Substrate Characterization and Outcomes of Ventricular Tachycardia Ablation in Amyloid Cardiomyopathy: A Multicenter Study.

BACKGROUND: Sustained ventricular tachycardia (VT) in cardiac amyloidosis is uncommon, and the substrate and outcomes of catheter ablation are not defined. METHODS: We included 22 consecutive patients (mean age, 68±10 years; male sex, 91%) with cardiac amyloidosis (ATTR [transthyretin], n=16; light chain, n=6) undergoing catheter ablation for VT/ventricular fibrillation (VF) between 2013 and 2023 in a retrospective, observational, international study. The primary efficacy outcome was recurrent VT/VF during follow-up, while the primary safety end point included major procedure-related adverse events. RESULTS: The indication for ablation was drug-refractory VT in 17 patients (77%), and premature ventricular complex-initiated polymorphic VT/VF in 5 patients (23%). Catheter ablation was performed using endocardial (n=17.77%) or endo-epicardial approaches (n=5.23%). Complete endocardial electroanatomical voltage maps of the left and right ventricles were obtained in 17 (77%) and 10 (45%) patients, respectively. Each patient had evidence of low-voltage areas, most commonly involving the interventricular septum (n=16); late potentials were recorded in 16 patients (73%). A median of 1 (1-2) VT was inducible per patient; 12 of the 26 mappable VTs (46%) originated from the interventricular septum. Complete procedural success was achieved in 16 patients (73%), with 4 (18%) major procedure-related adverse events. After a median follow-up of 32 (14-42) months, sustained VT/VF recurrence was observed in 9 patients (41%); survival free from VT/VF recurrence was 56% (95% CI, 36%-86%) at 36-month follow-up, and most patients remained on antiarrhythmic drugs. A significant reduction in per patient implantable cardioverter defibrillator therapies was noted in the 6-month period after ablation (before: 6 [4-9] versus after: 0 [0-0]; P<0.001). In multivariable analysis, complete procedural success was associated with reduced risk of recurrent VT/VF (hazard ratio, 0.002; P=0.034). CONCLUSIONS: Catheter ablation can achieve control of recurrent VT/VF in more than half of patients with cardiac amyloidosis, and the reduction in VT/VF burden post-ablation may be relevant for quality of life. Septal substrate and risk of procedure-related complications challenge successful management of patients with cardiac amyloidosis and VT/VF.

The Effect of First Metatarsal Shortening and Sagittal Displacement on Forefoot Pressure in Minimally Invasive Hallux Valgus Correction.

BACKGROUND: Minimally invasive (MIS) treatment of hallux valgus (HV) deformity is increasing in popularity. A 2-mm diameter burr is used to create a distal first metatarsal osteotomy prior to capital fragment translation and fixation. The metatarsal will shorten by the burr's diameter (2 mm). Plantar or dorsal capital fragment displacement may also cause load transference and possibly transfer metatarsalgia. The purpose of this study is to examine the effect of MIS HV on forefoot loading mechanics with respect to metatarsal shortening and sagittal plane displacement. METHODS: Four lower-limb cadaveric specimens were studied. A pedobarography pressure-sensing mat was used to record forefoot plantar pressure in a controlled weight-bearing stance position. Control and postosteotomy measurements were obtained with the capital fragment fixated in 3 possible positions: 0 mm, 5 mm dorsal, and 5 mm plantar displacement. Pedobarography data yielded pressure data within measurable graphical depictions. Raw mean contact pressure measurements were taken under the first and fourth metatarsal heads to establish medial and lateral forefoot loading pressure ratios. An a priori power analysis was performed based on previous peer-reviewed pedobarographic data, and our study was adequately powered. RESULTS: Around 40 measurements were recorded, and ratios of medial-to-lateral forefoot loading were constructed. Medial forefoot pressure control versus 0 mm displacement, and control versus dorsal displacement were not found to be statistically significant (p = 0.525, p = 0.55, respectively). Medial pressure significantly increased when comparing control versus plantar displacement (P = .006). Lateral pressure significantly increased with dorsal displacement of the osteotomy (P = .013). CONCLUSION: Our study found that MIS HV correction did not cause an increase in lateral forefoot pressure loading when sagittal plane displacements were controlled. Plantar displacement increased medial loading, and dorsal displacement increased lateral loading. It may be valuable for surgeons to consider metatarsal head position postosteotomy, as a decrease in medial loading and subsequent increase in lateral loading may lead to lateral forefoot pain and transfer metatarsalgia. LEVELS OF EVIDENCE: IV.

