Publications by authors named "Hao-Hua Wu"

37 Publications

Upper instrumented vertebra-femoral angle and correlation with proximal junctional kyphosis in adult spinal deformity.

Spine Deform 2021 Sep 3. Epub 2021 Sep 3.

Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Avenue, MU 320-W, San Francisco, CA, 94143, USA.

Introduction: Although matching lumbar lordosis (LL) with pelvic incidence (PI) is an important surgical goal for adult spinal deformity (ASD), there is concern that overcorrection may lead to proximal junctional kyphosis (PJK). We introduce the upper instrumented vertebra-femoral angle (UIVFA) as a measure of appropriate postoperative position in the setting of lower thoracic to pelvis surgical correction for patients with sagittal imbalance. We hypothesize that a more posterior UIV position in relation to the center of the femoral head is associated with an increased risk of PJK given compensatory hyperkyphosis above the UIV.

Methods: In this retrospective cohort study, adult patients undergoing lower thoracic (T9-T12) to pelvis correction of ASD with a minimum of 2-year follow-up were included. UIVFA was measured as the angle subtended by a line from the UIV centroid to the femoral head center to the vertical axis. Patients who developed PJK and those who did not were compared with preoperative and postoperative UIVFA as well as change between postoperative and preoperative UIVFA (deltaUIVFA).

Results: Of 119 patients included with an average 3.6-year follow-up, 51 (42.9%) had PJK and 24 (20.2%) had PJF. Patients with PJK had significantly higher postoperative UIVFA (12.6 ± 4.8° vs. 9.4 ± 6.6°, p = 0.04), deltaUIVFA (6.1 ± 7.6° vs. 2.1 ± 5.6°, p < 0.01), postoperative pelvic tilt (27.3 ± 9.2 vs. 23.3 ± 11, p = 0.04), postoperative lumbar lordosis (47.7 ± 13.9° vs. 42.4 ± 13.1, p = 0.04) and postoperative thoracic kyphosis (44.9 ± 13.2 vs. 31.6 ± 18.8) than patients without PJK. With multivariate logistic regression, postoperative UIVFA and deltaUIVFA were found to be independent risk factors for PJK (p < 0.05). DeltaUIVFA was found to be an independent risk factor for PJF (p < 0.05). A receiver operating characteristic (ROC) curve for UIVFA as a predictor for PJK was established with an area under the curve of 0.67 (95% CI 0.59-0.76). Per the Youden index, the optimal UIVFA cut-off value is 11.5 degrees.

Conclusion: The more posterior the UIV is from the femoral head center after lower thoracic to pelvis surgical correction for ASD, the more patients are at risk for PJK. The greater the magnitude of posterior translation of the UIV from the femoral head center from preop to postop, the greater the likelihood for PJF.
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http://dx.doi.org/10.1007/s43390-021-00408-1DOI Listing
September 2021

The accuracy of patient-reported weight prior to total joint arthroplasty and arthroscopy of the lower extremity.

Arch Orthop Trauma Surg 2021 Jul 31. Epub 2021 Jul 31.

Department of Orthopaedic Surgery, Center for Hip Preservation, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA.

Purpose: The accuracy of preoperative patient-reported weight was never evaluated in patients undergoing lower extremity procedures. The purpose of this study was to: (1) compare the disparity between patient-reported and measured weights in patients undergoing lower extremity total joint arthroplasty (LE-TJA) and arthroscopy; and (2) investigate the association between patient-specific factors (patient age, BMI, zip code, and psychiatric comorbidities) and the accuracy of patient-reported weight.

Methods: Preoperative self-reported weights were retrospectively compared to measured weights in 400 LE-TJA and 85 control arthroscopy patients. The difference between reported and measured weights was calculated. Additionally, the percent of accurate reporting within 0.5, 1, and 5 kg ranges of the measured weight was calculated. Outcomes were compared between surgical modalities as well as between patient-specific factors.

Results: There was low disparity (p = 0.838) between patient-reported and measured weights among LE-TJA (mean difference 0.18 ± 3.63 kg; p = 0.446) and that of arthroscopy (0.27 ± 4.08 kg; p = 0.129) patients. Additionally, LE-TJA patients were equally likely to report weights accurately within 0.5 kg of the measured weight (74% vs. 71.76%; p = 0.908). LE-TJA and arthroscopy patients had similar reporting accuracy within 1 and 5 kg of the measured weights (p > 0.05).

Conclusion: Preoperative patient-reported weights demonstrated acceptable accuracy in both LE-TJA and lower extremity arthroscopic orthopaedic patient populations making it a potentially reliable parameter of preoperative assessment.
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http://dx.doi.org/10.1007/s00402-021-04095-5DOI Listing
July 2021

Posterior Displacement of L1 May be a Risk Factor for Proximal Junctional Kyphosis After Adult Spinal Deformity Correction.

Global Spine J 2021 May 17:21925682211015651. Epub 2021 May 17.

Department of Neurosurgery, University of California San Francisco, USA.

Study Design: Retrospective cohort study.

Objective: Overcorrection in adult spinal deformity (ASD) surgery may lead to proximal junctional kyphosis (PJK) because of posterior spinal displacement. The aim of this paper is to determine if the L1 position relative to the gravity line (GL) is associated with PJK.

Methods: ASD patients fused from the lower thoracic spine to sacrum by 4 spine surgeons at our hospital were retrospectively studied. Lumbar-only and upper thoracic spine fusions were excluded. Spinopelvic parameters, the L1 plumb line (L1PL), L1 distance to the GL (L1-GL), and Roussouly type were measured.

Results: One hundred fourteen patients met inclusion criteria (63 patients with PJK, 51 without). Mean age and follow up was 65.51 and 3.39 years, respectively. There was no difference between the PJK and the non-PJK groups in baseline demographics, pre-operative and immediate post-operative pelvic incidence-lumbar lordosis mismatch, sagittal vertical axis, or coronal Cobb. The immediate postoperative L1-GL was -7.24 cm in PJK and -3.45 cm in non-PJK ( < 0.001), L1PL was 1.71 cm in PJK and 3.07 cm in non-PJK ( = 0.004), and PT (23.76° vs 18.90°, = 0.026) and TK (40.56° vs 31.39°, < 0.001) were larger in PJK than in non-PJK. After univariate and multivariate analyses, immediate postoperative TK and immediate postoperative L1-GL were independent risk factors for PJK without collinearity.

Conclusions: A dorsally displaced L1 relative to the GL was associated with an increased risk of PJK after ASD surgery. The postoperative L1-GL distance may be a factor to consider during ASD surgery.
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http://dx.doi.org/10.1177/21925682211015651DOI Listing
May 2021

Cost utility analysis of intramedullary nailing and skeletal traction treatment for patients with femoral shaft fractures in Malawi.

Acta Orthop 2021 Aug 24;92(4):436-442. Epub 2021 Mar 24.

Institute for Global Orthopedics and Traumatology, Orthopedic Trauma Institute, University of California San Francisco, San Francisco, CA, USA.

