Assessment of fetal corpus callosum biometry by 3D super-resolution reconstructed T2-weighted magnetic resonance imaging.

Objective: To assess the accuracy of corpus callosum (CC) biometry, including sub-segments, using 3D super-resolution fetal brain MRI (SR) compared to 2D or 3D ultrasound (US) and clinical low-resolution T2-weighted MRI (T2WS). Method: Fetal brain biometry was conducted by two observers on 57 subjects [21-35 weeks of gestational age (GA)], including 11 cases of partial CC agenesis. Measures were performed by a junior observer (obs1) on US, T2WS and SR and by a senior neuroradiologist (obs2) on T2WS and SR. CC biometric regression with GA was established. Statistical analysis assessed agreement within and between modalities and observers. Results: This study shows robust SR to US concordance across gestation, surpassing T2WS. In obs1, SR aligns with US, except for genu and CC length (CCL), enhancing splenium visibility. In obs2, SR closely corresponds to US, differing in rostrum and CCL. The anterior CC (rostrum and genu) exhibits higher variability. SR's regression aligns better with literature (US) for CCL, splenium and body than T2WS. SR is the method with the least missing values. Conclusion: SR yields CC biometry akin to US (excluding anterior CC). Thanks to superior 3D visualization and better through plane spatial resolution, SR allows to perform CC biometry more frequently than T2WS.

Patient-Reported Outcomes Following Open Broström-Gould Procedure: Minimum 5-Year Follow-Up.

Background: Ankle sprains are a common musculoskeletal injury among the general population and often involve the lateral ligament complex. Although the majority of ankle sprains are treated successfully with nonsurgical conservative measures, an estimated 5% to 20% of ankle injuries ultimately develop chronic lateral ankle instability (CAI). Multiple surgical treatment modalities for the lateral ankle complex exist, such as anatomical and nonanatomical reconstruction. The current gold standard for primary surgical repair is the Broström-Gould procedure. This is the first article to provide PROMIS scores following BG and the largest study with 5-year outcomes for an open BG. Methods: This was a descriptive study of a retrospective cohort of patients undergoing a BG with a minimum follow-up of 5 years. Patient-reported outcome instruments collected postoperatively were PROMIS Pain, Physical Function, Depression, and FAAM. Further preoperative clinic characteristics were analyzed to correlate with the final outcome. The electronic medical record was queried for Current Procedural Terminology (CPT) code 27698 (Broström-Gould) from January 2010 to June 2017. Surveys were conducted in the clinic and through phone interviews. Patient charts were reviewed to obtain basic patient demographic information including sex, age, race, and body mass index (BMI). The following preoperative variables were recorded: history of prior CAI procedures, history of major trauma, duration of symptoms, number of diagnosed ankle sprains, other collagen pathologies, generalized ligament laxity, participation in sports/activity level, peroneal subluxation, clinically diagnosed peroneus longus or brevis tendinopathy, deltoid ligament injury, anterior ankle impingement, and posterior ankle impingement. The PROMIS and Foot and Ankle Ability Measure (FAAM) scores were obtained with a combination of clinic and phone interviews. Data were aggregated in Microsoft Excel and entered in R (version 4.2.0) for statistical analysis. Results: Our results show that the minimum 5-year patient-reported PROMIS scores for patients following a Broström-Gould procedure are as follows: PROMIS physical function, 50.5; PROMIS pain interference, 48.2; and PROMIS depression, 38.2. This indicates, at a minimum, that patients 5 years removed from the procedure are within 1 SD of the general population in regard to PROMIS physical function and pain. Our patient-reported FAAM, activities of daily living, and FAAM sports scores were 59.6 and 13.0 respectively. Preoperative magnetic resonance imaging (MRI) findings were recorded. Arthroscopic examination was performed before lateral ligaments reconstruction for patients with intra-articular pathologies confirmed on MRI. Conclusion: The findings from our study offer evidence supporting the effectiveness of the Broström-Gould procedure to be associated with normal physical function, even 5 years after surgery. Furthermore, our research identified specific factors such as tobacco use, diabetes, and sports participation that independently correlated with reported outcome measures. These insights enable physicians to better manage patient expectations and tailor treatment strategies accordingly. Our study establishes a foundation for future prospective research endeavors that aim to leverage the PROMIS system for comprehensive outcome assessments. Level of Evidence: Level III, retrospective cohort study.

Factors Influencing PROMIS Scores and Patient Reported Outcomes Following Surgical Intervention of Isolated Lisfranc Injury: Minimum 2 Year Follow-up.

Lisfranc injuries are rare but significant foot injuries, as they often result from polytrauma patients, and are often misdiagnosed, which further complicate their evaluation and contribute to their propensity towards disability. It is recommended that, on diagnosis, Lisfranc injuries be treated as soon as possible to decrease the risk of future chronic pain, disability, or osteoarthritis. Our study evaluated patients who completed the patient reported outcome measurement information systems (PROMIS) along with the foot function index (FFI) following operative fixation for Lisfranc injury. Fifty-one patients between 2010 and 2020 met inclusion criteria and were selected for this study, with completion. Utilizing the electronic medical record (EMR), patient charts were reviewed to obtain basic patient demographic information and comorbidities. Operative reports were reviewed to determine which procedure was performed for definitive fixation. Primary arthrodesis was associated with a significant decrease in complication rates (p = .025) when compared to ORIF. Females, arthrodesis, and procedures using a home run (HR) screw were independent risk factors for significantly higher reports of PROMIS pain interference. Arthrodesis also was associated with lower PROMIS pain interference scores. Arthrodesis and males exhibited higher scores in all FFI categories. Our results provide evidence that patient reported outcomes following Lisfranc surgery reported via PROMIS, FFI and VAS scores are independently influenced by patient demographics, comorbidities, and surgical variables. Analysis of potential associations between these patient characteristics and PROMIS and FFI scores provides evidence for physicians to manage patient expectations prior to operative treatment of a nonpolytraumatic Lisfranc injury.

Vaccination impact: mortality and time shift to COVID-19 maximum severity in hospitalized patients. An Argentine multicenter registry.

