Outcomes of non-angiosarcoma radiation-associated soft tissue sarcomas of the chest.

BACKGROUND: Radiation-associated soft tissue sarcomas (RA-STS) are rare complications of patients receiving radiation therapy (RT) and are generally associated with a poor prognosis. Most of the literature surrounding RA-STS of the chest is centered on angiosarcoma. Therefore, we aim to document the management and outcome of patients with non-angiosarcoma RA-STS of the chest. METHODS: We reviewed 17 patients (all female, median age 65 years) diagnosed with RA-STS. The most common primary malignancy was breast carcinoma (n = 15), with a median RT dose of 57.9 Gy. All patients underwent surgical resection; five patients (29%) received radiotherapy; and five patients (29%) received peri-operative chemotherapy. RESULTS: The 5-year local recurrence and metastatic-free survival were 61% and 60%, while the 5-year disease-specific survival was 53%. Local recurrence was associated with death due to disease (HR 9.06, p = 0.01). Complications occurred in nine of patients, most commonly due to a wound complication (n = 7). At the most recent follow-up, the median Musculoskeletal Tumor Society Score was 63%. CONCLUSION: RA-STS involving the chest wall are aggressive tumors with a high risk of local relapse and death due to disease. Local recurrence was associated with death due to disease; as such, we recommend aggressive surgical management with evaluation for adjuvant therapies.

Total Knee Arthroplasty With and Without Schedule II Opioids: A Randomized, Double-Blinded, Placebo-Controlled Trial.

INTRODUCTION: Orthopedic surgeons are the third highest prescribers of narcotics. Previous work demonstrated that surgeons prescribe three times the narcotics required, and most patients do not properly dispose of leftover medication following surgery. This has prompted the creation of multimodal pain regimens to reduce reliance on narcotics. It is unknown if these pathways can effectively eliminate opioids following total knee arthroplasty (TKA). Our purpose was to evaluate a multimodal regimen without schedule II narcotics following TKA, in a randomized, blinded fashion. We hypothesized that there would be no difference in pain scores between groups. METHODS: A total of 43 narcotic-naïve patients participated in a randomized, double-blinded, placebo-controlled trial. Postoperative protocols were identical between cohorts, except for the study medication. The narcotic group received an encapsulated 5 mg oxycodone, whereas the control group received an encapsulated placebo. Perioperative outcomes were compared with routine statistical analysis. RESULTS: Four patients withdrew early secondary to pain: three in the placebo group and one in the narcotic group (p=1.00). We found no difference in hospital length of stay (p=0.09) or pain scores at all time points between cohorts (all p>0.05). There was a higher proportion of patients using a narcotic in the opioid treatment arm at day 30 (40% vs. 21.4%, p=0.29) and day 60 (20% vs. 7.1%, p=0.32), although this was not statistically significant. CONCLUSION: A multimodal regimen without schedule II narcotics demonstrates equivalent pain scores and may reduce the risk of long-term opioid dependence following TKA.

Lifetime cost-effectiveness analysis osseointegrated transfemoral versus socket prosthesis using Markov modelling.