Background and purpose - In Malawi, both skeletal traction (ST) and intramedullary nailing (IMN) are used in the treatment of femoral shaft fractures, ST being the mainstay treatment. Previous studies have found that IMN has improved outcomes and is less expensive than ST. However, no cost-effectiveness analyses have yet compared IMN and ST in Malawi. We report the results of a cost-utility analysis (CUA) comparing treatment using either IMN or ST.Patients and methods - This was an economic evaluation study, where a CUA was done using a decision-tree model from the government healthcare payer and societal perspectives with an 1-year time horizon. We obtained EQ-5D-3L utility scores and probabilities from a prospective observational study assessing quality of life and function in 187 adult patients with femoral shaft fractures treated with either IMN or ST. The patients were followed up at 6 weeks, and 3, 6, and 12 months post-injury. Quality adjusted life years (QALYs) were calculated from utility scores using the area under the curve method. Direct treatment costs were obtained from a prospective micro costing study. Indirect costs included patient lost productivity, patient transportation, meals, and childcare costs associated with hospital stay and follow-up visits. Multiple sensitivity analyses assessed model uncertainty.Results - Total treatment costs were higher for ST ($1,349) compared with IMN ($1,122). QALYs were lower for ST than IMN, 0.71 (95% confidence interval [CI] 0.66-0.76) and 0.77 (CI 0.71-0.82) respectively. Based on lower cost and higher utility, IMN was the dominant strategy. IMN remained dominant in 94% of simulations. IMN would be less cost-effective than ST at a total procedure cost exceeding $880 from the payer's perspective, or $1,035 from the societal perspective.Interpretation - IMN was cost saving and more effective than ST in the treatment of adult femoral shaft fractures in Malawi, and may be an efficient use of limited healthcare resources.
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http://dx.doi.org/10.1080/17453674.2021.1897927DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8428269PMC
August 2021

A study protocol for a Pilot Masked, Randomized Controlled Trial Evaluating Locally-applied Gentamicin versus Saline in Open Tibia Fractures (pGO-Tibia) in Dar es Salaam, Tanzania.

Pilot Feasibility Stud 2021 Feb 10;7(1):47. Epub 2021 Feb 10.

Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA.

Background: Open tibia fractures are a major source of disability in low- and middle-income countries (LMICs) due to the high incidence of complications, particularly infection and chronic osteomyelitis. One proposed adjunctive measure to reduce infection is prophylactic local antibiotic delivery, which can achieve much higher concentrations at the surgical site than can safely be achieved with systemic administration. Animal studies and retrospective clinical studies support the use of gentamicin for this purpose, but no high-quality clinical trials have been conducted to date in high- or low-income settings.

Methods: We describe a protocol for a pilot study conducted in Dar es Salaam, Tanzania, to assess the feasibility of a single-center masked randomized controlled trial to compare the efficacy of locally applied gentamicin to placebo for the prevention of fracture-related infection in open tibial shaft fractures.

Discussion: The results of this study will inform the design and feasibility of a definitive trial to address the use of local gentamicin in open tibial fractures. If proven effective, local gentamicin would be a low-cost strategy to reduce complications and disability from open tibial fractures that could impact care in both high- and low-income countries.

Trial Registration: ClinicalTrials.gov, Registration # NCT03559400 ; Registered June 18, 2018.
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http://dx.doi.org/10.1186/s40814-021-00766-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874655PMC
February 2021

Reoperation and Mortality Rates Following Elective 1 to 2 Level Lumbar Fusion: A Large State Database Analysis.

Global Spine J 2021 Jan 21:2192568220986148. Epub 2021 Jan 21.

Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA.

Study Design: Retrospective cohort.

Objective: Reoperation to lumbar spinal fusion creates significant burden on patient quality of life and healthcare costs. We assessed rates, etiologies, and risk factors for reoperation following elective 1 to 2 level lumbar fusion.

Methods: Patients undergoing elective 1 to 2 level lumbar fusion were identified using the Health Care Utilization Project (HCUP) state inpatient databases from Florida and California. Patients were tracked for 5 years for any subsequent lumbar fusion. Cox proportional hazard analyses for reoperation were assessed using the following covariates: fusion approach type, age, race, Charlson comormidity index, gender, and length of stay. Distribution of etiologies for reoperation was then assessed.

Results: 71, 456 patients receiving elective 1 to 2 level lumbar fusion were included. A 5-year reoperation rate of 13.53% and mortality rate of 2.22% was seen. Combined anterior-posterior approaches (HR = 0.904, p < 0.05) and TLIF (HR = 0.867, p < 0.001) were associated with reduced risk of reoperation compared to stand-alone anterior approaches and non-TLIF posterior approaches. Age, gender, and number of comorbidities were not associated with risk of reoperation. From 1 to 5 years, degenerative disease rose from 43.50% to 50.31% of reoperations; mechanical failure decreased from 37.65% to 29.77%.

Conclusions: TLIF and combined anterior-posterior approaches for 1 to 2 level lumbar fusion are associated with the lowest rate of reoperation. Number of comorbidities and age are not predictive of reoperation. Primary etiologies leading to reoperation were degenerative disease and mechanical failure. Mortality rate is not increased from baseline following 1 to 2 level lumbar fusion.
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http://dx.doi.org/10.1177/2192568220986148DOI Listing
January 2021

Return to Work After Shoulder Replacement for Glenohumeral Osteoarthritis Is Similar When Hemiarthroplasty Is Compared to Total Shoulder Arthroplasty.

HSS J 2020 Oct 17;16(3):212-217. Epub 2019 Jun 17.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY USA.

Background: Return to work after shoulder arthroplasty for glenohumeral osteoarthritis (OA) is an important consideration for an aging workforce.

Questions/purposes: The aim of this study was to compare the shoulder function, pain levels, and rate of return to work in patients treated with anatomic total shoulder arthroplasty (aTSA) versus humeral hemiarthroplasty (HHA).

Methods: A retrospective review of consecutive HHA patients was performed of our institution's shoulder arthroplasty registry. Inclusion criteria were pre-operative diagnosis of end-stage OA and more than 2 years' follow-up. HHA patients were statistically matched to aTSA patients and then screened for pre-operative work status; 26 HHA and 23 aTSA patients worked before surgery. There was no difference in average age (HHA, 62.4 years; aTSA, 61.7 years) or follow-up (HHA, 67.5 months; aTSA, 66.9 months).

Results: Average American Shoulder and Elbow Surgeons (ASES) scores (HHA, 37.6 to 70.3; aTSA, 35.6 to 80.1) and visual analogue scale (VAS) for pain scores (HHA, 6.1 to 2.3; aTSA, 6.5 to 0.6) improved in both groups. However, HHA patients had worse final VAS scores, and aTSA patients were more satisfied (100% vs 77%); 61.5% of HHA patients returned to work post-operatively versus 87.0% of aTSA patients. There was no difference in time to return to work (HHA, 1.9 ± 2.3 months; aTSA, 1.3 ± 1.0 months).

Conclusion: Patients with shoulder OA undergoing aTSA have higher rates of return to work, function, and satisfaction than those undergoing HHA.
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http://dx.doi.org/10.1007/s11420-019-09692-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534888PMC
October 2020

The association between lower Hounsfield units of the upper instrumented vertebra and proximal junctional kyphosis in adult spinal deformity surgery with a minimum 2-year follow-up.