INTRODUCTION: The COVID-19 vaccine became an effective instrument to prevent severe SARS-CoV-2 infections. However, 5% of vaccinated patients will have moderate or severe disease. OBJECTIVE: to compare mortality and days between the symptom onset to the peak disease severity, in vaccinated vs. unvaccinated COVID-19 hospitalized patients. METHODS: Retrospective observational study in 36 hospitals in Argentina. COVID-19 adults admitted to general wards between January 1, 2021, and May 31, 2022 were included. Days between symptoms onset to peak of severity were compared between vaccinated vs. unvaccinated patients with Cox regression, adjusted by Propensity Score Matching (PSM). Results in patients with one and two doses were also compared. RESULTS: A total of 3663 patients were included (3001 [81.9%] unvaccinated and 662 [18%] vaccinated). Time from symptom onset to peak severity was 7 days (IQR 4-12) vs. 7 days (IQR 4-11) in unvaccinated and vaccinated. In crude Cox regression analysis and matched population, no significant differences were observed. Regarding mortality, a Risk Ratio (RR) of 1.51 (IC95% 1.29-1.77) was observed in vaccinated patients, but in the PSM cohort, the RR was 0.73 (IC95% 0.60-0.88). RR in patients with one COVID-19 vaccine dose in PSM adjusted population was 0.7 (IC95% 0.45-1.03), and with two doses 0.6 (IC95% 0.46-0.79). DISCUSSION: The time elapsed between the onset of COVID-19 symptoms to the highest severity was similar in vaccinated and unvaccinated patients. However, hospitalized vaccinated patients had a lower risk of mortality than unvaccinated patients.

Introducción: A pesar de la eficacia de la vacuna contra el COVID-19 el 5% de los pacientes vacunados presentaran una enfermedad moderada o grave. El objetivo del presente estudio fue comparar los días entre el inicio de los síntomas y la gravedad máxima de la enfermedad, en pacientes con COVID-19 vacunados vs. no vacunados. Métodos: Estudio observacional retrospectivo en 36 hospitales de Argentina. Se incluyeron adultos con COVID-19 hospitalizados entre el 1/01/2021 y 31/5/2022. Se recolectaron datos demográficos, comorbilidades y progresión clínica de la enfermedad. Se compararon los días entre el inicio de los síntomas y el pico de gravedad entre vacunados y no vacunados mediante regresión de Cox, ajustada por emparejamiento por Propensity Score Matching (PSM). En un análisis de subgrupos, se compararon los resultados en pacientes con una y dos dosis de vacuna. Resultados: Se incluyeron 3663 pacientes (3001 [81.9%] no vacunados y 662 [18%] vacunados). El tiempo transcurrido desde el inicio de los síntomas hasta el pico de gravedad fue de 7 días (IQR 4 - 12) en no vacunados, y de 7 días (IQR 4-11) en vacunados. Tanto en el análisis de regresión de Cox crudo como en el ajustado, no se observaron diferencias significativas entre ambos grupos (HR ajustado 1.08 [IC 95% 0.82-1.4; p = 0.56]). En cuanto a la mortalidad, el Riesgo Relativo (RR) fue 1.51 (IC95% 1.29-1.77) en los pacientes vacunados, pero en la cohorte ajustada por Propensity Score, el RR fue de 0.73 (IC95% 0.60-0.88). El RR en el grupo con una dosis de vacuna COVID-19 en el análisis PSM fue 0.7 (IC95% 0.45-1.03), y con dos dosis 0.6 (IC95% 0.46-0.79). Discusión: El tiempo entre el inicio de los síntomas de COVID-19 y el pico de severidad fue igual en vacunados y no vacunados. Sin embargo, los pacientes vacunados hospitalizados presentaron menor mortalidad tras el ajuste por confundidores.

The economic and clinical impact of fast- versus slow-setting cement in primary total knee arthroplasty.

INTRODUCTION: New bone cement products have been developed attempting to shorten their setting time and thus cut down time in the operating room. This study determines whether faster-setting bone cement shortens time in the operating room, and whether the quantity used compromises postoperative TKA outcomes. Additionally, this study looks at cost analyses of the quantity of bone cement used in TKA procedures. MATERIALS AND METHODS: One-hundred and sixty patients at a single institution with primary TKA surgeries between January 2019 and December 2021, and a clinic follow-up of at least one year, were identified. Five cement products used in this time period were identified and categorized by fast- or slow-setting products if their set times were marketed below or above six minutes, respectively. RESULTS: Estimated blood loss was higher in patients receiving fast-setting cements (160.0 vs 126.4 mL; p = 0.0009); however, operative time showed no difference between the cohorts (88.2 vs 89.2 min; p = 0.99). Fewer bags of cement were used for the fast cohort (1.3 vs 1.8 bags; p < 0.0001). The fast group was significantly cheaper on average per patient only when comparing between antibiotic bone cements (p = 0.007). No differences were found in postoperative outcomes between the two groups. CONCLUSIONS: No differences were found in operative times between the fast and slow cemented groups. Fewer bags of faster-setting cement only proved cost saving relative to other antibiotic bone cements studied. Nonetheless, decreased usage of fast cement did not result in any different postoperative outcomes compared to slow cements. LEVEL OF EVIDENCE: III.

Is the shock index correlated with blood loss? An experimental study on a controlled hemorrhagic shock model in piglets.

INTRODUCTION: The quantification of blood loss in a severe trauma patient allows prognostic quantification and the engagement of adapted therapeutic means. The Advanced Trauma Life Support classification of hemorrhagic shock, based in part on hemodynamic parameters, could be improved. The search for reproducible and non-invasive parameters closely correlated with blood depletion is a necessity. An experimental model of controlled hemorrhagic shock allowed us to obtain hemodynamic and echocardiographic measurements during controlled blood spoliation. The primary aim was to demonstrate the correlation between the Shock Index (SI) and blood depletion volume (BDV) during the hemorrhagic phase of an experimental model of controlled hemorrhagic shock in piglets. The secondary aim was to study the correlations between blood pressure (BP) values and BDV, SI and cardiac output (CO), and pulse pressure (PP) and stroke volume during the same phase. METHODS: We analyzed data from 66 anesthetized and ventilated piglets that underwent blood spoliation at 2 mL.kg-1.min-1 until a mean arterial pressure (MAP) of 40 mmHg was achieved. During this bleeding phase, hemodynamic and echocardiographic measurements were performed regularly. RESULTS: The correlation coefficient between the SI and BDV was 0.70 (CI 95%, [0.64; 0.75]; p < 0.01), whereas between MAP and BDV, the correlation coefficient was -0.47 (CI 95%, [-0.55; -0.38]; p < 0.01). Correlation coefficient between SI and CO and between PP and stroke volume were - 0.45 (CI 95%, [-0.53; -0.37], p < 0.01) and 0.62 (CI 95%, [0.56; 0.67]; p < 0.01), respectively. CONCLUSIONS: In a controlled hemorrhagic shock model in piglets, the correlation between SI and BDV seemed strong.

