Publications by authors named "Heather J Roberts"

28 Publications

  • Page 1 of 1

Host Perspectives of High-Income Country Orthopaedic Resident Rotations in Low and Middle-Income Countries.

J Bone Joint Surg Am 2022 Jul 1. Epub 2022 Jul 1.

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

Background: International orthopaedic resident rotations in low and middle-income countries (LMICs) are gaining popularity among high-income country (HIC) residency programs. While evidence demonstrates a benefit for the visiting residents, few studies have evaluated the impact of such rotations on the orthopaedic surgeons and trainees in LMICs. The purpose of this study was to further explore themes identified in a previous survey study regarding the local impact of visiting HIC resident rotations.

Methods: Using a semistructured interview guide, LMIC surgeons and trainees who had hosted HIC orthopaedic residents within the previous 10 years were interviewed until thematic saturation was reached.

Results: Twenty attending and resident orthopaedic surgeons from 8 LMICs were interviewed. Positive and negative effects of the visiting residents on clinical care, education, interpersonal relationships, and resource availability were identified. Seven recommendations for visiting resident rotations were highlighted, including a 1 to 2-month rotation length; visiting residents at the senior training level; site-specific prerotation orientation with an emphasis on resident attitudes, including the need for humility; creation of bidirectional opportunities; partnering with institutions with local training programs; and fostering mutually beneficial sustained relationships.

Conclusions: This study explores the perspectives of those who host visiting residents, a viewpoint that is underrepresented in the literature. Future research regarding HIC orthopaedic resident rotations in LMICs should include the perspectives of local surgeons and trainees to strive for mutually beneficial experiences to further strengthen and sustain such academic partnerships.
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July 2022

International Orthopaedic Volunteer Opportunities in Low and Middle-Income Countries.

J Bone Joint Surg Am 2022 05 21;104(10):e44. Epub 2021 Dec 21.

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

Abstract: Globally, the burden of musculoskeletal conditions continues to rise, disproportionately affecting low and middle-income countries (LMICs). The ability to meet these orthopaedic surgical care demands remains a challenge. To help address these issues, many orthopaedic surgeons seek opportunities to provide humanitarian assistance to the populations in need. While many global orthopaedic initiatives are well-intentioned and can offer short-term benefits to the local communities, it is essential to emphasize training and the integration of local surgeon-leaders. The commitment to developing educational and investigative capacity, as well as fostering sustainable, mutually beneficial partnerships in low-resource settings, is critical. To this end, global health organizations, such as the Consortium of Orthopaedic Academic Traumatologists (COACT), work to promote and ensure the lasting sustainability of musculoskeletal trauma care worldwide. This article describes global orthopaedic efforts that can effectively address musculoskeletal care through an examination of 5 domains: clinical care, clinical research, surgical education, disaster response, and advocacy.
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May 2022

The Initial Economic Burden of Femur Fractures on Informal Caregivers in Dar es Salaam, Tanzania.

Malawi Med J 2021 06;33(2):135-139

Institute of Global Orthopaedics and Traumatology at the University of California San Francisco.

Background: Femur fracture patients require significant in-hospital care. The burden incurred by caregivers of such patients amplifies the direct costs of these injuries and remains unquantified.

Aim: Here we aim to establish the in-hospital economic burden faced by informal caregivers of femur fracture patients.

Methods: 70 unique caregivers for 46 femoral shaft fracture patients were interviewed. Incurred economic burden was determined by the Human Capital Approach, using standardized income data to quantify productivity loss (in $USD). Linear regression assessed the relationship between caregiver burden and patient time-in-hospital.

Results: The average economic burden incurred was $149, 9% of a caregiver's annual income and positively correlated with patient time in hospital (p<0.01).

Conclusion: Caregivers of patients treated operatively for femur fractures lost a large portion of their annual income, and this loss increased with patient time in hospital. These indirect costs of femur fracture treatment constitute an important component of the total injury burden.
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June 2021

Intramedullary nailing versus external fixation for open tibia fractures in Tanzania: a cost analysis.

OTA Int 2021 Sep 9;4(3):e146. Epub 2021 Aug 9.

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

Objectives: Open tibia fractures pose a clinical and economic burden that is disproportionately borne by low-income countries. A randomized trial conducted by our group showed no difference in infection and nonunion comparing 2 treatments: external fixation (EF) and intramedullary nailing (IMN). Secondary outcomes favored IMN. In the absence of clear clinical superiority, we sought to compare costs between EF and IMN.

Design: Secondary cost analysis.

Setting: Single institution in Tanzania.

Patients/participants: Adult patients with acute diaphyseal open tibia fractures who participated in a previous randomized controlled trial.

Intervention: SIGN IMN versus monoplanar EF.

Main Outcome Measurements: Direct costs of initial surgery and hospitalization and subsequent reoperation: implant, instrumentation, medications, disposable supplies, and personnel costs.Indirect costs from lost productivity of patient and caregiver.Societal (total) costs: sum of direct and indirect costs.All costs were reported in 2018 USD.

Results: Two hundred eighteen patients were included (110 IMN, 108 EF). From a payer perspective, costs were $365.83 (95% CI: $332.75-405.76) for IMN compared with $331.25 ($301.01-363.14) for EF, whereas from a societal perspective, costs were $2664.59 ($1711.22-3955.25) for IMN and $2560.81 ($1700.54-3715.09) for EF. The largest drivers of cost were reoperation and lost productivity. Accounting for uncertainty in multiple variables, probabilistic sensitivity analysis demonstrated that EF was less costly than IMN from the societal perspective in only 55% of simulations.

