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Audience: Emergency medicine (EM) residents. This simulation curriculum may also be utilized for senior medical students conducting EM rotations.Background: Ophthalmologic education represents only a small portion of medical school curriculums and continues to decrease over time, leaving physicians poorly equipped to diagnose and manage eye complaints.1 Of emergency physicians (EPs) surveyed, 72.5% felt that they could diagnose orbital compartment syndrome (OCS), yet only 40.3% felt comfortable performing a necessary lateral canthotomy and cantholysis (LCC).2 These survey results demonstrate the urgent need for improved ophthalmology education in EM residency to help us diagnose and manage potentially vision-threatening pathology.Educational Objectives: By the end of this simulation, learners will be able to: 1) demonstrate the major components and a systematic approach to the emergency ophthalmologic examination, 2) develop a differential diagnosis of sight-threatening etiologies that could cause eye pain or vision loss, 3) demonstrate proficiency in performing potentially vision-saving procedures within the scope of EM practice.Educational Methods: Low-fidelity simulation was conducted using a novel model adapted from that used by Phillips et al. during their ophthalmology day in the Department of Emergency Medicine at Vanderbilt University.3 The simulation case was developed by an interdepartmental team of ophthalmologists and EPs at our institution.Research Objectives: To evaluate for statistically significant changes in self-efficacy, knowledge, and performance after an educational intervention. Our primary outcome was defined as a checklist-based performance on a simulated case of orbital compartment syndrome necessitating LCC.Research Methods: We conducted a single-center prospective pre- and post-interventional study evaluating the impact of an educational intervention on EM resident management of a simulated case of OCS. Our two- part study intervention consisted of a lecture on OCS followed by a four and a half hour ophthalmology education day (OED). Residents were evaluated using self-efficacy scales (SES), multiple-choice questions (MCQ), and a performance checklist (developed via a modified Delphi process) at three timepoints: Pre- intervention, immediate post-intervention, and three months post-intervention. Post-graduate year (PGY)-1 through PGY-4 EM residents at an Urban Level 1 Trauma Center participated.Results: Initial recruitment consisted of 18 residents (PGY-1 through PGY-4), and 16 residents (PGY-1 through PGY-3) completed the study. Nine residents participated in the OED and seven residents did not. There were no pre-existing differences in median checklist-based performance, MCQ, or SES scores prior to the intervention. At three months post-OED, the OED attendees scored statistically significantly higher on checklist-based performance than non-attendees (lecture only).Discussion: Ophthalmology education in physician training is limited, and EP comfort with performing vision- saving procedures is poor. We developed a simulation case involving such a vision-saving procedure as well as an ophthalmology curriculum that increased skill retention surrounding management of ophthalmologic emergencies.Topics: Emergency medicine (EM), ophthalmology, orbital compartment syndrome (OCS), retrobulbar hematoma, vision loss, eye pain.

Introduction: Long guns (LGs) are uniquely implicated in firearm violence and mass shootings. On 1/1/2019 California (CA) raised the minimum age to purchase LGs from 18 to 21. This study aimed to evaluate the incidence of LG violence in CA vs. Texas (TX), a state with rising firearm usage and fewer LG regulations, hypothesizing decreased LG firearm incidents in CA vs increased rates in TX after CA LG legislation. Methods: A retrospective analysis of the Gun Violence Archive (2015–2021) was performed. An additional analysis of all firearm incidents within TX and CA was performed. CA and TX census data were used to calculate incidents of LG violence per 10,000,000 people. The primary outcome was the number of LG-related firearm incidents. Median yearly rates of LG violence per 10,000,000 people were compared for pre (2015–2018) vs post (2019–2021) CA LG legislation (Senate Bill 1100 (SB1100). Results: Median LG incidents decreased in CA post-SB1100 (4.21 vs 1.52, p

Background: Heart transplantation is the gold standard treatment for end-stage heart failure patients. However, the shortage of donor hearts limits its applicability. This study aims to evaluate the risk factors associated with survival within 1-year after heart transplantation. Methods: A single-center retrospective cohort study evaluated 299 adult patients who underwent transplantation at the Heart Institute (Incor) between January 2013 and December 2019. Univariate and multivariate Cox regression analyses were conducted to identify independent predictors of 1-year survival among well-established prognostic clinical characteristics described in the literature. Patients were followed until death or the last observation on October 12, 2022. A Simple Risk Index was created based on the hazard ratio of each factor. Results: Chagas disease was the most common cause of cardiomyopathy (36%). Most patients were male (65%) with a median age of 50 (39-58) years. Four variables observed during the last clinical assessment in the intensive care unit before surgery were found to be statistically significant: maximum Sequential Organ Failure Assessment (SOFA) score, creatinine clearance in 3 quartile categories, C-reactive protein in 3 categories, and white blood cell count in 3 categories. The model demonstrated good discrimination (C-index = 0.74) and calibration. The group at high risk (>20 points) exhibited significantly higher mortality rates at 1 year (p

Purpose: While there are many benefits to radiation oncology services, there can be emotional burdens in the care of patients with advanced cancer. Burnout is a prevalent problem in oncology. Existing literature suggests refocusing attention on providers’ sense of purpose to protect against burnout. “Sacred moments” are moments of deep interconnection between people with accompanying spiritual emotions such as awe, joy, and gratitude. These moments naturally occur in health care settings, offering potential benefits to both patient and provider. Little is known about the prevalence and impact of sacred moments among health care workers in a radiation oncology setting. Methods and Materials: We conducted an exploratory qualitative study of 13 semi-structured interviews among physicians, registered nurses, and advanced practice providers of a radiation oncology consult service at a large National Cancer Institute-designated cancer center between March and May 2023. Interviews were recorded, transcribed, and analyzed to identify key themes. Data were systematically coded and analyzed in NVivo software and organized into a codebook organized by domains and themes. Results: Of the 13 health care workers interviewed, 12 interviewees reported experiencing at least one sacred moment during their clinical careers. None of the interviewees were initially familiar with the term; however, all understood the concept once explained. Interview findings were organized into four domains: (1) common elements, (2) impact, (3) barriers, and (4) provider reactions. Common elements included a moment of deep interconnection between provider and patient, often involving end-of-life patients. The impact of these moments was most commonly described as an increased sense of purpose in their role. Lack of time with patients was the most common barrier. Conclusions: Sacred moments are commonly experienced by health care workers in a radiation oncology consult service. They helped to humanize the patient, buffer against provider burnout, and increase a sense of purpose and job satisfaction.

