Monitoring the adequacy of surgical margins after resection of bone and soft-tissue sarcoma.

PURPOSE: Local recurrence of a bone or soft-tissue sarcoma is a devastating complication. Minimizing the proportion of positive surgical margins, or tumor contamination, during resection is of paramount importance. METHODS: Resections of sarcomas were prospectively evaluated and considered inadequate if unplanned microscopic or macroscopic positive surgical margins were identified or if inadvertent tumor contamination of the wound occurred. Monitoring of performance was continuously performed with a statistical process control method, the cumulative sum test, and regular meetings were held to discuss the reasons for failures. A target performance of 5 % inadequate procedures was chosen. RESULTS: A total of 146 sarcomas-106 soft tissue and 40 bone-were resected during the monitoring period. Six (4 %) procedures were considered inadequate: three patients had inadvertent tumor contamination of the wound, two patients had unplanned microscopic positive margins, and one patient had both. Performance was considered to be adequate during the whole monitoring period. CONCLUSIONS: With adequate preoperative planning and surgical technique, the risk of an inadequate resection can be limited. Implementation of a statistical process control method allows for ongoing performance monitoring and ensures that quality remains adequate over time.

Using the CUSUM test to control the proportion of inadequate open biopsies of musculoskeletal tumors.

BACKGROUND: Biopsies of musculoskeletal tumors lead to alterations in treatment in almost 20% of cases. Control charts are useful to ensure that a process is operating at a predetermined level of performance, although their use has not been demonstrated in assessing the adequacy of musculoskeletal biopsies. QUESTIONS/PURPOSES: We therefore (1) assessed the incidence of and the reasons for inadequate musculoskeletal biopsies when following guidelines for performing the procedure; and (2) implemented a process control chart, the CUSUM test, to monitor the proportion of inadequate biopsies. METHODS: We prospectively studied 116 incisional biopsies. The biopsy was performed according to 10 rules to (1) minimize contamination in the tissues surrounding the tumor; and (2) improve accuracy. A frozen section was systematically performed to confirm that a representative specimen was obtained. Procedures were considered inadequate if: (1) another biopsy was necessary; (2) the biopsy tract was not appropriately placed; and (3) the treatment provided based on the diagnosis from the biopsy was not appropriate. RESULTS: Five (4.3%) of the 116 incisional biopsy procedures were considered failures. Three patients required a second repeat open biopsy and two were considered to receive inappropriate treatment. No alarm was raised by the control chart and the performance was deemed adequate over the monitoring period. CONCLUSIONS: The proportion of inadequate musculoskeletal open biopsies performed at a referral center was low. Using a statistical process control method to monitor the failures provided a continuous measure of the performance.

Bilateral Femoral Nutrient Foraminal Cement Penetration during Total Hip Arthroplasty.

INTRODUCTION: Cement pressurisation is important for the insertion of both the acetabular and femoral components during Total Hip Arthroplasty (THA). Secondary to pressurization the rare phenomenon of unilateral cement incursion into the nutrient foramen has previously been reported. No bilateral case has been reported to date. This has implications both for misdiagnosis of periprosthetic fractures and for medico-legal consequences due to a presumed adverse intra-operative event. CASE REPORT: We present a case report of a 59 year old, caucasian female who underwent staged bilateral cemented Stanmore THA. The post-operative radiographs demonstrate evidence of bilateral nutrient foramen penetration intra-operatively by standard viscosity cement. The patient suffered no adverse consequences. CONCLUSIONS: In summary, cement extravasation into the nutrient foramen is an important differential to be considered in presence of posterior-medial cement in the diaphysis of femur following THA. This requires no further intervention and has no effect on the outcome.