Cemented and Press-fit Femoral Stems for the Management of Oncologic Femoral Tumors.

BACKGROUND: Stem fixation in reconstruction after resection of femoral tumors is debated. Cemented stems offer immediate stability but risk aseptic loosening, while press-fit stems allow bone ingrowth but risk stress shielding and subsidence. Our retrospective review aimed to determine implant failure rates and their associated factors, as well as the rates of infection, debridement, and mortality for both fixation groups (cemented or press-fit stems) used in patients undergoing resection of femoral tumor disease and subsequent arthroplasty. METHODS: We retrospectively studied 252 patients who underwent resection of femoral tumors and subsequent arthroplasty using cemented (n = 173; 69%) or press-fit (noncemented) (n = 79; 31%) stems between 1999 and 2020. Implant failure was the primary outcome, with secondary outcomes including rates of implant infection, debridement, and mortality. Multivariable regression was done to assess risk factors for implant failures. RESULTS: The study found implant failure rates of 11% and 18% for cemented stems and press-fit stems, respectively. Lower stem to diaphyseal ratios ( P = 0.024) and younger patients ( P = 0.008) were associated with a higher risk of implant failure in cemented stems. The infection rates were 14% and 10% for cemented and press-fit stems, respectively. Debridement rates were 16% and 13% for cemented and press-fit stems, respectively, while the 1-year mortality rate was 16% for cemented stems and 1.5% for press-fit stems. CONCLUSIONS: This study is the largest of its kind, providing patient characteristics and outcomes in both cemented and press-fit stems in the setting of reconstruction for femoral tumors. Both methods can be effective, with outcomes dependent on patient-specific factors, such as life expectancy, activity level, and body habitus, as well as proper implant fit. Additional studies of both implants and longer follow-up are required to elucidate the optimal fixation method for each individual patient. LEVEL OF EVIDENCE: Level III, retrospective noncomparative study.

What is the Value of Radiology Input During a Multidisciplinary Orthopaedic Oncology Conference?

BACKGROUND: Multidisciplinary orthopaedic oncology conferences are important in developing the treatment plan for patients with suspected orthopaedic bone and soft tissue tumors, involving physicians from several services. Past studies have shown the clinical value of these conferences; however, the impact of radiology input on the management plan and time cost for radiology to staff these conferences has not been fully studied. QUESTIONS/PURPOSES: (1) Does radiology input at multidisciplinary conference help guide clinical management and improve clinician confidence? (2) What is the time cost of radiology input for a multidisciplinary conference? METHODS: This prospective study was conducted from October 2020 to March 2022 at a tertiary academic center with a sarcoma center. A single data questionnaire for each patient was sent to one of three treating orthopaedic oncologists with 41, 19, and 5 years of experience after radiology discussion at a weekly multidisciplinary conference. A data questionnaire was completed by the treating orthopaedic oncologist for 48% (322 of 672) of patients, which refers to the proportion of those three oncologists' patients for which survey data were captured. A musculoskeletal radiology fellow and musculoskeletal fellowship-trained radiology attending physician provided radiology input at each multidisciplinary conference. The clinical plan (leave alone, follow-up imaging, follow-up clinically, recommend different imaging test, core needle biopsy, surgical excision or biopsy or fixation, or other) and change in clinical confidence before and after radiology input were documented. A second weekly data questionnaire was sent to the radiology fellow to estimate the time cost of radiology input for the multidisciplinary conference. RESULTS: In 29% (93 of 322) of patients, there was a change in the clinical plan after radiology input. Biopsy was canceled in 30% (24 of 80) of patients for whom biopsy was initially planned, and surgical excision was canceled in 24% (17 of 72) of patients in whom surgical excision was initially planned. In 21% (68 of 322) of patients, there were unreported imaging findings that affected clinical management; 13% (43 of 322) of patients had a missed finding, and 8% (25 of 322) of patients had imaging findings that were interpreted incorrectly. For confidence in the final treatment plan, 78% (251 of 322) of patients had an increase in clinical confidence by their treating orthopaedic oncologist after the multidisciplinary conference. Radiology fellows and attendings spent a mean of 4.2 and 1.5 hours, respectively, reviewing and presenting at a multidisciplinary conference each week. The annual combined prorated time cost for the radiology attending and fellow was estimated at USD 24,310 based on national median salary data for attendings and internal salary data for fellows. CONCLUSION: In a study taken at one tertiary-care oncology program, input from radiology attendings and fellows in the setting of a multidisciplinary conference helped to guide the final treatment plan, reduce procedures, and improve clinician confidence in the final treatment plan, at an annual time cost of USD 24,310. CLINICAL RELEVANCE: Multidisciplinary orthopaedic oncology conferences can lead to changes in management plans, and the time cost to the radiologists should be budgeted for by the radiology department or parent institution.

