Purpose:To evaluate the literature regarding the efficacy of various repair and reconstruction surgical techniques for chronic quadriceps tendon ruptures (QTRs) in native knees and to assess their associated outcomes. Methods:A comprehensive literature search of the EMBASE, PubMed/MEDLINE, and Cochrane databases was conducted from October 2023 to November 2024 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Clinical studies that analyzed outcomes following surgical intervention of chronic QTRs with Level IV or greater evidence were included. We excluded case reports and QTRs in the setting of total knee arthroplasty. Quality assessment was conducted using Methodological Index for Non-Randomized Studies criteria. Results:Ten studies published between 1981 and 2022 were included. Described techniques included direct tendon repair, lengthening procedures, and various graft and mesh augmentations. Reported failure rates ranged from 0 to 33%. Extensor lag remained a common reported complication (5 of 10 studies). Conclusions:The current body of literature on the surgical management of chronic QTRs is characterized by significant heterogeneity in surgical technique and a predominantly low quality of evidence. The various surgical techniques described suffer from limited follow-up and inconsistently reported outcome measures. Level of Evidence:Level IV, systematic review of Level III and IV studies.

BACKGROUND:Hallux rigidus with an associated osteochondral lesion is a common condition that can effectively be treated with a cheilectomy and Moberg osteotomy (CM). The use of biological adjuncts such as extracellular matrix (ECM) and bone marrow aspirate concentrate (BMAC) have been suggested to facilitate healing and restore forefoot function. The aim was to report if the addition of ECM and BMAC improves clinical outcomes for the treatment of hallux rigidus. METHODS:Patients who received open cheilectomy with first proximal phalangeal dorsal closing wedge osteotomy with and without ECM and BMAC for the diagnosis of hallux rigidus between February 2016 to July 2022 by the principal investigator were reviewed. A total of 137 patients were included, 71 in the cheilectomy with Moberg osteotomy group (CM) and 66 in the cheilectomy with Moberg osteotomy and ECM/BMAC group (CM + ECM/BMAC). All patients received Patient-Reported Outcomes Measurement Information System (PROMIS) surveys preoperatively and at minimum 1 year postoperatively. Postoperative complications were also noted for the patient cohort. RESULTS:The average time from surgery to final follow-up was 21.6 (range, 12-36.2) months for CM patients and 27.8 (range, 12-82.5) months for CM+BMAC patients (P = .001). Both CM and CM+BMAC cohorts demonstrated significant improvement in physical function, pain interference, pain intensity, and global physical health. However, there were no significant differences in preoperative or postoperative PROMIS domains between the 2 cohorts. CONCLUSION:In conclusion, this study compares short-term patient-reported clinical outcomes and complications of cheilectomy and Moberg osteotomy against cheilectomy and Moberg osteotomy with ECM and BMAC for hallux rigidus. This study suggests that any potential differences in outcomes between groups are not large enough to be clinically meaningful in the short term and that other factors may be more relevant in determining the best course of treatment. A longer follow-up is required to evaluate long-term functional and clinical outcomes, and to see if addressing the cartilage has long-term effects.

Background: There is a lack of consensus on how deltoid injuries should be addressed in the setting of acute ankle fractures. This study aims to evaluate whether deltoid repair during lateral malleolar fracture fixation leads to improved clinical outcomes compared to fixation without deltoid repair. Methods: This was a single-center retrospective study involving 13 surgeons. Inclusion criteria were patients aged 18 years or older who underwent open fixation for a supination external rotation type IV (SER IV) equivalent ankle fracture. SER IV fractures were confirmed with stress radiographs. Deltoid injury was confirmed with an intraoperative external rotation stress test. A total of 146 patients were included. Eighty patients received a deltoid repair (DR), and 66 patients did not receive a deltoid repair (NDR). Patient-reported outcomes via PROMIS scores were collected preoperatively and at least 1 year postoperatively for all patients. Preoperative and postoperative medial clear space (MCS) were reviewed for all patients. Results: There were no significant differences in preoperative and postoperative PROMIS domains between the 2 cohorts. There were also no significant differences in preoperative MCS and postoperative MCS between the 2 cohorts. There were no significant differences in the incidence of subsequent procedures for removal of painful hardware, revisions, infections, progression to arthritis, and persistent pain. Conclusion: This study compares short- to medium-term outcomes and complications of SER IV–equivalent ankle fractures with and without deltoid repair. No significant differences between PROMIS scores, postoperative MCS, and complication rates were observed between groups. Level of Evidence: Level III, retrospective case control study.

