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Background:. The aesthetic plastic surgery industry has seen tremendous growth, with Americans spending an estimated 20 billion dollars on procedures in 2020. However, the effect of complications from these procedures on the healthcare system is poorly understood. This study aims to create awareness regarding aesthetic procedure complications through the scope of plastic surgeons at a tertiary medical facility. Methods:. A retrospective chart review was performed on patients who received care at a single academic tertiary referral center over 5 years for complications from a cash-paid aesthetic procedure at an outside facility. Physician and hospital billing data were analyzed for relevant encounters. Results:. Patients in this study (n = 40) presented to the emergency department most frequently with complications secondary to abdominoplasty (35%), breast augmentation (27.5%), and injectable fillers (17.5%). The most common complications were infection (32.5%) and wound dehiscence (22.5%). Of those evaluated, 50% required inpatient admission. Additionally, 42.5% required surgical intervention. The distribution of payors included Medicaid (55%), commercial insurance (30%), and Medicare (7.5%), and 7.5% were uninsured. For physician billing, the total gross collection ratio was 21.3%, whereas the hospital billing total gross collection ratio was 25.16%. Conclusions:. Larger referral hospitals are well-suited to support the aesthetic community with complication management; however, the care required to serve this population is resource-intensive. These data advocate for thorough closed-loop patient–surgeon communication regarding risk–benefit analysis and detailed courses of action should complications arise. Likewise, stronger communication between ambulatory surgical centers and tertiary referral centers may also help minimize complications and subsequent healthcare needs.

Background. The impact of induction type or high-risk viral discordance on older kidney transplant recipients is unclear. Herein, we analyzed the association between induction type, viral discordance, and outcomes for older recipients. Methods. We analyzed the Scientific Registry of Transplant Recipients standard analysis file for all primary kidney transplant recipients older than 55 y who were transplanted between 2005 and 2022. All transplants were crossmatch negative and ABO-compatible. Recipients were discharged on tacrolimus and mycophenolate ± steroids. Recipients were categorized into 3 groups by induction received: rabbit antithymocyte globulin (r-ATG; N = 51 079), interleukin-2 receptor antagonist (IL-2RA; N = 22 752), and alemtuzumab (N = 13 465). Kaplan-Meier curves were generated for recipient and graft survival, and follow-up was censored at 10 y. Mixed-effect Cox proportional hazard models examined the association between induction type, high-risk viral discordance, and outcomes of interest. Models were adjusted for pertinent recipient and donor characteristics. Results. Induction type did not predict recipient survival in the multivariable model, whereas Epstein-Barr virus high-risk discordance predicted 14% higher mortality (1.14 [1.07-1.21], P

BACKGROUND: Fetal growth restriction secondary to chronic placental insufficiency is a major cause of perinatal morbidity and mortality. A significant proportion of fetuses with fetal growth restriction are small for gestational age, defined as a birthweight of ≤10th percentile. However, not all small-for-gestational-age fetuses are growth restricted. Some are constitutionally small and otherwise healthy. It is important to distinguish between small-for-gestational-age fetuses with and without fetal growth restriction to ensure appropriate interventions in small-for-gestational-age fetuses with fetal growth restriction and to minimize unnecessary interventions in healthy small-for-gestational-age fetuses. The maternal serum ratio of soluble fms-like tyrosine kinase-1 and placental growth factor is an indicator of placental insufficiency in the latter half of pregnancy. As such, the soluble fms-like tyrosine kinase-1–to–placental growth factor ratio may be a clinically useful tool to distinguish between small-for-gestational-age fetuses with and without fetal growth restriction. OBJECTIVE: This study aimed to determine whether the soluble fms-like tyrosine kinase-1–to–placental growth factor ratio can distinguish between small-for-gestational-age fetuses with and without fetal growth restriction with a birthweight of ≤10th percentile. STUDY DESIGN: A retrospective audit of 233 singleton pregnancies delivering an infant with a birthweight of ≤10th percentile corrected for gestational age with an antenatal maternal serum soluble fms-like tyrosine kinase-1–to–placental growth factor result was performed. Fetal growth restriction was defined as a birthweight of ≤10th percentile with an umbilical artery pulsatility index of >95th percentile, fetal middle cerebral artery pulsatility index of

Spontaneous coronary artery dissection occurs predominantly in women and is associated with fibromuscular dysplasia. We illustrate a rare case of sudden coronary death as a result of cardiac rupture from spontaneous coronary artery dissection in a 54-year-old man without fibromuscular dysplasia. Cardiac rupture has been previously reported in 6 cases, mostly in women.

Objective:. To assess the 5-year recurrence rate of incisional hernia repair in Ventral Hernia Working Group (VHWG) 3 hernia with a slowly resorbable mesh. Summary Background Data:. Incisional hernia recurs frequently after initial repair. In potentially contaminated hernia, recurrences rise to 40%. Recently, the biosynthetic Phasix mesh has been developed that is resorbed in 12–18 months. Resorbable meshes might be a solution for incisional hernia repair to decrease short- and long-term (mesh) complications. However, long-term outcomes after resorption are scarce. Methods:. Patients with VHWG grade 3 incisional midline hernia, who participated in the Phasix trial (Clinilcaltrials.gov: NCT02720042) were included by means of physical examination and computed tomography (CT). Primary outcome was hernia recurrence; secondary outcomes comprised of long-term mesh complications, reoperations, and abdominal wall pain [visual analogue score (VAS): 0–10]. Results:. In total, 61/84 (72.6%) patients were seen. Median follow-up time was 60.0 [interquartile range (IQR): 55–64] months. CT scan was made in 39 patients (68.4%). A recurrence rate of 15.9% (95% confidence interval: 6.9–24.8) was calculated after 5 years. Four new recurrences (6.6%) were found between 2 and 5 years. Two were asymptomatic. In total, 13/84 recurrences were found. No long-term mesh complications and/or interventions occurred. VAS scores were 0 (IQR: 0–2). Conclusions:. Hernia repair with Phasix mesh in high-risk patients (VHWG 3, body mass index >28) demonstrated a recurrence rate of 15.9%, low pain scores, no mesh-related complications or reoperations for chronic pain between the 2- and 5-year follow-up. Four new recurrences occurred, 2 were asymptomatic. The poly-4-hydroxybutyrate mesh is a safe mesh for hernia repair in VHWG 3 patients, which avoids long-term mesh complications like pain and mesh infection.