Open Ankle Fractures in Older Individuals: A Multi-center Study.

The purpose of this study is to identify demographics, etiology, comorbidities, treatment, complications, and outcomes for older patients with open ankle fractures. Patients ≥60 years old who sustained an open ankle fracture between January 1, 2004 and March 31, 2014 at 6 Level 1 trauma centers were retrospectively reviewed. Univariate analysis using chi-squared or Student's t test was performed to identify associations between preoperative variables and 2 postoperative outcomes of interest: amputation and 1-year mortality. Multivariate analysis was performed using stepwise logistical regression to identify independent predictors of postoperative amputation and 1-year mortality. Of the 162 total patients, the most common mechanism of injury was a ground-level fall (51.9%). The most common fracture types were bimalleolar fractures (52.5%) followed by trimalleolar fractures (26.5%), with 41.5% of the fractures classified as Gustilo Anderson Classification Type 2 and 38.6% classified as Type 3A. The average number of surgeries required per patient was 2.1. Complications included: 15.4% superficial infection rate, 9.9% deep infection rate, and 9.3% amputation rate. The 1-year mortality rate was 13.6% and the overall mortality rate was 25.9%. Male gender and fracture type were found to be independent predictors for amputation after surgery (p = .009, .005, respectively). Older age and having diabetes were independent predictors for 1-year mortality after surgery (p = .021, .005 respectively). Overall, open ankle fractures in older individuals were associated with high rates of amputation and mortality.

The surgical learning curve for percutaneous Zadek osteotomy for treatment of insertional achilles tendinopathy.

INTRODUCTION: The Zadek Osteotomy has been described as an effective technique for the treatment of insertional Achilles tendinopathy. Recently, this strategy has been modified using minimally invasive techniques. A learning curve has been observed in many minimally invasive procedures in foot and ankle surgery. This retrospective study first intended to evaluate if there is a learning curve associated with the percutaneous Zadek Osteotomy. Further, if a learning curve was observed, we planned to assess the data for associated changes in complications and postoperative outcomes. METHODS: A retrospective analysis of 98 patients who underwent percutaneous Zadek Osteotomy was performed. Patient charts were reviewed for operative times, complications, union rates, and Foot Function Index (FFI) and Visual Analogue Scale (VAS) scores. Analysis of variance was utilized to assess for differences between groups of cases. RESULTS: Patients included 61 females and 37 males. Mean age was 51.28 ± 11.12 (range 28-81) years. Mean follow-up time was 42.07 ± 12.99 (range 24-65) months. Significant increases in operative times were observed in cases 1-14 when compared to cases 15-98 (p < 0.001). Improvements in FFI and VAS scores were observed at final follow-up within each case group (p < 0.001); there were no differences detected in FFI or VAS scores between groups of cases. There was no difference detected in number of complications between intervals of cases. CONCLUSION: A learning curve was observed for the percutaneous Zadek Osteotomy, which was overcome around case 14. This learning curve was only observed in terms of procedure length. A surgeon's level of inexperience with the technique does not appear to affect functional outcomes, nonunion, or need for revision. LEVEL OF EVIDENCE IV: Data will not be deposited in a repository.

Human Papillomavirus and Associated Cancers: A Review.

The human papillomavirus is the most common sexually transmitted infection in the world. Most HPV infections clear spontaneously within 2 years of infection; however, persistent infection can result in a wide array of diseases, ranging from genital warts to cancer. Most cases of cervical, anal, and oropharyngeal cancers are due to HPV infection, with cervical cancer being one of the leading causes of cancer death in women worldwide. Screening is available for HPV and cervical cancer, but is not available everywhere, particularly in lower-resource settings. HPV infection disproportionally affects individuals living with HIV, resulting in decreased clearance, increased development of cancer, and increased mortality. The development of the HPV vaccine has shown a drastic decrease in HPV-related diseases. The vaccine prevents cervical cancer with near 100% efficacy, if given prior to first sexual activity. Vaccination uptake remains low worldwide due to a lack of access and limited knowledge of HPV. Increasing awareness of HPV and access to vaccination are necessary to decrease cancer and HPV-related morbidity and mortality worldwide.