Conclusions: Intramedullary nail fixation compared with external fixation of open tibia fractures in a resource-constrained setting is not associated with increased cost from a societal perspective.
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September 2021

Assessment of clinical and radiographic outcomes following retrograde versus antegrade nailing of infraisthmic femoral shaft fractures without the use of intraoperative fluoroscopy in Tanzania.

OTA Int 2021 Jun 22;4(2):e125. Epub 2021 Mar 22.

Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, CA.

To compare clinical and radiographic outcomes following antegrade versus retrograde intramedullary nailing of infraisthmic femoral shaft fractures.

Design: Secondary analysis of prospective cohort study.

Setting: Tertiary hospital in Tanzania.

Participants: Adult patients with infraisthmic diaphyseal femur fractures.

Intervention: Antegrade or retrograde SIGN intramedullary nail.

Outcomes: Health-related quality of life (HRQOL), radiographic healing, knee range of motion, pain, and alignment (defined as less than or equal to 5 degrees of angular deformity in both coronal and sagittal planes) assessed at 6, 12, 24, and 52 weeks postoperatively.

Results: Of 160 included patients, 141 (88.1%) had 1-year follow-up and were included in analyses: 42 (29.8%) antegrade, 99 (70.2%) retrograde. Antegrade-nailed patients had more loss of coronal alignment ( = .026), but less knee pain at 6 months ( = .017) and increased knee flexion at 6 weeks ( = .021). There were no significant differences in reoperations, HRQOL, hip pain, knee extension, radiographic healing, or sagittal alignment.

Conclusions: Antegrade nailing of infraisthmic femur fractures had higher incidence of alignment loss, but no detectable differences in HRQOL, pain, radiographic healing, or reoperation. Retrograde nailing was associated with increased knee pain and decreased knee range of motion at early time points, but this dissipated by 1 year. To our knowledge, this is the first study to prospectively compare outcomes over 1 year in patients treated with antegrade versus retrograde SIGN intramedullary nailing of infraisthmic femur fractures.Level of Evidence: III.
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June 2021

Prophylactic Topical Antibiotics in Fracture Repair and Spinal Fusion.

Adv Orthop 2021 14;2021:1949877. Epub 2021 Oct 14.

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

Introduction: The objective of this systematic review with meta-analysis is to determine whether prophylactic local antibiotics prevent surgical site infections (SSIs) in instrumented spinal fusions and traumatic fracture repair. A secondary objective is to investigate the effect of vancomycin, a common local antibiotic of choice, on the microbiology of SSIs.

Methods: An electronic search of PubMed, EMBASE, and Web of Science databases and major orthopedic surgery conferences was conducted to identify studies that (1) were instrumented spinal fusions or fracture repair and (2) had a treatment group that received prophylactic local antibiotics. Both randomized controlled trials (RCTs) and comparative observational studies were included. Meta-analysis was performed separately for randomized and nonrandomized studies with subgroup analysis by study design and antibiotic.

Results: Our review includes 44 articles (30 instrumented spinal fusions and 14 fracture repairs). Intrawound antibiotics significantly decreased the risk of developing SSIs in RCTs of fracture repair (RR 0.61, 95% CI: 0.40-0.93,  = 32.5%) but not RCTs of instrumented spinal fusion. Among observational studies, topical antibiotics significantly reduced the risk of SSIs in instrumented spinal fusions (OR 0.34, 95% CI: 0.27-0.43,  = 52.4%) and in fracture repair (OR 0.49, 95% CI: 0.37-0.65,  = 43.8%). Vancomycin powder decreased the risk of Gram-positive SSIs (OR 0.37, 95% CI: 0.27-0.51,  = 0.0%) and had no effect on Gram-negative SSIs (OR 0.95, 95% CI: 0.62-1.44,  = 0.0%).

Conclusions: Prophylactic intrawound antibiotic administration decreases the risk of SSIs in fracture surgical fixation in randomized studies. Therapeutic efficacy in instrumented spinal fusion was seen in only nonrandomized studies. Vancomycin appears to be an effective agent against Gram-positive pathogens. There is no evidence that local vancomycin powder is associated with an increased risk for Gram-negative infection.
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October 2021

Orthopaedic Trauma Research Priorities in Latin America: Developing Consensus Through a Modified Delphi Approach.

J Bone Joint Surg Am 2021 12;103(24):2318-2323

University of California San Francisco, San Francisco, California.

Background: Despite a substantial burden of musculoskeletal injury, orthopaedic trauma studies in Latin America are lacking. The purpose of the present study was to identify research priorities among orthopaedic trauma surgeons in Latin America.

Methods: Research questions were solicited from members of the Asociación de Cirujanos Traumatólogos de las Américas. Participants rated questions by importance from 1 to 9. All questions were redistributed with an aggregate rating, and participants rerated questions with knowledge of group responses.

