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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: 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.

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

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.

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.

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.

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.

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:. 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.

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

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.

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.

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 (

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.

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.

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.

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Navicular fractures are uncommon foot fractures and there is scarce literature exploring the complications and radiologic outcomes of these fractures. The aim of this study is to examine fracture patterns and surgical data to see the effect they have on complications and radiographic outcomes after open reduction internal fixation of the navicular. Methods: A retrospective study was performed to identify patients who underwent operative treatment of a navicular fracture over a nine-year period (2013-2022). Patients were screened by review of CPT codes that included tarsal fractures and imaging review was used to identify those with navicular fractures. Minimum follow-up for inclusion was 6 months. Patient demographics were recorded and radiographs were reviewed and fractures were classified per the Sangeorzan and Schmid classification systems. Surgical data including approach(es), implants, and supplemental fixation was recorded. Postoperative radiographs were assessed for the presence of union, avascular necrosis, foot collapse, and arthritis. Complications defined as infection, unanticipated reoperation, and amputation were recorded. Results: 38 patients met inclusion criteria. 8 patients had a postoperative complication (21.1%). There was 1 superficial infection (2.6%) and 7 patients needed unanticipated reoperations: 2 (5.3%) for wound dehiscence, two (5.3%) for secondary arthritis, and 3 for symptomatic hardware removal (7.9%). Radiologic outcomes consisted of 7 cases of TNJ arthritis (18.4%), 6 cases of avascular necrosis (15.8%), and 7 cases of foot collapse (18.4%). There were significantly increased rates of TNJ arthritis in Schmid type III navicular fractures compared to type I and II (7 vs 0 vs 0, respectively; p=0.021), with 35% of Schmid type IIIs going on to develop TNJ arthritis. The need for reoperation of the navicular was increased if patients required a TNJ spanning construct [2 (50%) vs 2 (5.9%), p=0.007]. Conclusion: Navicular fractures that require ORIF have a high complication rate and a likelihood of developing suboptimal radiographic outcomes. We found that patients who dislocate their TNJ (Schmid Type-III), had an increased rate of TNJ arthritis which likely stems from the more severe nature of the injury, the keystone role of the navicular and the instability present across Chopart’s joint. For patients requiring a TNJ spanning construct there was an increased risk for unanticipated reoperation likely due to the size and nature of the spanning construct hardware. Patient education on these risk factors will guide treatment options and set proper expectations.

Category: Sports; Ankle Introduction/Purpose: Vega et al. describe two components of the anterior talofibular ligament(ATFL), including the intracapsular superior fascicle(sATFL) and the extracapsular inferior fascicle(iATFL). Based on this anatomic distinction, ankle “microinstability” describes instability arising from injury to the sATFL alone. Because the sATFL resides within the ankle joint, synovial fluid limits its healing, potentially leading to pain and subjective ankle instability without a positive anterior drawer exam. Since physical examination is unreliable for microinstability, arthroscopic examination is considered the gold standard for diagnosing sATFL injury. A noninvasive approach for diagnosis would be ideal; however, the efficacy of MRI in detecting injury to the sATFL is not understood. Therefore, we aimed to assess whether MRI could identify the sATFL as an independent structure and diagnose an isolated sATFL tear. Methods: Fourteen mid-tibia cadaveric specimens (7 males, age: 33-78 years) with neutral alignment and no history of trauma or previous surgery were included in the study. A board-certified foot and ankle orthopedic surgeon dissected the lateral ankle ligament complex to confirm the independent presence of the sATFL and the iATFL. After initial dissection, all specimens underwent a clinical MRI scan sequence, and two musculoskeletal radiologists with > 15 years of experience read the images in consensus to identify the sATFL. Half of the specimens were randomly assigned to undergo bisection of the sATFL. All 14 specimens underwent a second MRI scan, and the same radiologists assessed the images while blinded to the sATFL condition. The percentage of specimens with identifiable sATFL during the initial MRI scan and identifiable injury of the sATFL during the second scan were calculated. Results: A total of 14 specimens were dissected down to the lateral ligament complex. The ATFL was observed as a two- fascicle(sATFL and iATFL) ligament in all 14 specimens. A gap between both fascicles was observed. The fibular insertion of the sATFL was located just distal to the fibular insertion of the anterior tibiofibular ligament. In contrast, the fibular insertion of the iATFL was located between the insertion of the sATFL and the fibular tip. In the initial MRI scans, radiologists identified both the sATFL and the iATFL in 10/14(71.4%) specimens. The distinction between the two fascicles was not possible in the other four specimens. In the second set of MRI scans, radiologists correctly identified 6/7(85.7%) specimens that underwent sATFL bibisection and 7/7(100%) specimens with intact sATFL. Conclusion: Our cadaveric dissection confirmed the presence of two distinct fascicles of the ATFL in all specimens. While the radiologists could only identify the discrete bundles of the sATFL and iAFTL in 71.4% of intact specimens, they distinguished the bisected sATFL in 6 out of 7 specimens. These findings suggest that MRI can be a potential tool for diagnosing microinstability. Since microinstability frequently involves intraarticular pathology, performing MRI can be considered if patients experience subjective ankle instability and pain but without signs of ankle laxity on clinical examination.