Background:. The paucity of pain management options in resource-limited settings is a significant and systemically unaddressed problem. To improve global health equity, it is important to bridge this gap in care without introducing the peril of opioid dependence. We present a proof-of-concept case series wherein virtual reality (VR) was successfully used to manage discomfort in patients undergoing burn dressing changes in sub-Saharan Africa. Methods:. Nine patients presenting with burn injuries of variable severity underwent routine stabilization and dressing as part of standard-of-care treatment. During dressing changes, a VR intervention consisting of the Dream Flight interactive game displayed on an Oculus Quest 2 headset was offered to patients. Patient mood scores were collected before VR initiation and at the conclusion of the dressing change by a translator using the Youth Feelings Scale. Results:. There were no adverse events associated with use of the VR headset and no patients elected to terminate the VR during their procedure. Patients and physicians subjectively reported satisfaction with the device’s utility in the procedure. Before VR initiation, the 95% confidence interval for patient mood score was 4.89 ± 1.725. After VR initiation, the 95% confidence interval for patient mood score was 8.78 ± 1.40. Conclusions:. Our results of this proof-of-concept case series to suggest both feasibility of use and positive influence on patient discomfort and periprocedural satisfaction. We propose that VR should be explored as an analgesic alternative and/or adjunct to narcotics in resource-limited countries, particularly for high-pain, low-duration procedures.

Background: Injuries to the medial structures of the knee are common in multi-ligamentous knee injuries (MLKIs), which account for 0.02% of orthopedic injuries each year. The most common medial structure involved is the superficial medial collateral ligament (sMCL) with possible additional injury to the posterior oblique ligament (POL) and deep medial collateral ligament (dMCL). There has been little evidence for the superior management of these structures regarding the use of repair or reconstruction to reproduce overall knee function. Although reconstruction may provide more valgus stability postoperatively, the use of sMCL repair over reconstruction may be superior at reestablishing native anatomic alignment and kinematic relationships of the knee while also preserving proprioception and providing similar valgus stability. Indications: Surgical repair of medial structures is typically indicated for third-degree injuries, bony avulsions, tibial plateau fracture, intra-articular entrapment of the end of the ligament (Stener-type lesions), or anteromedial stability. They are particularly indicated in the elite athlete who presents with excessive valgus laxity due to valgus knee loading, external rotation, or combined force vectors. Technique Description: This surgical technique video demonstrates an open, medial-sided femoral and tibial approach to repair proximal and distal medial knee structures in the setting of MLKIs using case examples of a Stener lesion and a combined sMCL, POL, and medial patellofemoral ligament tears. Results: Repair of sMCL injuries has been reported to show favorable healing, knee stability, and function. Discussion/Conclusion: The use of fixation of the sMCL to its anatomical attachment points offers similar valgus stability and improved functional and patient-reported outcomes when compared with sMCL reconstruction. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), represents a substantial healthcare challenge. Provoked and unprovoked DVT cases carry distinct risks and treatment considerations. Recognizing the limitations of this classification, molecular markers may enhance diagnostic precision and guide anticoagulation therapy duration relying on patient history and risk factors. This preliminary, open-label, prospective cohort study was conducted including 15 patients (10 provoked DVT and 5 unprovoked DVT) and a control group of healthy plasmatic subjects. Plasma levels of 9 biomarkers were measured at diagnosis (baseline, day 0, and D0) and after 30 days (day 30-D30). Patient demographics, clinical data, and biomarker concentrations were analyzed. Serum concentrations of D-dimer, von Willebrand factor, C-reactive protein, and Anti-Xa were elevated in DVT groups at D0 compared to controls. No significant differences were observed between the provoked and unprovoked groups on the day of diagnosis and 30 days later. Over 30 days, the provoked group exhibited significant biomarker changes related to temporal assessment. No significant differences were noted in the biomarker profile between provoked and unprovoked DVT groups. This study is indicative of the concept of individualized thrombosis assessment and subsequent treatment for VTE. Larger cohorts are warranted to validate these findings and further define the most appropriate use of the molecular markers.

Splenic arteriovenous fistulas (SAVFs) are rare vascular anomalies, which have a described association with splenic artery aneurysms. Treatment options include surgical fistula excision, splenectomy, or percutaneous embolization. Here we present a unique case of endovascular repair of a splenic arteriovenous fistula (SAVFs) associated with a splenic aneurysm. A patient with past medical history of early-stage invasive lobular carcinoma was referred to our interventional radiology practice to discuss an incidentally discovered splenic “vascular malformation” discovered during magnetic resonance imaging of the abdomen and pelvis. Arteriography demonstrated smooth dilatation of the splenic artery, with a fusiform aneurysm which had fistulized to the splenic vein. There were high flows and early filling of the portal venous system. The splenic artery, immediately proximal to the aneurysm sac, was catheterized using a microsystem and embolized using coils and N-butyl cyanoacrylate. Complete occlusion of the aneurysm and resolution of the fistulous connection was achieved. The patient was discharged home the following day, without complication. Associated splenic artery aneurysms and SAVFs are rare occurrences. Timely management is necessary to prevent adverse sequelae such as aneurysm rupture, further enlargement of the aneurysmal sac, or portal hypertension. Endovascular treatment, including n-Butyl Cyanoacrylate glue and coils, offers a minimally invasive treatment option, with facile recovery and low morbidity.

Summary:. Postoperative sensitivity of the nipple–areola complex (NAC) is an important concern for women after reduction mammoplasty. Previous studies have demonstrated that sensory branches of the fifth anterior intercostal nerve are important for innervating the NAC and that using an inferior pedicle technique is associated with improved sensory retention. The significance of this case report is that it demonstrates the importance of the fifth anterior intercostal sensory nerve branches using a prototype fluorescent imaging camera. The benefit of this device is that it can detect intraoperative auto-fluorescence of nerves and facilitate their identification and preservation, potentially facilitating the retention of sensation in the NAC and surrounding skin. The goals of this article are, therefore, to demonstrate the importance of this neurovascular pedicle when the inferior pedicle technique is used for breast reduction; and to provide demonstrative evidence of the nerve’s presence within the fifth anterior intercostal artery perforator pedicle. The case involved a woman with mammary hypertrophy who underwent bilateral reduction mammoplasty using the inferior pedicle technique. Full NAC sensation was demonstrated on postoperative day 3 with complete sensory recovery at 1- and 3-month follow-up confirmed. To our knowledge, this is the first reported instance of the fifth intercostal nerve being visualized during aesthetic breast surgery, demonstrating the importance of this neurovascular bundle for sensory preservation when an inferior pedicle reduction mammaplasty technique is used.

A 55-year-old man submitted to emergency surgery due to cardiac perforation by stabbing. One month later, he presented with chest pain, and a transthoracic echocardiogram revealed moderate-severe mitral regurgitation. After 6 months, a new transthoracic echocardiogram showed a left ventricular pseudoaneurysm, being later submitted to pseudoaneurysm exclusion and mitral valvuloplasty.

