Hospital, 6000 Lucerne, Switzerland
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Zurich, 8032 Zurich, Switzerland
| | | | - Markus Wepf
- Sarkomzentrum KSW & Klinik für Orthopädie und Traumatologie, Kantonsspital Winterthur, 8400 Winterthur, Switzerland
| | - Barbara Di Federico
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Zurich, 8032 Zurich, Switzerland
| | - Annika Frei
- Sarkomzentrum KSW & Klinik für Orthopädie und Traumatologie, Kantonsspital Winterthur, 8400 Winterthur, Switzerland
| | - Kim van Oudenaarde
- Faculty of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, 6002 Luzern, Switzerland
- Sarcoma Center & Department of Orthopedics & Trauma, LUKS University Hospital, 6000 Lucerne, Switzerland
| | - Pietro Giovanoli
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Zurich, 8032 Zurich, Switzerland
| | - Beata Bode-Lesniewska
- Faculty of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, 6002 Luzern, Switzerland
- Sarcoma Center & Department of Orthopedics & Trauma, LUKS University Hospital, 6000 Lucerne, Switzerland
- Pathologie Enge, Pathology Institute, 8031 Zurich, Switzerland
| | - Gabriela Studer
- Sarcoma Center & Department of Orthopedics & Trauma, LUKS University Hospital, 6000 Lucerne, Switzerland
| | - Bruno Fuchs
- Sarcoma Center & Department of Orthopedics & Trauma, LUKS University Hospital, 6000 Lucerne, Switzerland
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Ke S, Zhang B, He Y, Zhou Y, Hu X, Fan Y, Wang M, Zhang Y, Wang C. Reconstruction Strategy for Upper Extremity Defects After Bone Tumor Resection Based on 3D Customized Bone Cement Mold. Surg Innov 2024:15533506241244493. [PMID: 38606504 DOI: 10.1177/15533506241244493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
BACKGROUND Reconstructing bone defects in the upper extremities and restoring their functions poses a significant challenge. In this study, we describe a novel workflow for designing and manufacturing customized bone cement molds using 3D printing technology to reconstruct upper extremity defects after bone tumor resection. METHODS Computer tomography data was acquired from the unaffected upper extremities to create a detachable mold, which can be customized to fit the joint precisely by shaping the bone cement accordingly. Fourteen patients who underwent reconstructive surgery following bone tumor resection in the proximal humerus (13 cases) or distal radius (1 case) between January 2014 and December 2022 were retrospectively evaluated. The medical records of this case series were reviewed for the demographic, radiological, and operative data. Metastasis, local recurrence, and complication were also reviewed. Additionally, Musculoskeletal Tumor Society Score (MSTS) and Visual Analogue Scale (VAS) were used to assess clinical outcomes. RESULTS The mean follow-up period was 49.36 ± 15.18 months (range, 27-82 months). At the end of follow-up, there were no cases of metastasis or recurrence, and patients did not experience complications such as infection, dislocation, or implant loosening. Two cases complicated with subluxation (14.3%), and 1 case underwent revision surgery for prosthetic fracture (7.1%). The average MSTS score was 23.2 ± 1.76 (77.4%, range, 66.7%-86.7%), and the postoperative VAS score was 1.86 ± 1.03 (range, 1-4), which was significantly lower than that before surgery (average preoperative VAS score was 5.21 ± 2.00 (range, 2-8)) (P < .001). CONCLUSION Customized 3D molds can be utilized to shape bone cement prostheses, which may serve as a potential alternative for reconstructing the proximal humerus and distal radius following en bloc resection of bone tumors. This reconstruction strategy offers apparent advantages, including precise matching of articular surfaces and comparatively reduced costs.
