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Abstract. Objectives:. This systematic review examined the literature regarding management of fracture patients who take direct oral anticoagulant (DOAC) medications, with a focus on delay in surgical treatment, and need for transfusions. In addition, a survey of orthopaedic trauma surgeons was conducted to gain insight on current practices. Data Sources:. A review of PubMed, Cochrane, Embase, and Scopus databases was performed from inception through March 2024, including English language publications. Study Selection:. Studies were included if they reported time to surgery and transfusion rates among fracture patents who were taking DOAC medications. Additional data points were collected on an “if-reported” basis, including mortality, venous thromboembolism, and bleeding complications. Data Extraction:. In all, 4546 abstracts were screened. Full-text review was conducted on 86 publications, and 25 articles were included in the final analysis. Each article was independently screened by 2 reviewers, with disputes settled by a third reviewer. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) tool. Data Synthesis:. Descriptive statistics are reported for overall study findings. Meta-analysis was performed for the variables “time to surgery” and “transfusion rate.” Conclusions:. Our findings indicate that fracture patients taking DOACs experience longer delays before surgery but have equivalent transfusion rates compared with nonanticoagulated patients. Survey results indicate that surgeons do not delay operating on emergent or percutaneous cases, regardless of anticoagulant medications. In circumstances when they do delay, they are more likely to do so for patients taking DOAC medications. Level of Evidence:. Level III, systematic review and meta-analysis of Level II and III articles.

Background: Spiritual beliefs and spiritual support from clinicians can affect medical decision-making and coping during times of serious illness. Research Question: How do religion and spirituality affect the critical illness experience of Black and White family caregivers of patients who are critically ill? Study Design and Methods: Twenty-one semistructured interviews were conducted with Black and White family caregivers of patients admitted to ICUs in a southeastern United States health system between January 3, 2023, and May 11, 2023. Eligible family caregivers either reported unmet spiritual needs or a high degree of importance of spirituality in their lives. Participants were asked how spirituality affected medical decision-making and coping while their loved ones were seriously ill. Coders were masked to participant race during thematic analysis. Results: Of 21 family caregivers, 9 caregivers (42.9%) were Black and 12 caregivers (57.1%) were White. Black and White family caregivers generally were middle-aged (mean [SD]: 50.6 [13.6] years and 61.7 [10.7] years, respectively) and female (n = 7 [77.8%] and n = 9 [75.0%], respectively). We observed that clinicians showed less engagement about spirituality with Black compared with White family caregivers in this sample. Black family caregivers felt more comfortable discussing their spirituality with members of their community, such as pastors or friends. A common belief among all family caregivers in this sample was that God, rather than the medical team, was in control of their loved one’s outcome. This was accompanied by a shared desire for accessible spiritual spaces in the ICU and proactive clinician engagement in their spirituality. Interpretation: Although spirituality served as an important coping mechanism for all family caregivers in this sample, racial differences in spiritual support offered to family caregivers were identified. Ensuring that multidisciplinary critical care teams are prepared to deliver culturally competent spiritual care is a priority.

Summary:. As surgeons, we work in a high-stress, high-stakes environment to take care of our patients. In this setting, it is not uncommon for us to experience microaggressions—subtle or indirect actions or statements that communicate a demeaning or exclusionary message, often unintentionally. Microaggressions can bring us down, taking away from the fulfillment that attracted many of us to this profession. In this article, we introduce the Institute for Professional Excellence in Coaching energy leadership framework as a tool to understand and address microaggressions. We then apply it to real-life scenarios surgeons may encounter, demonstrating how this framework can help us to build resilience and recover our joy for our profession.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Following Minimally Invasive Bunionectomy (MISB), removal of hardware rates are about 5% and commonly due to midfoot pain near the distal metatarsal screw site. This distal screw head site corresponds to the proximal midshaft width measurement location, which has shown to increase postoperatively. One explanation for this increased width is medial subluxation of the first metatarsal at the tarsal-metatarsal (TMT) joint. This “TMT slippage” occurs as the metatarsal base is shifted medially to accommodate the metatarsal head lateralization at the metatarsal phalangeal joint. The force across the TMT joint overcomes the ligamentous stabilizers, allowing the metatarsal to “slip.” The aim of this study was to investigate the relation between TMT slippage and removal of hardware (ROH) rates. Methods: A retrospective analysis of prospectively collected data identified 38 patients undergoing MISB for hallux valgus (HV) with subsequent distal chevron screw removal and a control group of 40 MISB cases without hardware removal. Demographic data and surgical details were obtained via chart review. Pre- and at least 6-month post-operative radiographs were measured to obtain transverse TMT slippage on anteroposterior (AP) radiographs (Figures 1). Additionally, distal foot width, midshaft foot width, hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured. Independent samples t-tests and chi-square analyses were used to compare continuous and categorical characteristics, respectively, between patients who underwent removal of hardware. Multivariable logistic regression modeling was used to identify risk factors for undergoing hardware removal. Results: Interobserver reliability, measured by intraclass correlation coefficients (ICCs), was high for all measurements (ICC > 0.70). The change in TMT slip was significantly higher in the hardware removal (ROH) group compared to the control group (+1.39 versus +0.80, p=0.004) (Table 1). A greater decrease in distal foot width (narrower distal width postoperatively) was associated with an increased likelihood of hardware removal (OR: 0.76), while smaller reductions in HVA and IMA were linked to a higher likelihood of requiring ROH (OR: 1.12 and 1.42, respectively). Notably, a larger increase in TMT slip correlated with the highest likelihood of being in the ROH cohort (OR: 2.87) (Table 2). TMT slippage did not correlate with any other measurements (all p > 0.05). Conclusion: Our study highlights the relationship between MISB outcomes and TMT slippage. Patients requiring distal chevron screw removal showed significantly higher transverse TMT slippage. Interestingly, a smaller distal foot width reduction was associated with decreased hardware removal likelihood, suggesting a potential protective mechanism. Conversely, smaller corrections of both HVA and IMA were associated with higher chances of hardware removal. Notably, for every 1-centimeter increase in TMT slippage postoperatively, there was a nearly 3-fold increase in the likelihood of distal chevron screw removal. Further research is needed to understand the mechanisms underlying TMT slippage and its impact on HV correction outcomes.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Hallux Valgus (HV) is a common foot condition often requiring surgical intervention. Minimally invasive bunionectomy (MISB) has gained popularity for HV correction. While previous research has focused on distal foot width changes following surgery, this study introduces a novel midshaft measurement to assess proximal transverse midfoot width. The study aims to provide a comprehensive evaluation of foot width changes post-MISB. Methods: A retrospective review of prospectively collected data was conducted for 44 patients who underwent MISB for HV via an institutional outcome registry. Demographic data, surgical details, radiographs, and foot width measurements were collected. Changes in hallux valgus angle (HVA) and intermetatarsal angle (IMA) were also measured. The novel midshaft bony and soft tissue foot width measurements were included. Two independent observers conducted all preoperative and postoperative measurements. Results: Intraclass correlation coefficients (ICCs) demonstrated high interobserver reliability (all ICCs >0.70) for all measurements. MISB resulted in a consistent reduction in distal foot width, both bony (8.17%) and soft tissue (5.24%)(p 0.375, p