OBJECTIVES:. DNA methylation can be used to determine an individual’s biological age, as opposed to chronological age, an indicator of underlying health status. This study aimed to assess epigenetic age in critically ill patients with and without sepsis to determine if higher epigenetic age is associated with admission diagnosis or mortality. DESIGN:. Secondary analysis of whole blood DNA methylation data generated from a nested case–control study of critically ill septic and nonseptic patients. SETTING:. Four tertiary care hospitals in Canada. INTERVENTIONS:. None. PATIENTS:. Critically ill patients with and without sepsis. MEASUREMENTS AND MAIN RESULTS:. Epigenetic age was derived from DNA methylation data using the Hannum and PhenoAge algorithms and deviation from the patient’s chronological age in years was determined. Of the 66 patients with sepsis, 34 were male (51.5%), the mean age was 65.03 years and 25 patients (37.8%) died before discharge. Of the 68 nonseptic patients, 47 were male (69.1%), the mean age was 64.92 years and 25 (36.7%) died before discharge. Epigenetic age calculated using the PhenoAge algorithm showed a significant age acceleration of 4.97 years in septic patients (p = 0.045), but no significant acceleration in nonseptic patients. Epigenetic age calculated using the Hannum algorithm showed no significant acceleration in the septic or nonseptic patients. Similarly, in the combined septic and nonseptic cohorts, nonsurvivors showed an epigenetic age acceleration of 7.62 years (p = 0.004) using the PhenoAge algorithm while survivors showed no significant age acceleration. Survivor status was not associated with age acceleration using the Hannum algorithm. CONCLUSIONS:. In critically ill patients, epigenetic age acceleration, as calculated by the PhenoAge algorithm, was associated with sepsis diagnosis and mortality.

Background: Patellar tendon ruptures presenting in a chronic setting are rare events that impose technical surgical challenges due to proximal retraction of the patella, quadriceps muscle atrophy and contracture, and peripatellar adhesions. Various reconstruction techniques have been described using different grafts and fixation methods; however, there is a paucity of reported outcomes and there is no consensus on standard of care. Indications: The patient is a 36-year-old man who presented with a failed patellar tendon reconstruction 14 months after his initial surgery (performed 1 year after the initial injury) with functional weakness and loss of extension. The patient was indicated for a revision patellar tendon reconstruction due to persistent functional limitations. Technique Description: The revision patellar tendon reconstruction was performed with gracilis and semitendinosus tendon autografts harvested from the ipsilateral limb. Hardware was removed from the initial graft tunnels in the tibial tubercle and patella. Patellar height was estimated using fluoroscopic measurement of the contralateral patellar tendon length. The graft is first passed through the patellar tunnel, and the individual limbs of the graft are then both placed through the tibial tubercle tunnel. A sternal wire in a figure-of-eight configuration was used to progressively distalize the patella to match the native patellar height, and the graft was then tensioned and secured together. Results: The patient regained full range of motion at 2-year follow-up and was able to return to work and activities without functional limitations. Recent case series also using ipsilateral hamstring tendon autograft for chronic patellar tendon reconstruction report improved patient outcome scores, normal Insall-Salvati index, improved quadriceps strength, and high levels of patient satisfaction. Discussion/Conclusion: Chronic patellar tendon ruptures are technically challenging to treat, especially in the context of revision of a failed reconstruction. The technique presented in this video may aid orthopaedic surgeons in treating this rare but debilitating injury. Given the lack of high-quality evidence, future studies are needed to explore graft choices, graft fixation techniques, and postoperative protocols. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Category: Ankle; Sports Introduction/Purpose: Syndesmotic injury in an athletic population is associated with a prolonged ankle disability after an ankle sprain and often requires a longer recovery than a lateral collateral ligament injury. Although several imaging tests are available, diagnosing syndesmotic instability remains challenging. The main objective was to determine the diagnostic accuracy of conventional ankle computed tomography (CT) scans with the joint in external rotation and dorsiflexion and compare it with that of conventional ankle CT scans in a neutral position. Methods: Between September 2018 and April 2021, this prospective study consecutively included adults visiting the foot and ankle outpatient clinic with a positive orthopedic examination for acute syndesmotic injury. Participants underwent 3 CT scan tests. First, ankles were scanned in a neutral position. Second, ankles were scanned with 45° of external rotation, dorsiflexion, and extended knees. Third, ankles were scanned with 45° of external rotation, dorsiflexion, and flexed knees. Three measurements, comprising rotation (measurement a), lateral translation (measurement c), and anteroposterior translation (measurement f) of the fibula concerning the tibia, were used to diagnose syndesmotic instability in the 3 CT scans. Magnetic resonance imaging was used as a reference standard. The area under the curve (AUC) was used to compare the diagnostic accuracy, and Youden’s J index was calculated to determine the ideal cutoff point. Results: Images obtained in 68 participants (mean age, 36.5 years; range, 18-69 years) were analyzed, comprising 36 syndesmotic injuries and 32 lateral collateral ligament injuries. The best diagnostic accuracy occurred with the rotational measurement a, in which the second and third CT scans with stress maneuvers presented greater AUCs (0.97 and 0.99) than the first CT scan in a neutral position (0.62). The ideal cutoff point for the stress maneuvers was 1.0 mm in the rotational measurement and reached a sensitivity and specificity of 83% and 97% for the second CT scan with extended knees and 86% and 100% for the third CT scan with flexed knees, respectively. Conclusion: Conventional ankle CT with stress maneuvers has excellent performance for diagnosing subtle syndesmotic rotational instability, as it shows a greater AUC and enhanced sensitivity at the ideal cutoff point compared with ankle CT in the neutral position.

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: Ankle; Sports Introduction/Purpose: A ligament-centered analysis is currently incorporated in the assessment of joint stability in malleolar fractures. Although several imaging tests are available, in the setting of acute isolated non-displaced posterior malleolar fractures Bartoníček/Rammelt types II and IV diagnosing syndesmotic instability remains challenging. The objective of this multi-center cross- sectional study was to evaluate the syndesmotic and fracture instability using conventional ankle CT with external rotation and dorsiflexion in the setting of acute, isolated non-displaced Bartoníček and Rammelt type II posterior malleolar fractures. Methods: Between March 2018 and September 2022, a consecutive sample of 123 individuals with an ankle sprain were assessed for eligibility. In total, 33 participants met the inclusion criteria. All participants underwent a CT scan (CTSM), comprising a first phase with the ankles in a neutral position, then a stress phase with the ankles in external rotation and dorsiflexion and semiflexed knees. Investigators used the patterns of ligament tear found at MRI and instability at CTSM to classify all participants into West Point grades I, IIA, IIB, or III. Mann-Whitney test was used to test the differences in the numerical variables between injured and uninjured syndesmoses. The Spearman correlation tested the strength of the association between the tibial joint surface involved in posterior malleolus fracture and syndesmotic instability. Results: In MRI reading parameters two patterns of syndesmotic ligament injury predominated. A completely torn AITF and IO ligaments and a completely torn AITF was combined with a partially torn IO. Regarding the deep layer of the deltoid ligament, participants were classified as normal, strained and partially torn. In CT scan reading parameters in the neutral phase, the median difference of 0.2 mm in d measurements between injured and uninjured syndesmoses was not statistically significant (P = 0.057). During the stress phase, the injured and uninjured syndesmoses had distinct behavior, and the 2.3 mm median difference for d measurement was statistically significant (P < 0.0001). Conclusion: The conventional computed tomography with external rotation and dorsiflexion represent a reproducible and accurate diagnostic option for the detection of syndesmosis instability and fracture instability in acute isolated posterior malleolar fractures Bartonícek and Rammelt type II.