Neurosurg Focus 2020 08;49(2):E7

Departments of1Neurological Surgery and.

Objective: Patients undergoing long-segment fusions from the lower thoracic (LT) spine to the sacrum for adult spinal deformity (ASD) correction are at risk for proximal junctional kyphosis (PJK). One mechanism of PJK is fracture of the upper instrumented vertebra (UIV) or higher (UIV+1), which may be related to bone mineral density (BMD). Because Hounsfield units (HUs) on CT correlate with BMD, the authors evaluated whether HU values were correlated with PJK after long fusions for ASD.

Methods: The authors performed a retrospective study of patients older than 50 years who had undergone ASD correction from the LT spine to the sacrum in the period from October 2007 to January 2018 and had a minimum 2-year follow-up. Demographic and spinopelvic parameters were measured. HU values were measured on preoperative CT at the UIV, UIV+1, and UIV+2 (2 levels above the UIV) levels and were assessed for correlations with PJK.

Results: The records of 127 patients were reviewed. Fifty-four patients (19 males and 35 females) with a mean age of 64.91 years and mean follow-up of 3.19 years met the study inclusion criteria; there were 29 patients with PJK and 25 patients without. There was no statistically significant difference in demographics or follow-up between these two groups. Neither was there a difference between the groups with regard to postoperative pelvic incidence (PI), sacral slope (SS), lumbar lordosis (LL), PI minus LL (PI-LL), thoracic kyphosis (TK), or sagittal vertical axis (SVA; all p > 0.05). Postoperative pelvic tilt (p = 0.003) and T1 pelvic angle (p = 0.014) were significantly higher in patients with PJK than in those without. Preoperative HUs at UIV, UIV+1, and UIV+2 were 120.41, 124.52, and 129.28 in the patients with PJK, respectively, and 152.80, 155.96, and 160.00 in the patients without PJK, respectively (p = 0.011, 0.02, and 0.018). Three receiver operating characteristic (ROC) curves for preoperative HU values at the UIV, UIV+1, and UIV+2 as a predictor for PJK were established, with areas under the ROC curve of 0.710 (95% CI 0.574-0.847), 0.679 (95% CI 0.536-0.821), and 0.681 (95% CI 0.539-0.824), respectively. The optimal HU value by Youden index was 104 HU at the UIV (sensitivity 0.840, specificity 0.517), 113 HU at the UIV+1 (sensitivity 0.720, specificity 0.517), and 110 HU at the UIV+2 (sensitivity 0.880, specificity 0.448).

Conclusions: In patients undergoing long-segment fusions from the LT spine to the sacrum for ASD, PJK was associated with lower HU values on CT at the UIV, UIV+1, and UIV+2. The measurement of HU values on preoperative CTs may be a useful adjunct for ASD surgery planning.
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http://dx.doi.org/10.3171/2020.5.FOCUS20192DOI Listing
August 2020

Outcome at 1 year in patients with femoral shaft fractures treated with intramedullary nailing or skeletal traction in a low-income country: a prospective observational study of 187 patients in Malawi.

Acta Orthop 2020 12 23;91(6):724-731. Epub 2020 Jul 23.

Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.

Background and purpose - Intramedullary nailing (IMN) is underutilized in low-income countries (LICs) where skeletal traction (ST) remains the standard of care for femoral shaft fractures. This prospective study compared patient-reported quality of life and functional status after femoral shaft fractures treated with IMN or ST in Malawi. Patients and methods - Adult patients with femoral shaft fractures managed by IMN or ST were enrolled prospectively from 6 hospitals. Quality of life and functional status were assessed using EQ-5D-3L, and the Short Musculoskeletal Function Assessment (SMFA) respectively. Patients were followed up at 6 weeks, 3, 6, and 12 months post-injury. Results - Of 248 patients enrolled (85 IMN, 163 ST), 187 (75%) completed 1-year follow-up (55 IMN, 132 ST). 1 of 55 IMN cases had nonunion compared with 40 of 132 ST cases that failed treatment and converted to IMN (p < 0.001). Quality of life and SMFA Functional Index Scores were better for IMN than ST at 6 weeks, 3 and 6 months, but not at 1 year. At 6 months, 24 of 51 patients in the ST group had returned to work, compared with 26 of 37 in the IMN group (p = 0.02). Interpretation - Treatment with IMN improved early quality of life and function and allowed patients to return to work earlier compared with treatment with ST. Approximately one-third of patients treated with ST failed treatment and were converted to IMN.
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http://dx.doi.org/10.1080/17453674.2020.1794430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8023961PMC
December 2020

Return to Work Following Tibial Tubercle Osteotomy for Patellofemoral Osteoarthritis and Pain.

Cartilage 2020 Apr 22:1947603520916544. Epub 2020 Apr 22.

Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA.

Purpose: To evaluate the ability of patients to return to work following anteromedialization (AMZ) tibial tubercle osteotomy (TTO) due to isolated patellofemoral osteoarthritis or pain.

Methods: Consecutive patients undergoing AMZ TTO were reviewed retrospectively at a minimum of 1 year postoperatively. Patients completed a subjective work questionnaire, a visual analog scale for pain, as well as a Kujala questionnaire and satisfaction questionnaire.

Results: Fifty-seven patients (61 knees; average age: 32.7 ± 9.6 years) were contacted at an average follow-up of 4.86 ± 2.84 years postoperatively. The preoperative Kujala score improved from 55.7 ± 17.8 to 84.6 ± 15.8 at final follow-up ( < 0.001). Thirty-seven patients (64.9%) were employed within 3 years prior to surgery and 34 patients (91.9%) were able to return to work by 2.8 ± 2.6 months postoperatively. However, only 27 patients (73.0%) of patients were able to return to the same level of occupational intensity. Patients who held sedentary, light-, medium-, or high-intensity occupations were able to return to work at a rate of 100.0%, 93.8%, 77.8%, and 100.0% by 2.2 months, 3.0 months, 3.1 months, and 4.0 months, postoperatively. No patients underwent revision TTO or conversion to arthroplasty by the time of final follow-up.

Conclusion: In patients with focal patellofemoral osteoarthritis or pain, AMZ TTO provides a high rate of return to work (91.9%) by 2.8 ± 2.6 months postoperatively. Patients with higher intensity occupations may take longer to return to work than those with less physically demanding occupations.

Level Of Evidence: III.
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http://dx.doi.org/10.1177/1947603520916544DOI Listing
April 2020

Wearable activity sensors and early pain after total joint arthroplasty.

Arthroplast Today 2020 Mar 6;6(1):68-70. Epub 2020 Mar 6.

University of California San Francisco, San Francisco, CA, USA.