Background:Subtle Lisfranc injuries, defined by 2-5 mm of first webspace diastasis, pose unique treatment challenges distinct from more severe injuries. This study aimed to evaluate whether a primary open reduction internal fixation (ORIF) or a primary arthrodesis (PA) optimizes clinical outcomes and minimizes complications in treating subtle Lisfranc injuries. Methods:This study included patients who had a nondislocation Lisfranc injury with a proximal first webspace (between the medial cuneiform and second metatarsal base) diastasis of 2-5 mm, and underwent either a primary ORIF or primary arthrodesis. Preoperative weightbearing radiographs were reviewed to confirm subtle Lisfranc injuries. Of the 73 patients who met the inclusion criteria, 41 received a PA and 32 received an ORIF. Treatment selection was based on surgeon preference. Patient-reported outcomes via PROMIS scores were collected preoperatively and at least 2 years postoperatively. Subsequent procedures were also recorded. Results:We received PROMIS surveys from 57 patients (78%). The average preoperative diastasis of the ORIF group significantly differed from that of the PA group (P < .05). Both ORIF and PA cohorts demonstrated significant improvement in all physical PROMIS criteria on minimum 2-year follow-up (P < .05). Our results did not demonstrate a significant difference in patient-reported outcomes between the ORIF and PA groups. There was no significant difference in the incidence of complications between groups, but the ORIF group underwent significantly more hardware removal procedures than the PA group (P < .01). Conclusion:This study compared outcomes of subtle Lisfranc injuries treated with ORIF and PA. Our results demonstrated no significant differences between ORIF and PA outcomes. This study suggests that both ORIF and PA may be viable options for subtle Lisfranc injuries; however, further research is needed to determine which may be optimal for different patient populations. Level of Evidence:Level III, retrospective comparative study.

INTRODUCTION:This study provides the first comparison of patient-reported outcomes between isolated cheilectomy (C) and cheilectomy with Moberg (CM) osteotomy for hallux rigidus.METHODS:A single-center, retrospective registry search identified all patients with preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores who underwent cheilectomy, with and without concomitant proximal phalangeal dorsiflexion osteotomy, for hallux rigidus between January 2016 and December 2020. Because there were far fewer isolated cheilectomies (62), all C patients were compared with a commensurate number of consecutive CM cases (67) using preoperative, 1-year, and 2-year PROMIS scores for physical function, pain interference, pain intensity, global physical health, global mental health, and depression, as well as complication and revision data from a chart review. A multivariable linear regression analysis was performed to compare adjusted postoperative PROMIS scores between the 2 cohorts.RESULTS:There were no differences between groups among the demographic and preoperative variables compared. The CM cohort reported worse pain interference scores preoperatively (P < .001) and at 1 year postoperatively (P = .01). However, the C cohort reported worse pain intensity scores preoperatively (P < .001) and at 1 year postoperatively (P < .001). Adjusted postoperative PROMIS score comparison demonstrated that the CM cohort had better 1-year postoperative pain intensity scores (P < .05). However, there were no differences between cohorts for additional PROMIS scores or complications data.CONCLUSION:The addition of a Moberg osteotomy does not appear to significantly change short- to medium-term outcomes of cheilectomy for hallux rigidus treatment.LEVELS OF EVIDENCE:Level III: Retrospective comparative study.

