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Objective: Static cold storage with ice has been the mainstay of cardiac donor preservation. Early preclinical data suggest that allograft preservation at 10 °C may be beneficial. We tested this hypothesis by using a static 10 °C storage device to preserve and transport cardiac allografts. Methods: In total, 52 allografts were recovered between July 2023 and March 2024 and transported using a 10 °C storage cooler. Results were compared to a 3:1 propensity match of allografts transported on ice. Patients were excluded for the following reasons: dual viscera transplant, previous heart transplant, complex congenital heart disease, or allograft injury during procurement. Results: Among the 10 °C cooler cohort, median total ischemic time was 222 minutes at 10 °C versus 193 minutes on ice (P .99). 10 °C hearts demonstrated less change in lactate but no difference in vasoactive inotrope scores or cardiac index. In hearts with extended ischemic time, delta lactate was lower in 10 °C cooler hearts. There was no statistical difference in outcomes for donor hearts >40 years old. Conclusions: This is an early experience of static preservation in a 10 °C cooler. Postoperative allograft function was excellent, and lactate profiles lower in those allografts with extended ischemic times. Static cold storage targeting 10 °C may offer an inexpensive method for extended heart preservation. Further investigation is needed to assess long-term outcomes of 10 °C storage.

Objective: Coronary artery disease remains a leading cause of morbidity and mortality worldwide. Patients with advanced coronary artery disease who are not eligible for endovascular or surgical revascularization have limited options. Extracellular vesicles have shown potential to improve myocardial function in preclinical models. Extracellular vesicles can be conditioned to modify their components. Hypoxia-conditioned extracellular vesicles have demonstrated the ability to reduce infarct size and apoptosis in small animals. Our objective is to assess the potential benefits of hypoxia-conditioned extracellular vesicles in a large animal model of coronary artery disease. Methods: Coronary artery disease was induced in 14 Yorkshire swine by ameroid constriction of the left circumflex coronary artery. Two weeks postsurgery, swine underwent a repeat left thoracotomy for injections of hypoxia-conditioned extracellular vesicles (n = 7) or saline (control, n = 7). Five weeks later, all animals underwent terminal harvest for perfusion measurements and myocardial sectioning. Results: Myocardial perfusion analysis demonstrated a trend toward increase at rest and a significant increase during rapid pacing (P = .09, P

Brain arteriovenous malformations (AVM) present complex treatment decisions, particularly for low-grade AVM where surgical resection is often considered the standard. This case report emphasizes the importance of patient preferences and cultural considerations in selecting endovascular embolization over traditional surgical approaches for Spetzler-Martin Grade I AVM management, highlighting the evolving practice of patient-centered care in neurointervention. A 30-year-old male presented with recurrent seizures, characterized by a sudden onset of headache followed by speech arrest, without any preceding medical history of neurological deficits. Initial physical examination revealed no focal neurological deficits. Non-contrast computed tomography, magnetic resonance imaging, and magnetic resonance angiography suggested an AVM involving the cortical-subcortical regions of the left frontal lobe, measuring approximately 1.7 × 2.6 × 1.5 cm, fed by the left middle cerebral artery M3 segment, and draining into the superior sagittal sinus. Spetzler-Martin Grade I classification was confirmed via digital subtraction angiography. Given the patient's strong preference against invasive procedures, driven by personal and cultural beliefs, endovascular embolization was selected as the treatment strategy. Post-embolization, the patient showed marked symptomatic improvement with no evidence of residual AVM on follow-up imaging, and no postprocedure complications were reported. This case highlights the importance of considering patient preferences in AVM treatment planning, illustrating that endovascular embolization can be an effective and less invasive alternative to surgery in selected patients, reinforcing the need for personalized, patient-centered approaches in neurointerventional care.

Purpose To compare outcomes, between stemmed and stemless reverse shoulder arthroplasty (RSA) at a minimum follow-up of 5 years. Methods The authors retrospectively assessed a consecutive series of 45 patients that underwent RSA between September 2014 and October 2018 (23 stemless and 22 stemmed). All patients underwent plain anteroposterior and scapular Y-view radiographs for assessment immediately post-operatively and at final follow-up. At a minimum follow-up of 5 years, an independent observer assessed the clinical scores, including Constant score, QuickDASH score, and American Shoulder and Elbow Surgeons score. Results Of the 45 patients that underwent RSA, 5 patients died (11%), 2 were revised due to infection (4%), and 4 patients were lost to follow-up (9%). This left a final cohort of 34 patients (18 stemless and 16 stemmed). Significant differences between groups were found immediately post-operatively for lateralisation shoulder angle (LSA) (p = 0.021), but at 5 years post-operative for distalisation shoulder angle (DSA) (p = 0.017) and QuickDASH scores (p = 0.041) (Table 4), while the outcomes were comparable for absolute Constant scores, ASES score, and range of motion. Finally, stemless RSA had a 17% complication rate, while stemmed RSA had a 31% complication rate. Conclusion Stemless RSA had significantly more lateralisation, and significantly less distalisation, compared to stemmed RSA. Furthermore, at a 5-year follow-up, stemless RSA granted significantly greater QuickDASH scores. Finally, stemless RSA had comparable complication rates as stemmed RSA. The clinical relevance of this study is that stemless RSA is a safe alternative to stemmed RSA, while granting comparable or greater scores. Level of Evidence: III, Comparative Study

Objectives: To identify patient and process factors that contribute to the high cost of lung transplantation (LTx) in the perioperative period, which may allow transplant centers to evaluate situations in which transplantation is most cost-effective to inform judicious resource allocation, avoid futile care, and reduce costs. Methods: The MarketScan Research databases were used to identify 582 privately insured patients undergoing single or bilateral LTx between 2013 and 2019. The patients were subdivided into groups by disease etiology using the United Network of Organ Sharing classification system. Multivariable generalized linear models using a gamma distribution with a log link were fit to examine the associations between the etiology of lung disease and costs during the index admission, 3 months before admission, and 3 months after discharge. Results: Our results indicate that the index admission contributed the most to the total transplantation costs compared to the 3 months before admission and after discharge. The regression-adjusted mean index hospitalization cost was 35% higher for patients with pulmonary vascular disease compared to those with obstructive lung disease ($527,156 vs $389,055). The use of extracorporeal membrane oxygenation, mechanical ventilation, and surgical complications in the post-transplantation period were associated with higher costs during the index admission. Surprisingly, age ≥55 was associated with lower costs during the index admission. Conclusions: This analysis identifies pivotal factors influencing the high cost of LTx, emphasizing the significant impact of the index admission, particularly for patients with pulmonary vascular disease. These insights offer transplant centers an opportunity to enhance cost-effectiveness through judicious resource allocation and service bundling, ultimately reducing overall transplantation costs.

Lifestyle factors and their impact on cancer prevention, prognosis, and survivorship are increasingly recognized in the medical literature. Lifestyle factors are primarily defined here as diet and physical activity. We conducted a narrative review of the primary published data, including randomized controlled trials and prospective studies, on the impact of primary lifestyle factors on oncogenesis and clinical outcomes in the preventative and survivorship setting. First, we discuss the oncogenic mechanisms behind primary lifestyle factors (diet, physical activity and, within these 2, obesity). Then, we discuss the impact of adherence to lifestyle guidelines and dietary patterns on cancer incidence based on primary data. Owing to the plethora of published literature, to summarize the data in a more efficient manner, we describe the role of physical activity on cancer incidence using summative systematic reviews. We end by synthesizing the primary data on lifestyle factors in the survivorship setting and conclude with potential future directions. In brief, the various large-scale studies investigating the role diet and physical activity have reported a beneficial effect on cancer prevention and survivorship. Although the impact of single lifestyle factors on cancer incidence risk reduction is generally supported, holistic approaches to address the potential synergistic impact of multiple lifestyle factors together in concert is limited. Future research to identify the potentially synergistic effects of lifestyle modifications on oncogenesis and clinical outcomes is needed, particularly in cancer subtypes beyond colorectal and breast cancers.