Stress injury of the rib in a swimmer.

Rib stress injuries are uncommonly reported but have been documented among athletes, most notably rowers. There have only been two prior case reports of rib stress injuries in swimmers, both of which were young females. Magnetic resonance (MR) imaging was either not obtained or the imaging characteristics were incompletely described. We present a case of an isolated third rib stress injury in a collegiate male swimmer diagnosed via MR imaging. We briefly discuss the possible etiologies for rib stress injuries, their MR appearance, as well as their treatment.

Functional results of the Darrach procedure: a long-term outcome study.

PURPOSE: To assess long-term functional outcome after ulnar head excision for distal radioulnar joint dysfunction with prior or concomitant wrist trauma. We hypothesized that long-term outcomes would reflect good functional results with satisfactory pain relief. METHODS: A retrospective chart review identified patients who had undergone the Darrach procedure for traumatic or posttraumatic distal radioulnar joint (DRUJ) pathology. We assessed subjective outcomes using a visual analog scale questionnaire to assess pain, wrist stability, and overall satisfaction. We evaluated objective functional outcomes using the Quick Disabilities of the Shoulder, Arm, and Hand and Patient-Rated Wrist Evaluation measures. Final radiographs were compared with preoperative x-rays to investigate the effect of possible ulnar impingement syndrome (convergent instability). RESULTS: A total of 98 patients with 99 wrists met our predetermined inclusion criteria. Of these, 27 patients with a total of 27 wrists were available for final follow-up, 15 of whom were available for final in-office follow-up with radiographs (6-20 y). Patients displayed an average Quick Disabilities of the Shoulder, Arm, and Hand score of 17 and a Patient-Rated Wrist Evaluation score of 14. Final average visual analog scale scores for pain (0-4), pain with activity (0-4), overall satisfaction (0-4), and wrist stability (0-10) were 0.1, 0.6, 3.7, and 1.5, respectively. Final average wrist range of motion was 85°/78° and 41°/45° for pronation-supination and flexion-extension, respectively. A total of 7 patients displayed radioulnar impingement based on dynamic radiography. This ulnar impingement was not associated with clinical reports of pain and did not affect outcome measures in a statistically significant manner. CONCLUSIONS: The Darrach procedure provides reliably good long-term subjective and objective results for the treatment of a symptomatic DRUJ after a distal radius fracture. Patients can expect to have excellent forearm range of motion at long-term follow-up. Nearly one-half of patients had dynamic convergence of the DRUJ when stressed radiographically; however, the presence of radiographic dynamic convergence did not influence clinical outcomes.

Functional analyses and interaction of the XAPC7 proteasome subunit with Rab7.

Proteasomes have long been known to mediate the degradation of polyubiquitinated proteins in the cytoplasm and the nucleus. Additionally, proteasomes have been identified as participating in cellular degradative pathways involving the endomembrane system. In conjunction with the endoplasmic reticulum, proteasomes serve as a quality control mechanism for disposing of malfolded newly synthesized proteins, while on the endocytic pathway they serve to facilitate the degradation of key signaling and nutrient receptors as well as the destruction of phagocytosed pathogens. Our laboratory has identified a direct interaction between the late endocytic Rab7 GTPase and the alpha-proteasome subunit, XAPC7, thus providing the first molecular link between the endocytic trafficking and cytosolic degradative machineries. In this chapter reagents and methods for studying the regulation and interactions between XAPC7, the 20S proteasome, and Rab7 are described.