A prospective observational cohort of 20 primary total hip arthroplasty (n = 12) and total knee arthroplasty (n = 8) patients (mean age: 63 ± 6 years) was passively monitored with a consumer-level wearable activity sensor before and 6 weeks after surgery. Patients were clustered by minimal change or decreased activity using sensor data. Decreased postoperative activity was associated with greater pain reduction (-5.5 vs -2.0,  = .03). All patients surpassed minimal clinical benefit thresholds of total joint arthroplasty (TJA) (Hip Disability and Osteoarthritis Score Junior 30.5 vs 20.8,  = .23; Knee Injury and Osteoarthritis Outcome Score Junior 23.3 vs 18.2,  = .77) within 6 weeks. Patients who objectively "take it easy" after TJA may experience less pain with no difference in early subjective outcome. Remote, passive analysis of outpatient wearable sensor data may permit real-time detection of early problems after TJA.
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http://dx.doi.org/10.1016/j.artd.2019.12.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7083735PMC
March 2020

Prophylactic surgical drainage is associated with increased infection following intramedullary nailing of diaphyseal long bone fractures: A prospective cohort study in Nigeria.

SICOT J 2020 18;6. Epub 2020 Feb 18.

Consultant Orthopaedic Surgeon, University of Calabar Teaching Hospital, Court Rd, Duke Town, Calabar, Cross River State, Nigeria.

Introduction: Prophylactic surgical drains are commonly used in Nigeria following intramedullary nailing (IMN) of long bone diaphyseal fractures. However, evidence in the literature suggests that drains do not confer any benefit and predispose clean wounds to infection. This study compares outcomes between patients treated with and without prophylactic surgical drainage following diaphyseal long bone fractures treated with IMN.

Methods: A prospective cohort study with randomization was conducted at a tertiary referral center in Enugu, Nigeria. Investigators included skeletally mature patients with diaphyseal long bone (femur, tibia, humerus) fractures treated with SIGN IMN. Patients followed-up at 5, 14, and 30 days post-operatively. The primary outcome was surgical site infection (SSI) rate. Secondary outcomes included post-operative pain at 6 and 12 h, need for blood transfusion, wound characteristics (swelling, ecchymosis, and gaping), need for dressing changes, and length of hospital stay.

Results: Of the enrolled patients, 76 (96%) of 79 completed 30-day follow-up. SSI rate was associated with patients who received a prophylactic drain versus those who did not (23.7% vs. 10.5%, p = 0.007). There were no significant differences in transfusion need (p = 0.22), wound swelling (p = 0.74), wound ecchymosis (p = 1.00), wound gaping (p = 1.00), dressing change need (p = 0.31), post-operative pain at 6 h (p = 0.25) or 12 h (p = 0.57), or length of stay (p = 0.95).

Discussion: Surgical drain placement following IMN of diaphyseal long bone fractures is associated with a significantly higher risk of SSI. Reducing surgical drain use following orthopaedic injuries in lower resource settings may translate to reduced infection rates.
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http://dx.doi.org/10.1051/sicotj/2020003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7027394PMC
February 2020

Validation of Chichewa Short Musculoskeletal Function Assessment (SMFA) questionnaire: A cross-sectional study.

Malawi Med J 2019 03;31(1):65-70

Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway. Department of Clinical Sciences, University of Bergen, Bergen, Norway.

Background: The Short Musculoskeletal Function Assessment (SMFA) tool measures function and quality of life in patients with musculoskeletal conditions.

Objective: This study aimed to translate and adapt culturally the SMFA into and assess its clinimetric properties.

Methods: The translated version was administered to 53 patients with musculoskeletal disorders. To assess repeatability, an additional 20 patients answered the questionnaire twice over a time interval of two weeks. Internal consistency, floor and ceiling effects, and repeatability were tested; construct validity was assessed with the World Health Organization Quality of Life Assessment tool (WHOQOL-BREF).

Results: There was good internal consistency for both Dysfunction and Bothersome indices (Cronbach's alpha 0.90) and good construct validity between both indices with the WHOQOL-BREF. Pearson's correlation coefficient and intraclass correlation coefficient (ICC) for repeatability for the Dysfunction Index were 0.941 and 0.922 (95% CI: 0.772, 0.971) respectively, and 0.877 and 0.851 (95% CI: 0.629, 0.941) for the Bothersome Index respectively.

Conclusion: The translated SMFA is a valid tool for populations that speak the language.
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http://dx.doi.org/10.4314/mmj.v31i1.11DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6526350PMC
March 2019

Development of Squat-and-Smile Test as Proxy for Femoral Shaft Fracture-Healing in Patients in Dar es Salaam, Tanzania.

J Bone Joint Surg Am 2019 Feb;101(4):353-359

University of California San Francisco, San Francisco, California.

Background: There are few validated instruments that serve as a proxy for fracture-healing after lower-extremity trauma in low-resource settings. The squat-and-smile test (S&S) has been under development by SIGN (Surgical Implant Generation Network) Fracture Care International to monitor outcomes of lower-extremity long-bone fractures after intramedullary nailing in resource-limited settings. The goals of this study were to develop and identify domains of the S&S test.

Methods: The S&S domains were developed through an iterative process, and consensus was achieved regarding 3: squat depth, support needed to squat, and facial expression. Adult patients with an OTA/AO type-32 femoral shaft fracture were included in this retrospective study and had the S&S administered at 6 weeks and 3, 6, and 12 months postoperatively. Two authors independently assessed photographs of the patients performing the S&S. S&S domains were correlated with the EuroQol 5-Dimensions (EQ-5D) index score, and comparisons were made between S&S domains and reoperation status. Interrater and test-retest reliability was assessed using the kappa statistic. Sensitivity and specificity analyses were performed.

Results: Six hundred and nine S&S images were evaluated for 231 patients. Each domain improved over time and correlated positively with EQ-5D scores (p < 0.05). Squat depth and support needed to squat correlated with the need for a reoperation (p ≤ 0.01), and both had high specificity (0.95 and 0.97, respectively) for ruling out the need for a reoperation at 1 year. All 3 domains had high test-retest reliability (κ = 0.95, 0.92, and 0.96). Squat depth and need for support also had strong interrater reliability (κ = 0.75 and 0.78).

Conclusions: The S&S is a potential tool for monitoring clinical and functional outcome of femoral shaft fractures in low-resource settings. Our data support the binary assessment of squat depth and need for support, but not facial expression, as a proxy for fracture-healing. Future prospective studies in external populations are warranted to evaluate the validity, reliability, and responsiveness of the S&S.

Clinical Relevance: The S&S provides a valuable proxy for femoral shaft fracture assessment for middle to low-income countries because it is locally relevant (based on squatting), it is easy to administer, and assessment can be performed remotely via mobile telephone or text messaging.
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http://dx.doi.org/10.2106/JBJS.18.00387DOI Listing
February 2019

The extent of pediatric orthopaedic research in low- and middle-income countries and the impact of academic collaboration on research quality: a scoping review.

Pediatr Surg Int 2019 Mar 9;35(3):397-411. Epub 2018 Nov 9.

Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA.

Introduction: This review aims to (1) assess the breadth of pediatric orthopaedic research in low- and middle-income countries (LMICs) and (2) determine the impact of academic collaboration (an LMIC and a non-LMIC investigator) in published LMIC research.

Methods: Pediatric orthopaedic clinical studies conducted in LMICs from 2004 to 2014 were extracted from Embase, Cochrane, and Pubmed databases. Of 22,714 searched studies, 129 met inclusion criteria.

Results: 85% generated low-quality evidence (level IV or lower). 21% were collaborative, and these were more likely than non-collaborative papers to generate level III evidence or higher (25% vs 13%, p = 0.141).