Category: Midfoot/Forefoot; Other Introduction/ Purpose: Hallux rigidus is characterized by arthritic changes of the first metatarsophalangeal joint (MTPJ) with joint space narrowing, osteophyte formation, and painful MTPJ motion. Although MTPJ arthrodesis is considered the “gold standard,” a Modified Oblique Keller Capsular Interposition Arthroplasty (MOKCIA) is an alternative treatment for hallux rigidus in patients who desire to retain MTPJ motion. The purpose of this study is to compare long-term outcomes (patient satisfaction, radiographic alignment, MTPJ walking kinematics, and plantar pressure) between the MOKCIA and 1st MTPJ arthrodesis. We hypothesized that patients undergoing MOKCIA will retain motion, but when compared to Arthrodesis at long-term follow-up, some MOKCIA patients may develop abnormal forefoot loading, toe malalignment and need revision. Methods: 26 patients who underwent a MOKCIA (n=14, 74±7 years old, 9 female, average 15 years from surgery) or an arthrodesis (n=12, 70±4 years old, 6 female, average 13 years from surgery) were recruited from a retrospective chart review (January 1, 2005, and December 31, 2018). Study measures included 11-point visual analog scale (VAS) Pain and satisfaction, Foot and Ankle Assessment Measure (FAAM) and PROMIS physical function scores, weight bearing radiographs (MTPJ valgus and 1st proximal phalanx to ground sagittal), walking MTPJ (first phalanx relative to forefoot) sagittal plane kinematics, forefoot and 1st toe peak plantar pressure during walking, MTPJ goniometer range of motion, and number of additional 1st MTPJ surgical interventions required. Two-sample t-tests or Chi-square were used to compare groups. Results: Groups did not differ on demographic characteristic or patient reported outcomes [VAS Pain (MOKCIA=0.1±0.3, Arthrodesis=1.2±1.8, p=0.06), satisfaction (MOKCIA=9.4±0.9, Arthrodesis=8.3±1.6, p=0.054), FAAM (MOKCIA=94±9, Arthrodesis=95±7, p=0.65), PROMIS (MOKCIA=50±6, Arthrodesis=48±6, p=0.41)]. MTPJ valgus was increased in the Arthrodesis group (MOKCIA=4±5°, Arthrodesis=7±4°, p=0.05). First phalanx to ground was more plantarflexed in the MOKCIA group (MOKCIA=9±7°, Arthrodesis=1±7°, p=0.01)]. Walking MTPJ excursion was greater in the MOKCIA group (MOKCIA=25±9°, Arthrodesis=13±8°, p< 0.001). There was no group difference in forefoot and 1st toe walking peak plantar pressure (Forefoot: MOKCIA=111±29 N/cm 2 , Arthrodesis=127±22 N/cm 2 , p=0.12 and Toe: MOKCIA=77±28 N/cm 2 , Arthrodesis=101±41 N/cm 2 , p=0.10). MTPJ extension range of motion was greater in the MOKCIA group (MOKCIA=48°±13, Arthrodesis=25°±8, p< 0.001). One person in the Arthrodesis group required hardware removal, but no MOKCIA patient required additional surgery. Conclusion: More than 10 years of follow-up after surgery, patients in both MOKCIA and Arthrodesis groups had little pain, were similarly satisfied, and reported high function with little limitation due to their toe surgery. Radiograph alignment showed no progressive deformity in the MOKCIA group and patients were able to retain MTPJ extension range of motion during walking. Plantar pressures were not impacted by surgical intervention. No MOKCIA patient required revision. These results suggest MOKCIA is a reasonable alternative option compared to first MTPJ arthrodesis for long term treatment of hallux rigidus in patients who desire to preserve toe range of motion.

Category: Midfoot/Forefoot; Sports Introduction/Purpose: Turf toe, a plantar plate injury of the first metatarsophalangeal joint, commonly occurs in athletes participating in outdoor cutting sports. To the knowledge of the authors, this study reports on clinical and return to sport outcomes after surgical repair of turf toe for the largest cohort of patients presenting with a Grade III turf toe injury. The purpose of this study is to identify risk factors for turf toe and analyze foot function after turf toe injury and surgical repair. This study reports on clinical outcomes and return to sport for athletic patients treated for a turf toe injury at our institution. We hypothesize that patients will have significant improvement in pre- to postoperative clinical outcomes and quickly return to sport after surgical repair. Methods: This was a single-center retrospective study conducted from the institutional review board-approved Foot and Ankle Registry data, and the protocol was approved by the steering committee at the investigators’ institution. Inclusion criteria included athletes of at least high school level competition who underwent plantar plate repair at the first metatarsophalangeal joint between 2016 to 2023 by 3 fellowship-trained foot and ankle orthopedic surgeons. Excluded were patients with histories of ipsilateral forefoot surgeries, rheumatoid arthritis, or gout. Twenty-eight patients were identified. Patient-reported outcomes via PROMIS scores were collected preoperatively and at least one year postoperatively for all patients. Return to sport surveys were distributed to patients at least one year postoperatively. Results: The average time from surgery to final follow-up was 2.8 (range, 1-5.3) years. PROMIS scores were found to significantly improve for Physical Function, Pain Interference, Pain Intensity, and Global Physical Health domains. 21 return to sport surveys were completed from the patient cohort. 19 out of 21 (90.5%) of patients were able to return to pre-injury levels of physical competition with an average time to return to sport was 20.35 (range, 12-32) weeks. Conclusion: This study compared short- to medium-term patient-reported clinical outcomes and return to sport data for athletes after a Grade III turf toe injury and surgical repair. Patients demonstrated significant improvement in patient-reported outcomes and were able to return to sport approximately five months after surgery.

Category: Bunion Introduction/ Purpose: Hallux valgus deformity affects more than 35% of people over 65 years old. Surgical correction in this population can be more complicated due to the likelihood of poor bone quality, worse deformity, and post-operative recovery challenges associated with weight bearing restrictions. There is no consensus on which surgical option is the best in this age-group. Minimally invasive bunionectomy (MIS) has gained popularity, namely due to evidence showing reduced recovery time, earlier weight-bearing, and less post-operative pain which can eliminate the need for opioids, all of which are beneficial to older surgical patients. The purpose of this study was to compare the radiographic and clinical outcomes of patients age 65 and older who underwent either open Lapidus or minimally invasive chevron akin osteotomy for bunion correction. Methods: A retrospective review of prospectively collected data within an institutional registry was performed. We identified 62 patients age 65 or older who were treated surgically for hallux valgus (open Lapidus or minimally invasive chevron akin osteotomy) between January 2017 and August 2022 with at least 1-year post-operative PROMIS scores. Chart review was performed to obtain demographic information and to confirm the surgical procedures completed. Pre- and at least 6-month post-operative radiographs were measured to obtain the hallux valgus angle (HVA) and intermetatarsal angle (IMA). PROMIS scores were obtained pre-operatively and at one and/or two years post-operatively. Differences in demographic, clinical, and radiographic outcomes between cohorts were assessed using the Mann Whitney U test and p-values were adjusted for a false discovery rate of 5%. Results: Both the MIS and open cohorts showed significant improvement in radiographic measurements between pre- and post-operative radiographs (p < 0.001), though there was no significant difference between groups (p > 0.05). There was a clinically and statistically significant improvement within the PROMIS domain of Pain Interference for the open and MIS groups and Physical Function for the MIS group at 1 and 2-years post-operatively, however, there was only a significant difference at 2-years for the PROMIS Physical Function domain in the open group. No difference was noted in Physical Function at 1-year post-operatively for the open group or between groups (Table 1). Within the MIS and open groups, there was an overall complication rate of 26% in each group (p > 0.05). Conclusion: Patients in both the MIS and open surgical groups had improvement in radiographic measurements and PROMIS scores, though there was no clinical or statistical difference found between groups. Additionally, patients in the open group may take longer to improve as there was not a significant improvement in the PROMIS Physical Function domain until the 2-year post-operative time point. Further investigation of recovery metrics between techniques in the earlier post-operative time-point is warranted. Given the results, both MIS and open surgical techniques appear to be safe and effective in correcting hallux valgus in older patients.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Hallux valgus(HV) is a triplanar deformity that includes the pronation of the first ray. Although there is little data regarding the effect of pronation on clinical outcomes, the rotational component of HV may play an important role. One study suggested that the modified Lapidus technique effectively decreased the pronation of the first ray. However, there is no evidence for alternative procedures such as minimally invasive(MIS) bunionectomy. This study sought to assess if MIS bunionectomy can effectively correct the first ray's pronation and determine the correlation with improved PROMIS scores. In addition, the association between postoperative first-ray pronation and the sesamoid station was investigated. We hypothesized a significant decrease in first-ray pronation after MIS bunionectomy, which would be associated with improved PROMIS scores. Methods: Sixty-three consecutive patients who underwent MIS bunionectomy with available pre- and at least 5-month postoperative WBCT-scans were included. Pre- and postoperative measurements of HV deformity, including the intermetatarsal angle(IMA) and hallux valgus angle (HVA) on plain radiographs, and triplanar pronation angle (TAP – a measure of first ray pronation) and sesamoid station from WBCTs, were performed as previously described. The TAP was referenced to the dorsal aspect of the second metatarsal base. Pre- and 1-year postoperative PROMIS scores were reviewed. Sample t-tests were used to compare pre- and postoperative values. The Kruskal-Wallis test assessed statistical differences between postoperative sesamoid station groups regarding postoperative TAP or IMA. Spearman rank (rho) was used to assess correlations between pre- to postoperative change in TAP with PROMIS scores in the physical function (PF), pain interference (PIF), and pain intensity (PI) domains. Scatterplots were simultaneously presented to visualize potential trends between TAP and PROMIS scores. Results: The mean TAP significantly decreased by 8.21º(95%CI -9.62,-6.8) after MIS bunionectomy (p< 0.05). Mean(SD) pre- and postoperative TAP values were 31.57º(8.3) and 23.36º(7.6), respectively. Similarly, mean HVA and IMA values decreased by 21.98º and 11.41º, respectively. Mean preoperative sesamoid station was 1.84, which decreased to 0.95 after surgery. Forty-four patients reduced their sesamoid position by one station. There was a statistically significant difference in TAP between postoperative sesamoid station groups (p=0.038). Mean(SD) postoperative TAP according to sesamoid station was 25.93º(6.2) for group 1, 23.83º(7.9) for group 2, and 18.75º(6.6) for group 3. No significant differences between groups were observed regarding IMA (p=0.25). There was a modest correlation between TAP change and PROMIS PF (rho = 0.046), PIF ( rho = -0.30), and PI (rho = -0.03). Conclusion: Our study suggests that MIS bunionectomy is an effective tool for reducing first-ray pronation in patients with HV. Although there was a statistically significant correlation between first-ray pronation and sesamoid station, our results showed that patients with higher first-ray pronation had less reduced sesamoids. Therefore, these should be considered separate deformities, and the sesamoid station shouldn’t be used as a guide for pronation correction. It appears that correction of the first-ray pronation is poorly associated with 1-year PROMIS scores. Consequently, future studies assessing mid-to-long-term effects of first-ray pronation on clinical outcomes, such as recurrence, are still warranted.

