Publications by authors named "Peter F M Choong"

215 Publications

The need for improved patient reported outcome measures in patients with extremity sarcoma: A narrative review.

ANZ J Surg 2021 Jul 5. Epub 2021 Jul 5.

Department of Surgery, University of Melbourne, Melbourne, Australia.

Background: Extremity sarcoma causes impairments to functionality and quality of life. Patient-reported outcome measures (PROMS) assess patient perspectives relating to domains of health and quality of life.

Methods: To describe PROMs utilised in extremity sarcoma, the available literature was screened for studies that utilised PROMs to evaluate outcomes in extremity sarcoma following surgery.

Results: Seventy articles met eligibility criteria; six PROMs were identified. The Toronto Extremity Salvage Score, The Short-Form 36, The EORTC QLQ-C30, The Disabilities of the Arm, Shoulder and Hand questionnaire, the Reintegration to Normal Living index and the Patient-Reported Outcomes Measurement Information System. Most sarcoma patients score well in these tools, with bone sarcoma, and extent of resection being predictors of poor outcomes.

Conclusion: TESS is the only sarcoma-specific PROM, and though a valid assessment of functionality, it has difficulty differentiating patients with minor functional impairments. The absence of a disease-specific measure of health is concerning, as generic tools do not account for the unique experiences sarcoma patients face and may impair their accuracy in analysing intervention effectiveness.
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http://dx.doi.org/10.1111/ans.17028DOI Listing
July 2021

In the dark about physical activity - exploring patient perceptions of physical activity after elective total knee joint replacement: a qualitative study.

Arthritis Care Res (Hoboken) 2021 May 31. Epub 2021 May 31.

School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Australia.

Objective: The study aimed to explore patient perceptions of and motivations for physical activity after total knee joint replacement.

Methods: Participants were purposively sampled after completing a public outpatient rehabilitation exercise group. Semi-structured interviews were completed with 22 participants (mean age 70 years, 45% women) 6 to 12 months after total knee joint replacement. Interviews were audiotaped and transcribed verbatim. Themes were identified by an inductive and iterative process of data analysis.

Results: The main theme to emerge was participants were in the dark about physical activity. Participants were typically not familiar with physical activity guidelines and had difficulty distinguishing between low and moderate-intensity physical activity. Three subthemes were identified: (1) people prioritise participation in meaningful life situations after total knee joint replacement; (2) rehabilitation was perceived to not explicitly address moderate-intensity physical activity levels; and (3) other health and social reasons replaced knee osteoarthritis as barriers to physical activity.

Conclusion: Limited understanding of physical activity recommendations, prioritisation of participation in meaningful life situations, rehabilitation that was impairment focused and other health and social reasons appeared to contribute to low levels of moderate-intensity physical activity for adults after knee joint replacement. Addressing being in the dark about physical activity may be an important first step to increase the effectiveness of behavioural interventions designed to promote physical activity after total knee joint replacement.
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http://dx.doi.org/10.1002/acr.24718DOI Listing
May 2021

The Impact of Enhanced Recovery After Surgery on Total Joint Arthroplasty: Protocol for a Systematic Review and Meta-analysis.

JMIR Res Protoc 2021 Mar 12;10(3):e25581. Epub 2021 Mar 12.

Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, Australia.

Background: The number of total joint arthroplasties (TJAs) being performed is increasing worldwide. To match this increasing demand, there has been focus on hastening patients' recovery of function. This effort has culminated in the formulation of enhanced recovery after surgery (ERAS) strategies. However, with evolving ERAS programs and new recommendations, a review of current evidence is required to provide clinicians with up-to-date information about its effect on outcomes for TJA.

Objective: The objective of this study is to assess the utility of ERAS programs on patient, health service, and economic outcomes for primary, elective total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Methods: A systematic search will be conducted in Medline (Ovid), EMCARE (Ovid), EMBASE (Ovid), Web of Science, CINAHL, National Health Service Economic Evaluations Database, and the Cochrane Library. Analytical, observational, and experimental designs will be included in this systematic review. Only studies including patients undergoing primary TKA and THA comparing ERAS programs with conventional surgery and postoperative care will be included. Data related to patient outcomes, health service outcomes, safety, and economic evaluation will be extracted.

Results: The search terms and primary database searches have been finalized. Findings will be reported in narrative and tabular form. Where appropriate, random effects meta-analyses will be conducted for each outcome, and heterogeneity quantified with Cochran Q test and I2 statistic. Measures of effect or mean differences will be reported with 95% confidence intervals. The results of this systematic review will be disseminated in a peer-reviewed journal.

Conclusions: This protocol will guide a systematic review assessing outcomes associated with ERAS surgery in primary THA and TKA.

Trial Registration: Open Science Framework osf.io/y4bhs; https://osf.io/y4bhs.

International Registered Report Identifier (irrid): PRR1-10.2196/25581.
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http://dx.doi.org/10.2196/25581DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7998324PMC
March 2021

Low grade of radiographic osteoarthritis predicts unsatisfactory response of the contralateral knee replacement in two-stage bilateral total knee arthroplasty.

Knee Surg Sports Traumatol Arthrosc 2021 Feb 2. Epub 2021 Feb 2.

Department of Orthopaedics, St. Vincent's Hospital (Melbourne), PO Box 2900, Fitzroy, VIC, 3065, Australia.

Purpose: It is difficult to counsel patients with bilateral osteoarthritis who are unsatisfied with their first knee replacement as to whether they are likely to have a better outcome after the contralateral knee is replaced. The purpose of this study was to determine whether predictive factors can be found to prognosticate outcome of the second-side knee replacement when a patient has an unsatisfactory response to the first, with the hypothesis that predictors, such as prosthetic factors and radiographic level of osteoarthritis, may be able to predict a satisfactory response to the contralateral knee replacement.

