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Acute calcific longus colli tendinitis is a differential diagnosis of neck pain. Typical presentation consists in a triad of symptoms including acute onset neck pain, neck stiffness and odynophagia. Computed tomography (CT) is the gold standard for acute calcific longus colli tendinitis diagnosis and the main radiological findings include prevertebral soft tissue swelling and the presence of amorphous calcifications. The case involves a 39-year-old female who presented to the emergency department with acute unilateral cervical pain that resulted in acute calcific longus colli tendinitis.

Spontaneous renal vein thrombosis is a rare entity. A 28-year-old woman with a history of a double-lung transplant was admitted with flank pain and found to have acute kidney injury. A magnetic resonance venogram demonstrated isolated left renal vein thrombosis with extension into the inferior vena cava. Initial management with therapeutic anticoagulation and hydration was unsuccessful. Thus, pharmacochemical thrombectomy was performed. A temporary suprarenal inferior vena cava filter was placed for intraoperative pulmonary prophylaxis. The patient's renal function returned to baseline and remained normal 13 months later. Early incorporation of percutaneous pharmacomechanical thrombectomy can improve renal function when medical therapy alone is unsuccessful.

There is a lack of consensus over the description and severity assignment of allergic adverse reactions to immunotherapy, although there seems to be a consensus at least in terms of using the World Allergy Organization (WAO) grading systems to describe local adverse events for Sublingual Immunotherapy (SLIT) and Systemic Allergic Reactions (SARs) to Subcutaneous Immunotherapy (SCIT) amongst the major national/regional allergy societies. In this manuscript, we propose a modification of the previous WAO Grading system for SARs, which aligns with the newly-proposed Consortium for Food Allergy Research (CoFAR) Grading Scale for Systemic Allergic Reactions in Food Allergy (version 3.0). We hope this can facilitate a unified grading system appropriate to SARs due to allergen immunotherapy, independent of allergen and route of administration, and across clinical and research practice.

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

Percutaneous deep venous arterialization (pDVA) is an important technique in the pursuit of limb salvage for a certain high-risk subset of patients with chronic limb-threatening ischemia (CLTI) considered to have “no option” owing to the lack of tibial or pedal targets for revascularization. pDVA seeks to establish an arteriovenous connection at the level of the tibial vessels, in addition to tibial and/or pedal venoplasty, to provide a pathway for arterial perfusion via the tibial and/or plantar venous system. A commercial system for pDVA exists; however, it is not yet approved by the U.S. Food and Drug Administration. In the present report, we detail a method of pDVA that uses commercially available devices for a patient with no-option CLTI related to Buerger disease.

Purpose: Oligometastatic disease (OMD) refers to a limited state of metastatic cancer, which potentially derives benefit from local treatments. Given the relative novelty of this paradigm, oncologist perspectives on OMD are not well established. We thus explored oncologist views on curability of and treatment recommendations for patients with OMD. Methods and Materials: We developed a survey focused on oncologist views of 3 subtypes of OMD: synchronous, oligorecurrent, and oligoprogressive. Eligible participants included medical and radiation oncologists at 2 large cancer centers invited to participate between May and June 2022. Participants were presented with 3 hypothetical patient scenarios and asked about treatment recommendations, rationale, and demographic information. Results: Of 44 respondents, over half (61.4%) agreed that synchronous OMD is curable. A smaller proportion (46.2% and 13.5%) agreed for oligorecurrence and oligoprogression, respectively. When asked whether they use the word “cure” or “curative” in discussing prognosis, 31.8% and 33.3% agreed for synchronous and oligorecurrent OMD, respectively, while 78.4% disagreed for oligoprogression. Views on curability did not significantly affect treatment recommendations. More medical oncologists recommended systemic treatment only compared with radiation oncologists for the synchronous OMD (50.0% vs 5.3%; P < .01) and oligoprogression cases (43.8% vs 10.5%; P = .02), not the oligorecurrent case. There were no significant differences in confidence in treatment recommendations by specialty. Conclusions: In this exploratory study, we found notable divergence in oncologists’ views about curability of OMD as well as variability in treatment recommendations, suggesting need for more robust research on outcomes of patients with OMD.