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Affiliation(s)
- Song Ke
- Department of Orthopeadic, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Bokai Zhang
- Department of Orthopeadic, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yongqin He
- Department of Orthopeadic, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yuanyuan Zhou
- Department of Orthopeadic, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Xu Hu
- Department of Orthopeadic, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yubo Fan
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, School of Engineering Medicine, Beihang University, Beijing, China
| | - Min Wang
- Department of Orthopeadic, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yuan Zhang
- Department of Orthopeadic, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chao Wang
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, School of Engineering Medicine, Beihang University, Beijing, China
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Zhang C, He H, Tong X, Zeng H, Qiu X, Liu Q. Synthetic Ligament-Assisted Functional Soft-Tissue Reconstruction in Tumor-Related Proximal Femoral Replacements. J Arthroplasty 2024; 39:472-479. [PMID: 37598780 DOI: 10.1016/j.arth.2023.08.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND Soft-tissue functional reconstruction is important for restoring hip function in proximal femoral replacement for tumor resection. This study evaluated the functional outcome and postoperative complications of a specific synthetic ligament for soft-tissue functional reconstruction in proximal femoral replacement for tumor resection. METHODS This cohort included 80 patients (40 men and 40 women, mean age, 40 years (range, 10 to 79)) who had benign invasive tumors (n = 13), primary malignant bone tumors (n = 40), or bone metastases (n = 27). Patients' medical records, imaging files, surgical details, and postoperative pathological diagnoses were collected. Tumor staging was performed with the Enneking staging criteria. Lower limb and hip functions were assessed using the Musculoskeletal Tumor Society scoring system and Harris Hip score, respectively. RESULTS Mean postoperative Musculoskeletal Tumor Society and Harris Hip scores were 27 (range, 24 to 30) and 90 (range, 76 to 97), respectively, indicating satisfactory range of motion and stability. Trendelenburg gait was observed in 3 osteosarcoma patients (3.8%), and 6 patients showed unequal lower-limb lengths. Reoperations occurred in 5 cases, including 3 cases of deep vein thromboses and 1 case each of giant cell granuloma and periprosthetic infection. There were 27 patients who had bone metastases who did not require reoperation. CONCLUSIONS The synthetic ligament reconstruction of the hip with proximal femoral replacement for tumor resection was associated with improved outcomes. Its implementation exhibits the potential to reduce postoperative incidences of hip dislocation and periprostheses infection, thereby warranting its prospective clinical application.
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Affiliation(s)
- Can Zhang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, China
| | - Hongbo He
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, China
| | - Xiaopeng Tong
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, China
| | - Hao Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xinzhu Qiu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qing Liu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, China
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Eckert KA, Fife CE, Carter MJ. The Impact of Underlying Conditions on Quality-of-Life Measurement Among Patients with Chronic Wounds, as Measured by Utility Values: A Review with an Additional Study. Adv Wound Care (New Rochelle) 2023; 12:680-695. [PMID: 37815559 PMCID: PMC10615090 DOI: 10.1089/wound.2023.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/27/2023] [Indexed: 10/11/2023] Open
Abstract
Significance: Quality of life (QoL) is important to patients with chronic wounds and is rarely formally evaluated. Understanding what comorbidities most affect the individual versus their wounds could be a key metric. Recent Advances: The last 20 years have seen substantial advances in QoL instruments and conversion of patient data to a single value known as the health utilities index (HUI). We review these advances, along with wound-related QoL, and analyze real-world comorbidities challenging wound care. Critical Issues: To understand the impact of underlying comorbidities in a real-world patient population, we examined a convenience sample of 382 patients seen at a hospital-based outpatient wound center. This quality reporting study falls outside the regulations that govern human subject research. Comorbid conditions were used to calculate HUIs using a variety of literature-reported approaches, while Wound-Quality-of-Life (W-QoL) questionnaire data were collected from patients during their first visit. The mean number of conditions per patient was 8; 229 patients (59.9%) had utility values for comorbidities/conditions, which were worse/lower than their wounds' values. Sixty-three (16.5%) patients had depression and/or anxiety, 64 (16.8%) had morbid obesity, and 204 (53.4%) had gait and mobility disorders, all of which could have affected W-QoL scoring. The mean minimum utility value (0.5) was within 0.05 units of an average of 13 studies reporting health utilities from wound care populations using the EuroQol 5 Dimension instrument. Future Directions: The comorbidity associated with the lowest utility value is what might most influence the QoL of patients with chronic wounds. This finding needs further investigation.