Factors and Radiographic Findings Influencing Patient-Reported Outcomes Following Maisonneuve Fractures.

BACKGROUND: This research adds to the literature by providing prognostic information for physicians and patients regarding the outcomes of operative management of Maisonneuve fractures (MFs). To date, this is the only cohort study of patient-reported outcomes measurement information systems (PROMIS) scores following surgical fixation of MF. Patient outcomes were compared focusing on the mean population with an inter-analysis using basic demographic information, radiographic findings, and patient comorbidities and their respective impact on PROMIS scores. METHODS: A total of 24 patients between 2012 and 2020 met the inclusion criteria and completed PROMIS surveys at a minimum of 18 months postoperatively. Patient charts were reviewed through the electronic medical record (EMR) for demographic information and comorbidities as well as operative variables. PROMIS scores for physical function (PF), pain interference (PI), and depression were obtained via follow-up visits and phone calls. The impact of categorical variables on complications was compared using Chi-Squared tests. Variables were analyzed with a type 3 SS test to stratify independent risk factors' effect on PROMIS scores and to account for confounding variables. RESULTS: PROMIS PF averaged 44.84 and was significantly affected by BMI>30 (p=.033), hypertension (HTN) (p=.026), patients with clinical anxiety or depression (p=.047), and subsequent screw removal (p=.041). PROMIS PI averaged a score of 54.57 and was significantly affected by BMI>30 (p=.0046), coronary artery disease (CAD) (p=.0123), patients with clinical anxiety or depression (p=.0206), and subsequent screw removal (p=.0039). PROMIS depression scores averaged 46.03 and were significantly affected by the presence of CAD (p=.049) and subsequent screw removal (p=.023). CONCLUSION: Patient-reported outcomes following MF surgery demonstrated PROMIS scores within +/- 1 standard deviation of the population-based control, and thus many patients can reasonably expect to return to a level of function comparable to the general population. Nonetheless, the significant effects of patient comorbidities and surgical variables ought to be evaluated and utilized as prognostic indicators when managing patient expectations prior to operative treatment of an MF injury.

Factors Associated With Poor Patient-Reported Outcomes in Isolated Gastrocnemius Recession for Heel Pain.

Background: Gastrocnemius recession is commonly performed for a variety of pathologies of the foot and ankle, yet studies characterizing risk factors associated with patient-reported outcomes are limited. In this cohort study, patient outcomes were compared against the general population for PROMIS scores with correlation analysis comparing demographics and comorbidities. Our primary goal in this study is to identify risk factors associated with poor patient-reported outcomes following isolated gastrocnemius recession for patients with plantar fasciitis or insertional Achilles tendinopathy. Methods: A total of 189 patients met inclusion criteria. The open Strayer method was preferred. However, if the myotendinous junction could not be adequately visualized without expanding the excision, then a Baumann procedure was performed. The decision between the two did not depend on preoperative contracture. Patient demographics and visual analog scale (VAS) scores were obtained via the electronic medical record. Telephone interviews were completed to collect postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) and Foot Function Index (FFI) scores. The data were analyzed using the type 3 SS analysis of variance test to identify individual patient factors associated with reduced PROMIS, FFI, and VAS scores. Results: No demographic variables were found to be significantly associated with postoperative complications. Patients who reported tobacco use at the time of surgery had significantly decreased postoperative PROMIS physical function (P = .01), PROMIS pain interference (P < .05), total FFI scores (P < .0001), and each individual FFI component score. Patients undergoing their first foot and ankle surgeries reported numerous significant postoperative outcomes, including decreased PROMIS pain interference (P = .03), higher PROMIS depression (P = .04), and lower FFI pain scores (P = .04). Hypertension was significantly associated with an increased FFI disability score (P = .03) and, along with body mass index (BMI) >30 (P < .05) and peripheral neuropathy (P = .03), significantly higher FFI activity limitation scores (P = .01). Pre- and postoperative VAS scores demonstrated improvement in patient-reported pain from a mean of 5.53 to 2.11, respectively (P < .001). Conclusion: We found in this cohort that numerous patient factors were independently associated with differences in patient-reported outcomes following a Strayer gastrocnemius recession performed for plantar fasciitis or insertional Achilles tendinopathy. These factors include, but are not limited to, tobacco use, prior foot and ankle surgeries, and BMI. This study strengthens previous reports demonstrating the efficacy of isolated gastrocnemius recession and elucidates variables that may affect patient-reported outcomes. Level of Evidence: Level III, retrospective cohort study.

The Impact of Surgical Timing After Ankle Fracture on Clinical and Long-Term Patient Reported Outcomes.

