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Background: Recognizing aggressive tumor biology is essential to optimizing patient management for papillary thyroid carcinomas (PTC). Aggressive lymph node (ALN) status is one feature that influences decision-making. We evaluated genomic deletions in regions of tumor suppressor genes, detected by loss of heterozygosity (LOH) analysis, to understand causal alterations linked to thyroid cancer aggressiveness and to serve as a molecular diagnostic biomarker for ALN status., Methods: We analyzed 105 primary PTC enriched for patients with ALN (64% with, 36% without). We also analyzed 39 positive lymph nodes (79% with, 21% without ALN). LOH was determined using a panel of 25 polymorphic microsatellite alleles targeting 10 genomic loci harboring common tumor suppressor genes. Additionally, ThyGeNEXT® and ThyraMIR® assays were performed., Results: LOH was detected in 43/67 primary PTC from patients with ALN status, compared with only 5/38 primary PTC without ALN (minimal metastatic burden) (P=0.0000003). This is further supported by post hoc analyses of paired primary and metastatic samples. Paired samples from patients with ALN are more likely to harbor LOH, compared to the ALN negative group (P=0.0125). Additionally, 12/31 paired samples from patients with ALN demonstrated additional or different LOH loci in metastatic samples compared to the primary tumor samples. No association was seen between ALN and mutational, translocation, or microRNA data., Conclusions: LOH detected in primary PTC significantly predicts ALN status. Analysis of paired primary and metastatic samples from patients with / without ALN status further supports this relationship. The acquisition of LOH at additional loci is common in lymph nodes from patients with ALN status., Simple Summary: A subset of patients with papillary thyroid carcinoma (PTC) will develop recurrent disease. One known predictor of recurrence is the American Thyroid Association category "Aggressive Lymph Node" (ALN) disease, considering metastatic burden. Loss of heterozygosity (LOH) - chromosomal loss in regions of tumor suppressor genes - has yet to be investigated as a possible mechanism driving ALN status in PTC. The ability to predict ALN status prior to surgery can guide the extent of surgery and postoperative treatment options. We found that paired samples from patients with ALN are more likely to harbor LOH, compared to patients without ALN disease. 38% of patients with ALN demonstrated additional or different LOH loci in metastatic samples compared to the primary tumor samples. LOH complements current molecular analysis of thyroid cancer when searching for evidence of aggressive biology., Competing Interests: Declaration of Competing Interest SDF, JL and VAT are employees of Interpace Diagnostics and own limited stock in the company., (Copyright © 2023 Elsevier GmbH. All rights reserved.)

Study Design: case series., Objective: The restoration of defects in a single procedure with microvascular free flap reconstruction has become a mainstay of head and neck surgery. Yet in patients with complex defects and pre-existing comorbid medical conditions, a staged-reconstructive approach can enhance the safety of the procedure and improve the patient's outcome., Methods: We present 3 representative case examples of a larger series of patients who underwent reconstruction of major defects and discuss the usefulness of a staged-reconstructive approach in the management of complex patients., Results: All 3 patients, with an existing composite defect in the setting of prior radiation therapy, underwent successful staged-reconstructive surgery using a variety of free tissue and regional flap transfers., Conclusions: A staged approach facilitates the reconstruction of complex composite defects, increases vessel availability, and mitigates the risk of flap failure. Although this approach commits the patient to multiple procedures and a more prolonged plan of care, it is preferable to 1 operation in specific complex situations with adverse, high-risk clinical features., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Introduction: The diagnosis of tall cell variant papillary thyroid carcinoma (TCV-PTC) corresponds to the feature of "aggressive histology" within the framework of the American Thyroid Association (ATA) Risk of Recurrence (ROR) guidelines. Using the current World Health Organization (WHO) definition for TCV-PTC (tall cells with height at least twice the width, distribution ≥ 30 %), we examined the impact of this diagnosis on disease-free survival (DFS)., Methods: The study cohort consisted of 347 patients treated for primary papillary thyroid carcinoma (PTC). Current ATA guidelines were followed for the extent of surgery and the administration of adjuvant radioiodine therapy. Clinical surveillance included ultrasound examination and biochemical parameters according to ATA standards. The outcome was measured as time from surgery to first disease recurrence (DR) versus time from surgery until the last documented disease-free encounter (no evidence of disease, NED). Disease-free patients with fewer than 6 months of follow-up were excluded from this cohort. Structural recurrences are documented by histology or cytology whereas biochemical recurrences are documented by rising serum thyroglobulin in the absence of structural disease. All slides on all patients were examined by two pathologists with the substantial interobserver agreement (Kappa = 73 %). The primary tumors are categorically classified either as (1) TCV-PTC (definition above), (2) Papillary thyroid carcinoma with tall cell features (PTC-TCF) (≥ 10 % < 30 % tall cells), or (3) Control (< 10 % tall cells). Tumor size is categorized as either (1) ≤ 10 mm, (2) 11-29 mm, or (3) ≥ 30 mm. Degree of ETE is categorized as either intrathyroidal, microscopic ETE, histologic spread to strap muscles, or pT4 disease., Results: 185 patients are classified as TCV-PTC (≥ 30 % tall cells), 62 as PTC-TCF (≥ 10 % < 30 % tall cells), and 100 as control group (< 10 % tall cells). TCV-PTC is associated with ≥ 30 mm size (p = .0246) and invasion of strap muscles and/or pT4 (p = .0325). There was no relationship between TCV-PTC and aggressive lymph node (ALN) status defined by ATA. Overall follow-up ranged from two months (one patient death) to 203 months (mean 40.8, median 33.0). DR occurred in 61 patients (mean 31.4 months, range 0 -184, 59 structural recurrences, 2 biochemical recurrences). Three models for TCV-PTC were examined: Model 1 - Tall cells ≥ 10% versus control, Model 2 - TCV-PTC versus TCF-PTC versus control, and Model 3 - TCV-PTC versus control. Kaplan Meier curves demonstrated decreased DFS with ALN status (p = .0001), ETE (p = .0295), and TCV-PTC (Model 1, p = .041). On multivariate analysis, TCV-PTC (Model 1) remained significantly predictive when adjusted for ALN (p = .0059). ETE dropped out of the model., Conclusion: TCV-PTC is significantly associated with larger tumors and a greater degree of ETE. The diagnosis of TCV-PTC significantly impacts DFS at the 10 % cut-point on multivariate analysis., (Copyright © 2022 Elsevier GmbH. All rights reserved.)