Immune effector cell-associated neurotoxicity syndrome (ICANS) secondary to chimeric antigen receptor T-cell therapy is common in adult patients with relapsed/refractory (R/R) B-cell acute lymphoblastic leukemia (ALL), but imaging findings during neurologic toxicity and their meaning have yet to be systematically described in this patient population. Brexucabtagene autoleucel (brexu-cel) is a CD19-directed autologous T-cell immunotherapy for the treatment of adult patients with R/R B-cell ALL that can enter the central nervous system. We present a case of an adult patient with R/R B-cell ALL and prior leptomeningeal disease who developed neurologic toxicity and new findings on magnetic resonance imaging of the brain while receiving brexu-cel. We interpret the patient's neuroimaging studies within clinical context to differentiate ICANS from active treatment of residual leukemia.

Trunnion fracture is an incredibly rare complication of total hip arthroplasty. Of the few reported cases, all involve implants with faulty designs, a small neck taper, or an extended neck length or offset. Most also report corrosion and an adverse soft-tissue reaction. We present a review of the literature and report on the first case, to our knowledge, of trunnion fracture in a well-fixed, cemented cobalt-chromium femoral component with a standard neck length and offset with no evidence of corrosion. This failure was likely related to scratching of the metal during previous procedures which led to crack propagation and catastrophic failure. The patient was treated with revision hip arthroplasty to an uncemented, distal-fit femoral component and insertion of new bearing surfaces.

Summary:. Regenerative peripheral nerve interface (RPNI) surgery has been demonstrated to be an effective tool as an interface for neuroprosthetics. Additionally, it has been shown to be a reproducible and reliable strategy for the active treatment and for prevention of neuromas. The purpose of this article is to provide a comprehensive review of RPNI surgery to demonstrate its simplicity and empower reconstructive surgeons to add this to their armamentarium. This article discusses the basic science of neuroma formation and prevention, as well as the theory of RPNI. An anatomic review and discussion of surgical technique for each level of amputation and considerations for other etiologies of traumatic neuromas are included. Lastly, the authors discuss the future of RPNI surgery and compare this with other active techniques for the treatment of neuromas.

Background. Surgical-site infection (SSI) is the most common early infectious complication after pancreas transplantation (PT). Although SSI has been shown to worsen outcomes, little data exist to guide optimal choices in perioperative prophylaxis. Methods. We performed a retrospective cohort study of PT recipients from 2010–2020 to examine the effect of perioperative antibiotic prophylaxis with Enterococcus coverage. Enterococcus coverage included antibiotics that would be active for penicillin-susceptible Enterococcus isolates. The primary outcome was SSI within 30 d of transplantation, and secondary outcomes were Clostridioides difficile infection (CDI) and a composite of pancreas allograft failure or death. Outcomes were analyzed by multivariable Cox regression. Results. Of 477 PT recipients, 217 (45.5%) received perioperative prophylaxis with Enterococcus coverage. Eighty-seven recipients (18.2%) developed an SSI after a median of 15 d from transplantation. In multivariable Cox regression analysis, perioperative Enterococcus prophylaxis was associated with reduced risk of SSI (hazard ratio [HR] 0.58; 95% confidence interval [CI], 0.35-0.96; P = 0.034). Anastomotic leak was also significantly associated with elevated risk of SSI (HR 13.95; 95% CI, 8.72-22.32; P

Summary:. Avulsion of the medial canthal tendon secondary to nasoorbitoethmoidal fractures leads to severe aesthetic and functional impairments. The tendon should be repositioned at the posterior lacrimal crest. Owing to the complexity of nasoorbitoethmoidal fractures, accurate location of this point during surgery can be challenging. With the aid of computer-assisted planning and surgical navigation, the point at which the medial canthal tendon should be repositioned can be easily and precisely located. We have developed an innovative navigation-assisted technique that increases the reliability and safety of internal canthus repositioning. We performed a case series of three consecutive patients who underwent medial canthal tendon repositioning using computer-assisted planning and surgical navigation. We believe that this innovation provides a new and useful application of computer-assisted planning and surgical navigation in craniomaxillofacial surgery.

Background: The rate at which patients regain shoulder strength after anatomic and reverse total shoulder arthroplasty (TSA) is unknown. In this study, we aimed to quantify differences in the timeline during which patients gained shoulder strength after primary anatomic and reverse TSA. Methods: We retrospectively reviewed prospectively collected data from 374 shoulders after primary anatomic TSA (aTSA) and 601 shoulders after primary reverse TSA (rTSA). Postoperative improvement in external rotation (ER) strength and forward elevation (FE) strength from baseline was assessed at 3 months, 6 months, 1 year, and 2 years. Percent change in mean shoulder strength between each time point was determined for anatomic and reverse groups separately. A handheld dynamometer was used to assess ER strength with the involved shoulder in 0° ER, 0° abduction, and the elbow in 90° flexion and FE strength with the involved shoulder in the scapular plane at 30° of flexion and 30° of abduction. Results: Both aTSA and rTSA groups ceased to have statistically significant gains in FE strength after 1 year postoperatively. In contrast, patients continued to have statistically significant gains in ER strength between 1 year and 2 years postoperatively after rTSA (P = .001), but not after aTSA (P = .476). Both aTSA and rTSA groups saw improvement in strength in both ER (+32.1% and +51.4%, respectively) and FE (+38.3% and +90.3%, respectively) at 2-year follow-up. The aTSA group’s ER and FE strength increased the most between 3 and 6 months (+16.2% and +35.7%, respectively). In contrast, the rTSA group gained the most ER strength between 6 months and 1 year (+14.8%) and the greatest FE strength between baseline and 3 months (+40.3%). Conclusion: Patients gain ER strength earlier and FE strength later after aTSA compared with rTSA. Most gains in strength occurred in the first year. However, statistically significant gains in shoulder ER strength in the rTSA group continued between 1 year and 2 years postoperatively, suggesting that 2-year follow-up may be inadequate to capture the full benefits of rTSA on shoulder strength. The results of this study provide insight into the timeline of strength recovery after aTSA and rTSA that will help inform patient counseling and future study design.