Category: Hindfoot; Ankle Introduction/Purpose: Minimally Invasive Zadek osteotomy (MIS ZO) has been demonstrated to be a safe and effective surgical intervention for patients with Insertional Achilles Tendinopathy (IAT) and Haglund’s deformity. However, there is limited literature to guide surgeons one which patients may be the best candidates for MIS ZO. Severity of IAT on preoperative MRI may correlate with post operative functional outcomes and help guide patient selection for treatment with MIS ZO. The current study evaluated the postoperative outcomes of MIS ZO in patients with various grades of Achilles tendinopathy on preoperative MRI, to determine if severity of disease on preoperative MRI could be predictive of improved functional outcomes after MIS ZO. Methods: Patients who underwent MIS ZO for IAT and Haglund’s deformity were identified and retrospectively analyzed at a mean of 15.59 months follow-up. Achilles pathology was graded as previously described by Nicholson et al. on preoperative MRI. Grade 1 describes anteroposterior diameter of 6-8 mm and nonuniform degeneration; grade 2 describes diameter >8 mm and < 50% uniform tendon degeneration; grade 3 describes tendon diameter >8 mm and uniform degeneration of >50% tendon width. Fourteen patients met our inclusion criteria. Four patients exhibited grade 1 pathology preoperatively, 3 patients exhibited grade 2 pathology preoperatively, and 7 patients exhibited grade 3 pathology preoperatively. Preoperative and postoperative Patient Reported Outcome Measurement Information System (PROMIS) scores, complications, and revisions were recorded for each patient. PROMIS scores were compared using a paired t-test. All other continuous data was compared by Analysis of Variance (ANOVA); all categorical data was compared using Chi-squared analysis. P< 0.05 were considered significant. Results: PROMIS pain score improved postoperatively in patients with grade 1 66.75±5.50 to 59.00±7.75, p=0.036) and grade 3 (69.86±6.17 to 55.71±10.44, p=0.011) Achilles tendinopathy on preoperative MRI. Meanwhile, in patients with grade 2 pathology, PROMIS physical function (38.33±8.50 to 43.67±9.07, p=0.02) improved postoperatively. In the grade three group, 1/7 (14.29%) patients experienced transient neuritis that resolved at 3 months without further treatment and 1/7 (14.29%) patients required revision surgery to an open midline splitting Haglund’s resection. Meanwhile no patients in either the grade one or grade two groups required reoperation, rehospitalization, or complications. 13/14 (93%) patients were very satisfied with their procedure and wound undergo it again. Conclusion: These early data suggest that patients with IAT, regardless of severity, improve after MIS ZO. Therefore, ZO may be a reasonable first line option for all patients presenting with IAT. In our small retrospective study, we were able to demonstrate significant improvement in pain and/or function following ZO in all grades of IAT tendinous pathology on preoperative MRI. This study may help guide surgeons when deciding between MIS ZO and other surgical options for IAT and Haglund’s deformity. Further, large prospective studies are warranted to further investigate outcomes and indications of MIS ZO in patients with IAT and Haglund’s deformity

Category: Hindfoot; Ankle Introduction/Purpose: The Zadek osteotomy (ZO) has been demonstrated to be an effective treatment for patients with Haglund deformity and Insertional Achilles Tendinopathy (IAT). Radiographic measurements are one method of diagnostic criteria that have been utilized to define a more specific patient cohort that is a superior candidate for Zadek intervention. Tourné et al. most recently proposed an X/Y < 2.5 to define candidates that will benefit from the Zadek. However, many clinicians do not consider radiographic measurements to define efficacy of ZO. Additionally, current literature is lacking a direct comparison of ZO efficacy in patients with preoperative X/Y ratios above and below Tourné’s criteria. The current study tested the hypothesis: patients with IAT, regardless of X/Y ratio, would improve in pain and physical function after ZO. Methods: This was a retrospective, multi-center study. Patients underwent ZO at two different institutions, by three different fellowship trained orthopedic foot and ankle surgeons. 48 cases in 46 patients treated with Zadek osteotomy were included in our retrospective analysis. There were 34 cases with preoperative X/Y < 2.5 and 14 cases with preoperative radiographs measuring an X/Y > 2.5. All patients had a minimum of one-year follow-up (mean 23.24±4.82). Pain, function, and mobility PROMIS scores, VAS scores, complications, X/Y ratio measurements, and calcaneal pitch angle measurement were collected preoperatively and at final follow-up appointment. Cases were placed in cohorts based on preoperative X/Y above or below 2.5). T-tests were used to determine statistical differences following ZO. Similarly, chi-squared analysis was used to compare differences in categorical data between our groups. Results: A summary of preoperative and postoperative PROMIS scores, VAS scores, calcaneal pitch measurements, and X/Y ratios can be found in Table 1. Patients with X/Y < 2.5 demonstrated significant improvement in PROMIS pain, function, mobility scores, VAS score, calcaneal pitch angle, and X/Y ratio following ZO intervention (p< 0.05). In comparison, following ZO, patients with X/Y > 2.5 demonstrated significant improvement in PROMIS pain, VAS, and X/Y ratio (p< 0.05). However, in patients with X/Y > 2.5, preoperative VAS scores were higher (p=0.014) and improved to a significantly larger degree (p=0.006). There was one case of minor neuropathy (X/Y > 2.5); there was one patient that required revision to open debridement and repair (X/Y < 2.5). We observed a 98% rate of satisfaction overall following ZO intervention. Conclusion: Zadek osteotomy demonstrated improvement in patients’ pain and excellent patient satisfaction, regardless of their preoperative X/Y ratio on radiograph. However, patients with X/Y ratio < 2.5 did demonstrate significant improvement in patient reported function and mobility scores. Overall, a 98% satisfaction was observed following ZO in all patients. Preoperative X/Y ratio did not seem to determine success of ZO in the treatment of IAT, however, further clinical correlation is needed. to better understand differences if PROMIS physical function and mobility in terms of long-term success of the ZO.

Telehealth has been shown as a tool to improve health access and outcomes in rural areas. There is less literature examining the usability and utility of telehealth by rural and low-income populations. Existing literature focuses on examining telehealth usability for specific telehealth platforms and specific use cases. There is minimal literature broadly examining telehealth usability in rural and low-income populations. Using the Telehealth Usability Questionnaire in conjunction with demographic questions, we examined telehealth usability in the Wyoming Medicaid population. Additionally, we explored whether factors such as rurality, age, gender, and whether the visit was behavioral, affected usability scores. (1) We found that overall, usability scores were high in all cases. (2) Wyoming Medicaid clients with behavioral visits demonstrated statistically significant increased usability scores compared to the already positive scores in patients with nonbehavioral visits. (3) The other variables we examined did not show any statistically significant differences in usability scores. (4) These results demonstrate broad usability of telemedicine in a rural and low-income population and may be used to justify expansion of telehealth services.