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Affiliation(s)
| | - Caroline E. Fife
- Intellicure, LLC, The Woodlands, Texas, USA
- U.S. Wound Registry (501 3C Nonprofit), The Woodlands, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
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Tóth L, Krieg AH, Nowakowski AM. How much is a leg worth following radical tumor resection in bone sarcomas? Literature review. Surg Oncol 2023; 46:101900. [PMID: 36577174 DOI: 10.1016/j.suronc.2022.101900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 11/04/2022] [Accepted: 12/21/2022] [Indexed: 12/25/2022]
Abstract
Bone sarcomas of the lower extremities are rare malignancies occurring mostly amongst adolescents and young adults. Necessarily, the therapy conducted in sarcoma centers is multimodal and multidisciplinary. In certain cases, in a metastasis free situation with adequate therapy, an overall survival rate of 90% can be achieved. Two principal surgical procedures exit for the local control of the malignancy: 1. Limb salvage with biological with/or endoprosthetic reconstruction; and, 2. amputation with restoration of the function with exoprosthesis or endo-exoprosthesis. Currently, limb salvage procedures are performed in up to 95% of cases. In contrast, amputation is performed when the disease has reached an advanced stage or limb salvage has failed. Both of the surgical options have their risks and possible complications. According to the literature, there should be no significant difference between limb salvage and amputation with respect to long-term overall survival, overall quality of life, psycho-socio-economic outcomes, or patient satisfaction. An important advantage of limb salvage is greater everyday functionality. With the expanded indication of limb salvage and great survival rates, the cases of late complications in patients expecting to maintain their own leg continues to increase. In some cases, it requires multiple interventions, ranging from minor up to the most complex revisions, to maintain the functionality of the extremity. Despite the great costs, personal effort, and the possible complications, limb salvage could be a suitable method to achieve functionally beneficial outcomes and patient satisfaction in bone sarcomas of the lower extremities over the long-term even in cases involving complications.
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Affiliation(s)
- László Tóth
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, 4101, Bruderholz, Switzerland
| | - Andreas H Krieg
- Orthopaedic Department, University Children's Hospital (UKBB), 4056, Basel, Switzerland
| | - Andrej M Nowakowski
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, 4101, Bruderholz, Switzerland; University of Basel, Medical Faculty, 4056, Basel, Switzerland.
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Shao X, Dou M, Yang Q, Li J, Zhang A, Yao Y, Chu Q, Li K, Li Z. Reconstruction of massive bone defects after femoral tumor resection using two new-designed 3D-printed intercalary prostheses: a clinical analytic study with the cooperative utilization of multiple technologies. BMC Musculoskelet Disord 2023; 24:67. [PMID: 36698116 PMCID: PMC9875495 DOI: 10.1186/s12891-023-06171-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/17/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND To reconstruct massive bone defects of the femoral diaphysis and proximal end with limited bilateral cortical bone after joint-preserving musculoskeletal tumor resections, two novel 3D-printed customized intercalary femoral prostheses were applied. METHODS A series of nine patients with malignancies who received these novel 3D-printed prostheses were retrospectively studied between July 2018 and November 2021. The proximal and diaphyseal femur was divided into three regions of interest (ROIs) according to anatomic landmarks, and anatomic measurements were conducted on 50 computed tomography images showing normal femurs. Based on the individual implant-involved ROIs, osteotomy level, and anatomical and biomechanical features, two alternative 3D-printed prostheses were designed. In each patient, Hounsfield Unit (HU) value thresholding and finite element analysis were conducted to identify the bone trabecula and calcar femorale and to determine the stress distribution, respectively. We described the characteristics of each prosthesis and surgical procedure and recorded the intraoperative data. All patients underwent regular postoperative follow-up, in which the clinical, functional and radiographical outcomes were evaluated. RESULTS With the ROI division and radiographic measurements, insufficient bilateral cortical bones for anchoring the traditional stem were verified in the normal proximal femur. Therefore, two 3D-printed intercalary