Objective: To assess the effectiveness of telemedicine video visits in the management of hypertensive patients at home during the first year of the COVID-19 pandemic. Methods: A quantitative analysis was performed of all home video visits coded with a diagnosis of essential hypertension during the first 12 months of the COVID-19 pandemic (March 2020 through February 2021). A total of 10,634 patients with 16,194 hypertension visits were present in our national telemedicine practice database during this time. Among this population, a total of 569 patients who had 1785 hypertension visits met the criteria of having 2 or more blood pressure (BP) readings, with the last BP reading occurring in the report period. We analyzed baseline characteristics and BP trends of these 569 patients during the study period. Voluntarily submitted patient satisfaction ratings, which were systematically requested at the end of each visit, were also analyzed. Results: The mean age of the patients in this study cohort of 569 patients was 43.9 years, and 48.3% (275) were women. More than 62% (355) of the patients had an initial systolic BP (SBP) above 140 mm Hg, and 25.3% (144) had an initial SBP of greater than 160 mm Hg. The average number of visits during the study period was 3.1 visits per patient; an average of 6.4 BP measurements per patient were available. During the study period, 77% (438) of the patients experienced an improvement in either SBP or diastolic BP (DBP), with mean reductions of −9.7 mm Hg and −6.8 mm Hg in SBP and DBP, respectively. A total of 416 patients in the cohort started with a BP above 140/90 mm Hg. For this subset of patients, 55.7% (232) achieved a BP of 140/90 mm Hg or lower by the end of the study period, and the average reductions in SBP and DBP were −17.9 mm Hg and −12.8 mm Hg, respectively, which corresponded to improvements of 11.2% and 12.4%. These improvements did not vary significantly when patients were stratified by age, sex, or geographic region of residence (rural vs urban/suburban). Voluntarily submitted patient surveys indicated a high degree of patient satisfaction, with a mean satisfaction score of 4.94 (5-point scale). Conclusion: Clinician-patient relationships established in a video-first telemedicine model were broadly effective for addressing suboptimally controlled hypertension. Patient satisfaction with these visits was high.

Inguinal hernias are rare in female infants, and when present, there is an increased incidence of androgen insensitivity in these infants. We present a case of bilateral inguinal hernias in a 26-day-old full-term phenotypic female. On physical exam, the patient was found to have bilateral palpable inguinal masses which were suspected to be testicular tissue on ultrasound. Patient also had bilateral inguinal hernias, but otherwise there were no other concerning symptoms, and the remaining physical examination was overall unremarkable. Initial workup included a pelvic ultrasound that did not visualize a uterus or ovaries. In addition, genetic testing confirmed normal male genotype with 100% 46, on fluorescence in situ hybridization (FISH) and array comparative genomic hybridization (CGH) was negative and did not reveal any copy number changes. Molecular testing was consistent with a diagnosis of androgen insensitivity syndrome with hemizygous pathogenic variant in the androgen receptor (AR) gene (deletion of Exon 2 of AR gene Xq12 ). This case highlights the importance of a high clinical suspicion of complete androgen insensitivity syndrome (CAIS) in a phenotypic female infant with inguinal hernias. To our knowledge, this is one of the earliest diagnoses of CAIS in a phenotypically female infant.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Minimally invasive hallux valgus correction is increasing in popularity. Third generation minimally invasive chevron / Akin (MICA) techniques have low complication rates and high patient satisfaction. The MICA technique utilizes burrs to make percutaneous osteotomies of the distal first metatarsal and base of the first proximal phalanx. Deformity correction is achieved through lateral translation of the metatarsal head and closure of the Akin osteotomy. In open hallux valgus procedures, derotation of the first metatarsal and reduction of the sesamoids has shown to be essential to optimizing outcome. To our knowledge, the impact of the MICA technique on sesamoid and first metatarsal rotation has not been evaluated. In this study, we attempt to quantify the correction of metatarsal rotation and sesamoid rotation following MICA bunion correction. Methods: A cohort of patients undergoing minimally invasive hallux valgus correction at a single center were prospectively followed. All bunion deformities were corrected utilizing the MICA technique. Demographic information including age, sex, BMI, and laterality were collected. Concomitant procedures and any complications were recorded. All patients underwent a weight bearing CT scan and had weight bearing radiographs performed both before surgery and at a minimum of 6 months after surgery, after the osteotomy sites had healed. Weight bearing CTs were utilized to compare sesamoid station, sesamoid rotation, and metatarsal rotation (alpha angle). Radiographs were used to compare HVA, IMA, and sesamoid station pre and postoperatively. PROMIS scores were also collected from patients before surgery and at their most recent follow-up visit to assess the impact of minimally invasive bunion correction on patient outcomes. Results: Twelve patients, all female, with an average age of 49.8 +- 13.5 years were included. There were no major complications and all osteotomies healed. Hallux valgus angle (HVA) and intermetatarsal angle (IMA) improved significantly from 29.4 +- 5.00 and 13.6 +- 1.38 to 13.6 +- 7.13 and 5.92 +- 3.99 respectively (p