Aims: Prior cost-effectiveness analyses on osseointegrated prosthesis for transfemoral unilateral amputees have analyzed outcomes in non-USA countries using generic quality of life instruments, which may not be appropriate when evaluating disease-specific quality of life. These prior analyses have also focused only on patients who had failed a socket-based prosthesis. The aim of the current study is to use a disease-specific quality of life instrument, which can more accurately reflect a patient's quality of life with this condition in order to evaluate cost-effectiveness, examining both treatment-naïve and socket refractory patients. Methods: Lifetime Markov models were developed evaluating active healthy middle-aged male amputees. Costs of the prostheses, associated complications, use/non-use, and annual costs of arthroplasty parts and service for both a socket and osseointegrated (OPRA) prosthesis were included. Effectiveness was evaluated using the questionnaire for persons with a transfemoral amputation (Q-TFA) until death. All costs and Q-TFA were discounted at 3% annually. Sensitivity analyses on those cost variables which affected a change in treatment (OPRA to socket, or socket to OPRA) were evaluated to determine threshold values. Incremental cost-effectiveness ratios (ICERs) were calculated. Results: For treatment-naïve patients, the lifetime ICER for OPRA was $279/quality-adjusted life-year (QALY). For treatment-refractory patients the ICER was $273/QALY. In sensitivity analysis, the variable thresholds that would affect a change in the course of treatment based on cost (from socket to OPRA), included the following for the treatment-naïve group: yearly replacement components for socket > $8,511; cost yearly replacement parts OPRA < $1,758; and for treatment-refractory group: yearly replacement component for socket of > $12,467. Conclusion: The use of the OPRA prosthesis in physically active transfemoral amputees should be considered as a cost-effective alternative in both treatment-naïve and treatment-refractory socket prosthesis patients. Disease-specific quality of life assessments such as Q-TFA are more sensitive when evaluating cost-effectiveness.

Intravenous tranexamic acid is associated with an increased risk of pulmonary embolism following sarcoma resection.

INTRODUCTION: Tranexamic acid (TXA) is an antifibrinolytic drug that has been shown to reduce blood loss following surgery. The use of TXA during orthopedic procedures has gained widespread acceptance, with multiple clinical studies demonstrating no increase in thrombotic complications. While TXA has been shown to be safe and effective for several orthopedic procedures, its use in orthopedic sarcoma surgery is not well established. Cancer-associated thrombosis remains a significant cause of morbidity and mortality in patients with sarcoma. It is unknown if intraoperative TXA use will increase the risk of developing a postoperative thrombotic complication in this population. This study aimed to compare the risk of postoperative thrombotic complications in patients who received TXA during sarcoma resection to patients who did not receive TXA. METHODS: A retrospective review was performed of 1099 patients who underwent resection of a soft tissue or bone sarcoma at our institution between 2010 and 2021. Baseline demographics and postoperative outcomes were compared between patients who did and did not receive intraoperative TXA. We evaluated 90-day complication rates, including: deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), cerebrovascular accident (CVA), and mortality. RESULTS: TXA was used more commonly for bone tumors (p < 0.001), tumors located in the pelvis (p = 0.004), and larger tumors (p < 0.001). Patients who received intraoperative TXA were associated with a significant increase in developing a postoperative DVT (odds ratio [OR]: 2.22, p = 0.036) and PE (OR: 4.62, p < 0.001), but had no increase in CVA, MI, or mortality (all p > 0.05) within 90 days of surgery, following univariate analysis. Multivariable analysis confirmed that TXA was independently associated with developing a postoperative PE (OR: 10.64, 95% confidence interval: 2.23-50.86, p = 0.003). We found no association with DVT, MI, CVA, or mortality within 90 days postoperatively, following intraoperative TXA use. CONCLUSION: Our results demonstrate a higher associated risk of PE following TXA use in sarcoma surgery and caution is warranted with TXA use in this patient population.

A Survey of Personal Health Habits, Wellness, and Burnout in Practicing Orthopaedic Surgeons-Are We Taking Care of Ourselves?