Purpose: Pelvic lymph node metastases (ypN+) after multiagent neoadjuvant chemotherapy (NAC) is a poor prognostic sign in nonmetastatic muscle-invasive bladder cancer (nmMIBC). We sought to create a nomogram predicting probability of ypN+ after NAC for cN0 nmMIBC and determine association with overall survival (OS). Methods and Materials: We reviewed the National Cancer Database for patients with cT2-4N0M0 urothelial carcinoma of the bladder receiving multiagent NAC and surgery from 2004 to 2020. Following a data split, univariate logistic regression identified variables associated with ypN+ at P < .05. Eligible variables were used for multivariate logistic regression and nomogram generation. A threshold for 95% sensitivity defined high- and low-risk groups for ypN+. Fine–Gray models assessed ypN+ risk group and OS, accounting for competing risks of surgical mortality. Results: A total of 6194 patients were identified with a median follow-up of 39.5 months (interquartile range [IQR], 20.5-67.2 months). Most patients had high-grade (97.7%) cT2 disease (70.8%) with nonpapillary urothelial histology (67.3%) and initiated NAC at a median of 41.0 days after diagnosis (IQR, 28.0-59.0 days).The nomogram included age in decades (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.87–1.03; P = .172), weeks from diagnosis to NAC (OR, 1.02; 95% CI, 1.01-1.04; P = .004), nonpapillary histology (OR, 1.17; 95% CI, 0.99-1.39; P = .068), and clinical T-stage. Within the testing cohort, ypN+ was found in 392 (22.8%) high-risk and 12 (8.0%) low-risk patients (P < .001), with median OS of 36.1 and 74.0 months, respectively (P < .001). High-risk patients had worse OS despite competing risks of 30-day (subdistribution hazard ratio [SHR], 1.80; 95% CI, 1.49-2.18; P < .001) and 90-day surgical mortality (SHR, 1.68; 95% CI, 1.39-2.04; P < .001). Conclusions: This is the first study to provide a tool for predicting ypN+ and prognosticate worse OS in primarily high-grade nmMIBC and could select patients for alternative neoadjuvant therapy and facilitate future study.

Evaluating stroke campaigns and associated behavioural changes is crucial to assess intervention effectiveness and inform future strategies. We aimed to evaluate patient's and bystanders’ foreknowledge of stroke signs and symptoms and their response at stroke onset. We interviewed stroke patients using a validated questionnaire or their bystanders if the stroke patient had disabling stroke. The questionnaire was administered to 165 participants, 142 (86.1%) stroke patients and 23 (13.9%) bystanders. The mean age was 52.6 (SD = 11.7), and male–female ratio was 7:1. Among the participants, 33 (20.1%) had foreknowledge of stroke signs, and of these, 27 (16.5%) were aware of the stroke campaign in Qatar. The behavioural responses at stroke onset included; activating Emergency Medical Services (EMS) ( n = 55, 33.3%), calling friends/relatives ( n = 69, 41.8%), driving to hospital ( n = 33, 20%), waiting for improvement in condition ( n = 21, 12.7%). There was no association of ethnicity, marital status, or campaign awareness with EMS activation. Despite limited community awareness of stroke signs and campaign, help-seeking behaviour through EMS activation was generally high, underscoring the need for focused educational efforts and public health interventions.

Introduction:. The role of elective rotations in the orthopaedic residency selection process varies between programs. Our study aims to identify factors associated with residency programs that interview and match a greater proportion of applicants who have completed an elective rotation with their program. Methods:. Data were collected through the American Orthopaedic Association's Orthopaedic Residency Information Network database. Bivariate correlations and multivariate regression models were used to identify independent predictors of programs with a greater proportion of interviewees or residents who completed an elective rotation at the respective program. Results:. One hundred seventy-eight of the 218 existing residency programs were included in this study. Programs that offered fewer interviews and more away rotation positions per year were associated with a greater odds of its interviewees (OR = 0.36, p = 0.01; OR = 4.55, p < 0.001, respectively) and residents (OR = 0.44, p = 0.04; OR = 4.23, p < 0.001, respectively) having completed an elective rotation with the program. In addition, programs with fewer attendings (OR = 0.39, p = 0.03) and in-person interviews (OR = 3.04, p = 0.04) matched a greater proportion of their rotators. However, programs that interviewed applicants during the elective rotation were less likely to match their rotators (OR = 0.35, p = 0.04). Conclusion:. Certain program characteristics independently predict the likelihood of a program interviewing and matching their rotators. These findings may provide information for applicants and programs regarding the rotation process. Level of Evidence:. III.

Objective: To determine the change in rates of physical restraint (PR) use and associated outcomes among hospitalized adults. Patients and Methods: Using national inpatient sample databases, we analyzed years 2011-2014 and 2016-2019 to determine trends of PR usage. We also compared the years 2011-2012 and 2018-2019 to investigate rates of PR use, in-hospital mortality, length of stay, and total hospital charges. Results: There were 242,994,110 hospitalizations during the study period. 1,538,791 (0.63%) had coding to signify PRs, compared with 241,455,319 (99.3%), which did not. From 2011 to 2014, there was a significant increase in PR use (p-trend

Background: Coronary artery disease remains a leading cause of death worldwide. Bone mesenchymal stem cell–derived extracellular vesicles (EVs) have shown promise in the setting of myocardial ischemia. Furthermore, the properties of the EVs can be modified via preconditioning of progenitor cells. Previous research from our lab demonstrated a significant decrease in proinflammatory signaling following treatment with EVs derived from starvation preconditioning of human bone mesenchymal stem cells (MVM EVs) in a porcine model of chronic myocardial ischemia. However, rodent models have demonstrated that the use of EVs derived from hypoxia preconditioning of bone mesenchymal stem cells (HYP EVs) may have extended benefits compared to MVM EVs. This study evaluated the effect of HYP EVs on inflammation in a swine model of chronic myocardial ischemia. We hypothesized that HYP EVs would have a greater anti-inflammatory effect than MVM EVs or saline (CON). Methods: Yorkshire swine fed a standard diet underwent placement of an ameroid constrictor to the left circumflex artery. Two weeks later, the animals received intramyocardial injection of saline (CON; n = 6), starvation-derived EVs (MVM; n = 10), or hypoxia-derived EVs (HYP; n = 7). After 5 weeks, myocardial perfusion was assessed, and left ventricular myocardial tissue was harvested. Protein expression was measured using immunoblotting. Data were analyzed via the Kruskal-Wallis test or one-way analysis of variance based on the results of a Shapiro-Wilk test. Coronary perfusion was plotted against relative cytokine concentration and analyzed with the Spearman rank-sum test. Results: HYP EV treatment was associated with decreased expression of proinflammatory markers interleukin (IL)-6 (P = .03), Pro-IL-1ß (P = .01), IL-17 (P

Background: It is unclear whether the use of higher dialysate bicarbonate concentrations is associated with clinically relevant changes in the pre-dialysis serum bicarbonate concentration. Objective: The objective is to examine the association between the dialysate bicarbonate prescription and the pre-dialysis serum bicarbonate concentration. Design: This is a retrospective cohort study. Setting: The study was performed using linked administrative health care databases in Ontario, Canada. Patients: Prevalent adults receiving maintenance in-center hemodialysis as of April 1, 2020 (n = 5414) were included. Measurements: Patients were grouped into the following dialysate bicarbonate categories at the dialysis center-level: individualized (adjustment based on pre-dialysis serum bicarbonate concentration) or standardized (>90% of patients received the same dialysate bicarbonate concentration). The standardized category was stratified by concentration: 35, 36 to 37, and ≥38 mmol/L. The primary outcome was the mean outpatient pre-dialysis serum bicarbonate concentration at the patient level. Methods: We examined the association between dialysate bicarbonate category and pre-dialysis serum bicarbonate using an adjusted linear mixed model. Results: All dialysate bicarbonate categories had a mean pre-dialysis serum bicarbonate concentration within the normal range. In the individualized category, 91% achieved a pre-dialysis serum bicarbonate ≥22 mmol/L, compared to 87% in the standardized category. Patients in the standardized category tended to have a serum bicarbonate that was 0.25 (95% confidence interval [CI] = −0.93, 0.43) mmol/L lower than patients in the individualized category. Relative to patients in the 35 mmol/L category, patients in the 36 to 37 and ≥38 mmol/L categories tended to have a serum bicarbonate that was 0.70 (95% CI = −0.30, 1.70) mmol/L and 0.87 (95% CI = 0.14, 1.60) mmol/L higher, respectively. There was no effect modification by age, sex, or history of chronic lung disease. Limitations: We could not directly confirm that all laboratory measurements were pre-dialysis. Data on prescribed dialysate bicarbonate concentrations for individual dialysis sessions were not available, which may have led to some misclassification, and adherence to a practice of individualization could not be measured. Residual confounding is possible. Conclusions: We found no significant difference in the pre-dialysis serum bicarbonate concentration irrespective of whether an individualized or standardized dialysate bicarbonate was used. Dialysate bicarbonate concentrations ≥38 mmol/L (vs 35 mmol/L) may increase the pre-dialysis serum bicarbonate concentration by 0.9 mmol/L.

