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Aim To explore the feasibility and possible effects of low‐frequency repetitive transcranial magnetic stimulation (rTMS) delivered to the supplementary motor area (SMA) on tic severity and motor system neurophysiology in children with Tourette syndrome. Method Ten children with Tourette syndrome (eight males, two females; 9–15y) participated in this open‐label, phase 1 clinical trial. Treatment consisted of 1800 low‐frequency (1Hz) neuronavigated robotic rTMS (100% resting motor threshold) to the SMA, bilaterally for 15 sessions. The primary outcome was a change in Yale Global Tic Severity Scale (YGTSS) total score from baseline to posttreatment. Secondary outcome measures included changes in magnetic resonance spectroscopy metabolite concentrations, TMS neurophysiology measures, TMS motor maps, and clinical assessments (anxiety, depression) from baseline to the end of treatment. Results The YGTSS score decreased from baseline after treatment ( p <0.001; Cohen's d =2.9). All procedures were well‐tolerated. Interpretation Robot‐driven, neuronavigated bilateral rTMS of the SMA is feasible in children with Tourette syndrome and appears to reduce tic severity. What this paper adds Repetitive transcranial magnetic stimulation (rTMS) is feasible to use in children with Tourette syndrome. rTMS is tolerated by children with Tourette syndrome. Precise targeting of the supplementary motor area using functional magnetic resonance imaging is also feasible in these children.

ObjectivesTo compare ureteroenteric stricture rates after radical cystectomy in patients who undergo an intracorporeal urinary diversion versus other surgical approaches.MethodsWe retrospectively reviewed health records of all patients who underwent cystectomy with urinary diversion at Mayo Clinic Hospital (Phoenix, AZ, USA) from 1 January 2007 through 1 January 2018. Ureteroenteric stricture was identified by surveillance imaging. Patients were stratified by surgical approach: open radical cystectomy, robot‐assisted radical cystectomy with extracorporeal urinary diversion and robot‐assisted radical cystectomy‐intracorporeal urinary diversion. A Cox proportional hazards model was fitted that included independent predictors of stricture development.ResultsOf the 573 cystectomies assessed, 236 (41.2%) were carried out robotically. In the robot‐assisted radical cystectomy cohort, 39 patients (16.5%) underwent intracorporeal urinary diversion. The median follow‐up period was 55, 70 and 71 months for the open radical cystectomy, robot‐assisted radical cystectomy‐extracorporeal urinary diversion and robot‐assisted radical cystectomy‐intracorporeal urinary diversion groups, respectively. Subgroup stricture rates were as follows: open radical cystectomy, 8.0%; robot‐assisted radical cystectomy‐extracorporeal urinary diversion, 9.6%; and robot‐assisted radical cystectomy‐intracorporeal urinary diversion, 2.6% (P = 0.33). The median time to stricture was 5 months (interquartile range 3.3–11.5 months). In the bivariable analysis, factors that were associated with the development of ureteroenteric stricture were postoperative urinary leak (hazard ratio 3.177, 95% confidence interval 1.129–8.935; P = 0.03) and body mass index (hazard ratio 1.078, 95% confidence interval 1.027–1.132; P = 0.002). On multivariable logistic regression analysis, intracorporeal urinary diversion approach was not associated with the development of ureteroenteric stricture (hazard ratio 0.272, 95% confidence interval 0.036–2.066; P = 0.21).ConclusionsUreteroenteric stricture is a complication that typically occurs within the first postoperative year. Although our results did not support major differences in outcomes between intracorporeal urinary diversion and extracorporeal urinary diversion, the small sample size did not exclude the possibility of a type 2 statistical error.