Background: The proposed advantages of hamstring autograft reconstruction when compared to alternative procedures, such as flexor hallucis longus (FHL) transfer, V-Y lengthening, and allograft reconstruction, are improved healing and reproduction of normal tendon biomechanics and reduced morbidity within the foot and ankle. In this study, we examined the effect of Achilles tendon reconstruction using hamstring autografts on strength and functional outcomes. Methods: Patients who underwent Achilles repair with a hamstring autograft for insertional or midsubstance tendinopathy, delayed diagnosis of rupture, or infection after primary repair were evaluated for inclusion. Forty-six patients were identified; 12 further augmented with an FHL transfer are included in the analysis. Isokinetic testing was completed with a Biodex dynamometer under supervision of a physical therapist masked to surgical side. Pre- and postoperative Foot and Ankle Outcome Scores (FAOS, before March 2016) or Patient-Reported Outcomes Measurement Information System (PROMIS, after March 2016) surveys were collected. Results: For knee flexion, peak torque was not significantly different when comparing operative and nonoperative sides at 180 degrees/second (45.38 Nm vs 45.96 Nm; P = .69) nor at 300 degrees/second (44.2 Nm vs 47.02 Nm; P = .069). Knee extension absolute peak torque was only found to be significantly weaker on the operative side at the faster testing (75.5 Nm vs 79.56 Nm; P < .05). Peak ankle plantarflexion torque was significantly weaker on the operative side at both the slower speed (60 degrees/second: 39.9 Nm vs 48.76 Nm; P < .005) and the faster speed (120 degrees/second: 31.3 Nm vs 40.7 Nm; P < .001). Average power for ankle plantarflexion did not differ significantly from the operative side to the nonoperative side in the slower test (26.46 W vs 27.48 W; P = .60) but did significantly differ on the faster test (32.13 W vs 37.63 W; P = .041). At an average of 19.9 months postoperation, all physical function and pain-related patient-reported outcome scores showed clinically and statistically significant improvement. Conclusion: Achilles reconstruction with a hamstring autograft ± FHL transfer allowed patients with severe Achilles pathology to return to good subjective function, with modest deficits in calf strength compared with the uninjured side. Overall knee flexion strength did not appear impaired. These results suggest that hamstring autograft reconstruction is a viable method to treat these complex cases involving a lack of healthy tissue, allowing patients to return to symptom-free physical function and athletic activity. Level of Evidence: Level IV, case series.

Category: Hindfoot; Midfoot/Forefoot Introduction/ Purpose: Progressive collapsing foot deformity (PCFD) is recognized as a three-dimensional deformity centered around the talus. Although sagittal plane talar sagging or coronal plane valgus talar tilt have been well described, axial plane alignment referencing the talus, calcaneus and second metatarsal to the ankle has not been studied in PCFD patients. The purpose of this study was to examine the axial plane alignment of PCFD versus controls using weightbearing computed tomography (WBCT) and to determine if talar rotation in the axial plane is associated with increased abduction deformity. We hypothesized that the talus would exhibit greater internal rotation in PCFD patients than in control patients, and that this rotation would increase with worsening abduction deformity. Methods: Multiplanar reconstructed (MPR) WBCT scans of 79 patients with PCFD were analyzed. Patients were divided into two groups according to their preoperative talonavicular coverage angle (TNC): moderate abduction (TNC 20-40, n=57) and severe abduction (TNC >40, n=22). 39 WBCT scans from healthy patients without PCFD or hindfoot deformity were included as controls. Using the MPR WBCT images, the axis of talus (TM [transmalleolar]-Tal), calcaneus (TM-Calc), and 2nd metatarsal (TM-2MT) were measured in reference to the transmalleolar axis (Figure 1). Smaller angles represented internal rotation relative to the TM axis. The difference between TM-Tal and TM-Calc was calculated to assess talocalcaneal subluxation. The prevalence of medial tibiotalar joint space narrowing, which was assessed with medial to dorsal tibiotalar joint space ratio (M/D ratio < 0.5 was defined as ‘narrowing’), and medial ankle spurs were also evaluated. Results: TM-Tal was significantly smaller in PCFD patients compared to controls (Figure 2). This difference was accentuated in PCFD with severe abduction, who saw significantly smaller TM-Tal than the moderate abduction group. TM-Calc did not differ between groups, indicating similar axial calcaneal orientation. The TM-2MT revealed a significant difference between groups, reflecting foot abduction in PCFD. Diff Tal-Calc values were greater in PCFD patients, indicating that PCFD patients have more talocalcaneal subluxation in the axial plane. The severe abduction group had a higher Diff Tal-Calc value than the moderate abduction group. PCFD patients had a significantly higher prevalence of medial ankle joint space narrowing and medial spur formation than controls; however, there were no significant differences between the severe and moderate abduction groups. Conclusion: This study found that internal rotation of the talus is a key component of PCFD and is accentuated in more severe abduction deformities. These findings suggest that talar malrotation in the axial plane should be considered an underlying feature of abduction deformity and that this deformity should be corrected at the time of reconstructive surgery, especially in cases of severe abduction deformity. In addition, these findings support the observations of medial joint narrowing and medial spur formation in PCFD patients. Further research is warranted to identify optimal strategies for correction of talar rotation and how to reproducibly assess this intraoperatively.