Background: Posterior glenohumeral instability is much less common than anterior instability, and there is a paucity of studies looking at glenoid bone loss as it relates to posterior instability. However, while the data are not as robust, posterior glenoid bone loss can lead to recurrent instability and failed soft tissue procedures. Arthroscopic posterior glenoid augmentation with distal tibial allograft (DTA) is a minimally invasive option to restore stability and preserve function. Indications: The primary indication for posterior glenoid augmentation is posterior instability with >20% to 25% posterior glenoid bone loss or recurrent posterior instability after prior stabilization procedure. In this case, the patient is a 21-year-old man with recurrent instability after 2 prior soft tissue stabilization procedures. Technique Description: The patient was positioned in lateral decubitus, and portals were established. Arthroscopic evaluation was performed to assess the labrum, biceps, rotator cuff, glenoid, and humeral head. Glenoid mobilization was performed, and an incision was made for introduction of the bone block. The glenoid was prepared, and a trial was used to guide preparation of the graft, which was harvested from the articular cartilage of the distal tibia. The graft was irrigated and bathed in platelet-rich plasma (PRP) and then introduced and positioned for maximal coverage of the defect. Screw fixation was performed with two 3.75-mm screws. The posterior capsule was reapproximated, and a layered closure was performed. Results: Previous studies have reported significant improvements in patient-reported outcomes, high rates of healing, and no cases of recurrent instability after DTA for anterior glenoid bone loss. Additional studies have reported few patients with recurrent instability and no instances of partial or non-union. Significant loss of range of motion has not been reported in the most recent case series. One previous study reported significantly improved patient-reported outcomes and near-complete osseous reabsorption with DTA after failed Latarjet procedure. Discussion/Conclusion: Arthroscopic posterior glenoid augmentation with DTA is a viable treatment option for patients with shoulder pain and instability with >20% to 25% posterior glenoid bone loss and/or following prior stabilization procedures.

Proximal tibiofibular joint (PTFJ) pathology is an uncommon but perhaps underappreciated cause of lateral knee pain. While imaging guided therapeutic injections for diagnosis and management of joint related symptoms are now commonplace and numerous techniques for accessing most joints in the body have been documented, a technique for fluoroscopically guided injection of the PTFJ has not been yet described in the literature. We present a case of an adult patient who presented with lateral knee pain refractory to conservative management who opted for a fluoroscopically-guided therapeutic injection of her PTFJ.

Category: Bunion Introduction/Purpose: Multiple operative techniques have been developed for hallux valgus with varying success. While correction has been traditionally achieved through open surgical approaches, there has been a growing interest in minimally invasive surgical (MIS) techniques. The purpose of this study was to compare clinical and patient-reported outcomes for patients undergoing hallux valgus correction with Lapidus, Scarf and MIS. Our hypothesis was that while a superior clinical correction would be achieved with open techniques there would be similar patient-reported outcomes among open and MIS techniques. Methods: A total of 257 patients who underwent Lapidus (n=82), Scarf (n=82) or MIS (n=93) hallux valgus correction between January 2017- January 2020 at one of two academic institutions by 1 of 9 foot and ankle-fellowship trained orthopedic surgeons were included in this study. Only 3 of 9 performed MIS correction. The average age at the time of surgery 55.4 (range 14-79). Patients were required to have a minimum baseline and 1-year postoperative Patient-Reported Outcomes Measurement Information Scores (PROMIS) and minimum 3-month clinical follow-up. Retrospective chart review was performed to assess the incidence of postoperative complications and reoperations, with an average clinical follow-up of 8 months. Results: All groups had statistically significant differences between pre- and post-operative measurements of HVA, IMA, DMAA, and tibial sesamoid position (20) (Lapidus n=7 (8.5%), Scarf n=9 (11.0%), MIS n=9 (9.7%)). Conclusion: In the last decade, there has been a growing interest in the use of minimally invasive surgical MIS techniques for the treatment of hallux valgus. When compared with traditional open techniques using Lapidus and Scarf osteotomies MIS presents a safe and effective approach to treating hallux valgus.

Background: Posterior glenoid labrum lesions occur in only 2% to 10% of all cases of shoulder instability, yet these injuries may cause significant shoulder dysfunction in an athletic population. Moreover, these injuries frequently require surgical intervention and present a unique surgical challenge. Indications: Indications for arthroscopic posterior labral repair include symptomatic posterior labral tears identified on magnetic resonance imaging with or without contrast, that failed nonsurgical management (ie, lifestyle modification, nonsteroidal anti-inflammatory drug, and physical therapy). Patients may present with a positive posterior load and shift or positive posterior apprehension test. Technique Description: With the patient in the lateral decubitus position, use a standard posterior superior portal, an ancillary anterior superior portal, a posterior-inferior, and the portal of Wilmington. After portal placement and diagnostic arthroscopy, the torn labrum is debrided. The torn portion of the posterior labrum is then mobilized from approximately the 6 o’clock to 10 o’clock positions, and a curette and shaver are used to produce a bleeding margin for fixation. Two double-loaded 2.4-mm suture anchors are placed, passed, and tied; one at the 6:30 o’clock position and the other at the 8 o’clock position. A cinch stich configuration using a 2.9-mm pushlock anchor can be used at the 10 o’clock position. A polydioxanone suture is used to assist with capsular plication and to close the posterior portal. Results: The literature suggests that 90% to 94% of patients are able to return to their desired sport with 5% to 10% reporting recurrent instability by 2 years after operation. Two out of 3 patients report no limitations at 2 years. Discussion/Conclusion: Arthroscopic repair of posterior labral tears with suture anchors can be an effective surgical option for patients with reverse Bankart lesions. Using advanced imaging to identify concomitant pathologies, meticulous surgical technique, direct visualization of the anatomy and anchor placement, and a dedicated rehabilitation program, greater than 90% of patients can expect to return to sport.