Background: Open access (OA) publications are increasingly common in orthopaedic literature. However, whether OA publications are associated with increased readership or citations among total ankle arthroplasty (TAA) literature is unclear. We hypothesize that compared with non-OA status, OA status is associated with increased social media dissemination, and readership, but not with citation count. This study aimed to analyze social media attention, citations, readership, and cost of TAA OA and non-OA publications. Methods: Using a PubMed query search, there were 368 publications from 81 journals, with 25% (91/368) being OA articles and 75% (277/368) non-OA articles from 2016 to 2023. We analyzed the Altmetric Attention Score (AAS), Mendeley readership score, and citations between OA vs non-OA articles. Citations and cost of OA articles were determined using an altered timeline and publisher’s website, respectively. Subgroup analysis was performed among articles published in the top 5 TAA journals (Tables 2 and 3). Negative binomial regression was used while adjusting for days since publication. Significance was considered at P

Introduction/Purpose: Chondral injuries of the ankle are common, often requiring surgical intervention. The purpose of this multicenter study of ankle osteochondral injuries is to report minimum one year outcomes for patients undergoing arthroscopic surgical treatment. Methods: Thirty-nine patients undergoing arthroscopic surgery to treat chondral ankle injuries between December 2017 and January 2022 were enrolled in the present multicenter study. Intraoperative information including diagnoses and procedures performed were recorded. All patients completed the Visual Analog Scale for Pain (VAS), the Veteran RAND 12-Item Health Survey (VR-12) Physical and Mental component scales, and Foot and Ankle Ability Measure Sports subscale (FAAM-S). These measures were collected at the pre-operative visit within two weeks before surgery and at a minimum of one year post- operatively. Patient demographics and perioperative complications were also recorded. Paired T-test was used to determine statistical significance. Results: Of the thirty-nine patients with a minimum of 1 year follow-up, the average age was 46 years old and 51% were male. Average patient BMI was 29. Laterality was right in 54% of the patients, and 8% of surgeries were revisions. Relative to baseline, there was a significant decrease in VAS at minimum 1-year post-operatively (4.9 to 1.7, p< 0.001). Additionally, the VR-12 Physical was significantly higher at minimum 1-year post-operatively (35.4 to 46.8, p< 0.001). The VR-12 Mental was also significantly higher at minimum 1-year post-operatively (47.6 to 54.6, p=0.005). Finally, there was a significant increase in FAAM Sports (11.3 to 34.0, p< 0.001). There were no recorded complications. Conclusion: For patients undergoing arthroscopic surgery to treat chondral ankle injuries, our study found significant improvements in self-reported pain, overall physical health, overall mental health, and sport activities at minimum one-year follow- ups with no complications.

We present a case of a 70-year-old male who was brought to the hospital with altered mental status and was found to have 2 serious complications of cocaine use which are Cerebellar Hippocampal and Basal Nuclei Transient Edema with Restricted diffusion (CHANTER) syndrome and mesenteric ischemia. CHANTER syndrome is a recently described constellation of radiologic and clinical findings and has a strong association with opiates, and/or other drugs of abuse, including cocaine. Even though CHANTER has many similarities with other ischemic, anoxic, and/or toxic injuries related to substance abuse such as clinical presentation and restricted diffusion on magnetic resonance imaging (MRI); the typical distribution of affected regions in the brain is helpful in differentiating from other injuries. With this study, we aim to emphasize the clues that separate CHANTER syndrome from other acute neurologic problems in the setting of substance use. Our case also suggests that the obstructive hydrocephalus, a known possible complication of CHANTER, is likely seen in the cases with severe and central cerebellar involvement. Additionally, it is not common to see complications in 2 different systems concurrently and a multisystemic approach is crucial to a patient with cocaine use to prevent missed life-threatening consequences throughout the various body systems.

Objective: Limited treatments exist for nonoperative chronic coronary artery disease. Previously, our laboratory has investigated extracellular vesicle (EV) therapy as a potential treatment for chronic coronary artery disease using a swine model and demonstrated improved cardiac function in swine treated with intramyocardial EV injection. Here, we seek to investigate the potential cardiac benefits of EVs by using hypoxia-conditioned EVs (HEV). Specifically, this study aims to investigate the effect of HEV on apoptosis in chronically ischemic myocardium in swine. Methods: Fourteen Yorkshire swine underwent placement of an ameroid constrictor on the left circumflex artery. Two weeks later, swine underwent redo left thoracotomy with injection of either saline (control, n = 7) or HEVs (n = 7). After 5 weeks, swine were euthanized for tissue collection. Terminal deoxynucleotidyl transferase dUTP nick end labeling was used to quantify apoptosis. Immunoblotting was used for protein quantification. Results: Terminal deoxynucleotidyl transferase dUTP nick end labeling staining showed a decrease in apoptosis in the HEV group compared with the control (P = .049). The HEV group exhibited a significant increase in the anti-apoptotic signaling molecule phospho-BAD (P = .005), a significant decrease in B-cell lymphoma 2 (P = .006) and an increase in the phospho-B-cell lymphoma to B-cell lymphoma 2 ratio (P

Objectives Immunotherapy with immune checkpoint inhibitors has shown only limited success in the management of metastatic soft tissue sarcoma. Overall response rates (ORR) with single agent pembrolizumab were 18% and median PFS was 18 weeks on the clinical trial SARC028. One strategy to improve the responses to immunotherapy is with stereotactic body radiation therapy (SBRT), which can enhance the antitumor CD8 T cell response through the release of tumor-specific antigens, potentially priming a more diverse class of T cell receptors. Methods This is a phase 0, pilot prospective study taking place at a single center with 2 arms. In Arm A, patients are treated with pembrolizumab 400 mg IV infusion on day 1 of a 42-day cycle. Stereotactic body radiation therapy (SBRT) is delivered in 1-5 fractions starting on C1D15-28 and given every other day. In Arm B, patients who have started an immune checkpoint inhibitor within 60 days are treated with SBRT in addition to the current therapy. Results In this study we outline testing the feasibility of adding SBRT to pembrolizumab. Conclusion The ultimate goal of combination therapy is improved overall response, including tumors not treated with SBRT. This trial can be found registered online: NCT05488366.

Category: Ankle; Trauma Introduction/Purpose: Ankle fractures are the third most common extremity fracture, and its incidence is increasing in the elderly [1,2]. While the operative indications in ankle fractures have been established, there is no consensus regarding timing of weightbearing. There has been a growing trend towards early weightbearing due to its advantages in rehabilitation and return to function [3,4,5]. Even so, a survey study revealed that physicians tend to increase the non-weightbearing period for their geriatric population [6]. Expanding on our prior data which advocated for early weightbearing in ankle ORIF patients with syndesmotic injuries, we investigated the effects of early weightbearing after ankle ORIF in the geriatric population [7]. We hypothesized that there would not be an increased complication rate in this study cohort. Methods: A retrospective review was performed of patients over the age of 60 that underwent ankle ORIF at a level 1 trauma center and three neighboring community hospitals from 2015 to 2023. One of three senior surgeons were involved in all cases. Patient demographics, medical comorbidities, concomitant injuries, fixation method and complications were recorded. Maisonneuve injuries, fractures with articular surface involvement greater than 25%, open fractures, and revision cases were excluded. Patients with neuropathy were also excluded. All patients underwent an ORIF with possible syndesmotic fixation depending on intraoperative findings. Postoperatively, patients were 50% partial weightbearing for 2-3 weeks for a period of soft tissue and wound healing. After that, all patients were permitted to bear as much weight as tolerable. Results: 113 patients were identified that met our criteria. The average age was 72.6 years old. 25 were male and 88 were female. The average BMI was 26.8%. 60.2% of patients reported one or more medical comorbidities. The average follow-up time was seven months. We had zero major postoperative complications to report. We considered major complications to include: hardware failure, gross loss of reduction, need for revision ORIF, and accelerated post traumatic arthritis. Four patients were noted to have delayed wound healing. An additional four patients had minor surgical site infections that resolved with oral antibiotics. Six patients underwent hardware removal for various reasons. 65/113 (57%) patients received syndesmotic fixation of some form. Conclusion: This is the largest study to date reporting on effects of early weightbearing in the geriatric ankle ORIF population. In our study of 113 patients, all patients were allowed to weight bear as tolerated after short period of soft tissue rest, indiscriminate of syndesmotic injury or osteoporosis. We report no major complications and a limited number of soft tissues related complications. In a patient population with a known morbidity from prolonged immobility, as evidenced from the hip fracture literature, we hope our data helps to build confidence in early postoperative weightbearing [8].