Materials And Methods: An analysis of staged bilateral knee replacements performed at a tertiary arthroplasty centre from 2012 to 2018 was undertaken. A total of 550 knee replacements in 275 patients were included in this study. The primary variable measured was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Satisfactory response to surgery was defined as a WOMAC score improved by 17 points or more, and 56 or greater. Patients who did not achieve a satisfactory response with their first knee replacement were further analysed for predictive factors (age, sex, pre-operative score, mental score, socioeconomic status, type of prosthesis, use of navigation, patella resurfacing and radiographic osteoarthritis) of an unsatisfactory response for their contralateral knee replacement.

Results: Overall, 44 (16%) patients failed to achieve a satisfactory response from both their first and contralateral knee replacements. The factor most predictive of an unsatisfactory response to their first knee replacement was pre-operative mental health score. However, in patients who did not achieve a satisfactory response with their first knee replacement, radiographic osteoarthritis, as measured by the Kellgren-Lawrence (KL) score was the main predictor of satisfactory response for their contralateral knee replacement. Only patients with KL grade 4 osteoarthritis were likely to have a satisfactory response with their contralateral knee replacements (KL4 versus KL3, Odds ratio 3.57 (CI 1.26-10.03) p = 0.016*). Patients with KL grade 3 osteoarthritis were unlikely to have a satisfactory response, and in this series, no patient with KL grade 2 osteoarthritis had a satisfactory response.

Conclusion: In a patient who has an unsatisfactory response to their first knee replacement, the best predictor of achieving a satisfactory response to his/her contralateral knee replacement is the level of radiographic osteoarthritis in that knee.

Level Of Evidence: IV: Retrospective Cohort study.
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http://dx.doi.org/10.1007/s00167-021-06465-3DOI Listing
February 2021

Addressing surgical inequity for Aboriginal and Torres Strait Islander people in Australia's universal health care system: a call to action.

ANZ J Surg 2021 03 28;91(3):238-244. Epub 2021 Jan 28.

Department of Surgery, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Victoria, Australia.

Aboriginal and Torres Strait Islander people continue to experience health inequity within the Australian health care system. Little research has examined how disparities in surgical care access and outcomes contribute to Aboriginal health. In this narrative review and call to action, we discuss five care points along the journey to high-quality surgical care: health care seeking, primary health care services, specialist services, surgery and surgical outcomes. We highlight barriers and disparities that exist along this journey, drawing examples from the field of joint replacement surgery. Finally, we present opportunities for change at the health system, health service and clinician level, calling upon researchers, clinicians and policy makers to confront the surgical disparities experienced by Aboriginal and Torres Strait Islander people.
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http://dx.doi.org/10.1111/ans.16557DOI Listing
March 2021

Placebo Surgery Controlled Trials: Do They Achieve What They Set Out To Do? A Systematic Review.

Ann Surg 2021 06;273(6):1102-1107

Department of Surgery, The University of Melbourne, St. Vincent's Hospital Melbourne, Victoria, Australia.

Objective: To explore whether placebo surgery controlled trials achieve what they set out to do by investigating discrepancy between projected and actual design aspects of trials identified through systematic review methods.

Summary Background: Interest in placebo surgery controlled trials is growing in response to concerns regarding unnecessary surgery and the societal cost of low-value healthcare. As questions about the justifiability of using placebo controls in surgery have been addressed, attention is now being paid to more practical concerns.

Methods: Six databases were searched from inception - May 2020 (MEDLINE, Embase, Emcare, APA PsycInfo, CINAHL, Cochrane Library). Placebo surgery controlled trials with a published protocol were included. Three authors extracted "projected" design aspects from protocols and "actual" design aspects from main findings papers. Absolute and relative difference between projected and actual design aspects were presented for each trial. Trials were grouped according to whether they met their target sample size ("completed") and were concluded in a timely fashion. Pairs of authors assessed risk of bias.

Results: Of 24 trials with data available to analyse; 3 were completed and concluded within target timeframe; 10 were completed and concluded outside the target timeline; 4 were completed without clear target timeframes; 2 were incomplete and concluded within the target framework; 5 were incomplete and concluded outside the target timeline. Trials which reached the recruitment target underestimated trial duration by 88% and number of recruitment sites by 87%.

Conclusions: Trialists need to factor additional time and sites into future placebo surgery controlled trials. A robust reporting framework of projected and actual trial design is imperative for trialists to learn from their predecessors.

Review Registration: PROSPERO (CRD42019133296).
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http://dx.doi.org/10.1097/SLA.0000000000004719DOI Listing
June 2021

Assessment of Native Human Articular Cartilage: A Biomechanical Protocol.

Cartilage 2020 Nov 20:1947603520973240. Epub 2020 Nov 20.

BioFab3D, Aikenhead Centre for Medical Discovery, St. Vincent's Hospital, Fitzroy, Victoria, Australia.

Objectives: Recapitulating the mechanical properties of articular cartilage (AC) is vital to facilitate the clinical translation of cartilage tissue engineering. Prior to evaluation of tissue-engineered constructs, it is fundamental to investigate the biomechanical properties of native AC under sudden, prolonged, and cyclic loads in a practical manner. However, previous studies have typically reported only the response of native AC to one or other of these loading regimes. We therefore developed a streamlined testing protocol to characterize the elastic and viscoelastic properties of human knee AC, generating values for several important parameters from the same sample.

Design: Human AC was harvested from macroscopically normal regions of distal femoral condyles of patients ( = 3) undergoing total knee arthroplasty. Indentation and unconfined compression tests were conducted under physiological conditions (temperature 37 °C and pH 7.4) and testing parameters (strain rates and loading frequency) to assess elastic and viscoelastic parameters.

Results: The biomechanical properties obtained were as follows: Poisson ratio (0.4 ± 0.1), instantaneous modulus (52.14 ± 9.47 MPa) at a loading rate of 1 mm/s, Young's modulus (1.03 ± 0.48 MPa), equilibrium modulus (7.48 ± 4.42 MPa), compressive modulus (10.60 ± 3.62 MPa), dynamic modulus (7.71 ± 4.62 MPa) at 1 Hz and loss factor (0.11 ± 0.02).

