Clinical Outcomes After Definitive Treatment of Soft Tissue Sarcoma of the Hand: A Retrospective Cohort Study of 109 Patients.

PURPOSE: The purpose of this study was to provide updated data on oncologic outcomes following definitive surgical treatment of soft tissue sarcoma of the hand in a cohort of 109 patients, as well as to characterize risk factors for poor oncologic and functional outcomes. METHODS: We analyzed data from 109 consecutive patients who had definitive surgical treatment for soft tissue sarcoma of the hand performed between 1996 and 2019 by a single surgeon at a sarcoma center. Primary outcomes included functional outcome (assessed by Musculoskeletal Tumor Society scores), disease-free survival (DFS), and overall survival (OS). We compiled descriptive data and used a multivariable linear model to identify factors associated with functional outcomes. Kaplan-Meier methods were used to estimate 5- and 10-year DFS and OS. RESULTS: Patients had a median age of 36 years at presentation. Median follow-up was 6.1 years among patients alive at the end of follow-up. The median Musculoskeletal Tumor Society score was 29; functional outcome was worse among patients with high-grade tumors or complications. Among the 107 patients who became disease-free, there were four local recurrences (one with metastasis), six distant recurrences, and one death without recurrence. All local recurrences were deep tumors (two myxofibrosarcoma and two myxoinflammatory fibrosarcoma). Estimated 5- and 10-year DFS rates were 89% (95% confidence interval [CI]: 83% to 96%) and 88% (95% CI: 80% to 95%). There were seven deaths, and the estimated 5- and 10-year OS rates were 95% (95% CI: 90% to 100%) and 92% (95% CI: 84% to 100%). Larger tumor size and higher stage at diagnosis were associated with shorter DFS and OS in univariable analyses; low event rates precluded multivariable analysis of survival. CONCLUSIONS: Aggressive disease-specific surgical and multidisciplinary treatment can yield long DFS and OS, and good functional outcomes. However, complications and high-grade tumors are associated with worse functional scores. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Reconstruction of oncologic upper extremity defects with fibula free flaps has high union rates and excellent functional outcomes.

BACKGROUND: Limb salvage has better functional outcomes than amputation in the upper extremity. This can however be challenging after bony tumor resections. METHODS: This is a retrospective case series of patients who underwent humerus, ulna, or radius reconstruction with a fibula free flap. Data were collected on demographics, oncologic history, surgical details, and complications. Functional outcome measures included the patient's ability to perform activities of daily living (ADL), presence of pain, and musculoskeletal tumor society (MSTS) score. RESULTS: Over a 25-year period, 38 reconstructions were performed. The flap success rate was 97.5%. Bony union was obtained in 19 of 19 (100%) forearm reconstructions and in 15 of 19 (79%) humerus reconstructions (p = 0.10). All 19 forearm reconstruction patients and 18/19 humerus reconstruction patients were able to perform ADLs with no pain or only occasional pain. The MSTS scores were not significantly different between the humerus and forearm cohorts (27.1 vs. 27.3, p = 0.68). Functional outcomes were significantly better in limbs that achieved union (p < 0.001). Recipient and donor site complications occurred in 10 (26.3%) and 5 (13%) patients, respectively. CONCLUSIONS: Oncologic upper-extremity reconstruction with fibula free flaps has excellent functional outcomes. Bone union is a predictor of superior limb function.

What is the Geographic Distribution of Women Orthopaedic Surgeons Throughout the United States?

BACKGROUND: Orthopaedic surgery has a shortage of women surgeons. An even geographic distribution of women orthopaedic surgeons may provide more uniform care to patients. However, little is known about the geographical distribution of women orthopaedic surgeons. QUESTIONS/PURPOSES: (1) Is there substantial geographic variation in the distribution of orthopaedic surgeons who are women? (2) How does the geographic distribution of women orthopaedic surgeons compare with that of other physicians? (3) What are the variables associated with increased region-based proportions of orthopaedic surgeons who are women? METHODS: To obtain a national snapshot of orthopaedic providers, two Medicare databases were used (Medicare Provider Utilization and Payment Data and Medicare's current and archived Physician Compare Data). These databases were used to identify physicians with self-reported specialties of "Orthopedic Surgeon," "Hand Surgeon," or "Sports Medicine" with at least 11 Medicare claims in 1 year for a single procedure type between 2012 and 2014. These databases are the only databases known to specifically report surgeon gender on a national scale and include physician demographics and education. The Dartmouth Atlas's hospital referral regions and United States Census Bureau divisions were used to group physicians by geographic region. The Gini coefficient, a measure of statistical dispersion, was used to quantify the regional distribution of orthopaedic surgeons. This was compared with the dispersion of non-orthopaedic physicians within the same Medicare databases. Surgeon and regional characteristics were correlated with the proportion of women orthopaedic surgeons in the region. RESULTS: There is substantial geographic variation in the distribution of orthopaedic surgeons who are women, ranging from 0% to 15%. There was a greater prevalence of women orthopaedic surgeons in New England (7.3%, 107 of 1469 surgeons) and the Pacific region (6.5%, 208 of 3196 surgeons) than in the South Atlantic (4.5%, 210 of 4618 surgeons) and East South Central regions (3.5%, 50 of 1442 surgeons). This represents a greater level of variation (Gini coefficient = 0.37) compared with other specialties (0.30 and 0.37) and compared with men orthopaedic surgeons (0.16). Variables independently associated with an increased prevalence of women orthopaedic surgeons based on hospital referral region were an increased proportion of currently practicing women physicians who graduated from medical schools in that region (beta = 0.03; p = 0.01), increased proportion of Medicaid-eligible patients (beta = 0.12; p = 0.002), increased proportion of regional population is black (beta = -0.06; p = 0.03), and increased regional supply of women physicians (beta = 0.26; p < 0.0001). CONCLUSIONS: Despite the recent increase in women orthopaedic surgeons nationally, gains have not been equally distributed throughout the United States. CLINICAL RELEVANCE: In other medical fields, gender diversity has been proven to be beneficial for patients. If this holds true in the field of orthopaedic surgery, we should be mindful of the geographic distribution of women orthopaedic surgeons as the percentage of these surgeons increases.