Category: Trauma; Arthroscopy Introduction/Purpose: Deltoid ligament rupture is a common occurrence in the setting of acute ankle fractures. The indications for surgical restoration of the deltoid ligament complex vary considerably throughout the literature. If medial ankle instability exists after ankle fracture fixation, repair or reconstruction of the deltoid ligament complex may be performed, which is traditionally done via an open approach. While the superficial deltoid is easily accessed with an open approach, the deep deltoid ligament is extremely difficult to visualize. We present a novel technique for reconstruction of the deep deltoid ligament complex utilizing suture augmentation via an arthroscopically-assisted approach and present our outcomes. With this method, the deep deltoid ligament disruption is easily visualized and reconstructed in a minimally invasive manner through an accessory anteromedial arthroscopy portal. Methods: This is a technique guide and retrospective case series. Data was obtained via chart review including pre-operative, intraoperative, and post-operative follow ups. Variables such as age, weight, body mass index (BMI), sex, side, history of previous ankle surgery, preoperative ambulatory status, length of hospital stay, as well as disposition were documented. Radiographs were reviewed for evidence of restoration of the medial clear space as well as hardware position and bony union. In addition, a technique guide was developed using expert surgeon experience and opinion while using this novel technique. Results: 7 patients who underwent this novel technique were reviewed with an average follow up time of six months (3-8 months). All patients suffered bimalleolar or trimalleolar equivalent fractures. Patients were indicated for deep deltoid ligament reconstruction if medial ankle instability existed intraoperatively with valgus stress testing under fluoroscopy. Medial clear space decreased from a mean 11mm preoperatively to 3.3mm postoperatively. 6 patients returned to ambulation without brace by three months postoperatively. One patient demonstrated increased medial clear space measured at 6.6mm postoperatively and residual pain on follow up, but was treated conservatively and able to progress to weight bearing as tolerated by 6 months. One patient developed a keloid scar that required a steroid injection. No postoperative infections occurred. Conclusion: Deep deltoid ligament reconstruction utilizing suture augmentation via an arthroscopically-assisted approach should be considered in patients who have residual medial ankle instability after ankle fracture fixation. This novel technique allows visualization of the deep deltoid ligament complex and reconstruction in a minimally invasive manner via an accessory anteromedial arthroscopy portal. Our short term outcomes demonstrate success in restoring ankle function and radiographic parameters of the medial clear space. Further studies are needed to evaluate long term postoperative functional outcomes, stability, and development of post-traumatic arthritis.

Background: Most of the current stemless implants are using a central neck fixation design. Easytech Stemless replacements (FX Solutions®, Viriat, France) were developed promoting the idea of peripheral fixation of the stemless implant. The aim of this study was to analyze clinical and radiological results of this stemless TSA implanted for osteoarthritis (OA). Methods: A retrospective study of patients who received TSA with the Easytech® Anatomical Shoulder System (FX Solutions®, Viriat, France) for OA was completed at five clinical sites. Preoperative and minimum 2 year follow-up Constant Scores and X-rays were evaluated. Two independent orthopedic surgeons analyzed X-rays to assess anatomy reconstruction and component migration. Revisions and serious adverse effects were reviewed. Results: 129 patients were analyzed with an average follow-up of 37.47 months (24-54). Seven patients had a revision surgery and one of these resulted in the removal of the Anchor Base. The postoperative Constant Scores showed significant improvement with a mean raw Constant Score of 73.78 (38.0-100.0, mean increase 40.96, P

Background:. Orthopaedic surgery residency programs have traditionally had less representation of underrepresented minority (URM) and female trainees compared with other medical specialties. Widespread efforts have been implemented to increase the diversity of orthopaedic surgery residency programs; however, it is not known whether URM and female applicants are increasingly likely to match as a result. Thus, we aimed to study the independent association between URM and female applicants and matching into orthopaedic surgery over the past decade. Methods:. Applicant-level data from the Electronic Residency Application Service were reviewed from 2011 to 2021 with variables including demographic variables, URM status, and matriculation to an orthopaedic surgery residency program. Multivariate logistic regression was used to identify the likelihood of matriculating into orthopaedic surgery when controlling for number of applications, top 40 medical school status, AOA status, and MD/other degree. Results:. Twelve thousand one hundred eleven applicants were identified from 2011 to 2021 with a match rate of 70% overall. Two thousand fifty-six applicants (17%) were female and 1,926 (16%) classified as URM. The total number of applications increased from 1,074 in 2011 to 1,229 in 2021. The adjusted odds ratio (OR) associated with matching among all applicants decreased from 0.75 in 2011 to 0.64 in 2021, p < 0.001, and the OR of non-URM male and female applicants also decreased (female: 0.79-0.69, p < 0.001; male: 0.78-0.65, p < 0.001). The OR of URM male applicants did not change significantly (0.57-0.55, p = 0.60). The OR for URM female applicants, however, increased significantly from 0.46 to 0.61, p < 0.001. Over the entire time frame, the odds of matching were significantly lower for URM applicants compared with non-URM applicants (both male and female). Conclusions:. Overall, the adjusted odds ratio of matching into orthopaedic surgery among female URM applicants has increased over the past decade, indicating successful efforts to improve the diversity of orthopaedic surgery training programs. The odds of URM male applicants have remained relatively constant, and the odds of URM male and female applicants were significantly lower than all non-URM applicants. Level of Evidence:. III.

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: The outcomes of total joint arthroplasty during the coronavirus disease 2019 (COVID-19) pandemic are unknown. We sought to compare early postoperative complications in total hip arthroplasty (THA) and total knee arthroplasty (TKA) prior to and during the COVID-19 pandemic. Methods: Patients in the American College of Surgeons National Surgical Quality Improvement Program database who had THA or TKA in the latter halves (July to December) of 2019 and 2020 were identified. Patients were divided into pre-COVID-19 (2019) and during-COVID-19 (2020) cohorts. Propensity score matching and logistic regression were used to detect correlations between operative period and outcomes. Statistical significance was set at α = 0.05. Results: A total of 38,234 THA and 61,956 TKA patients were included. There was a significantly higher rate of outpatient procedures in 2020 than that in 2019 for both THA (41.68% vs 6.59%, P < .001) and TKA (41.68% vs 7.56%, P < .001). On matched analysis, surgery in 2020 had lower odds of hospital stay for >1 day (THA: odds ratio [OR] 0.889; P < .001) (TKA: OR 0.644; P < .001) and nonhome discharge (THA: 0.655; P < .001) (TKA: 0.497; P < .001). There was also increased odds of superficial surgical site infection in THA (OR 1.272; P = .040) and myocardial infarction in TKA patients (OR 1.488; P = .042) in 2020 compared to those in 2019. There was no difference in the 15 other outcomes assessed. Conclusions: Total joint arthroplasty surgery remains safe despite the COVID-19 pandemic. A statistically significant increase was detected in superficial surgical site infection and myocardial infarction risk during 2020 compared to 2019; however, the clinical significance of this is questionable. A shift away from inpatient stay was also present, possibly reflecting efforts to minimize nosocomial exposure to COVID-19.