Osteolysis and adverse local soft-tissue reactions are well-documented complications of metal-on-metal prosthetic implants. This case report describes a 68-year-old man who presented to the clinic 10 years after staged bilateral metal-on-metal total hip arthroplasty revisions with the primary complaint of groin pain, intermittent right leg pain, swelling, and muscle cramping while ambulating that resolved with rest. A complete workup was negative for deep venous thrombosis and infection. His symptoms were found to be secondary to an iliopsoas bursal mass externally compressing the femoral vasculature resulting in vascular claudication. He was treated with revision arthroplasty and drainage of the fluid within the iliopsoas bursal effusion with symptomatic resolution. Keywords: Metallosis, Metal-on-metal, Total hip arthroplasty, THA, Revision arthroplasty, Adverse local tissue reaction, Pseudotumor, Mechanically assisted crevice corrosion

Objective: To identify preoperative factors predicting early admission (within 30 days) of adult kidney transplant recipients to the intensive care unit (ICU). Patients and Methods: This is a single-center retrospective study of consecutive kidney transplant recipients between January 1, 2007, and December 31, 2016. Children (aged

Xanthogranulomatous endometritis (XGE) is an extremely rare chronic inflammatory condition, which may be associated with endometrial hyperplasia, endometrial carcinoma, or cervical stenosis. Imaging features can be easily misdiagnosed as an aggressive malignancy. We present a case of XGE, which is the first case of XGE with serial multimodality imaging examinations, in addition to clinical, surgical and pathologic correlations. As such, this unique case illustrates the evolution of this rare disease. Keywords: Xanthogranulomatous endometritis, Xanthogranulomatous inflammation, Endometrial carcinoma

Spontaneous arterial aneurysms of the hand are uncommon but are well-described in the adult population. In the pediatric population, however, congenital or true aneurysms of the hand are exceptionally rare. A case report and a literature review were performed for published cases of arterial aneurysms of the hand in the pediatric population. A 13-month-old child presented with an aneurysm of the common digital artery and underwent surgical excision without need for reconstruction. Literature review found 13 documented cases. Patient characteristics and management strategies were summarized. There are very few documented cases of hand arterial aneurysms in the pediatric population, with our patient being the third youngest ever reported. No cases were associated with hereditary disease, and aneurysm excision was performed in all cases. Our report highlights the need to include arterial aneurysm in a differential diagnosis when evaluating a pediatric patient with a palpable hand mass. Keywords: Congenital Aneurysm, Vascular malformation, Hand surgery

Category: Lesser Toes; Midfoot/Forefoot Introduction/Purpose: The Jones fracture of the proximal fifth metatarsal metadiaphysis is predisposed to delayed union and nonunion due to a tenuous blood supply. Surgical fixation followed by delayed weightbearing is commonly recommended, though the optimal period of nonweightbearing after surgery is not well defined. In response to more recent literature and in an effort to facilitate functional recovery, the trend in our practice has begun to shift toward earlier weightbearing for all patients after Jones fracture fixation. The purpose of this study is to investigate the effect of earlier weightbearing after surgical fixation of Jones fractures. Methods: All Jones fractures treated with an intramedullary (IM) screw in a large, urban practice from 2012-2018 were identified. We excluded fractures that were chronic in nature and patients with underlying metabolic disease. We defined a delayed union as longer than 12.5 weeks based on published data. Time to weightbearing and early weightbearing (within 1 week of surgery) were investigated as risk factors for delayed union using logistic regression and Fisher exact tests, respectively. The relationship between time to weightbearing and time to union was assessed with Spearman correlation. Additional variables were explored in bivariate analysis: time to surgery from initial presentation; age, sex, chronicity, tobacco use, weight, BMI, screw size; preoperative NSAID use, and postoperative VTE prophylaxis. Multivariate regression analyses were then performed to identify variables independently predictive of delayed union. Results: Forty-one cases were included (17 males, 24 females), all treated with IM fixation. Median age in the sample was 45 years ( IQR, 32-62 years). Overall mean time to union was 10.9 +- 7.0 weeks (range, 4.9-41.4 weeks). There were nine (22.0%) delayed unions. Earlier weightbearing was not significantly predictive of delayed union (OR 1.02; 95% CI, 0.99-1.05; P = 0.211), and the incidence of nonunion was not significantly different between early and delayed weightbearing groups (OR, 1.20; 95% CI, 0.02- 17.54; P > .999). In bivariate analysis, increasing age was associated with increasing risk of delayed union (OR, 1.06; 95% CI, 1.01- 1.12; P = 0.031), and was correlated with time to union (ρ = 0.327, P = 0.037). Mutivariate analaysis demonstarted no significant variables. Conclusion: Our results suggest that earlier weightbearing after internal fixation of Jones fractures is not a risk factor for delayed union and does not significantly alter healing time. These findings are consistent with previously published data, but go further by assessing the effects of time to weightbearing in continuous regression models.

Category: Midfoot/Forefoot; Other Introduction/Purpose: Arthritis of the 1st metatarsophalangeal (MTP) joint is a common condition. Traditionally, advanced disease has been treated with arthrodesis. In 2016, Cartiva, a cylindrical polyvinyl 1st MTP implant, was approved for use in this condition by the FDA upon the basis of a company-sponsored, nonblinded, randomized controlled trial (MOTION) that reported noninferiority to arthrodesis at a -15% difference of proportions margin using a multipart ad hoc definition of surgical success. A subsequent independent level IV case series reported poor PROMIS score outcomes for the procedure but lacked any preoperative data. We report the short-term reoperation rate and pre- and postoperative VAS pain score outcomes for Cartiva in an independent multicenter series. Methods: A retrospective, multicenter review was performed of patients who had a Cartiva hemiarthroplasty placed from 2016- 18 and who had at least 6 months of follow-up. Demographic information, surgical data, and prospectively collected VAS pain scores on a 0-100 point scale on were reviewed. The primary endpoint was reoperation of the implant, defined as removal or revision during the follow-up period. Implant subsidence was measured by comparing early postoperative radiographs with final radiographs. Subgroup analysis was performed comparing Cartiva failures to the remainder of the group. Results: Fifty-three patients with 56 operated toes were included. Forty-seven (88.7%) females and 6 (11.3%) males had a mean age of 57.7 +- 7.14 years (range 43-73). At an average follow-up of 11.1 +- 4.24 months, there were 6 (10.7%) reoperations. Younger age was the only factor found to be associated with failure of the implant (p=.043). Radiographic subsidence >1 mm was identified in 26.6% of patients but did not correlate with failure. VAS pain scores improved from a preoperative average of 49.7 +/- 24.8 to a postoperative average of 33.1 +- 23.3 at final follow-up. Despite this improvement, 40.4% of patients failed to show a 30% improvement, the MCID, in their VAS pain score, and 42.6% of patients had residual pain scores above 30. Conclusion: Our cohort had a 10.7% reoperation rate for the Cartiva implant which is comparable to the results of the MOTION trial. Although aggregate results demonstrated a statistically significant improvement in VAS pain scores, many patients failed to have a satisfactory outcome as demonstrated by the large standard deviation and low achievement of the MCID. Compared to the 1-year results of the MOTION study, our final VAS pain scores were slightly worse, but the very high variance mirrored that reported in the company-sponsored trail (17.8 +- 23.0). This suggests that use of Cartiva does not reliably produce satisfactory pain outcomes.