6634 Background: Suicide rates are elevated acutely after cancer diagnosis. We sought to create a unifying theory that explains variations in suicide risk across cancer sites, stages, and demographics. Based on the stress-diathesis model, we hypothesized that suicide risk correlates with cancer prognosis and that the impact of prognosis on suicide risk is greatest for populations with higher baseline risks of suicide. Methods: We identified all patients with newly diagnosed cancers from 2000-2019 in the Surveillance, Epidemiology, and End Results (SEER) 17 database, representing 27% of U.S. cancers diagnosed over the past 20 years. Multiple primary-standardized mortality ratios (SMR) were used to determine the relative risk of suicide within the first 6 months compared to the general U.S. population, adjusted for age, sex, race, and year of follow-up. We correlated suicide and 2-year overall survival rates for 20 cancer sites using a weighted linear regression model. Results: We identified 9,046 suicides among 6,811,940 persons diagnosed with cancer, 1,610 of which occurred within 6 months of diagnosis. There were 5.3 suicides per 10,000 person-years, compared with an expected rate of 1.7 (SMR 3.1 [95% CI 3.0-3.3]). Suicide risk correlated strongly with prognosis (increased risk of 9.5% per percent survival deficit at 2 years, R 2 = 0.88, P < .0001). The impact of prognosis on suicide risk was greater for demographic groups with higher baseline risks of suicide. For men, the risk of suicide increased by 3 suicides per 10,0000 person-years (R 2 = 0.84, P < .0001) versus 0.3 in women (R 2 = 0.54, P < .0001). The impact of prognosis on suicide risk was also greater for persons age 60+ and for white (versus black) race. Conclusions: Poorer prognosis correlates with suicide risk in patients with cancer and has a greater effect on populations with higher baseline rates of suicide. Our model should provide a useful framework for triaging patients that need increased surveillance or urgent psychiatric referral.

IMPORTANCE O6-methylguanine-DNA methyltransferase (MGMT [OMIM 156569]) promoter methylation (mMGMT) is predictive of response to alkylating chemotherapy for glioblastomas and is routinely used to guide treatment decisions. However, the utility of MGMT promoter status for low-grade and anaplastic gliomas remains unclear due to molecular heterogeneity and the lack of sufficiently large data sets. OBJECTIVE To evaluate the association of mMGMT for low-grade and anaplastic gliomas with chemotherapy response. DESIGN, SETTING, AND PARTICIPANTS This cohort study aggregated grade II and III primary glioma data from 3 prospective cohort studies with patient data collected from August 13, 1995, to August 3, 2022, comprising 411 patients: MSK-IMPACT, EORTC (European Organization of Research and Treatment of Cancer) 26951, and Columbia University. Statistical analysis was performed from April 2022 to January 2023. EXPOSURE MGMT promoter methylation status. MAIN OUTCOMES AND MEASURES Multivariable Cox proportional hazards regression modeling was used to assess the association of mMGMT status with progression-free survival (PFS) and overall survival (OS) after adjusting for age, sex, molecular class, grade, chemotherapy, and radiotherapy. Subgroups were stratified by treatment status andWorld Health Organization 2016 molecular classification. RESULTS A total of 411 patients (mean [SD] age, 44.1 [14.5] years; 283 men [58%]) met the inclusion criteria, 288 of whom received alkylating chemotherapy. MGMT promoter methylation was observed in 42% of isocitrate dehydrogenase (IDH)-wild-type gliomas (56 of 135), 53% of IDH-mutant and non-codeleted gliomas (79 of 149), and 74% of IDH-mutant and 1p/19q-codeleted gliomas (94 of 127). Among patients who received chemotherapy, mMGMT was associated with improved PFS (median, 68 months [95% CI, 54-132 months] vs 30 months [95% CI, 15-54 months]; log-rank P < .001; adjusted hazard ratio [aHR] for unmethylated MGMT, 1.95 [95% CI, 1.39-2.75]; P < .001) and OS (median, 137 months [95% CI, 104 months to not reached] vs 61 months [95% CI, 47-97 months]; log-rank P < .001; aHR, 1.65 [95% CI, 1.11-2.46]; P = .01). After adjusting for clinical factors, MGMT promoter status was associated with chemotherapy response in IDH-wild-type gliomas (aHR for PFS, 2.15 [95% CI, 1.26-3.66]; P = .005; aHR for OS, 1.69 [95% CI, 0.98-2.91]; P = .06) and IDH-mutant and codeleted gliomas (aHR for PFS, 2.99 [95% CI, 1.44-6.21]; P = .003; aHR for OS, 4.21 [95% CI, 1.25-14.2]; P = .02), but not IDH-mutant and non-codeleted gliomas (aHR for PFS, 1.19 [95% CI, 0.67-2.12]; P = .56; aHR for OS, 1.07 [95% CI, 0.54-2.12]; P = .85). Among patients who did not receive chemotherapy, mMGMT status was not associated with PFS or OS. CONCLUSIONS AND RELEVANCE This study suggests that mMGMT is associated with response to alkylating chemotherapy for low-grade and anaplastic gliomas and may be considered as a stratification factor in future clinical trials of patients with IDH-wild-type and IDH-mutant and codeleted tumors.