An expanded role for cardiac implantable electronic devices (CIEDs) in recent decades reflects an aging population and broader indications for devices, including both primary prevention and management of dysrhythmias. CIED infection is one of the most important device-related complications and has a major impact on mortality, quality of life, healthcare utilization, and cost. Unfortunately, the investigation and management of CIED infection remain complex, often necessitating complete and timely removal of the device and leads in order to eradicate the infection. In addition, the translation of knowledge from an extensive literature to a disparate group of medical practitioners has often been inadequate. This review of CIED infection management highlights the significant advances made during the past decade, including diagnostic criteria, advanced imaging, and next-generation sequencing for culture-negative cases or those in which uncertainty remains. We also outline the role and indication for powered lead extraction, the process of antibiotic choice and treatment duration, considerations related to the timing and location for reimplantation, and preimplantation risk stratification and associated interventions to reduce the risk of CIED infection. Résumé: L’élargissement du rôle des dispositifs électroniques cardiaques implantables (DECI) au cours des dernières décennies reflète le vieillissement de la population et les indications plus vastes des dispositifs, notamment dans la prévention primaire et la prise en charge des dysrythmies. Les infections liées aux DECI sont l’une des plus importantes complications liées aux dispositifs et ont des conséquences majeures sur la mortalité, la qualité de vie, l’utilisation et les coûts des soins de santé. Malheureusement, le dépistage et la prise en charge des infections liées aux DECI demeurent complexes et nécessitent souvent le retrait complet et rapide du dispositif et des sondes en vue d’éradiquer l’infection. De plus, l’application des connaissances issues d’une vaste littérature à un groupe disparate de médecins praticiens a souvent été inadéquate. La présente revue sur la prise en charge des infections liées aux DECI illustre les avancées importantes réalisées au cours de la dernière décennie, notamment les critères diagnostiques, l’imagerie avancée et le séquençage de prochaine génération des cas à culture négative ou de ceux pour lesquels des incertitudes demeurent. Nous avons aussi décrit le rôle et les indications d’extraction des sondes fonctionnelles, le processus du choix des antibiotiques et de la durée du traitement, les considérations relatives au moment et au lieu de la réimplantation, et la stratification du risque en préimplantation et les interventions associées afin de réduire le risque d’infections liées aux DECI.

Mycotic aortic aneurysms are a rare and potentially fatal aortic pathology. Advancements in vascular technology have allowed endovascular repair to be a durable and less invasive option for the treatment of mycotic aortic aneurysms. We have presented the case of a 51-year-old man with a mycotic aneurysm of the descending thoracic aorta secondary to chronic, disseminated aspergillosis infection after liver transplantation. The aneurysm was successfully treated with thoracic aortic stent graft deployment. No perioperative complications occurred, and follow-up computed tomography angiography showed no signs of an endoleak. The patient will continue with lifelong antifungal therapy and close follow-up with vascular surgery.

OBJECTIVES:. To analyze the temporal trend in enrollment rates in a COVID-19 platform trial during the first three waves of the pandemic in the United States. DESIGN:. Secondary analysis of data from the I-SPY COVID randomized controlled trial (RCT). SETTING:. Thirty-one hospitals throughout the United States. PATIENTS:. Patients who were approached, either directly or via a legally authorized representative, for consent and enrollment into the I-SPY COVID RCT. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Among 1,338 patients approached for the I-SPY COVID trial from July 30, 2020, to February 17, 2022, the number of patients who enrolled (n = 1,063) versus declined participation (n = 275) was used to calculate monthly enrollment rates. Overall, demographic and baseline clinical characteristics were similar between those who enrolled versus declined. Enrollment rates fluctuated over the course of the COVID-19 pandemic, but there were no significant trends over time (Mann-Kendall test, p = 0.21). Enrollment rates were also comparable between vaccinated and unvaccinated patients. In multivariable logistic regression analysis, age, sex, region of residence, COVID-19 severity of illness, and vaccination status were not significantly associated with the decision to decline consent. CONCLUSIONS:. In this secondary analysis of the I-SPY COVID clinical trial, there was no significant association between the enrollment rate and time period or vaccination status among all eligible patients approached for clinical trial participation. Additional studies are needed to better understand whether the COVID-19 pandemic has altered clinical trial participation and to develop strategies for encouraging participation in future COVID-19 and critical care clinical trials.

Background: The impact of adjunctive anti-inflammatory treatment on outcomes for patients with Kawasaki disease (KD) and coronary artery aneurysms (CAAs) is unknown. Methods: Using data from the International KD Registry in patients with ≥ medium CAA we evaluate associations of treatment with outcomes and major adverse cardiac events (MACE). Results: Medium or large CAA was present in 527 (32%) patients. All were treated with intravenous immunoglobulin (IVIG), 70% were male, and the median age was 1.3 years (interquartile range: 0.4-4.0 years). The most common acute therapies included single IVIG alone in 243 (46%), multiple IVIG in 100 (19%), multiple IVIG + corticosteroids in 75 (14%), and multiple IVIG + infliximab + corticosteroids in 44 (8%) patients. Patients who received therapy beyond single IVIG had a larger CA z-score at baseline (P < 0.001) and a higher rate of bilateral CAA (P < 0.001). Compared with IVIG alone, early adjunctive treatments (within 3 days of initial IVIG) were not associated with time to CAA regression or MACE, whereas later adjunctive therapy was associated with MACE and longer time to CAA regression. Patients receiving IVIG plus steroids vs IVIG alone had a trend towards shorter time to CAA regression and lower risk of MACE (P = 0.07). A larger CAA z-score at baseline was the strongest predictor of an increase in the CAA z-score over follow-up, lower likelihood of CAA regression, and higher risk of MACE. Conclusions: Persistence of CAA and MACE are more strongly associated with baseline severity CAA than with acute adjuvant anti-inflammatory therapy. Patients who received late adjunctive therapy are at higher risk for worse outcomes. Résumé: Contexte: L’incidence d’un traitement anti-inflammatoire d’appoint chez les patients atteints de la maladie de Kawasaki (MK) compliquée d’anévrismes coronariens est inconnue. Méthodologie: À partir de données provenant du registre international de la maladie de Kawasaki portant sur les patients ayant subi des anévrismes coronariens modérés ou importants, nous avons évalué l’incidence des différents traitements sur les résultats cliniques et les événements cardiovasculaires indésirables majeurs (ECIM). Résultats: Des anévrismes coronariens modérés ou importants ont été relevés chez 527 patients (32 %). Tous les patients recevaient des immunoglobulines administrées par voie intraveineuse (IgIV); 70 % d’entre eux étaient de sexe masculin, et leur âge médian était de 1,3 an (écart interquartile : de 0,4 an à 4,0 ans). Les traitements d’urgence les plus fréquents comprenaient un seul traitement par IgIV chez 243 patients (46 %), plusieurs traitements par IgIV chez 100 patients (19 %), une association de plusieurs traitements IgIV et de corticostéroïdes chez 75 patients (14 %) et une association de plusieurs traitements IgIV, de corticostéroïdes et d’infliximab chez 44 patients (8 %). Les patients ayant reçu un traitement autre qu’un seul traitement IgIV présentaient des scores z initiaux plus élevés pour le diamètre des artères coronaires (P < 0,001) et un taux plus élevé d’anévrismes coronariens bilatéraux (P < 0,001). En comparaison d’un traitement par IgIV seulement, les traitements d’appoint précoces (administrés dans les trois jours suivant le début du traitement par IgIV) n’ont pas eu d’incidence sur la durée avant la régression des anévrismes coronariens ni sur la survenue d’ECIM, alors que les traitements d’appoint plus tardifs ont été associés à un risque plus élevé d’ECIM et à une régression plus tardive des anévrismes coronariens. Les patients ayant reçu une association d’IgIV et de corticostéroïdes avaient tendance à présenter une régression plus rapide des anévrismes coronariens et un plus faible risque d’ECIM que ceux recevant uniquement un traitement par IgIV (P = 0,07). Un score z initial plus élevé pour un anévrisme coronarien était le facteur prédictif le plus puissant d’une augmentation du score z pendant la période de suivi, d’une probabilité plus faible de régression de l’anévrisme et d’un risque plus élevé d’ECIM. Conclusions: La gravité initiale de l’anévrisme coronarien est plus fortement associée à la persistance de l’anévrisme et à la survenue d’ECIM que le recours à un traitement anti-inflammatoire d’urgence en appoint. Les patients recevant un traitement d’appoint tardif étaient par ailleurs plus susceptibles de présenter des résultats défavorables.

