Publications by authors named "Saam Morshed"

144 Publications

Decolonizing Global Surgery: Bethune Round Table, 2022 Conference on Global Surgery (virtual), June 16-18, 2022.

Authors:
Fabio Botelho Karen Gripp Natalie Yanchar Abbie Naus Dan Poenaru Robert Baird Eliane Reis Leonildo Farias Ana Gabriely Silva Francisco Viana José Armando Pessoa Neto Sidney Silva Karen Ribeiro Luana Gatto Matheus Daniel Faleiro Miguel Godeiro Fernandez Lucas Sousa Salgado Natália Zaneti Sampaio Matheus Daniel Faleiro Anna Luiza Mendes Rodrigo Vaz Ferreira Luiz Marcião Gabriel Canto José Borges Victor Araújo Gabrielly Andrade Joyce Braga Lívia Bentes Luís Pinto Henry T Ndasi

Can J Surg 2022 Jul-Aug;65(4 Suppl 1):S1-S18. Epub 2022 Aug 12.

From the Harvard Global Orthopaedics Collaborative, Baltimore, USA (Amlani) and Boston, USA (Lechtig, Agarwal-Harding); and the Baptist Hospital Mutengene, Cameroon (Ndasi, Aminake, Penda, Tima).

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http://dx.doi.org/10.1503/cjs.007622DOI Listing
August 2022

Public Insurance Payment Does Not Compensate Hospital Cost for Care of Long-Bone Fractures Requiring Additional Surgery to Promote Union.

Authors:
Erika Roddy Ericka P von Kaeppler Matthew C Chan David W Shearer Utku Kandemir Saam Morshed

J Orthop Trauma 2022 Aug;36(8):e318-e325

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

Objectives: To quantify the total hospital costs associated with the treatment of lower extremity long-bone fracture aseptic and septic unhealed fracture, to determine if insurance adequately covers these costs, and to examine whether insurance type correlates with barriers to accessing care.

Design: Retrospective cohort study.

Setting: Academic Level II trauma center.

Patients: All patients undergoing operative treatment of OTA/AO classification 31, 32, 33, 41, 42, and 43 fractures between 2012 and 2020 at a single Level II trauma center with minimum of 1-year follow-up.

Main Outcome Measures: The primary outcome was the total cost of treatment for all hospital-based episodes of care. Distance traveled from primary residence was measured as a surrogate for barriers to care.

Results: One hundred seventeen patients with uncomplicated fracture healing, 82 with aseptic unhealed fracture, and 44 with septic unhealed fracture were included in the final cohort. The median cost of treatment for treatment of septic unhealed fracture was $148,318 [interquartile range(IQR) 87,241-256,928], $45,230 (IQR 31,510-68,030) for treatment of aseptic unhealed fracture, and $33,991 (IQR 25,609-54,590) for uncomplicated fracture healing. The hospital made a profit on all patients with commercial insurance, but lost money on all patients with public insurance. Among patients with unhealed fracture, those with public insurance traveled 4 times further for their care compared with patients with commercial insurance (P = 0.004).

Conclusions: Septic unhealed fracture of lower extremity long-bone fractures is an outsized burden on the health care system. Public insurance for both septic and aseptic unhealed fracture does not cover hospital costs. The increased distances traveled by our Medi-Cal and Medicare population may reflect the economic disincentive for local hospitals to care for publicly insured patients with unhealed fractures.

Level Of Evidence: Economic Level V. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002350DOI Listing
August 2022

Establishing Sustainable Arthroscopy Capacity in Low- and Middle-Income Countries (LMICs) through High-Income Country/LMIC Partnerships: A Qualitative Analysis.

Authors:
Ericka P von Kaeppler Nathan Coss Claire A Donnelley Dave M Atkin Marc Tompkins Billy Haonga Alberto M V Molano Saam Morshed David W Shearer

JB JS Open Access 2022 Jul-Sep;7(3). Epub 2022 Jul 5.

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

Disparities exist in treatment modalities, including arthroscopic surgery, for orthopaedic injuries between high-income countries (HICs) and low- and middle-income countries (LMICs). Arthroscopy training is a self-identified goal of LMIC surgeons to meet the burden of musculoskeletal injury. The aim of this study was to determine the necessary "key ingredients" for establishing arthroscopy centers in LMICs in order to build capacity and expand training in arthroscopy in lower-resource settings.

Methods: This study utilized semi-structured interviews with orthopaedic surgeons from both HICs and LMICs who had prior experience establishing arthroscopy efforts in LMICs. Participants were recruited via referral sampling. Interviews were qualitatively analyzed in duplicate via a coding schema based on repeated themes from preliminary interview review. Subgroup analysis was conducted between HIC and LMIC respondents.

Results: We identified perspectives shared between HIC and LMIC stakeholders and perspectives unique to 1 group. Both groups were motivated by opportunities to improve patients' lives; the LMIC respondents were also motivated by access to skills and equipment, and the HIC respondents were motivated by teaching opportunities. Key ingredients identified by both groups included an emphasis on teaching and the need for high-cost equipment, such as arthroscopy towers. The LMIC respondents reported single-use materials as a key ingredient, while the HIC respondents reported local champions as crucial. The LMIC respondents cited the scarcity of implants and shaver blades as a barrier to the continuity of arthroscopy efforts.

Conclusions: Incorporation of the identified key ingredients, along with leveraging the motivations of the host and the visiting participant, will allow future international arthroscopy partnerships to better match proposed interventions with the host-identified needs.