Background: There is limited information on return to shooting following shoulder surgery. The purpose of this study is to determine the rate and timing for resuming shooting a rifle following shoulder surgery. Methods: We performed a retrospective review of prospectively collected data. The study included patients undergoing arthroscopic and open shoulder stabilization for unidirectional shoulder instability, and arthroscopic surgery for rotator cuff tears, SLAP lesions, biceps tendinopathy, and acromioclavicular pathology. Data collected included the laterality of surgery, shooting dominance, and patient-reported outcome measures at the preoperative and postoperative visits. Starting at the 4.5-month clinic visit, patients were asked if they could shoot a military rifle. Results: One hundred patients were identified with arthroscopic and open shoulder surgery with a mean age of 30 years (range, 18-45) and a mean follow-up of 24 months (range, 12-32). The cohort consisted of patients undergoing arthroscopic Bankart repair (n = 23), arthroscopic posterior labral repair (n = 18), open Latarjet (n = 16), mini-open subpectoral biceps tenodesis (OBT) (n = 25), OBT with open distal clavicle resection (DCR) (n = 10), open DCR (n = 4), and arthroscopic rotator cuff repair with concomitant OBT (n = 4). Significant improvement in SSV, VAS, ASES, and WOSI was shown at 1-year postoperative, SSV 85, VAS 2, ASES 85, WOSI 239, P = .001. The percentage of patients reporting the ability to shoot a military rifle postoperatively were 47%, 63%, 85%, and 94% at 4.5 months, 6 months, 1 year, and 2 years, respectively. At 4.5 months postoperatively, patients who underwent surgery ipsilateral to their shooting dominance (n = 59) had a rate of return to shooting (33%) versus shoulder surgery on the contralateral side of shooting dominance (n = 41) (60%), P = .04. However, there was no significant difference in the groups at 6 months and 1 year. Additionally, there was a significant difference in the rate of return to shooting at 6 months in patients undergoing arthroscopic posterior labral repair versus the remainder of the cohort (posterior instability (33%) vs. (69%), P = .016), and a significant difference between posterior shoulder stabilization and anterior shoulder stabilization (70%), P = .03. Conclusion: Patients undergoing arthroscopic and open shoulder surgery have a high rate of return to shooting. Approximately 60% of patients resume shooting at 6 months postoperatively and 85% return at 1 year. Patients undergoing shoulder surgery on the contralateral side of their shooting dominance return to shooting significantly faster than those with shoulder surgery ipsilateral to their shooting dominance. Additionally, those undergoing arthroscopic posterior shoulder stabilization return to shooting at a slower rate than anterior stabilization surgery.

Background: Heterotopic ossification (HO), or the abnormal formation of bone in extra-skeletal tissue, is a well-known complication of orthopedic trauma, tendon avulsions, chronic injuries, spinal cord injuries, and soft tissue damage from surgery. Heterotopic ossification commonly develops at the direct or indirect head of the rectus femoris. Athletes are especially susceptible to chronic microtearing and acute tendon avulsion, which may result in HO. When HO develops in the setting of concurrent intra-articular hip pathology, it may be amendable to arthroscopic excision, depending on its size and location. Indications: Heterotopic ossification that develops adjacent to the hip joint can affect range of motion of the joint and is often a source of pain. Arthroscopic excision is indicated when the HO that develops within or about the hip joint is symptomatic and is of a location and size that it can be reached and excised arthroscopically. Technique Description: In this technical note, we describe our method to excise HO using initial arthroscopic surgery to address femoroacetabular impingement syndrome (FAIS) and perform initial dissection of the HO fragment. Heterotopic ossification resection was then completed via an anterior open approach followed by reconstruction of the rectus femoris origin with Achilles allograft. This is followed by our HO prophylaxis protocol of indomethacin 75 mg daily for 4 days, followed by naproxen 500 mg 2 times daily through postoperative day 30, although many other regimens exist for HO prophylaxis. Results: Using arthroscopy for the removal of symptomatic HO at the time of surgery allows for the management of concomitant intra-articular pathology and efficient and precise dissection of the undersurface of the HO fragment. Discussion/Conclusion: Heterotopic ossification is a well-characterized complication of soft tissue damage, including tendon avulsion, trauma, previous surgery, and chronic microtear of the hip musculature. Oftentimes, HO develops in a location that can be reached arthroscopically. Surgeons should consider combining intra-articular arthroscopic surgery with arthroscopic excision of HO when appropriate, noting that there are many advantages to arthroscopic removal when compared with open procedures. 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.