Percutaneous vs Open Zadek Osteotomy for Treatment of Insertional Achilles Tendinopathy and Haglund's Deformity: A Systematic Review.

Background: Percutaneous Zadek osteotomy (ZO) has emerged as a surgical treatment of insertional Achilles tendinopathy (IAT) over the last decade. Existing literature is limited regarding the comparison of this approach with the more established, open ZO technique. This systematic review aims to evaluate and compare the current data on open vs percutaneous ZO approaches to help set evidence-based guidelines. Methods: A systematic literature search was performed using the keywords (Zadek osteotomy) OR (Keck and Kelly osteotomy) OR (dorsal closing wedge calcaneal osteotomy) OR (Haglund Deformity) OR (Haglund Syndrome) OR (Insertional Achilles Tendinopathy) and MeSH terms Osteotomy, Calcaneus, Syndrome, Insertional, Achilles tendon, and Tendinopathy. Our search included the following databases: PubMed, Embase, and the Cochrane Library. The PRISMA protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2009 to 2024 and included the use of open or percutaneous approaches of ZO for the treatment of IAT with at least a 12-month follow-up. The MINORS score criteria were used to evaluate the strength and quality of studies. Results: A total of 17 studies were reviewed, including 611 subjects and 625 ZO procedures. Of these procedures, 81 (11%) subjects had a percutaneous and 544 (89%) subjects had an open ZO. The mean follow-up time was 16.1 months for patients treated with percutaneous ZO and 36.1 months for patients treated with open ZO. Both open and percutaneous studies included in this review showed postoperative improvements in AOFAS, FFI, VISA-A, and VAS scores in patients with IAT. The reported complication rate was 5.8% among patients treated with percutaneous ZO and 10.2% among patients treated with open ZO. Conclusion: Percutaneous ZO is an emerging approach with substantially fewer documented cases compared with the open ZO. Both percutaneous and open ZO appear to be relatively effective treatments for insertional Achilles tendinopathy with Haglund's deformity. The lower complication rates reported for percutaneous ZO is encouraging. Further investigation with more subjects undergoing percutaneous ZO is clearly needed.

Minimally invasive Dorsal cheilectomy and Hallux metatarsophalangeal joint arthroscopy for the treatment of Hallux Rigidus.

BACKGROUND: Minimally invasive dorsal cheilectomy (MIDC) has become a popular alternative to an open approach for treating Hallux Rigidus (HR). To reduce some of the complications related to the MIDC approach, a first metatarsophalangeal (MTP) joint arthroscopy can be performed in addition to address the intra-articular pathology associated with Hallux Rigidus. This study aims to examine the effectiveness of MIDC with first MTP arthroscopy in patients with HR with a minimum 1-year follow-up. METHODS: This was a multicenter retrospective review for adult patients with Coughlin and Shurnass Grade 0-3 who were treated with MIDC and first MTP arthroscopy between 3/1/2020 and 8/1/2022, with at least one year of follow-up data. Demographic information, first MTP range of motion (ROM), visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOXFQ), and EQ-5D-5 L scores were collected. Continuous data was expressed as a mean and standard deviation, categorical data was expressed as a percentage. Wilcoxon Rank Sum test was used to compare continuous variables. All P < 0.05 was considered significant. RESULTS: A total of 31 patients were included in the study. Average follow-up time was 16.5 months (range: 12 to 26.2). There was 1 (3.2%) undersurface EHL tendon tear, 2 (6.5%) conversions to an MTP fusion, and 1 (3.2%) revision cheilectomy and capsular release for MTP joint contracture. There was a significant improvement in patient's ROM in dorsiflexion (50 vs 89.6 degrees, P = 0.002), postoperative VAS pain scores (6.4 vs 2.1, P < 0.001), MOXFQ pain scores (58.1 vs 30.7, P = 0.001), MOXFQ Walking/Standing scores (56.6 vs 20.6, P = 0.001), MOXFQ Social Interaction scores (47.3 vs 19.36, P = 0.002), and MOXFQ Index scores (54.7 vs 22.4, P < 0.001). CONCLUSION: We found that MIDC with first MTP arthroscopy was effective at improving patient-reported outcomes at one year with low complication and revision rates. These results suggest that MIDC with first MTP arthroscopy is an effective treatment for early-stage HR. LEVEL OF EVIDENCE: IV.