Discussion: Pediatric orthopaedic research produced by LMICs rarely achieves level I-III evidence, but collaborative studies are associated with higher levels of evidence.

Level Of Evidence: N/A.
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http://dx.doi.org/10.1007/s00383-018-4412-4DOI Listing
March 2019

Developing Research to Change Policy: Design of a Multicenter Cost-Effectiveness Analysis Comparing Intramedullary Nailing to Skeletal Traction in Malawi.

J Orthop Trauma 2018 Oct;32 Suppl 7:S52-S57

Beit Cure International, Blantyre, Malawi.

Introduction: The purpose of our study is to prospectively evaluate the cost effectiveness of intramedullary nailing compared with skeletal traction in a resource-limited setting where traction remains the most common definitive treatment.

Methods: This multicenter, prospective multicenter investigation was conducted in Malawi at 2 central hospitals and 3 district hospitals. The project was divided into phases. In phase 1, the EuroQol-5D and SMFA were translated and validated in Chichewa. In phase 2, adult patents with OTA/AO 32 femur shaft fractures were prospectively enrolled, and a comparison of quality of life and functional status was made. In phase 3, a cost-effectiveness analysis was performed between those treated with intramedullary nail and those treated with skeletal traction.

Conclusion: This study serves as an example of an economic study in orthopaedic surgery conducted in a resource-poor environment through academic collaboration.
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http://dx.doi.org/10.1097/BOT.0000000000001299DOI Listing
October 2018

Orthopaedic Trauma in the Developing World: Where Are the Gaps in Research and What Can Be Done?

J Orthop Trauma 2018 Oct;32 Suppl 7:S43-S46

Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA.

Purpose: There are an estimated 1.2 million deaths from road traffic injuries annually, disproportionately affecting patients in low-resource settings. The purpose of this scoping review is to identify knowledge gaps in global orthopaedic trauma in an effort to help prioritize future research.

Methods: Using the 6-stage Arksey and O'Malley framework for conducting a scoping review, orthopaedic trauma literature was reviewed over a ten-year period from 2004 to 2014. Studies from low-resource settings were included and categorized by geographic location, anatomic region, study type, and level of evidence.

Results: Of 548 included studies, 51.4% were from low- and middle-income countries in South Asia and 33.7% were from sub-Saharan Africa. Therapeutic (53.3%), epidemiologic (26.4%), and qualitative (8.9%) studies were most common. Only 10.2% of the studies were considered high level of evidence, whereas the vast majority (89.8%) was level 3 or below. Overall, lower extremity injuries were much more frequently represented in the literature compared with upper extremity injuries (233 vs. 78). Pelvic and acetabular fractures were the least studied anatomic region of the lower extremity (3.4%).

Conclusions: Our study identified a lack of cost-effectiveness analyses pertaining to injury and intervention, paucity of high-quality research, and under-representation of pelvic, acetabular, and upper extremity injuries. Improved and prioritized research in low- and middle-income countries may help optimize care and inform policy makers of how to reduce the global burden of musculoskeletal trauma.
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http://dx.doi.org/10.1097/BOT.0000000000001293DOI Listing
October 2018

Can a 2-Day Course Teach Orthopaedic Surgeons Rotational Flap Procedures? An Evaluation of Data From the Nepal SMART Course Over 2 years.

J Orthop Trauma 2018 Oct;32 Suppl 7:S38-S42

Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA.

Introduction: Traumatic lower extremity injuries requiring multidisciplinary treatment pose a challenge in low- and middle-income countries, where access to specialists may be limited. The surgical management and reconstructive training (SMART) course teaches orthopaedic surgeons muscle and fasciocutaneous flap procedures to address this scarcity. The purpose of this study is to assess the effectiveness of the SMART course in improving competency and comfort in performing common lower extremity flap procedures among participants.

Methods: Sixty-four orthopaedic surgeons from different regions of Nepal and Bhutan participated in the Nepal SMART course in 2016 and 2017. A competency test-consisting of questions from US in-training plastic and orthopaedic surgery examinations-was administered to attendees before and after the course. Thirty-two participants from 2016 were asked to rate their comfort level in performing flap procedures both pre- and postcourse.

Results: Overall competency test scores, as well as scores in the plastic surgery section, increased significantly after the course (P < 0.01). The precourse competency test scores were higher in 2016 compared with 2017 (P = 0.02). There was a higher increase in overall competency test scores after the course in 2016 compared with 2017 (P = 0.03). The procedure comfort levels reported by attendees increased for all flaps (P < 0.01).

Conclusions: These results demonstrate the ability of the SMART course to improve the competency and comfort levels of orthopaedic surgeons in performing common lower extremity flap procedures. Despite the differences in years in practice and previous experience in performing flaps, the course yielded significantly better results in 2017 compared with 2016, showing that the implementation of the course has been improving.
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http://dx.doi.org/10.1097/BOT.0000000000001298DOI Listing
October 2018

Clinical Research Course for International Orthopaedic Surgeons: 2-Year Outcomes.

J Orthop Trauma 2018 Oct;32 Suppl 7:S35-S37

Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA.

Background: Although orthopaedic trauma occurs at higher rates in low- and middle-income countries (LMICs), most research on this topic is conducted in high-resource settings. Few initiatives exist to promote local research in LMICs. Investigators created the Institute for Global Orthopaedics and Traumatology (IGOT) International Research Symposium to promote local research initiatives by surgeons practicing in low-resource environments. The purpose of this study is to determine the efficacy of this symposium in teaching orthopaedic surgeons practicing in LMICs how to conduct clinical research.

Methods: In this prospective observational study, orthopaedic surgeons from LMICs with no formal research training were recruited to attend the 1-day IGOT International Research Symposium in San Francisco. A survey was administered immediately before and after the symposium to inquire about the participants' confidence in different aspects related to research using a 1-5 Likert scale. A second survey, conducted 2 years later, recorded the attendees' research productivity after the workshop.

Results: Forty-three participants representing 10 different LMICs from Africa and Asia attended the 2013 course. At 2 year postcourse, participants reported starting 25 research projects, authored 7 "accepted or published manuscripts" (vs. 1 before the course; P < 0.01), and were selected for 12 podium or poster presentations (vs. 3 before the course; P < 0.01). Two research symposium attendees received "Top International Forum Paper" at the 2015 Orthopaedic Trauma Association Annual Meeting.

Discussion: A 1-day research course resulted in increased participant confidence in conducting research. This was associated with greater research productivity by participants 2 years later. These results suggest that the IGOT International Research Symposium can improve the number of initiated research projects by surgeons in LMICs.
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http://dx.doi.org/10.1097/BOT.0000000000001292DOI Listing
October 2018

Protocols for Management of Underserved Patients Undergoing Arthroplasty: A National Survey of Safety Net Hospitals.

Arch Bone Jt Surg 2018 Jul;6(4):294-300

University of Rochester School of Medicine & Dentistry, Rochester, USA.

Background: Although it has been shown that perioperative protocols enhance arthroplasty care and safety, it is not known how prevalent their use is in safety net hospitals, which operate with a mandate to treat the poor and underserved. Understanding the elements currently included in standard perioperative arthroplasty protocols at various institutions may help guide future interventions and policy aimed at improving underserved patients' outcomes.