Objective To compare the association of margin sampling technique on survival outcomes in surgically treated cT1-2 oral cavity and oropharyngeal squamous cell carcinoma. Study Design A prospective longitudinal cohort study. Setting Tertiary care academic teaching hospital in Halifax, Nova Scotia. Methods All cases of surgically treated cT1-2 oral cavity and oropharyngeal cancer undergoing specimen-oriented margin analysis between January 1, 2017, and December 31, 2018 were analyzed. The specimen-oriented cohort was compared with a cohort of patients from January 1, 2009, to December 31, 2014, where a defect-oriented margin sampling protocol was used. Kaplan-Meier survival curves were used to estimate 2-year overall survival, disease-specific survival, local control, and recurrence-free survival rates in oral cavity and p16-positive oropharyngeal squamous cell carcinoma. Cox proportional hazards models were used to assess the effect of margin sampling method on disease-specific survival and local control. Results There was no significant association between margin sampling technique and 2-year survival outcomes for surgically treated cT1-2 oral cavity and oropharyngeal squamous cell carcinoma. In the multivariate Cox proportional hazard model, the hazard ratio (HR) of specimen-oriented sampling was not significantly different for disease-specific survival (HR, 1.32; 95% CI, 0.3032-5.727; P = .713) or local control (HR, 0.4087; 95% CI, 0.0795-2.099; P = .284). Conclusion Intraoperative margin sampling method was not associated with a significant change in 2-year survival outcomes. Despite no effect on survival outcomes, implementation of a specimen-oriented sampling method has potential for cost avoidance by decreasing the number of re-resections for positive or close margins.

Objective Socioeconomic and other demographic factors are associated with outcomes in head and neck cancer. This study uses a national cancer database to explore how patient race, ethnicity, and socioeconomic status (SES) are associated with esthesioneuroblastoma outcomes, including 5-year disease-specific survival (DSS), conditional DSS, stage at diagnosis, and treatment. Study Design Retrospective cohort analysis. Setting Patients with esthesioneuroblastomas between 1973 and 2015 from the SEER registry (Surveillance, Epidemiology, and End Results). Methods The National Cancer Institute Yost Index, a census tract–level composite score composed of 7 parameters, was used to categorize the SES of patients. Kaplan-Meier analysis and Cox regression were conducted to assess DSS. Conditional DSS was calculated per estimates from simplified Cox models. Logistic regression was conducted to identify risk factors for advanced cancer stage at diagnosis and the likelihood of receiving multimodal therapy. Results Complete data were included for 561 patients. DSS was significantly associated with SES (log-rank, P < .01) but not race. According to Cox regression, DSS was worse for the lowest SES tertile vs the highest (hazard ratio, 1.70 [95% CI, 1.05-2.75]; P = .03). Patients of the lowest SES tertile exhibited an increased risk of advanced cancer stage at diagnosis as compared with the highest SES tertile (odds ratio, 1.84 [95% CI, 1.06-3.30]; P = .035). Black patients (odds ratio, 0.44 [95% CI, 0.24-0.84]; P = .011) were less likely than other patients to receive multimodal therapy. SES alone was not associated with receiving multimodal therapy. Conclusion SES is significantly associated with DSS and conditional DSS for patients with esthesioneuroblastomas. Inequalities in access to care and treatment likely contribute to these disparities.