INTRODUCTION: The personality traits of those who become orthopaedic surgeons may also lead to overwork, work-life balance issues, and burnout. Health and wellness practices of orthopaedic surgeons have not been widely explored. This study evaluated the personal health habits, wellness, and burnout of practicing orthopaedic surgeons in the United States. METHODS: An anonymous self-assessment survey was completed by 234 practicing orthopaedic surgeon alumni from two large residency programs. The survey assessed exercise habits according to Centers for Disease Control and Prevention recommendations, compliance with preventive medical care practices according to the United States Preventive Services Task Force, prioritization of occupational wellness strategies, and the presence of burnout via an adapted Maslach Burnout Inventory. Survey responders' mean age was 52 years, 88% were male, and 93% had a body mass index <30 kg/m2. Surgeons were stratified according to practice type, years in practice, and subspecialty. RESULTS: Among orthopaedic surgeons, compliance with aerobic and strength exercise recommendations was 31%. Surgeons in academic practice were significantly (P = 0.007) less compliant with exercise recommendations (18%) compared with private (34%) or employed (43%) practicing surgeons. Most (71%) had seen their primary care provider within 2 years and were up to date on age-appropriate health care screening including a cholesterol check within 5 years (79%), colonoscopy (89%), and mammogram (92%). Protecting time away from work for family/friends and finding meaning in work were the most important wellness strategies. The overall burnout rate was 15% and remained not significantly different (P > 0.3) regardless of years in practice, practice type, or subspecialty. CONCLUSION: This survey study identifies practicing orthopaedic surgeons' health habits and wellness strategies, including limited compliance with aerobic and strength exercise recommendations. Orthopaedic surgeons should be aware of areas of diminished personal wellness to improve quality of life and avoid burnout.

Pragmatic, Prospective Comparative Effectiveness Trial of Carbon Ion Therapy, Surgery, and Proton Therapy for the Management of Pelvic Sarcomas (Soft Tissue/Bone) Involving the Bone: The PROSPER Study Rationale and Design.

Surgical treatment of pelvic sarcoma involving the bone is the standard of care but is associated with several sequelae and reduced functional quality of life (QOL). Treatment with photon and proton radiotherapy is associated with relapse. Carbon ion radiotherapy (CIRT) may reduce both relapse rates and treatment sequelae. The PROSPER study is a tricontinental, nonrandomized, prospective, three-arm, pragmatic trial evaluating treatments of pelvic sarcoma involving the bone. Patients aged at least 15 years are eligible for inclusion. Participants must have an Eastern Cooperative Oncology Group Performance Status score of two or less, newly diagnosed disease, and histopathologic confirmation of pelvic chordoma, chondrosarcoma, osteosarcoma, Ewing sarcoma with bone involvement, rhabdomyosarcoma (RMS) with bone involvement, or non-RMS soft tissue sarcoma with bone involvement. Treatment arms include (1) CIRT (n = 30) delivered in Europe and Asia, (2) surgical treatment with or without adjuvant radiotherapy (n = 30), and (3) proton therapy (n = 30). Arms two and three will be conducted at Mayo Clinic campuses in Arizona, Florida, and Minnesota. The primary end point is to compare the 1-year change in functional QOL between CIRT and surgical treatment. Additional comparisons among the three arms will be made between treatment sequelae, local control, and other QOL measures.

Patient Satisfaction and Pain Relief After Deep Peroneal Nerve Neurectomy for Midfoot Arthritis: A Preliminary Short Report.

BACKGROUND: The deep peroneal nerve (DPN) plays a role in afferent nociceptive dorsal midfoot joint pain perception. DPN neurectomy for treatment of symptomatic dorsal midfoot osteoarthritis allows early mobilization and weightbearing. The purpose of our study was to evaluate the patient satisfaction and pain relief after DPN neurectomy for treatment of chronic dorsal midfoot pain due to osteoarthritis. METHODS: In this retrospective, IRB-approved, questionnaire-based study, we evaluated 48 patients (55 feet) with an average follow-up of 35.1 (range, 16-51) months who underwent DPN neurectomy at our institution between September 2017 and February 2021. There were 38 women and 10 men, 41 unilateral (22 right, 19 left) and 7 bilateral procedures, with an average age of 67.8 (range, 35-88) years at the time of surgery. A questionnaire that included questions regarding postsurgical dorsal midfoot pain relief, surgical result satisfaction, and current functional limitations was administered via telephone. Demographic information, patient responses, and complications were recorded. RESULTS: Of the 48 patients, 80.8% were satisfied with the result of the surgery in relieving their dorsal midfoot pain, 84.6% would repeat the surgery under the same circumstances, 83.8% would recommend the surgery to a friend, 10.4% reported they wish they had undergone arthrodesis, 91.7% reported pain relief in the first 6 months, and 55.6% reported current activity limitations. Six feet (10.9%) underwent a second procedure with an average postoperative time of 20.5 (range, 1-36) months. Complications included 1 hematoma and deep wound infection, 1 DPN neuroma and superficial peroneal nerve entrapment, and 4 patients with inadequate pain relief. CONCLUSION: In this cohort, DPN neurectomy appeared to be a reasonable surgical alternative to arthrodesis for the management of chronic dorsal midfoot pain due to midfoot osteoarthritis after failed nonoperative management. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Is Heterotopic Ossification Associated With Surgical Approach in Total Hip Arthroplasty?