Purpose: The Retinal Ganglion Cell (RGC) Repopulation, Stem Cell Transplantation, and Optic Nerve Regeneration (RReSTORe) consortium was founded in 2021 to help address the numerous scientific and clinical obstacles that impede development of vision-restorative treatments for patients with optic neuropathies. The goals of the RReSTORe consortium are: (1) to define and prioritize the most critical challenges and questions related to RGC regeneration; (2) to brainstorm innovative tools and experimental approaches to meet these challenges; and (3) to foster opportunities for collaborative scientific research among diverse investigators. Design and Participants: The RReSTORe consortium currently includes > 220 members spanning all career stages worldwide and is directed by an organizing committee comprised of 15 leading scientists and physician-scientists of diverse backgrounds. Methods: Herein, we describe the structure and organization of the RReSTORe consortium, its activities to date, and the perceived impact that the consortium has had on the field based on a survey of participants. Results: In addition to helping propel the field of regenerative medicine as applied to optic neuropathies, the RReSTORe consortium serves as a framework for developing large collaborative groups aimed at tackling audacious goals that may be expanded beyond ophthalmology and vision science. Conclusions: The development of innovative interventions capable of restoring vision for patients suffering from optic neuropathy would be transformative for the ophthalmology field, and may set the stage for functional restoration in other central nervous system disorders. By coordinating large-scale, international collaborations among scientists with diverse and complementary expertise, we are confident that the RReSTORe consortium will help to accelerate the field toward clinical translation. Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

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.

The UK has a significant and growing population of older adults with frailty and complex healthcare needs, necessitating innovative care solutions. This study aimed to explore patients’ and carers’ experiences of a novel integrated service that was set up to address the increasing healthcare needs of older people living with frailty. A qualitative study that combined free-text survey questions with in-depth interviews. This study is part of a larger non-randomized trial of the service, with evaluation of wellbeing and quality of life at baseline, 2 to 4 weeks, and 10 to 14 weeks. Patients (aged 65 and above) with an electronic Frailty Index in the severe range and their informal family carers participated in this study. Data were collected between April 2019 and March 2020. Free text survey responses and interview data were subjected to reflexive thematic analyses. Four themes were generated: the overall experience of the service; interactions within the service; treatment and interventions; and outcomes due to the service. Most participants wanted further follow-up and more extensive integration with other services. Most participants described their overall experience positively, especially the available time to address their full range of concerns, but opportunities to integrate the service more fully and to extend follow-up remain.

Background:. Few evidence-based suggestions are available to help applicants and mentors improve reapplication outcomes. We sought to provide program directors' (PDs) perspectives on actionable steps to improve reapplicants' chances for a match. Methods:. The PDs were asked to rank positions unmatched applicants can pursue, steps these applicants can take for the next application cycle, and reasons why reapplicants do not match. Results:. Responses from 66 of 123 PDs were received (53.6% response rate). Obtaining new recommendation letters and rotating with orthopaedics were the highest 20 ranked steps unmatched applicants can take. No curriculum vitae (CV) improvement, poor interview, and poor letters of recommendation were the most important reasons hindering applicants from matching when reapplying. Conclusions:. Steps reapplicants could prioritize include obtaining new recommendation letters, rotating in orthopaedics, and producing new research items. CV strengthening and improving interview skills address the 2 main reasons why unmatched applicants failed in subsequent attempts. Level of Evidence:. Level IV