Background: Hip instability is a challenging clinical diagnosis, which often overlaps with the presentation of hip impingement and/or hip dysplasia. Many factors contribute to hip instability, including acetabular undercoverage, femoroacetabular-impingement-induced instability, and soft tissue laxity. It can cause significant pain and disability, either as a primary pathology or as a complication of surgery and if untreated can ultimately lead to early osteoarthritis. Indications: Hip dysplasia is often diagnosed with an anterior-posterior pelvic radiograph. The literature has supported a normal lateral center edge angle (LCEA) as ≥25°, borderline dysplasia an LCEA of 18° to 25°, and an LCEA

Objectives: The urinary excretion of organic and inorganic substances and their concentrations have attracted extensive attention for their role in the pathogenesis of urinary stone disease. The urinary excretion of specific factors associates with sex and age and seems to have a hereditary component, but the precise genomic determinants remain ill-defined. Methods: Genome-wide association studies previously conducted in 3 cohorts (Genetic Epidemiology Network of Arteriopathy study, January 1, 2006, through December 31, 2012; the combined Nurses’ Health Study (NHS), NHS II, and Health Professionals Follow-up Study, January 1, 1994, through December 31, 2003; and the Prevention of Renal and Vascular End-stage Disease study, January 1, 1997, through December 31, 1998) were combined into meta-analyses to evaluate genetic associations with available urinary phenotypes relevant to stone pathogenesis (calcium, magnesium, and uric acid excretion; total urine volume). Results: One region on chromosome 9q21.13 showed strong evidence of an association with urinary magnesium excretion. The strongest signal in this region was near TRPM6, whose protein product mediates magnesium transport in the colon and kidney, and C9orf40, C9orf41, NMRK1, and OSTF1 (rs1176815; P=1.70×10–14, with each copy of the A allele corresponding to a daily 5.29-mg decrease in magnesium excretion). The single nucleotide polymorphism (SNP) that achieved genome-wide significance for calcium excretion (rs17216707 on chromosome 20; P=1.12×10–8) was previously associated with fibroblast growth factor 23 levels, which regulate phosphorus and vitamin D metabolism. Urine volume and uric acid excretion did not have any genome-wide significant SNPs. Conclusion: Common variants near genes important for magnesium metabolism and bone health associate with urinary magnesium and calcium excretion.

Summary:. Percutaneous needle fasciotomy (PNF) is a favorable approach to Dupuytren’s contracture management, usually reserved for Tubiana stage 1–2, uncomplicated disease. It is growing in popularity globally. Epidermal inclusion cysts are benign, commonly encountered cavities usually found on acral skin, rarely glabrous skin, and often following trauma. We present a 43-year-old laborer with two incidentally found epidermal inclusion cysts in the open excision of painful, Tubiana 3 and 2 Dupuytren’s recurrence of his middle and ring fingers. He had undergone PNF to same 4 years prior. One cyst had ruptured. Both seemed to have migrated distally over time from the initial PNF site with progression of the Dupuytren’s disease. This may be the only case of multiple epidermal inclusion cysts post PNF for Dupuytren’s disease in the literature. The authors discuss factors contributing to epidermal inclusion cyst formation, and postulate whether needle choice may impact the risk of their development as a complication of PNF.

Purpose: Postoperative stereotactic radiosurgery (SRS) is associated with up to 30% risk of subsequent leptomeningeal disease (LMD). Radiographic patterns of LMD (classical sugarcoating [cLMD] vs. nodular [nLMD]) in this setting has been shown to be prognostic. However, the association of these findings with neurologic death (ND) is not well described. Methods and Materials: The records for patients with brain metastases who underwent surgical resection and adjunctive SRS to 1 lesion (SRS to other intact lesions was allowed) and subsequently developed LMD were combined from 7 tertiary care centers. Salvage radiation therapy (RT) for LMD was categorized according to use of whole-brain versus focal cranial RT. Results: The study cohort included 125 patients with known cause of death. The ND rate in these patients was 79%, and the rate in patients who underwent LMD salvage treatment (n = 107) was 76%. Univariate logistic regression demonstrated radiographic pattern of LMD (cLMD vs. nLMD, odds ratio: 2.9; P = .04) and second LMD failure after salvage treatment (odds ratio: 3.9; P = .02) as significantly associated with ND. The ND rate was 86% for cLMD versus 68% for nLMD. Whole-brain RT was used in 95% of patients with cLMD and 52% with nLMD. In the nLMD cohort (n = 58), there was no difference in ND rate based on type of salvage RT (whole-brain RT: 67% vs. focal cranial RT: 68%, P = .92). Conclusions: LMD after surgery and SRS for brain metastases is a clinically significant event with high rates of ND. Classical LMD pattern (vs. nodular) and second LMD failure after salvage treatment were significantly associated with a higher risk of ND. Patients with nLMD treated with salvage focal cranial RT did not have higher ND rates compared with WBRT. Methods to decrease LMD and the subsequent high risk of ND in this setting warrant further investigation.