Methods: In this cross-sectional study, safety net hospitals were asked to complete a survey over the phone, via email or in person regarding existence and elements of perioperative management protocols for total hip arthroplasty (THA) and total knee arthroplasty (TKA). Implementation barriers were also addressed. Specifically, survey questions sought to determine the total yearly number of arthroplasty procedures performed at each institution and better understand, among other elements, the following: presence of preoperative pain management protocols, inpatient care pathways, use of social workers and involvement of physical therapy services. Descriptive statistics were calculated and reported.

Results: Over 90% of safety net hospitals performing arthroplasty utilized regional anesthetic techniques, inpatient clinical care pathways and inpatient physical therapy. However, 16.7%, 20.0%, 23.3% and 73% lacked social services, anesthesia preoperative clinics, inpatient pain management protocols and preoperative sobriety pathways, respectively.

Conclusion: Barriers to receiving arthroplasty care included lack of qualified surgical personnel and concerns about surgical risk in vulnerable patient populations. These findings suggest that further effort is warranted to expand and improve arthroplasty care for the underserved to ensure safety and high quality outcomes.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6110425PMC
July 2018

The Cost of Intramedullary Nailing Versus Skeletal Traction for Treatment of Femoral Shaft Fractures in Malawi: A Prospective Economic Analysis.

World J Surg 2019 01;43(1):87-95

Beit CURE International Hospital, Blantyre, Malawi.

Background: In many low- and middle-income countries, non-surgical management of femoral shaft fractures using skeletal traction is common because intramedullary (IM) nailing is perceived to be expensive. This study assessed the cost of IM nailing and skeletal traction for treatment of femoral shaft fractures in Malawi.

Methods: We used micro-costing methods to quantify the costs associated with IM nailing and skeletal traction. Adult patients who sustained an isolated closed femur shaft fracture and managed at Queen Elizabeth Central Hospital in Malawi were followed from admission to discharge. Resource utilization and time data were collected through direct observation. Costs were quantified for procedures and ward personnel, medications, investigations, surgical implants, disposable supplies, procedures instruments and overhead.

Results: We followed 38 nailing and 27 traction patients admitted between April 2016 and November 2017. Nailing patient's average length of stay (LOS) was 36.35 days (SD 21.19), compared to 61 (SD 18.16) for traction (p = 0.0003). The total cost per patient was $596.97 ($168.81) for nailing and $678.02 (SD $144.25) for traction (p = 0.02). Major cost drivers were ward personnel and overhead; both are directly proportional to LOS. Converting patients from traction to nailing is cost-saving up to day 23 post-admission.

Conclusion: Savings from IM nailing as compared with skeletal traction were achieved by shortened LOS. Although this study did not assess the effectiveness of either intervention, the literature suggests that traction carries a higher rate of complications than nailing. Investment in IM nailing capacity may yield substantial net savings to health systems, as well as improved clinical outcomes.
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http://dx.doi.org/10.1007/s00268-018-4750-3DOI Listing
January 2019

Primary Hip and Knee Arthroplasty in a Safety Net Hospital: Substance Abuse and Other Factors Affecting Short-term Complications.

J Arthroplasty 2018 09 9;33(9):3003-3008. Epub 2018 May 9.

Institute for Global Orthopaedics and Traumatology, Zuckerberg San Francisco General Hospital, Department of Orthopaedic Surgery, University of California, San Francisco, California.

Background: Arthroplasty outcomes and patient risk factors have not been studied in detail in safety net hospital settings. This study examines the relationship between selected risk factors and short-term complications in such a population, including a large subgroup with treated substance abuse.

Methods: This retrospective cohort study contains 486 consecutive patients after primary hip and knee arthroplasty. One hundred three of these had a history of substance abuse and completed a 1-year sobriety pathway preoperatively. Primary outcomes included the presence of any complication, deep infection, and reoperation. Bivariable analyses were used to compare outcomes with demographic and health risk factors. A multivariate analysis was performed to identify independent risk factors.

Results: Adverse outcomes were more common in patients with higher rates of substance abuse, mental illness, and infection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV). Substance abuse alone was not an independent risk factor for the occurrence of complications, but infections with HIV and HCV were. In the substance abuse subgroup, with its higher prevalence of risk factors, complications were more frequent (31.1% vs 16.4%, P = .0009), and, in particular, deep infections (5.8% vs 1.8%, P = .0256).

Conclusions: Specific risk factors were associated with short-term complications in safety net arthroplasty patients. Despite having completed a preoperative sobriety pathway, substance abuse patients had more complications than did others. However, substance abuse alone was not an independent risk factor for adverse surgical outcomes. Other factors, notably HCV and HIV infection that were more common in patients with substance abuse, were most closely associated with adverse outcomes.
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http://dx.doi.org/10.1016/j.arth.2018.05.007DOI Listing
September 2018

Return to Work After Anatomic Total Shoulder Arthroplasty for Patients 55 Years and Younger at Average 5-Year Follow-up.

Orthopedics 2018 May 19;41(3):e310-e315. Epub 2018 Feb 19.

As the number of anatomic total shoulder arthroplasties performed on younger patients continues to grow, return to work after surgery becomes increasingly important. The purpose of this study was to evaluate the ability of anatomic total shoulder arthroplasty to return patients 55 years or younger to work postoperatively. A retrospective review was performed of consecutive anatomic total shoulder arthroplasty patients. Inclusion criteria were age 55 years or younger at surgery, greater than 2 years of follow-up, and employment within 3 years of surgery. Employment was stratified by intensity of work (sedentary, light, moderate, or heavy). Return to work status and time out of work were also evaluated. Fifty-two patients worked before surgery. Average age was 48.4 years, with average follow-up of 5.4 years. Seventy-three percent were male, and average body mass index was 28.0 kg/m. Average visual analog scale score improved from 5.5 to 0.9 (P<.0001) and American Shoulder and Elbow Society score improved from 39.9 to 88.3 (P<.0001). Forty-eight (92%) of 52 returned to work postoperatively after an average of 2.1 months. When stratified by intensity, all patients with sedentary, light, or moderate work returned, whereas 64% returned to heavy work (P<.01). Eighty-seven percent were satisfied to very satisfied after surgery. In summary, most patients (92%) who undergo anatomic total shoulder arthroplasty at 55 years or younger return to work, on average, 2.1 months after surgery. [Orthopedics. 2018; 41(3):e310-e315.].
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http://dx.doi.org/10.3928/01477447-20180213-08DOI Listing
May 2018

Return to Sports After Tibial Tubercle Osteotomy for Patellofemoral Pain and Osteoarthritis.

Arthroscopy 2018 04 9;34(4):1022-1029. Epub 2017 Dec 9.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, U.S.A.

Purpose: To determine the rate of return to sports and clinical outcomes after anteromedialization (AMZ) tibial tubercle osteotomy (TTO) for patients with patellofemoral pain and/or osteoarthritis.