Conclusions: The measurements fell within the range of reported values for human knee AC biomechanics. To the authors' knowledge this study is the first to report such a range of biomechanical properties for human distal femoral AC. This protocol may facilitate the assessment of tissue-engineered composites for their functionality and biomechanical similarity to native AC prior to clinical trials.
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http://dx.doi.org/10.1177/1947603520973240DOI Listing
November 2020

Denosumab induced atypical fracture of free vascularized fibular graft 20 years after tumour reconstruction.

ANZ J Surg 2021 05 12;91(5):E335-E337. Epub 2020 Oct 12.

Department of Surgery, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1111/ans.16358DOI Listing
May 2021

Sex-based differences in the outcomes of total hip and knee arthroplasty: a narrative review.

ANZ J Surg 2021 04 21;91(4):553-557. Epub 2020 Sep 21.

Department of Surgery, The University of Melbourne, St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.

Total joint arthroplasty (TJA) is an effective treatment for end-stage osteoarthritis, which aims to alleviate pain and improve function and mobility. Despite the remarkable success of TJA, complications can arise, leading to unplanned hospital readmission, implant failure, morbidity and mortality. Recently, there has been a growing interest in analysing sex-based differences in diseases and response to medical interventions. This review summaries evidence pertaining to the widening gap between men and women regarding the utilization and outcome of TJA surgery. Interactions between sex and patient-reported outcome, implant failure and medical complication are complex and often demonstrate conflicting results. Significantly, there is a global consensus that men are at a higher risk of developing prosthetic joint infection following joint arthroplasty. Guided by the literature, there is a clear need for standardized methods of collecting, analysing and reporting sex-specific data to improve outcomes for both men and women who undergo TJA.
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http://dx.doi.org/10.1111/ans.16299DOI Listing
April 2021

Opioid Use and Total Joint Replacement.

Curr Rheumatol Rep 2020 08 17;22(10):58. Epub 2020 Aug 17.

Department of Surgery, St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia.

Purpose Of Review: We provide an overview of recent research into the relationship between preoperative opioid use and total joint replacement outcomes.

Recent Findings: Recent findings indicate that total joint replacement patients with a history of preoperative opioid use experience higher rates of infection, revision, short-term complications, and prolonged postoperative opioid use, along with fewer improvements in pain and function following surgery. These risks are particularly pronounced among chronic opioid users. While the baseline risk profiles of these patients may contribute to higher rates of adverse outcomes, it is also plausible that certain outcomes are directly impacted by opioid use through mechanisms such as opioid-induced hyperalgesia and immunosuppression. There is little available data on the efficacy of interventions that aim to mitigate these risks. Well-designed clinical trials are needed to evaluate the efficacy of targeted perioperative interventions that aim to improve outcomes for this high-risk surgical population. Where such trials are not feasible, additional high-quality observational studies are necessary to further our understanding of the mechanisms underlying the relationships between opioid use and specific adverse outcomes.
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http://dx.doi.org/10.1007/s11926-020-00929-0DOI Listing
August 2020

Human Stem Cell Based Tissue Engineering for Cartilage Repair: A Systematic Review.

Tissue Eng Part B Rev 2021 02 14;27(1):74-93. Epub 2020 Oct 14.

BioFab3D, Aikenhead Centre for Medical Discovery, St. Vincent's Hospital, Fitzroy, Australia.

Pure chondral defects represent the most clinically significant articular cartilage injuries. To inform the development of clinically suitable tissue-engineering strategies for chondral repair using cells from a human patient, the combination of human stem cells (HSCs), biomaterial scaffolds, and growth factors has been widely harnessed in preclinical animal models. Due to the large heterogeneity in study designs and outcome reporting in such studies, we aimed to systematically review literature pertaining to HSC based tissue engineering strategies in animal models of chondral repair such that trends may be identified and the utility of HSCs in chondral repair can be elucidated. An extensive search strategy was carried out through PubMed, MEDLINE, and EMBASE databases to identify relevant studies. Initially the title and abstract of 787 studies were screened after which inclusion and exclusion criteria sorted 56 studies for full-text evaluation. Following full text review, a final number of 22 articles were included. Out of 22 included studies, 16 used scaffold implantation, 2 used cell pellet implantation, and 4 used intra-articular injection to administer HSCs to the region of chondral defects. HSC-containing implants outperformed scaffold-only or untreated control groups in both large and small animals for chondral regeneration. Umbilical cord mesenchymal stem cells and hyaluronic acid-containing scaffolds emerged as popular stem cell and scaffold choices, respectively. However, the short analysis timepoints post cell implantation was a key limitation in many studies. This review highlights the versatility of HSCs in achieving chondral regeneration and the enhancement of chondral repair through the selection of appropriate three-dimensional scaffolds and growth factors which are essential to support cell growth, attachment, migration, and extracellular matrix synthesis. Considerable heterogeneity exists in outcome reporting, and only one article reported biomechanical evaluation of neocartilage. Standardized outcome reporting systems that include comprehensive biomechanical testing protocols should be utilized in future studies of cartilage tissue engineering as the biomechanical quality of neocartilage is of great functional significance.
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http://dx.doi.org/10.1089/ten.TEB.2020.0155DOI Listing
February 2021

Early surgical complications of total hip arthroplasty related to surgical approach.

ANZ J Surg 2020 10 20;90(10):2050-2055. Epub 2020 Jul 20.

Department of Orthopaedics, St. Vincent's Hospital, Melbourne, Victoria, Australia.

Background: Total hip arthroplasty (THA) can be performed through a number of surgical approaches. The aim was to compare the incidence of early surgical complications in THA related to approach.