IMPORTANCE:. Receipt of fluid and vasopressors, common treatments in septic shock, may affect cardiac function. OBJECTIVES:. We sought to determine whether a liberal or restrictive fluid resuscitation strategy was associated with changes in cardiac function. DESIGN:. We prospectively studied a subset of patients enrolled in the Crystalloid Liberal or Vasopressors Early Resuscitation in Sepsis (CLOVERS) trial, performing echocardiography at baseline and at 24 hours after randomization. Among patients who had an echocardiogram performed at 24 hours, we measured left ventricular global longitudinal strain (LV GLS) and right ventricular free-wall longitudinal strain (RVFWLS). We performed linear regressions with dependent variables of LV GLS, change in LV GLS (ΔLV GLS), and RVFWLS using treatment assignment as an independent variable. We adjusted for ratio of early diastolic mitral inflow velocity to early diastolic mitral annulus velocity, mean arterial pressure, and history of congestive heart failure and myocardial infarction. SETTING:. Emergency department and ICUs. PATIENTS:. Adults with sepsis enrolled in the CLOVERS trial. MAIN OUTCOMES AND MEASURES:. We enrolled 180 patients. Our analytic cohort comprised 131 patients with an echocardiogram performed at 24 hours. We observed no differences between treatment arms with respect to demographic, clinical, or echocardiographic data at baseline. We observed no association between restrictive fluid assignment and LV GLS (coefficient, 1.22; p = 0.23), ΔLV GLS (–1.97; p = 0.27), or RVFWLS (2.33; p = 0.19). CONCLUSIONS AND RELEVANCE:. In a subset of patients enrolled in CLOVERS, we observed no association between receipt of fluid and vasopressors and short-term changes in cardiac function. Decreased enrollment may limit inferences.

Category: Ankle; Hindfoot Introduction/Purpose: Surgical options for Insertional Achilles Tendinopathy (IAT) and Haglund‘s deformity include the open midline Achilles tendon splitting approach with Haglund’s resection and Achilles debridement and repair. However, many have cited high rates of complications with this approach such as wound dehiscence, infections, and persistent postoperative pain. Alternative surgical management of IAT and Haglund’s deformity includes the Zadek osteotomy (ZO). ZO can be accomplished percutaneously, reducing potential wound complications, pain, and infections. The current study compared outcomes and complications of the open midline Achilles tendon splitting approach with the percutaneous ZO in patients with IAT and Haglund’s deformity. We hypothesized that the percutaneous ZO would allow for improvement in patient reported outcomes, yet less complications in comparison to the traditional, open midline Achilles tendon splitting approach. Methods: Patients who received an open midline Achilles tendon splitting procedure or percutaneous ZO for IAT and Haglund’s deformity were identified and retrospectively analyzed at a minimum of one-year follow-up. 21 patients treated with percutaneous ZO and 45 patients treated with open midline Achilles tendon splitting procedure for IAT and Haglund’s deformity met our inclusion criteria. Patients had average follow up of 23.65±6.87 months. Preoperative Patient Reported Outcome Measurement Information System (PROMIS) scores, postoperative PROMIS scores, complications, and revisions were recorded for each patient. Preoperative and postoperative PROMIS scores were compared using a paired t-test. All other continuous data was compared by t-test; all categorical data was compared using Chi-squared analysis. All p< 0.05 were considered significant. Results: In patients who underwent percutaneous ZO or an open midline Achilles tendon splitting Haglund’s resection, PROMIS function (p< 0.01), pain (p< 0.01), and mobility (p< 0.01) scores improved at 12-month minimum follow-up. In the ZO group, 1/21 (4.6%) patients experienced nerve injury and 1/21 (4.6%) patients required revision surgery to an open midline splitting Haglund’s resection. Meanwhile, 3/45 (6.67%) patients who underwent an open midline Achilles tendon splitting procedure experienced significant postoperative pain, 3/45 (6.67%) wound dehiscence, 3/45 (6.67%) wound infection, and 1/45 (2.22%) nerve injury. 4/45 (8.89%) patients who underwent the open midline Achilles tendon splitting approach required revision. Additionally, 1/45 required hardware removal and 1/45 required incision and debridement. All cause complication were found to be higher in the open midline Achilles tendon splitting approach (p=0.02). Conclusion: There are several surgical treatment options for IAT and Haglund‘s deformity, yet IAT remains a challenging lower extremity disorder to treat. In the current study, both the open, midline Achilles tendon splitting Haglund’s resection and percutaneous ZO led to significant improvement in patient reported outcomes. However, our study demonstrated a significant lower complication and revision in the ZO group. Data presented in this study may guide surgeons’ decision making when choosing suitable treatment options for patients with IAT and Haglund deformity.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Third-generation minimally invasive (MIS) bunionectomy requires a lateral shift of the metatarsal head, pushing the shaft into adduction and levering off the 1st-tarsometatarsal (TMT) joint. A previous study on plain radiographs reported postoperative 1st-TMT joint slippage in the transverse plane, with a medial subluxation of the 1st metatarsal base. However, risk factors and clinical implications have yet to be determined. This study sought to assess the prevalence of postoperative 1st-TMT joint slippage in the transverse plane and to identify associated risk factors using weight-bearing CT (WBCT) scans. In addition, the effect of 1st-TMT slippage on postoperative midshaft foot width was investigated. We hypothesized that postoperative 1st-TMT slippage in the transverse plane would be associated with preoperative 1st-TMT instability and increased postoperative midshaft foot width. Methods: Sixty-three consecutive patients who underwent MIS bunionectomy with available pre- and postoperative WBCT-scans were included. Radiographic measurements included hallux valgus angle(HVA), intermetatarsal angle(IMA), and midshaft foot width, measured from the 1st metatarsal shaft to the 5th metatarsal head on AP-foot radiographs. Tri-planar rotation angle(TAP), and 1st-TMT plantar-gap and medial-middle(MM) intercuneiform distances(mm) were obtained from WBCTs. Two raters measured pre- and postoperative 1st-TMT distances between the most lateral aspect of the medial cuneiform and 1st metatarsal base at the dorsal, central, and plantar thirds on axial cuts. The average corresponds to the overall 1st-TMT lateral distance, a measure of 1st-TMT slippage. Rater agreement was assessed. Paired t-tests were used to compare pre- and postoperative values. Logistic regression models were used to investigate the association of postoperative 1st-TMT lateral distance with potential risk factors (preoperative 1st-TMT lateral distance, 1st-TMT plantar-gap distance, IMA, TAP, and MM intercuneiform distance) and postoperative midshaft foot width. Results: The interobserver reliability of the 1st-TMT lateral distance was excellent (r=0.97). Mean (SD) 1st-TMT lateral distance increased from 0.26 mm(0.4) to 1.33 mm(0.9) after surgery(P< 0.05). Postoperative 1st-TMT lateral distance was > 2 mm in 15 patients(24%), and > 1 mm in 33(52%). Mean(SD) dorsal 1st-TMT lateral distance (2.7mm[1.3]) was significantly higher than central (0.85mm[1.1]) and plantar (0.55mm[0.99]) 1st-TMT lateral distances. Mean(SD) midshaft foot width increased from 80.04mm(6.7) to 84.25mm(6.1) postoperatively (P< 0.05). Regression analysis showed that pre- and postoperative 1st-TMT lateral distances were correlated (Coef=0.64,P=0.02), and identified a 1 mm increase in postoperative 1st-TMT lateral distance with each 0.63 mm increase in preoperative 1st-TMT plantar-gap distance (Coef=0.63,P=0.008). A significant positive correlation was also observed between postoperative 1st-TMT lateral distance and postoperative midshaft foot width (Coef=1.43,P< 0.05). Conclusion: Our study suggests a possible association between postoperative 1st-TMT joint slippage and preoperative 1st-TMT multiaxial instability following MIS bunionectomy. This raises an important question as to whether alternative techniques, such as modified Lapidus, should be preferred over MIS bunionectomy in patients with 1st-TMT instability. Notably, medial slippage was significantly higher at the dorsal aspect of the 1st-TMT joint, suggesting a component of rotational instability. It appears that 1st-TMT slippage is associated with a wider midshaft foot width postoperatively, and patients should be warned about it. Future studies assessing mid-to-long-term effects of 1st-TMT slippage, like recurrence or degenerative changes, are warranted.