Clinical Relevance: Arthroscopy is an important tool for treatment of musculoskeletal injury. Increasing access to arthroscopy is an important goal to achieve greater equity in musculoskeletal care globally. Developing successful partnerships between HICs and LMICs to support arthroscopic surgery requires sustained relationships that address local needs.
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http://dx.doi.org/10.2106/JBJS.OA.21.00160DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9260732PMC
July 2022

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

Authors:
Heather J Roberts Nathan Coss Mayur Urva Billy Haonga Pierre-Marie Woolley Bibek Banskota Saam Morshed David W Shearer Sanjeev Sabharwal

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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http://dx.doi.org/10.2106/JBJS.22.00050DOI Listing
July 2022

Reliability of Modified Radiographic Union Score for Tibia Scores in the Evaluation of Femoral Shaft Fractures in a Low-resource Setting.

Authors:
Mayur Urva Sravya T Challa Billy T Haonga Edmund Eliezer Zachary M Working Ashraf El Naga Saam Morshed David W Shearer

J Am Acad Orthop Surg Glob Res Rev 2022 May 1;6(5). Epub 2022 May 1.

From the Institute for Global Orthopaedics and Traumatology, University of California, San Francisco San Francisco, CA (Mr. Urva, Dr. Morshed, and Dr. Shearer); Harvard Combined Orthopaedic Residency Program, Boston, MA (Dr. Challa); Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania (Dr. Haonga and Dr. Eliezer); Oregon Health & Sciences University, Portland, OR (Dr. Working); and University of California, San Francisco, San Francisco, CA (Dr. El Naga).

Introduction: The modified Radiographic Union Score for Tibia (RUST) fractures was developed to better describe fracture healing, but its utility in resource-limited settings is poorly understood. This study aimed to determine the validity of mRUST scores in evaluating fracture healing in diaphyseal femur fractures treated operatively at a single tertiary referral hospital in Tanzania.

Methods: Radiographs of 297 fractures were evaluated using the mRUST score and compared with outcomes including revision surgery and EuroQol five dimensions questionnaire (EQ-5D) and visual analog scale (VAS) quality-of-life measures. Convergent validity was assessed by correlating mRUST scores with EQ-5D and VAS scores. Divergent validity was assessed by comparing mRUST scores in patients based on revision surgery status.

Results: The mRUST score had moderate correlation (Spearman correlation coefficient 0.40) with EQ-5D scores and weak correlation (Spearman correlation coefficient 0.320) with VAS scores. Compared with patients who required revision surgery, patients who did not require revision surgery had higher RUST scores at all time points, with statistically significant differences at 3 months (2.02, P < 0.05).

Discussion: These results demonstrate that the mRUST score is a valid method of evaluating the healing of femoral shaft fractures in resource-limited settings, with high interrater reliability, correlation with widely used quality of life measures (EQ-5D and VAS), and expected divergence in the setting of complications requiring revision surgery.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-21-00211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9126518PMC
May 2022

Identification of Risk Factors in the Development of Heterotopic Ossification after Primary Total Hip Arthroplasty.

Authors:
Sukhmani Singh Saam Morshed Daria Motamedi Joseph Kidane Alexandra Paul Edward C Hsiao Kelly L Wentworth

J Clin Endocrinol Metab 2022 Apr 22. Epub 2022 Apr 22.

Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, 513 Parnassus Ave., HSE901, San Francisco, CA.

Purpose: Heterotopic ossification (HO) is a process by which bone forms abnormally in soft tissues. Known risk factors for developing HO include male sex, spinal cord injury, trauma, and surgery. We investigated additional risk factors in the development of HO after hip arthroplasty.

Methods: We performed a retrospective review of electronic medical records of 4070 individuals who underwent hip arthroplasty from September 2010 to October 2019 at the University of California, San Francisco Hospital. Demographics, anthropometrics, medications, and comorbid conditions were used in logistic regression analysis to identify factors associated with the development of HO.

Results: 2541 patients underwent primary hip arthroplasty in the analyzed timeframe (46.04% men, mean age at procedure: 62.13±13.29 years). The incidence of post-surgical HO was 3% (n=80). A larger proportion of individuals who developed HO had underlying osteoporosis (p<0.001), vitamin D deficiency (p<0.001), spine disease (p<0.001), Type 1 or 2 diabetes (p<0.001), amenorrhea (p=0.037), post-menopausal status (p<0.001), parathyroid disorders (p=0.011), and history of pathologic fracture (p=0.005). Significant predictors for HO development were African American race (OR 2.97, p=0.005), pre-existing osteoporosis (OR 2.72, p=0.001), spine disease (OR 2.04, p=0.036) and low estrogen states (OR 1.99, p=0.025). In the overall group, 75.64% received peri-operative non-steroidal anti-inflammatory drugs (NSAIDs), which negatively correlated with HO formation (OR 0.39, p=0.001).

Conclusions: We identified new factors potentially associated with an increased risk of developing HO after primary hip arthroplasty, including African American race, osteoporosis, and low estrogen states. These patients may benefit from HO prophylaxis, such as peri-operative NSAIDs.
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http://dx.doi.org/10.1210/clinem/dgac249DOI Listing
April 2022

Risk Factors for Delayed Hospital Admission and Surgical Treatment of Open Tibial Fractures in Tanzania.

Authors:
Jordan T Holler Abigail Cortez Sravya Challa Edmund Eliezer Billy Hoanga Saam Morshed David W Shearer

J Bone Joint Surg Am 2022 04 1;104(8):716-722. Epub 2022 Feb 1.

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

Background: Open fractures, especially of the tibia, require prompt intervention to achieve optimal patient outcomes. While open tibial shaft fractures are common injuries in low- and middle-income countries (LMICs), there is a dearth of literature examining delays to surgery for these injuries in low-resource settings. This study investigated risk factors for delayed management of open tibial fractures in Tanzania.