AbstractBackground and ObjectivesChordomas of the mobile spine (C1–L5) are rare malignant tumors. The purpose of this study was to review the outcome of surgical treatment for patients with primary mobile spine chordomas.MethodsThe oncologic outcomes and survival of 26 patients undergoing surgical resection for a primary mobile spine chordoma were assessed over a 25‐year period. The mean follow‐up was 12 ± 6 years.ResultsThe 2‐, 5‐, and 10‐year disease‐free survivals were 95%, 61%, and 55%. The local recurrence‐free survival was improved in patients receiving en bloc resection with negative margins (83% vs. 35%, p = 0.02) and similar in patients receiving adjuvant radiation therapy (43% vs. 45%, p = 0.30) at 10 years. Debulking of the tumor (hazard ratio [HR] = 6.41, p = 0.01) and a local recurrence (HR = 9.52, p = 0.005) were associated with death due to disease. Complications occurred in 19 (73%) patients, leading to reoperation in 9 (35%) patients; this rate was similar in intralesional and en bloc procedures.ConclusionSurgical resection of mobile spine chordomas is associated with a high rate of complications; however, en bloc resection can provide a hope for cure and appears to confer better oncologic outcomes for these tumors without an increase in complications compared to lesser resections.

AimsHip reconstruction after resection of a periacetabular chondrosarcoma is complex and associated with a high rate of complications. Previous reports have compared no reconstruction with historical techniques that are no longer used. The aim of this study was to compare the results of tantalum acetabular reconstruction to both historical techniques and no reconstruction.MethodsWe reviewed 66 patients (45 males and 21 females) with a mean age of 53 years (24 to 81) who had undergone acetabular resection for chondrosarcoma. A total of 36 patients (54%) underwent acetabular reconstruction, most commonly with a saddle prosthesis (n = 13; 36%) or a tantalum total hip arthroplasty (THA) (n = 10; 28%). Mean follow-up was nine years (SD 4).ResultsThere was no difference in the mean age (p = 0.63), sex (p = 0.110), tumour volume (p = 0.646), or type of resection carried out (p > 0.05) between patients with and without reconstruction. Of the original 66 patients, 61 (92%) were ambulant at final follow-up. There was no difference in the proportion of patients who could walk in the reconstruction and 'no reconstruction' groups (p = 0.649). There was no difference in the mean Musculoskeletal Tumor Society (MSTS) score between patients who were reconstructed and those who were not (61% vs 56%; p = 0.378). Patients with a tantalum THA had a significantly (p = 0.015) higher mean MSTS score (78%) than those who were reconstructed with a saddle prosthesis (47%) or who had not been reconstructed (56%). Patients who had undergone reconstruction were more likely to have complications (81% vs 53%; p = 0.033).ConclusionReconstruction after resection of the acetabulum is technically demanding. In selected cases, reconstruction is of benefit, especially when reconstruction is by tantalum THA; however, the follow-up for these patients remains mid-term. When not feasible, patients with no reconstruction have an acceptable functional outcome. Level of Evidence: Level III Therapeutic. Cite this article: Bone Joint J 2021;103-B(2):391–397.

Abstract BACKGROUND Low-grade intracranial dural arteriovenous fistulas (dAVF) have a benign natural history in the majority of cases. The benefit from treatment of these lesions is controversial. OBJECTIVE To compare the outcomes of observation versus intervention for low-grade dAVFs. METHODS We retrospectively reviewed dAVF patients from institutions participating in the CONsortium for Dural arteriovenous fistula Outcomes Research (CONDOR). Patients with low-grade (Borden type I) dAVFs were included and categorized into intervention or observation cohorts. The intervention and observation cohorts were matched in a 1:1 ratio using propensity scores. Primary outcome was modified Rankin Scale (mRS) at final follow-up. Secondary outcomes were excellent (mRS 0-1) and good (mRS 0-2) outcomes, symptomatic improvement, mortality, and obliteration at final follow-up. RESULTS The intervention and observation cohorts comprised 230 and 125 patients, respectively. We found no differences in primary or secondary outcomes between the 2 unmatched cohorts at last follow-up (mean duration 36 mo), except obliteration rate was higher in the intervention cohort (78.5% vs 24.1%, P < .001). The matched intervention and observation cohorts each comprised 78 patients. We also found no differences in primary or secondary outcomes between the matched cohorts except obliteration was also more likely in the matched intervention cohort ( P < .001). Procedural complication rates in the unmatched and matched intervention cohorts were 15.4% and 19.2%, respectively. CONCLUSION Intervention for low-grade intracranial dAVFs achieves superior obliteration rates compared to conservative management, but it fails to improve neurological or functional outcomes. Our findings do not support the routine treatment of low-grade dAVFs.