Methods: A retrospective review of prospectively recorded data extracted from St. Vincent's Melbourne Arthroplasty Registry was performed between January 2006 and December 2016. Surgical approach was identified: lateral, posterior, anterior and superior. Primary outcome measure was return to theatre (RTT) for any cause within 1 year. Age, comorbidity, body mass index and femoral fixation were assessed for potential confounding. Secondary outcomes were RTT for revision procedure and for specific complications: intra or post-operative fracture, dislocation/instability, aseptic loosening and prosthetic joint injection (PJI). Variables were assessed for their association with outcome using unadjusted and adjusted quantile median regression for continuous outcomes and Cox proportional hazards regression for binary time-to-event outcomes.

Results: There were a total of 2906 consecutive THA's recorded, 1413 lateral, 1188 posterior, 233 anterior and 72 superior. A total of 140 cases (4.5%) required RTT within 1 year. No approach was associated with RTT on unadjusted analyses or multivariate modelling. There was no association between approach and revision, PJI or periprosthetic fracture. The posterior approach was associated with 2.90 times the rate of dislocation relative to the lateral (P = 0.005).

Conclusions: There was no difference in the RTT rate between surgical approaches for THA. There was no difference in revision rates, PJI or periprosthetic fracture. The posterior approach was associated with a higher rate of dislocation relative to the lateral, but not the anterior.
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http://dx.doi.org/10.1111/ans.16149DOI Listing
October 2020

Risk Factors for Chronic Opioid Use Following Hip and Knee Arthroplasty: Evidence from New Zealand Population Data.

J Arthroplasty 2020 11 27;35(11):3099-3107.e14. Epub 2020 Jun 27.

Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, Victoria, Australia.

Background: Patients awaiting total joint arthroplasty (TJA) have high rates of opioid use, and many continue to use opioid medications long term after surgery. The objective of this study is to estimate the risk factors associated with chronic opioid use after TJA in a comprehensive population-based cohort.

Methods: All patients undergoing TJA in the New Zealand public healthcare system were identified from Ministry of Health records. Dispensing of opioid medications up to 3 years postsurgery and potential risk factors, including demographic, socioeconomic, and surgery-related characteristics, pre-existing medical comorbidities, and use of other analgesic medications prior to surgery, were identified from linked population databases. Logistic regression analysis was used to identify factors associated with chronic postoperative opioid use.

Results: The strongest risk factor for chronic postoperative opioid use was preoperative opioid use. Other significant risk factors included perioperative opioid use, history of alcohol or drug abuse, younger age, female gender, knee arthroplasty, several comorbid health conditions, and preoperative use of some analgesic medications. Protective factors included higher education levels and preoperative use of nonsteroidal anti-inflammatory drugs. Most risk factors had similar effects on chronic postoperative opioid use irrespective of the length of follow-up considered (1, 2, or 3 years).

Conclusion: This study of a comprehensive nationwide population-based cohort of TJA patients with 3 years of follow-up identified several modifiable risk factors and other easily measured patient characteristics associated with higher risk of long-term postoperative opioid use.
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http://dx.doi.org/10.1016/j.arth.2020.06.040DOI Listing
November 2020

Culture Time Needed to Scale up Infrapatellar Fat Pad Derived Stem Cells for Cartilage Regeneration: A Systematic Review.

Bioengineering (Basel) 2020 Jul 4;7(3). Epub 2020 Jul 4.

Department of Surgery, The University of Melbourne, Melbourne, VIC 3065, Australia.

Adipose tissue is a rich source of stem cells, which are reported to represent 2% of the stromal vascular fraction (SVF). The infrapatellar fat pad (IFP) is a unique source of tissue, from which human adipose-derived stem cells (hADSCs) have been shown to harbour high chondrogenic potential. This review aims to calculate, based on the literature, the culture time needed before an average knee articular cartilage defect can be treated using stem cells obtained from arthroscopically or openly harvested IFP. Firstly, a systematic literature review was performed to search for studies that included the number of stem cells isolated from the IFP. Subsequent analysis was conducted to identify the amount of IFP tissue harvestable, stem cell count and the overall yield based on the harvesting method. We then determined the minimum time required before treating an average-sized knee articular cartilage defect with IFP-derived hADSCs by using our newly devised equation. The amount of fat tissue, the SVF cell count and the stem cell yield are all lower in arthroscopically harvested IFP tissue compared to that collected using arthrotomy. As an extrapolation, we show that an average knee defect can be treated in 20 or 17 days using arthroscopically or openly harvested IFP-derived hADSCs, respectively. In summary, the systematic review conducted in this study reveals that there is a higher amount of fat tissue, SVF cell count and overall yield (cells/volume or cells/gram) associated with open (arthrotomy) compared to arthroscopic IFP harvest. In addition to these review findings, we demonstrate that our novel framework can give an indication about the culture time needed to scale up IFP-derived stem cells for the treatment of articular cartilage defects based on harvesting method.
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http://dx.doi.org/10.3390/bioengineering7030069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7552776PMC
July 2020

CORR Insights®: Patterns of Change Over Time in Knee Bone Shape Are Associated with Sex.

Authors:
Peter F M Choong

Clin Orthop Relat Res 2020 07;478(7):1503-1505

P.F.M. Choong, Department of Orthopaedics St. Vincent's Hospital Melbourne and The University of Melbourne, Department of Surgery, Victoria, Australia.

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http://dx.doi.org/10.1097/CORR.0000000000001307DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7310454PMC
July 2020

In pursuit of enhanced recovery after total joint replacement: a narrative review of drivers of length of stay.

ANZ J Surg 2020 04;90(4):454-459

University of Melbourne Department of Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia.

