Faculty Bibliography

OBJECTIVES/HYPOTHESIS/OBJECTIVE:To describe the incidence and determinants of survival of patients with nasopharyngeal adenocarcinoma between the years of 1973 to 2012 using the Surveillance, Epidemiology, and End Result (SEER) database. STUDY DESIGN/METHODS:Retrospective cohort study using a national database. METHODS:The SEER registry was utilized to calculate survival trends for patients with nasopharyngeal adenocarcinoma between 1973 and 2012. Patient data was then analyzed with respect to histopathology, age, sex, race, stage, grade, and treatment modalities (surgery and radiation therapy). Overall (OS) and disease-specific survival (DSS) were calculated. RESULTS:A total of 148 cases of nasopharyngeal adenocarcinoma were identified. The cohort was composed of 54.7% males. The mean age at diagnosis was 59.0years. The median OS was 60.6months. 59.4% of cases were treated with surgery, while 64.1% received radiation therapy. OS at 2, 5, and 10years was 63%, 49%, and 36%, respectively. There was no significant difference in OS and DSS between adenocarcinoma of the nasopharynx versus the sinonasal tract (p>0.05). On univariate analysis, younger age, surgery, surgery and radiation, and lower tumor grade were associated with improved OS and DSS, while papillary subtype, lower stage, and no distant metastasis were associated with improved OS alone (all p<0.05). CONCLUSIONS:Nasopharyngeal adenocarcinoma is an extremely rare malignancy with poor prognosis, with the exception of the papillary subtype. Age, grade, and surgical therapy are predictors of survival.

BACKGROUND CONTEXT:Osteosarcoma (OGS) and Ewing sarcoma (EWS) are the two classic primary malignant bone tumors. Due to the rarity of these tumors, evidence on demographics, survival determinants, and treatment outcomes for primary disease of the spine are limited and derived from small case series. PURPOSE:To use population-level data to determine the epidemiology and prognostic indicators in patients with OGS and EWS of the osseous spine. STUDY DESIGN/SETTING:Large-scale retrospective study. PATIENT SAMPLE:Patients diagnosed with OGS and EWS of the spine in the Surveillance, Epidemiology, and End Results (SEER) registry from 1973 to 2012. OUTCOME MEASURES:Overall survival (OS) and disease-specific survival (DSS). METHODS:Two separate queries of the SEER registry were performed to identify patients with OGS and EWS of the osseous spine from 1973-2012. Study variables included age, sex, race, year of diagnosis, tumor size, extent of disease (EOD), and treatment with surgery and/or radiation therapy. Primary outcome was defined as OS and DSS in months. Univariate survival analysis was performed using the Kaplan-Meier method and the log-rank test. Multivariate analysis was performed using Cox proportional hazards regression models. RESULTS:The search identified 648 patients with primary OGS and 736 patients with primary EWS of the spine from 1973 to 2012. Mean age at diagnosis was 48.1 and 19.9 years for OGS and EWS, respectively, with OGS showing a bimodal distribution. The median OS and DSS were 1.3 and 1.7 years, respectively, for OGS, with OGS in Paget's disease having worse OS (0.7 years) relative to the mean (log-rank p=.006). The median OS and DSS for EWS were 3.9 and 4.3 years, respectively. Multivariate cox regression analysis showed that age (OS p<.001, DSS p<.001), decade of diagnosis (OS p=.049), surgical resection (OS p<.001, DSS p<.001), and EOD (OS p<.001, DSS p<.001) were independent positive prognostic indicators for spinal OGS; radiation therapy predicted worse OS (hazard ratio [HR] 1.48, confidence interval [CI] 1.05-2.10, p=.027) and DSS (HR 1.74, CI 1.13-2.66, p=.012) for OGS. For EWS, age (OS p<.001, DSS p<.001), surgical resection (OS p=.030, DSS p=.046), tumor size (OS p<.001, DSS p<.001), and EOD (OS p<.001, DSS p<.001) were independent determinants of improved survival; radiation therapy trended toward improved survival but did not achieve statistical significance for both OS (HR 0.76, CI 0.54-1.07, p=.113) and DSS (0.76, CI 0.54, 1.08, p=.126). CONCLUSIONS:Age, surgical resection, and EOD are key survival determinants for both OGS and EWS of the spine. Radiation therapy may be associated with worse outcomes in patients with OGS, and is of potential benefit in EWS. Overall prognosis has improved in patients with OGS of the spine over the last four decades.