BACKGROUND: Although risk factors for heterotopic ossification (HO) have been defined, the effect from surgical approach is not fully understood. The primary objective of our study was to evaluate the effect that surgical approach has on the risk for developing severe HO after total hip arthroplasty (THA) and compare this with other known risk factors. We hypothesized that there would be no difference in HO formation based on the surgical approach. METHODS: We retrospectively reviewed all patients who underwent primary THA at our hospital between March 2011 and March 2021. Patients with HO documented in the radiology reports were cross-referenced with our THA data set and manually reviewed to determine Brooker classification. Patient demographics, medical comorbidities, surgical details, and medication information were collected from the electronic medical record and compared. RESULTS: Of 3,427 patients who underwent THA, 677 (19.8%) developed HO postoperatively. A multivariable analysis confirmed that surgical approach was independently associated with increased odds for HO development. The anterolateral (odds ratio [OR], 3.43; P < 0.001) and posterior (OR, 2.24; P < 0.001) approaches had increased odds for developing HO compared with the direct anterior approach. However, only the anterolateral approach (OR, 1.85; P = 0.033) demonstrated an increased association with the development of severe HO (Brooker 3, 4) postoperatively. CONCLUSION: Although the use of the direct anterior approach had the lowest overall OR for developing HO after THA, this is likely only clinically notable when compared with the anterolateral approach. LEVEL OF EVIDENCE: III.

The Development and Early Experience of a Destination Center of Excellence Program for Total Joint Arthroplasty.

High-volume total joint arthroplasty centers are becoming designated as destination centers of excellence to ensure quality of care while containing costs. This study aimed to evaluate the surgical patient journey through a new destination center of excellence program, review acute perioperative course trajectories, and report clinical outcomes. Our institution developed and implemented a destination center of excellence program to integrate into the existing total joint arthroplasty practice. A retrospective record review and analysis were performed for the first 100 destination center of excellence total knee arthroplasties and total hip arthroplasties enrolled in the program to evaluate program efficacy at a minimum 1-year follow-up. The study initially screened 213 patients, of whom 100 (47%) met program criteria and completed surgery (67 total knee arthroplasties and 33 total hip arthroplasties). The complication rate was 2%, and five patients (7.5%) required manipulation under anesthesia for stiffness after total knee arthroplasty. Two reoperations were needed: a neurectomy after total knee arthroplasty and a revision after total hip arthroplasty. The early experience of a destination center of excellence program has been favorable, with low complication rates and excellent outcomes.

A case report of 2 distinct primary sarcomas arising in an extremity in rapid succession.

A 59-year-old male presented with a primary synovial sarcoma around his knee. Two months after resection, he presented with a new, rapidly-growing mass in the ipsilateral proximal thigh. A biopsy of the new mass demonstrated a pleomorphic liposarcoma, distinct from the prior synovial sarcoma. He underwent neoadjuvant radiation, followed by wide resection. He is now undergoing surveillance for recurrence. While 2 distinct primary sarcomas developing in rapid succession is rare, this case emphasizes the need for a complete work-up, including obtaining a tissue diagnosis for suspected recurrent lesions as this may alter treatment and follow-up recommendations.

A Pilot Study of Intralesional Injection of Triamcinolone Acetonide for Desmoid Tumors: Two-Year Outcomes.

