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INTRODUCTION: Foot and ankle pathology can often require complex surgical reconstruction. Until recently, circular external fixators such as the Ilizarov frame have proven to be useful, yet they fall short when progressive, precise corrections are required. Computer-assisted hexapod external fixators seek to address many of the shortfalls of traditional circular fixators. However, evidence for their use is scarce. The objective of this work was to evaluate the functional and quality of life outcomes and post-operative complications of patients treated with computer-assisted hexapod external fixation. METHODS: A retrospective, observational study was conducted. All cases were treated with either a TrueLok hex (TL-HEX) or a Taylor Spatial Frame (TSF) fixator. Primary outcomes were post-operative improvement in 12-Item Short Form Survey (SF12) and American Orthopaedic Foot and Ankle Score (AOFAS) scores, and complications following Paley's classification. RESULTS: A total of 59 patients with complex foot and ankle conditions using 64 external fixation frames were included. The median sum of both SF12 score domains improved from a preoperative score of 63.6 to 91.3 at last follow-up (p < 0.001). Median AOFAS improved from a preoperative score of 35 to 75.5 at last follow up (p < 0.001). Functional improvement was not affected by the choice of external fixator. Complications occurred in 49 cases (77 %). The most common post-operative complications included pin tract complications in 37 (58 %) cases, joint rigidity in 24 (38 %) and axial deviation in 9 (14 %). CONCLUSIONS: Computer-assisted hexapod external fixation is an effective technique to correct complex foot and ankle deformities and leads to a marked improvement in post-operative functional and quality-of-life outcomes with a high minor complication rate.

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BACKGROUND: Levothyroxine (LT4) monotherapy is the standard treatment for hypothyroidism; however, 10-15% of patients have persistent hypothyroid symptoms despite normalizing thyroid hormone levels with LT4. This study aims to summarize the best available evidence on interventions to improve symptomatology in patients with hypothyroidism and persistent symptoms. METHODS: A systematic search was conducted in March 2022 for randomized controlled trials and observational studies on interventions for adult patients with persistent hypothyroid symptoms despite biochemical euthyroidism on thyroid hormone replacement. RESULTS: A total of 277 articles were reviewed and seven fulfilled the inclusion criteria. 455 participants were included. Most intervention participants were female (78.6%) with a mean age of 47.5 (±2.8) years. Five clinical trials evaluating ginger (vs. starch), L-carnitine (vs. placebo), combination LT4 and liothyronine (LT3) (vs. LT4 or placebo), and surgery for patients with serum antithyroid peroxidase (TPO Ab) titers greater than 1000 IU/ml (vs. LT4) found inconsistent improvement in hypothyroidism related symptoms and general health. The two clinical trials with the largest improvement in fatigue scores were the use of ginger and surgery. One observational study comparing thyroidectomy vs observation found no significant difference on general health. Lastly, another observational study evaluating combination LT4/LT3 (vs. LT4 monotherapy) found improvement in fatigue and quality of life. There were 31 (12%) adverse events in the intervention group and 18 (10.8%) in the comparator group. CONCLUSIONS: There is no high-quality evidence supporting any intervention for persistent symptoms in hypothyroidism. Available evidence, limited by the risk of bias, inconsistency, and heterogeneity, suggests that some persistent symptoms, particularly fatigue, could improve with ginger and thyroidectomy.

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¼ Unicameral bone cysts (UBCs) can increase the risk of pathologic fractures of both long and short bones. Although multiple treatments exist, data are conflicting regarding optimal management.¼ We sought to analyze treatment strategies for UBCs and their rates of successful treatment.¼ Success rates were analyzed according to treatment modality, with emphasis on filling techniques and/or decompression associated with curettage, and injection compounds.¼ Curettage with bone substitute and cyst decompression was identified as a highly successful technique for UBC treatment.¼ Decompressing the cyst wall after injection, regardless of the specific compound used, had a greater potential to enhance healing rates.¼ The management decision should be individually guided within the patient's context.

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BACKGROUND: Soft tissue sarcomas are a group of rare neoplasms which can be mistaken for benign masses and be excised in a non-oncologic fashion (unplanned excision). Whether unplanned excision (UE) is associated with worse outcomes is highly debated due to conflicting evidence. METHODS: We performed a systematic review and meta-analysis following PRISMA guidelines. Main outcomes analyzed were five-year overall survival (OS), five-year local recurrence-free survival (LRFS), amputation rate and plastic reconstruction surgery rate. Risk ratios were used to compare outcomes between patients treated with planned and unplanned excision. RESULTS: We included 16,946 patients with STS, 6017 (35.5%) with UE. UE was associated with worse five-year LRFS (RR 1.35, p = 0.019). Residual tumor on the tumor bed was associated with lower five-year LRFS (RR = 2.59, p < 0.001). Local recurrence was associated with worse five-year OS (RR = 1.82, p < 0.001). UE was not associated with a worse five-year OS (RR = 0.90, p = 0.16), higher amputation rate (RR = 0.77, p = 0.134), or a worse plastic reconstruction surgery rate (RR = 1.25, p = 0.244). CONCLUSIONS: Unplanned excision of Soft Tissue Sarcomas and the presence of disease in tumor bed after one were associated with worse five-year LRFS. Tumor bed excision should remain the standard approach, with special consideration to the presence of residual disease.