Category: Trauma; Ankle Introduction/Purpose: The importance of the deltoid ligament in the congruency of the tibiotalar joint is well known. The current trend is to repair it in cases of acute injuries in the context of ankle fractures, however, there is no information on how it should be reconstructed. The objective of this study was to compare different deltoid ligament repair types in an ankle fracture cadaveric model. Methods: 16 cadaveric foot-ankle-distal tibia specimens were used to conduct the study. All samples were prepared as a supination external rotation ankle fracture model. An axial load and cyclic axial rotations were applied on every specimen using a specifically designed frame. This test was performed without deltoid injury, with deltoid injury and finally with the ligament reconstructed. The reconstruction was performed in 4 different ways (anterior, posterior, middle, combined) using 4 specimens per group. Medial clear space (MCS) was measured for each condition on simulated weight-bearing and gravity stress radiographs. Reflective markers were utilized in tibia and talus, registering through a motion analysis system the kinematics, to record the tibiotalar uncoupling. Statistical analysis was performed using the SPSS software. Results: In all cases, the MCS increased significantly on gravity stress radiographs after damaging the deltoid ligament. There was no increase in the MCS on load radiographs. After repair, in all cases, the MCS was normalized. Kinematically, after damage the tibiotalar uncoupling increased significantly, decreasing after repair. All repairs significantly corrected the tibiotalar uncoupling, observing a significantly increased coupling effect (increased stiffness) with the combined repair. Conclusion: Our results show that deltoid repair recovers the tibiotalar coupling mechanism in an ankle fracture model. We suggest that the ideal repair should aim to repair the middle aspect of the deltoid ligament. The combined repair may lead to postoperative stiffness. Clinical studies are needed to prove these results and show clinically improved outcomes.

Category: Hindfoot; Sports Introduction/Purpose: Zadek's procedure is a surgical option to treat insertional Achilles tendinopathy(IAT). This procedure consists of a closing wedge osteotomy of the calcaneus with biomechanical consequences. Great modifications in the hindfoot alignment can result in poor functional outcomes for athletes. Additionally, some authors stated that Zadek osteotomy is a good choice for patients with IAT associated with cavovarus foot. This study aims to analyze the hindfoot alignment and the parameters related to Haglund's syndrome after Zadek's osteotomy using a virtual surgical simulation by specific software. The authors hypothesize that the Zadek is an effective technique to decompress the Achilles tendon against the Haglund deformity without major modifications in the alignment. Methods: A total of 20 WBCT scans of patients with IAT were included. The WBCT images were run through the Foot & Ankle module of Disior's BonelogicTM software, creating a 3D virtual model. With this 3D model built into this software, 20 virtual Zadeck osteotomies standardized with a 10 mm resection wedge were performed using the virtual osteotomy module of Bonelogic®. The Calcaneal Inclination angle (sagittal view)7; Talocalcaneal angle (sagittal view)8; Talocalcaneal angle (axial view)8; Saltzman angle (45 degrees view)9; Saltzman angle (20 degrees view)9; Hindfoot moment arm angle;10 Hindfoot angle10; Fowler Philips angle11 and the calcaneal length7 were measured before and after the virtual osteotomy. These results were compared and statistically analyzed. Results: A virtual Zadek osteotomy was realized in 20 WBCT from patients with an insertional Achilles tendinopathy. Most of the patients were female, and the mean age was 55 years. There were significant statistical differences in the average of the calcaneal length (79 mm to 73 mm), Fowler Philips angle (57º to 43º), calcaneal pitch ( 24º to 20º ), sagittal talocalcaneal angle (55º to 47º ), and the hindfoot moment arm angle (20 º to 21,8º). The axial talocalcaneal angle, Saltzman view 45 º and 20 º, and Hindfoot moment arm showed subtle modifications. Conclusion: The virtual analysis of Zadek's osteotomy decreased the Fowler Philips angle, shortened the calcaneus, and modified the alignment in the sagittal view. It suggests that Zadek's procedure reduces the bone impingement with Achilles and the Achilles push. The effect of this osteotomy in Hindfoot Alignment was subtle, modifying only the sagittal plane.

Category: Sports; Arthroscopy Introduction/Purpose: Rotational ankle injuries are frequent and mostly benign. However, chronic pain and residual instability following an index rotational trauma can happen. The diagnostic elucidation of the pain source is challenging, with ligamentous insufficiency, osteochondral injuries, and impingement/arthritis representing potential causes for symptoms. The prevalence and pattern of the residual isolated or combined ligamentous ankle instability following rotational injuries are not entirely elucidated in the literature. In this prospective cohort study, we aimed to assess the frequency of combined ligamentous instability (lateral, medial, and syndesmotic) in patients with chronic ankle pain (>6 months) following rotational ankle injuries that failed conservative treatment and underwent surgical treatment. We also aimed to assess improvement in patient-reported outcomes (PROs) following treatment of the diagnosed conditions. Methods: IRB-approved prospective cohort study. We included patients with history of chronic pain (>6 months) following a rotational ankle injury, with clinical signs of combined ligamentous instability of at least two ligamentous complexes (lateral, medial, and syndesmotic), and that failed conservative treatment (>3 months). All patients underwent surgical treatment. Diagnostic arthroscopic assessment was performed. Syndesmotic instability was considered positive if a metallic sphere of 3mm could be inserted in the anterior syndesmotic space. Deep deltoid instability was confirmed with a “pass-through sign” when a 4.0mm shaver could be introduced in the medial gutter. Lateral ankle instability was confirmed with a positive rotatory drawer test under fluoroscopic assessment. Presence of isolated or combined ligamentous instability was noted and patients received appropriate open surgical treatment for the confirmed ligamentous insufficiencies. Presence of associated osteochondral injuries, peroneal pathology and anterior bony impingement was also recorded. PROs were collected pre-operatively and at most recent follow-up. Results: A total of 27 patients were included (9 males/18 females), mean age 35.9 years (range, 18-68) and average BMI 31.3kg/m 2 (CI, 28.1-34.5). Eighty-nine percent had ankle sprains, and 11% rotational ankle fractures treated conservatively. Intraoperative assessment demonstrated positive lateral, medial, and syndesmotic instability in respectively 96%, 81%, and 78% of the patients. Most common combined instabilities were: 59% multidirectional (all three complexes), 19% rotational (medial+lateral), 15% anterolateral (lateral+syndesmotic), and 4% anteromedial (medial+syndesmotic). Isolated lateral instability was present in only one patient (4%). Peroneal tendon pathology, osteochondral injuries and anterior bony impingement were found in respectively 67%, 19%, and 26% of the patients. The average postoperative follow-up was 22.2 months (3-39 months). Significant improvements in VAS (P=0.0024), PROMIS Pain Interference (p=0.024), and EFAS scores (p=0.022) were observed. Conclusion: In this prospective cohort study, combined multiligament instability was extremely frequent in patients with chronic pain following rotational ankle injuries. Ninety-six percent of patients had confirmed intraoperative instability of at least two of the three ankle ligamentous complexes. Multidirectional (lateral, medial, and syndesmotic) (49%), rotational (lateral and medial) (19%), and anterolateral (syndesmotic and lateral) (15%) instabilities were the most frequent injury patterns. Following ligamentous repair/reconstruction, significant improvements in PROs were observed at an average follow-up of 22-months. Our study highlights that the diagnosis of residual multiligament ankle instability should be considered in patients with chronic ankle pain following rotational injuries.