endoprostheses, a Type A prosthesis with a proximal curved stem and a Type B prosthesis with a proximal anchorage-slot and corresponding locking screws, were designed. Based on HU value thresholding and finite element analysis, the 3D-printed proximal stems in all prostheses maximally preserved the trabecular bone and calcar femorale and optimized the biomechanical distribution, as did the proximal screws. With the 3D-printed osteotomy guide plates and reaming guide plates, all patients underwent the operation uneventfully with a satisfactory duration (325.00 ± 62.60 min) and bleeding volume (922.22 ± 222.36 ml). In the follow-up, Harris Hip and Musculoskeletal Tumor Society scores were ameliorated after surgery (P < 0.001 and P < 0.001, respectively), reliable bone ingrowth was observed, and no major complications occurred. CONCLUSIONS Two novel 3D-printed femoral intercalary prostheses, which achieved acceptable overall postoperative outcomes, were used as appropriate alternatives for oncologic patients with massive bone defects and limited residual bone and increased the opportunities for joint-preserving tumor resection. Several scientific methodologies utilized in this study may promote the clinical design proposals of 3D-printed implants.
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Affiliation(s)
- Xianhao Shao
- grid.460018.b0000 0004 1769 9639Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021 Shandong China
| | - Mengmeng Dou
- Department of Orthopaedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012 China ,grid.417024.40000 0004 0605 6814Department of Biomedical Engineering, Tianjin First Central Hospital, Tianjin, 300070 China
| | - Qiang Yang
- Department of Orthopaedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012 China
| | - Jianmin Li
- Department of Orthopaedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012 China
| | - Ailin Zhang
- grid.417021.10000 0004 0627 7561Physiotherapy department, Acute Neurosciences, the Wesley Hospital, 451 Coronation Drive, Auchenflower, QLD 4066 Australia
| | - Yuan Yao
- Department of Radiography, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012 China
| | - Qing Chu
- grid.415105.40000 0004 9430 5605State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037 China ,grid.415105.40000 0004 9430 5605Department of Cardiac Surgery, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100037 China
| | - Ka Li
- Department of Orthopaedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012 China
| | - Zhenfeng Li
- Department of Orthopaedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012 China
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Kuek T, Schilling CG, Choong PF. The impact of cost on quality of surgical management in non-metastatic extremity sarcoma: A cross-country narrative literature review with a systematic approach. J Orthop Surg (Hong Kong) 2023; 31:10225536231168989. [PMID: 37053184 DOI: 10.1177/10225536231168989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Extremity sarcoma surgery entails significant costs for patients, governments and insurers. Multiple studies have described individual costs, however, the overall impact of cost on the quality of surgical care remains unclear. OBJECTIVES A narrative review with a systematic approach was undertaken to compare the impact of cost on the quality of extremity sarcoma care across low-middle-income and high-income countries. DATA SOURCES MEDLINE, EMBASE, Cochrane, PsycInfo, DARE, NHS-EED, HTA. METHODS A systematic search was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Inclusion criteria were: discussion of costs and the surgical management of primary extremity sarcoma. There were no restrictions on study design, publication type, date, geographic location or publication status. A data extraction table was used to identify study location, type and findings. RESULTS 1012 studies were retrieved and 44 met the inclusion criteria. Four additional studies were identified from the reference lists of included articles. 27 studies were published in high-income countries (HIC) including all four full health economic analyses and 20 studies were published in low-middle income countries (LMC). Within LMC, cost impeded access to diagnosis, resection and options for reconstruction. In HIC, cost varied with choice of management, particularly during the long-term postoperative period. CONCLUSIONS Within LMC, cost impaired the provision of quality, curative care for patients with extremity sarcoma. Within HIC, while costs varied with chosen management, they were not prohibitive to the provision of quality care. Further research is required, specific to both socioeconomic contexts, to further describe the long-term cost-utility of different methods for the surgical management of extremity sarcoma.