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INTRODUCTION: Radiation-induced soft tissue sarcomas (RISs) are rare secondary malignancies with a dire prognosis. The literature on the management of these tumors remains scarce due to their low incidence. Our systematic review sought to assess the treatment alternatives and outcomes of patients with RIS. METHODS: A systematic review was conducted following the PRISMA guidelines. Our study was registered in PROSPERO (ID: CRD42023438415). Quality assessment was performed using the STROBE checklist. Weighted means for both continuous and categorical values were calculated. RESULTS: Twenty-one studies comprising 1371 patients with RIS were included. The mean latency period from radiation to RIS diagnosis was 14 years, and the mean radiation dose delivered to the primary malignancy was 29.2 Gy. The most common histological type was undifferentiated pleomorphic sarcoma (42.2%), and 64% of all tumors were high-grade. The trunk was the most common location (59%), followed by extremities (21%) and pelvis (11%). Surgery was performed in 68% of patients and, among those with an appendicular tumor, the majority (74%) underwent limb-salvage surgery. Negative margins were attained in 58% of patients. Chemotherapy and radiotherapy were administered in 29% and 15% of patients, respectively. The mean 5-year overall survival was 45%, and the local recurrence and metastasis rates were 39% and 27%, respectively. CONCLUSIONS: In our study, the most common treatment was surgical resection, with RT and chemotherapy being administered in less than one third of patients. Patients with RIS exhibited poor oncologic outcomes. Future studies should compare RIS with de novo STS while controlling for confounders.

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BACKGROUND: Total femur replacement (TFR) is used for primary reconstruction after extensive tumor resection or as a revision surgery due to prosthetic failure. Studies on TFR rates of failure and functional outcomes are scarce. The purpose of our study was to compare the modes of failure, amputation rates, and functional outcomes after TFR between oncologic and nononcologic patients. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were for this manuscript. Our study was registered on PROSPERO (413582). Quality assessment of all studies was performed using Strengthening the Reporting of Observational Studies in Epidemiology checklist. Endoprosthesis failure was assessed using the Henderson classification and functional outcomes using the Musculoskeletal Tumor Society score. Weighted means and standard deviations were calculated. RESULTS: Overall failure rate was similar between groups. Henderson type 4 failures were more common within the nononcologic group, while the others were more frequently found in the oncologic group. Overall amputation rate was higher in the oncologic group mainly due to type 5 failure. Amputations occurred mainly after type 4 and type 5 failures. Functional outcome was better within the oncologic group (70.5 versus 61.7, respectively; P < .001). CONCLUSIONS: Total femoral replacement in the oncologic and nononcologic group is associated with a high rate of failure (31% and 32.5%, respectively). Overall amputation rate was higher in the oncologic group mainly due to type 5 failure. Functional outcome was better within the oncologic group. LEVEL OF EVIDENCE: Level III.

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BACKGROUND: Statin intolerance is a key barrier to the effective prevention of atherosclerotic cardiovascular disease (ASCVD). Experts do not agree on what it is and how to respond to this problem clinically. OBJECTIVE: To characterize the range of expert recommendations about the care of patients with statin intolerance. METHODS: Systematic review registered in PROSPERO that searched on April 1 2022 in PubMed, EMBASE, Scopus, Cochrane, online textbooks, and specialty textbooks for expert reviews (e.g., review articles and book chapters), systematic reviews, or clinical practice guidelines published in the past 5 years without language restriction. Authors working in duplicate extracted definitions, management recommendations, and supportive evidence cited. RESULTS: We identified 26 eligible articles, none of which described a systematic method to summarize the evidence or to develop and grade recommendations. Of these, 14 (54%) offered a definition of statin intolerance. A sequenced approach to management of statin intolerance was suggested in 24 (92%) articles describing 12 different approaches without supporting evidence of efficacy. Investigating for other causes was the most common first step. All authors suggested rechallenging after a washout period with either the same or other statin. Few considered nonlipid approaches to reducing ASCVD risk and none recommended involving patients in shared decision making. CONCLUSION: We found substantial variability in the definition and management of statin intolerance among experts. Few focused on ASCVD risk reduction and none promoted the participation of patients in shared decision making about how to address the threat of ASCVD with or without statins.

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