A continual increase in the prevalence of osteoarthritis drives growing demand for total joint arthroplasty. So far, a decrease in length of stay has been the target for health professionals globally. However, a consensus pathway of achieving this has not yet been reached. This article reviews recent advances in pre-operative and perioperative factors impacting length of stay.
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http://dx.doi.org/10.1111/ans.15790DOI Listing
April 2020

Attitudes of patients and surgeons towards sham surgery trials: a protocol for a scoping review of attributes to inform a discrete choice experiment.

BMJ Open 2020 03 10;10(3):e035870. Epub 2020 Mar 10.

Newcastle Business School, The University of Newcastle Faculty of Business and Law, Newcastle, New South Wales, Australia.

Introduction: In order to properly evaluate the efficacy of orthopaedic procedures, rigorous, randomised controlled sham surgery trial designs are necessary. However, randomised controlled trials (RCTs) for surgery involving a placebo are ethically debated and difficult to conduct with many failing to reach their desired sample size and power. A review of the literature on barriers and enablers to recruitment, and patient and surgeon attitudes and preferences towards sham surgery trials, will help to determine the characteristics necessary for successful recruitment.

Methods And Analysis: This review will scope the diverse literature surrounding sham surgery trials with the aim of informing a discrete choice experiment to empirically test patient and surgeon preferences for different sham surgery trial designs. The scoping review will be conducted in accordance with the methodological framework described in Arksey and O'Malley (2005) and reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols extension for Scoping Reviews. The review will be informed by a systematic search of Medline, Embase, PsycInfo, CINAHL and EconLit databases (from database inception to 21 June 2019), a Google Scholar search, and hand searching of reference lists of relevant studies or reviews. Studies or opinion pieces that involve patient, surgeon or trial characteristics, which influence the decision to participate in a trial, will be included. Study selection will be carried out independently by two authors with discrepancies resolved by consensus among three authors. Data will be charted using a standardised form, and results tabulated and narratively summarised with reference to the research questions of the review.

Ethics And Dissemination: The findings from this review will inform the design of a discrete choice experiment around willingness to participate in surgical trials, the outcomes of which can inform decision and cost-effectiveness models of sham surgery RCTs. The qualitative information from this review will also inform patient-centred outcomes research. The review will be published in a peer-reviewed journal.

Trial Registration Number: CRD42019133296.
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http://dx.doi.org/10.1136/bmjopen-2019-035870DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7066609PMC
March 2020

The Surgeon's Role in the Opioid Crisis: A Narrative Review and Call to Action.

Front Surg 2020 18;7. Epub 2020 Feb 18.

Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia.

Over the past two decades, there has been a sharp rise in the use of prescription opioids. In several countries, most notably the United States, opioid-related harm has been deemed a public health crisis. As surgeons are among the most prolific prescribers of opioids, growing attention is now being paid to the role that opioids play in surgical care. While opioids may sometimes be necessary to provide patients with adequate relief from acute pain after major surgery, the impact of opioids on the quality and safety of surgical care calls for greater scrutiny. This narrative review summarizes the available evidence on rates of persistent postsurgical opioid use and highlights the need to target known risk factors for persistent postoperative use before patients present for surgery. We draw attention to the mounting evidence that preoperative opioid exposure places patients at risk of persistent postoperative use, while also contributing to an increased risk of several other adverse clinical outcomes. By discussing the prevalence of excess opioid prescribing following surgery and highlighting significant variations in prescribing practices between countries, we note that there is a pressing need to optimize postoperative prescribing practices. Guided by the available evidence, we call for specific actions to be taken to address important research gaps and alleviate the harms associated with opioid use among surgical patients.
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http://dx.doi.org/10.3389/fsurg.2020.00004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7041404PMC
February 2020

Lymphoedema rates in pedicled anterolateral thigh flaps for coverage of irradiated groin defects.

ANZ J Surg 2020 01 15;90(1-2):135-138. Epub 2019 Dec 15.

Department of Plastic and Reconstructive Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia.

Background: Limb salvage surgery in conjunction with adjuvant radiotherapy is the preferred treatment for soft tissue sarcoma. This study aims to determine if ipsilateral pedicled anterolateral thigh (ALT) flap reconstruction of groin defects post soft tissue sarcoma resection results in acceptable rates of lymphoedema, while also providing good soft tissue cover and minimal donor site morbidity.

Methods: A retrospective chart audit was conducted with ethics approval, obtaining a case series of 16 patients operated on at a single institution by the senior surgeon. Patients who underwent ipsilateral pedicled ALT flap coverage of irradiated groin defects following soft tissue sarcoma resection were included. Comparative six-point limb circumference measurements were utilized to diagnose lymphoedema, with a difference of 10% when compared to the non-operative side being deemed significant.

Results: Lymphoedema was noted in three patients (18.8%) with an average follow-up period of 40.9 (range 8-59) months.

Conclusion: Previously published lymphoedema rates in sarcoma limb salvage surgery of 15.5-30% are comparable to the rates obtained in this cohort. Lymphoedema rates do not appear to be higher in patients undergoing ipsilateral pedicled ALT flap reconstruction, thus making it a useful soft tissue coverage technique in this cohort.
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http://dx.doi.org/10.1111/ans.15576DOI Listing
January 2020

Human articular cartilage repair: Sources and detection of cytotoxicity and genotoxicity in photo-crosslinkable hydrogel bioscaffolds.

Stem Cells Transl Med 2020 03 26;9(3):302-315. Epub 2019 Nov 26.

Department of Surgery, University of Melbourne, St Vincent's Hospital, Fitzroy, Victoria, Australia.

Three-dimensional biofabrication using photo-crosslinkable hydrogel bioscaffolds has the potential to revolutionize the need for transplants and implants in joints, with articular cartilage being an early target tissue. However, to successfully translate these approaches to clinical practice, several barriers must be overcome. In particular, the photo-crosslinking process may impact on cell viability and DNA integrity, and consequently on chondrogenic differentiation. In this review, we primarily explore the specific sources of cellular cytotoxicity and genotoxicity inherent to the photo-crosslinking reaction, the methods to analyze cell death, cell metabolism, and DNA damage within the bioscaffolds, and the possible strategies to overcome these detrimental effects.
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http://dx.doi.org/10.1002/sctm.19-0192DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7031631PMC
March 2020

Opioid use prior to elective surgery is strongly associated with persistent use following surgery: an analysis of 14 354 Medicare patients.