Methods: We conducted an ad hoc analysis of adult patients enrolled in a prospective observational study at a tertiary referral center in Tanzania from 2015 to 2017. Multivariable models were utilized to analyze risk factors for delayed hospital presentation of ≥2 hours, median time from injury to the treatment hospital, and delayed surgical treatment of ≥12 hours after admission among patients with diaphyseal open tibial fractures.

Results: Two hundred and forty-nine patients met the inclusion criteria. Only 12% of patients used an ambulance, 41% were delayed ≥2 hours in presentation to the first hospital, 75% received an interfacility referral, and 10% experienced a delay to surgery of ≥12 hours after admission. After adjusting for injury severity, having insurance (adjusted odds ratio [aOR] = 0.48; 95% confidence interval [CI] = 0.24 to 0.96) and wounds with approximated skin edges (aOR = 0.37; 95% CI = 0.20 to 0.66) were associated with a decreased risk of delayed hospital presentation. Interfacility referrals (2.3 hours greater than no referral; p = 0.015) and rural injury location (10.9 hours greater than urban location; p < 0.001) were associated with greater median times to treatment hospital admission. Older age (aOR = 0.54 per 10 years; 95% CI = 0.31 to 0.95), single-person households (aOR = 0.12 compared with ≥8 people; 95% CI = 0.02 to 0.96), and an education level greater than pre-primary (aOR = 0.16; 95% CI = 0.04 to 0.62) were associated with fewer delays to surgery of ≥12 hours after admission.

Conclusions: Prehospital network and socioeconomic characteristics are associated with delays to open tibial fracture care in Tanzania. Reducing interfacility referrals and implementing surgical cost-reduction strategies may help to reduce delays to open fracture care in LMICs.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.21.00727DOI Listing
April 2022

Cost-effectiveness analysis of prosthesis provision for patients with transfemoral amputation in Tanzania.

Authors:
Claire A Donnelley Ericka P von Kaeppler Alexander Hetherington Corin Shirley Billy T Haonga Sravya T Challa Jan Andrysek Emily Mochizuki Lutyens Leah Mamseri Geofrey Mwakasungula Saam Morshed David W Shearer

Prosthet Orthot Int 2022 Apr 8. Epub 2022 Apr 8.

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

Background: Limb loss leads to significant disability. Prostheses may mitigate this disability but are not readily accessible in low- and middle-income countries (LMICs). Cost-effectiveness data related to prosthesis provision in resource-constrained environments such as Tanzania is greatly limited.

Objectives: This study aimed to compare the cost-effectiveness of a prosthesis intervention compared with that of no prosthesis for persons with transfemoral amputations in an LMIC.

Study Design: This is a prospective cohort study.

Methods: Thirty-eight patients were prospectively followed up. Clinical improvement with prosthesis provision was measured using EuroQuol-5D, represented as quality-adjusted life years gained. Direct and indirect costs were measured. The primary outcome was incremental cost per quality-adjusted life year, measured at 1 year and projected over a lifetime using a Markov model. Reference case was set as a single prosthesis provided without replacement from a payer perspective. Additional scenarios included the societal perspective and replacement of the prosthesis. Uncertainty was measured with one-way probabilistic sensitivity analysis.

Results: From the payer perspective, the incremental cost-effectiveness ratio (ICER) was $242 for those without prosthetic replacement over a lifetime, and the ICER was $390 for those with prosthetic replacement over a lifeime. From the societal perspective, prosthesis provision was both less expensive and more effective. One-way sensitivity analysis demonstrated the ICER remained below the willingness to pay threshold up to prosthesis costs of $763.

Conclusions: These findings suggest prosthesis provision in an LMIC may be cost-effective, but further studies with long-term follow up are needed to validate the results.
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http://dx.doi.org/10.1097/PXR.0000000000000129DOI Listing
April 2022

Scoping review to evaluate existing measurement parameters and clinical outcomes of transtibial prosthetic alignment and socket fit.

Authors:
Nae Yeon Won Alexandra Paul Matthew Garibaldi Rita E Baumgartner Kenton R Kaufman Lisa Reider Jordan Wrigley Saam Morshed

Prosthet Orthot Int 2022 Apr;46(2):95-107

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

Introduction: Fit and alignment are observable objectives of the prosthesis rendering process for individuals with lower limb amputation. Nevertheless, there is a dearth of validated measures to directly assess the quality of this clinical procedure.

Objectives: The objectives of this scoping review are to evaluate existing measurement parameters and clinical outcomes used in investigations of transtibial socket fit or prosthetic alignment and to identify gaps in the literature regarding tools for evaluation of prosthetic fitting.

Study Design: Scoping literature review.

Methods: A comprehensive search was conducted in the following databases: MEDLINE (through PubMed), Embase (through Elsevier), Scopus (through Elsevier), and Engineering Village (through Elsevier), resulting in 6107 studies to be screened.

Results: Sixty-three studies were included in the review. When measuring fit, studies most frequently reported on patient-reported comfort (n = 22) and socket size compared with the residual limb volume (n = 9). Alignment was most frequently measured by the prosthetists' judgment and/or use of an alignment jig (n = 34). The measurement parameters used to determine alignment or fit varied greatly among the included studies.

Conclusion: This review demonstrated that most measures of socket fit rely on a patient's self-report and may vary with biopsychosocial factors unrelated to the socket fitting process. Meanwhile, alignment is determined mostly by the prosthetist's judgment, paired with objective measurements, such as alignment jigs and gait analysis. Efforts to standardize and validate measures of these parameters of prosthetic fitting are vital to improving clinical practice and reporting outcomes.
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http://dx.doi.org/10.1097/PXR.0000000000000061DOI Listing
April 2022

Appendicular Fracture and Polytrauma Correlate with Outcome of Spinal Cord Injury: A Transforming Research and Clinical Knowledge in Spinal Cord Injury Study.