Results: Seventy-eight participants completed the first survey and were included in subsequent surveys. The mean age was 51.8 years, and most participants were male (92%), had completed an orthopaedic trauma fellowship (60.3%), and participated in research (80.8%). Seventeen countries were represented; 5 respondents were from a high-income country, 67 were from an upper middle-income country, and 6 were from a lower middle-income country. Sixty-five questions were identified. Six questions were rated from 1 to 3 ("more important") by >70% of participants: (1) What is the optimal treatment protocol for elderly patients with hip fracture? (2) What is the most effective initial and definitive management of musculoskeletal injury, including timing and surgical strategy, for the polytraumatized patient? (3) What is the ideal state of open fracture treatment, including timeliness and method of antibiotics, debridement, surgical fixation, and closure or coverage, at each hospital level in the health-care system? (4) What patient and fracture characteristics predict infection after musculoskeletal injury? (5) What is the current state of treatment for fracture-related infection, including timeliness and method of antibiotics and surgical intervention, at each hospital level in the health-care system? (6) What is the optimal protocol for temporary management for the hemodynamically unstable patient with a pelvic or acetabular fracture?

Conclusions: This modified Delphi study of orthopaedic trauma surgeons in Latin America identified geriatric hip fractures, polytrauma, open fractures, musculoskeletal infection, and pelvic and acetabular fractures as top research priorities. This information is important for resource allocation and goal setting for orthopaedic trauma in the region.
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December 2021

2021 John Charnley Award: A protocol-based strategy when using hemiarthroplasty or total hip arthroplasty for femoral neck fractures decreases mortality, length of stay, and complications.

Bone Joint J 2021 Jul;103-B(7 Supple B):3-8

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

Aims: While interdisciplinary protocols and expedited surgical treatment improve the management of hip fractures in the elderly, the impact of such interventions on patients specifically undergoing arthroplasty for a femoral neck fracture is not clear. We sought to evaluate the efficacy of an interdisciplinary protocol for the management of patients with a femoral neck fracture who are treated with an arthroplasty.

Methods: In 2017, our institution introduced a standardized interdisciplinary hip fracture protocol. We retrospectively reviewed adult patients who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fracture between July 2012 and March 2020, and compared patient characteristics and outcomes between those treated before and after the introduction of the protocol.

Results: A total of 157 patients were treated before the introduction of the protocol (35 (22.3%) with a THA), and 114 patients were treated after its introduction (37 (32.5%) with a THA). The demographic details and medical comorbidities were similar in the two groups. Patients treated after the introduction of the protocol had a significantly reduced median time between admission and surgery (22.8 hours (interquartile range (IQR) 18.8 to 27.7) compared with 24.8 hours (IQR 18.4 to 43.3) (p = 0.042), and a trend towards a reduced mean time to surgery (24.1 hours (SD 10.7) compared with 46.5 hours (SD 165.0); p = 0.150), indicating reduction in outliers. Patients treated after the introduction of the protocol had a significantly decreased rate of major complications (4.4% vs 17.2%; p = 0.005), decreased median hospital length of stay in hospital (4.0 days vs 4.8 days; p = 0.008), increased rate of discharge home (26.3% vs 14.7%; p = 0.030), and decreased one-year mortality (14.7% vs 26.3%; p = 0.049). The 90-day readmission rate (18.2% vs 21.7%; p = 0.528) and 30-day mortality (3.7% vs 5.1%; p = 0.767) did not significantly differ. Patients who underwent HA were significantly older than those who underwent THA (82.1 years (SD 10.4) vs 71.1 years (SD 9.5); p < 0.001), more medically complex (mean Charlson Comorbidity Index 6.4 (SD 2.6) vs 4.1 (SD 2.2); p < 0.001), and more likely to develop delirium (8.5% vs 0%; p = 0.024).

Conclusion: The introduction of an interdisciplinary protocol for the management of elderly patients with a femoral neck fracture was associated with reduced time to surgery, length of stay, complications, and one-year mortality. Such interventions are critical in improving outcomes and reducing costs for an ageing population. Cite this article:  2021;103-B(7 Supple B):3-8.
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July 2021

Evaluating reliability and validity of the modified radiographic union scale for tibia (mRUST) among North American and Tanzanian surgeons.

OTA Int 2021 Mar 23;4(1):e093. Epub 2020 Dec 23.

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

Objectives: To determine the international reliability and validity of the modified Radiographic Union Scale for Tibial fracture (mRUST) scoring method for open tibial shaft fractures based on ratings of radiographs by separate groups of North American and Tanzanian surgeons.

Methods: Seven North American and 9 Tanzanian surgeons viewed 100 pairs of AP and lateral radiographs of open tibial shaft fractures obtained in Dar Es Salaam, Tanzania. The radiographs showed 25 patients' fractures at 4 time points postfracture after treatment with either external fixation or intramedullary nailing. Surgeons evaluated each fracture using the mRUST scoring method and indicated their confidence that the fracture was healed on a scale from 1 to 10. Reliability of mRUST was determined using inter-rater agreement among North American and Tanzanian surgeons. Validity was determined via analysis of correlation between mRUST scores and EQ-5D-3L index scores at each time point postfracture.

Results: mRUST scores demonstrated strong reliability overall (ICC = 0.64) as well as within each group of North American (ICC = 0.72) and Tanzanian (ICC = 0.69) surgeons. Reliability was stronger for external fixation than for intramedullary nailing cases. mRUST scores were significantly correlated with overall healing confidence at all time points and with quality of life at 6 months and 1 year postfracture. mRUST scores also correlated significantly with patients' quality of life scores (EQ-5D index) at 6 months and 1 year postfracture.