The goal of this study is to evaluate the effect of time-to-surgery following closed ankle fractures on long-term patient reported outcomes, fracture healing, and wound complications. To date, little research has been done focusing on the impact "time to definitive fixation" has on patient reported outcomes. We performed a retrospective analysis of 215 patient records who underwent open reduction and internal fixation (ORIF) for an ankle fracture from July 2011 to July 2018. A total of 86 patients completed the patient reported outcome measurement information systems (PROMIS) survey at long-term follow-up. Primary outcomes were the rate of delayed union, postoperative wound complications, patient reported outcome measurement information system (PROMIS) pain interference (PI), and physical function (PF) scores. No differences were found when comparing time to surgery on a continuous scale with rates of delayed union, nonunion, or wound complications (p = .84, .47, and .63, respectively). PROMIS scores were collected at a median of 4.5 years (2.0 interquartile range (IQR), range 2.5-12.3) postoperatively. The time from ankle fracture to surgery was independently associated with worse PROMIS PI scores (unstandardized ß 0.38, 95% CI 0.07-0.68) but not PROMIS PF scores. Severe Lauge-Hansen injuries were independently associated with decreased PROMIS PF scores (unstandardized ß -7.02, 95% CI -12.0 to -2.04). Increased time to surgical intervention and severe Lauge-Hansen injuries were independently associated with worse long-term patient reported outcomes. Surgical timing did not impact union rates or wound complications. Surgeons should be aware that delaying ankle fracture repair beyond 12 days after injury may negatively affect long-term patient reported pain scores.

First Metatarsophalangeal Arthrodesis for Hallux Rigidus and Hallux Valgus: A Comparison of Patient Reported and Clinical Outcomes.

Few prior studies have compared the patient reported outcomes of first metatarsophalangeal arthrodesis between hallux rigidus and hallux valgus patients. Furthermore, we sought to examine the impact of postoperative radiographic hallux alignment on outcomes scores within each group. A retrospective review of 98 patients who a received primary metatarsophalangeal arthrodesis from January 2010 to March 2020. Clinical complications including nonunion were collected. Patient Reported Outcomes Measurement Information Systems (PROMIS) Physical Function, PROMIS Pain Interference, and the foot function index (FFI) revised short form scores were obtained via telephone. Patients were grouped based on review of preoperative radiographs of the foot and this grouping 37 hallux rigidus and 61 hallux valgus patients. Clinical and patient reported outcomes were compared between these pathologies. No differences in the rate of wound complications, radiographic union, and revision surgery were found between the 2 subgroups. At a median of 2.4 years (3.9 IQR) postoperatively, PROMIS and FFI scores did not vary by pathology group. For both groups, PROMIS scores were similar to the general population of the United States. The postoperative first MTP dorsiflexion angle in the hallux rigidus group was correlated with decreased FFI Pain, FFI Total, and PROMIS Pain Interference domain scores (|r| ≥ 0.40, p < .05 for all). When performing MTP arthrodesis in patients with hallux rigidus, increasing the first MTP dorsiflexion angle may correlate with improved intermediate term patient reported outcomes. However, further studies will need to be done to confirm this theoretical relationship.

PROMIS Scores for Plantar Fasciitis Before and After Gastrocnemius Recession.

BACKGROUND: There has been an established relationship between increased loading on the Achilles tendon and tension on the plantar fascia. This supports the idea that either tight gastrocnemius and soleus muscles or contractures of the Achilles tendon are risk factors for plantar fasciitis. Gastrocnemius recession has gained popularity as a viable surgical intervention for cases of chronic plantar fasciitis due to isolated gastrocnemius contracture. To our knowledge, this is the first study to investigate Patient-Reported Outcome Measurement Information Systems (PROMIS) scores in patients with plantar fasciitis before and after gastrocnemius recession. METHODS: The Electronic Medical Record was queried for medical record numbers associated with Current Procedural Terminology code 27687 (gastrocnemius recession). Our study included all patients with a preoperative diagnosis of chronic plantar fasciitis with treatment via isolated gastrocnemius recession with 1-year minimum follow-up. Forty-one patients were included in our study. Patient variables were collected via chart review. Preoperative and postoperative PROMIS scores were collected in the clinic. RESULTS: We followed up 41 patients with a median age of 48 years (interquartile range [IQR] 38-55) and median body mass index of 29.02 (IQR 29.02-38.74) for 1 year post surgery. Preoperative and postoperative PROMIS scores improved for physical function from 39.3 to 44.5 (P = .0005) and for pain interference from 62.8 to 56.5 (P = .0001). PROMIS depression scores were not significantly different (P = .6727). Visual analog scale (VAS) scores significantly decreased from 7.05 to 1.71 (P < .0001). CONCLUSION: In this case series, we found the gastrocnemius recession to be an effective option for patients with refractory pain in plantar fasciitis. Our PROMIS and VAS data confirm this procedure's utility and highlight its ability to significantly decrease pain and improve physical function in patients with chronic plantar fasciitis, although final median scores did not reach normative standards for the population, suggesting some residual pain and/or dysfunction was, on average, present. Based on the results of this study, the authors conclude that gastrocnemius recession is a reasonable treatment option for chronic plantar fasciitis patients who fail nonoperative management. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Surgical treatment of a hindfoot plantar leiomyoma: A case study.

Leiomyomas within the foot are rare and are difficult to diagnose with only the radiographic and clinical picture. They are benign, slow growing, and very rarely cause pain. We present an unusual case of a dermatology referral patient complaining of callus formation on the plantar aspect of the foot as well as shoe discomfort. The mass was believed to be a lipoma or a fibroma but after surgical excision was found to be a leiomyoma. Our case highlights the rarity of this diagnosis and presents a unique surgical technique utilizing a medial approach to the plantar hindfoot for lesion removal.

Temporal trends in hematopoietic stem cell transplantation in Argentina between 2009 and 2018: A collaborative study by GATMO-TC and INCUCAI.

INTRODUCTION: Hematopoietic stem cell transplantation is the only curative treatment for many disorders and international data shows a growing trend. METHOD: We aimed to evaluate the temporal trends in HSCT transplant rates in Argentina. A time-series analysis was performed for the period 2009 to 2018 using the national database from the National Central Coordinating Institute for Ablations and Implants. Crude and standardized transplant rates were calculated. A permutation joinpoint regression model analysis was used to identify significant changes over time. RESULTS: Altogether, 8,474 transplants were reported to INCUCAI by 28 centers (autologous 67.5%); the main indication was multiple myeloma (30%). The WHO age-sex standardized HSCT rates for the entire country were 153.3 HSCT/10 million inhabitants (95% CI 141.7-165.8) in 2009 and 260.1 HSCT/10 million inhabitants (95% CI 245.5-275.5) in 2018. There was a large gap in HSCT rates among the states and regions. The transplant rate was higher for autologous transplants throughout the years. Within the allogeneic group, the related donor transplant rate was higher than the unrelated donor transplant rate. The joinpoint regression analysis of HSCT rates for the whole country over time showed an observed annual percentage change of 6.3% (95% CI 5.4-7.3; p < 0.01). No changes were observed for unrelated donors during the study period. CONCLUSIONS: Age-sex standardized HSCT rates in Argentina are increasing, mainly due to autologous and family donor allogeneic transplants. A wide variation across the country was found, demonstrating differences in the access to transplantation among Argentine regions.