ANZ J Surg 2019 11 21;89(11):1410-1416. Epub 2019 Oct 21.

Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia.

Background: Persistent opioid use following total joint replacement (TJR) surgery is common; however, the association between pre-surgical opioid use and surgery type has not been established. The objective of this study was to determine the association between pre-surgery opioid use and persistent post-surgery opioid use in TJR patients compared to other elective surgical patients.

Methods: This is a retrospective cohort study, of univariate and multinomial logistic regression of linked, de-identified Medicare Benefits Schedule and Pharmaceutical Benefits Schedule data, adjusted for perioperative opioid use, age and sex. Oral morphine equivalents daily doses (OMEDD) were calculated and opioid use was categorized into three mutually exclusive categories for each observation window: low (0-5 OMEDD), moderate (5-10 OMEDD), high (10+ OMEDD). Persistent opioid use was defined as opioid use between 180 and 270 days after the date of surgery.

Results: Persistent opioid use was associated with older age, female gender and pre-surgery opioid use. There was no increased risk for persistent opioid use for TJR patients compared to other surgical patients. The intensity of pre-surgery opioid usage is strongly associated with persistent opioid use in all observed surgical patients.

Conclusions: Our results suggest that many patients who use opioids prior to surgery will persist in their opioid use following surgery. No association was found between persistent opioid use and TJR surgery, but rather a risk reduction compared to other elective surgeries when associations with opioid use are controlled for. Primary care clinicians and surgeons should monitor the duration and dosage of perioperative opioid use.
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http://dx.doi.org/10.1111/ans.15492DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6900005PMC
November 2019

Predicting the prognosis of undifferentiated pleomorphic soft tissue sarcoma: a 20-year experience of 266 cases.

ANZ J Surg 2019 09 30;89(9):1045-1050. Epub 2019 Jul 30.

Department of Orthopaedics, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.

Background: Undifferentiated pleomorphic sarcoma (UPS) is a rare malignant tumour of mesenchymal origin, which was conceived following re-classification of malignant fibrous histiocytoma (MFH). The objective of this study is to determine prognostic factors for the outcome of UPS, following multi-modal treatment.

Methods: Data of UPS tumours from 1996 to 2016 were collected, totalling 266 unique UPS patients. Median follow-up was 7.8 years. All tumours were retrospectively analysed for prognostic factors of the disease, including local recurrence (LR) and metastatic disease (MD) at diagnosis, tumour size, grade, location and depth, patient age, adjuvant therapy and surgical margin. Overall survival (OS), post-treatment LR and metastatic-free survival were assessed as outcomes.

Results: The 5- and 10-year OS rates for all ages were 60% and 48%, respectively, with a median survival time of 10.1 years. Multivariate analysis revealed that the adverse prognostic factors associated with decreased OS were older age (P < 0.001; hazard ratio 1.03) and MD at diagnosis (P = 0.001; 2.89), with upper extremity tumours being favourable (P = 0.043; 2.30). Poor prognosis for post-operative LR was associated with older age (P = 0.046; 1.03) and positive surgical margins (P = 0.028; 2.68). Increased post-treatment MD was seen in patients with large tumours (5-9 cm (P < 0.001; 4.42), ≥10 cm (P < 0.001; 6.80)) and MD at diagnosis (P < 0.001; 3.99), adjuvant therapy was favourable, shown to reduce MD (P < 0.001; 0.34).

Conclusions: UPS is a high-grade soft tissue sarcoma, for which surgery striving for negative margins, with radiotherapy, is the treatment of choice. Older age, lower extremity location, MD at presentation, large size and positive surgical margins, were unfavourable.
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http://dx.doi.org/10.1111/ans.15348DOI Listing
September 2019

How do surgeons' trade-off between patient outcomes and risk of complications in total knee arthroplasty? a discrete choice experiment in Australia.

BMJ Open 2019 07 3;9(7):e029406. Epub 2019 Jul 3.

Department of Surgery, St Vincent's Hospital, The University of Melbourne, Fitzroy, Victoria, Australia.

Objective: To measure the trade-off between risk of complications versus patient improvement in pain and function in orthopaedic surgeons' decisions about whether to undertake total knee arthroplasty (TKA).

Methods: A discrete choice experiment asking surgeons to make choices between experimentally-designed scenarios describing different levels of operative risk and dimensions of pain and physical function. Variation in preferences and trade-offs according to surgeon-specific characteristics were also examined.

Results: The experiment was completed by a representative sample of 333 orthopaedic surgeons (n=333): median age 52 years, 94% male, 91% fully qualified. Orthopaedic surgeons were willing to accept substantial increases in absolute risk associated with TKA surgery for greater improvements in a patient's pain and function. The maximum risk surgeons were willing to accept was 40% for reoperation and 102% for the need to seek further treatment from a general practitioner or specialist in return for a change from postoperative severe night-time pain at baseline to no night-time pain at 12 months. With a few exceptions, surgeon-specific characteristics were not associated with how much risk a surgeon is willing to accept in a patient undergoing TKA.

Conclusion: This is the first study to quantify risk-benefit trade-offs among orthopaedic surgeons performing TKA, using a discrete choice experiment. This study provides insight into the risk tolerance of surgeons.
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http://dx.doi.org/10.1136/bmjopen-2019-029406DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6615832PMC
July 2019

Clinical Features of High-Grade Extremity and Trunk Sarcomas in Patients Aged 80 Years and Older: Why Are Outcomes Inferior?

Front Surg 2019 31;6:29. Epub 2019 May 31.