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Affiliation(s)
- Timothy Kuek
- Department of Surgery, St Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Chris G Schilling
- Department of Surgery, St Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Peter F Choong
- Department of Surgery, St Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia
- Department of Orthopaedics, St Vincent's Hospital, Melbourne, VIC, Australia
- Bone and Soft Tissue Sarcoma Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Alder KD, Morris MT, Hao Z, Li L, Yu KE, Lee FY. Avoiding Limb-Length Discrepancy with Reconstruction of a Massive Tibial Defect Using a Bone Allograft and a Minimally Invasive Lengthening System in a Pediatric Patient: A Case Report. JBJS Case Connect 2021; 10:e0456. [PMID: 32649132 DOI: 10.2106/jbjs.cc.19.00456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 7-year-old boy was found to have Ewing sarcoma of the left tibia. The sarcoma was resected, and the defect was reconstructed using a humeral head allograft and intramedullary limb-lengthening nail. CONCLUSIONS Limb-salvage reconstruction in children can be complicated by the sacrifice of epiphyseal plates and limb-length discrepancies and thus requires techniques tailored to each case.
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Affiliation(s)
- Kareme D Alder
- 1Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
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Zoller SD, Hegde V, Burke ZDC, Park HY, Ishmael CR, Blumstein GW, Sheppard W, Hamad C, Loftin AH, Johansen DO, Smith RA, Sprague MM, Hori KR, Clarkson SJ, Borthwell R, Simon SI, Miller JF, Nelson SD, Bernthal NM. Evading the host response: Staphylococcus "hiding" in cortical bone canalicular system causes increased bacterial burden. Bone Res 2020; 8:43. [PMID: 33303744 PMCID: PMC7728749 DOI: 10.1038/s41413-020-00118-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 08/22/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023] Open
Abstract
Extremity reconstruction surgery is increasingly performed rather than amputation for patients with large-segment pathologic bone loss. Debate persists as to the optimal void filler for this "limb salvage" surgery, whether metal or allograft bone. Clinicians focus on optimizing important functional gains for patients, and the risk of devastating implant infection has been thought to be similar regardless of implant material. Recent insights into infection pathophysiology are challenging this equipoise, however, with both basic science data suggesting a novel mechanism of infection of Staphylococcus aureus (the most common infecting agent) into the host lacunar-canaliculi network, and also clinical data revealing a higher rate of infection of allograft over metal. The current translational study was therefore developed to bridge the gap between these insights in a longitudinal murine model of infection of allograft bone and metal. Real-time Staphylococci infection characteristics were quantified in cortical bone vs metal, and both microarchitecture of host implant and presence of host immune response were assessed. An orders-of-magnitude higher bacterial burden was established in cortical allograft bone over both metal and cancellous bone. The establishment of immune-evading microabscesses was confirmed in both cortical allograft haversian canal and the submicron canaliculi network in an additional model of mouse femur bone infection. These study results reveal a mechanism by which Staphylococci evasion of host immunity is possible, contributing to elevated risks of infection in cortical bone. The presence of this local infection reservoir imparts massive clinical implications that may alter the current paradigm of osteomyelitis and bulk allograft infection treatment.
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Affiliation(s)
- Stephen D Zoller
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Vishal Hegde
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Zachary D C Burke
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Howard Y Park
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Chad R Ishmael
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Gideon W Blumstein
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - William Sheppard
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Christopher Hamad
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Amanda H Loftin
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Daniel O Johansen
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Ryan A Smith
- David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Marina M Sprague
- Department of Internal Medicine, University of California, Los Angeles, 757 Westwood Plaza, Suite 7501, Los Angeles, CA, 90095, USA
| | - Kellyn R Hori
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
- David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Samuel J Clarkson
- David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Rachel Borthwell
- David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Scott I Simon
- Department of Biomedical Engineering, University of California, Davis, Davis, CA, 95616, USA
| | - Jeff F Miller
- California NanoSystems Institute, University of California, Los Angeles, 570 Westwood Plaza, Los Angeles, CA, 90095, USA
- Department of Microbiology, Immunology, and Molecular Genetics, David Geffen School of Medicine, University of California, Los Angeles, 90095, USA
| | - Scott D Nelson
- Department of Pathology, University of California, Los Angeles, 1250 16th St Suite 3450, Santa Monica, CA, 90404, USA
| | - Nicholas M Bernthal
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA.