Total Joint Arthroplasty Outcomes in Eligible Patients Versus Patients Who Failed to Meet at Least 1 Eligibility Criterion: A Single-Center Retrospective Analysis.

BACKGROUND: This study looks to investigate how not meeting eligibility criteria affects postoperative outcomes following total joint arthroplasty surgery. METHODS: A retrospective review was conducted of total joint arthroplasty patients at a single academic institution. Demographics, laboratory values, and complications were recorded. Continuous and categorical variables were compared using the Student's T-test and the Chi-Square test, respectively. Multivariable analysis was used to control for confounding variables. RESULTS: Our study included 915 total hip and 1,579 total knee arthroplasty patients. For total hip and total knee arthroplasty, there were no significant differences in complications (P = .11 and .87), readmissions (P = .83 and .2), or revision surgeries (P = .3 and 1) when comparing those who met all criteria to those who did not. Total hip arthroplasty patients who did not meet two criteria had 16.1 higher odds (P = .02) of suffering a complication. There were no differences in complications (P = .34 and .41), readmissions (P = 1 and .55), or revision surgeries (P = 1 and .36) between ineligible patients treated by total joint arthroplasty surgeons and those who were not. Multivariable analysis demonstrated no eligibility factors were associated with outcomes for both total hip and knee arthroplasty. CONCLUSIONS: There was no significant difference in outcomes between those who met all eligibility criteria and those who did not. Not meeting two criteria conferred significantly higher odds of suffering a complication for total hip arthroplasty patients. Total joint arthroplasty surgeons had similar outcomes to non-total joint surgeons, although their patient population was more complex. LEVEL OF EVIDENCE: III.

A Retrospective Comparative Analysis on the Effect of Tranexamic Acid to Reduce Perioperative Blood Loss in Patients Undergoing Cervical Spine Surgery.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: The purpose of this study is to assess the impact of intravenous TXA on blood loss outcomes in anterior, posterior, and combined approaches for elective cervical spine surgery. SUMMARY OF BACKGROUND DATA: Tranexamic acid (TXA) has been shown to reduce blood loss in a variety of operations, such as lumbar spine surgery. However, limited studies have evaluated the efficacy of TXA in cervical spine surgery. METHODS: We performed a retrospective review of a single surgeon's elective cervical spine operations between September 2011 and March 2017. Patients were divided into 3 groups: anterior approach, posterior approach, or combined approach. Patients were then further subdivided into TXA versus control groups based on whether they received TXA treatment. We performed multiple linear regressions to assess the relationship between the use of TXA and other dependent variables (number of vertebral levels treated, need for a vertebral corpectomy) on total perioperative blood loss, intraoperative estimated blood loss, postoperative drain output, total operative time, postoperative change in hemoglobin, and occurrence of transfusion and/or postoperative deep venous thrombus (DVT). RESULTS: We found that the use of TXA statistically significantly reduced total perioperative blood loss ( P =0.04) and postoperative drain output ( P =0.004) in posterior surgical approach cervical spine surgery but did not statistically significantly impact any blood loss variables in anterior or combined surgical approaches to elective cervical spine surgery. The use of TXA was a significant predictor for a decrease in intraoperative ( P =0.02) and postoperative ( P <0.01) blood loss. CONCLUSIONS: This study found that TXA statistically significantly decreased total blood loss and postoperative drain output when controlling for multiple confounding factors. LEVEL OF EVIDENCE: Level III.

Retrospective Review of Complications and Revision Rates Between Isolated Talonavicular vs Talonavicular and Subtalar (Double) Arthrodesis vs Triple Arthrodesis.