Department of Orthopedics, St. Vincent's Hospital, Fitzroy, VIC, Australia.

The population of many countries is aging and a significant number of elderly patients with soft-tissue sarcoma are being seen at cancer centers. The unique therapeutic and prognostic implications of treating soft-tissue sarcoma in geriatric patients warrant further consideration in order to optimize outcomes. This is a single-institution retrospective study of consecutive non-metastatic primary extremity and trunk high-grade sarcomas surgically treated between 1996 and 2012, with at least 2 years of follow-up for survivors. Patient characteristics and oncological outcomes were compared between age groups (≥80 vs. <80 years), using Chi-square or Fisher-exact test and Log-Rank or Wilcoxon test, respectively. Deaths from other causes were censored for disease-specific survival estimation. A p< 0.05 was regarded as statistically significant. A total of 333 cases were eligible for this study. Thirty-six patients (11%) were aged ≥80 years. Unplanned surgery incidence and surgical margin status were comparable between the age groups. Five-year local-recurrence-free, metastasis-free and disease-specific survivals were 72% (≥80 years) vs. 90% (<80 years) ( = 0.004), 59 vs. 70% ( = 0.07) and 55 vs. 80% ( < 0.001), respectively. A significantly earlier first metastasis after surgery (8.3 months vs. 20.5 months, mean) and poorer survival after first metastasis ( = 0.03) were observed. Cox analysis revealed "age ≥80 years" as an independent risk factor for local failure and disease-specific mortality, with hazard ratios of 2.41 (95% CI: 1.09-5.32) and 2.52 (1.33-4.13), respectively. A competing risks analysis also showed that "age ≥80 years" was significantly associated with the disease-specific mortality. Oncological outcomes were significantly worse in high-grade sarcoma patients aged ≥80 years. The findings of more frequent local failure regardless of a consistent primary treatment strategy, an earlier time to first metastasis after surgery, and poorer prognosis after first metastasis suggest that more aggressive tumor biology, in addition to multiple co-morbidity, may explain the inferiority.
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http://dx.doi.org/10.3389/fsurg.2019.00029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6554445PMC
May 2019

Strategies for neural control of prosthetic limbs: from electrode interfacing to 3D printing.

Materials (Basel) 2019 Jun 14;12(12). Epub 2019 Jun 14.

Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne 3065, VIC, Australia.

Limb amputation is a major cause of disability in our community, for which motorised prosthetic devices offer a return to function and independence. With the commercialisation and increasing availability of advanced motorised prosthetic technologies, there is a consumer need and clinical drive for intuitive user control. In this context, rapid additive fabrication/prototyping capacities and biofabrication protocols embrace a highly-personalised medicine doctrine that marries specific patient biology and anatomy to high-end prosthetic design, manufacture and functionality. Commercially-available prosthetic models utilise surface electrodes that are limited by their disconnect between mind and device. As such, alternative strategies of mind-prosthetic interfacing have been explored to purposefully drive the prosthetic limb. This review investigates mind to machine interfacing strategies, with a focus on the biological challenges of long-term harnessing of the user's cerebral commands to drive actuation/movement in electronic prostheses. It covers the limitations of skin, peripheral nerve and brain interfacing electrodes, and in particular the challenges of minimising the foreign-body response, as well as a new strategy of grafting muscle onto residual peripheral nerves. In conjunction, this review also investigates the applicability of additive tissue engineering at the nerve-electrode boundary, which has led to pioneering work in neural regeneration and bioelectrode development for applications at the neuroprosthetic interface.
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http://dx.doi.org/10.3390/ma12121927DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6631966PMC
June 2019

Effectiveness of behavioural interventions on physical activity levels after hip or knee joint replacement: a systematic review.

Disabil Rehabil 2020 12 8;42(25):3573-3580. Epub 2019 May 8.

School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Australia.

To evaluate the effect of behavioural interventions on levels of physical activity after hip or knee joint replacement. A systematic review with meta-analysis of randomised controlled trials to determine the effectiveness of behavioural interventions to increase physical activity levels after hip or knee joint replacement. Six databases were searched. Standardised mean differences (SMD) were calculated. The GRADE approach was used to evaluate the level of evidence of each meta-analysis. From a yield of five trials, physical activity was quantified as active minutes per day, daily energy expenditure and daily steps. There was low to moderate-quality evidence from three meta-analyses with observed positive effects that could not conclude whether behavioural interventions increased physical activity in active minutes per day (SMD = 0.18, 95% CI -0.14, 0.51), daily energy expenditure (SMD = 0.31, 95% CI -0.24, 0.87) or daily steps (MD = 844.7, 95% CI -178.6, 1,868.0). The effectiveness of behavioural interventions to address the low levels of physical activity levels observed after hip or knee joint replacement remains uncertain.Implications for rehabilitationPhysical activity levels after hip or knee joint replacements fail to meet recommended daily activity guidelines, increasing the associated risk of cardiovascular disease and early mortality.Rehabilitation interventions that target behaviour change may have an impact in increasing physical activity levels after hip or knee joint replacement surgery.The optimal type and timing of behavioural interventions to effectively increase physical activity levels in this cohort remains unclear.Rehabilitation professionals are advised to highlight the benefits of meeting physical activity recommendations (150 min of moderate-intensity aerobic physical activity or 75 min of vigorous-intensity aerobic physical activity per week) to people who have undergone hip or knee joint replacement, and that behavioural intervention may support patients to meet these recommendations.
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http://dx.doi.org/10.1080/09638288.2019.1603328DOI Listing
December 2020

The innervated rectus abdominis flap for quadriceps reconstruction.

J Plast Reconstr Aesthet Surg 2019 Jun 21;72(6):941-945. Epub 2019 Mar 21.

Department of Surgery, The University of Melbourne, Grattan Street, Parkville Victoria 3052, Australia; Department of Orthopaedic Surgery, St.Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia.