Methods: This study is a retrospective case series of consecutive patients who underwent unilateral or staged bilateral AMZ TTO for a primary diagnosis of patellofemoral pain or arthritis. Included were all patients with minimum 1-year follow-up. The indication for surgery was failure of at least 6 months of nonoperative treatment. Simultaneous tubercle distalization or proximal-medial soft-tissue procedures were excluded; however, prior patellar instability procedures did not prohibit inclusion if there was no recurrence. A diagnostic arthroscopy was performed to evaluate the cartilage surfaces; AMZ TTO was performed by use of a freehand technique and two 4.5-mm fully threaded screws for fixation. A gradual return to activities was permitted at 6 months; however, contact sports were prohibited until 9 months postoperatively. Patients were evaluated retrospectively for participation in sports using a questionnaire about the level of participation, return to sporting activities, and Kujala score. Statistical analysis included 1-way analysis of variance and χ or Fisher exact and paired t tests.

Results: Forty-eight patients played sports within 3 years before surgery. The majority were female patients (84.2%). The average age at surgery was 29.6 years, with an average follow-up period of 4.6 years. The average Kujala score improved from 51.2 to 82.6 (P < .0001); the average pain score improved from 4.1 to 1.8 (P < .001). Of the patients, 83.3% returned to at least 1 sport on average 7.8 months postoperatively. Of these, 77.5% believed they returned to sports at the same level or a higher level.

Conclusions: Patients undergoing AMZ TTO for patellofemoral pain or arthritis had an 83.3% rate of return to 1 or more sporting activities at an average of 7.8 months after surgery, with many patients returning at the same level or a higher level of intensity compared with their preoperative state.

Level Of Evidence: Level IV, retrospective case series.
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http://dx.doi.org/10.1016/j.arthro.2017.09.021DOI Listing
April 2018

The impact of antegrade intramedullary nailing start site using the SIGN nail in proximal femoral fractures: A prospective cohort study.

Injury 2018 Feb 16;49(2):323-327. Epub 2017 Nov 16.

Institute for Global Orthopedics and Traumatology, University of California San Francisco, San Francisco, CA, United States.

Introduction: In many low and middle-income countries (LMICs) SIGN nail is commonly used for antegrade femoral intramedullary (IM) nailing, using a start site either at the tip of the greater trochanter or piriformis fossa. While a correct start site is considered an essential technical step; few studies have evaluated the impact of using an erroneous start site. This is particularly relevant in settings with limited access to fluoroscopy to aid in creating a nail entry point. The purpose of this study was to evaluate the impact of antegrade SIGN IM nailing start site on radiographic alignment and health-related quality of life.

Methods: In this prospective cohort study, adult patients with proximal femur fractures (OTA 32, subtrochanteric zone) treated with antegrade IM SIGN nail at Muhimbili Orthopaedic Institute (MOI), Dar es Salaam, Tanzania were enrolled. Start site was determined on the immediate postoperative X-ray and was graded on a continuous scale based on distance of the IM nail center from the greater trochanteric tip. The primary outcome measurement was coronal alignment on the post-operative x-ray. The secondary outcomes were reoperation rates, RUST scores and EQ5D scores at one year follow-up.

Results: Seventy-nine patients were enrolled. 50 of them (63.3%) had complete data at 1year and were included in the final data analysis. Of the fifty patients, nine (18%) had IM nails placed laterally, 26 (52%) medially and 15 (30%) directly over the tip of the greater trochanter. Compared to a start site at the tip or medial to the greater trochanter, a lateral start site was 9 times more likely to result in a varus malalignment (95% CI: 1.42-57.70, p=0.021).

Conclusions: Lateral start site was associated with varus malalignment. Although lateral start site was not significantly associated with reoperation, varus deformity was associated with higher reoperation rates. Surgeons should consider avoiding a start site lateral to the tip of the greater trochanter or allow the nail to rotate to avoid malalignment when using the SIGN nail for proximal femur fractures.
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http://dx.doi.org/10.1016/j.injury.2017.11.020DOI Listing
February 2018

Validation and reliability of the Chichewa translation of the EQ-5D quality of life questionnaire in adults with orthopaedic injuries in Malawi.

Malawi Med J 2017 06;29(2):84-88

Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA.

Background: The EQ-5D is a standardised instrument that measures health-related quality-of-life and explores cost-effectiveness of treatments. Malawi is a low-resource country that would benefit from assessment of quality-of-life among individuals living with chronic conditions. Chichewa is the official native language of Malawi. The Chichewa version of the EQ-5D-3L developed by EuroQoL group has not been validated with Chichewa speakers. The purpose of this study was to evaluate the clinimetric properties of the Chichewa EQ-5D-3L.

Methods: Patients with orthopaedic conditions were recruited in the outpatient orthopaedic clinics and wards at Queen Elizabeth Central Hospital, Blantyre, Malawi. Fifty-three patients with various musculoskeletal problems were administered the Chichewa EQ-5D-3L and World Health Organization quality of life (WHO-QOL) questionnaires. To assess repeatability, a separate test-retest population of 20 patients were also selected from orthopaedic clinics and wards to fill out the questionnaire twice.

Results: Convergence validity was determined, with each of the WHO-QOL domains and the EQ-5D descriptive index and visual analogue scale (VAS) having good to moderate correlation (r = 0.3-0.7). Internal consistency was measured for the descriptive index, and the Cronbach's alpha was 0.7. The ceiling effect for the descriptive index and the VAS were 9.4% and 0%, respectively. No respondents reached floor effect for the descriptive index or the VAS. The test-retest intraclass correlation coefficient reliability at 14 days was 0.984 for the VAS and 1 for the descriptive index, with all 20 respondents providing the same responses.

Conclusions: The EuroQoL translated version of the Chichewa EQ-5D-3L was found to demonstrate adequate validity, internal consistency, floor/ceiling effects, and reliability.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5610275PMC
http://dx.doi.org/10.4314/mmj.v29i2.2DOI Listing
June 2017

High Satisfaction and Return to Sports After Total Shoulder Arthroplasty in Patients Aged 55 Years and Younger.

Am J Sports Med 2017 Jun 20;45(7):1664-1669. Epub 2017 Mar 20.

Hospital for Special Surgery, New York, New York, USA.

Background: Young, active candidates for total shoulder arthroplasty (TSA) are a unique group of patients. Not only do they demand longevity and improved function, but they also desire a return to physical activities.

Purpose: To determine the rate of return to sports in patients aged ≤55 years undergoing TSA.

Study Design: Case series; Level of evidence, 4.

Methods: This was a retrospective review of consecutive patients who underwent anatomic TSA at a single institution. Exclusion criteria included age at the time of surgery >55 years and <2 years of follow-up. All patients had end-stage osteoarthritis with significant glenohumeral joint space narrowing. The final follow-up consisted of a patient-reported sports questionnaire, American Shoulder and Elbow Surgeons (ASES) score, and visual analog scale (VAS) score.