Introduction: Fatal drug overdoses have risen sharply in the U.S. since 2015, reaching their highest levels during the pandemic. Non-Hispanic Black men have been disproportionately harmed by this latest surge; overdose mortality per 100,000 has increased fourfold since 2015. Whether the mortality rate will continue to climb is unknown. In this study, we addressed the narrower question of which age groups are likely to experience a significant increase or decrease in the burden of drug overdose deaths through 2025, based on foreseeable changes in the age structure of the Black male population. Methods: We used the 2020 and provisional 2021 age-specific mortality rates from the Centers for Disease Control WONDER (Wide-Ranging Online Data for Epidemiologic Research) database and the standard population balancing equation to project overdose deaths in 2025. Overdose deaths were identified by ICD-10 codes. We bracketed the projections between 2 plausible alternatives: a pessimistic forecast based on time series extrapolations and an optimistic forecast that assumes success nationally in lowering overdose deaths through prevention, treatment, and harm reduction initiatives. Results: Among Black men aged 31‒47 years, overdose deaths in 2025 are expected to increase by 440 or 11% (95% CI=8%, 14%) relative to 2020. By contrast, overdose deaths among younger Black men aged 19‒30 years are expected to decline by 160 or –9% (95% CI= –15%, –5%). Among older Black men aged 48‒64 years, overdose deaths are also expected to decline by 330 or –7% (95% CI= –10%, –4%). Similar results were found using 2021 provisional mortality rates. Conclusions: Overdose deaths are predicted to increase significantly over current levels among Black men in their 30s and 40s. Local policy makers should direct harm reduction resources, such as naloxone kits, syringes, and fentanyl test strips, to places frequented by Black men in this age group. Outreach messaging should be tailored to resonate with men of middle age. Equally urgent is the scaling up of nonstigmatizing, evidence-based drug treatment and recovery support services in Black neighborhoods.

Incarceration of the gravid uterus is a rare obstetric complication characterized by entrapment of the gravid uterus between the sacral promontory and pubic symphysis. Clinical symptoms are highly variable and may include low back pain, urinary retention, and nausea. A presumptive diagnosis can often be established based on correlation of clinical history and physical examination. However, ultrasound and/or pelvic magnetic resonance imaging are essential for confirmation. Herein, we describe a 30-year-old female who presented with uterine incarceration and discuss the diagnosis, imaging features, and management of this uncommon but important clinical entity.

Background: Physical activity (PA) is important for cardiovascular health as well as social and emotional well-being of children. Patients with long QT syndrome (LQTS) often face PA restrictions and are often prescribed beta-blockers for disease management. The aim of this study was to determine if PA levels were lower in patients with LQTS compared with healthy controls. Methods: Participants with LQTS from an inherited arrhythmia clinic completed the Physical Activity Questionnaire for Children and Adolescents (PAQ-C/A) and an exercise stress test. PAQ score (a general measure of PA for youth, unitless) and endurance time were compared with healthy controls. Results: Twenty-three patients with LQTS completed the PAQ and had an exercise stress test within a year of having completed the PAQ. No difference was observed in PAQ scores between LQTS and control groups (LQTS: 2.3 ± 0.15 vs controls: 2.3 ± 0.18; P = 0.78). There was no effect of age on PA in patients with LQTS (P > 0.05), whereas PA significantly decreased in controls with age (eg, 11-12 vs 17-20 years: 3.2 ± 0.07 vs 1.5 ± 0.08, P = 0.005). Endurance time and heart rate at peak exercise were significantly lower in patients with LQTS compared with controls (11 ± 0.5 vs 15 ± 0.5 minutes, P < 0.0001; 169 ± 5 vs 198 ± 2 beats per minute, P < 0.0001). Conclusions: Despite guideline recommendations restricting PA, risk of sudden cardiac death, and use of beta-blockers, our cohort of patients with LQTS reported similar PA levels as healthy controls. Résumé: Contexte: L’activité physique est importante pour la santé cardiovasculaire ainsi que le bien-être social et émotionnel des enfants. Chez les patients qui présentent un syndrome du QT long (SQTL), l’activité physique est souvent restreinte, et des bêta-bloquants sont fréquemment prescrits pour la maîtrise de la maladie. L’objectif de cette étude était de déterminer si le degré d’activité physique était inférieur chez les patients atteints du SQTL à celui de témoins en bonne santé. Méthodologie: Des patients atteints du SQTL d’une clinique d’arythmie héréditaire ont rempli le questionnaire sur l’activité physique pour les enfants et les adolescents (PAQ-C/A, pour Physical Activity Questionnaire for Children and Adolescents) et subi une épreuve d’effort. Le score du PAQ (mesure générale de l’activité physique pour les jeunes, sans unité) et le temps d’endurance ont été comparés à ceux obtenus chez des témoins en bonne santé. Résultats: Vingt-trois patients atteints du SQTL ont rempli le PAQ et, dans l’année suivante, subi une épreuve d’effort. Pour ce qui est du score du PAQ, aucune différence n’a été observée entre le groupe atteint du SQTL et le groupe témoin (2,3 ± 0,15 chez les patients atteints du SQTL vs 2,3 ± 0,18 chez les témoins; p = 0,78). L’âge était sans effet sur l’activité physique chez les patients atteints du SQTL (p > 0,05), tandis que le degré d’activité physique diminuait significativement avec l’âge chez les témoins (p. ex. 3,2 ± 0,07 chez les témoins de 11 à 12 ans vs 1,5 ± 0,08 chez les témoins de 17 à 20 ans, p = 0,005). Pendant l’effort maximal, le temps d’endurance était significativement plus court et la fréquence cardiaque, significativement plus basse chez les patients atteints du SQTL que chez les témoins (11 ± 0,5 vs 15 ± 0,5 minutes, p < 0,0001; 169 ± 5 vs 198 ± 2 battements par minute, p < 0,0001). Conclusions: Malgré la restriction de l’activité physique recommandée par les lignes directrices, le risque de mort subite d’origine cardiaque et l’utilisation de bêta-bloquants, dans notre cohorte de patients atteints du SQTL, le degré d’activité physique a été semblable à celui des témoins en bonne santé.

Background: Congenital heart disease, the most common congenital anomaly, often presents in neonates. Because of perceived risks, health care providers may consider deferring immunizations in this population. We sought to understand the perceived risk of immunizations in those providing health care to children with particular heart conditions. Methods: A survey, which included 6 hypothetical scenarios assessing immunization recommendations, was distributed internationally to relevant health care providers, and responses were compared between the different scenarios. Results: Majority of responses (n = 142) were from paediatric cardiologists (n = 98; 69%) and nurse practitioners (n = 27; 19%) located in the United States (n = 77; 54%) or Canada (n = 53; 37%) working in academic teaching hospitals (n = 133; 93.7%). Most favoured vaccinations (n = 107; 75.4%) and less likely to proceed with the first immunization in infants with structural heart disease compared with channelopathy (risk ratio: 0.80, confidence interval: 0.73-0.87; P

Background:. In May 2022, the Association of American Medical Colleges (AAMC) published guidelines regarding interviews for the 2022-2023 residency application cycle. These guidelines recommended virtual interviews and discouraged “hybrid” interviewing. We conducted a survey of orthopaedic program directors (PDs) to understand their perspectives on these new guidelines and their plans for the upcoming cycle. Methods:. A 19-question multicenter, cross-sectional research survey was emailed to 98 PDs (38.8% response rate) through Qualtrics XM. Contact information was obtained from a public national database. Results:. Most orthopaedic residency programs (60.5%) were planning on conducting in-person interviews before any AAMC and hospital guidelines, and most (65.8%) will likely be conducting virtual interviews post-guidelines. PDs voiced mixed opinions about virtual interviews (39.4% in favor vs. 47.4% against). PDs were also split on whether forgoing the AAMC guidance would be irresponsible for residency programs (47.4% believe it would be irresponsible vs. 44.8% believe it would not); however, a plurality are in favor of the AAMC's guidance (42.1%). Furthermore, PDs agreed that virtual interviews have disadvantages including favoring top-tier applicants, students from home institutions, and in-person rotators, making ranking applicants and learning about a program's culture more difficult. Most PDs (84.2%) felt that hybrid interviews would disadvantage applicants who would choose the virtual option. Conclusion:. AAMC guidance seems to be influencing how most orthopaedic surgery programs will conduct residency interviews for the 2022-2023 cycle. Most PDs agreed with the AAMC guidelines but voiced concerns regarding several disadvantages for all 3 proposed interview options (virtual, in-person, and hybrid). Our results indicate that the recent AAMC guidelines may have contributed to a shift in opinions among PDs but are not sufficient to create a consensus on the best practices for residency interviews. Our findings should encourage solutions focused on the deeper systemic issues within the orthopaedic application process in the post-coronavirus 2019 pandemic era.