Conclusion: North American and Tanzanian surgeons exhibited strong agreement in rating open tibial shaft fractures. Using mRUST scores is a valid means of assessing radiographic healing of tibial fractures in austere environments like Tanzania.
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March 2021

Protocol-based interdisciplinary co-management for hip fracture care: 3 years of experience at an academic medical center.

Arch Orthop Trauma Surg 2022 Jul 2;142(7):1491-1497. Epub 2021 Mar 2.

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

Background: Interdisciplinary standardized protocols for the care of patients with hip fractures have been shown to improve outcomes. A hip fracture protocol was implemented at our institution to standardize care, focusing on emergency care, pre-operative medical management, operative timing, and geriatrics co-management. The aim of this study was to evaluate the efficacy of this protocol.

Methods: We conducted a retrospective review of adult patients admitted to a single tertiary care institution who underwent operative management of a hip fracture between July 2012 and March 2020. Comparison of patient characteristics, hospitalization characteristics, and outcomes were performed between patients admitted before and after protocol implementation in 2017.

Results: A total of 517 patients treated for hip fracture were identified: 313 before and 204 after protocol implementation. Average age, average Charlson Comorbidity Index, percent female gender, and distribution of hip fracture diagnosis did not vary significantly between groups. There was a significant reduction in time from admission to surgical management, from 37.0 ± 47.7 to 28.5 ± 27.1 h (p = 0.0016), and in the length of hospital stay, from 6.3 ± 6.5 to 5.4 ± 4.0 days (p = 0.0013). The percentage of patients whose surgeries were performed under spinal anesthesia increased from 12.5 to 26.5% (p = 0.016). There was no difference in 90-day readmission rate or mortality at 30 days, 90 days, or 1 year between groups.

Conclusion: With the implementation of an interdisciplinary hip fracture protocol, we observed significant and sustained reductions in time to surgery and hospital length of stay, important metrics in hip fracture management, without increased readmission or mortality. This has implications to minimize health care costs and improve outcomes for our aging population.

Level Of Evidence: III, therapeutic.
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July 2022

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:, Registration # NCT03559400 ; Registered June 18, 2018.
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February 2021

Monoplanar external fixation of comminuted open tibial shaft fractures predicts loss of alignment by one year compared to a statically locked intramedullary SIGN nail.

Injury 2021 Apr 17;52(4):982-987. Epub 2020 Oct 17.

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

Aims: This investigation develops a predictive model for loss of alignment (LOA) following fixation of open tibia fractures.

Patients/methods: An analysis was performed of adults with diaphyseal open tibia fractures randomized to intramedullary nailing (IMN) or external fixation (EF) followed at 6, 12, 24, and 52 weeks postoperatively. Demographic data were collected at baseline. Pre-injury and follow-up EuroQol 5-Dimensions (EQ-5D) and pain score were measured. Radiographs, taken postoperatively and in follow-up, were assessed for coronal and sagittal angulation, and used to calculate the modified Radiographic Union Scale for Tibia fractures (mRUST). LOA was defined as an increase in angulation >5° by one year follow-up. Fracture comminution was defined using AO/OTA classification. Putative risk factors were assessed for association with LOA using bivariate logistic regression. Adjusted associations with LOA were estimated using multivariable logistic regression and marginal analysis.

Results: Analyses included 129 patients (70 IMN, 59 EF), majority male, of mean age 33 years (range 17.7-73) and body mass index (BMI) 25.2 (range 15.5-45.1), with 48% Type A, 41% Type B, and 11% Type C fractures (AO/OTA classification). The likelihood of LOA with EF increased with greater fracture comminution; 45.21% (p<0.001), 77.50% (p<0.001), and 100% LOA for Type A, B, and C fractures respectively. Relative risk of LOA for EF compared to IMN was 3.87 (95% CI 1.36, 11.02), 3.75 (95% CI 1.77, 7.92), and 5.76 for Type A, B, and C fractures, respectively. Compared to patients who lost alignment, patients without LOA had improved fracture healing (p = 0.003) and higher EQ-5D scores (p = 0.03) at one year.

Conclusion: Increasing age and BMI are associated with LOA and segmental fracture amplifies the protective effect of IMN versus EF. The importance of LOA as a surrogate outcome after operative treatment of open tibial fractures is supported by its association with inferior radiographic and functional patient outcomes.
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April 2021

Motivations and impact of international rotations in low- and middle-income countries for orthopaedic surgery residents: Are we on the same page?

Am J Surg 2021 02 12;221(2):245-253. Epub 2020 Sep 12.

University of California, Department of Orthopaedic Surgery, 500 Parnassus Ave MU320-W, San Francisco, CA, USA, 94143. Electronic address:

Background: Despite interest among North American orthopaedic residents to pursue rotations in resource-limited settings, little is known regarding resident motivations and impact on host surgeons.

Methods: Surveys were distributed to North American orthopaedic surgeons and trainees who participated in international rotations during residency to assess motivations for participation and to orthopaedic surgeons at partnering low- and middle-income country (LMIC) institutions to assess impact of visiting trainees.