Background: Tibialis anterior tendon ruptures are rare and can cause significant dysfunction. Often, conservative measures are prescribed because of the morbidity of a tendon transfer as an operative solution. We present a novel reconstruction technique using hamstring autograft, which may obviate the need for local tendon transfer and long-term bracing., Methods: Patients who underwent tibialis anterior reconstruction with hamstring autograft between 2011 and 2015 were screened for inclusion. Eight were included. Functional outcomes were assessed pre-and-postoperatively using the Foot and Ankle Outcome Score (FAOS), Visual Analog Pain Scale (VAS), and Short-Form-12 (SF-12) general health questionnaire. Isokinetic testing using a dynamometer (Biodex System 4 Pro) was performed at 60 and 120 degrees/s, respectively, for inversion/eversion and plantarflexion/dorsiflexion on both ankles at a minimum of 6 months postoperatively to determine peak torque, average power, and total work. Range of motion (ROM) testing was also performed, using a goniometer, at a minimum of 6 months postoperatively. Average follow-up was 17.3 (6.0-40.0) months for strength testing and ROM testing, and 18.5 (12.0-26.0) months for functional outcome scores., Results: Average postoperative functional scores improved for all tests. ROM was similar between the uninvolved and involved ankles for inversion/eversion and plantarflexion/dorsiflexion. Patients showed deficits in dorsiflexion strength in all measures tested and improvements in inversion strength. All patients were able to ambulate without a brace., Conclusion: Use of a hamstring autograft for tibialis anterior reconstruction resulted in good clinical outcomes. This procedure successfully restored ankle ROM postoperatively and tendon strength in inversion and dorsiflexion, with most patients showing little deficit when comparing their involved and uninvolved sides., Level of Evidence: Level IV, Case series.

Background: Percutaneous internal fixation is currently the method of choice treating proximal zone II fifth metatarsal fractures. Complications have been reported due to poor screw placement and inadequate screw sizing. The purpose of this study was to define the morphology of the fifth metatarsal to help guide surgeons in selecting the appropriate screw size preoperatively., Methods: Multiplanar analysis of fifth metatarsal morphology was completed using computed tomographic (CT) scans from 241 patients. Specific parameters were analyzed and defined in anteroposterior (AP), lateral, and oblique views including metatarsal length, distance from the base to apex of curvature, apex medullary canal width, apex height, and fifth metatarsal angle., Results: The average metatarsal length in the AP view was 71.4 ± 6.1 mm and in the lateral view 70.4 ± 6.0 mm, with 95% of patients having lengths between 59.3 and 83.5 mm and 58.4 and 82.4 mm, respectively. The average canal width at the apex of curvature was 4.1 ± 0.9 mm in the AP view and 5.3 ± 1.1 mm in the lateral view, with 95% of patients having widths between 2.2 and 5.9 mm and 3.2 and 7.5 mm, respectively. Average distance from apex to base was 42.6 ± 5.8 mm in the AP and 40.4 ± 6.4 mm in the lateral views. Every measurement taken in all 3 views had a significant correlation with height., Conclusions: When determining screw length, we believe lateral radiographs should be used since the distance from the base of the metatarsal to the apex was smaller in the lateral view. On average, the screw should be 40 mm or less to reduce risk of distraction. For screw diameter, the AP view should be used because canal shape is elliptical, and width was found to be significantly smaller in the AP view. Most canals can accommodate a 4.0- or 4.5-mm-diameter screw, and one should use the largest diameter screw possible. Larger individuals were likely to have more bowing in their metatarsal shaft, which may lead to a higher tendency to distract., Level of Evidence: Level III, comparative series., (© The Author(s) 2015.)

