Faculty Bibliography

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.

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.

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.

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.

Anterior cruciate ligament (ACL) rupture is a common injury often necessitating surgical treatment with graft reconstruction. Due to limitations associated with current graft options, there is interest in a tissue-engineered substitute for use in ACL regeneration. While they represent an important step in translation to clinical practice, relatively few in vivo studies have been performed to evaluate tissue-engineered ACL grafts. In the present study, we immobilized heparin onto electrospun polycaprolactone scaffolds as a means of incorporating basic fibroblast growth factor (bFGF) onto the scaffold. In vitro, we demonstrated that human foreskin fibroblasts (HFFs) cultured on bFGF-coated scaffolds had significantly greater cell proliferation. In vivo, we implanted electrospun polycaprolactone grafts with and without bFGF into athymic rat knees. We analyzed the regenerated ACL using histological methods up to 16 weeks post-implantation. Hematoxylin and eosin staining demonstrated infiltration of the grafts with cells, and picrosirius red staining demonstrated aligned collagen fibers. At 16 weeks postop, mechanical testing of the grafts demonstrated that the grafts had approximately 30% the maximum load to failure of the native ACL. However, there were no significant differences observed between the graft groups with or without heparin-immobilized bFGF. While this study demonstrates the potential of a regenerative medicine approach to treatment of ACL rupture, it also demonstrates that in vitro results do not always predict what will occur in vivo.

Objectives To profile the clinical presentation and treatment results of esthesioneuroblastomas at the University of California, Los Angeles (UCLA), from 2002 to 2013. Design Retrospective review. Setting Tertiary academic institution. Participants Forty-one patients with esthesioneuroblastomas treated at UCLA. Main Outcome Measures Overall survival (OS) and recurrence-free survival (RFS). Results Thirty-six patients were included with a mean age of 50.1 years and a median duration of follow-up of 33 months. The 5-year RFS and OS were 54% and 82%, respectively. Modified Kadish stage was the only factor identified to affect OS. Multivariate analysis demonstrated that tumor grade was the only factor that had an independent impact on RFS. There was no statistical difference in survival among the surgical approaches chosen. Conclusions The updated data on the UCLA experience reveals that all three surgical approaches chosen provide comparable survival, although longer follow-up will be needed to ascertain if these findings hold true. The endoscopic approach had a statistically significant decrease in length of hospital stay and a trend toward reduced blood loss, intensive care unit admission, and complications. The modified Kadish staging was the only factor identified to predict OS. Multivariate analysis revealed that tumor grade was an independent predictor of recurrence; therefore, its importance should be emphasized in future staging systems.

Anterior cruciate ligament (ACL) rupture is a common ligamentous injury often necessitating surgery. Current surgical treatment options include ligament reconstruction with autograft or allograft, which have their inherent limitations. Thus, there is interest in a tissue-engineered substitute for use in ACL regeneration. However, there have been relatively few in vivo studies to date. In this study, an athymic rat model of ACL reconstruction was used to evaluate electrospun polycaprolactone (PCL) grafts, with and without the addition of basic fibroblast growth factor (bFGF) and human foreskin fibroblasts. We examined the regenerative potential of tissue-engineered ACL grafts using histology, immunohistochemistry, and mechanical testing up to 16 weeks postoperatively. Histology showed infiltration of the grafts with cells, and immunohistochemistry demonstrated aligned collagen deposition with minimal inflammatory reaction. Mechanical testing of the grafts demonstrated significantly higher mechanical properties than immediately postimplantation. Acellular grafts loaded with bFGF achieved 58.8% of the stiffness and 40.7% of the peak load of healthy native ACL. Grafts without bFGF achieved 31.3% of the stiffness and 28.2% of the peak load of healthy native ACL. In this in vivo rodent model study for ACL reconstruction, the histological and mechanical evaluation demonstrated excellent healing and regenerative potential of our electrospun PCL ligament graft.

IMPORTANCE/OBJECTIVE:Osteosarcoma of the jaws is rare and clinically distinct from osteosarcoma of the long bones of the body with different treatment and outcomes. The literature on these tumors is limited to case reports and small case series mostly from single institutions. We used data from the population-based national Surveillance, Epidemiology and End Results (SEER) cancer registry to determine the epidemiology and prognostic factors associated with osteosarcoma of the jaws. OBJECTIVE:To investigate the epidemiologic characteristics and prognostic factors for survival in patients diagnosed with osteosarcoma of the jaws. DESIGN, SETTING, AND PARTICIPANTS/METHODS:A retrospective, population-based cohort study of 541 patients in the SEER tumor registry diagnosed with osteosarcoma of the jaws from 1973 through 2011 were reviewed. EXPOSURES/METHODS:Patients had been treated with surgery, radiation, both, or neither. MAIN OUTCOMES AND MEASURES/METHODS:Overall and disease-specific survival. RESULTS:A total of 541 patients diagnosed with osteosarcoma of the jaws were identified (49.9% male and 50.1% female, with a mean age of 41.3 years). Kaplan-Meier analysis demonstrated an overall survival (OS) and disease-specific survival (DSS) of 53% and 62%, respectively, at 5 years and 35% and 54%, respectively, at 10 years. Multivariate Cox regression analysis revealed that independent predictors of OS and DSS included age at diagnosis (hazard ratio [HR], 1.03; 95% CI, 1.02-1.04 [P < .001] for OS; and HR, 1.03; 95% CI, 1.02-1.05 [P < .001] for DSS); stage at presentation (HR, 1.37; 95% CI, 1.10-1.71 [P = .006] for OS; and HR, 1.34; 95% CI, 1.01-1.76 [P = .04] for DSS); and surgical resection (HR, 0.31; 95% CI, 0.16-0.60 [P < .001] for OS; and HR, 0.22; 95% CI, 0.09-0.56 [P = .001] for DSS). Tumor size was not significant for OS (HR, 1.00; 95% CI, 1.00-1.01 [P = .11] but significant for DSS (HR, 1.01; 95% CI, 1.00-1.01 [P = .003]). CONCLUSIONS AND RELEVANCE/CONCLUSIONS:To our knowledge, this is the largest study to date investigating prognostic factors for survival in patients diagnosed with osteosarcoma of the jaws. Determinants of survival include age at diagnosis, stage at presentation, tumor size, and surgical therapy. Radiation therapy was not associated with improved survival, reflecting the controversy surrounding its use in clinical literature.

Anterior cruciate ligament (ACL) rupture is a common ligamentous injury that often requires surgery because the ACL does not heal well without intervention. Current treatment strategies include ligament reconstruction with either autograft or allograft, which each have their associated limitations. Thus, there is interest in designing a tissue-engineered graft for use in ACL reconstruction. We describe the fabrication of an electrospun polymer graft for use in ACL tissue engineering. This polycaprolactone graft is biocompatible, biodegradable, porous, and is comprised of aligned fibers. Because an animal model is necessary to evaluate such a graft, this paper describes an intra-articular athymic rat model of ACL reconstruction that can be used to evaluate engineered grafts, including those seeded with xenogeneic cells. Representative histology and biomechanical testing results at 16 weeks postoperatively are presented, with grafts tested immediately post-implantation and contralateral native ACLs serving as controls. The present study provides a reproducible animal model with which to evaluate tissue engineered ACL grafts, and demonstrates the potential of a regenerative medicine approach to treatment of ACL rupture.