Background: Hindfoot fusion procedures are common for the treatment of end-stage arthritis or deformity. Surgical treatments for these conditions include talonavicular joint (single) arthrodesis, talonavicular and subtalar (double) arthrodesis, or talonavicular, subtalar, and calcaneocuboid (triple) arthrodesis. This study evaluated the complication rate, revision surgery rate, and hardware removal rate for those treated with either single, double, or triple arthrodesis. Methods: A retrospective review was conducted for patients who underwent single (Current Procedural Terminology [CPT] code 28740), double (CPT 28725 and 28740), or triple (CPT 28715) arthrodesis to treat hindfoot arthritis/deformity (International Classification of Diseases, Ninth Revision [ICD-9] code: 734, International Classification of Diseases, Tenth Revision [ICD-10] codes: M76821, M76822, and M76829) from 2005 to 2022 using the South Carolina Revenue and Fiscal Affairs databank. Data collected included demographics, comorbidities, procedure data, and postoperative outcomes within 1 year of principal surgery. Student t test, chi-squared test, and multivariable logistic regression analysis were utilized during data analysis. Results: A total of 433 patients were identified, with 248 undergoing single arthrodesis, 67 undergoing double arthrodesis, and 118 undergoing triple arthrodesis. There was no significant difference between single, double, and triple arthrodesis in the rate of complications, hardware removals, revision surgeries, or 30-day readmission when controlling for confounding variables. However, a decrease in Charlson Comorbidity Index (CCI) was found to be predictive of an increase in the revision surgery rate (OR = 0.46, 95% CI 0.22-0.85, P = .02). Conclusion: We found no difference in the rate of complications, hardware removals, or revision surgeries in those undergoing single, double, or triple arthrodesis. Surprisingly we found that a lower Charlson Comorbidity Index, indicating a healthier patient had a significant relationship with a higher rate of revision surgery. Further study including radiographic indications for surgery or the impact of overall health status on revision surgery rates may further elucidate the other components of this relationship. Level of Evidence: Level III, cohort study.

Comparison of the Acute Postoperative Complications Between Isolated Talonavicular Versus Talonavicular and Subtalar (Double) Arthrodesis in Flatfoot Deformity.

BACKGROUND: Both isolated talonavicular arthrodesis and talonavicular and subtalar (such as double) arthrodesis can be effective treatments for adult-acquired flatfoot deformity (AAFD) with good success rates, but double arthrodesis has become more commonly performed in recent years. The purpose of this study is to evaluate whether isolated talonavicular versus talonavicular and subtalar arthrodesis led to significantly different 30-day postoperative complication rates in patients with AAFD. METHODS: We performed a retrospective review to identify a large cohort of adult patients with the diagnosis of AAFD or posterior tibial tendon deformity (PTTD) who underwent isolated talonavicular or talonavicular and subtalar arthrodesis between 2006 and 2020 from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). To investigate whether there was a difference in complication rate between the 2 surgical cohorts, we estimated logistic regression models and log-binomial models on each of the outcomes while also adjusting for sex and age. RESULTS: We found that there was no significant difference in the rate of major complications (P = .567) or readmissions (P = .567) between patients who underwent isolated talonavicular versus talonavicular and subtalar arthrodesis for AAFD. However, there was a significantly higher rate of minor complications in patients who underwent isolated talonavicular arthrodesis when compared with patients who underwent talonavicular and subtalar arthrodesis (P = .009). CONCLUSION: This study found that there was no increased risk of 30-day postoperative complications or readmissions with talonavicular and subtalar arthrodesis when compared with isolated talonavicular arthrodesis for AAFD. In addition, there was no increased risk of major complications for talonavicular and subtalar arthrodesis when compared with isolated talonavicular arthrodesis, and isolated talonavicular arthrodesis actually carried a higher risk of minor complications for this surgical cohort. This may provide valuable information for surgeons considering surgical treatment for a particular case of AAFD. LEVEL OF EVIDENCE: Level III.

Ventricular Tachycardia Ablation in Patients With Desmoplakin Cardiomyopathy.

BACKGROUND: Desmoplakin (DSP) pathogenic variants are rare causes of arrhythmogenic cardiomyopathy and often involve the right and left ventricles. Ventricular tachycardia (VT) ablations may be required in these patients, but procedural characteristics have not been reported. OBJECTIVES: In this study, the authors sought to report a multicenter experience of VT ablation in patients with DSP pathogenic variants. METHODS: VT ablations performed in patients with known DSP pathogenic variants were analyzed across 6 centers in 3 countries. Patient characteristics and acute and long-term procedural outcomes were reported. RESULTS: A total of 20 patients (13 men, median age 43 years [Q1-Q3: 41.5-53.0 years], left ventricular ejection fraction 43.0% [Q1-Q3: 41.5%-53.0%], 11 previous failed ablations) were referred for VT ablation procedures. All patients had symptomatic VTs, with ICD therapy in 19 patients. Epicardial procedures were performed in 16 of the 20 patients. VT target sites were located in the right ventricular (RV) endocardium (n = 11), the RV epicardium (n = 4), the left ventricular (LV) endocardium (n = 2) and the LV epicardium (n = 7). In 3 patients, the VT target sites were in close proximity to coronary arteries, limiting ablation. During follow-up, VTs recurred in 11 patients, and repeated ablations were performed in 9 patients. Allowing for multiple procedures, 19 of the 20 patients remained free of VT recurrence after a median follow-up of 18 months [Q1-Q3: 5-60 months]. CONCLUSIONS: Patients with DSP cardiomyopathy often have biventricular involvement, and ablation procedures often require ablation in both ventricles and the epicardium. Recurrences are not uncommon, and the pathologic substrate can be located in close proximity to epicardial coronary arteries, limiting the success rate of ablations.