Revision Surgery for Recurrent Morton Neuroma with Use of a Collagen Conduit.

Background: Painful neuromas of the foot and ankle frequently pose a treatment dilemma because of persistent pain or recurrence after resection. Primary surgical treatment of painful neuromas includes simple excision with retraction of the residual nerve ending to a less vulnerable location1-4. The use of a collagen conduit for recurrent neuromas is advantageous, particularly in areas with minimal soft-tissue coverage options, and is a technique that has shown 85% patient satisfaction regarding surgical outcomes7. Additionally, the use of a collagen conduit limits the need for deep soft-tissue dissection and reduces the morbidity typically associated with nerve burial. Description: Specific steps include appropriate physical examination, preoperative planning, and supine patient positioning. The patient is placed supine with a lower-extremity bolster under the ipsilateral extremity in order to allow improved visualization of the plantar surface of the foot. A nonsterile tourniquet is placed on the thigh. The incision site is marked out, and a longitudinal plantar incision is made until proximal healthy nerve is identified-typically approximately 1 to 2 cm, but the incision can be extended up to 6 cm. The incision is made between the metatarsals, with blunt dissection carried down to the neuroma. The neuroma is sharply excised distally through healthy nerve, and a whip stitch is placed to facilitate the collagen conduit placement. The collagen conduit is passed dorsally into the intermetatarsal space and secured to the dorsal fascia of the foot. The wound is closed with 3-0 nylon horizontal mattress sutures. Postoperatively, a soft dressing is applied to the operative extremity, and patients are advised to be non-weight-bearing for two weeks. At two weeks, patients begin partial weight-bearing with use of a boot, and physical therapy is initiated. No antibiotics are necessary, and 300 mg of gabapentin is prescribed and tapered off by the six-week follow-up visit. Follow-ups are conducted at 2, 6, 12, 24, and fifty-two weeks. It is necessary to monitor for signs and symptoms of infection, surgical complications, and neuroma recurrence during follow-up appointments. Alternatives: Simple excision of the neuroma with proximal burial into muscle or bone is a common surgical technique. However, inadequate resection of the nerve or poor surgical technique can lead to recurrent neuromas. For neuromas not responding to simple excision, other techniques have been utilized, including cauterization, chemical agents, nerve capping, and muscle or bone burial5,6. The results of these techniques have varied, and none has gained clinical superiority over the other6. Rationale: A study analyzing the use of collagen conduits for painful neuromas of the foot and ankle has shown this technique to be a safe and successful alternative to the previously discussed methods of resection7. That study by Gould et al. found that 85% of patients had a substantial reduction in pain, with mean visual analog scale (VAS) pain scores reducing from 8 to 10 preoperatively to 0 to 4 postoperatively7. Moreover, alternative biological conduits, such as the greater saphenous vein, have proven to be costly in time and resources, as this structure is often utilized in cardiovascular bypass surgery and its harvest conveys a risk of iatrogenic nerve injury to the patient7.Numerous studies focusing on excision of recurrent Morton neuromas via a plantar approach have found variable success rates. Of the patients surveyed in those studies, 75% reported substantial pain improvement. However, <50% of these queried patients reported complete pain relief8,9. Studies analyzing the dorsal approach for revision Morton neuroma excision found similar success rates. Approximately 78% of patients reported good or excellent postoperative outcomes, and significant improvements were observed in patient postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores for pain interference, intensity, and global physical health10,11. One study comparing outcomes following plantar versus dorsal approaches for recurrent Morton neuroma found no significant difference in postoperative patient outcomes. That study suggested that surgeons utilize the approach with which they are most comfortable12. Gould et al. reported an 85% success rate with collagen conduit, which was similar to if not slightly improved compared with the other prior studies. The utilization of a collagen conduit technique thus offers comparable patient outcomes for patients with difficult neuromas7. Expected Outcomes: Recurrent neuroma resection with the use of a collagen conduit has proven to provide satisfactory patient outcomes regarding pain and neuritis symptoms7. The goal of any neuroma resection is to greatly diminish or entirely eliminate nerve pain. Based on the available evidence, there has been no proven clinical superiority of any particular technique over the others6. However, in the present example case, the location of the patient's neuroma in this video makes it 85% likely that the patient will report satisfactory outcomes and 50% likely that the patient will be entirely symptom-free7. At two weeks postoperatively, the patient reported well controlled pain, absence of burning or tingling sensation, full range of movement in the foot, and intact sensation throughout all major nerve distributions, including the saphenous; superficial peroneal nerve; deep peroneal nerve; and sural, medial, and lateral plantar nerves. However, sensation is absent distal to the site of a neuroma resection. Important Tips: Careful preoperative planting is of utmost importance.Ruling out other potential pathologies is necessary to ensure proper outcomes.Meticulous dissection should be carried out, with delicate handling of the proximal nerve ending.Excision of the nerve should be done sharply through the healthy portion of the nerve.Appropriate sizing of the nerve conduit (with a commercially available industry sizer) should be performed.The nerve conduit should be passed dorsally and secured to the dorsal fascia without any tension. Acronyms and Abbreviations: MRI = magnetic resonance imagingUS = ultrasoundVAS = visual analog scale.

Tibiotalocalcaneal Arthrodesis with Intramedullary Fibular Strut Graft and Adjuvant Hardware Fixation.