Background: Proximal fractures of the fifth metatarsal (zone II and III) are common in the elite athlete and can be difficult to treat because of a tendency toward delayed union, nonunion, or refracture. The purpose of this case series was to report our experience in treating 10 NBA players, determine the healing rate, return to play, refracture rate, and role of foot type in these athletes., Methods: The records of 10 professional basketball players were retrospectively reviewed. Seven athletes underwent standard percutaneous internal fixation with bone marrow aspirate concentrate (BMAC) whereas the other 3 had open bone grafting primarily in addition to fixation and BMAC. Radiographic features evaluated included fourth-fifth intermetatarsal, fifth metatarsal lateral deviation, calcaneal pitch, and metatarsus adductus angles., Results: Radiographic healing was observed at an overall average of 7.5 weeks and return to play was 9.8 weeks. Three athletes experienced refractures. There were no significant differences in clinical features or radiographic measurements except that the refracture group had the highest metatatarsus adductus angles. Most athletes were pes planus and 9 of 10 had a bony prominence under the fifth metatarsal styloid., Conclusion: This is the largest published series of operatively treated professional basketball players who exemplify a specific patient population at high risk for fifth metatarsal fracture. These players were large and possessed a unique foot type that seemed to be associated with increased risk of fifth metatarsal fracture and refracture. This foot type had forefoot metatarsus adductus and a fifth metatarsal that was curved with a prominent base. We continue to use standard internal fixation with bone marrow aspirate but advocate additional prophylactic open bone grafting in patients with high fourth-to-fifth intermetatarsal, fifth metatarsal lateral deviation, and metatarsus adductus angles as well as prominent fifth metatarsal styloids in order to improve fracture healing and potentially decrease the risk of refracture., Level of Evidence: Level IV, case series., (© The Author(s) 2016.)

Background: Current literature reports excellent rates of union following various lesser metatarsal osteotomy techniques. However, it is our experience that segmental midshaft shortening osteotomies heal very slowly and have a greater potential for nonunion than has previously been reported. The purpose of this study was to assess union rates and report the time required for segmental midshaft shortening osteotomies to achieve radiographic union., Methods: We reviewed the charts and postoperative radiographs of 58 patients (representing 91 osteotomies) who underwent segmental midshaft shortening osteotomies with internal fixation between January 2009 and December 2013. Radiographs were reviewed to determine when union was achieved. Union was defined as the bridging of 2 or more cortices in the anteroposterior, lateral, and oblique radiographic views. Osteotomies were classified as delayed union if they were not healed at 3 months postoperatively and nonunions if they were not healed at 6 months postoperatively., Results: Overall, 27 of 91 osteotomies met our radiographic classification of union and were healed by 3 months (29.7%). Sixty-nine of the 91 osteotomies healed by 6 months (75.8%) and were considered delayed unions. Twenty-two osteotomies were not healed yet and therefore were considered nonunions (24.2%). Of the 22 nonunions, 7 healed in an additional 2 months (8 months) for an overall healing percentage of 83.5%, (76 of 91). By 10 months, 6 more nonunions were healed (overall healing percentage of 90.1%, 82 of 91). Three additional nonunions went on to heal by 12.9 months, yielding a final union rate of 93.4% (85 of 91), while 6 were still considered nonunions (6.6%)., Conclusion: We report that a significant percentage of segmental midshaft metatarsal shortening osteotomies experienced delayed unions and nonunions. These findings contrast those previously reported in the literature that metatarsal osteotomies have very low nonunion rates. These results support our hypothesis that these osteotomies require a prolonged amount of time to achieve bony healing and that they have a higher tendency to develop delayed and nonunions than previously reported., Level of Evidence: Level IV, retrospective case series., (© The Author(s) 2015.)