Introduction: Solitary fibrous tumor/hemangiopericytoma (SFT/HPC) of the central nervous system (CNS) is a rare meningeal tumor. Given the absence of prospective or randomized data, there are no standard indications for radiotherapy. Recently, the NRG Oncology and EORTC cooperative groups successfully accrued and completed the first prospective trials evaluating risk-adapted adjuvant radiotherapy strategies for meningiomas. Using a similar framework, we sought to develop prognostic risk categories that may predict the survival benefit associated with radiotherapy, using two large national datasets. Methods: We queried the National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) databases for all newly diagnosed cases of SFT/HPC within the CNS. Risk categories were created, as follows: low risk—grade 1, with any extent of resection (EOR) and grade 2, with gross–total resection; intermediate risk—grade 2, with biopsy/subtotal resection; high risk—grade 3 with any EOR. The Kaplan–Meier method and Cox proportional hazards regressions were used to determine the association of risk categories with overall and cause-specific survival. We then determined the association of radiotherapy with overall survival in the NCDB, stratified by risk group. Results: We identified 866 and 683 patients from the NCDB and SEER databases who were evaluated, respectively. In the NCDB, the 75% survival times for low- (n = 312), intermediate- (n = 239), and high-risk (n = 315) patients were not reached, 86 months (HR 1.60 (95% CI 1.01–2.55)), and 55 months (HR 2.56 (95% CI 1.68–3.89)), respectively. Our risk categories were validated for overall and cause-specific survival in the SEER dataset. Radiotherapy was associated with improved survival in the high- (HR 0.46 (0.29–0.74)) and intermediate-risk groups (HR 0.52 (0.27–0.99)) but not in the low-risk group (HR 1.26 (0.60–2.65)). The association of radiotherapy with overall survival remained significant in the multivariable analysis for the high-risk group (HR 0.55 (0.34–0.89)) but not for the intermediate-risk group (HR 0.74 (0.38–1.47)). Similar results were observed in a time-dependent landmark sensitivity analysis. Conclusion: Risk stratification based on grade and EOR is prognostic of overall and cause-specific survival for SFT/HPCs of the CNS and performs better than any individual clinical factor. These risk categories appear to predict the survival benefit from radiotherapy, which is limited to the high-risk group and, potentially, the intermediate-risk group. These data may serve as the basis for a prospective study evaluating the management of meningeal SFT/HPCs.