Background: In patients with irreparable damage to the articular surfaces of the hindfoot, hindfoot arthrodesis is frequently chosen to provide pain relief and improve activities of daily living. Common etiologies leading to hindfoot arthrodesis procedures include osteonecrosis, failed total ankle arthroplasty, and deformities resulting from Charcot arthropathy or rheumatoid arthritis. Traditionally, this operation utilizes an intramedullary nail to obtain fusion of the tibiotalocalcaneal joint. Although 80% to 90% of patients achieve postoperative union, the remaining 10% to 20% experience nonunion1-3. Factors affecting the rate of nonunion include Charcot neuroarthropathy, use of nonsteroidal anti-inflammatory drugs or methotrexate, osteopenic bone, and smoking4. In the present video article, we describe a tibiotalocalcaneal arthrodesis performed with use of a fibular strut autograft for repeat arthrodesis following failure of primary tibiotalocalcaneal arthrodesis or as a salvage operation in end-stage pathologies of the hindfoot. Our surgical technique yields union rates of approximately 80% and provides surgeons with a viable surgical technique for patients with complex hindfoot pathologies or fusion failure. Description: The patient is placed in the supine position, and a 10-cm curvilinear incision is made including the distal 6 to 8 cm of the fibula. The incision is centered directly lateral on the fibula proximally and transitions to the posterolateral aspect of the fibula distally. As the incision continues distally, it extends inferiorly and anteriorly over the sinus tarsi and toward the base of the 4th metatarsal, using an internervous plane between the superficial peroneal nerve anteriorly and the sural nerve posteriorly. Exposure of the periosteum is carried out through development of full-thickness skin flaps. The periosteum is stripped, and a sagittal saw is used to make a beveled cut on the fibula at a 45° angle, approximately 6 to 8 cm proximal to the ankle. The fibular strut is decorticated, drilled, and stripped of the cartilage on the distal end. Preparation of the tibiotalar and subtalar joints for arthrodesis are completed through the lateral incision. The foot is placed in 0° of dorsiflexion, 5° of external rotation in relation to the tibial crest, and 5° of hindfoot valgus while maintaining a plantigrade foot. This placement can be temporarily maintained with Kirschner wires if needed. Next, the plantar surface overlying the heel pad is incised, and a guidewire is passed through the center of the calcaneus and into the medullary cavity of the tibia. Correct alignment of the guidewire is then confirmed on fluoroscopy. The fibular strut autograft is prepared for insertion while the tibiotalocalcaneal canal is reamed to 1 to 2 mm larger than the graft. The graft is tapped into position, followed by placement of two 6.5-mm cancellous screws to immobilize the joint, taking care to avoid excess contact of the fibular graft with the screws. Alternatives: Alternatives to this procedure include traditional arthrodesis techniques, nonoperative treatment (such as rehabilitation or bracing), or no intervention. Patients with failed primary hindfoot arthrodesis may undergo an additional traditional arthrodesis, but may face an increased risk of complications and failure1,2. Rationale: A recent study1 has shown that the use of a fibular strut autograft for tibiotalocalcaneal arthrodesis produces union rates similar to those seen with the traditional intramedullary nailing technique4,5. These results are important to note, as the presently described technique, which is used as a salvage procedure, produces outcomes that are equivalent to those observed for primary tibiotalocalcaneal arthrodesis with nailing, which is used for the treatment of severe trauma, extensive bone loss, or severe hindfoot pathologies. We recommend using this technique particularly in cases of failed primary tibiotalocalcaneal arthrodesis or in patients with end-stage hindfoot pathologies. The fibular strut autograft is a viable salvage option to decrease daily pain and provide quality improvement in patient activities of daily living. Expected Outcomes: Tibiotalocalcaneal arthrodesis with a fibular strut autograft has been shown to produce a union rate (81.2%) similar to that of the traditional arthrodesis technique with intramedullary nailing (74.4% to 90%). The strut graft provides an osteoinductive environment for healing and increases the post-arthrodesis load tolerance1. Mean visual analog scale pain scores improved from 6.9 preoperatively to 1.2 postoperatively with use of this procedure1. The most common complication was wound dehiscence requiring additional wound care (37.5%); its rate was higher than the rates reported in other studies of tibiotalocalcaneal arthrodesis, possibly because of the small sample size of patients undergoing such a complex procedure for a complex medical issue2,11. Although 7 patients required a reoperation, all ultimately experienced a union and recovered postoperatively. All non-retired patients were all able to return to work1. Important Tips: Place your incision precisely to allow adequate exposure of both the tibiotalar and subtalar joints.Curvilinear incision should begin 6 to 8 cm proximal to, and directly lateral to, the distal end of the fibula. It should continue posterolaterally to the fibula distally and extend inferiorly and anteriorly over the sinus tarsi, toward the base of the 4th metatarsal.Prepare the tibiotalar and subtalar joints this same incision.Decorticate the fibular strut autograft; this plays a key role in obtaining fusion.Harvest the fibula 6 to 8 cm above the ankle joint line. Once the graft is harvested, smooth the edges of the fibula with a burr; this facilitates graft insertion.Finally, when immobilizing the joint, take care to avoid excessive perforation of the graft as this increases the likelihood of fracture. Acronyms and Abbreviations: OR = operating roomIM = intramedullaryCT = computed tomographyTTCA = tibiotalocalcaneal arthrodesisTTC = tibiotalocalcanealK-wire - Kirschner wire.

Achilles Tendon Rupture Repair Using the Mini-Open Approach in a Supine Position.