ABSTRACT: Background: Traumatic thoracolumbar fracture fixation without neurological injury can be performed using the traditional open, mini-open Wiltse, and percutaneous approaches. This systematic review and meta-analysis aims to compare perioperative outcomes between these approaches. Methods: PubMed, Web of Science, Scopus, Embase, and the Cochrane Library were searched for all relevant observational comparative studies. Results: 5 randomized trials and 22 comparative cohort studies were included. Compared to the traditional open approach (n=959), the Wiltse approach (n=410) was associated with significantly lower operative time, intraoperative estimated blood loss (EBL), and length of stay (LOS). There was no significant difference between the two in terms of postoperative visual analog scale (VAS) and Cobb angle. Compared to the percutaneous approach (n=980), the Wiltse approach was associated with shorter operative and fluoroscopy time, as well as significantly improved Cobb and vertebral body angles. The percutaneous approach was associated with improved vertebral body height. There was no significant difference between the two for blood loss, postoperative VAS, or LOS. Compared to the traditional open approach, the percutaneous approach was associated with shorter operative time, lower EBL, shorter LOS and better postoperative VAS and Oswestry Disability Index. There was no difference between the two in postoperative Cobb angle, vertebral angle, or vertebral body height. Overall study heterogeneity was high. Conclusions: Utilization of minimally invasive surgical approaches holds great promise for lowering patient morbidity and optimizing care. A prospective trial is needed to assess outcomes and guide surgical decision making.

Background: Anti-Program-Death-1 (PD-1) is a standard adjuvant therapy for patients with resected melanoma. We hypothesized that there are discrepancies in survival, recurrence pattern and toxicity to adjuvant PD-1 between different ethnicities and melanoma subtypes. Objective: We performed a multicenter cohort study incorporating 6 independent institutions in Australia, China, Japan, and the United States. The primary outcomes were recurrence free survival (RFS) and overall survival (OS). Secondary outcomes were disease recurrence patterns and toxicities. Results: In total 534 patients were included. East-Asian/Hispanic/African reported significantly poorer RFS/OS. Nonacral cutaneous or melanoma of unknown primary reported the best RFS/OS, followed by acral, and mucosal was the poorest. Within the nonacral cutaneous or melanoma of unknown primary subtypes, East-Asian/Hispanic/African reported significantly poorer RFS/OS than Caucasian. In the multivariate analysis incorporating ethnicity/melanoma-subtype/age/sex/stage/lactate dehydrogenase/BRAF (v-Raf murine sarcoma viral oncogene homolog B)-mutation/adjuvant radiotherapy, East-Asian/Hispanic/African had independently significantly poorer outcomes (RFS: HR, 1.71; 95% CI, 1.19-2.44 and OS: HR, 2.34; 95% CI, 1.39-3.95), as was mucosal subtype (RFS: HR, 3.25; 95% CI, 2.04-5.17 and OS: HR, 3.20; 95% CI, 1.68-6.08). Mucosal melanoma was an independent risk factor for distant metastasis, especially liver metastasis. East-Asian/Hispanic/African had significantly lower incidence of gastrointestinal/musculoskeletal/respiratory/other-rare-type-toxicities; but higher incidences of liver toxicities. Limitations: A retrospective study. Conclusions: Ethnicity and melanoma subtype are associated with survival and recurrence pattern in melanoma patients treated with adjuvant anti-PD-1. Toxicity profile differs by ethnicity and may require a precision toxicity surveillance strategy.

Background: Lung nodule incidence is increasing. Many nodules require biopsy to discriminate between benign and malignant causes. The gold standard for minimally invasive biopsy, CT scan-guided transthoracic needle biopsy (CT-TTNB), has not been compared directly with navigational bronchoscopy, a method that recently has seen rapid technological innovation and is associated with improving diagnostic yield and lower complication rates. Current estimates of the diagnostic usefulness of both methods are based largely on noncomparative data with significant risk for selection, referral, and publication biases. Research Question: Is contemporary navigational bronchoscopy noninferior to CT scan-guided transthoracic needle biopsy for the diagnosis of indeterminate pulmonary nodules? Study Design and Methods: Navigation Endoscopy to Reach Indeterminate Lung Nodules vs Transthoracic Needle Aspiration, a Randomized Controlled Study, is a multicenter, 1:1 randomized, parallel-group trial designed to ascertain whether electromagnetic navigational bronchoscopy with integrated digital tomosynthesis is noninferior to CT-TTNB for the diagnosis of peripheral lung nodules 10 to 30 mm in diameter with before testing probability of malignancy of at least 10%. The primary end point is diagnostic accuracy through 12 months of follow-up. Secondary end points include diagnostic yield, complication rate, procedure duration, need for additional invasive diagnostic procedures, and radiation exposure. Results: This article describes the protocol and rationale for the Navigation Endoscopy to Reach Indeterminate Lung Nodules vs Transthoracic Needle Aspiration, a Randomized Controlled Study, designed to answer the study question. Interpretation: The results of this rigorously designed trial will provide high-quality data regarding the management of lung nodules, a common clinical entity that often represents the earliest and most treatable stage of lung cancer. Several design challenges are described. Notably, all nodules are reviewed centrally by an independent interventional pulmonology and radiology adjudication panel relying on prespecified exclusions to ensure enrolled nodules are amenable to sampling by both methods while protecting against selection bias favoring either method. Conservative diagnostic yield and accuracy definitions with prespecified criteria for what nonmalignant findings may be considered diagnostic were chosen to avoid inflation of estimates of diagnostic usefulness. Trial Registry: ClinicalTrials.gov; No.: NCT04250194; URL: www.clinicaltrials.gov

Background: Both an open cheilectomy with a Moberg osteotomy and percutaneous cheilectomy have been successfully used to treat hallux rigidus and preserve motion. However, there have been no studies that have compared these 2 procedures using validated patient-reported outcomes such as the Patient Reported Outcome Measurement Information System. Methods: A retrospective review of hallux rigidus patients between January 2016 and July 2021 collected 48 percutaneous cheilectomy (PC) patients and 71 open cheilectomy with Moberg (OCM) patients. Preoperative and minimum 1-year postoperative PROMIS scores were collected. Results: The OCM and PC cohorts did not have significant differences in their postoperative PROMIS scores. Both cohorts had modest but significant improvements postoperatively in the physical function, pain interference, and pain intensity domains. The OCM group had a larger degree of improvement in physical function, pain interference, and pain intensity ( P = .015, .011, .001, respectively). No significant difference was identified in the reoperation rate. Conclusion: Patients undergoing an OCM had worse preoperative PROMIS scores and a modestly greater change in patient-reported outcomes than patients undergoing a PC. Level of Evidence: Level III, retrospective review.

Background. Heart transplantation is always an emergency because the transplant needs to occur within 6 h after procurement to prevent primary graft dysfunction. Static cold storage (SCS) is the gold-standard preservation method. This study describes the outcomes of hearts preserved after prolonged SCS (12 and 24 h); those are then resuscitated with a novel normothermic ex situ heart perfusion (NEHP) system. Methods. Anesthetized piglets (n = 10) were used as heart donors. Hearts were procured and stored at 5 °C CoStorSol following standard SCS protocols. Two groups were studied: SCS-12 h and SCS-24 h. After SCS, 8 h of NEHP (37 °C blood-based perfusate) was performed at 0.7–1.0 mL/min/g of cardiac tissue. NEHP parameters were monitored continuously. Results were corroborated with 3 additional hearts transplanted orthotopically in healthy recipients (n = 3) after SCS (24 h) + NEHP (5 h). Recipients were observed for 90 min after weaning off cardiopulmonary bypass support. Results. All hearts (after 12 and 24 h of SCS) regained normal function and metabolism within 10 min and retained it throughout 8 h of NEHP. No differences were observed in NEHP parameters and histopathology between groups. Three hearts were successfully transplanted after a total ~30 h of preservation (24 h of SCS + 5 h of NEHP + 1 h of second cold ischemia time). The 3 recipients were weaned off cardiopulmonary bypass with mild vasopressor support. Conclusions. NEHP has the potential to routinely resuscitate porcine hearts that have undergone SCS for up to 24 h, restoring them to viable function. By objectively assessing heart function before transplant, NEHP may enhance the success rate of transplants. If these resuscitated hearts can be successfully transplanted, it would support the effectiveness of NEHP in ensuring heart viability.

Tenosynovial giant cell tumor (TGCT) occurs in both diffuse and localized forms. While diffuse TGCT is an uncommon but well-described complication after total knee arthroplasty (TKA), localized TGCT has only once been previously described as a postoperative complication after TKA. We report on the diagnosis and management of a patient who developed postoperative localized TGCT after routine TKA and underwent uncomplicated removal. Postoperatively the patient noted a resolution of pain and mechanical symptoms. Early consideration of this rare occurrence after TKA can prevent significant pain and disability due to delayed diagnosis.