ABSTRACT Background Since the Accreditation Council for Graduate Medical Education (ACGME) established the designated institutional official (DIO) role in 1998, there have been major changes in sponsoring institutions (SIs) and DIO responsibilities. Yet there remains a large gap in our knowledge regarding baseline SI and DIO characteristics as well as a need for institutions wanting to increase diversity in the DIO role and other leadership positions within the medical education community. Objective We sought to characterize demographics of DIOs and the SIs they oversee. Methods We identified SIs and DIOs on the ACGME website on February 15, 2020. Reviewed data included SI accreditation status, number of programs and resident/fellow positions, and DIO characteristics. Results We identified 831 SIs. SIs with continued accreditation sponsored more programs (median 4.0) than SIs with initial accreditation (median 1.0, P &lt; .001). DIO age ranged from 29–81 years (median 57 years). Two-hundred eighty-three of 831 (34%) DIOs were women. Of 576 DIOs with known academic rank, 356 (62%) DIOs held senior academic rank. A higher proportion of male DIOs had senior academic rank (68% vs 52%; OR 1.90 [95% CI 1.34–2.70]; P &lt; .001) and professor rank (39% vs 24%; OR 2.01 [95% CI 1.38–2.94]; P &lt; .001) compared to female DIOs. Female gender was associated with a greater number of ACGME-accredited programs and filled resident/fellow positions per SI (P &lt; .001 for both). Conclusions This study describes characteristics of DIOs and SIs and offers insights for those pursuing a DIO position.

AbstractIntroductionAll‐polyethylene (AP) tibial components have demonstrated equivalent or improved long‐term survivorship and reduced cost compared with metal‐backed (MB) components in primary total knee arthroplasty; however, there is a lack of data comparing these outcomes in the setting of an oncologic endoprosthetic reconstruction.MethodsA total of 115 (88 AP:27 MB) patients undergoing cemented distal femur endoprosthetic reconstruction following oncologic resection were reviewed. Mean age was 40 years and 51% were females. Cumulative incidences of all‐cause revision, tibial component revision, reoperation, and infection were calculated utilizing a competing risk analysis with death as the competitor. Mean follow‐up was 14 years.ResultsThe 10‐year cumulative incidence of all‐cause revision was 19.9% in the AP group and 16.3% in the MB group (hazard ratio [HR] = 0.93, p = 0.88). The cumulative incidence of tibial component revision was significantly lower in AP compared with MB at 10 years (1.1% vs. 12.5%, HR = 0.18, p = 0.03). There was no difference in infection‐free survival when comparing the two groups (p = 0.72).ConclusionsReconstruction utilizing an MB or AP tibia component resulted in equivalent overall outcome; however, the tibial component in the AP group was less likely to be revised. AP tibial component should be considered for all primary oncologic reconstructions in the distal femur.Level of EvidenceLevel III Therapeutic.

AbstractIntroductionAdvances in the care of cancer patients have resulted in increased survival. The proximal femur is a common site for metastatic disease, often requiring surgical intervention. Tranexamic acid (TXA) has proven to be safe in elective and traumatic femoral hemiarthroplasty; however, its use has not been investigated in oncologic patients.MethodWe reviewed 66 patients (37 males) with a mean age of 64 ± 3 years undergoing a hemiarthroplasty for metastatic disease in the femoral neck. A total of 22 (33%) patients received intraoperative TXA. Primary outcomes included postoperative blood loss, intraoperative and postoperative transfusion requirement, and postoperative complications.ResultsThere was no difference in the baseline characteristics between the TXA and non‐TXA groups. When comparing the TXA and non‐TXA groups, there were no differences in 72 h postoperative blood loss between groups (1.21 L vs. 1.33 L, p = 0.61), percentage of patients requiring transfusion (36.4% vs. 36.4%, p = 1.0), or the incidence of postoperative complications including venous thromboembolism (14% vs. 11%, p = 0.70) and pulmonary embolism (0% vs. 5%, p = 1.0).ConclusionOncology patients are a high‐risk population for thromboembolic events. This initial study supports the safe use of TXA intraoperatively in femoral hemiarthroplasty performed for metastatic disease.