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

Background:. Immediate expander/implant-based breast reconstruction after mastectomy has become more sought after by patients. Although many patients choose this technique due to good aesthetic outcomes, lack of donor site morbidity, and shorter procedure times, it is not without complications. The most reported complications include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, and implant exposure, with an overall complication rate as high as 45%. Closed incision negative pressure therapy (ciNPT) has shown value in wound healing and reducing complications; however, the current literature is inconclusive. We aimed to examine if ciNPT improves outcomes for patients receiving this implant-based reconstruction. Methods:. This is a retrospective single-institution study evaluating the ciNPT device, 3M Prevena Restor BellaForm, on breast reconstruction patients. The study was performed between July 1, 2019 and October 30, 2020, with 125 patients (232 breasts). Seventy-seven patients (142 breasts) did not receive the ciNPT dressing, and 48 patients (90 breasts) received the ciNPT dressing. Primary outcomes were categorized by major or minor complications. Age, BMI, and final drain removal were summarized using medians and quartiles, and were compared with nonparametric Mann-Whitney test. Categorical variables were compared using chi-square or Fisher exact test. Results:. There was a statistically significant reduction in major complications in the ciNPT group versus the standard dressing group (P = 0.0247). Drain removal time was higher in the ciNPT group. Conclusion:. Our study shows that ciNPT may help reduce major complication rates in implant-based breast reconstruction patients.

In the midst of the current opioid crisis, it has become critically important to properly manage opioid-prescribing patterns for the treatment of postoperative pain. There is currently a scarcity of literature specifying prescription and consumption patterns following orthopedic surgery and specifically foot and ankle surgery. Clinical guidelines for postoperative pain management are deficient.

Background: This study aimed to assess the preferred operative treatment for patients over the age of 60 with end-stage ankle arthritis and perspectives on total ankle replacement (TAR) among American Orthopaedic Foot & Ankle Society (AOFAS) members. Associated factors were analyzed for potential contraindications among members with different levels of experience. Method: A questionnaire containing 6 questions was designed and sent to 2056 members of the AOFAS. Responses were received from 467 orthopaedic surgeons practicing in the United States (76%), Canada (5%), and 26 other countries (20%). Participants were grouped for response comparisons according to country as well as experience level. Differences in contraindications were compared using χ 2 tests or exact tests. Results: Respondents practicing in the United States and surgeons who perform 11 or more TARs per year tended to recommend operative treatments favoring TAR and displayed recognition of its increasing role (P < .05). Overall, respondents felt that 41% of typical patients over 60 years old with end-stage arthritis would be best treated with TAR. Talus avascular necrosis, morbid obesity (body mass index >40 kg/m 2 ), and poorly controlled diabetes with neuropathy were most recognized as the absolute contraindications to TAR. Surgeon’s experience affected the consideration of these clinical factors as contraindications. Conclusions: Total ankle replacement has a substantial and increasing role in the treatment of end-stage ankle arthritis in patients over the age of 60. Absolute and potential contraindications of the procedures were indicated from a cross-sectional survey of AOFAS members. Surgeons more experienced with total ankle replacement felt more comfortable employing it in a wider range of clinical settings. Level of Evidence: Level III, therapeutic.

Background: Given the increased attention to functional improvement in spine surgery as it relates to activities of daily living and cost, it is critical to fully understand the health care economic impact of enabling technologies. The use of intraoperative neuromonitoring (IOM) during spine surgery has long been controversial. Questions pertaining to utility, medico-legal considerations, and cost-effectiveness continue to be unresolved. The purpose of this study is to determine the cost-effectiveness by assessing quality-of-life due to adverse events averted, decreased postoperative pain, decreased revision rates, and improved patient reported outcomes (PROs). Methods: The study patient population was extracted from a large multicenter database collected by a single, national IOM provider. Over 50,000 patient charts were abstracted and included in this analysis. The analysis was conducted in accordance with the second panel on cost-effectiveness health and medicine. Health-related utility was derived from questionnaire answers and expressed in quality-adjusted life years (QALYs). Both cost and QALY outcomes were discounted at a yearly rate of 3% to reflect their present value. Cost-effectiveness was calculated as the incremental cost-effectiveness ratio (ICER) for IOM. A value under the commonly accepted United States-based willingness-to-pay (WTP) threshold of $100,000 per QALY was considered cost-effective. Scenario (including litigation), probabilistic (PSA), and threshold sensitivity analyses were conducted to determine model discrimination and calibration. Results: The primary time horizon used to estimate cost and health utility was 2-years following index surgery. On average, index surgery for patients with IOM costs are approximately $1,547 greater than non-IOM cases. The base case assumed an inpatient Medicare population however multiple outpatient and payer scenarios were assessed in the sensitivity analysis. From a health system perspective IOM is cost-effective, yielding better utilities but at a higher cost than the non-IOM strategy (ICER $60,734 per QALY). From a societal perspective the IOM strategy was dominant, suggesting that better outcomes were achieved at less cost. Except for an entirely privately insured population, alternative scenarios such as, outpatient and a 50:50 Medicare/privately insured population sample also demonstrated cost-effectiveness. Notably, IOM benefits were unable to overcome the sheer costs associated many litigation scenarios, but the data was severely limited. In the 5,000 iteration PSA, at a WTP of $100,000, 74% of simulations using IOM were cost-effective. Conclusions: The use of IOM in spine surgery is cost-effective in most scenarios examined. In the emerging and rapidly expanding field of value-based medicine, there will be an increased demand for these analyses, ensuring surgeons are empowered to make the best, most sustainable solutions for their patients and the health care system.