COVID-19 is generally a benign or asymptomatic infection in children, but can occasionally be severe or fatal. Delayed presentation of COVID-19 with hyperinflammation and multi-organ involvement was recently recognized, designated the Multisystem Inflammatory Syndrome in Children (MIS-C). Six children with MIS-C with molecular and serologic evidence of SARS-CoV-2 infection were admitted to our hospital between May 5, 2020 and June 25, 2020. All had fever and weakness; 4/6 presented with gastrointestinal symptoms. Two children had features of complete Kawasaki disease, 3 had incomplete Kawasaki disease, while 1 had terminal ileitis with delayed onset of circulatory shock. Treatment consisted of intravenous immunoglobulin and aspirin for Kawasaki-like disease. Remdesivir, corticosteroids, and infliximab were used when indicated. Median hospitalization was 7 days. Immediate treatment resulted in rapid clinical improvement. In children presenting with hyperinflammatory syndromes without cardiac manifestations, testing for SARS-CoV-2 RNA and antibodies, with close cardiac monitoring should be pursued due to the manifold presentations of SARS-CoV-2 infection in children.

Background: Patient reported outcome measures (PROMs) are becoming well recognized as an important component of health care outcomes and determinants of value in patient-centered care. Yet, there is emerging recognition that guidance is lacking in the utilization of PROMs in hip fracture patients. The aim of this study was to collect input from hip fracture patients and their health care advocates as proxies to identify outcomes that are important and to gain insight into which ones are of greatest importance. Methods: A cross-section of patients aged 65 and older treated for hip fractures at a single level 1 trauma center within the previous 3 to 9 months was identified. Semistructured telephone interviews of patients and/or health care proxies were performed in 2 phases: (1) concept identification and conceptual framework development and (2) item generation and assessment of relative importance of health care outcomes. Each phase was completed by separate patient cohorts. Results: Sixty-four interviews were completed. Eighteen interviews with 13 patients and 5 proxies were completed for framework development . Forty-six interviews with 33 patients and 13 proxies were completed for the assessment of relative importance . Care team and communication were reported as important in hip fracture patients. Physical outcomes were ranked as most important by only 9% of respondents. “Having confidence that I/my loved one received the best care possible” was perceived as very important by 98% of respondents and “Having access to the surgeon” was perceived as very important by 76% of the respondents. Conclusions: In our study, communication between patients and care providers as well as collaboration among patients’ care providers ranked as the most important postoperative preferences in our cohort. Notably, physical outcomes were ranked as most important by only 9% of respondents.

Background: Role clarity is important for patient care but challenging in graduate medical education (GME). Methods: Badge buddies were integrated for all GME trainees at a single institution, and surveys were conducted prior to and 5 months following implementation. Results: There were 932 pre- and 498 postimplementation respondents. Following implementation, both trainees and nurses reported improved awareness of GME training level, but there were no changes in patient/family perceptions. Conclusions: Badge buddies improved caregiver awareness of GME training level but did not impact patient/family perception. Patients appear to be focused primarily on relationships with caregivers and communication skills rather than a provider’s specific role.