Nonopioid Pain Management Pathways for Stone Disease.

Introduction: New opioid dependency after urologic surgery is a serious adverse outcome that is well-described in the literature. Patients with stone disease often require multiple procedures because of recurrence of disease and hence are at greater risk for repeat opioid exposures. Despite this, opioid prescribing after urologic surgery remains highly variable and in an emergency setting, opioids are still used commonly in management of acute renal colic. Methods: Two literature searches were performed using PubMed. First, we searched available literature concerning opioid-sparing pathways in acute renal colic. Second, we searched available literature for opioid-sparing pathways in ureteroscopy and percutaneous nephrolithotomy (PCNL). Abstracts were reviewed for inclusion in our narrative review. Results: In the setting of acute renal colic, multiple randomized control trials have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) attain greater reduction in pain scores, decreased need for rescue medications, and decreased vomiting events in comparison with opioids. NSAIDs also form a core component in management of postureteroscopy pain and have been demonstrated in randomized trials to have equivalent to improved pain control outcomes compared with opioids. Multiple opioid-free pathways have been described for postureteroscopy analgesia with need for rescue narcotics falling under 20% in most studies, including in patients with ureteral stents. Enhanced Recovery After Surgery protocols after percutaneous nephrolithotomy are less well described but have yielded a reduction in postoperative opioid requirements. Conclusions: In select patients, both acute renal colic and after kidney stone surgery, adequate pain management can usually be obtained with minimal or no opioid medication. NSAIDs form the core of most described opioid-sparing pathways for both ureteroscopy and PCNL, with the contribution of other components to postoperative pain outcomes limited because of lack of head-to-head comparisons. However, medications aimed specifically at targeting stent-related discomfort form a key component of most multimodal postsurgical pain management pathways. Further investigation is needed to develop pathways in patients unable to tolerate NSAIDs.

Outcomes and Complications After Bone Marrow Aspirate Harvest From the Calcaneus.

Background: Bone marrow aspirate (BMA) is used with the putative goal of enhancing healing of injured tissue. The most common sites to harvest BMA are the iliac crest, the tibia, and the calcaneus. Investigators have found that the tibia and calcaneus have fewer progenitor cells than the iliac crest. This retrospective review evaluates the efficacy and safety profile of harvesting BMA from the calcaneus bone. We hypothesized that harvesting BMA from the calcaneus will have high efficacy and safety profile with low complication rates. Methods: A retrospective chart review of patients undergoing bone marrow aspiration from the calcaneus bone from January 2019 to October 2022 was performed. The main data points evaluated were patient satisfaction and pain level, follow-up times, quantity of BMA harvested, fusion rates, and complications including nerve damage, infections, and nonunions. Results: There were 45 (34 female and 11 male) patients who underwent 45 procedures. The average age, BMI, and amount of BMA were 45.1 years (range 23-79), 33.1 (range 19.2-61.3), and 10.3 mL (range 2-40), respectively. There was no pain reported at the final follow-up in 32 patients (71.1%), and there was minimal to no pain in the area of surgery in the remaining 13 patients (28.9%). The 10 cases of fusion successfully healed with combined use of allograft and BMA. The average follow-up time was 12.3 months (range 2.4-33.7). There were no infections, wound complications, or nerve injuries. Conclusion: Harvesting BMA from the calcaneus bone is a safe procedure. In this heterogenous series where BMA augmented other surgical strategies, patients had little to no pain and there were no cases of wound complication or iatrogenic neuropraxia after undergoing bone marrow harvest from the calcaneus. Level of Evidence: Level IV, case series.

Low host immune pressure may be associated with the development of hepatocellular carcinoma: a longitudinal analysis of complete genomes of the HBV 1762T, 1764A mutant.