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Minimally invasive surgery (MIS) is being increasingly used for bunion deformity correction. New third generation minimally invasive chevron/akin (MICA) techniques are used but limited data on patient outcomes have been reported. The goal of this IRB-approved study was to look at outcomes of percutaneous, extra-articular distal metatarsal osteotomies for mild to moderate bunion deformity, including the degree of deformity correction obtained, patient pain control, and complication rates. We also describe strategies for avoiding the intra-operative and post-operative complications that may arise with MIS bunion surgery. Methods: The participants were the treating surgeon’s first 75 consecutive patients 18 years and older who were treated with MICA procedures. Via retrospective chart review, outcome measures including pre and final post-operative intermetatarsal angles (IMA), hallux valgus angles (HVA), visual analogue scale (VAS) score, and complication rates were assessed. Statistical analysis was done utilizing student’s t-test for continuous variables and chi square test for categorical variables. Results: Average follow-up was 105.0 days. VAS scores dropped one week post-operatively, from 5.4 pre-operatively to 2.5 (p< 0.05). IMA angles improved from 12.7 degrees (range 6.1-18.1) pre-op to 6.1 (range 1.2-12.5) at final follow-up (p< 0.05). HVA angles improved from 27.2 degrees (range 9.7-43.4) to 10.4 (range 1.3-25.9) (p

Category: Basic Sciences/Biologics; Ankle; Hindfoot; Midfoot/Forefoot; Sports Introduction/Purpose: Artelon is a synthetic degradable polyurethaneurea graft which has been investigated and utilized for soft tissue reconstruction in a variety of orthopaedic settings. However, in the field of foot and ankle surgery, there is very limited reported clinical data on outcomes of surgery utilizing Artelon. The goal of this study was look at outcomes of foot and ankle surgery in which Artelon is used, including post-op VAS scores and complications including adverse foreign body reaction, infection, repeat surgery, and implant failure. Our hypothesis was that soft tissue reconstruction procedures utilizing artelon will have a low complication rate, similar to established complication rates for other soft tissue reconstruction procedures such as those utilizing allograft, autograft, or other synthetic tissue. Methods: The treating surgeon’s first 55 consecutive patients 18 years and older who were treated with artelon graft as part of a foot and ankle surgery are being included in this IRB-approved study. Through retrospective chart review, outcome measures including the procedure for which artelon was utilized, pre and post-op Visual Analogue Scale (VAS) scores, and complications including repeat surgery for graft failure, foreign body reaction, wound healing issues, infection, and osteolysis were assessed. Statistical analysis was done utilizing Student’s t-test for continuous variables and chi square test for categorical variables. Results: Average follow-up time was 246.5 days. The majority of patients had artelon placed for spring ligament reconstruction, brostrom procedures, or achilles tendon reconstruction. VAS scores dropped significantly from before surgery to 3 weeks post- operatively (5.6 to 3.2, p

Purpose: Residency training environments can differ significantly; therefore, resident satisfaction may vary widely among programs. Here, we sought to examine several variables in program satisfaction through a survey of radiation oncology (RO) trainees in the United States. Methods and materials: An anonymous, institutional review board-approved, internet-based survey was developed and distributed to U.S. residents in RO in September 2016. This email-based survey assessed program-specific factors with regard to workload, work-life balance, and education as well as resident-specific factors such as marital status and postgraduate year. Binomial multivariable regression assessed the correlations between these factors and the endpoint of resident-reported likelihood of selecting an alternative RO residency program if given the choice again. Results: A total of 215 residents completed the required survey sections, representing 29.3% of U.S. RO residents. When asked whether residency allowed for an adequate balance between work and personal life, the majority of residents (75.6%) agreed or strongly agreed, but a minority (9.3%) did not feel that residency allowed for sufficient time for personal life. The majority of residents (69.7%) indicated that they would choose the same residency program again, but 12.2% would have made a different choice. Almost three-fourths of residents (73.0%) felt that faculty and staff cared about the educational success of residents, but 9.27% did not. Binomial multivariable regression revealed that senior residents (odds ratio: 6.70; 95% confidence interval, 2.20-22.4) were more likely to desire a different residency program. In contrast, residents who reported constructive feedback use by the residency program (odds ratio:0.22; 95% confidence interval, 0.06-0.91) were more satisfied with their program choice. Conclusions: Most RO residents reported satisfaction with their choice of residency program, but seniors had higher rates of dissatisfaction. Possible interventions to improve professional satisfaction include incorporating constructive resident feedback to enhance the program. The potential impact of job market pressures on seniors should be further explored.

Objective: To characterize large adrenal tumors (≥4 cm in diameter) and to identify features associated with malignancy. Patients and Methods: We investigated the clinical, biochemical, and imaging characteristics in a large retrospective single-center cohort of patients with adrenal tumors of 4 cm or more in diameter during the period of January 1, 2000, through December 31, 2014. Results: Of 4085 patients with adrenal tumors, 705 (17%) had adrenal masses measuring 4 cm or more in diameter; of these, 373 (53%) were women, with a median age of 59 years (range, 18-91 years) and median tumor size of 5.2 cm (range, 4.0-24.4 cm). Underlying diagnoses were adrenocortical adenomas (n=216 [31%]), pheochromocytomas (n=158 [22%]), other benign adrenal tumors (n=116 [16%]), adrenocortical carcinomas (n=88 [13%]), and other malignant tumors (n=127 [18%]). Compared with benign tumors, malignant tumors were less frequently diagnosed incidentally (45.5% vs 86.7%), were larger (7 cm [range, 4-24.4 cm] vs 5 cm [range, 4-20 cm]), and had higher unenhanced computed tomographic (CT) attenuation (34.5 Hounsfield units [HU] [range, 14.1-75.5 HU] vs 11.5 HU [range, −110 to 71.3 HU]; P