Authors:
Theodore A Miclau Abel Torres-Espin Saam Morshed Kazuhito Morioka J Russell Huie Ashraf N El Naga Austin Chou Lisa Pascual Xuan Duong-Fernandez Yu-Hung Kuo Philip Weinstein Sanjay S Dhall Jacqueline C Bresnahan Michael S Beattie Anthony Digiorgio Adam R Ferguson

J Neurotrauma 2022 Aug 25;39(15-16):1030-1038. Epub 2022 Mar 25.

Department of Neurological Surgery, Spine Center, University of California San Francisco, San Francisco, California, USA.

Spinal cord injuries (SCIs) frequently occur in combination with other major organ injuries, such as traumatic brain injury (TBI) and injuries to the chest, abdomen, and musculoskeletal system (e.g., extremity, pelvic, and spine fractures). However, the effects of appendicular fractures on SCI recovery are poorly understood. We investigated whether the presence of SCI-concurrent appendicular fractures is predictive of a less robust SCI recovery. Patients enrolled in the Transforming Research and Clinical Knowledge in SCI (TRACK-SCI) prospective cohort study were identified and included in this secondary analysis study. Inclusion criteria resulted in 147 patients, consisting of 120 with isolated SCIs and 27 with concomitant appendicular fracture. The primary outcome was American Spinal Injury Association (ASIA) Impairment Scale (AIS) neurological grades at hospital discharge. Secondary outcomes included hospital length of stay, intensive care unit (ICU) length of stay, and AIS grade improvement during hospitalization. Multivariable binomial logistical regression analyses assessed whether SCI-concomitant appendicular fractures associate with SCI function and secondary outcomes. These analyses were adjusted for age, gender, injury severity, and non-fracture polytrauma. Appendicular fractures were associated with more severe AIS grades at hospital discharge, though covariate adjustments diminished statistical significance of this effect. Notably, non-fracture injuries to the chest and abdomen were influential covariates. Secondary analyses suggested that appendicular fractures also increased hospital length of stay. Our study indicated that SCI-associated polytrauma is important for predicting SCI functional outcomes. Further statistical evaluation is required to disentangle the effects of appendicular fractures, non-fracture solid organ injury, and SCI physiology to improve health outcomes among SCI patients.
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http://dx.doi.org/10.1089/neu.2021.0375DOI Listing
August 2022

The 1-Year Economic Impact of Work Productivity Loss Following Severe Lower Extremity Trauma.

Authors:
Joseph F Levy Lisa Reider Daniel O Scharfstein Andrew N Pollak Saam Morshed Reza Firoozabadi Kristin R Archer Joshua L Gary Robert V O'Toole Renan C Castillo Stephen M Quinnan Laurence B Kempton Clifford B Jones Michael J Bosse Ellen J MacKenzie

J Bone Joint Surg Am 2022 Jan 28. Epub 2022 Jan 28.

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

Background: Severe lower extremity trauma among working-age adults is highly consequential for returning to work; however, the economic impact attributed to injury has not been fully quantified. The purpose of this study was to examine work and productivity loss during the year following lower extremity trauma and to calculate the economic losses associated with lost employment, lost work time (absenteeism), and productivity loss while at work (presenteeism).

Methods: This is an analysis of data collected prospectively across 3 multicenter studies of lower extremity trauma outcomes in the United States. Data were used to construct a Markov model that accumulated hours lost over time due to lost employment, absenteeism, and presenteeism among patients from 18 to 64 years old who were working prior to their injury. Average U.S. wages were used to calculate economic loss overall and by sociodemographic and injury subgroups.

Results: Of 857 patients working prior to injury, 47.2% had returned to work at 1 year. The average number of productive hours of work lost was 1,758.8/person, representing 84.6% of expected annual productive hours. Of the hours lost, 1,542.3 (87.7%) were due to working no hours or lost employment, 71.1 (4.0%) were due to missed hours after having returned, and 145.4 (8.3%) were due to decreased productivity while working. The 1-year economic loss due to injury totaled $64,427/patient (95% confidence interval [CI], $63,183 to $65,680). Of the 1,758.8 lost hours, approximately 88% were due to not being employed (working zero hours), 4% were due to absenteeism, and 8% were due to presenteeism. Total productivity loss was higher among older adults (≥40 years), men, those with a physically demanding job, and the most severe injuries (i.e., those leading to amputation as well as Gustilo type-IIIB tibial fractures and type-III pilon/ankle fractures).

Conclusions: Patients with severe lower extremity trauma carry a substantial economic burden. The costs of lost productivity should be considered when evaluating outcomes.
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http://dx.doi.org/10.2106/JBJS.21.00632DOI Listing
January 2022

Outcomes of Patients With Large Versus Small Bone Defects in Open Tibia Fractures Treated With an Intramedullary Nail: A Descriptive Analysis of a Multicenter Retrospective Study.

Authors:
William T Obremskey Paul Tornetta Jason Luly Saam Morshed Robert V O'Toole Joseph R Hsu Stuart L Mitchell Ellen J Mackenzie Katherine P Frey Renan C Castillo Michael J Bosse Daniel O Scharfstein

J Orthop Trauma 2022 Aug;36(8):388-393

University of Utah School of Medicine, Salt Lake City, UT.

Objectives: To compare outcomes in patients with open tibia shaft fractures based on defect size.

Design: Retrospective review.

Setting: Eighteen trauma centers.

Population: The study included 132 patients with diaphyseal tibia bone defects >1 cm and ≥50% cortical loss treated with intramedullary nail.