PURPOSE: The purpose of this pilot study was to examine the clinical efficacy and safety of serial triamcinolone injections for the treatment of desmoid tumors. PATIENTS AND METHODS: Nine patients were enrolled into this prospective study and underwent three serial ultrasound-guided triamcinolone injections (120 mg) at 6-week intervals. MRI was compared at baseline and every 6 months, out to 24 months. Safety and tolerability were assessed by clinical evaluation and questionnaires, including the 12-item short form survey (SF-12), visual analog scale (VAS), and desmoid patient-reported outcome (PRO) tool. RESULTS: At 24 months, 8 (88.9%) patients demonstrated a reduction in the volume of their tumor while 1 (11.1%) enlarged. Median tumor volume change was -26.9% (-81.1% to 34.6%; P = 0.055) All 9 tumors remained stable based on World Health Organization criteria, whereas 2 (22.2%) demonstrated partial response based on RECIST. There was a significant decrease in the tumor:muscle postcontrast mean signal intensity ratio at 6 months (P = 0.008) and 24 months (P = 0.004). There was a similar decrease in the tumor:muscle T2 mean signal intensity ratio at 24 months (P = 0.02). We found no difference in the SF-12 and VAS scores, but there were significant improvements in the desmoid PRO. CONCLUSIONS: Treatment of desmoid tumors with serial triamcinolone injections appears safe and well tolerated by patients, with a 22% partial response based on RECIST. Further research is needed to confirm our results and determine factors predictive of response.

Management of Scapular Tumors.

Scapular resections are large oncologic undertakings. Due to the soft tissue coverage of the scapula, tumors are often able to be resected with a negative margin. Involvement of the brachial plexus and axillary vessels is rare, allowing for a limb-salvage surgery in most cases. Functional outcomes are based on the magnitude of resection; patients undergoing a partial scapulectomy and those with glenoid preservation demonstrate improved outcomes compared to patients undergoing a total scapulectomy or glenoid resection. Although scapular endoprosthetics are available, there is limited data to support their routine use.

Percutaneous biopsy of musculoskeletal tumors and the potential for needle tract seeding: technical considerations, current controversies, and outcomes.

Multidisciplinary communication and planning between the musculoskeletal radiologist and orthopedic oncologist are essential for proper biopsy planning when a primary musculoskeletal malignancy is suspected. Image-guided percutaneous biopsy allows for real-time visualization of the biopsy needle and surrounding structures, combining high diagnostic accuracy with safety and cost-effectiveness. However, determining a surgically optimal biopsy trajectory for a mass can be technically challenging due to critical surrounding anatomy or challenging needle approach angles. Inappropriately placed biopsies can have serious repercussions on patient function and oncological survival. The potential for needle tract seeding and local recurrence after biopsy of sarcoma has been central to the debate regarding the need for excision of the biopsy tract. This multidisciplinary review highlights current controversies in the field, including the issue of core needle biopsy tracts and their excision, technical considerations and advances in image-guidance in the setting of challenging biopsies, advances in histopathological diagnostics with implications for targeted therapy in sarcoma, as well as surgical and oncological outcomes after needle tract biopsy.

Perioperative Outcomes of Immersive Virtual Reality as Adjunct Anesthesia in Primary Total Hip and Knee Arthroplasty.