Results: Responses were received from 136 North American resident rotators and 51 LMIC host surgeons and trainees. North American respondents were motivated by a desire to increase surgical capacity at the LMIC while host surgeons reported a greater impact from learning from residents than on surgical capacity. Negative aspects reported by hosts included selfishness, lack of reciprocity, racial discrimination, competition for surgical experience, and resource burdens.

Conclusions: The motivations and impact of orthopaedic resident rotations in LMICs need to be aligned. Host perceptions and bidirectional educational exchange should be incorporated into partnership guidelines.
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February 2021

Resident Rotations in Low- and Middle-Income Countries: Motivations, Impact, and Host Perspectives.

JB JS Open Access 2020 Jul-Sep;5(3). Epub 2020 Jul 31.

UCSF Benioff Children's Hospital Oakland, Oakland, California and Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California.

Interest in clinical rotations in low- and middle-income countries (LMICs) has grown among high-income country (HIC) orthopaedic residents. This study addresses the following questions: (1) What motivates HIC surgical residents to rotate in LMICs? (2) What is the impact of rotations on HIC residents? (3) What are the LMIC partner perceptions of HIC collaboration?

Materials And Methods: A search strategy of multiple databases returned 3,740 unique articles pertaining to HIC surgical resident motivations for participating in rotations in LMICs or the LMIC host perspective. Data extraction was dually performed using meta-ethnography, the qualitative equivalent of meta-analysis.

Results: Twenty-one studies were included in the final analysis. HIC residents were primarily motivated to rotate in LMICs by altruistic intent, with greatest impact on professional development. LMIC partners mostly valued HIC sustained investment and educational opportunities for LMIC partners. From LMIC's perspective, potential harm from collaboration arose from system-level and individual-level discordance between HIC and LMIC expectations and priorities. HIC priorities included the following: (1) adequate operative time, (2) exposure to varied pathology, and (3) mentorship. LMIC priorities included the following: (1) avoiding competition with HIC residents for surgical cases, (2) that HIC groups not undermine LMIC internal authority, (3) that HIC initiatives address local LMIC needs, and (4) that LMIC partners be included as authors on HIC research initiatives. Both HIC and LMIC partners raised ethical concerns regarding collaboration and perceived HIC residents to be underprepared for their LMIC rotation.

Discussion: This study synthesizes the available literature on HIC surgical resident motivations for and impact of rotating in LMICs and the LMIC host perception of collaboration. Three improvement categories emerged: that residents (1) receive before departure, (2) long enough to develop site-specific skills, and (3) and . Specific suggestions based on synthesized data are offered for each concept and can serve as a foundation for mutually beneficial international electives in LMICs for HIC orthopaedic trainees.
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July 2020

Open Tibial Shaft Fractures: Treatment Patterns in Latin America.

J Bone Joint Surg Am 2020 Nov;102(22):e126

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

Background: Open tibial shaft fractures are an important source of disability in Latin America. High-income countries (HICs) worldwide have established standardized treatment protocols for open tibial fractures, but less is known about their treatment in middle-income countries (MICs) in Latin America. This survey of Latin American orthopaedic surgeons characterizes open tibial fracture treatment patterns.

Methods: Orthopaedic surgeons from 20 national orthopaedic societies throughout Latin America completed an online survey assessing their treatment of open tibial fractures. Demographic information was collected. Treatment patterns were queried according to 2 groupings of Gustilo-Anderson (GA) fracture types: treatment of type-I and type-II fractures (GA-I/II) and treatment of type-III fractures (GA-III). Treatment patterns were evaluated across 4 domains: antibiotic prophylaxis, irrigation and debridement, fracture stabilization, and wound management. Summary statistics were reported; analysis was performed using the Fisher exact test (p < 0.05).

Results: There were 616 survey participants from 20 Latin American countries (4 HICs and 16 MICs). Initial external fixation followed by staged internal fixation was preferred for GA-I/II (51.0%) and GA-III fractures (86.0%). Nearly one-third (31.5%) of GA-IIIB fractures did not receive a soft-tissue coverage procedure. Stratifying by country socioeconomic status, surgeons in MICs more commonly utilized delayed internal fixation for GA-I/II (53.3% versus 22.0%, p < 0.001) and GA-III fractures (94.0% versus 80.4%, p = 0.002). Surgeons in MICs more commonly used primary closure for GA-I/II (88.9% versus 62.8%, p < 0.001) and GA-III fractures (32.6% versus 9.8%, p < 0.001).

Conclusions: This survey reports Latin American orthopaedic surgeons' treatment patterns for open tibial shaft fractures. Surgeons in MICs reported higher delayed internal fixation use for all fracture types, while surgeons in HICs more routinely avoid primary closure. Soft-tissue coverage procedures are not performed in nearly one-third of GA-IIIB fractures because of a lack of operative personnel and training.
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November 2020

Management of Lower Extremity Fractures in the Elderly: A Focus on Post-Operative Rehabilitation.

Injury 2020 May 11;51 Suppl 2:S118-S122. Epub 2020 May 11.

Sunnybrook Health Sciences Centre, Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada. Electronic address:

Fractures in the elderly population are increasing in incidence and represent a rising burden of disease. It is difficult for the elderly population to adhere to restricted weight bearing, and immobility poses significant risks and increased morbidity. Therefore, a primary goal of fracture management in the elderly population is early post-operative weight bearing. This review examines published literature regarding lower extremity fracture management in the elderly, with a focus on post-operative rehabilitation. While extensive literature supports early weight bearing after hip fractures in the elderly, further research is warranted to provide guidelines for management of other lower extremity fractures in this population.
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May 2020

Impact of North American Institutions on Orthopedic Research in Low- and Middle-Income Countries.