Background. Despite substantial evidence demonstrating clear benefit, rates of preemptive kidney transplantation (PreKTx) remain low in the United States. Our goal was to identify barriers to PreKTx. Methods. Using a telephone-administered questionnaire including questions about barriers, timing of referral, timing of education, we retrospectively studied first living donor kidney transplant recipients (2006-2010) at Mayo Clinic, Rochester, MN. Of 235 patients, 145 (62%) responded to the questionnaire (74 PreKTx and 71 non-PreKTx). We compared categorical data with Fisher exact test and median times with Wilcoxon rank sum test. Results. Polycystic kidney disease (PCKD), longer median time between diagnosis and transplant, and time between education about transplant and transplant correlated with PreKTx (P < 0.01). The presence of at least 1 patient-identified barrier (lack of referral, financial barriers, medical barriers, no identified living donor and donor evaluation delays) was associated with non-PreKTx (0.034) though no single barrier predominated. Age, education level, insurance status and source of referral (primary care, nephrology, and nonphysician referral) were not associated with the rate of PreKTx. Univariate logistic regression identified white race, PCKD, and increased time from diagnosis as factors favoring PreKTx; PCKD and increased time remained significant factors after multivariate analysis. Conclusions. Even among a patient population that is primarily white, educated, and has a spouse or first-degree relative donor, PreKTx rates remain concerningly low. Increased time between diagnosis or education and transplant are predictors of PreKTx. Greater emphasis on transplant education earlier in the stages of chronic kidney disease and community outreach from transplant centers may help to increase the rate of PreKTx.

Category: Ankle, Bunion, Hindfoot, Lesser Toes, Midfoot/Forefoot Introduction/Purpose: Orthopaedic surgeons frequently prescribe pain medications during the postoperative period. The efficacy of these medications at alleviating pain after foot/ankle surgery and the quantity of medication required (and conversely, the quantity of medication leftover) are unknown. Methods: All patients that underwent foot/ankle surgery during a three month period and met inclusion criteria were surveyed at their first postoperative visit (4-10 days after surgery). Information collected from the patients included gender, number of narcotic tablets remaining in the bottle, satisfaction with pain control, and willingness to surrender leftover narcotics to a Drug Enforcement Administration (DEA) disposal center. These data were collected prospectively. Additional data, including utilization of a perioperative nerve block, type of procedure (bony vs non-bony), and anatomic region of procedure, were collected by review of the medical record. All data were analyzed in a retrospective fashion. Results: A total of 47 surveys were filled out over the course of 4 weeks. Eighty-five percent of patients were either extremely satisfied or satisfied with their pain control. Ninety-six percent of patients had short acting opioids leftover, and 94% of patients had long acting opioids leftover. On average, there were 27 short acting and 11 long acting narcotic pills leftover at the first postoperative visit (4-10 days after surgery). Of those with leftover narcotic medications, 72% were willing to surrender them to a DEA disposal center. Conclusion: Most patients undergoing foot/ankle surgery had both short and long acting narcotic pain pills leftover at the first postoperative visit (4-10 days after surgery). While it is unknown how many patients continue to require narcotics after the first week from surgery, most patients said they would be willing to surrender any leftover opioid medications to a DEA disposal center. In the future, perhaps patients should be given information on the location of the nearest disposal center when given prescriptions for narcotics.

Category: Ankle, Arthroscopy, Trauma Introduction/Purpose: High fibula fractures, including Maisonneuve and Weber type C fractures are commonly associated with syndesmotic injuries resulting in subluxation and dislocation of the ankle. These injuries to the joint are rarely evaluated or addressed during operative fixation, which generally consists of open reduction internal fixation of the fibula with or without fixation of the syndesmosis. Chondral lesions and loose bodies in ankle fractures may predict a poor result and can be addressed using arthroscopy to avoid exacerbating articular damage. The purpose of this study is to identify the frequency and severity of articular pathology in Weber C and Maisonneuve fibula fractures. Methods: A single surgeon case series of operatively managed ankle fractures with arthroscopic assessment from 2011-2015 was retrospectively reviewed. Inclusion criteria were patients with AO 44-C ankle fractures who were aged >17 and underwent arthroscopic assessment of the ankle joint prior to open reduction and internal fixation. Patients were excluded from the series if they presented

Introduction: The International Society for Sexual Medicine (ISSM) Ad Hoc Committee for the Definition of Premature Ejaculation developed the first evidence-based definition for lifelong premature ejaculation (PE) in 2007 and concluded that there were insufficient published objective data at that time to develop a definition for acquired PE. Aim: The aim of this article is to review and critique the current literature and develop a contemporary, evidence-based definition for acquired PE and/or a unified definition for both lifelong and acquired PE. Methods: In April 2013, the ISSM convened a second Ad Hoc Committee for the Definition of Premature Ejaculation in Bangalore, India. The same evidence-based systematic approach to literature search, retrieval, and evaluation used by the original committee was adopted. Results: The committee unanimously agreed that men with lifelong and acquired PE appear to share the dimensions of short ejaculatory latency, reduced or absent perceived ejaculatory control, and the presence of negative personal consequences. Men with acquired PE are older, have higher incidences of erectile dysfunction, comorbid disease, and cardiovascular risk factors, and have a longer intravaginal ejaculation latency time (IELT) as compared with men with lifelong PE. A self-estimated or stopwatch IELT of 3 minutes was identified as a valid IELT cut-off for diagnosing acquired PE. On this basis, the committee agreed on a unified definition of both acquired and lifelong PE as a male sexual dysfunction characterized by (i) ejaculation that always or nearly always occurs prior to or within about 1 minute of vaginal penetration from the first sexual experience (lifelong PE) or a clinically significant and bothersome reduction in latency time, often to about 3 minutes or less (acquired PE); (ii) the inability to delay ejaculation on all or nearly all vaginal penetrations; and (iii) negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy. Conclusion: The ISSM unified definition of lifelong and acquired PE represents the first evidence-based definition for these conditions. This definition will enable researchers to design methodologically rigorous studies to improve our understanding of acquired PE. Serefoglu EC, McMahon CG, Waldinger MD, Althof SE, Shindel A, Adaikan G, Becher EF, Dean J, Giuliano F, Hellstrom WJG, Giraldi A, Glina S, Incrocci L, Jannini E, McCabe M, Parish S, Rowland D, Segraves RT, Sharlip I, and Torres LO. An evidence-based unified definition of lifelong and acquired premature ejaculation: Report of the second International Society for Sexual Medicine Ad Hoc Committee for the Definition of Premature Ejaculation. Sex Med 2014;2:41–59.