Background: It has been reported that hepatitis B virus (HBV) double mutations (A1762T, G1764A) are an aetiological factor of hepatocellular carcinoma (HCC). However, it is unclear who is prone to develop HCC, among those infected with the mutant. Exploring HBV quasispecies, which are strongly influenced by host immune pressure, may provide more information about the association of viral factors and HCC. Materials and methods: Nine HCC cases and 10 controls were selected from the Long An cohort. Serum samples were collected in 2004 and 2019 from subjects with HBV double mutations and the complete genome of HBV was amplified and sequenced using next-generation sequencing (NGS). Results: The Shannon entropy values increased from 2004 to 2019 in most cases and controls. There was no significant difference in mean intrahost quasispecies genetic distances between cases and controls. The change in the values of mean intrahost quasispecies genetic distances of the controls between 2004 and 2019 was significantly higher than that of the cases (P<0.05). The viral loads did not differ significantly between cases and controls in 2004(p=0.086) but differed at diagnosed in 2019 (p=0.009). Three mutations occurring with increasing frequency from 2004 to 2019 were identified in the HCC cases, including nt446 C→G, nt514 A→C and nt2857T→C. Their frequency differed significantly between the cases and controls (P<0.05). Conclusions: The change in the values of mean intrahost quasispecies genetic distances in HCC was smaller, suggesting that HBV in HCC cases may be subject to low host immune pressure. Increasing viral loads during long-term infection are associated with the development of HCC. The novel mutations may increase the risk for HCC.

Evaluating ChatGPT Performance on the Orthopaedic In-Training Examination.

Background: Artificial intelligence (AI) holds potential in improving medical education and healthcare delivery. ChatGPT is a state-of-the-art natural language processing AI model which has shown impressive capabilities, scoring in the top percentiles on numerous standardized examinations, including the Uniform Bar Exam and Scholastic Aptitude Test. The goal of this study was to evaluate ChatGPT performance on the Orthopaedic In-Training Examination (OITE), an assessment of medical knowledge for orthopedic residents. Methods: OITE 2020, 2021, and 2022 questions without images were inputted into ChatGPT version 3.5 and version 4 (GPT-4) with zero prompting. The performance of ChatGPT was evaluated as a percentage of correct responses and compared with the national average of orthopedic surgery residents at each postgraduate year (PGY) level. ChatGPT was asked to provide a source for its answer, which was categorized as being a journal article, book, or website, and if the source could be verified. Impact factor for the journal cited was also recorded. Results: ChatGPT answered 196 of 360 answers correctly (54.3%), corresponding to a PGY-1 level. ChatGPT cited a verifiable source in 47.2% of questions, with an average median journal impact factor of 5.4. GPT-4 answered 265 of 360 questions correctly (73.6%), corresponding to the average performance of a PGY-5 and exceeding the corresponding passing score for the American Board of Orthopaedic Surgery Part I Examination of 67%. GPT-4 cited a verifiable source in 87.9% of questions, with an average median journal impact factor of 5.2. Conclusions: ChatGPT performed above the average PGY-1 level and GPT-4 performed better than the average PGY-5 level, showing major improvement. Further investigation is needed to determine how successive versions of ChatGPT would perform and how to optimize this technology to improve medical education. Clinical Relevance: AI has the potential to aid in medical education and healthcare delivery.

Effect of Supplemental Regional Anesthesia on the Complication and Readmission Rate of Patients After Elective Foot and Ankle Surgery.

BACKGROUND: The purpose of this study is to define the effect of facility type (inpatient vs outpatient) for the use of supplemental regional anesthesia (SRA), and SRA's effect on complications, readmissions, operation time, and length of hospital stay after elective foot and ankle surgery. METHODS: We performed a retrospective review to identify a large cohort of adult patients who underwent elective foot and ankle surgery between 2006 and 2020 from the American College of Surgeons National Surgical Quality Improvement Program database. We fit log-binomial generalized linear models to estimate risk ratios for general anesthesia (GA) with SRA versus GA alone, and linear regression models to estimate the effect of GA with SRA on the average total hospital length of stay (in days) and operation time (in minutes); we also performed inverse propensity scores. RESULTS: We found that there is no statistical difference in the rate of readmissions (P = .081) between patients under GA alone versus GA with SRA. In the propensity score analysis, patients who underwent midfoot/forefoot surgery had 3.85 times the risk of complications under GA with SRA compared with GA alone (P = .045). Also, patients who received GA with SRA had a longer unadjusted operative duration (102.22 minutes) when compared with patients who received GA alone (93.84 minutes) (P < .001). However, patients who received GA alone had a longer unadjusted hospital length of stay (0.88 days) when compared with patients who received GA with SRA (0.70 days) (P = .006). CONCLUSION: This study found that, when compared with GA alone, GA with SRA leads to a statistically significant increased operative time but a shorter hospital stay without significantly increasing readmissions and only increasing the risk of complications for midfoot/forefoot surgery within 30 days postoperatively for elective foot and ankle surgery. LEVEL OF EVIDENCE: Level III.