Importance:Squamous cell carcinoma of the lip (lip SCC) composes more than 25% of all oral cancers. Most of the demographic and prognostic indicators for lip SCC are only available through retrospective case series. Objective:To examine the incidence, treatment, overall survival, and disease-specific survival (DSS) of patients with lip SCC. Design, Setting, and Participants:Population-based cohort analysis using the Surveillance, Epidemiology, and End Results database identified patients with lip SCC between January 1, 1973, and December 31, 2012. Main Outcomes and Measures:Overall survival and DSS. Results:A total of 15 832 cases of lip SCC were identified. The cohort was composed of 12 945 men (81.8%) and 2887 women (18.2%). The mean age at diagnosis was 66.1 years. White patients accounted for 98.4% of the cases. Most of the tumors presented in the lower lip (77.8% external and 10.2% mucosal), whereas the external upper lip, mucosal upper lip, and the oral commissure represented 8%, 1%, and 1.2% of all cases, respectively. Of the patients, 91.2% underwent surgical therapy, 7.7% received radiation therapy, and 4.7% received both. Overall survival at 2 years, 5 years, and 10 years was 85.5%, 69.9%, and 50.2%, respectively. Multivariate analysis revealed that age, primary site, T stage, and N stage were determinants of overall survival and DSS. Kaplan-Meier survival analysis showed that SCC of the upper and lower lip had similar overall survival (163.6 months vs 163.8 months) and DSS (418.6 months vs 423.6 months). In contrast, SCC of the oral commissure had significantly lower overall survival (128.5 months) and DSS (286.7 months). Conclusions and Relevance:Our study demonstrates that lip SCC predominantly affects white men in their mid-60s. The determinants of survival for lip SCC include age at diagnosis, primary site, T stage, and N stage. Squamous cell carcinoma of the upper lip and lower lip had similar survival, whereas SCC of the oral commissure was associated with decreased survival.

Successful management of patellar osteochondral lesions has proved difficult, with unreliable outcomes reported using traditional cartilage repair and restoration procedures. Unique considerations for this type of defect include the multiplanar contours of the articular surface of the patella, high compressive and shear forces with knee range of motion that may disrupt graft healing, and the potential need for concomitant surgery to address patellar malalignment and instability. We describe our preferred method for treatment of a symptomatic chondral defect in the setting of recurrent patellar instability using particulated juvenile articular cartilage allograft transplantation and medial patellofemoral ligament reconstruction with semitendinosus allograft. Distinct advantages of this cartilage restoration technique include single-stage restoration of relevant cartilage pathology and the ability to easily contour the graft to the size and shape of the chondral defect.