Background: Immersive virtual reality (IVR) is utilized as an adjunct to anesthesia to distract patients from their intraoperative environment, thereby potentially reducing sedative and narcotic medication usage. This study evaluated intraoperative and acute postoperative results of patients undergoing primary total hip (THA) and total knee arthroplasty (TKA) with and without IVR. Methods: Utilizing IVR as an adjunct to spinal anesthesia, 18 primary THAs (n = 8) and TKAs (n = 10) were performed. These cases were 1:2 matched based on procedure type, age, sex, and body mass index to those performed without IVR. Intraoperative and postanesthesia care unit sedative/narcotic usage, vital signs, and pain scores were compared. Acute perioperative outcomes, including 24-hour oral morphine equivalent (OME), first ambulation distance, length of stay, and 30-day complications, were also analyzed. Pearson Chi-square and Wilcoxon-Mann-Whitney tests evaluated categorical and continuous variables, respectively. Results: When compared to non-IVR primary THAs and TKAs, those performed with IVR utilized significantly less intraoperative sedation (48 mg vs 708 mg of propofol; P < .001) and trended toward less narcotic usage (13 mcg vs 39 mcg of fentanyl; P = .07). In the postanesthesia care unit, IVR and non-IVR patients showed no significant differences (P > .3) in vital signs, pain scores, or OME received. Additionally, similar (P > .3) postoperative outcomes were noted in both cohorts' 24-hour OME use, distance at first ambulation, length of stay, and 30-day complications. Conclusions: The use of spinal anesthesia with the IVR adjunct to perform primary THAs and TKAs appears to be well-tolerated and associated with less intraoperative sedative medication usage than spinal anesthesia alone.

A retrospective case series of prophylactic neurectomy during total knee arthroplasty.

INTRODUCTION: Total knee arthroplasty is a common operation performed to relieve pain and restore functional activity. While overall widely successful, a subset of patients has continued pain postoperatively with no identifiable cause. Neuroma formation has been identified as a possible contributor to this unexplained pain, often necessitating an additional procedure for neuroma removal. The purpose of our study was to evaluate if prophylactic neurectomy could reduce the occurrence of postoperative pain. METHODS: A total of 112 patients were compared, 44 control patients and 68 neurectomy patients. Demographic information, Numerical rating pain scale (NRS) and Knee Society Scores (KSS) were collected pre- and post-operatively. Patients were additional asked if they were overall satisfied with the operation. RESULTS: There were no differences between groups with respect to age (Median: 71 vs 69 years, p = 0.28), male sex (41% vs 44%, p = 0.85), or body mass index (Median: 32.2 vs 31.3, p = 0.80). When comparing the degree of change following surgery there were no statistically significant differences observed in NRS pain scores (Median change: -7 vs -6, p = 0.89) or KSS scores (Median change: +44 vs +40, p = 0.14). Similarly, there was no statistically significant difference in overall patient-reported satisfaction with the knee replacement (82.5% vs 86.6%, p = 0.59). CONCLUSION: We did not find a statistically significant difference in NRS, KSS, or overall patient satisfaction between the prophylactic neurectomy and control patient groups. Larger studies with evaluation of the nerve diameter will be needed to determine which patients are at risk for symptomatic neuroma development following total knee arthroplasty.

Tranexamic Acid Was Not Associated with Increased Complications in High-Risk Patients with Intertrochanteric Fracture.

BACKGROUND: For elective total joint arthroplasty, tranexamic acid (TXA) is considered safe and efficacious. However, evidence of TXA's safety in high-risk patients undergoing nonelective surgery for hip fracture is sparse. This study aimed to assess whether TXA administration to high-risk patients with an intertrochanteric (IT) hip fracture increased the risk of thromboembolic complications or mortality. METHODS: All patients treated surgically for IT hip fracture between 2015 and 2019 across 4 hospitals of a single hospital system were considered. High- versus low-risk patients and those receiving TXA versus no TXA treatment were identified. Propensity scores adjusted for risk differences between patient groups with TXA and no TXA administration were calculated for (1) high-risk patients (n = 141) and (2) the entire population (n = 316). Postoperative mortality, deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), and stroke within 90 days of surgery were evaluated. RESULTS: No association between TXA administration and increased risk of mortality or complications in either group was identified. Specifically, out of 282 matched high-risk patients, no differences in mortality (odds ratio [OR], 0.97 [95% confidence interval (CI), 0.90, 1.05]), DVT (OR, 0.97 [95% CI, 0.93, 1.00]), PE (OR 1.00 [95% CI, 0.95, 1.05]), MI (OR, 1.04 [95% CI, 0.98, 1.10]), or stroke (OR, 1.00 [95% CI, 0.95, 1.05]) were identified. CONCLUSIONS: In our review of propensity-matched high-risk patients undergoing surgical repair for IT fracture, we found that TXA administration compared with no TXA administration was not associated with an increased risk of mortality, DVT, PE, MI, or stroke within 90 days of surgery. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Skeletal Sarcomas: Diagnosis, Treatment, and Follow-up from the Orthopedic Oncologist Perspective.