Orthop Clin North Am 2020 Apr 22;51(2):177-188. Epub 2020 Jan 22.

Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA. Electronic address:

There exists an unmet need for locally relevant and sustainable orthopedic research in low- and middle-income countries. Partnerships between high-income countries and low- and middle-income countries can bridge gaps in resources, knowledge, infrastructure, and skill. This article presents a select list of models for high-income countries/low- and middle-income countries research partnerships including academic partnerships, international research consortia, professional society-associated working groups, and nongovernmental organization partnerships. Models that produce research with lasting legacy are those that promote mutually beneficial partnerships over individual gains.
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April 2020

Staged Bilateral Total Knee Arthroplasty: Increased Risk of Recurring Complications.

J Bone Joint Surg Am 2020 Feb;102(4):292-297

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

Background: As the demand for knee arthroplasty increases, risk assessment and counseling are critical for optimal patient outcomes perioperatively. The purpose of this study was to determine if specific complications occurring after unilateral knee replacement predict the risk of recurrence after a staged replacement of the contralateral knee for patients with bilateral symptomatic disease.

Methods: Linked, nationwide data from the U.S. Hospital Cost and Utilization Project from 2005 to 2014 were used to measure the occurrence of complications after the first and second procedures in staged bilateral total knee arthroplasties (TKAs). Odds ratios (ORs) and conditional probabilities were determined to assess whether having a specific complication after the first TKA increased the chance that the same complication occurred after the second procedure.

Results: A total of 36,278 patients who underwent staged bilateral TKAs were analyzed. All complications occurring after the first arthroplasty were associated with both a significantly increased probability and odds of recurrence following the second arthroplasty. These included myocardial infarction (OR, 56.63 [95% confidence interval (CI), 18.04 to 155.44]; p < 0.001), ischemic stroke (OR, 41.38 [95% CI, 1.98 to 275.82]; p = 0.03), other cardiac complications (OR, 7.73 [95% CI, 4.24 to 14.11]; p < 0.001), respiratory complications (OR, 8.58 [95% CI, 2.85 to 23.17]; p = 0.002), urinary complications (OR, 11.19 [95% CI, 5.44 to 22.25]; p = 0.001), hematoma (OR, 15.05 [95% CI, 7.90 to 27.27]; p < 0.001), deep vein thrombosis (OR, 7.40 [95% CI, 5.37 to 10.08]; p < 0.001), and pulmonary embolism (OR, 11.00 [95% CI, 5.01 to 23.92]; p < 0.001).

Conclusions: Medical complications that occur postoperatively after TKA are associated with a significantly increased risk of recurrence of these complications after staged replacement of the contralateral knee. Although overall complication rates remain low, patients who develop these medical complications after the first replacement should be counseled on their increased risk profile prior to the contralateral surgical procedure.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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February 2020

Patient self-reported utility of hand surgery online patient education materials.

Musculoskeletal Care 2018 12 30;16(4):458-462. Epub 2018 Aug 30.

Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Objective: Online patient education materials in orthopaedic surgery are consistently written above the recommended grade level. However, no algorithmic measure of readability has been validated in a medical context. The primary objective of the present study was to determine whether Flesch-Kincaid readability scores correlate with patient self-reported utility of online education materials from the American Society for Surgery of the Hand (ASSH).

Methods: This was a prospective survey study of 35 patients with one of five common upper extremity diagnoses. Study outcomes included self-reported utility, understandability, clarity, novelty and scope of the information of the ASSH online patient education material. Flesch-Kincaid Grade Level and Flesch Reading Ease were calculated for each article and correlated with self-reported utility.

Results: The majority of patients found the articles useful, understandable and clear. Self-reported utility was not correlated with Flesch-Kincaid Grade Level (ρ = 0.017) or Flesch Reading Ease (ρ = -0.020). Patients with high school education or below found the articles less useful and more difficult to understand than those with post-secondary education.

Conclusions: Flesch-Kincaid readability scores do not correlate with self-reported utility of ASSH online patient education materials. In the evaluation of these materials, metrics other than algorithmic readability scores should be considered.
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December 2018

Factors influencing the enrollment in randomized controlled trials in orthopedics.

Contemp Clin Trials Commun 2017 Dec 16;8:203-208. Epub 2017 Oct 16.

Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.

Background: Low enrollment rates are a threat to the external validity of clinical trials. The purpose of this study was to identify factors associated with lower enrollment rates in randomized controlled trials (RCTs) involving orthopedic procedures.

Methods: We performed a search in PubMed/MEDLINE for RCTs that involved any orthopedic surgical procedure, compared different intraoperative interventions, were published in English in a peer-reviewed journal between 2003 and 2014, and reported the numbers of both enrolled and eligible subjects. The primary outcome was the enrollment rate, defined as the number of enrolled subjects divided by the number of eligible subjects. We used a meta-regression to identify factors associated with lower enrollment rates.