Outcomes: The primary outcome was number of secondary surgeries to promote healing (bone graft, revision fixation, or bone transport). Additional outcomes included occurrence of secondary surgeries (bone graft, infection, amputation, and flap failure) and proportion healed at one year. Results are compared by "radiographic apparent bone gap" of <2.5 or ≥2.5 cm.

Results: The estimated conditional probability of bone grafting within one year given graft-free at 90 days was 44% and 47% in the <2.5 cm and ≥2.5 cm groups, respectively. An estimated infection risk of 14% was observed in both groups [adjusted hazard ratio (HR) 0.98, 95% confidence interval (CI): 0.33-2.92], estimated amputation risk was 9% (<2.5 cm) and 4% (≥2.5 cm) (unadjusted HR 0.66, 95% CI: 0.13-3.29), and estimated flap failure risk (among those with flaps) was 10% and 13%, respectively (unadjusted HR 1.71, 95% CI: 0.24-12.25). There was no appreciable difference in the proportion healed at one year between defect sizes [adjusted HR: 1.07 (95% CI, 0.63-1.82)].

Conclusions: Larger size bone defects were not associated with higher number of secondary procedures to promote healing or a lower overall one-year healing rate.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002337DOI Listing
August 2022

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

Authors:
Theodore Miclau Madeline C MacKechnie Christopher T Born Michael A MacKechnie George S M Dyer Brandon J Yuan John Dawson Cassandra Lee Chad R Ishmael Verena M Schreiber Nirmal C Tejwani Todd Ulmer David W Shearer Kiran J Agarwal-Harding Herman Johal Sariah Khormaee Sheila Sprague Paul S Whiting Heather J Roberts Richard Coughlin Rich Gosselin Melvin P Rosenwasser Anthony Johnson Jacob M Babu Myles Dworkin Melvin C Makhni Trigg McClellan Chinenye O Nwachuku Elizabeth Miclau Saam Morshed

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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http://dx.doi.org/10.2106/JBJS.21.00948DOI Listing
May 2022

Streamlining Trauma Research Evaluation With Advanced Measurement (STREAM) Study: Implementation of the PROMIS Toolbox Within an Orthopaedic Trauma Clinical Trials Consortium.

Authors:
Anthony R Carlini Susan C Collins Elena D Staguhn Katherine P Frey Robert V O'Toole Kristin R Archer William T Obremskey Julie Agel Conor P Kleweno Saam Morshed Michael J Weaver Thomas F Higgins Michael J Bosse Joseph F Levy Albert W Wu Renan C Castillo

J Orthop Trauma 2022 Jan;36(Suppl 1):S33-S39

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Level Of Evidence: Prognostic Level II.
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http://dx.doi.org/10.1097/BOT.0000000000002291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8694658PMC
January 2022

Long-Term Consequences of Major Extremity Trauma: A Pilot Study.

Authors:
Renan C Castillo Anthony R Carlini Trisha Chaffee Michael J Bosse Robert V O'Toole Conor P Kleweno Todd O McKinley Julie Agel Thomas F Higgins Saam Morshed Elena D Staguhn Rachel V Aaron Lisa Reider Albert W Wu Ellen J MacKenzie

J Orthop Trauma 2022 Jan;36(Suppl 1):S21-S25

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Summary: Limited data are available on the longer-term physical and psychosocial consequences after major extremity trauma apart from literature on the consequences after major limb amputation. The existing literature suggests that although variations in outcome exist, a significant proportion of service members and civilians sustaining major limb trauma will have less than optimal outcomes or health and rehabilitation needs over their life course. The proposed pilot study will address this gap in current research by locating and consenting METRC participants with the period of 5-7 years postinjury, identifying potential participation barriers and appropriate use of incentives, and conducting the follow-up examination at several data collection sites. The resulting data will inform the primary objective of refining and developing specific hypotheses to determine the design, scope, and feasibility of the main long-term consequences of major extremity trauma. Three METRC enrollment centers will contact past participants to achieve the goal of completing an interview, select patient-reported outcomes, perform a medical record review, and conduct an in-person clinic visit that will consist of a physical examination, blood draw, and x-ray of the study injury area. If successful, it will be possible to design studies to further examine these effects and develop future therapeutic interventions.
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http://dx.doi.org/10.1097/BOT.0000000000002297DOI Listing
January 2022

Early Advanced Weight-Bearing After Periarticular Fractures: A Randomized Trial Comparing Antigravity Treadmill Therapy Versus Standard of Care.

Authors:
Daniel J Stinner Jessica C Rivera Christopher S Smith David B Weiss Robert A Hymes Paul E Matuszewski Joshua L Gary Saam Morshed Andrew H Schmidt Jason M Wilken Kristin R Archer Lane Bailey Jacquelyn Kleihege Kevin H McLaughlin Richard E Thompson Suna Chung Craig Remenapp Ellen J MacKenzie Lisa Reider

J Orthop Trauma 2022 Jan;36(Suppl 1):S8-S13

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Summary: In current clinical practice, weight-bearing is typically restricted for up to 12 weeks after definitive fixation of lower extremity periarticular fractures. However, muscle atrophy resulting from restricting weight-bearing has a deleterious effect on bone healing and overall limb function. Antigravity treadmill therapy may improve recovery by allowing patients to safely load the limb during therapy, thereby reducing the negative consequences of prolonged non-weight-bearing while avoiding complications associated with premature return to full weight-bearing. This article describes a multicenter randomized controlled trial comparing outcomes after a 10-week antigravity treadmill therapy program versus standard of care in adult patients with periarticular fractures of the knee and distal tibia. The primary hypothesis is that, compared with patients receiving standard of care, patients receiving antigravity treadmill therapy will report better function 6 months after definitive treatment.
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http://dx.doi.org/10.1097/BOT.0000000000002285DOI Listing
January 2022