Category: Ankle Arthritis; Ankle Introduction/Purpose: A comprehensive analysis of lower limb alignment may be a critical component of successful ankle joint preservation surgery. Although it is widely recognized that the combined effect of lower limb orientation and ankle and hindfoot alignment plays a fundamental role in ankle arthritis, supramalleolar/lower limb alignment has received less attention in valgus ankle arthritis. This study aims to analyze the lower limb alignment of patients with valgus ankle arthritis with primary origin, compared to those with varus ankle arthritis and normal controls. We hypothesize that patients with valgus ankle arthritis will exhibit the opposite pattern of lower limb alignment to those with varus ankle arthritis: valgus mechanical axis, valgus distal tibial plafond, and valgus hindfoot alignment. Methods: A retrospective radiographic analysis was conducted on 61 patients (62 ankles, mean age: 59.2 years) with valgus ankle arthritis with primary origin was performed. Preoperative weightbearing radiographs were used to measure seven radiographic parameters: Talar tilt angle, medial distal tibial angle (MDTA), talar center migration (TCM), anterior distal tibial angle (ADTA), talo-first metatarsal (Meary’s) angle, hindfoot moment arm (HMA), and mechanical axis deviation (MAD). For comparative radiographic analysis, a varus arthritis group with primary origin (n=55, mean age: 59.7 years) and a control group (n=58, mean age: 29.3 years) were included. Subgroup analyses of lower limb alignment were performed in the valgus arthritis group based on the MDTA (greater or less than 90 degrees, subgroup analysis 1) and Meary's angle (greater or less than -20 degrees, subgroup analysis 2). Results: The valgus group had a significantly lower mean MDTA than the control group (p < 0.0001, Figure 1), indicating a varus distal tibial plafond in comparison to the control group. Meary's angle and HMA were significantly lower in the valgus group compared to the varus group (p < 0.05 and p< 0.0001, respectively). On whole limb radiographs, the valgus group showed a greater MAD than the control group (p < 0.05), indicating a varus lower limb alignment. However, there was no significant difference in MAD between the valgus and varus groups (p=0.7031). Subgroup analysis 1 revealed that the MAD was varus- angulated regardless of the MDTA. Subgroup analysis 2 showed that both groups had comparable MDTA (p=0.8504); however, patients with a lower Meary’s angle had a significantly greater MAD. Conclusion: Our findings indicate that a significant proportion of ankles with primary valgus arthritis have a varus tibial plafond and a varus lower limb mechanical axis, which contradicts our current understanding. The similar lower limb and distal tibia orientation and different foot and hindfoot alignment between the valgus and varus group suggest that foot and hindfoot alignment may play an important role in the development of both types of arthritis. This study adds to our understanding of primary valgus ankle arthritis and suggests that lower limb alignment should be analyzed and considered throughout valgus ankle arthritis realignment procedures.

AbstractPurpose:While MGMT promoter methylation (mMGMT) is predictive of response to alkylating chemotherapy and guides treatment decisions in glioblastoma, its role in grade 2 and 3 glioma remains unclear. Recent data suggest that mMGMT is prognostic of progression-free survival in 1p/19q-codeleted oligodendrogliomas, but an effect on overall survival (OS) has not been demonstrated.Experimental Design:We identified patients with newly diagnosed 1p/19q-codeleted gliomas and known MGMT promoter status in the National Cancer Database from 2010 to 2019. Multivariable Cox proportional hazards regression modeling was used to assess the effect of mMGMT on OS after adjusting for age, sex, race, comorbidity, grade, extent of resection, chemotherapy, and radiotherapy.Results:We identified 1,297 eligible patients, 938 (72.3%) of whom received chemotherapy in their initial course of treatment. The MGMT promoter was methylated in 1,009 (77.8%) patients. Unmethylated MGMT (uMGMT) was associated with worse survival compared with mMGMT [70% {95% confidence interval (CI), 64%–77%} vs. 81% (95% CI, 78%–85%); P < 0.001; adjusted HR (aHR), 2.35 (95% CI, 1.77–3.14)]. uMGMT was associated with worse survival in patients who received chemotherapy [63% (95% CI, 55–73%) vs. 80% (95% CI, 76%–84%); P < 0.001; aHR, 2.61 (95% CI, 1.89–3.60)] but not in patients who did not receive chemotherapy [P = 0.38; HR, 1.31 (95% CI, 0.71–2.42)]. Similar results were observed regardless of World Health Organization grade and after single- or multiagent chemotherapy.Conclusions:Our study demonstrates an association between mMGMT and OS in 1p/19q-codeleted gliomas. MGMT promoter status should be considered as a stratification factor in future clinical trials of 1p/19q-codeleted gliomas that use OS as an endpoint.