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Advances in the Functional Assessment of Patients with Sarcoma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020. [PMID: 32483728 DOI: 10.1007/978-3-030-43032-0_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
Functional assessment of patients with osteosarcoma may yield unique insights into the guide and advance treatment. A range of patient-reported outcomes has been validated, including general health and condition-specific measures as well as computer adaptive testing. Health state utility measures, which facilitate comparative-effectiveness research, are also available. Beyond these surveys, and laboratory-dependent gait analyses, is the potential for real-world evaluation through research-oriented and consumer-oriented accelerometers. Initial studies have shown promising validity of these activity trackers and may also have implications for traditional oncologic outcomes.
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Rodriguez-Martin AM, Zacharopoulou P, Hassan AB, Tsiachristas A. Cost-effectiveness of healthcare interventions for rare cancers: Evidence from a systematic literature review and meta-analysis. J Cancer Policy 2018. [DOI: 10.1016/j.jcpo.2018.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Gilg MM, Gaston CL, Jeys L, Abudu A, Tillman RM, Stevenson JD, Grimer RJ, Parry MC. The use of a non-invasive extendable prosthesis at the time of revision arthroplasty. Bone Joint J 2018; 100-B:370-377. [PMID: 29589498 DOI: 10.1302/0301-620x.100b3.bjj-2017-0651.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The use of a noninvasive growing endoprosthesis in the management of primary bone tumours in children is well established. However, the efficacy of such a prosthesis in those requiring a revision procedure has yet to be established. The aim of this series was to present our results using extendable prostheses for the revision of previous endoprostheses. Patients and Methods All patients who had a noninvasive growing endoprosthesis inserted at the time of a revision procedure were identified from our database. A total of 21 patients (seven female patients, 14 male) with a mean age of 20.4 years (10 to 41) at the time of revision were included. The indications for revision were mechanical failure, trauma or infection with a residual leg-length discrepancy. The mean follow-up was 70 months (17 to 128). The mean shortening prior to revision was 44 mm (10 to 100). Lengthening was performed in all but one patient with a mean lengthening of 51 mm (5 to 140). Results The mean residual leg length discrepancy at final follow-up of 15 mm (1 to 35). Two patients developed a deep periprosthetic infection, of whom one required amputation to eradicate the infection; the other required two-stage revision. Implant survival according to Henderson criteria was 86% at two years and 72% at five years. When considering revision for any cause (including revision of the growing prosthesis to a non-growing prosthesis), revision-free implant survival was 75% at two years, but reduced to 55% at five years. Conclusion Our experience indicates that revision surgery using a noninvasive growing endoprosthesis is a successful option for improving leg length discrepancy and should be considered in patients with significant leg-length discrepancy requiring a revision procedure. Cite this article: Bone Joint J 2018;100-B:370-7.
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Affiliation(s)
- M M Gilg
- Department of Orthopedic Surgery and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - C L Gaston
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham B31 2AP, UK and The Department of Orthopedics, Philippine General Hospital, Manila Taft Avenue, Manila, 1000, Philippines
| | - L Jeys
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham, B31 2AP, United Kingdom
| | - A Abudu
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham, B31 2AP, United Kingdom
| | - R M Tillman
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham, B31 2AP, United Kingdom
| | - J D Stevenson
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham, B31 2AP, United Kingdom
| | - R J Grimer
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham, B31 2AP, United Kingdom
| | - M C Parry
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham, B31 2AP, United Kingdom
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