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

Authors:
Ericka P von Kaeppler Erik J Kramer Claire A Donnelley Hao-Hua Wu Elliot Marseille Edmund Eliezer Heather J Roberts David Shearer Saam Morshed

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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http://dx.doi.org/10.4314/mmj.v33i2.9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8560354PMC
June 2021

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

Authors:
Heather J Roberts Claire A Donnelley Billy T Haonga Erik Kramer Edmund N Eliezer Saam Morshed David Shearer

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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http://dx.doi.org/10.1097/OI9.0000000000000146DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8568384PMC
September 2021

Fixation of intertrochanteric femur fractures using the SIGN intramedullary nail augmented by a lateral plate in a resource-limited setting without intraoperative fluoroscopy: assessment of functional outcomes at one-year follow-up at Juba Teaching Hospital.

Authors:
Mapuor M M Areu Ericka P von Kaeppler Brian Billy Madison Akau A Aguto James Alphones Lewis G Zirkle Saam Morshed David W Shearer

OTA Int 2021 Sep 16;4(3):e133. Epub 2021 Jul 16.

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

Objectives: The incidence of hip fracture is high and increasing globally due to an aging population. Morbidity and mortality from these injuries are high at baseline and worse without prompt surgical treatment to facilitate early mobilization. Due to resource constraints, surgeons in low-income countries often must adapt available materials to meet these surgical needs. The objective of this study is to assess functional outcomes after surgical fixation of intertrochanteric femur fractures with the Surgical Implant Generation Network (SIGN) intramedullary nail augmented by a lateral SIGN plate.

Design: Prospective case series.

Setting: Juba Teaching Hospital, Tertiary Referral Hospital for South Sudan.

Participants: Adult patients with intertrochanteric hip fractures.

Intervention: SIGN nail augmented by a lateral plate.

Main Outcome Measurements: Primary outcome was hip function as measured by a modified Harris Hip Score (mHHS) at 1-year after surgery. Secondary endpoints were the occurrence of reoperation or infection at 1-year after surgery.

Results: Thirty patients were included, 16 (53%) men and 14 (47%) women, with a mean age of 62 years. Fractures were classified as AO/OTA Type 31A1 in 12 (40%) patients, 31A2 in 15 (50%) patients, and 31A3 in 3 (10%) patients. Mean mHHS at 1-year was 75.10 ± 21.2 with 76% categorized as excellent or good scores. There was 1 (3%) infection and 2 (7%) reoperations.

Conclusions: The SIGN nail augmented by a lateral plate achieved good or excellent hip function in the majority of patients with intertrochanteric hip fractures. This may be a suitable alternative to conventional implants for hip fracture patients in low-resource settings to allow mobilization.
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http://dx.doi.org/10.1097/OI9.0000000000000133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8568479PMC
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.

Authors:
Ericka P von Kaeppler Claire A Donnelley Heather J Roberts Edmund N Eliezer Billy T Haonga Saam Morshed David W Shearer

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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http://dx.doi.org/10.1097/OI9.0000000000000125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8568407PMC
June 2021

Open Ankle Fractures: What Predicts Infection? A Multicenter Study.

Authors:
Margaret E Cooke Paul Tornetta Reza Firoozabadi Heather Vallier Douglas S Weinberg Timothy B Alton Megan R Dillman Jerald R Westberg Andrew Schmidt Michael Bosse Daniel P Leas Michael Archdeacon Rafael Kakazu Ifeanyi Nzegwu Robert V OToole Timothy G Costales Max Coale Brian Mullis Rashad H Usmani Kenneth Egol Stephen Kottmeier David Sanders Cliff Jones Anna N Miller Daniel S Horwitz Harish Kempegowda Saam Morshed Tigist Belaye David Teague

J Orthop Trauma 2022 Jan;36(1):43-48

Department of Orthopaedic Surgery, University of OK Health Sciences Center, Oklahoma City, OK.

Objective: To identify the patient, injury, and treatment factors associated with an acute infection during the treatment of open ankle fractures in a large multicenter retrospective review. To evaluate the effect of infectious complications on the rates of nonunion, malunion, and loss of reduction.

Design: Multicenter retrospective review.

Setting: Sixteen trauma centers.

Patients: One thousand and 3 consecutive skeletally mature patients (514 men and 489 women) with open ankle fractures.

Main Outcome Measures: Fracture-related infection (FRI) in open ankle fractures.

Results: The charts of 1003 consecutive patients were reviewed, and 712 patients (357 women and 355 men) had at least 12 weeks of clinical follow-up. Their average age was 50 years (range 16-96), and average BMI was 31; they sustained OTA/AO types 44A (12%), 44B (58%), and 44C (30%) open ankle fractures. The rate FRI rate was 15%. A multivariable regression analysis identified male sex, diabetes, smoking, immunosuppressant use, time to wound closure, and wound location as independent risk factors for infection. There were 77 cases of malunion, nonunion, loss of reduction, and/or implant failure; FRI was associated with higher rates of these complications (P = 0.01).

Conclusions: Several patient, injury, and surgical factors were associated with FRI in the treatment of open ankle fractures.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002293DOI Listing
January 2022

Impact of prostheses on quality of life and functional status of transfemoral amputees in Tanzania.

Authors:
Ericka P von Kaeppler Alexander Hetherington Claire A Donnelley Syed H Ali Corin Shirley Sravya T Challa Emily Lutyens Billy T Haonga Saam Morshed Jan Andrysek David W Shearer

Afr J Disabil 2021 7;10:839. Epub 2021 Sep 7.

Institute of Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, United States of America.