Background: The mini-open approach with supine patient positioning is a useful technique to consider for acute Achilles rupture repair, ideally performed within 2 weeks from the time of injury. The traditional surgical approach is completed with the patient in the prone position with an extensile midline incision. Here we describe a mini-open approach with supine positioning that utilizes a single incision measuring approximately 3 to 4 cm in length and avoids the pitfalls of prone positioning, which include greater operative time and potential difficult airway management, vision loss, and brachial plexus palsies1. Description: When positioning the patient supine, lower-extremity bolsters are placed beneath the contralateral hip and the operative ankle in order to allow for exaggerated external rotation of the ankle and improved medial visualization. A thigh tourniquet is then applied on the operative side in a standard sterile fashion.After appropriate draping, begin by palpating the tendon rupture site and mark a 3 to 4-cm incision line just medial to the tendon. Sharp dissection through the skin to the level of the paratenon is then performed. Incise the paratenon with a knife, separate the paratenon from the underlying Achilles tendon with a Freer elevator or scissors, subsequently remove any hematoma formation, and cut the paratenon proximally and distally with scissors or a knife. Debride any damaged tendon thoroughly.The steps of the procedure are performed under direct visualization. If the sural nerve is encountered, it is noted and retracted, and extra care is taken to avoid damaging it with instruments or suture.Now that the proximal and distal ends of the Achilles tendon are free, utilize a 4-stranded double Krackow locking stitch with two #2 FiberWires (Arthrex) on both the proximal and the distal stump. The stumps of the ruptured tendon are approximated by tying the free suture ends together with use of a simple surgeon's knot. A running epitendinous repair is performed with use of number-0 Vicryl (Ethicon) suture in a cross-stich weave technique to provide additional strength to the repair. Finally, test the integrity of the repair via an intraoperative Thompson test. The postoperative protocol includes non-weight-bearing with the operative limb in a posterior splint for 2 weeks. At the 2-week follow-up, stitches are removed and the limb is placed in a tall CAM (controlled ankle motion) walker boot with 2 heel wedges measuring 6.35 mm (0.25 inches) apiece. The patient can begin partial weight-bearing with crutches at 2 weeks postoperatively. At 4 weeks postoperatively, 1 heel wedge is removed, and at 6 weeks postoperatively, the second heel wedge is removed. Patients are instructed to begin gentle range-of-motion exercises at 2 weeks, with formal physical therapy scheduled to begin at 6 weeks. Most patients are out of the boot at 8 to 10 weeks postoperatively. Alternatives: Nonoperative treatment of Achilles rupture includes functional bracing or casting with the foot resting in the equinus position and early weight-bearing and rehabilitation. As mentioned earlier, the traditional operative approach with prone positioning is a viable option but is associated with a higher incidence of procedural and anesthesia-related complications, as well as potentially increased cost1. Rationale: Recent studies have shown that a mini-open approach will produce a repair that is comparable with the traditional open approach, while also minimizing the anesthesia and postural complications associated with prone positioning1. Previous studies focusing on supine positioning have generally utilized a larger incision more comparable with that of the traditional prone approach6. Other studies have utilized a minimally invasive approach but require >1 incision and often utilize specialized instrumentation, which may limit the technique to certain facilities7. The technique described in the present article utilizes a single 3 to 4-cm incision that requires no specialized instrumentation, has a minimal learning curve, and can be performed at any facility. Expected Outcomes: McKissack et al. demonstrated that the overall complication rate of the mini-open supine approach (7.7%) was lower than that of the traditional prone approach (9.3%), while the average cost of the prone approach exceeded that of the supine approach by $1,8231. This increased cost, although not significant, may be attributable to longer operating room and post-anesthesia care unit times. Additionally, no patient in either cohort experienced tendon rerupture within the first year after repair, further proving the effectiveness of this technique. We have utilized this mini-open supine technique for acute Achilles ruptures for over 9 years now, with good patient outcomes and satisfaction. Throughout this duration we have not had a single patient experience rerupture of the repaired tendon. In our experience, we find this technique to be effective, with fewer complications than prone positioning. Additionally, this approach may be associated with decreased financial and anesthesia burdens. Important Tips: Always palpate the tendon rupture site to determine the best incision placement.With ruptures close to the tendon insertion site, it can be notoriously difficult to mobilize the distal tendon stump, so extended incisions may be required.Test the integrity of the repair with use of the intraoperative Thompson test.This technique does not utilize any special equipment and thus can be performed at any facility.This supine approach decreases operating room turnover time, anesthesia burden, and complications associated with prone positioning. Acronyms & Abbreviations: AP = anteroposteriorMRI = magnetic resonance imagingUS = ultrasoundDVT = deep vein thrombosisVAS = visual analog scaleNWB = non-weight-bearingCAM = controlled ankle motionPWB = partial weightbearingROM = range of motionPT = physical therapyOR = operating room.

Pediatric fractures following implant removal: A systematic review.

Objectives: To evaluate the available literature for postoperative fracture rates following implant removal in the pediatric population. Methods: A systematic review of articles in the PubMed and Embase computerized literature databases from January 2000 to June 2022 was performed using PRISMA guidelines. Randomized controlled trials, case-control studies, cohort studies (retrospective and prospective), and case series involving pediatric patients that included data on fracture rate following removal of orthopedic implants were eligible for review. Two authors independently extracted data from selected studies for predefined data fields for implant type, anatomic location of the implant, indication for implantation, fracture or refracture rate following implant removal, mean time to implant removal, and mean follow-up time. Results: Fifteen studies were included for qualitative synthesis. Reported fracture rates following implant removal vary based on several factors, with an overall reported incidence of 0%-14.9%. The available literature did not offer sufficient data for conduction of a meta-analysis. Conclusion: Our systematic review demonstrates that fracture following implant removal in pediatric patients is a relatively frequent complication. In children, the forearm and femur are the most commonly reported sites of fracture following removal of implants. Traumatic fractures treated definitively with external fixation have the highest reported aggregate rate of refracture. Knowledge of the incidence of this risk is important for orthopedic surgeons. There remains a need for well-designed studies and trials to further clarify the roles of the variables that contribute to this complication.

Monitoreo serológico y psicológico en personal de salud durante el comienzo de la pandemia COVID-19 / Serological and psychological monitoring of healthcare workers during the start of the COVID-19 pandemic