This article focuses on skeletal sarcomas, a group of rare, heterogenous malignant tumors. We present information on the multi-disciplinary approach to the diagnosis, staging, treatment, and surveillance of these complex tumors that are critical to enhancing function and improving survival.

Soft Tissue Tumors: Diagnosis, Treatment, and Follow-up from the Orthopedic Oncologist Perspective.

This article focuses on soft tissue sarcomas, including the workup, management, and potential complications in dealing with these rare mesenchymal tumors. We present the information that is critical in the decision-making process for orthopedic oncologists to help facilitate a multidisciplinary approach to these complex cases.

The Impact of Metabolic Syndrome on Reoperations and Complications After Primary Total Hip Arthroplasty.

BACKGROUND: Metabolic syndrome (MetS) represents a constellation of interrelated conditions including insulin resistance, abdominal obesity, hypertension, and dyslipidemia. The goals of this study are to determine the impact of MetS on implant survivorship, complications, and clinical outcomes after primary total hip arthroplasty (THA). METHODS: Utilizing our institutional total joint registry, 1,268 patients undergoing primary THA were identified with MetS based on the World Health Organization definition and matched 1:1 to those without MetS based on age, gender, and surgical year. MetS patients were further stratified according to the World Health Organization body mass index (BMI) classification to contextualize obesity. Kaplan-Meier analyses were utilized to compare survivorship free of any reoperation, revision, and complications. Clinical outcomes were assessed with Harris hip scores. Mean follow-up after THA was 5 years. RESULTS: MetS patients had significantly worse 5-year survivorship free from any reoperation compared to those without MetS (93.5% vs 96.1%, respectively; hazard ratio [HR] 1.4, P = .04). When stratifying MetS and BMI classification, the BMI >40 kg/m2 had significantly decreased 5-year implant survivorship free from any reoperation (85.9% vs 96.1%, HR 3.4, P < .001), any revision (91.7% vs 97.3%, HR 2.7, P < .001), and reoperation for periprosthetic joint infection (95% vs 99%, HR 5.1, P < .001). Both groups experienced significant and similar improvement in final Harris hip scores (P < .001). CONCLUSION: Patients with MetS had a 1.4-fold increased risk of reoperation after primary THA compared to a matched cohort without the condition. MetS patients with a BMI >40 kg/m2 had the highest risk of reoperation, and had a significantly higher revision and periprosthetic joint infection rates, suggesting that morbid obesity remains a critical, independent risk factor beyond MetS. LEVEL OF EVIDENCE: Level 3, Case-control study.

NTRK-rearranged spindle cell neoplasm of the lower extremity: radiologic-pathologic correlation.

Neurotrophic tyrosine receptor kinase (NTRK)-rearranged spindle cell neoplasm is a recently characterized soft tissue tumor and has been classified as provisional by the World Health Organization. Detection of the genetic rearrangement is important because these tumors are amenable to targeted tyrosine kinase inhibitor therapy, which can play a key role in patients with unresectable or advanced disease. Although the spectrum of histopathology associated with this entity is broad, one notable feature is the infiltrative growth pattern, which is most reminiscent of lipofibromatosis-like neural tumor. Description of their diverse histologic attributes has aided recognition, but so far little attention has been paid to correlating the gross appearance and imaging features of these lesions. In this report, we describe the clinical, imaging, histopathological, and genetic features of a soft tissue NTRK-rearranged spindle cell neoplasm. Inclusion of this more recently identified entity into the imaging differential of tumors with intratumoral relatively hypovascular nodules and infiltrative margins is important because testing for NTRK rearrangement is not routinely performed.