Profiles of Practicing Female Orthopaedists Caring for Medicare Patients in the United States.

BACKGROUND: The increase in the percentage of women in orthopaedics in the United States over the last half century has been substantially slower than in every other surgical specialty. While this percentage has improved recently, the current demographic and practice characteristics of female orthopaedic surgeons are not well known. This study defines the landscape of practicing female orthopaedic surgeons caring for Medicare patients. METHODS: Publicly available Medicare billing data sets from 2012 to 2014 were utilized to identify practicing orthopaedic surgeons. We analyzed demographics, medical training, practice characteristics, case volume, specialization, and procedure profiles of orthopaedic surgeons. Representative Current Procedural Terminology (CPT) codes were utilized for each subspecialty. Multivariate analysis was performed to confirm the independent characteristics that were associated with female orthopaedic surgeons after identification by univariate statistics. RESULTS: The percentage of practicing female orthopaedic surgeons caring for Medicare patients increased significantly from 4.7% (1,043 of 22,038) in 2012 to 5.2% (1,179 of 22,510) in 2014. Women had graduated from medical school in more recent years than men (mean, 14.9 versus 22.5 years, respectively; p < 0.001), and were more likely to have attended a top-25 medical school (27.5% versus 24.5%, respectively; p = 0.01). Women were more likely to be part of larger practices (median, 49.5 versus 24 partners, respectively; p < 0.001), and were more likely to leave practice (4.4% versus 3.1% in 2013, respectively; p = 0.02). Women submitted fewer claims for billing per year (median, 528 versus 1,193, respectively; p < 0.001), and performed 6.8% (9,852 of 144,492) of hand procedures compared with 1.5% (10,043 of 651,856) of all other common procedures (p < 0.001). Multivariate analysis demonstrated that despite confounders, gender was an independent predictor of number of claims, the likelihood of leaving clinical practice, and Medicare reimbursement. CONCLUSIONS: There are significant differences between female and male orthopaedic surgeons caring for Medicare patients in terms of subspecialty choices, education, billing practices, and attrition rates. Despite the recent increase in the number of female orthopaedic surgeons, there are significant gender differences within the specialty.

Antibiotic Management and Operative Debridement in Open Fractures of the Hand and Upper Extremity: A Systematic Review.

Open fractures of the hand are thought to be less susceptible to infection than other open fractures because of the increased blood supply to the area. Current evidence for all open fractures shows that antibiotic use and the extent of contamination are predictive of infection risk, but time to debridement is not. We reviewed in a systematic review the available literature on open fractures of the hand and upper extremity to determine infection rates based on the timing of debridement and antibiotic administration. We continue to recommend prompt debridement and treatment of most open fractures of the upper extremity.

Ulnar Nerve Management with Distal Humerus Fracture Fixation: A Meta-Analysis.

Ulnar nerve dysfunction following distal humerus fractures is a well-recognized phenomenon. There is no consensus regarding optimal handling of the ulnar nerve during surgical management of these fractures between in situ management and transposition. Using an electronic database to identify retrospective studies involving surgical fixation of distal humerus fractures yielded 46 studies, 5 trials meeting the authors' inclusion criteria, totaling 362 patients. An overall incidence of 19.3% for ulnar neuropathy was identified. Of those patients undergoing in situ release, the incidence was 15.3%. Of those who underwent transposition, there was a 23.5% incidence of ulnar neuropathy.

A microRNA network regulates proliferative timing and extracellular matrix synthesis during cellular quiescence in fibroblasts.

BACKGROUND: Although quiescence (reversible cell cycle arrest) is a key part in the life history and fate of many mammalian cell types, the mechanisms of gene regulation in quiescent cells are poorly understood. We sought to clarify the role of microRNAs as regulators of the cellular functions of quiescent human fibroblasts. RESULTS: Using microarrays, we discovered that the expression of the majority of profiled microRNAs differed between proliferating and quiescent fibroblasts. Fibroblasts induced into quiescence by contact inhibition or serum starvation had similar microRNA profiles, indicating common changes induced by distinct quiescence signals. By analyzing the gene expression patterns of microRNA target genes with quiescence, we discovered a strong regulatory function for miR-29, which is downregulated with quiescence. Using microarrays and immunoblotting, we confirmed that miR-29 targets genes encoding collagen and other extracellular matrix proteins and that those target genes are induced in quiescence. In addition, overexpression of miR-29 resulted in more rapid cell cycle re-entry from quiescence. We also found that let-7 and miR-125 were upregulated in quiescent cells. Overexpression of either one alone resulted in slower cell cycle re-entry from quiescence, while the combination of both together slowed cell cycle re-entry even further. CONCLUSIONS: microRNAs regulate key aspects of fibroblast quiescence including the proliferative state of the cells as well as their gene expression profiles, in particular, the induction of extracellular matrix proteins in quiescent fibroblasts.