Category: Ankle; Sports Introduction/Purpose: Syndesmotic injuries and residual chronic subtle distal tibiofibular syndesmotic instability (DTFSI) are relatively common injuries, especially in athletes prone to suffering high ankle sprains. The diagnosis of subtle DTFSI remains challenging, with a high prevalence of false-negative results using conventional non-invasive clinical-radiographical diagnostic tools. The current gold standard for diagnosis, arthroscopy, is a surgical operation, which is invasive and, therefore, not ideal. Weightbearing Computed-Tomography (WBCT) has emerged as a possible dynamic non-invasive alternative diagnostic option, with proven high diagnostic accuracy for syndesmotic incisura area measurements in major DTFSI. Our study aimed to assess the capability of semiautomatic weight-bearing computed tomography (WBCT) syndesmotic incisura area in diagnosing subtle chronic syndesmotic instability. Methods: In this diagnostic case-control study, patients with suspected unilateral chronic subtle DTFSI underwent bilateral standing weight-bearing CT (WBCT) before surgical treatment. All patients had gold-standard arthroscopic assessment for DTFSI, introducing a 3mm diameter arthroscopic sphere into the syndesmotic incisura for diagnosis. Bilateral syndesmotic incisura areas were measured 10mm proximally to the apex of the distal tibia articular dome using a semiautomatic measurement algorithm. Two tangent lines marked the anterior and posterior borders of the syndesmotic incisura to the anterior and posterior edges of the distal tibia and fibula. Once borders were marked, the incisura area was automatically calculated by the software based on a Hounsfield units (HU) contrast algorithm. A HU threshold of 200HU was utilized. Measurements were done independently by two fellowship-trained readers. Comparisons between injured and control ankles were made using Student T-test or Wilcoxon, according to normality. Measurements' reliability was assessed with the Intraclass Correlation Coefficient (ICC). Results: From an initial sample of 32 patients, 20 patients (12 female) with arthroscopically confirmed DTFSI (11 right sides) with a mean age of 31.7 years (range 18 to 55 years) and a mean BMI of 30.35kg/m² (SD +/-8.29 kg/m²) were included in the study. All patients had a history of an old ankle sprain 6 to 182 months before the assessment, and athletic lesions were reported in 53% of the population. ICCs were above 0.98 for both intra and interobserver reliability. The average syndesmotic area was 96.91mm 2 (SD +/-27.9mm 2 ) in injured ankles compared to 84.61mm 2 (SD +/-26.9 mm 2 ) in uninjured ankles. The difference between injured and non-injured tibiofibular areas was 12.31mm 2 (95%CI: 9.04-15.58mm 2 ), which was shown statistically significant (p < 0.001; effect size: 1.43). Conclusion: In this case-control study, we assessed the accuracy of semiautomatic WBCT syndesmotic incisura area measurements in diagnosing subtle chronic DTFSI. We found an increased syndesmotic area in injured ankles that reached statistical significance. Due to the minimal differences between injured and uninjured contralateral ankles, larger cohorts would likely solidify this study's findings further. The use of external rotation stress, volumetric assessment, distance, and coverage maps could increase the diagnostic accuracy in DTFSI. However, automatic area measurements have a higher overall reproducibility and applicability in the clinical setting, which could help providers make therapeutic decisions.

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Interpositional arthroplasty (IPA) is a motion-preserving surgery in patients with advanced hallux rigidus. Literature displays several complications after the procedure including transfer metatarsalgia, cock-up deformity and infection. In a finite element model, shortening of the first metatarsal was associated with increased plantar pressure on lateral rays during gait. Additionally, there are reports of a positive correlation between first metatarsal shortening after hallux valgus surgery and transfer metatarsalgia of the second, third and fourth metatarsophalangeal joints. The goals of this study were to report the outcomes and complications of IPA using acellular dermal allograft (IPA-ADA) as well as study the changes in the length of the proximal phalanx of the hallux (P1) and the first metatarsal (M1) following the procedure. Methods: In this IRB-approved retrospective study, we assessed patients who underwent IPA-ADA in a single academic institute during the period 2019-2022. All patients’ demographic data, surgical details, complications, and patient-reported outcomes (PROs) were extracted. On standing conventional anteroposterior (AP) foot views, we measured the lengths of the first metatarsal (M1), the second metatarsal (M2), the proximal phalanx of the big toe (P1) and the entire length of the hallux (HX). The ratio of M1/M2 and P1/HX were calculated. The first metatarsophalangeal joint space was measured at the medial and lateral aspects of the joint on the AP view. All measurements were recorded pre-operatively, at six weeks follow-up and at the final follow-up. Descriptive statistics were performed, comparison between groups was performed using analysis of variance (ANOVA) or Kruskal Wallis test according to data normality. The Dunn-Bonferroni test was then performed for pairwise group comparisons.A p-value < 0.05 was considered significant. Results: Eleven patients were included, 9 being females (81.81%). Six were hallux rigidus Coughlin grade III (54.55%) and 5 were grade IV (45.45%). The average age was 59 years (SD±6.78) and the body mass index (BMI) was 26 (SD±4.79). At the final follow- up, there was significant shortening of the first ray in comparison to the pre-operative length evidenced by lower M1/M2 (82.63 SD±2.29 versus 75.42 SD±5.1; p=0.001) and P1/HX ratio 53.38 ± 2.29 versus 48.98 SD ± 7.92; p=0.001). Although there was no significant difference between M1/M2 at 6 weeks and at the final follow-up (p=0.716), there was a significant negative correlation between follow-up length and M1/M2 (r= -0.76, p=0.003). Follow-up was (19.95 months; range 3-39). Complications and PROs are listed in Figure 1. Conclusion: Interposition arthroplasty using dermal allograft for HR is associated with progressive shortening of the first ray at the level of the first metatarsal as well as the proximal phalanx. Although the study did show shortening of the first ray, the small sample size didn't allow for a correlation between this shortening and complications such as transfer metatarsalgia and cock-up toe deformity. The potential shortening should be considered in the selection of patients, particularly in the setting of an already short first metatarsal or when simultaneous Akin/Moberg osteotomy is planned.