Background: Hallux valgus deformity affects more than 35% of people aged ≥65 years. Surgical correction in this population can be more complicated because of poor bone quality, worse deformity, and postoperative recovery challenges. The purpose of this study was to compare the radiographic and clinical outcomes of patients aged ≥65 years who underwent either open Lapidus or minimally invasive chevron Akin osteotomy for bunion correction. Methods: A retrospective review identified 62 patients aged ≥65 years who were treated surgically for hallux valgus with at least 1-year postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores (physical function and pain interference). Preoperative and at least 6-month postoperative radiographs were measured for the hallux valgus angle and intermetatarsal angle. PROMIS scores were obtained preoperatively and at 1 and/or 2 years postoperatively. Differences in demographic, clinical, and radiographic outcomes were assessed using the Mann Whitney U test and P values were adjusted for a false discovery rate of 5%. Results: There was no difference between the MIS and open cohorts in pre- or postoperative radiographic measurements or clinical outcomes at any time point. At 1 year postoperatively, both groups had statistically significant improvements in the PROMIS pain interference domain but only the MIS group had a statistically significant improvement in the PROMIS physical function domain. Clinical significance was equivocal. At 2 years postoperatively, there were clinically and statistically significant improvements in the PROMIS pain interference and physical function domains for the open and MIS groups. Conclusion: Patients in both surgical groups had improvement in radiographic measurements and 2-year PROMIS scores, although there was no clinical or statistical difference found between groups. MIS and open surgical techniques appear to be safe and effective in correcting hallux valgus in older patients; however, patients may need to be counseled that maximum improvement after surgery may take more than 1 year. Level of Evidence: Level III, retrospective cohort study.

Background: Majocchi's granuloma (MG) is an uncommon deep fungal folliculitis predominantly caused by dermatophytes. Given the rarity of this condition, available data regarding predisposing comorbidities/risk factors, clinical characteristics, offending microbiologic pathogens, diagnostics, pathologic findings, and treatment approaches has been inferred from historical cases. Objectives: To review our institutional experience with MG. Methods: We retrospectively analyzed a multicenter cohort of adult patients diagnosed with MG between 1992 and 2022. Results: We analyzed 147 patients with MG, 105 of which were male with a median age of 55.6 years. Immunosuppressant and topical corticosteroid use were common prior to development of MG. Dermatologic lesions and their sites of involvement did not differ based on the immune status of patients. Trichophyton rubrum was the most common causative pathogen of MG, in addition to other dermatophytes. Treatment duration for all prescribed agents was median 31.5 days with oral terbinafine being the most frequently utilized agent. Clinical resolution was achieved in 96.6% of cases. Limitations: Retrospective, nonrandomized study. Conclusions: Although rare and clinically variable in presentation, diagnosis of MG often requires histopathologic confirmation to subsequently direct prolonged treatment with systemic antifungal therapy for mycological cure.

Background: The Single-Incision Power Optimizing Cost-Effective Repair (SPOC) method reattaches the distal biceps tendon to its original posterior anatomic footprint and utilizes the anterior cortex of the supinated radius for fixation. The purpose of the study was to define the long-term complications and durability of the SPOC method. Methods: Two hundred and eighteen patients underwent the SPOC repair of distal biceps ruptures from 2008 to 2020, with 185 having at least 1-year follow-up data. The average follow-up was 50.1 months. Information regarding smoking, body mass index, interval between injury and surgery, peripheral nerve injury, heterotopic ossification, vascular injury, re-rupture, chronic regional pain syndrome, fracture of the radius, loss of motion, pain with use, and deformity were acquired. Results: No complication occurred beyond the third postoperative month. No patient complained of severe lateral antebrachial cutaneous nerve-related symptoms. Major complications exclusive of re-rupture occurred include 1 case of heterotopic ossification and 1 deep infection. Major complications with re-ruptures occurred in 9 patients (4.8%). Seven of the re-ruptures (78%) were associated with an unexpected forceful contraction within the first 4 weeks postop. All complications aside from 1 minor complication occurred in the chronic group. Long term follow-up revealed no re-ruptures and high satisfaction rate with return of strength, motion, and biceps profile. Conclusion: The safety profile of the SPOC repair is consistent with those of other published repairs. Major complications were associated with prolonged intervals between injury and reconstruction. Re-ruptures were associated with worker’s compensation status and patient noncompliance with postoperative protocols.

Chronic low back pain (CLBP) is a debilitating, painful, and costly condition. Implantable neuromuscular electrical stimulation targeting the multifidus musculature is growing as a non-pharmacologic option for patients with recalcitrant nociceptive mechanical CLBP who have failed conservative treatments (including medications and physical therapy) and for whom surgery is not indicated. Properly selecting patients who meet specific criteria (based on historical results from randomized controlled trials), who diligently adhere to implant usage and precisely implement neuromuscular rehabilitation, improve success of significant functional recovery, as well as pain medication reductions. Patients with nociceptive mechanical CLBP who underwent implanted multifidus neurostimulation have been treated by physicians and rehabilitation specialists who have honed their experience working with multifidus neurostimulation. They have collaborated on consensus and evidence-driven guidelines to improve quality outcomes and to assist providers when encountering patients with this device. Physicians and physical therapists together provide precision patient-centric medical management with quality neuromuscular rehabilitation to encourage patients to be experts of both their implants and quality spine motion to help override long-standing multifidus dysfunction related to their CLBP.

Immune checkpoint inhibitors have become essential antineoplastic agents in medical oncology over the past decade. However, they are associated with potentially fatal multisystem abnormalities, with increasing concern in gastrointestinal tract and its associated organs. We present a patient with advanced renal cell carcinoma, who presented with acute liver failure after the first dose of combined immunotherapy with nivolumab and ipilimumab. A thorough evaluation for viral, metabolic, and autoimmune causes was unremarkable. He was managed with steroids and made significant improvement. To our knowledge, this is the first documented case of acute liver failure following ipilimumab and nivolumab.

Background:. Due to variations in perforator vasculature, deep inferior epigastric artery perforator (DIEP) flap preoperative imaging can minimize operative time required to locate the most suitable perforators. Dedicated computed tomography angiography (CTA) has been the gold standard; however, many patients have already undergone a staging computed tomography (CT) per oncologic workup. The benefits from CTA may also be realized with a staging CT or CT with IV contrast. Methods:. Ten patients who underwent DIEP flap reconstruction with staging CT and CTA within 3 years of one another were included in this study. Reviewers evaluated axial views of both imaging modalities separately to identify each visible perforator in reference to the pubic symphysis from the xiphoid to the pubic symphysis. An intraclass correlation coefficient (ICC) was used to determine agreement in location of perforators between the two imaging studies. Statistical analysis was performed using an ICC and Wilcoxon signed rank-tests. Results:. The identified perforators within the patient cohort had an excellent correlation between their location on CT and CTA based upon ICC. The mean number of perforators identified in the CT group was 15.3 (SD 4.9) and in the CTA group was 18.8 (SD 6.4), which was not statistically different (P = 0.247). Conclusions:. CT has similar efficacy in identifying number of perforators and perforator location to dedicated CTA for preoperative planning in DIEP flaps. This has the potential for decreased patient contrast and ionizing radiation exposure as well as improved patient and healthcare resource utilization.

Background: Percutaneous Zadek osteotomy (ZO) has emerged as a surgical treatment of insertional Achilles tendinopathy (IAT) over the last decade. Existing literature is limited regarding the comparison of this approach with the more established, open ZO technique. This systematic review aims to evaluate and compare the current data on open vs percutaneous ZO approaches to help set evidence-based guidelines. Methods: A systematic literature search was performed using the keywords (Zadek osteotomy) OR (Keck and Kelly osteotomy) OR (dorsal closing wedge calcaneal osteotomy) OR (Haglund Deformity) OR (Haglund Syndrome) OR (Insertional Achilles Tendinopathy) and MeSH terms Osteotomy , Calcaneus , Syndrome , Insertional , Achilles tendon , and Tendinopathy . Our search included the following databases: PubMed, Embase, and the Cochrane Library. The PRISMA protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2009 to 2024 and included the use of open or percutaneous approaches of ZO for the treatment of IAT with at least a 12-month follow-up. The MINORS score criteria were used to evaluate the strength and quality of studies. Results: A total of 17 studies were reviewed, including 611 subjects and 625 ZO procedures. Of these procedures, 81 (11%) subjects had a percutaneous and 544 (89%) subjects had an open ZO. The mean follow-up time was 16.1 months for patients treated with percutaneous ZO and 36.1 months for patients treated with open ZO. Both open and percutaneous studies included in this review showed postoperative improvements in AOFAS, FFI, VISA-A, and VAS scores in patients with IAT. The reported complication rate was 5.8% among patients treated with percutaneous ZO and 10.2% among patients treated with open ZO. Conclusion: Percutaneous ZO is an emerging approach with substantially fewer documented cases compared with the open ZO. Both percutaneous and open ZO appear to be relatively effective treatments for insertional Achilles tendinopathy with Haglund’s deformity. The lower complication rates reported for percutaneous ZO is encouraging. Further investigation with more subjects undergoing percutaneous ZO is clearly needed.