Results: The combined estimate of enrollment rate across all 393 studies meeting inclusion criteria was 90% (95% CI: 89-92%). Trials in North America had significantly lower enrollment rates compared to trials in the rest of the world (80% vs. 92%, p < 0.0001). Trials comparing operative and non-operative treatments had significantly lower enrollment rates than trials comparing two different operative interventions (80% vs. 91%, p < 0.0001). Among trials comparing operative and non-operative interventions, there was a marked difference in enrollment rate by region: 49% in North America and 86% elsewhere (p < 0.0001).

Conclusions: RCTs investigating orthopedic procedures have variable enrollment rates depending on their location and the difference between the interventions being studied. North American trials that compare operative and non-operative interventions have the lowest enrollment rates. Investigators planning RCTs would be well advised to consider these data in planning recruitment efforts.
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December 2017

A Self-Reported Needs Assessment Survey of Pediatric Orthopaedic Education in Haiti.

J Surg Educ 2018 Jan - Feb;75(1):140-146. Epub 2017 Aug 31.

Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

Objective: The burden of musculoskeletal disease remains high in low-income countries, with a high rate of pediatric disease. Efforts continue for orthopedic education, but there is little guidance on local needs and desires. Our aim was to determine the specific content and modalities that would be most useful for pediatric orthopedic educational programs abroad, and we demonstrate a practical method of identifying country-specific educational deficits through a self-reported needs survey in Haiti.

Design: A cross-sectional survey was administered using an automated response system. We obtained demographic information as well as training and practice patterns, comfort levels with pediatric diagnoses, and desired topics for education using a 5-point Likert Scale.

Setting: Haitian Annual Assembly for Orthopaedic Trauma (HAAOT), the only national, continuing medical education conference for orthopedic providers in Haiti.

Participants: Of 60 eligible participants, 51 were included in the final analysis.

Results: Time spent on pediatric orthopedics varied widely, centered at 10% to 25%. Median comfort level with pediatric orthopedics was 3 of 5. Skills with lowest self-reported competence included spica casting, clubfoot casting, and management of supracondylar humerus fractures. Skills with highest self-reported competence were long-leg casting and Salter-Harris classification. Modes of education highly requested included didactics/lectures, hands-on sessions, dedicated rotations, and exchanges with foreign peers/mentors. Diagnoses most encountered were osteomyelitis, trauma, and clubfoot; lowest comfort levels were in neuromuscular, spine, lower extremity deformity, congenital hip, and clubfoot; and most requested for future teaching were congenital hip, neuromuscular, and spine.

Conclusions: Haitian orthopedic providers express a strong desire and need for ongoing pediatric orthopedic education. They describe a high prevalence of trauma and infection, but convey a requirement for more comprehensive, multimodal teaching that also includes congenital deformities/dysplasias, neuromuscular, and spine. Our results demonstrate the importance of assessing country-specific needs and involving local care providers in curriculum development.
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November 2018

A Randomized Controlled Pilot Study of Educational Techniques in Teaching Basic Arthroscopic Skills in a Low-income Country.

Arch Bone Jt Surg 2017 Mar;5(2):82-88

Harvard Combined Orthopaedics Residency Program, Boston, MA, USA.

Background: Little is known about how to introduce complex technologies like arthroscopy into low-income countries. Thus, we compared low- versus high-resource intensive methods of teaching basic arthroscopic skills in a randomized controlled trial in Haiti.

Methods: Forty-eight Haitian orthopaedic surgeons and residents attending an orthopaedic conference in Haiti were block randomized to receive instruction through a composite video (Control) or a composite video plus hands-on teaching with an expert visiting surgeon (Intervention). A low-fidelity surgical simulator tested visualization and triangulation skills. Participants completed a pre- and post-test where the goal was to sequentially tap the most numbers in 2.5 minutes. Outcome metrics included highest tapped number, number of errors, visualization loss, and number of lookdowns. Multivariate linear regression was used to confirm randomization and compare outcomes between groups.

Results: Seventy-five percent of initially randomized attendees participated with similar attrition rates between both groups. All participants who performed a pre-test completed a post-test. In terms of highest tapped number, treatment and control groups significantly improved compared to pre-test scores, with mean improvement of 3.2% (P=0.007) and 2.2% (P=0.03), respectively. Improvement between treatment and control groups was not statistically different (P=0.4). No statistically significant change was seen with regard to other metrics.

Conclusion: We describe a protocol to introduce basic arthroscopic skills in a low-income country using a low-resource intensive teaching method. However, this method of learning may not be optimal given the failure to improve in all outcome measures.
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March 2017

Enhanced Wnt signaling improves bone mass and strength, but not brittleness, in the Col1a1(+/mov13) mouse model of type I Osteogenesis Imperfecta.

Bone 2016 09 11;90:127-32. Epub 2016 Jun 11.

Orthopaedic Research Laboratories, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, United States; Department of Genetics, Harvard Medical School, Boston, MA, United States; Howard Hughes Medical Institute, Boston Children's Hospital, Boston, MA, United States.