Background:Ankle fractures involving the posterior malleolus (PM) tend to result in inferior clinical outcomes compared to other ankle fractures. However, it is unclear which specific risk factors and fracture characteristics are associated with negative outcomes in these fractures. The aim of this study was to identify risk factors for poor postoperative patient-reported outcomes in patients with fractures involving the PM.Methods:This retrospective cohort study included patients who sustained ankle fractures involving the PM between March 2016 and July 2020 and had preoperative computed tomography (CT) scans. In total, 122 patients were included for analysis. One patient (0.8%) had an isolated PM fracture, 19 (15.6%) had bimalleolar ankle fractures involving the PM, and 102 (83.6%) had trimalleolar fractures. Fracture characteristics including the Lauge-Hansen (LH) and Haraguchi classifications and posterior malleolar fragment size were collected from preoperative CT scans. Patient Reported Outcome Measurement Information System (PROMIS) scores were collected preoperatively and at a minimum of 1 year postoperatively. The association between various demographic and fracture characteristics with postoperative PROMIS scores was assessed.Results:Involvement of more malleoli was associated with worse PROMIS Physical Function (P = .04), Global Physical Health (P = .04), and Global Mental Health (P < .001), and Depression scores (P = .001). Elevated BMI was also associated with worse PROMIS Physical Function (P = .0025), Pain Interference (P = .0013), and Global Physical Health (P = .012) scores. Time to surgery, fragment size, Haraguchi classification, and LH classification were not associated with PROMIS scores.Conclusion:In this cohort, we found that trimalleolar ankle fractures were associated with inferior PROMIS outcomes compared with bimalleolar ankle fractures involving the PM in multiple domains.Level of Evidence:Level III, retrospective cohort study.

Transl Lung Cancer Res 2022 | https://dx.doi.org/10.21037/tlcr-22-292 Approximately 54% of non-small cell lung cancer (NSCLC) patients present with early-stage or locally-advanced disease and are potentially curable, of which 40% receive radiotherapy as a part of their initial course of treatment (1,2). Although biomarkers routinely guide treatment decisions for systemic therapies in NSCLC, there are no clinical biomarkers that predict response to radiotherapy. Two independent studies have recently converged on alterations in the NRF2 pathway as potential biomarkers of radioresistance in NSCLC (3,4). In Clinical Cancer Research, Sitthideatphaiboon et al. identify STK11 (LKB1) mutations as a predictive biomarker of radioresistance in NSCLC (3). The authors retrospectively analyze a cohort of 194 stage I–III patients treated with radiotherapy and find STK11 mutations to be the strongest predictor of disease-free survival (DFS) and overall survival (OS). They demonstrate that STK11 and KEAP1 mutations confer radioresistance in NSCLC xenograft models and identify glutaminase as a potential therapeutic target to overcome NRF2-mediated radioresistance in vitro. This manuscript complements a recent publication in Cancer Discovery, which identifies pathogenic KEAP1/NFE2L2 (NRF2) mutations as a biomarker of radioresistance in NSCLC, which can similarly be reversed by glutaminase inhibition in vitro (4). Together, these studies support a unifying theory for NRF2-mediated radioresistance and “glutamine-addiction” in NSCLC (5,6). The study by Sitthideatphaiboon et al. (3) is the first to examine clinical outcomes based on STK11 status in a radiotherapy cohort. The authors acknowledge limitations, including its retrospective nature, limited sample size, and inability to access KEAP1 mutations. We, therefore, sought to validate their findings using three large prospective cohorts (Table 1). Putative driver (pathogenic) mutations versus variants of unknown significance were defined via OncoKB and Cancer Hotspots annotations in the cBioportal (https://www.cbioportal.org/). Among nonmetastatic NSCLC patients in The Cancer Genome Atlas (TCGA) (n=736, 34% prospective) (7), STK11 pathogenic mutations were associated with poorer OS in patients who received radiotherapy {n=83, HR: 3.03 [95% confidence interval (CI): 1.38–6.68]}, but not in patients who received no radiotherapy (n=547). Including KEAP1 and NFE2L2 pathogenic mutations in adenocarcinomas (8) increased the number of patients with potentially radioresistant tumors from 6.9% to 9.8% and was a stronger predictive biomarker. KEAP1/NFE2L2/STK11 mutations were associated with poorer OS [HR: 3.78 (1.85–7.74)], progression-free survival [3.80 (1.87–7.72)], DFS [4.46 (0.94–21.1)], and disease-specific survival [4.83 (2.20–10.6)] only in patients that received radiotherapy (interaction with treatment P=0.02, 0.09, 0.23, and 0.02, respectively; Table 1; Figure 1). Letter to the Editor