Brainstem gliomas are rare form of primary brain tumors in adult and represent

Urine pH is critical for net acid and solute excretion, but the genetic factors that contribute to its regulation are incompletely understood. Methods: We tested the association of single nucleotide polymorphisms (SNPs) from 16 genes related to ammonia (NH3) metabolism (15 biological candidates selected a priori, 1 selected from a previous genome-wide association study analysis) to that of 24-hour urine pH in 2493 individuals of European descent across 2 different cohorts using linear regression, adjusting for age, sex, and body mass index. Results: Of 2871 total SNPs in these genes, 13 SNPs in ATP6V0A4 (a4 subunit of hydrogen− adenosine triphosphatase), SLC9A3 (sodium/hydrogen exchanger, isoform 3), and RHCG (Rhesus C glycoprotein), and 12 SNPs from insulin-like growth factor binding protein 7 (IGFBP7) had a meta-analysis P value

Background: Infection following Achilles tendon surgery is a devastating complication and can be difficult to treat and often leads to poor outcomes. A number of treatments have been described, but there is little information concerning outcomes of these treatments. Our purpose was to evaluate the clinical and functional outcomes of patients who have undergone treatment for an infected Achilles tendon after acute and chronic midsubstance repair. Methods: We retrospectively reviewed the medical records of 20 patients who had undergone surgical treatment for an infected Achilles tendon between 2000 and 2016. The mean follow-up time was 21 months (range, 2-68 months). All patients underwent extensive debridement of the tendon with removal of all infected tissue and foreign material. Soft tissue wound coverage was utilized for large wounds that were not amenable to primary or secondary closure. All patients received culture-specific intravenous (IV) antibiotics for 3 to 6 weeks. Postoperatively, the extremity was immobilized in a splint followed by a cast until the wound was healed. The cast was then replaced with a walking boot and the patients were provided a physical therapy program. Functional outcomes were measured using the Foot and Ankle Ability Measure (FAAM) Activity of Daily Living (ADL) scale. Results: All wounds had healed at the time of last follow-up. Three patients (15%) required an unplanned return to the operating room for repeat debridement. All patients were able to walk without the use of a gait aid. Five patients (25%) required continued use of a boot or brace during ambulation. Fourteen patients participated in the FAAM ADL survey. There were 6 patients lost to follow-up. The average FAAM score was 87 (range, 71.4-100). At last follow-up, most patients reported their overall function as “normal” or “nearly normal.” Eradication of infection and satisfactory functional results can be attained after radical debridement, wound closure, and administration of culture-specific IV antibiotics. Level of Evidence: Level IV, retrospective case series.

Background:. Rotational vascularized autografts are ideal for achieving spinal arthrodesis because they maintain bony vascularization while avoiding the morbidity and challenges of free-tissue transfer. Although proximal ribs are ideal candidates for vascularized bone grafts, their use is restricted to the thoracic spine. This study describes a novel technique for harvesting lateral rib grafts on an intercostal pedicle for use in cervical and lumbar posterolateral arthrodesis. Methods:. Six cadaveric dissections were performed (2 included upper and all 6 included lower rib dissections). Measurements included graft width and thickness, distance reached from harvest level to the top of the graft, and ipsilateral and contralateral spine levels reached by the graft. Results:. Overall, 60 lateral rib grafts were harvested. Intercostal vessel pedicles were torn during harvest in 4/48 (8.3%) of the lower rib and 5/12 (41.7%) of the upper rib grafts. Mean measurements of successful upper rib grafts were 1.4 ± 0.12 cm × 0.5 ± 0.15 cm (width × thickness), 14.1 ± 2.79 cm (distance) reached, and C2 (occiput–C4) reached ipsilaterally and C3 (occiput–C5) reached contralaterally. Mean lower rib graft measurements were 1.4 ± 0.26 cm × 0.4 ± 0.15 cm (width × thickness), 18.0 ± 6.19 cm (distance), S1 (L1–S2) reached ipsilaterally, and L4 (L1–S1) reached contralaterally. Conclusions:. It is technically feasible to rotate a far-lateral rib graft on an intercostal pedicle into the posterolateral cervical or lumbar spine for the augmentation of arthrodesis. Upper ribs seem to be more difficult to harvest and rotate while keeping the intercostal pedicle intact than lower ribs.

