Progressive flatfoot deformity accompanied with avulsion and dislocation of accessory navicular

The accessory navicular is one of the most common accessory bones in the foot, and it is mostly asymptomatic. Symptomatic cases largely belong to type 2, which is characterized by the presence of a 1-3 mm synchondrosis between the large accessory navicular and the native navicular. Chronic injury to the synchondrosis is considered to be a major cause of symptoms. In this case report, we describe an uncommon case of an avulsed type 2 accessory navicular, which was dislocated to the level of the medial malleolus. A plantar slip existed between the accessory and the native naviculars, which enabled the patient to perform an active inversion of the foot, but not a single heel raise. The collapse of the medial longitudinal arch progressed rapidly over 4 months prior to surgery, with an increased lateral hindfoot pain, suggesting an impingement due to the progression of hindfoot valgus. Surgical treatments, including plication of the ruptured spring ligament, excision of the accessory navicular, and transfer of the flexor digitorum longus tendon, were successful in improving the symptoms and flatfoot deformity. This case represents an uncommon subtype of symptomatic accessory navicular with complete avulsion and dislocation, presenting as a posterior tibial tendon dysfunction disorder and progressive flatfoot deformity

Clinical Characteristics and Pharmacokinetics Change of Long-Term Responders to Antiprogrammed Cell Death Protein 1 Inhibitor Among Patients With Advanced NSCLC

Introduction: Immune checkpoint inhibitors (ICIs) induce long-term, durable responses in patients with advanced NSCLC. Nevertheless, these responses are limited to a few patients, and most responders have disease progression. The purpose of this study was to determine the differences in clinical factors and blood drug concentrations between long-term responders (LTRs) and non-LTRs. Methods: We retrospectively analyzed consecutive patients with advanced NSCLC who received antiprogrammed cell death protein 1 (PD-1) inhibitor monotherapy (nivolumab) from December 22, 2015, to May 31, 2017. Patients who obtained a clinical benefit for more than 6 months were referred to as “responders”; among these, individuals who had a durable response for more than 2 years were defined as “LTRs.” Those with a clinical benefit for less than 2 years were defined as “non-LTRs.” Results: A total of 212 patients received anti–PD-1 inhibitor monotherapy. The responders accounted for 35% (75 of 212) of the patients. Of these, 29 (39%) were LTRs and 46 (61%) were non-LTRs. The overall response rate and median tumor shrinkage in the LTR group were significantly higher than those in the non-LTR group (76% versus 35%, p < 0.0001, and 66% versus 16%, p < 0.001, respectively). The groups had no significant difference in PD-L1 expression and serum drug concentration at 3- and 6-month post-treatment initiation. Conclusions: Significant tumor shrinkage was associated with a long-term response to an anti–PD-1 inhibitor. Nevertheless, the PD-L1 expression level and pharmacokinetic profile of the inhibitor could not be used to predict the durable response among the responders