Abstract Objective To evaluate the efficacy, tolerability, and safety of eptinezumab 100 and 300 mg compared with placebo in patients with the dual diagnosis of chronic migraine (CM) and medication‐overuse headache (MOH). Background Eptinezumab, a humanized monoclonal antibody targeting calcitonin gene‐related peptide, may be effective for treating patients with a dual diagnosis of CM and MOH. Methods PROMISE‐2 (NCT02974153) was a double‐blind, randomized, placebo‐controlled, phase 3 study that comprised a screening visit, a 28‐day pretreatment period, and a 32‐week study duration. Patients in this exploratory analysis of a prespecified subgroup had confirmed diagnoses of both CM and MOH at screening. Patients were randomly assigned to receive intravenous eptinezumab 100, 300 mg, or placebo every 12 weeks. Efficacy outcomes included mean changes from baseline in monthly migraine days (MMDs) during weeks 1–12, migraine responder rates at week 12, and percentages of patients below International Classification of Headache Disorders thresholds for CM and MOH over weeks 1–24. Results There were 431 patients who were diagnosed with CM and MOH as specified in the protocol and received eptinezumab 100 mg ( n = 139), 300 mg ( n = 147), or placebo ( n = 145). During the baseline period, these patients experienced an average of 16.7 migraine days across treatment arms. Over weeks 1–12, eptinezumab‐treated patients experienced greater reductions from baseline in MMDs than placebo patients (100 mg, change from baseline = −8.4, difference from placebo [95% confidence interval (CI)] = −3.0 [−4.56, −1.52], p < 0.0001 vs. placebo; 300 mg, change from baseline = −8.6, difference from placebo [95% CI] = −3.2 [−4.66, −1.78], p < 0.0001 vs. placebo; placebo, −5.4). Compared with placebo, more eptinezumab‐treated patients were ≥50% migraine responders (100 mg, 84/139 [60.4%]; 300 mg, 91/147 [61.9%]; placebo, 50/145 [34.5%]) or ≥75% responders (100 mg, 38/139 [27.3%]; 300 mg, 44/147 [29.9%]; placebo, 21/145 [14.5%]) over weeks 1–12. Therapeutic benefits with eptinezumab were observed from day 1 after dosing, and improvements were sustained with an additional dose. For the full 24‐week treatment period, 71/139 (51.1%), 80/147 (54.4%), and 47/145 (32.4%) of 100, 300 mg, and placebo‐treated patients, respectively, were below CM thresholds, and of the patients who provided sufficient acute medication data, 47/93 (50.5%), 53/107 (49.5%), and 26/96 (27.1%), respectively, were below medication‐overuse thresholds. Conclusions In patients diagnosed with both CM and MOH, eptinezumab treatment resulted in greater reductions in MMDs, higher responder rates, and fewer patients meeting CM and MOH criteria, thus demonstrating the efficacy and clinical utility of eptinezumab in this patient population.

AbstractIntroductionThe proximal humerus is a common location for primary and non‐primary tumors. Reconstruction of the proximal humerus is commonly performed with an endoprosthesis with low rates of structural failure. The incidence and risk factors for stress shielding are under reported.MethodsThirty‐nine (19 male, 20 female) patients underwent resection of the proximal humerus and reconstruction with a cemented modular endoprosthesis between 2000 and 2018. The mean resection length was 12 ± 4 cm and was most commonly performed for metastatic disease (n = 26, 67%).ResultsStress shielding was observed in 9 (23%) patients at a mean of 29 (6–132) months postoperatively. Patients with stress shielding were noted to have shorter intramedullary stem length (87 vs. 107 mm, p < .001), longer extramedullary implant length (16 vs. 14 cm, p = .01) and a higher extramedullary implant to stem length ratio (2.1 vs. 1.1, p < .001). The incidence of stress shielding was higher (p = .003) in patients reconstructed with 75 mm stem (n = 6, 67%) lengths.ConclusionStress shielding of the humerus was associated with the use of shorter stems and long extramedullary implants. The long‐term ramifications of stress shielding on implant stability, complications at the time of revision surgery, and overall patient outcomes remain unknown.