A young man presented with acute stabbing chest pain. A 12-lead electrocardiogram revealed electrical alternans with phasic variation of the QRS amplitude in all leads. Lung auscultation revealed absent left hemithorax breath sounds. Chest radiography confirmed a left-sided tension pneumothorax. Tension pneumothorax is a very rare cause for electrical alternans. (Level of Difficulty: Intermediate.)

Background. Large-airway lymphocytic inflammation (LB), assessed on endobronchial biopsies, has been associated with acute cellular rejection and chronic lung allograft dysfunction (CLAD). Azithromycin (AZI) prophylaxis has been used to prevent airway inflammation and subsequent CLAD, with inconsistent results. We hypothesized that AZI prophylaxis would be associated with reduced LB, changes in bronchoalveolar lavage (BAL) immune cell populations, and improved CLAD-free survival. Methods. We compared frequencies of LB from endobronchial biopsies before (N = 1856) and after (N = 975) protocolized initiation of AZI prophylaxis at our center. LB was classified as none, minimal, mild, or moderate by histopathologic analysis. LB grades were compared using ordinal mixed-model regression. Corresponding automated BAL leukocyte frequencies were compared using mixed-effects modeling. The effect of AZI prophylaxis on CLAD-free survival was assessed by a Cox proportional hazards model adjusted for age, sex, ethnicity, transplant indication, and cytomegalovirus serostatus. Results. Biopsies in the pre-AZI era had 2-fold increased odds (95% confidence interval, 1.5-2.7; P < 0.001) of higher LB grades. LB was associated with BAL neutrophilia in both eras. However, there was no difference in risk for CLAD or death between AZI eras (hazard ratio 1.3; 95% confidence interval, 0.7-2.0; P = 0.45). Conclusions. Decreased airway inflammation in the era of AZI prophylaxis may represent a direct effect of AZI therapy or reflect other practices or environmental changes. In this cohort, AZI prophylaxis was not associated with improved CLAD-free survival.

Summary:. In sub-Saharan Africa, options for reconstruction of traumatic injuries are limited due to lack of access to microsurgery-trained surgeons. Recently, the Plastic Surgery Foundation-sponsored Surgeons in Humanitarian Alliance for Reconstruction, Research and Education group hosted a virtual microsurgery skills course for junior plastic surgeons in this region. In this report, we describe a case of complete brachial artery transection requiring microsurgical techniques and use of vein graft for repair at our provincial hospital in Mozambique. By highlighting this case, we aimed to describe a direct clinical application of the Surgeons in Humanitarian Alliance for Reconstruction, Research and Education virtual microsurgery skills course and to demonstrate the profound impact such courses can have on patient outcomes in low-and middle-income countries with limited or no access to microsurgery-trained surgeons. Further, through newly gained familiarity with standard microsurgery instruments used in reconstructive procedures, we were able to improvise and develop modified instruments to overcome lack of resources at our institution.

Background: We designed a prospective feasibility study to assess the 5x-multiplier (5x) calculation (eg, 3 pills in last 24 hours × 5 = 15) to standardize discharge opioid prescriptions compared to usual care. Methods: Faculty-based surgical teams volunteered for either 5x or usual care arms. Patients undergoing inpatient (≥48 hours) surgery and discharged by surgical teams were included. The primary end point was discharge oral morphine equivalents. Secondary end points were opioid-free discharges and 30-day refill rates. Results: Median last 24-hour oral morphine equivalents was similar between arms (7.5 mg 5x vs 10 mg usual care, P = .830). Median discharge oral morphine equivalents were less in the 5x arm (50 mg 5x vs 75 mg usual care, P

Introduction: Ticagrelor might reduce infarct size by exerting a more potent antiplatelet effect or by promoting a potential conditioning stimulus in ST-elevation myocardial infarction (STEMI) patients. Pre-infarction angina (PIA) is an effective preconditioning stimulus that reduces ischemia-reperfusion injury. Because little is known on the interaction of PIA in STEMI-patients loaded with ticagrelor, we sought to determine if patients loaded with ticagrelor had improved clinical outcomes as compared to clopidogrel and to study if it is modulated by the presence of PIA. Methods: From 1272 STEMI patients submitted to primary percutaneous coronary intervention and treated with clopidogrel or ticagrelor from January 2008 to December 2018, 826 were analyzed after propensity score matching. Infarct size was estimated using peak creatine kinase (CK) and troponin T (TnT), and clinical impact was evaluated through cumulative major cardiac and cerebrovascular events (MACCE) at 1-year follow-up. Matched patients and their interaction with PIA were analyzed. Results: Patients loaded with ticagrelor had lower peak CK [1405.50 U/L (730.25-2491.00), P < .001] and TnT [3.58 ng/mL (1.73-6.59), P < .001)], regardless of PIA. The presence of PIA was associated with lower CK ( P = .030), but not TnT ( P = .097). There was no interaction between ticagrelor loading and PIA ( P = .788 for TnT and P = .555 for CK). There was no difference in MACCE incidence between clopidogrel or ticagrelor loading ( P = .129). Cumulative survival was also similar between clopidogrel or ticagrelor, regardless of PIA ( P = .103). Conclusion: Ticagrelor reduced infarct sizes independently and without a synergic effect with PIA. Despite reducing infarct size, clinical outcomes were similar across both groups.