BACKGROUND:Treatment of patellofemoral instability has evolved as our understanding of the relevant pathoanatomy has improved. In light of these developments, current practice patterns and management trends have likely changed to reflect these advancements; however, this has not been evaluated in a formal study. PURPOSE/OBJECTIVE:To determine nationwide patient demographics, surgical trends, and postoperative complications associated with the operative management of patellar instability surgery. STUDY DESIGN/METHODS:Descriptive epidemiological study. METHODS:A large private-payer database (PearlDiver) comprising patients covered by Humana and United Healthcare insurance policies was retrospectively reviewed using Current Procedural Terminology (CPT) codes to identify patients who underwent surgery for patellar instability. The study cohort was established by querying for patients billed under CPT codes 27420, 27422, or 27427 while satisfying the diagnostic requirement of patellar instability (International Classification of Diseases-9th Revision codes 718.36, 718.86, or 836.3). Patient demographics, surgical trends, concomitant procedures, and postoperative complications were determined. RESULTS:A total of 6190 patients underwent surgical management for patellar instability. Adolescents (age range, 10-19 years) represented 51.5% of cases, and 59.6% were female. The number of patellar instability procedures increased annually over the study period in both the Humana (P = .004, R (2) = 0.76) and United Healthcare (P = .097, R (2) = 0.54) cohorts. The most common concomitant procedures were lateral retinacular release (43.7%), chondroplasty (31.1%), tibial tubercle osteotomy (13.1%), removal of loose bodies (10.5%), osteochondral grafting (9.5%), and microfracture surgery (9.5%). Manipulation under anesthesia was required in 4.6% of patients within 1 year. Patellar fracture within 1 year and infection within 30 days occurred in 2.1% and 1.2% of patients, respectively. CONCLUSION/CONCLUSIONS:Patellar instability surgery has increased over the past decade. This finding may be attributed to growing clinical evidence to support these procedures as well as increased surgeon familiarity and comfort with these specific techniques. We observed an unexpectedly high rate of concomitant lateral retinacular release. Overall, the rates of commonly recognized complications (stiffness, patellar fracture, and postoperative infection) were similar to those observed in smaller case series.

OBJECTIVE:To determine the 50 most cited articles in orthopedic cartilage surgery and their characteristics. DESIGN/METHODS:A systematic review of the Science Citation Index Expanded was performed for articles related to cartilage surgery published in the 66 journals under the category "Orthopedics." The 50 most cited articles were determined, and the following characteristics were analyzed for each article: authors, journal and year of publication, number of citations, geographic origin, article type (basic science or clinical), article subtype by study design, and level of evidence. Citation density (total number of citations/years since publication) was also computed. RESULTS:The 50 most cited articles ranged from 989 to 172 citations, with citation density ranging from 71.5 to 4.1. The publication years spanned from 1968 to 2008, with the 2000s accounting for half (25) of the articles and the highest mean citation density (14.6). The 50 most cited articles were published in 11 journals. The majority of the articles (29) were clinical, with level IV representing the most common level of evidence (10). The remaining basic science articles were most commonly animal in vivo studies (14). Stronger level of evidence was correlated with overall number of citations (P = 0.044), citation density (P < 0.001), and year of publication (P = 0.003). CONCLUSIONS:Articles with stronger levels of evidence are more highly cited, with an increasing trend as evidence-based practice has been emphasized. This article list provides clinicians, researchers, and trainees with a group of "citation classics" in orthopedic cartilage surgery.

IMPORTANCE:Synovial cell sarcoma of the head and neck (SCSHN) is a rare tumor associated with significant morbidity and mortality. The literature regarding these tumors is limited to case series and case reports. We used data from the population-based US Surveillance, Epidemiology, and End Results (SEER) cancer registry to determine factors affecting both overall survival and disease-specific survival of patients with SCSHN. OBJECTIVE:To determine the clinicopathologic and therapeutic factors determining survival in patients with SCSHN. DESIGN, SETTING, AND PARTICIPANTS:The SEER registry was reviewed for patients with primary SCSHN from January 1, 1973, to January 1, 2011. MAIN OUTCOMES AND MEASURES:Overall survival (OS) and disease-specific survival. RESULTS:A total of 167 cases of SCSHN were identified. The mean (SD) age at diagnosis was 37.9 (17.3) years, and 100 (59.9%) of the patients were males. The monophasic spindle cell and biphasic variants were the most common histologic subtypes. Surgical resection and radiotherapy were performed in 150 (89.8%) and 108 (64.7%) of the cases, respectively. The median OS at 2, 5, and 10 years was 77%, 66%, and 53%, respectively. Univariate Kaplan-Meier survival analysis revealed that age, race, and tumor stage and size were associated with improved survival. Histologic subtype was not associated with significant differences in survival. Radiotherapy was associated with improved disease-specific survival (hazard ratio [HR], 0.29 [95% CI, 0.12-0.68]; P = .003), but surgical management was not associated with improved survival (HR, 0.52 [95% CI, 0.19-1.46]; P = .21). Multivariate Cox regression analysis revealed that size greater than 5 cm (adjusted HR, 3.60 [95% CI, 1.43-9.08]; P = .007) and stage at presentation (adjusted HR, 3.86 [95% CI, 2.01-7.44]; P < .001) were independent determinants of OS. In separate analysis of cohorts with tumors 5 cm or less and larger than 5 cm, stage at presentation was found to be a significant indicator of the probability of survival in both cohorts (adjusted HR, 3.10 [95% CI, 1.46-6.60]; P = .003 and 5.32 [95% CI, 1.49-18.98]; P = .01, respectively); surgical resection and radiotherapy were not associated with differential survival outcomes using this model. CONCLUSIONS AND RELEVANCE:Synovial cell sarcoma of the head and neck is rare. Independent significant determinants of survival include size (>5 cm) and stage at presentation. Histologic subtype of the tumor is not a significant indicator of the probability of survival. Surgical resection and radiotherapy were not independent determinants of survival.