Results: From 70 eligible patients, 59 patients (61 shoulders) were included with an average follow-up of 61.0 months (range, 25-103 months) and average age at the time of surgery of 48.9 years (range, 25-55 years). The average VAS score improved from 5.6 to 0.9 ( P < .001), and the average ASES score improved from 39.3 to 88.4 ( P < .001). Forty-nine procedures (80.3%) were performed for a primary diagnosis of osteoarthritis. Four shoulders returned to the operating room; none were for glenoid loosening. There was a 93.2% satisfaction rate, and 67.7% of patients (n = 40) stated that they underwent their surgery to return to sports. Moreover, patients in 96.4% of shoulders (55/57) restarted at least 1 sport at an average of 6.7 months. Direct rates of return were as follows: fitness sports (97.2%), golf (93.3%), singles tennis (87.5%), swimming (77.7%), basketball (75.0%), and flag football (66.7%). Patients in 47 shoulders (82.4%) returned to a similar or higher level of sports; 90.3% returned to high-demand sports, and 83.8% returned to high upper extremity sports. There was no significant difference in rates of return to sports by body mass index, sex, age, preoperative diagnosis, revision status, and dominant extremity.

Conclusion: In patients aged ≤55 years undergoing TSA, there was a 96.4% rate of return to ≥1 previous sports at an average of 6.7 months. Furthermore, at an average follow-up of 61.0 months, no patients needed revision of their glenoid component, despite an 83.8% rate of return to high upper extremity sports. While caution should still be advised in young, active patients undergoing TSA, these results demonstrate a high satisfaction rate and improved ability to return to most sports after surgery.
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http://dx.doi.org/10.1177/0363546517695220DOI Listing
June 2017

Impact of academic collaboration and quality of clinical orthopaedic research conducted in low- and middle-income countries.

SICOT J 2017 30;3. Epub 2017 Jan 30.

Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA 94110, USA.

Background: Little is known about the quality of orthopaedic investigations conducted in low- and middle-income countries (LMICs). Academic collaboration is one model to build research capacity and improve research quality. Our study aimed to determine (1) the quality of clinical orthopaedic research conducted in LMICs, (2) the World Bank Regions and LMICs that publish the highest quality studies, (3) the pattern of collaboration among investigators and (4) whether academic collaboration between LMIC and non-LMIC investigators is associated with studies that have higher levels of evidence.

Methods: Orthopaedic studies from 2004 to 2014 conducted in LMICs were extracted from multiple electronic databases. The World Bank Region, level of evidence and author country-affiliation were recorded. Collaboration was defined as a study that included an LMIC with non-LMIC investigator.

Results: There were 958 studies that met inclusion criteria of 22,714 searched. Ninety-seven (10.1%) of included studies achieved Level 1 or 2 evidence, but case series (52.3%) were the most common. Collaboration occurred in 14.4% of studies and the vast majority of these (88.4%) were among academic institutions. Collaborative studies were more likely to be Level 1 or 2 (20.3% vs. 8.4%, p < 0.01), prospective (34.8% vs. 22.9% p = 0.04) and controlled (29.7% vs. 14.4%, p < 0.01) compared to non-collaborative studies.

Conclusions: Although orthopaedic studies in LMICs rarely reach Level 1 or 2 evidence, studies published through academic collaboration between LMIC and non-LMIC investigators are associated with higher levels of evidence and more prospective, controlled designs.
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http://dx.doi.org/10.1051/sicotj/2016042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5278648PMC
January 2017

A comparative analysis of work-related outcomes after humeral hemiarthroplasty and reverse total shoulder arthroplasty.

J Shoulder Elbow Surg 2017 Jun 11;26(6):954-959. Epub 2017 Jan 11.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA.

Background: The return to work of young patients undergoing shoulder arthroplasty is increasingly important. Whereas studies have shown superior outcomes of reverse total shoulder arthroplasty (RTSA) compared with humeral hemiarthroplasty (HHA), no prior literature has compared RTSA with HHA in regard to return to work.

Methods: A retrospective review of a prospectively collected shoulder arthroplasty registry was performed to analyze all patients who underwent RTSA or HHA at a single institution. A validated questionnaire evaluating return to work postoperatively was administered at baseline and at follow-up in addition to the American Shoulder and Elbow Surgeons and visual analog scale (VAS) pain surveys.

Results: The study included 40 RTSA and 41 HHA patients. The average age at surgery was 68.6 years in the RTSA group and 60.8 years in the HHA group (P < .001). Postoperatively, 65% of RTSA patients returned to work compared with 70.7% of HHA patients (P = .64). There was no significant difference in the time to return to work between the RTSA (2.3 months) and HHA (3.1 months) groups (P = .46). Both groups had statistically significant improvements in both the American Shoulder and Elbow Surgeons and VAS scores. The improvement in pain on the VAS for patients undergoing RTSA (-5.6) trended toward significance compared with HHA (-4.2) (P = .056).

Conclusion: Roughly two-thirds of patients undergoing either HHA or RTSA were able to return to work postoperatively, with no significant difference found between the 2 groups in terms of time to return to work, despite that patients undergoing RTSA were significantly older.
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http://dx.doi.org/10.1016/j.jse.2016.10.004DOI Listing
June 2017

Surgical Management and Reconstruction Training (SMART) Course for International Orthopedic Surgeons.

Ann Glob Health 2016 Jul - Aug;82(4):652-658

Plastic Surgery Division, Department of Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, California.

Background: The burden of complex orthopedic trauma in low- and middle-income countries (LMICs) is exacerbated by soft-tissue injuries, which can often lead to amputations. This study's purpose was to create and evaluate the Surgical Management and Reconstruction Training (SMART) course to help orthopedic surgeons from LMICs manage soft-tissue defects and reduce the rate of amputations.

Methods: In this prospective observational study, orthopedic surgeons from LMICs were recruited to attend a 2-day SMART course taught by plastic surgery faculty in San Francisco. Before the course, participants were asked to assess the burden of soft-tissue injury and amputation encountered at their respective sites of practice. A survey was then given immediately and 1-year postcourse to evaluate the quality of instructional materials and the course's effect in reducing the burden of amputation, respectively.

Results: Fifty-one practicing orthopedic surgeons from 25 countries attended the course. No participant reported previously attempting a flap reconstruction procedure to treat a soft-tissue defect. Before the course, participants cumulatively reported 580-970 amputations performed annually as a result of soft-tissue defects. Immediately after the course, participants rated the quality and effectiveness of training materials to be a mean of ≥4.4 on a Likert scale of 5 (Excellent) in all 14 instructional criteria. Of the 34 (66.7%) orthopedic surgeons who completed the 1-year postcourse survey, 34 (100%, P < 0.01) reported performing flaps learned at the course to treat soft-tissue defects. Flap procedures prevented 116 patients from undergoing amputation; 554 (93.3%) of the cumulative 594 flaps performed by participants 1 year after the course were reported to be successful. Ninety-seven percent of course participants taught flap reconstruction techniques to colleagues or residents, and a self-reported estimate of 28 other surgeons undertook flap reconstruction as a result of information dissemination by 1 year postcourse.

Conclusion: The SMART Course can give orthopedic surgeons in LMICs the skills and knowledge to successfully perform flaps, reducing the self-reported incidence of amputations. Course participants were able to disseminate flap reconstructive techniques to colleagues at their home institution. While this course offers a collaborative, sustainable approach to reduce global surgical disparities in amputation, future investigation into the viability of teaching the SMART course in LMICs is warranted.
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http://dx.doi.org/10.1016/j.aogh.2016.06.002DOI Listing
January 2018
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