BACKGROUND: Childbirth via cesarean delivery can prevent intrapartum vertical transmission for women who are not virally suppressed at the time of delivery. Few studies have compared cesarean delivery trends between women living with HIV and women without HIV and have examined the role of cesarean delivery in the prevention of vertical transmission in the era of potent combination antiretroviral therapy. OBJECTIVE: We hypothesized that the cesarean delivery rate is high in women living with HIV compared with women without HIV and that cesarean delivery usage decreases over time among women living with HIV with advances in combined antiretroviral therapy in a country with a high national cesarean delivery rate. This study aimed (1) to evaluate cesarean delivery trends in women with and without HIV and (2) to examine its role in preventing vertical transmission among women living with HIV in a setting of free, universal combined antiretroviral therapy coverage in a retrospective cohort of nearly 56,000 deliveries at a major referral institution in a city with the highest prevalence of maternal HIV in Brazil. STUDY DESIGN: Data from maternal-infant pairs from January 1, 2008, to December 31, 2018, were extracted. Cesarean delivery rates were compared using the Pearson chi-square test. Cesarean delivery predictors were evaluated by multivariate log-linear Poisson regression using a generalized estimating equations approach. HIV viral suppression was defined as a viral load of

Echinococcus granulosus infection is the primary cause of spinal hydatidosis. We describe the case of a 22-year-old man from the Brazilian Amazon region with crural spastic paraparesis and back pain. Radiological examinations showed multilocular lesions involving compression of the thoracic spine and rib injury. The patient underwent vertebrectomy with spinal stabilization and thoracoplasty with resectioning of the costal arch. Subsequently, the patient was prescribed oral treatment with albendazole. Marked recovery of the neurological status was achieved. Bone hydatid disease is rare, accounting for 0.5%-0.4% of all hydatid cysts, affecting the spine in 50% of cases. The treatment of choice is surgery accompanied by antiparasitic medication.

Background: Few studies have compared conventional and self-assisted shoulder reduction maneuvers. The goal of this study was to evaluate the results of self-assisted Davos vs. traction/countertraction (T/Ct) techniques in the treatment of acute anterior shoulder dislocations. Methods: This was a single-center, prospective study carried out at a tertiary hospital emergency department. Patients aged 18-69 years old, with radiographic confirmation of anterior glenohumeral dislocations, were consecutively allocated to treatment groups. Recorded data included pain at admission (visual analog scale [VAS] score at admission), analgesia before reduction, maximum pain during reduction (maximum VAS score), demographic characteristics, lesion mechanism, laterality, prior dislocation, and immediate complications. The primary outcomes were reduction success rate and pain. Results: Eighty individuals were included (40/group). Regarding the success rate, no statistically significant differences were found between Davos or T/Ct (87.5% vs. 85%; P = .058). The maximum VAS score was significantly lower in Davos than that in T/Ct (4.18 ± 2.00 vs. 6.30 ± 2.13; P

Whipple's disease is a rare chronic infectious disease, caused by Tropheryma whipplei. The disease can be challenging to diagnose due to the variable clinical manifestations and the nonspecific laboratory and imaging findings. We report the case of a 75-year-old man, complaining of weight loss and arthralgias with an insidious onset. A thoracic, abdominal and pelvic CT was performed, demonstrating features suggestive of Whipple's disease. Although not specific, the imaging findings of fatty attenuation mesenteric and retroperitoneal enlarged lymph nodes are a common finding in Whipple's disease. Esophagogastroduodenoscopy with duodenal biopsy confirmed the diagnosis through PCR analysis.

Background: Tibiotalocalcaneal arthrodesis is a well-established procedure to treat some hindfoot diseases. Currently, the most used implants are retrograde intramedullary nails and locking plates combined with lag screws, but there are few articles comparing differences regarding the complications. Methods: We have retrospectively analyzed the medical records and the radiographs of patients older than 18 years who underwent this procedure in our service between 2005 and 2019 through retrograde intramedullary nails or lateral locking plates and compression screws with at least 12 months of follow-up and with no history of osteomyelitis in these bones. Results: We evaluated a total of 67 patients; of these, 48 received retrograde intramedullary nail implants and 19 received locking plates and compression screws. The overall mean age was 48 years; the median follow-up time was 64.3 months. The complication rate was 60.4% for the intramedullary nail procedure and 52.6% for the locking plate combined with compression screws procedure. Conclusion: No significant differences were found in the complication rates between the 2 implants. Level of Evidence: Level V, Case series

Background: While several scoring systems for the severity of anaphylactic reactions have been developed, there is a lack of consensus on definition and categorisation of severity of food allergy disease as a whole. Aim: To develop an international consensus on the severity of food allergy (DEfinition of Food Allergy Severity, DEFASE) scoring system, to be used globally. Methods: Phase 1: We conducted a mixed-method systematic review (SR) of 11 databases for published and unpublished literature on severity of food allergy management and set up a panel of international experts. Phase 2: Based on our findings in Phase 1, we drafted statements for a two-round modified electronic Delphi (e-Delphi) survey. A purposefully selected multidisciplinary international expert panel on food allergy (n = 60) was identified and sent a structured questionnaire, including a set of statements on different domains of food allergy severity related to symptoms, health-related quality of life, and economic impact. Participants were asked to score their agreement on each statement on a 5-point Likert scale ranging from “strongly agree” to “strongly disagree”. Median scores and percentage agreements were calculated. Consensus was defined a priori as being achieved if 70% or more of panel members rated a statement as “strongly agree” to “agree” after the second round. Based on feedback, 2 additional online voting rounds were conducted. Results: We received responses from 92% of Delphi panel members in round 1 and 85% in round 2. Consensus was achieved on the overall score and in all of the 5 specific key domains as essential components of the DEFASE score. Conclusions: The DEFASE score is the first comprehensive grading of food allergy severity that considers not only the severity of a single reaction, but the whole disease spectrum. An international consensus has been achieved regarding a scoring system for food allergy disease. It offers an evaluation grid, which may help to rate the severity of food allergy. Phase 3 will involve validating the scoring system in research settings, and implementing it in clinical practice.

Objective: In the present report, we have described the technical and clinical outcomes of percutaneous thrombectomy in the deep veins of the upper extremity and thorax using the ClotTriever system (Inari Medical, Irvine, CA). Methods: Fourteen patients with symptomatic deep venous occlusive disease in the upper extremity deep veins and thoracic central veins who had undergone thrombectomy using the ClotTriever system between October 2020 and January 2022 were reviewed. The technical results, adverse events, imaging follow-up data, and clinical outcomes were recorded. Results: Fourteen patients (seven men and seven women; mean age, 53.6 ± 13.3 years) constituted the study cohort. Of the 14 patients, 9 (64.3%) had had DVT due to intravascular invasion or external compression from known malignancy, 2 (14.3%) had had infected thrombi and/or vegetation due to Staphylococcus aureus refractory to intravenous antibiotic therapy, and 3 (21.4%) had had a benign etiology for thrombus formation. The presenting symptoms included upper extremity and/or facial swelling (n = 14), upper extremity pain (n = 6), fever (n = 2), and dyspnea (n = 1). Thrombectomy with the ClotTriever system was successfully completed in all 14 patients. Seven patients (50.0%) had required additional venous stent reconstruction after thrombectomy to address the underlying stenosis. No major adverse events were noted. All the patients had experienced resolution of the presenting symptoms. Conclusions: For the management of symptomatic deep venous occlusive disease of the upper extremity deep veins and thoracic central veins, thrombectomy using the ClotTriever system was feasible with excellent technical and clinical success.