Despite multiple advantages, subclavian vein (SCV) cannulation via the traditional landmark approach has become less used in comparison to ultrasound (US) guided internal jugular catheterization due to a higher rate of mechanical complications. A growing body of evidence indicates that SCV catheterization with real-time US guidance can be accomplished safely and efficiently. While several cannulation approaches with real-time US guidance have been described, available literature suggests that the infraclavicular, longitudinal “in-plane” technique may be preferred. This approach allows for direct visualization of needle advancement, which reduces risk of complications and improves successful placement. Infraclavicular SCV cannulation requires simultaneous use of US during needle advancement, but for an inexperienced operator, it is more easily learned compared to the traditional landmark approach. In this article, we review the evidence supporting the use of US guidance for SCV catheterization and discuss technical aspects of the procedure itself.

Category: Sports Introduction/Purpose: Infection following Achilles tendon surgery is a devastating complication and can be difficult to treat. Our purpose was to evaluate clinical and functional outcomes of patients who have undergone treatment for an infected Achilles tendon. Methods: We retrospectively reviewed the medical records of 20 patients who had undergone surgical treatment for an infected Achilles tendon between 2000 and 2016. The mean follow-up time was 21 months (range 2-68 months). All patients underwent extensive debridement of the tendon with removal of all infected tissue and foreign material. Soft tissue wound coverage was utilized for large wounds that were not amenable to primary or secondary closure. All patients received culture specific intravenous antibiotics for three to six weeks. Postoperatively, the extremity was immobilized in a splint followed by a cast until the wound was healed. The cast was then replaced with a walking boot and the patients were provided a physical therapy program. Functional outcomes were measured using the Foot and Ankle Ability Measure (FAAM) Activity of Daily Living (ADL) scale. Results: All wounds had healed at the time of last follow-up. Three patients (15%) required an unplanned return to the operating room for repeat debridement. All patients were able to walk without the use of a gait aid. Five patients (25%) required continued use of a boot or brace during ambulation. The average FAAM score was 87 (range, 71.4-100). At last follow-up, most patients reported their overall function as “normal” or “nearly normal”. Conclusion: Eradication of infection and satisfactory functional results can be attained after radical debridement, wound closure, and administration of culture specific IV antibiotics.

Category: Tumor Introduction/Purpose: Soft tissue sarcomas (STS) of the foot and ankle are common, accounting for 10% of sarcomas; however, there exists little published data on the outcome of treatment. Because of the unique anatomy of the foot and ankle, and the fact that benign lesions in this area are 200-fold more common than malignant lesions, these tumors can be frequently misdiagnosed, leading to unplanned excision and poor outcomes. The purpose of this study was to describe outcomes of the surgical treatment of STS of the foot and ankle at our institution, with an analysis on risk factors for local and distant recurrence, as well as overall survival. Methods: We reviewed the records of 62 foot and ankle soft tissue sarcomas treated with definitive surgery at our institution between 1992 and 2013. The cohort consisted of 35 males and 27 females with a mean age at diagnosis of 45 years and a mean follow-up of 7 years. Age, gender, anatomic location, tumor size, subtype, stage, neoadjuvant and adjuvant treatments, previous surgery, surgical procedure, and disease status at latest follow-up was recorded. Results: The most common tumor subtype was synovial sarcoma (n = 16). The overall limb salvage rate was 53%. Local recurrence was observed in 9 patients and distant metastases in 15 patients. Tumor size >=3 cm in maximal dimension was the greatest risk factor in mortality. Post treatment complications occurred in 15 patients. Local recurrence and development of distant disease was relatively common following wide excision of a soft tissue sarcoma of the foot and ankle. Tumors that were >=3 cm in maximal dimension were associated with a worse overall survival and patients with neoadjuvant radiation were at increased risk of complications. Conclusion: The results of our study highlight the aggressive nature of soft tissue sarcomas of the foot and ankle, with smaller tumors than previously reported (