Introduction: There is a paucity of data on immune checkpoint inhibitors (ICIs) plus doublet chemotherapy (C) in patients with advanced lung cancer whose tumor harbors an actionable mutation. We sought to provide insight into the role of this combination in relation to chemotherapy alone in this patient population. Methods: We conducted a retrospective study at the five University of California National Cancer Institute–designated Comprehensive Cancer Centers. The primary end point was progression-free survival (PFS). Secondary end points included overall survival (OS) and significant adverse events. Adverse events in patients who received a tyrosine kinase inhibitor (TKI) post-ICI were also captured. Results: A total of 246 patients were identified, 170 treated with C plus ICI and 76 treated with C alone. Driver alterations included EGFR (54.9%), KRAS (32.9%), ALK (5.3%), HER2/ERBB2 (2.9%), ROS1 (1.2%), MET (1.2%), RET (0.8%), and BRAF non-V600 (0.8%). The overall PFS and OS hazard ratios were not significant at 1.12 (95% confidence interval 0.83–1.51; p = 0.472) and 0.86 (95% confidence interval: 0.60–1.24, p = 0.429), respectively. No significant differences in PFS or OS were observed in the mutational subgroups. Grade 3 or greater adverse events were lower in the C plus ICI group. The multivariate analysis for PFS and OS revealed a performance status (Eastern Cooperative Oncology Group) score of 2, and previous TKI treatment was associated with poorer outcomes with C plus ICI. Conclusions: Our study suggests that patients with oncogenic-driven NSCLC, primarily those with EGFR-driven tumors, treated with a TKI should not subsequently receive C plus ICI. Analysis from prospective clinical trials will provide additional information on the role of ICIs in this group of patients.

Background: Minimal clinically important difference (MCID) estimates are useful for gauging clinical relevance when interpreting changes or differences in patient-reported outcomes scores. These values are lacking in the setting of elbow trauma. Our primary purpose was to estimate the MCID of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) computer adaptive test (CAT), the PROMIS upper extremity (UE) CAT, and the QuickDASH using an anchor-based approach for patients recovering from elbow trauma and related surgeries. Secondarily, we aimed to estimate the MCID using the 1/2 standard deviation method. Materials & methods: Adult patients undergoing treatment for isolated elbow injuries between July 2014 and April 2020 were identified at a single tertiary academic medical center. Outcomes, including the PROMIS PF CAT v1.2/2.0, PROMIS UE CAT v1.2, and QuickDASH, were collected via a tablet computer. For inclusion, baseline (6 months before injury up to 11 days postoperatively or after injury) and follow-up (11 to 150 days postoperative or after injury) PF or UE CAT scores were required, as well as a response to an anchor question querying improvement in physical function. The MCID was calculated using (1) an anchor-based approach using the difference in mean score change between anchor groups reporting “No change” and “Slightly Improved/Improved” and (2) the 1/2 standard deviation method. Results: Of the 146 included patients, the mean age was 46 ± 18 years and 67 (46%) were women. Most patients (129 of 146 or 88%) were recovering from surgery, and the remaining 12% were recovering from nonoperatively managed fractures and/or dislocations. The mean follow-up was 157 ± 192 days. Scores for each instrument improved significantly between baseline and follow-up. Anchor-based MCID values were calculated as follows: 5.7, 4.6, and 5.3 for the PROMIS PF CAT, PROMIS UE CAT, and QuickDASH, respectively. MCID values estimated using the 1/2 standard deviation method were 4.3, 4.8, and 11.7 for the PROMIS PF CAT, PROMIS UE CAT, and QuickDASH, respectively. Conclusions: In the setting of elbow trauma, we propose MCID ranges of 4.3 to 5.7 for the PROMIS PF CAT, 4.6 to 4.8 for the PROMIS UE CAT, and 5.3 to 11.7 for the QuickDASH. These values will provide a framework for clinical relevance when interpreting clinical outcomes studies, or powering clinical trials, for populations recovering from trauma.

Category: Diabetes; Ankle Introduction/Purpose: Diabetes mellitus (DM) may result in Charcot arthropathy (CA) in 0.1% to 2.5% of diabetic patients. Complications may arise including joint dislocation, deformities, ulcerations, and limb amputation. Surgical intervention has been shown to improve patient's walking ability and health-related quality of life compared to use of orthotics in addition to reduction of ulcer, bone infection, use of orthoses, and amputation. A retrospective review of patients with ankle charcot arthropathy was performed with hindfoot nail fixation. The aim of the study was to determine radiographic healing, complication rates of surgical intervention, and patients' ability to ambulate with therapeutic inserts or boots. The results obtained from this study serve to provide evidence for intervention via operative fixation and limb salvage in this cohort of patients. Methods: A retrospective review of patients treated with hindfoot nail with CA of the ankle was performed between 2016 to 2022. The demographic data, BMI, cause of the charcot arthropathy, the pre-operative radiographic deformity, and prior wounds and infection data was recorded. We identified 18 consecutive patients that underwent surgical intervention. The surgical technique included bimalleolar exposure, correction of the deformity, hindfoot fusion nail with or without structural femoral head graft. The follow up data collected included post-operative complications, radiographic evaluation of union, and clinical data on type of shoe wear or boots used for ambulation. Results: We identified 17 consecutive patients undergoing hindfoot deformity correction with hindfoot nail. The average follow- up for the patients was 1.7 year. The cause of neuropathy was diabetes in 15 patient and idiopathic in 2 patients. The average BMI for the cohort was 29.5. The initial 90-day complications rate for surgical intervention was 17%; with one superficial infection, one deep infection, and one death related to a cardiac event. At latest follow up 12 patients were ambulating with a CROW boot, 3 in diabetic shoes with therapeutic inserts, 1 below knee prosthesis, and 1 patient is in the initial perioperative period of healing. Radiographic union was seen in 12 patient, 3 patients had stable pseudo-union of the ankle joint with neutral alignment. Conclusion: The development of an acquired ankle deformity is associated with a poor quality of life. Traditional treatment of CA has shown to be effective when resolving infection and avoiding amputation. Our study supports the use of hindfoot nail for deformity correction/fixation and limb salvage of ankle CA patients. This patient population is highly comorbid but can have meaningful improvement in ambulator status post-surgery in a CROW boot or shoes with therapeutic insoles.

Background:. Diabetic foot complications are increasingly burdensome for patients, clinicians, and society. Development of innovative therapies to support good quality basic care is a priority among those with an interest in this area. One of these involves scanning and printing tissues to match and conform to a defect (so-called 3D printing). Methods:. A single-arm pilot study of ten consecutive patients with a history of a chronic diabetic foot ulcer (DFU), treated with autologous minimally manipulated homologous adipose tissue (AMHAT), dispensed by a specialized 3D bioprinter, Dr. INVIVO, was performed. Patients with nonhealing DFUs present for more than 4 weeks and refractory to standard-of-care therapies were included. Wounds were treated with a single application of AMHAT, and then followed up weekly for up to 12 weeks, or until the wounds healed. The primary outcome measure was complete epithelialization of the wound up to 12 weeks after the treatment. Secondary outcome measures included wound size and/or volume reduction, assessment of ulcer grade, and time to closure. Results:. Five wounds were healed by 5 weeks and one at 8 weeks. The mean percent area reduction at 12 weeks was 78.3% (SD: 33.23). Complete closure was achieved in 60% of wounds. The mean time to closure in these wounds was 49.1 days (95% CI, 29.9–68.3). No adverse events were reported. Conclusions:. Single treatment of bioprinted AMHAT appears to be a safe and potentially effective treatment modality for patients with chronic DFUs. Further studies are warranted to explore the full potential of 3D bioprinting for tissue repair in this high-risk population.