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Kim et al.'s simulated weight-bearing CT (WBCT) investigation classifying first metatarsal (M1) pronation and its relationship to the metatarso-sesamoid complex suggested a high prevalence (87.3%) of M1 hyper-pronation in hallux valgus (HV). These authors' conclusions have prompted a marked increase in M1 derotation (supination) in HV surgical correction. No subsequent study confirms their M1 pronation values, and two recent WBCT investigations suggest lower normative M1 pronation values. The objectives of our WBCT study were to (1) determine M1 pronation distribution in HV, (2) define the hyperpronation prevalence compared to preexisting normative values, and (3) assess the relationship of M1 pronation to the metatarso-sesamoid complex. We hypothesized identifying a high HV M1 head pronation distribution, but not as high as suggested by Kim et al. Methods: We retrospectively identified 88 consecutive feet with HV in our WBCT dataset and measured M1 pronation with two previously validated methods, the Metatarsal Pronation (MPA) and α angles. Similarly, using two previously published methods defining the pathologic pronation threshold, we assessed our cohort's M1 hyper-pronation prevalence, specifically (1) the upper value of the 95% confidence interval (CI95) and (2) adding 2 standard deviations at the mean normative value (2SD).The position of the sesamoids relative to the crista on the axial plane (sesamoid grading) was assessed according to Talbot et al. classification secondarily adapted by Yildirim et al. on CT scan (Figure).Normality of different variables was assessed using the Shapiro-Wilk test and distribution histogram. Two groups were compared using Student's t-test for normal, and Mann-Whitney U test for non- normal variables. P values less than .05 were considered significant. Results: The mean MPA was 11.4+/-7.4 degrees (IC95%:9.9-13.0; Range: -2.3-37.1) in our HV population and the α angle was 16.2+/-7.4 degrees (IC95%:14.7-17.7; Range: 2.8-43.2). A strong positive correlation was found between these two variables (ρ=0.82;r2=0.79;P

Category: Bunion; Lesser Toes; Midfoot/Forefoot Introduction/Purpose: Hallux valgus deformity (HVD) is a complex 3D distortion that involves varus, dorsiflexion and pronation of the first metatarsal. Deformity is usually assessed by conventional 2D measurements such as hallux valgus and intermetatarsal angle. Weightbearing CT (WBCT) 3D Distance Mapping (DM) and Coverage Mapping (CM) allow assessment of relative positioning between opposing articular surfaces, providing information in regards to articular coverage and joint subluxation, that can potentially influence development of arthritic degeneration and symptoms, as well as dictate outcomes. The aim of this study was to develop a DM and CM algorithm to assess metatarsophalangeal (MTP) and metatarso-sesamoid (MS) joint interaction in HVD patients and compare it to healthy controls. We hypothesized that significant MTP and MS joints lateral subluxation would be observed. Methods: In this IRB-approved study, we included 9 HVD patients (mean age 37.1y; 6F/3M) and 5 controls (mean age 39y; 4F/1M) that underwent foot WBCT foot. Bone segmentation of WBCT images for the first and second metatarsals, first and second proximal phalanxes as well as tibial and fibular sesamoids was performed using specific software. Joint interaction with DM and CM of the first and second MTP joints, as well as MS joints were calculated. The surface of the MTP joints were divided in a 2x2 grid using principal axes to provide a more detailed analysis. DMs were color coded to facilitate data interpretation (Figure). Blue color represented expected normal joint interaction (distances from 1 to 3 mm), yellow/red color symbolized increased joint distances (distances from 3 to 5 mm) and pink color indicate completely uncovered articular areas (distances >5mm). Comparisons were performed with independent t-tests/Wilcoxon. P values

Category: Midfoot/Forefoot Introduction/Purpose: Weight-Bearing Computed Tomography (WBCT) measurements represent a reliable tool for radiographic analysis of the first ray, including multiplanar assessment in the axial, sagittal, and coronal planes. WBCT can allow for more reliable studies of pathologies, such as Hallux Rigidus (HR), which permits several anatomical points to be evaluated for a correct clinical-radiographic diagnosis. In addition, new software with an advanced semi-automated segmentation system obtains semi-automatic 3D measurements of WBCT scan data sets, minimizing the errors in reading angular measurements. The study`s objective was (1) to assess the reliability of WBCT computer-assisted semi-automatic imaging measurements in HR, (2) to compare semi-automatic to manual measurements in the setting of HR, and (3) to compare semi-automatic measurements between a pathologic (HR) group and a control standard group. Methods: This was a retrospective, IRB approved study of patients with Hallux Rigidus deformity. The sample size calculation was based on the Metatarsus Primus Elevatus (MPE). A control group consisting of 20 feet without HR and a pathologic group consisting of 20 feet with HR was necessary for this study. All WBCT manual and semiautomatic 3D measurements were performed using the following parameters: (1) first Metatarsal-Proximal Phalanx Angle (1stMPP) (sagittal plane), (2) Hallux Valgus Angle (HVA), (3) first to second Intermetatarsal Angle (IMA), (4) Hallux Interphalangeal Angle (IPA), (5) first Metatarsal Lengths (1stML), (6) second Metatarsal Length (2ndML), (7) first Metatarsal Declination Angle (1stMD), (8) second Metatarsal Declination Angles (2ndMD), and (9) MPE. The semiautomatic 3D measurements were performed using the Bonelogic Software. The differences between pathologic and control cases were assessed with a Wilcoxon test and P

BACKGROUND: Pregnancy loss is poorly understood, but infection may be a risk factor. Few studies have evaluated pregnancy loss among women living with HIV in the era of potent combination antiretroviral therapy. OBJECTIVE: We hypothesize that maternal HIV and syphilis infection lead to increased risk of pregnancy loss, including both miscarriage and stillbirth. This study aimed to assess trends and possible predictors of spontaneous miscarriage and stillbirth among women living with HIV in a cohort of nearly 56,000 deliveries at a major referral institution in a city with the highest prevalence of HIV in Brazil. STUDY DESIGN: Data from hospital records for women delivering from January 1, 2008 to December 31, 2018 were reviewed. Rates of stillbirth, miscarriage, and any pregnancy loss were compared using the Pearson chi-square test. Predictors of pregnancy loss were evaluated by robust univariate log-linear Poisson regression using a generalized estimating equations approach. RESULTS: A total of 55,844 pregnancies were included in the analysis, with 54,308 pregnancies from 43,502 women without HIV and 1536 pregnancies from 1186 women living with HIV (seroprevalence of maternal HIV: 2.7%). Overall, 1130 stillbirths (2.0%) and 6558 miscarriages (11.7%) occurred. Any pregnancy loss was similar in both groups (13.8% in women without and 14.1% in women with HIV; P=.733). Stillbirth was higher among women living with HIV (3.4%) than among women without HIV (2.0%; P