Background: The vertical rectus abdominis myocutaneous (VRAM) and transverse rectus abdominis myocutaneous (TRAM) flaps have traditionally been excluded from consideration of reconstructions with functional potential, because of their segmental innervation. We present a case series that aimed to demonstrate that segmental innervation does not preclude successful neural anastomoses and can deliver a functional reconstruction of a total compartment in the anterior thigh.

Methods: This review included all patients who required total anterior thigh compartmentectomy and reconstruction between December 2009 and February 2016 were included from the first author's prospective database.

Results: Eleven cases were identified, with innervated rectus abdominis flaps used for anterior thigh reconstruction. During the median follow up period of 12 months, all patients had reinnervation of the rectus with six reaching M5, one M4+, one M4, two M3 and one M2, according to Medical Research Council power grades.

Conclusion: All patients had successful functional reconstruction in the thigh using the rectus abdominis myocutaneous flap.
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http://dx.doi.org/10.1016/j.bjps.2019.03.002DOI Listing
June 2019

Knee Arthroplasty Component Malrotation Does Not Affect Function or Quality of Life in the Short to Medium Term.

J Arthroplasty 2019 07 1;34(7):1382-1386. Epub 2019 Mar 1.

Department of Orthopaedics, St. Vincent's Hospital (Melbourne), Fitzroy, Victoria, Australia; Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia.

Background: Component rotation in total knee arthroplasty is thought to affect patella tracking, flexion gap, and balancing and hence is hypothesized to affect function, pain, and longevity. Few studies have directly correlated post-operative component rotation to function and quality of life in the short to medium term post-operatively, with findings in the current literature conflicting.

Methods: A retrospective study of prospectively collected data was used to determine the effect of femoral, tibial, and combined component rotation in primary total knee arthroplasty with primary outcomes being function as measured by the Knee Society Score, pain and quality of life as measured by the Short-Form 12 score, and secondary outcome being prosthesis failure. Malrotation was defined using the current literature as being internally rotated from neutral, or externally rotated greater than 5° for the femoral component, internally rotated greater than 6° for the tibial component, or internally rotated from neutral for the 2 components combined.

Results: No clinically relevant correlation between function or quality of life and component rotation could be found at 5 years. However, it was noted that those patients with combined component malrotation (femoral rotation added to tibial rotation resulting in overall component internal rotation) improved less in overall pain scores than those that were not malrotated.

Conclusion: In the mid-term, component malrotation may result in a decreased level of improvement from pain compared to pre-operative results. However, component malrotation does not make a significant difference to function or quality of life.

Level Of Evidence: Level III: Therapeutic Study.
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http://dx.doi.org/10.1016/j.arth.2019.02.056DOI Listing
July 2019

Cartilage Tissue Engineering Using Stem Cells and Bioprinting Technology-Barriers to Clinical Translation.

Front Surg 2018 27;5:70. Epub 2018 Nov 27.

Department of Surgery, University of Melbourne, Melbourne, VIC, Australia.

There is no long-term treatment strategy for young and active patients with cartilage defects. Early and effective joint preserving treatments in these patients are crucial in preventing the development of osteoarthritis. Tissue engineering over the past few decades has presented hope in overcoming the issues involved with current treatment strategies. Novel advances in 3D bioprinting technology have promoted more focus on efficient delivery of engineered tissue constructs. There have been promising studies and several animal studies looking at 3D bioprinting of engineered cartilage tissue. However, to date there are still no human clinical trials using 3D printed engineered cartilage tissue. This review begins with discussion surrounding the difficulties with articular cartilage repair and the limitations of current clinical management options which have led to research in cartilage tissue engineering. Next, the major barriers in each of the 4 components of cartilage tissue engineering; cells, scaffolds, chemical, and physical stimulation will be reviewed. Strategies that may overcome these barriers will be discussed. Finally, we will discuss the barriers surrounding intraoperative delivery of engineered tissue constructs and possible solutions.
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http://dx.doi.org/10.3389/fsurg.2018.00070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6278684PMC
November 2018

Treatment of patients with primary retroperitoneal sarcoma: predictors of outcome from an Australian specialist sarcoma centre.

ANZ J Surg 2018 11 4;88(11):1151-1157. Epub 2018 Oct 4.

Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.

Background: Several unanswered questions surround the management of retroperitoneal sarcoma (RPS). Guidelines recommend treatment by a multidisciplinary team at a specialized referral centre. The objective of this study was to describe the management of RPS at an Australian specialist sarcoma centre, comparing outcomes to international standards and analysing for predictors of local failure.

Methods: A retrospective review of a prospectively maintained database was performed on patients with RPS treated between 2008 and 2016. A 5-year outcome analyses focussed on patients undergoing curative-intent surgery for primary, non-metastatic RPS.

Results: Eighty-eight patients underwent surgery for primary RPS. Five-year overall survival was 66%, 5-year freedom from local recurrence was 65% and 5-year freedom from distant metastasis was 71%. Overall survival was associated with tumour grade (hazard ratio (HR) 6.1, P < 0.001) and histologic organ invasion (HR 5.7, P < 0.001). Variables associated with improved freedom from local recurrence were macroscopically complete resection (HR 0.14, P < 0.001) and neoadjuvant radiotherapy (HR 0.33, P = 0.014). Treatment at a specialist sarcoma centre was associated with a higher rate of preoperative biopsy and neoadjuvant radiotherapy (both with P < 0.001). There was a trend towards improved local control for patients undergoing surgery at a specialist centre (P = 0.055).

Conclusion: This is the largest Australian series of RPS and outcomes are comparable to major international sarcoma centres. Patients treated at a specialist centre had higher rates of preoperative diagnosis and tailored therapy which was associated with improved outcomes. Patients with suspected RPS should be referred to a specialist centre for optimal preoperative evaluation and multidisciplinary management.
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http://dx.doi.org/10.1111/ans.14842DOI Listing
November 2018
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