Background:. Patient-reported outcome measures (PROMs) and, specifically, the Patient-Reported Outcomes Measurement Information System (PROMIS), are increasingly utilized for clinical research, clinical care, and health-care policy. However, completion of these outcome measures can be inconsistent and challenging. We hypothesized that sociodemographic variables are associated with the completion of PROM questionnaires. The purposes of the present study were to calculate the completion rate of assigned PROM forms and to identify sociodemographic and other variables associated with completion to help guide improved collection efforts. Methods:. All new orthopaedic patients at a single academic medical center were identified from 2016 to 2020. On the basis of subspecialty and presenting condition, patients were assigned certain PROMIS forms and legacy PROMs. Demographic and clinical information was abstracted from the electronic medical record. Bivariate analyses were performed to compare characteristics among those who completed assigned PROMs and those who did not. A multivariable logistic regression model was created to determine which variables were associated with successful completion of assigned PROMs. Results:. Of the 219,891 new patients, 88,052 (40%) completed all assigned PROMs. Patients who did not activate their internet-based patient portal had a 62% increased likelihood of not completing assigned PROMs (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.58 to 1.66; p < 0.001). Non-English-speaking patients had a 90% (OR, 1.90; 95% CI, 1.82 to 2.00; p < 0.001) increased likelihood of not completing assigned PROMs at presentation. Older patients (≥65 years of age) and patients of Black race had a 23% (OR, 1.23; 95% CI, 1.19 to 1.27; p < 0.001) and 24% (OR, 1.24; 95% CI, 1.19 to 1.30; p < 0.001) increased likelihood of not completing assigned PROMs, respectively. Conclusions:. The rate of completion of PROMs varies according to sociodemographic variables. This variability could bias clinical outcomes research in orthopaedic surgery. The present study highlights the need to uniformly increase completion rates so that outcomes research incorporates truly representative cohorts of patients treated. Furthermore, the use of these PROMs to guide health-care policy decisions necessitates a representative patient distribution to avoid bias in the health-care system. Level of Evidence:. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:. Historically, medical students often match within the same geographic location or to an orthopaedic surgery residency program affiliated with their medical school. The objective of this investigation was to determine differences in geographic trends between orthopaedic residents matching before and during the Coronavirus-19 (COVID-19) pandemic. METHODS:. This study analyzed 2 groups of orthopaedic residents: Pre-COVID cohort (years 2016-2020) and COVID-impacted cohort (year 2021). A list of accredited orthopaedic surgery residency programs (n = 202) was obtained. Orthopaedic residency program webpages were located (region [n = 4], division [n = 9], state [n = 50]). For each resident, their medical school and year of postgraduate training were recorded. Year 2021 resident information was obtained from the orthopaedic residency program webpages, social media accounts, and medical school match lists. Residency programs affiliated with a medical school were also assigned. Descriptive statistics were performed. Two sample Student t tests with Bonferroni correction applied to p-values (α < 0.05 significant) were performed. RESULTS:. There were 4,832 residents analyzed (4,074 in Pre-COVID cohort; 758 in COVID-impacted cohort [758/868 of all positions in 2021 Match]). Statistically significant differences were detected between the COVID-impacted cohort (39.6%, p < 0.001) matching in the same state as their medical school (Pre-COVID 33.1%) and the COVID-impacted cohort (28.0%, p < 0.001) matching to a residency program affiliated with their medical school (Pre-COVID 21.2%). In the COVID-impacted cohort, students who matched in state matched to their home program more frequently (69.3%) compared with the Pre-COVID cohort (60.5%). Geographically, there was a difference in the COVID-impacted cohort (52.5%, p < 0.011) matching in the same division (Pre-COVID 47.5%). No statistically significant differences were identified for residents matching to the same region as their medical school (Pre-COVID 60.1%; COVID-impacted 61%, p = 0.968). CONCLUSION:. Residents matching in the same state, in the same division, and to a residency program affiliated with their medical school increased significantly in the COVID-impacted cohort. There was no difference between cohorts matching in the same region as their medical school. Level of Evidence:. Observational/Cross-Sectional

Sarcoidosis with manifest cardiac involvement typically presents with heart failure, conduction abnormalities, or ventricular arrhythmias. Here, we present a case of a young woman whose presentation raised suspicion for metastatic cardiac disease of unknown primary origin. Further investigation revealed cardiac sarcoidosis with multiple intramyocardial granulomatous masses in the absence of significant enlargement of hilar or mediastinal nodes. This case highlights the following: (i) sarcoidosis can mimic metastatic cardiac tumours; and (ii) hilar and mediastinal lymph nodes can be metabolically active in cardiac sarcoidosis in the absence of significant enlargement. Résumé: La sarcoïdose avec atteinte cardiaque patente se manifeste typiquement par une insuffisance cardiaque, des troubles de la conduction ou des arythmies ventriculaires. Nous présentons ici le cas d’une jeune femme dont le tableau clinique évoquait une pathologie cardiaque métastatique d’origine primitive inconnue. Des examens supplémentaires ont révélé une sarcoïdose cardiaque associée à de multiples granulomes intramyocardiques, en l’absence d’hypertrophie importante des ganglions hilaires ou médiastinaux. Ce cas illustre les points suivants : (i) les symptômes de la sarcoïdose peuvent imiter ceux de tumeurs cardiaques métastatiques; et (ii) les ganglions lymphatiques hilaires et médiastinaux associés à une sarcoïdose cardiaque peuvent présenter une activité métabolique en l’absence d’hypertrophie importante.

Objective: To assess demographic characteristics and perceptions of female physicians in attendance at a medical conference for women with content focused on growth, resilience, inspiration, and tenacity to better understand major barriers women in medicine face and to find solutions to these barriers. Patients and Methods: A Likert survey was administered to female physicians attending the conference (September 20 to 22, 2018). The survey consisted of demographic data and 4 dimensions that are conducive to women’s success in academic medicine: equal access, work-life balance, freedom from gender biases, and supportive leadership. Results: All of the 228 female physicians surveyed during the conference completed the surveys. There were 70 participants (31.5%) who were in practice for less than 10 years (early career), 111 (50%) who were in practice for 11 to 20 years (midcareer), and 41 (18.5%) who had more than 20 years of practice (late career). Whereas participants reported positive support from their supervisors (mean, 0.4 [SD 0.9]; P

Press fit fixation is becoming more popular in RSA to preserve, in theory, bone capital. Several studies report that bone resorption can be very high around humeral stems depending on their size, shape and mode of fixation. The aim of the current study is to mid-term follow-up clinical and radiological result of a press fit ovoid regular stem RSA in non acute trauma cases. Materials and Methods We performed a retrospective monocentric study of patients continuously implanted with the Humeris® stem RSA for degenerative change of the shoulder. Nineteen shoulders, in eighteen patients (74.6 y.o (from 69 to 81)), were available at minimum five years follow-up. Results The mean final adjusted Constant score was 111.9 (65 to 130), and the mean ASES score was 49.82 (10 to 60). Humeral resorption was observed in 21% of cases. We found a statistically significant ( p = .014) lower adjusted Constant score in patients presenting with resorption on post-operative X-rays compared to those without resorption (115.6 vs. 98.25). Half cases of patients presenting a resorption underwent L’Episcopo procedure during surgery. Humeral resorption occurs the first year after surgery and do not increase even 8 years after surgery. Analysis demonstrated no correlation between the value of filling ratios and bone resorption. Conclusion The current study confirms a low rate of stress shielding around the studied stem, with rare bony resorption and no osteopenia around the humeral stem. This study highlights the importance of choosing the appropriate proximal shape and length of the humeral stem for press fit fixation in RSA.