Purpose: To assess the intrasession repeatability of macular OCT angiography (OCTA) parameters in Alzheimer's disease (AD), mild cognitive impairment (MCI), Parkinson's disease (PD), and normal cognition (NC). Design: Cross sectional study. Subjects: Patients with a clinical diagnosis of AD, PD, MCI, or NC were imaged. Images with poor quality and of those with diabetes mellitus, glaucoma, or vitreoretinal disease were excluded from analysis. Methods, Intervention or Testing: All participants were imaged using the Zeiss Cirrus HD-5000 with AngioPlex (Carl Zeiss Meditec, Software Version 11.0.0.29946) and repeat OCTA images were obtained for both eyes. Perfusion density (PFD), vessel density (VD), and Foveal avascular zone (FAZ) area were measured from 3 × 3 mm and 6 × 6 mm OCTA images centered on the fovea using an ETDRS grid overlay. Main Outcome Measures: Intraclass correlation coefficients were used to quantify repeatability of PFD, VD, and FAZ area measurements obtained from imaging. Results: 3 × 3 mm scans of 22 AD, 40 MCI, 21 PD, and 26 NC participants and 6 × 6 mm scans of 29 AD, 44 MCI, 29 PD, and 30 NC participants were analyzed. Repeatability values ranged from 0.64 (0.49–0.82) for 6 × 6 mm PFD in AD participants to 0.87 (0.67–0.92) for 3 × 3 mm PFD in AD participants. No significant differences were observed in repeatability between NC participants and those with neurodegenerative disease. Conclusions: Overall, similar OCTA repeatability was observed between NC participants and those with neurodegeneration. Regardless of diagnostic group, macular OCTA metrics demonstrated moderate to good repeatability. Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article.

We perform a joint analysis of the auto and cross-correlations between threecosmic fields: the galaxy density field, the galaxy weak lensing shear field,and the cosmic microwave background (CMB) weak lensing convergence field. Thesethree fields are measured using roughly 1300 sq. deg. of overlapping opticalimaging data from first year observations of the Dark Energy Survey andmillimeter-wave observations of the CMB from both the South Pole TelescopeSunyaev-Zel'dovich survey and Planck. We present cosmological constraints fromthe joint analysis of the two-point correlation functions between galaxydensity and galaxy shear with CMB lensing. We test for consistency betweenthese measurements and the DES-only two-point function measurements, finding noevidence for inconsistency in the context of flat $\Lambda$CDM cosmologicalmodels. Performing a joint analysis of five of the possible correlationfunctions between these fields (excluding only the CMB lensing autospectrum)yields $S_{8}\equiv \sigma_8\sqrt{\Omega_{\rm m}/0.3} =0.782^{+0.019}_{-0.025}$ and $\Omega_{\rm m}=0.260^{+0.029}_{-0.019}$. We testfor consistency between these five correlation function measurements and thePlanck-only measurement of the CMB lensing autospectrum, again finding noevidence for inconsistency in the context of flat $\Lambda$CDM models.Combining constraints from all six two-point functions yields$S_{8}=0.776^{+0.014}_{-0.021}$ and $\Omega_{\rm m}= 0.271^{+0.022}_{-0.016}$.These results provide a powerful test and confirmation of the results from thefirst year DES joint-probes analysis.