Introduction/Purpose: Insertional Achilles tendinopathy (IAT) is a common source of posterior heel pain treated by orthopaedic foot and ankle surgeons. Traditional surgical treatment consists of an open Achilles tendon debridement with re-attachment as well as excision of the posterosuperior calcaneal prominence with or without a gastrocnemius recession. However, frequent complications include wound healing issue, scar pain, weakness and sural nerve injury. Accordingly, the percutaneous ZO is gaining popularity in the field as an alternative to an open midline splitting approach. Limited literature exists describing outcomes of the percutaneous ZO using a larger sample size. The purpose of this study was to analyze patient reported outcomes and complications after percutaneous ZO with a minimum two-year follow-up period. Methods: One hundred and eight cases treated with percutaneous ZO were retrospectively reviewed across October 2017-July 2021 and outcomes data was available for 104 cases with a minimum two-year follow-up. Patient sex, age, and pertinent comorbidities were recorded. Postoperative complications and patient satisfaction following intervention were evaluated. Foot Function Index score (FFI) was utilized to measure patients’ pain and functional outcomes. Visual Analyzing Scale score (VAS) was also utilized to evaluate pain. These measurements were taken at preoperative and final follow-up. Statistical comparisons were performed using two-tailed, paired t-test with p< 0.05. Results: Mean follow-up time was 41.2±13.1 months (range 24-65 months). The mean FFI score improved from 56.1±5.9 (range 47-88) preoperatively to 11.0±5.1 (range 7-59) postoperatively (p < 0.001). Average VAS score improved in patients receiving percutaneous ZO from 7.6±1.3 (range 5-10) to 0.4±0.9 (range 0-7) postoperatively (p < 0.001). The overall complication rate was 3.8% (N =4). Of 104 cases, 98.1% of patients were satisfied with their procedure (102/104). Conclusion: The percutaneous ZO is a safe and highly effective intervention for treatment of IAT. At a minimum of two-years follow-up, this intervention is associated with minimal complications, improved functional outcomes, reduced pain, and high patient satisfaction. Table 1 Functional and subjective pain preoperative and postoperative scores as evaluated by functional foot index (FFI) and visual analogue scale (VAS), respectively

Introduction:. Orthopaedic applicants have increased the average number of publications on their residency application to compete with the growing competitiveness of the field. The purpose of this study was to assess whether research productivity before orthopaedic residency and caliber of one's institution is correlated with academic productivity during residency. Methods:. Scopus was used to extract publication metrics. Quantity and quality (how often the publications were cited) were analyzed at 2 different time periods: before and during residency. All subjects in the study had graduated an ACGME-accredited orthopaedic surgery residency in 2021. Military residents, international medical graduates, and residents not listed on their department's website were excluded. Residents were categorized as both high (≥2 publications) or low (

Summary:. Accessibility of microsurgical equipment is a major barrier to proper training of surgeons before live patient free flap surgery. A technique is presented that uses a smartphone camera as the microscopic field, eliminating the need for an expensive operative microscope for surgical practice. A convenient and cost-effective simulation protocol could reduce the time frame of the microsurgery learning curve. Furthermore, the use of the smartphone video function may allow improved feedback by mentors, improving access and communication between microsurgical teachers and learners. The PocketSuture smartphone stand is a commercially available device that allows the smartphone camera to be used as magnification. The proposed education protocol included suture practice, vessel dissection, and free tissue transfer in nonliving animal models, with vessel anastomosis and patency confirmation performed with a smartphone camera for field magnification. Video of the suturing technique allowed feedback from the mentor. A progressive suturing protocol leading to the ability to perform microsurgical anastomosis on nonliving animal models was developed. The basic costs for the stand, instrument set and suture were less than $500. The PocketSuture smartphone stand can be used for microsurgical training with real-time video for plastic surgery learners with limited access to microscopes and local mentors.

Revision surgery is paramount to cure chronic prosthetic joint infections because these infections are associated with biofilms on prosthetics that conventional antibiotics cannot eradicate. However, there is a paucity of research on where in vivo biofilms are located on infected prosthetics. Consequently, the objective of this pilot study was to address this gap in knowledge by staining 5 chronically infected prosthetics, that were removed at the time of revision surgery, with methylene blue. Scanning electron microscopic images were then taken of the methylene blue–stained areas to visualize biofilms. The findings show that all chronically infected prosthetics had biofilms located on the bone–prosthetic interface, yet only 2 had biofilms also located on the prosthetic interface exposed to synovial fluid. Subsequently, this pilot study provides a pathophysiological understanding of why the current treatment paradigm for chronic periprosthetic joint infection requires a revision surgery and not debridement and an implant retention surgery.

Purpose: To develop a machine learning tool capable of differentiating eyes of subjects with normal cognition from those with mild cognitive impairment (MCI) using OCT and OCT angiography (OCTA). Design: Evaluation of a diagnostic technology. Participants: Subjects with normal cognition were compared to subjects with MCI. Methods: A multimodal convolutional neural network (CNN) was built to predict likelihood of MCI from ganglion cell-inner plexiform layer (GC-IPL) thickness maps, OCTA images, and quantitative data including patient characteristics. Main Outcome Measures: Area under the receiver operating characteristic curve (AUC) and summaries of the confusion matrix (sensitivity and specificity) were used as performance metrics for the prediction outputs of the CNN. Results: Images from 236 eyes of 129 cognitively normal subjects and 154 eyes of 80 MCI subjects were used for training, validating, and testing the CNN. When applied to the independent test set using inputs including GC-IPL thickness maps, OCTA images, and quantitative OCT and OCTA data, the AUC value for the CNN was 0.809 (95% confidence interval [CI]: 0.681–0.937). This model achieved a sensitivity of 79% and specificity of 83%. The AUC value for GC-IPL thickness maps alone was 0.681 (95% CI: 0.529–0.832), for OCTA images alone was 0.625 (95% CI: 0.466–0.784) and for both GC-IPL maps and OCTA images was 0.693 (95% CI: 0.543–0.843). Models using quantitative data alone were also tested, with a model using quantitative data derived from images, 0.960 (95% CI: 0.902–1.00), outperforming a model using demographic data alone, 0.580 (95% CI: 0.417–0.742). Conclusions: This novel CNN was able to identify an MCI diagnosis using an independent test set comprised of OCT and OCTA images and quantitative data. The GC-IPL thickness maps provided more useful decision support than the OCTA images. The addition of quantitative data inputs also provided significant decision support to the CNN to identify individuals with MCI. Quantitative imaging metrics provided superior decision support than demographic data. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

We present details on the observing strategy, data-processing techniques, and spectroscopic targeting algorithms for the first three years of operation for the Dark Energy Survey Supernova Program (DES-SN). This five-year program using the Dark Energy Camera mounted on the 4 m Blanco telescope in Chile was designed to discover and follow supernovae (SNe) Ia over a wide redshift range (0.05 < z < 1.2) to measure the equation-of-state parameter of dark energy. We describe the SN program in full: Strategy, observations, data reduction, spectroscopic follow-up observations, and classification. From three seasons of data, we have discovered 12,015 likely SNe, 308 of which have been spectroscopically confirmed, including 251 SNe Ia over a redshift range of 0.017 < z < 0.85. We determine the effective spectroscopic selection function for our sample and use it to investigate the redshiftdependent bias on the distance moduli of SNe Ia we have classified. The data presented here are used for the first cosmology analysis by DES-SN ("DES-SN3YR"), the results of which are given in Dark Energy Survey Collaboration et al. The 489 spectra that are used to define the DES-SN3YR sample are publicly available at https://des.ncsa.illinois.edu/releases/sn.