Background: The rise of diabetes and traumatic injury has increased limb loss-related morbidity in low- and middle-income countries (LMICs). Despite this, the majority of amputees in LMICs have no access to prosthetic devices, and the magnitude of prosthesis impact on quality of life (QOL ) and function has not been quantified.

Objectives: Quantify the impact of prostheses on QOL and function in Tanzanian transfemoral amputees.

Method: A prospective cohort study was conducted. Transfemoral amputees at Muhimbili Orthopaedic Institute were assessed twice before and three times after prosthetic fitting using EuroQol-5D-3L (EQ-5D-3L), Prosthetic Limb Users Survey of Mobility (PLUS-M), 2-minute walk test (2MWT) and Physiologic Cost Index (PCI). Data were analysed for change over time. Subgroup analysis was performed for amputation aetiology (vascular or non-vascular) and prosthesis use.

Results: Amongst 30 patients, EQ-5D, PLUS-M and 2MWT improved after prosthesis provision ( 0.001). EuroQol-5D increased from 0.48 to 0.85 at 1 year ( < 0.001). EuroQol-5D and 2MWT were higher in non-vascular subgroup ( < 0.030). At 1-year, 84% of non-vascular and 44% of vascular subgroups reported using their prosthesis ( = 0.068).

Conclusion: Prosthesis provision to transfemoral amputees in an LMIC improved QOL and function. This benefit was greater for non-vascular amputation aetiologies. Quality of life and function returned to pre-prosthesis levels with discontinued use of prosthesis.
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http://dx.doi.org/10.4102/ajod.v10i0.839DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8517763PMC
September 2021

Prophylactic Topical Antibiotics in Fracture Repair and Spinal Fusion.

Authors:
Eric K Kim Claire A Donnelley Madeline Tiee Heather J Roberts Ericka Von Kaeppler David Shearer Saam Morshed

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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http://dx.doi.org/10.1155/2021/1949877DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8531801PMC
October 2021

Proximal tibia fracture dislocations: Management and outcomes of a severe and under-recognized injury.

Authors:
Lukas G Keil Brian H Mullis Paul Tornetta Iii Maxwell C Alley Nathan P Olszewski Jonathan A Wheeler Ericka P von Kaeppler Saam Morshed Robert N Matar Michael T Archdeacon Tyler W Smith Anna N Miller Daniel S Horwitz Mirza Shahid Baig Zachary L Telgheder Emil Azer Givenchy W Manzano Heather A Vallier Scott A Barnett Peter C Krause Troy D Bornes William M Ricci Patrick J Dunne Seth R Yarboro Alexander J Ment Andrew J Marcantonio Rashed S Alqudhaya Ross K Leighton Robert F Ostrum

Injury 2022 Mar 23;53(3):1260-1267. Epub 2021 Sep 23.

Departmentof Orthopaedic Surgery, University of North Carolina, Chapel Hill, NC, United States.

Introduction: Proximal tibia fracture dislocations (PTFDs) are a subset of plateau fractures with little in the literature since description by Hohl (1967) and classification by Moore (1981). We sought to evaluate reliability in diagnosis of fracture-dislocations by traumatologists and to compare their outcomes with bicondylar tibial plateau fractures (BTPFs).

Methods: This was a retrospective cohort study at 14 level 1 trauma centers throughout North America. In all, 4771 proximal tibia fractures were reviewed by all sites and 278 possible PTFDs were identified using the Moore classification. These were reviewed by an adjudication board of three traumatologists to obtain consensus. Outcomes included inter-rater reliability of PTFD diagnosis, wound complications, malunion, range of motion (ROM), and knee pain limiting function. These were compared to BTPF data from a previous study.

Results: Of 278 submitted cases, 187 were deemed PTFDs representing 4% of all proximal tibia fractures reviewed and 67% of those submitted. Inter-rater agreement by the adjudication board was good (83%). Sixty-one PTFDs (33%) were unicondylar. Eleven (6%) had ligamentous repair and 72 (39%) had meniscal repair. Two required vascular repair. Infection was more common among PTFDs than BTPFs (14% vs 9%, p = 0.038). Malunion occurred in 25% of PTFDs. ROM was worse among PTFDs, although likely not clinically significant. Knee pain limited function at final follow-up in 24% of both cohorts.

Conclusions: PTFDs represent 4% of proximal tibia fractures. They are often unicondylar and may go unrecognized. Malunion is common, and PTFD outcomes may be worse than bicondylar fractures.
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http://dx.doi.org/10.1016/j.injury.2021.09.035DOI Listing
March 2022

Smith-Petersen Versus Watson-Jones Approach Does Not Affect Quality of Open Reduction of Femoral Neck Fracture.

Authors:
Joseph T Patterson Keisuke Ishii Paul Tornetta Ross K Leighton Darin M Friess Clifford B Jones Ari Levine Jeffrey J Maclean Theodore Miclau Brian H Mullis William T Obremskey Robert F Ostrum J Spence Reid John A Ruder Anas Saleh Andrew H Schmidt David C Teague Antonios Tsismenakis Jerald R Westberg Saam Morshed

J Orthop Trauma 2021 Oct;35(10):517-522

Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA.

Objective: To compare immediate quality of open reduction of femoral neck fractures by alternative surgical approaches.

Design: Retrospective cohort study.

Setting: Twelve Level 1 North American trauma centers.

Patients: Eighty adults 18-65 years of age with isolated, displaced, OTA/AO type 31-B2 or -B3 femoral neck fractures treated with internal fixation.

Intervention: Thirty-two modified Smith-Petersen anterior approaches versus 48 Watson-Jones anterolateral approaches for open reduction performed by fellowship-trained orthopaedic trauma surgeons.

Main Outcome: Reduction quality as assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs.