Assessing surgical risk calculators on hernia repair candidates with cirrhosis.

PURPOSE: Several risk calculators have been developed and deployed to help surgeons estimate the mortality risk that comes with performing hernia repair surgery on patient with severe liver disease. This study seeks to evaluate the accuracy of these risk calculators on patients with cirrhosis and identify the most suitable population of patient to use these calculators on. METHODS: The American College of Surgeons National Surgery Quality Improvement Program (NSQIP) 2013-2021 datasets were queried for patients who underwent hernia repair surgery. Mayo Clinic's "Post-operative Mortality Risk in Patients with Cirrhosis" risk calculator, Model for End-Stage Liver Disease (MELD) calculator, NSQIP's Surgical Risk Calculator, and a surgical 5-item modified frailty index were assessed to determine whether they accurately predict mortality following abdominal hernia repair. RESULTS: In total, 1368 patients met inclusion criteria. Receiver operating characteristic (ROC) curve analysis of the 4 mortality risk calculators resulted in the following: NSQIP Surgical Risk Calculator = 0.803 (p < 0.001); "Post-operative Mortality Risk in Patients with Cirrhosis" with an etiology of "Alcoholic or Cholestatic" yielded an AUC = 0.722 (p < 0.001); MELD score yielded an AUC = 0.709 (p < 0.001); and the modified 5-item frailty index yielded an AUC = 0.583 (p = 0.04). CONCLUSION: The NSQIP Surgical Risk Calculator more accurately predicts 30-day mortality in patients with ascites undergoing hernia repair. However, if the patient is missing one of the 21 input variables required by this calculator, Mayo Clinic's 30-day mortality calculator should be consulted before the more widely used MELD score.

Prevalence of Abnormal Ultrasonographic Findings in Asymptomatic Peroneal Tendons.

Background: The peroneus longus (PL) and peroneus brevis (PB) tendons comprise the lateral compartment of the leg and stabilize the foot during weightbearing. Peroneal tendinopathy can precipitate lateral ankle pain and induce functional disability. The progression of peroneal pathology to lateral ankle dysfunction is thought to stem from asymptomatic, subclinical peroneal tendinopathy. There may be clinical benefit to identifying asymptomatic patients with this condition before progression to disability. Various ultrasonographic characteristics have been observed in peroneal tendinopathy. The purpose of this study is to identify the frequency of subclinical tendinopathic characteristics in asymptomatic peroneal tendons. Methods: One hundred seventy participants underwent bilateral foot and ankle ultrasonographic examination. Images were assessed for abnormalities of the PL and PB tendons by a group of physicians who recorded frequencies of abnormalities. This team consisted of an orthopaedic surgeon specializing in foot and ankle surgery, a fifth-year orthopaedic surgery resident, and a family medicine physician with musculoskeletal sonographer certification. Results: A total of 340 PL and 340 PB tendons were assessed. Sixty-eight (20%) PL and 41 (12.1%) PB tendons had abnormal traits. Twenty-four PLs and 22 PBs had circumferential fluid, 16 PLs and 9 PBs had noncircumferential fluid, 27 PLs and 6 PBs had thickening, 36 PLs and 12 PBs had heterogenicity, 10 PLs and 2 PBs had hyperemia, and 1 PL had calcification. In Caucasian participants, male gender was associated with increased frequency of abnormal findings, but there were no other significant differences based on age, body mass index, or ethnicity. Conclusion: In our studied population of 170 patients who had no complaints of associated symptoms, we found that 20% of PLs and 12% of PBs displayed ultrasonographic abnormalities. When we included all unusual findings within and around the tendons, prevalence rates of ultrasonographic abnormalities were 34% for PLs and 22% for PBs. Level of Evidence: Level II, prospective cohort study.