Previously, we reported on the implantation of electrospun polycaprolactone (PCL) grafts for use in ACL tissue engineering in a small animal model. In the present study, we hypothesized that grafts fabricated from ultra-high molecular weight polycaprolactone (UHMWPCL) would have similarly favorable biologic properties but superior mechanical properties as compared to grafts fabricated from PCL. Two forms of polycaprolactone were obtained (UHMWPCL, MW = 500 kD, and PCL, MW = 80 kD) and electrospun into scaffolds that were used to perform ACL reconstruction in 7-8 week old male Lewis rats. The following groups were examined: UHMWPCL, PCL, flexor digitorum longus (FDL) allograft, native ACL, as well as sham surgery in which the ACL was transsected. At 16 weeks post-operatively, biomechanical testing, histology, and immunohistochemistry (IHC) were performed. Analysis of cellularity indicated that there was no significant difference among the UHMWPCL, PCL, and FDL allograft groups. Quantification of birefringence from picrosirius red staining demonstrated significantly more aligned collagen fibers in the allograft than the PCL group, but no difference between the UHMWPCL and allograft groups. The peak load to failure of the UHMWPCL grafts was significantly higher than PCL, and not significantly different from FDL allograft. This in vivo study establishes the superiority of the higher molecular weight version of polycaprolactone over PCL as a scaffold material for ACL reconstruction. By 16 weeks after implantation, the UHMWPCL grafts were not significantly different from the FDL allografts in terms of cellularity, peak load to failure, stiffness, and collagen fiber alignment. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:828-835, 2016.

OBJECTIVE:To describe the incidence and determinants of survival of patients with sinonasal undifferentiated carcinoma (SNUC) from 1973 to 2011 using the SEER database (Surveillance, Epidemiology, and End Results), with consideration of tumor stage based on the Kadish system. STUDY DESIGN/METHODS:Retrospective database analysis. SETTING/METHODS:Academic medical center. SUBJECTS AND METHODS/METHODS:The SEER registry was utilized to calculate survival trends for 328 patients with SNUC between 1973 and 2011. Patient data were then analyzed with respect to histopathology, age, sex, race, subsite, modified Kadish stage, tumor size, and treatments rendered. RESULTS:The cohort was composed of 61.9% males with median age of 60 years. The median overall survival (OS) was 1.9 years. Most tumors presented in the nasal cavity, maxillary sinus, and ethmoid sinus (29.3%, 27.4%, 21%, respectively); 43.7% of patients received both surgical and radiation therapy. OS at 2, 5, and 10 years was 43%, 30%, and 25%, respectively. On univariate analysis, age, Kadish stage, and tumor size were associated with worse OS and disease-specific survival (DSS), while surgery and radiation therapy were associated with improved OS and DSS (all P < .05). On multivariate analysis, radiation therapy and lower Kadish stage were associated with improved OS and DSS, while younger age was additionally associated with improved OS (all P < .05). CONCLUSION/CONCLUSIONS:SNUC is a rare but aggressive sinonasal malignancy. Tumor stage as determined by the Kadish system is associated with worse survival, with radiation therapy appearing to play a key role in therapeutic management.