Introducción: el personal de salud (PdS) es esencial en la lucha contra el COVID-19. Al inicio de la pandemia, el riesgo de adquirir la enfermedad en este grupo era desconocido. Buscamos estimar incidencia y prevalencia de anticuerpos anti-SARS-CoV-2, y prevalencia de burnout en una cohorte de PdS durante la pandemia COVID-19, así como valorar la prevalencia de burnout y depresión en la cohorte. Materiales y métodos: cohorte prospectiva conformada por médicos que atendían pacientes COVID-19 desde marzo de 2020 hasta enero de 2021, en un hospital de alta complejidad de la ciudad de Buenos Aires. Se evaluó IgM e IgG anti-SARS-CoV-2 quincenalmente durante 3 meses, así como la presencia de síntomas compatibles y factores asociados a la exposición. Se remitió a participantes con alteraciones de la esfera psíquica a contacto con el equipo de salud mental del hospital. Resultados: se incluyeron 52 participantes; de ellos, 31 eran mujeres; mediana de edad 32 años (rango 25-58). La mediana de horas semanales de trabajo autoinformadas fue 48 (IIC [intervalo intercuartil] 40-69,5). Inicialmente todos fueron PCR SARS-CoV-2 negativos en hisopado nasal; 11 (21,50% IC 95%; 9,62-32,53%) tuvieron COVID-19 sintomático con anticuerpos positivos. Los factores con mayor asociación a riesgo de COVID-19 fueron anosmia/disgeusia OR 403,33 (IC 95%; 47,60-3417,02), fiebre OR 172,53 (IC 95%; 28,82-1032,65), mialgias OR 41,97 (IC 95%; 8,08-217,84), conviviente con COVID-19 OR 28,17 (IC 95%; 5,67-179,97). Cerca del 40% presentaba alteraciones en las escalas de medición de burnout o depresión. Discusión: la incidencia hallada coincide con las cifras informadas acerca de personal de salud en la etapa inicial de la pandemia en la Argentina. Otro aspecto similar fue una mayoría de infecciones de curso leve, sin ningún paciente hospitalizado. No obstante, se halló una elevada incidencia de alteraciones de la esfera psíquica, tanto al comienzo como al final del seguimiento. Conclusiones: la incidencia de positivización de anticuerpos anti-SARS-CoV-2 fue cercana al 20%. No evidenciamos infecciones presintomáticas o asintomáticas. En cambio, la prevalencia de burnout y depresión fue elevada. La salud mental es un componente del personal de salud que debe ser priorizado en situaciones futuras de impacto similar. (AU)

Introduction: healthcare personnel are essential in the response against COVID-19. At the beginning of the pandemic the risk of acquiring the disease in this group was unknown. We sought to estimate incidence and prevalence of anti SARS-CoV-2 antibodies, as well as burnout prevalence in a cohort of healthcare staff during the pandemic, as well as assessing the prevalence of burnout and depression in this group. Materials and methods: prospective cohort formed by physicians tending to COVID-19 patients from march 2020 to january 2021 in a high-complexity hospital in the city of Buenos Aires. We evaluated anti SARS-CoV-2 IgM and IgG each 15 days for 3 months as well as the presence of compatible symptoms and factors associated to exposition to the virus. Patients showing signs of burnout and/or depression were referred to proper care by the mental health team in the hospital. Results: we included 52 patients, 31 women, median age was 32 years (range 25 - 58). Median amount of self-reported hours worked each week was 48 (IQR 40 - 69.5). Initially all participants had a negative COVID-19 PCR nasopharyngeal swab; 11 (21.50% CI95% 9.62 - 32.53%) had symptomatic COVID-19 with positive antibodies. Factors showing stronger association with testing positive were anosmia/dysgeusia OR 403.33 (CI95% 47.60-3417.02), fever OR 172.53 (CI95% 28.82 - 1032.65), myalgia OR 41.97 (CI95% 8.08 - 217.84), cohabitation with confirmed COVID-19 case OR 28.17 (CI95% 5.67 - 179.97). Near 40% showed alterations in burnout or depression scales. Discussion: the incidence rate we found was like reported values in the initial stages of the pandemic in Argentina. Another similarity was that all cases were mild; no hospitalization was required for any participant. We found an elevated incidence of alterations in the psychic sphere, both at the beginning and end of the follow up period. Conclusions:the incidence of positive SARS-CoV-2 antibodies was around 20%. No pre or asymptomatic cases were identified. Burnout and depression incidence was high. Mental health is a component that should never be overlooked in similar situations to come. (AU)

Euglena International Network (EIN): Driving euglenoid biotechnology for the benefit of a challenged world.

Euglenoids (Euglenida) are unicellular flagellates possessing exceptionally wide geographical and ecological distribution. Euglenoids combine a biotechnological potential with a unique position in the eukaryotic tree of life. In large part these microbes owe this success to diverse genetics including secondary endosymbiosis and likely additional sources of genes. Multiple euglenoid species have translational applications and show great promise in production of biofuels, nutraceuticals, bioremediation, cancer treatments and more exotically as robotics design simulators. An absence of reference genomes currently limits these applications, including development of efficient tools for identification of critical factors in regulation, growth or optimization of metabolic pathways. The Euglena International Network (EIN) seeks to provide a forum to overcome these challenges. EIN has agreed specific goals, mobilized scientists, established a clear roadmap (Grand Challenges), connected academic and industry stakeholders and is currently formulating policy and partnership principles to propel these efforts in a coordinated and efficient manner.

Cultivation of gastrointestinal microbiota in a new growth system revealed dysbiosis and metabolic disruptions in carcinoma-bearing rats.

A challenge in the study of gastrointestinal microbiota (GITm) is the validation of the genomic data with metabolic studies of the microbial communities to understand how the microbial networks work during health and sickness. To gain insights into the metabolism of the GITm, feces from healthy and sick rats with cancer were inoculated in a defined synthetic medium directed for anaerobic prokaryote growth (INC-07 medium). Significant differences between cultures of healthy and sick individuals were found: 1) the consumption of the carbon source and the enzyme activity involved in their catabolism (e.g., sucrase, lactase, lipases, aminotransferases, and dehydrogenases); 2) higher excretion of acetic, propionic, isobutyric, butyric, valeric, and isovaleric acids; 3) methane production; 4) ability to form biofilms; and 5) up to 500 amplicon sequencing variants (ASVs) identified showed different diversity and abundance. Moreover, the bowel inflammation induced by cancer triggered oxidative stress, which correlated with deficient antioxidant machinery (e.g., NADPH-producing enzymes) determined in the GITm cultures from sick individuals in comparison with those from control individuals. Altogether, the data suggested that to preserve the microbial network between bacteria and methanogenic archaea, a complete oxidation of the carbon source may be essential for healthy microbiota. The correlation of 16S rRNA gene metabarcoding between cultures and feces, as well as metabolomic data found in cultures, suggest that INC-07 medium may be a useful tool to understand the metabolism of microbiota under gut conditions.