Category: Ankle Introduction/Purpose: Treatment of osteochondral defects of the talus with particulated juvenile cartilage allograft is a relatively new procedure. Although other treatment options exist for large osteochondral defects of the talus, the potential advantage of particulated juvenile allograft is the ability to perform the procedure arthroscopically or through a minimal approach. No previous studies have looked at the results of an arthroscopic approach and no previous studies have compared an arthroscopic technique to an open approach. The purpose of this study was to compare the outcomes of an arthroscopic transfer technique to the previously published open technique. Methods: A total of 34 patients underwent treatment of talar cartilage lesions with juvenile particulated cartilage allograft. Twenty of these were done arthroscopically and 14 were done with an open arthrotomy. There was no statistically significant difference between the groups with respect to age, lesion width, lesion depth, lesion length, or operative time. Scores for 6 different validated outcome measures were recorded for patients in each group pre-operatively and subsequently at 6 months, 1 year, 18 months, and 2 years. Results: Comparing outcome measurements at each data point to baseline, there were no statistically significant post-operative differences found between open and arthroscopic approaches with regards to VAS Pain Scale, AOFAS Ankle-Hindfoot Scale, Foot and Ankle Ability Measure - Sport Scale, or SF12 Physical Health Scale. Conclusion: Treatment of talar articular cartilage lesions with particulated juvenile cartilage allograft is associated with improved outcomes at 2 years with regards to several validated outcome measures regardless of technique utilized. At 2 years follow up, there were no statistically significant differences in outcomes utilizing an arthroscopic technique versus open technique with the numbers given. This data supports the use of particulated juvenile cartilage allograft utilizing either arthroscopic or open techniques.

Objective: To examine patient preference regarding physician attire and whether perception of medical competence was influenced by the physician's clothing style.Methods: New patients presenting to the OB/GYN clinic at the Naval Medical Center Portsmouth were asked to complete a survey regarding patient preference for physcian attire and any effect on their comfort or confidence in the physician.Results: Surveys were collected over a 2-month period. Completed surveys (328) were analyzed with the following results: 86% had no preference whether the physician wore a white coat, 61% preferred scrubs, 13% were uncomfortable talking to a doctor about general topics, and 16% were uncomfortable talking about sexual, psychological, or personal topics based on physician attire. In a comparison between active duty women and dependent wives, a significantly greater number of dependent wives reported the physician attire having no influence on their comfort level discussing general topics with their physician (p = 0.037) or about sexual, psychological, or personal topics (p = 0.035). No difference was seen between groups in the preference to wear a white coat (p = 0.196) or other attire (p = 0.088) or of an influence of the doctors' clothing on the patient's confidence in the doctors' abilities (p = 0.063).Conclusion: Overall, female patients in a military setting do not have a preference for specific physician attire and attire does not influence their perception of the doctor's competence. However, a greater number of dependent wives report physician attire has no influence on their comfort level discussing both general and personal topics when compared with active duty women. This finding highlights the unique role of the military uniform in the eyes of active duty women and their potential discomfort in discussing personal medical issues with a physician in military uniform. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To investigate the molecular consequences of expressing mutated forms of tumor necrosis factor receptor I (TNFRI) as found in patients with TNFR-associated periodic syndrome (TRAPS). METHODS: We cloned and expressed full-length wild-type (WT) and T50K and P46L variants of TNFRI using a new tightly regulated doxycycline-dependent expression system. This system enabled the study of molecular interactions between these receptors at both physiologic and pathophysiologic levels of expression. RESULTS: We used chemical crosslinking on the cell surface to show that WT and mutant forms of TNFRI, derived from TRAPS patients, interact in the absence of TNF ligand. Doxycycline-controlled up-regulation of one TNFRI allele, either WT or mutant, caused down-regulation of the other allele, indicating dynamic control of cell surface assembly. We also demonstrated that increased expression of mutant TNFRI (T50K) was associated with a parallel increase in NF-kappaB p65 (RelA) subunit activation, which did not occur with increased expression of WT TNFRI. CONCLUSION: The T50K TRAPS-related variant is capable of sustaining inappropriate NF-kappaB activation, resulting in persistent auto-inflammation in target organs such as skin, synovial membrane, and the central nervous system. We conclude that some of the inflammatory processes seen in TRAPS do not involve direct interaction of TNF with its receptors, but that other proinflammatory mechanisms capable of up-regulating TNFRI expression may cause cellular activation through the NF-kappaB signaling pathway. [ABSTRACT FROM AUTHOR]