Osteogenesis Imperfecta (OI) comprises a group of genetic skeletal fragility disorders. The mildest form of OI, Osteogenesis Imperfecta type I, is frequently caused by haploinsufficiency mutations in COL1A1, the gene encoding the α1(I) chain of type 1 collagen. Children with OI type I have a 95-fold higher fracture rate compared to unaffected children. Therapies for OI type I in the pediatric population are limited to anti-catabolic agents. In adults with osteoporosis, anabolic therapies that enhance Wnt signaling in bone improve bone mass, and ongoing clinical trials are determining if these therapies also reduce fracture risk. We performed a proof-of-principle experiment in mice to determine whether enhancing Wnt signaling in bone could benefit children with OI type I. We crossed a mouse model of OI type I (Col1a1(+/Mov13)) with a high bone mass (HBM) mouse (Lrp5(+/p.A214V)) that has increased bone strength from enhanced Wnt signaling. Offspring that inherited the OI and HBM alleles had higher bone mass and strength than mice that inherited the OI allele alone. However, OI+HBM and OI mice still had bones with lower ductility compared to wild-type mice. We conclude that enhancing Wnt signaling does not make OI bone normal, but does improve bone properties that could reduce fracture risk. Therefore, agents that enhance Wnt signaling are likely to benefit children and adults with OI type 1.
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September 2016

Visualizing dermal permeation of sodium channel modulators by mass spectrometric imaging.

J Am Chem Soc 2014 Apr 17;136(17):6401-5. Epub 2014 Apr 17.

Department of Chemistry, Stanford University , Stanford, California 94305-5080, United States.

Determining permeability of a given compound through human skin is a principal challenge owing to the highly complex nature of dermal tissue. We describe the application of an ambient mass spectrometry imaging method for visualizing skin penetration of sodium channel modulators, including novel synthetic analogs of natural neurotoxic alkaloids, topically applied ex vivo to human skin. Our simple and label-free approach enables successful mapping of the transverse and lateral diffusion of small molecules having different physicochemical properties without the need for extensive sample preparation.
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April 2014

Targeting the LRP5 pathway improves bone properties in a mouse model of osteogenesis imperfecta.

J Bone Miner Res 2014 Oct;29(10):2297-306

Orthopaedic Research Laboratories, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA; Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA; Division of Genetics, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.

The cell surface receptor low-density lipoprotein receptor-related protein 5 (LRP5) is a key regulator of bone mass and bone strength. Heterozygous missense mutations in LRP5 cause autosomal dominant high bone mass (HBM) in humans by reducing binding to LRP5 by endogenous inhibitors, such as sclerostin (SOST). Mice heterozygous for a knockin allele (Lrp5(p.A214V) ) that is orthologous to a human HBM-causing mutation have increased bone mass and strength. Osteogenesis imperfecta (OI) is a skeletal fragility disorder predominantly caused by mutations that affect type I collagen. We tested whether the LRP5 pathway can be used to improve bone properties in animal models of OI. First, we mated Lrp5(+/p.A214V) mice to Col1a2(+/p.G610C) mice, which model human type IV OI. We found that Col1a2(+/p.G610C) ;Lrp5(+/p.A214V) offspring had significantly increased bone mass and strength compared to Col1a2(+/p.G610C) ;Lrp5(+/+) littermates. The improved bone properties were not a result of altered mRNA expression of type I collagen or its chaperones, nor were they due to changes in mutant type I collagen secretion. Second, we treated Col1a2(+/p.G610C) mice with a monoclonal antibody that inhibits sclerostin activity (Scl-Ab). We found that antibody-treated mice had significantly increased bone mass and strength compared to vehicle-treated littermates. These findings indicate increasing bone formation, even without altering bone collagen composition, may benefit patients with OI.
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October 2014

Identification of novel isoforms of activin receptor-like kinase 7 (ALK7) generated by alternative splicing and expression of ALK7 and its ligand, Nodal, in human placenta.

Biol Reprod 2003 May 27;68(5):1719-26. Epub 2002 Dec 27.

Department of Biology, York University, Toronto, Ontario, Canada M3J 1P3.

Members of the transforming growth factor (TGF) beta family play critical roles in regulating placental functions. Using polymerase chain reaction (PCR)-based strategies, we have cloned four transcripts encoding full-length activin receptor-like kinase 7 (ALK7) and three novel ALK7 isoforms from the human placenta. The full-length ALK7 has 493 amino acids and exhibits all characteristics of TGFbeta type I receptors, including an activin receptor-binding domain, a transmembrane domain, a GS domain, and a serine/threonine kinase domain. The three ALK7 isoforms identified include a truncated ALK7 (tALK7) and two soluble proteins designated as soluble ALK7a (sALK7a) and soluble ALK7b (sALK7b). The tALK7 lacks the first 50 amino acids of the full-length ALK7, resulting in a truncated receptor-binding domain. Both sALK7a and sALK7b lack transmembrane and GS domains. The ALK7 gene, located on chromosome 2q24.1, is composed of at least nine exons and eight introns. The isoforms of ALK7 are generated by alternative splicing. Transcripts encoding the sALK7 isoforms differ from the full-length transcript by lacking exon III or both exons III and IV in sALK7a and sALK7b, respectively. The transcript for tALK7 uses an alternative exon located within the first intron of the full-length transcript. These results indicate that four distinct proteins are encoded by the human ALK7 gene. Both reverse transcription-PCR and Western blot analysis showed that ALK7 and its isoforms are expressed in human placentae of different stages of pregnancy and that their expression is developmentally regulated. In addition, mRNA expression of Nodal, a ligand for ALK7, was also detected in placentae of different gestational age. The role of Nodal and ALK7 in human placenta is currently under investigation.
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May 2003