Objective: To describe the clinical and radiographic findings in a large cohort of patients with positive cultures for Nocardia emphasizing the differences between invasive disease and colonization. Patients and Methods: We conducted a single-center, retrospective cohort study of 133 patients with a positive Nocardia isolate between August 1, 1998, and November 30, 2018, and a computed tomography (CT) of the chest within 30 days before or after the bacteria isolation date. Results: Patients with colonization were older (71 vs 65 years; P=.004), frequently with chronic obstructive pulmonary disease (56.8% vs 16.9%; P

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Minimally invasive surgery (MIS) Chevron-osteotomy for HV treatment offers a surgical alternative to open surgery with minimal surgical dissection and a hypothetical decreased risk for soft-tissue complications. During this procedure, there is a concern regarding the injury to the blood supply of the 1st-metatarsal-head. The objective of this study was to assess the incidence of injuries: (1) to the soft-tissue envelope around the first metatarsal head complex and, (2) to the blood supply of the first metatarsal head and also by using Micro-CT, (3) looking for safe zones close to the first metatarsal head to perform MIS Chevron osteotomy. We hypothesized that the MIS Chevron-type osteotomy procedure would preserve the soft-tissue envelope of the first-metatarsal-head complex and the blood supply of the 1st-metatarsal-head. Methods: Sixteen HV deformity cadaveric specimens were used to perform MIS Chevron-type osteotomy of the first metatarsal head. Anatomical dissection of all specimens was then performed to assess macroscopic injury to the first metatarsal head complex soft-tissue structures, including Extensor Hallucis Longus (EHL) tendon, Extensor Hallucis Brevis (EHB) tendon, Flexor Hallucis Longus (FHL) tendon, Flexor Hallucis Brevis (FHB) tendon, Abductor Hallucis tendon, Adductor Hallucis tendon, Sesamoid complex, Dorsolateral and Dorsomedial digital branches of the first toe and the Dorsomedial digital branch to the second. Macroscopic injuries were classified using a calibrated digital caliper. Any chondral damage to the first metatarsal head was quantified in mm². To assess the amount of first metatarsal head blood supply, specimens were perfused with 200 ml of a low viscosity radiopaque polymer, MV 117 (Flowtech), preoperatively, followed by Micro-CT assessment. Descriptive statistics and percentages were utilized for categorical data. Results: We did not find injuries in the EHL, EHB, FHL, Abductor-Hallucis, and Adductor-Hallucis tendons. We found a 2mm injury in the FHB tendon in one specimen. No injuries were found in the Dorsomedial and Dorsolateral nerves of the first-toe, the Dorsomedial-nerve of the second-toe, and Medial branch of the dorsomedial-nerve of the first-toe. In 3 cases, we found an injury on first-metatarsal-head (1mm) due to the passage of the K-wire and, in 1 case, due to the inadvertent passage of the drill (4.41mm). Macroscopically and using Micro-CT, we did not observe injuries in the First-Dorsal-Metatarsal-Artery (FDMA), Lateral-Dorsal-Branch of FDMA, and Plantar-Metatarsal-Artery. Micro-CT helped estimate a safe distance to finish the proximal exit of Chevron-osteotomy (25mm from the most distal point of the first metatarsal head). Conclusion: In this study, the minimally invasive Chevron osteotomy for treating HV seems to be a technically safe procedure, presenting a low rate of iatrogenic injuries with a low degree of severity. In addition, using Micro-CT promoted a better visualization of the microvasculature that nourishes the first metatarsal head. We observed that a proximal distance of 25 mm from the most distal part of the first metatarsal head could be a safe place to finalize the Chevron osteotomy, minimizing the risk of injury to the blood supply of the first metatarsal head.

Category: Midfoot/Forefoot; Other Introduction/ Purpose: Cheilectomy of the first metatarsophalangeal joint (MTP) is employed as an early treatment option to alleviate pain and restore some motion in patients with hallux rigidus. A dorsal closing wedge osteotomy of the proximal phalanx (Moberg) is often added to the cheilectomy to theoretically increase functional range of motion of the MTP joint. While cheilectomy with Moberg (OCM) has traditionally been performed through an open dorsal incision exposing the entire joint, percutaneous cheilectomy (PC) has become increasingly popular due to smaller incisions, minimal pain, and quicker recovery; however, few studies have compared the PC to commonly practiced open techniques to determine if the PC could deliver similar outcomes. Therefore, we aimed to compare the patient reported outcomes of PC to open cheilectomy with Moberg osteotomy. Methods: This retrospective cohort study included 119 patients who underwent PC or OCM for a diagnosis of hallux rigidus. Patients were included if they were over 18 years old and had preoperative and minimum 1-year postoperative PROMIS scores. Patients were excluded if they had prior cheilectomy or any concomitant procedures on the ipsilateral forefoot. Patients were divided into two groups based on their procedures. Forty-eight patients were classified into the “percutaneous cheilectomy” group (mean age: 60 years) while 71 patients belonged to the “open cheilectomy with Moberg” group (mean age 54.2 years). Preoperative, minimum 1-year postoperative, and preoperative to postoperative change in PROMIS physical function, pain interference, pain intensity, global physical health, global mental health, and depression domains were analyzed between groups. Complications were also noted and compared. Results: Preoperatively, the OCM group demonstrated worse physical function, pain interference, pain intensity, and global physical health compared to the PC group. There were no significant differences in mental health-related domains. Postoperatively, there were no significant differences in any PROMIS domain between groups (Table 1). Length of follow-up was 20.3 months in the PC group and 13.8 months for the OCM group (p

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Pes planus is believed to play a role in hallux valgus (HV) development and recurrence. While symptomatic flatfoot can be treated with a dedicated reconstruction at the time of HV correction, addressing the asymptomatic flatfoot remains unclear. Theoretically, stabilizing the medical column while correcting HV could decrease the likelihood of flatfoot progression, however these procedures are invasive, technically difficult, and require prolonged recovery. Minimally invasive techniques are becoming increasingly popular due to immediate weight bearing, less pain, and quicker recovery; however, their role for treating HV with asymptomatic flatfoot is unknown. Therefore, we aimed to investigate whether the outcomes of the minimally invasive chevron and Akin bunionectomy (MISB) are influenced by the presence of asymptomatic flatfoot. Methods: This retrospective cohort study included 62 patients treated by 2 fellowship-trained surgeons who have been performing MIS bunionectomy for at least 3 years. Patients were included if they were over 18 years old, underwent a MISB procedure to correct a hallux valgus deformity, had minimum 1-year postoperative PROMIS scores, and preoperative and minimum 6-months postoperative radiographs. Patients were excluded if they had any prior procedures on the ipsilateral forefoot. Twenty-five asymptomatic patients (mean age: 55 years) met the radiographic criteria for flatfoot (Meary’s angle > 4 degrees, calcaneal pitch (CP) < 18 degrees, and talonavicular coverage angle (TNCA) > 7 degrees) while 37 had a normal arch (mean age: 56.4 years). Clinical outcomes were evaluated using validated PROMIS measures. Radiographic outcomes including hallux valgus angle (HVA), intermetatarsal angle (IMA), Meary’s angle, CP, and TNCA were measured and compared preoperatively and minimum 6 months postoperatively. Results: The average clinical follow-up was 16.7 months in the control group and 15.9 months in the flatfoot group (p=0.6) while the average radiographic follow-up was 8.5 months for the control and 9.7 months for the flatfoot group (p=0.2). Both groups demonstrated similar preoperative and postoperative PROMIS scores with significant improvements in physical function, pain interference, and pain intensity (Table 1). Preoperative and postoperative HVA and IMA were similar between groups, however patients in the flatfoot group had a significantly higher Meary’s angle, TNCA, and lower CP preoperatively and postoperatively. Both groups showed significant improvements in HVA, IMA, and TNCA (Table 2). The flatfoot group demonstrated a 1.4-degree improvement in Meary’s angle while the control group had a 1.5-degree worsening in Meary’s angle. Conclusion: Our study indicates that the minimally invasive chevron and Akin bunionectomy improves patient-reported outcomes and provides significant correction of the hallux valgus deformity without adversely impacting flatfoot parameters. Additionally, although the MISB procedure was not able to normalize the flatfoot parameters, this did not seem to affect patient-reported outcomes 1-2 years after surgery. Therefore, the MIS bunionectomy may be an effective option for hallux valgus correction in patients with mild, asymptomatic flatfoot, however longer-term radiographic follow-up is required to determine if outcomes are influenced by further progression of the flatfoot.