Background: Osteochondral autograft transplant (OAT) is often used to treat large osteochondral lesions of the talus and is generally associated with good outcomes. The addition of adjuncts such as cartilage extracellular matrix with bone marrow aspirate concentrate (ECM-BMAC) may further improve the OAT procedure but have not been thoroughly studied. We hypothesized that the placement of ECM-BMAC around the OAT graft would improve radiographic and patient-reported outcomes following OAT. Methods: Patients who received OAT, with ECM-BMAC or BMAC alone, were screened and their charts were reviewed. For patients who did receive ECM-BMAC, the mixture was spread around the edges of the OAT plug and into any surrounding areas of cartilage damage. Survey and radiographic data were collected. Average follow-up in both groups was over 2 years. Magnetic resonance imaging scans were scored using the Magnetic Resonance Observation of Cartilage Tissue (MOCART) system. Outcomes were compared statistically between groups. Results: Patients treated with ECM-BMAC (n = 34) demonstrated significantly greater improvement of scores in the FAOS categories Symptoms (17 vs −3; P = .02) and Sports Activities (40 vs 7; P = .02), and the MOCART category Subchondral Lamina (P = .008) compared to those treated with BMAC alone (n = 30). They also experienced significantly lower rates of postoperative cysts (53% vs 18%, P = .04) and edema (94% vs 59%, P = .02). Conclusion: The addition of ECM-BMAC to OAT was associated with improved imaging and clinical outcomes compared to OAT with BMAC alone.

BACKGROUND:There has been concern about lateral prominence pain at the osteotomy site following medial displacement calcaneal osteotomy (MDCO). However, no study has investigated this complication. This study aimed to investigate the incidence of lateral prominence pain following MDCO and examine the efficacy of crushplasty as a surgical technique to minimize this complication.METHODS:This was a retrospective cohort study in which 137 patients (148 feet) who underwent MDCO were divided into 2 groups by whether they had concurrent crushplasty at the time of MDCO (crushplasty [n = 81] vs noncrushplasty group [n = 67]). Crushplasty was performed by flattening the bony step-off using a rongeur and bone impactor. Lateral prominence pain was defined as pain or irritating symptoms over the osteotomy site that persisted over 12 months after MDCO. The overall incidence of lateral prominence pain after MDCO and within each group was investigated. Multiple logistic regression analysis was used to determine the influence of possible risk factors on the development of postoperative lateral prominence pain.RESULTS:The overall incidence of lateral prominence pain was 9.5% (14 of 148): 3.4% (3 of 87) in the crushplasty group, and 18% (11 of 61) in the noncrushplasty group, and χ2 analysis showed a statistically significant relationship between crushplasty and lateral prominence pain (P < .05). A relationship between the amount of medial displacement and the development of lateral prominence pain was observed in the noncrushplasty group (OR = 5.31, 95% CI 2.35-16.4, P < .05), but this was not observed in the crushplasty group (P = .641). The amount of medial displacement was an independent risk factor for the development of lateral prominence pain (OR = 2.72, 95% CI 1.54-4.79, P < .05), and concurrent crushplasty had a negative relationship with lateral prominence pain development (OR = 0.12, 95% CI 0.03-0.57, P < .05).CONCLUSION:This study revealed that lateral prominence pain is a significant complication of MDCO, especially in the setting of a larger displacement. The crushplasty following MDCO may minimize this complication, particularly when a greater degree of hindfoot correction is attempted.