Introduction: In 2009, the International Society for Sexual Medicine (ISSM) convened a select panel of experts to develop an evidence-based set of guidelines for patients suffering from lifelong premature ejaculation (PE). That document reviewed definitions, etiology, impact on the patient and partner, assessment, and pharmacological, psychological, and combined treatments. It concluded by recognizing the continually evolving nature of clinical research and recommended a subsequent guideline review and revision every fourth year. Consistent with that recommendation, the ISSM organized a second multidisciplinary panel of experts in April 2013, which met for 2 days in Bangalore, India. This manuscript updates the previous guidelines and reports on the recommendations of the panel of experts. Aim: The aim of this study was to develop clearly worded, practical, evidenced-based recommendations for the diagnosis and treatment of PE for family practice clinicians as well as sexual medicine experts. Method: A comprehensive literature review was performed. Results: This article contains the report of the second ISSM PE Guidelines Committee. It offers a new unified definition of PE and updates the previous treatment recommendations. Brief assessment procedures are delineated, and validated diagnostic and treatment questionnaires are reviewed. Finally, the best practices treatment recommendations are presented to guide clinicians, both familiar and unfamiliar with PE, in facilitating treatment of their patients. Conclusion: Development of guidelines is an evolutionary process that continually reviews data and incorporates the best new research. We expect that ongoing research will lead to a more complete understanding of the pathophysiology as well as new efficacious and safe treatments for this sexual dysfunction. We again recommend that these guidelines be reevaluated and updated by the ISSM in 4 years. Althof SE, McMahon CG, Waldinger MD, Serefoglu EC, Shindel AW, Adaikan PG, Becher E, Dean J, Giuliano F, Hellstrom WJG, Giraldi A, Glina S, Incrocci L, Jannini E, McCabe M, Parish S, Rowland D, Segraves RT, Sharlip I, and Torres LO. An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE). Sex Med 2014;2:60–90.

Category: Trauma Introduction/Purpose: Risk factors associated with short-term functional outcomes in patients with operative ankle fractures have been established. However, no previous studies have reported on the association between these risk factors and long-term functional outcomes. Using the Patient Reported Outcomes Measurement System (PROMIS) physical function (PF) and pain interference (PI) measures, we attempt to identify predictors of long-term functional outcome in patients with operative ankle fractures. Methods: We retrospectively reviewed a multicenter cohort of patients aged ≥18 years old who underwent operative management of a closed ankle fracture from 2001-2013 with a minimum of 2 years follow-up. Patients with posterior pilon variants, Maisonneuve fractures, prior ankle surgery, and chronic ankle fractures were excluded from the study. Patients meeting inclusion criteria were contacted and evaluated using the PROMIS PF and PI computerized adaptive tests. PROMIS scores are standardized to a US population with a mean of 50 and a standard deviation of 10. Higher PF scores represent increased physical function, while increased PI scores are indicative of higher pain. Patient risk factors including sex, age, diabetes, smoking, ASA class, BMI, education level, ankle dislocation, energy of injury, and fracture pattern were obtained through a retrospective chart review. Univariate and multivariate regression models were developed to determine independent predictors of physical function and pain at long-term follow up. Results: In total, 199 patients met inclusion criteria. Of those, 142 patients (64 females, 78 males) with a mean age of 52.7 years (SD=14.7) averaging 6.3 years of follow-up (range 2 – 14) participated. Patients had a mean PF score of 51.9 (SD=10.0) and a mean PI score of 47.8 (SD=8.45). Multivariate analysis demonstrated that independent predictors of decreased PF score included higher age (B=0.16, p=0.03), higher ASA class (B =10.3, p < 0.01) and higher BMI (B=0.44, p < 0.01). Predictors of decreased PI score included higher ASA class (B=11.5, p < 0.01) and lower BMI (B=0.41, p < 0.01). Sex, presence of diabetes, smoking status, education level, presence of ankle dislocation, energy of injury mechanism, and fracture pattern did not independently impact long- term pain or functional outcomes. Conclusion: At long-term follow-up of operative ankle fractures, increased ASA class, increased BMI, and higher age at time of surgery are independently predictive of decreased physical function. Factors that are associated with increased pain at long-term follow-up include lower BMI and higher ASA class. ASA class had the strongest effect on both physical function and pain.

A 25-year-old male was brought in by ambulance to the emergency department (ED) after sustaining a gunshot wound to his chin and left shoulder. Upon arrival to the ED, his airway was intact without evidence of blood in the oropharynx. He was found to have slightly diminished breath sounds on the left side, with respirations at 34 breaths per minute, a blood pressure of 72/50mmHg, and a heart rate of 76 beats per minute with cool extremities and poor peripheral pulses. His focused abdominal sonography in trauma exam showed a foreign body within the right ventricle without a pericardial effusion (Figure 1 and Video). An upright portable chest radiograph performed immediately thereafter showed blunting of the left costophrenic angle with a bullet fragment overlying the cardiac shadow (Figure 2).

Research describes the population dynamics associated with double and single Wolbachia infections in Drosophila simulans. Data reveal that the population predominantly consists of doubly infected flies and both male and female components are involved in the phenotypic expression of incompatibility. Furhter, infection status does not correlate with mitochondrial sequence polymorphism.

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