Results: No difference was observed in the rate of acceptable reduction by modified Smith-Petersen (81%) versus Watson-Jones (81%) approach (risk difference null, 95% confidence interval -17.4% to 17.4%, P = 1.00) with 90.4% panel agreement (Fleiss' weighted κ = 0.63, P < 0.01). Stratified analyses did not identify a significant difference in the rate of acceptable reduction between approaches when stratified by Pauwels angle, basicervical or transcervical fracture location, or posterior comminution. The Smith-Petersen approach afforded a better reduction when preoperative skeletal traction was not applied (RR = 1.67 [95% CI 1.10-2.52] vs. RR = 0.87 [95% CI 0.70-1.08], P = 0.006).

Conclusions: No difference was observed in the quality of open reduction of displaced femoral neck fractures in young adults when a Watson-Jones anterolateral approach versus a modified Smith-Petersen anterior approach was performed by orthopaedic trauma surgeons.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002068DOI Listing
October 2021

Unilateral Sacral Fractures Demonstrate Slow Recovery of Patient-Reported Outcomes Irrespective of Treatment.

Authors:
Brian H Mullis Julie Agel Clifford Jones Jason Lowe Heather Vallier David Teague Laurence Kempton Andrew Schmidt Darin Friess Saam Morshed Anna N Miller Ross Leighton Paul Tornetta

J Orthop Trauma 2022 Apr;36(4):179-183

Department of Orthopaedics, Boston Medical Center, Boston, MA.

Objectives: To report functional outcomes of unilateral sacral fractures treated both operatively and nonoperatively.

Design: Prospective, multicenter, observational study.

Setting: Sixteen Level 1 trauma centers.

Patients/participants: Skeletally mature patients with unilateral zone 1 or 2 sacral fractures categorized as displaced nonoperative (DN), displaced operative (DO), nondisplaced nonoperative (NN), and nondisplaced operative (NO).

Main Outcome Measurements: Pelvic displacement was documented on injury plain radiographs. Short Musculoskeletal Function Assessment (SMFA) scores were obtained at baseline and at 3, 6, 12, and 24 months after injury. Displacement was defined as greater than 5 mm in any plane at the time of injury.

Results: Two hundred eighty-six patients with unilateral sacral fractures were initially enrolled, with a mean age of 40 years and mean injury severity score of 16. One hundred twenty-three patients completed the 2-year follow-up as follows: 29 DN, 30 DO, 47 NN, and 17 NO with 56% loss to follow-up at 2 years. Highest dysfunction was seen at 3 months for all groups with mean SMFA dysfunction scores: 25 DN, 28 DO, 27 NN, and 31 NO. The mean SMFA scores at 2 years for all groups were 13 DN, 12 DO, 17 NN, and 17 NO.

Conclusions: All groups (operative/nonoperative and displaced/nondisplaced) reported worst function 3 months after injury, and all but (DN) continued to recover for 2 years after injury, with peak recovery for DN seen at 1 year. No functional benefit was seen with operative intervention for either displaced or nondisplaced injuries at any time point.

Level Of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002260DOI Listing
April 2022

Effect of Severe Distal Tibia, Ankle, and Mid- to Hindfoot Trauma on Meeting Physical Activity Guidelines 18 Months After Injury.

Authors:
Kevin H McLaughlin Stuart L Mitchell Kristin R Archer Hiral Master Saam Morshed Joshua L Gary Clifford B Jones Ellen J MacKenzie Lisa Reider

Arch Phys Med Rehabil 2022 03 21;103(3):409-417.e2. Epub 2021 Aug 21.

Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD.

Objective: To examine the effect of severe lower extremity trauma on meeting Physical Activity Guidelines for Americans (PAGA) 18 months after injury and perform an exploratory analysis to identify demographic, clinical, and psychosocial factors associated with meeting PAGA.

Design: Secondary analysis of observational cohort study.

Setting: A total of 34 United States trauma centers PARTICIPANTS: A total of 328 adults with severe distal tibia, ankle and mid- to hindfoot injuries treated with limb reconstruction (N=328).

Interventions: None.

Main Outcome Measures: The Paffenbarger Physical Activity Questionnaire was used to assess physical activity levels 18 months after injury. Meeting PAGA was defined as combined moderate- and vigorous-intensity activity ≥150 minutes per week or vigorous-intensity activity ≥75 minutes per week.

Results: Fewer patients engaged in moderate- or vigorous-intensity activity after injury compared with before injury (moderate: 44% vs 66%, P<.001; vigorous: 18% vs 29%; P<.001). Patients spent 404±565 minutes per week in combined moderate- to vigorous-intensity activity before injury compared with 224±453 minutes postinjury (difference: 180min per week; 95% confidence interval [CI], 103-256). The adjusted odds of meeting PAGA were lower for patients with depression (adjusted odds ratio [AOR], 0.45; 95% CI, 0.28-0.73), women (AOR, 0.59; 95% CI, 0.35-1.00), and Black or Hispanic patients (AOR, 0.49; 95% CI, 0.28-0.85). Patients meeting PAGA prior to injury were more likely to meet PAGA after injury (odds ratio, 2.0; 95% CI, 1.20-3.31).

Conclusions: Patients spend significantly less time in moderate- to vigorous-intensity physical activity after injury. Patients with depression are less likely to meet PAGA. Although the causal relationship is unclear, results highlight the importance of screening for depression.
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http://dx.doi.org/10.1016/j.apmr.2021.07.805DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9178527PMC
March 2022

The Burden of Patients With Lower Limb Amputations in a Community Safety-net Hospital.

Authors:
Christopher C Stewart Eleni Berhaneselase Saam Morshed

J Am Acad Orthop Surg 2022 Jan;30(1):e59-e66

From the Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA.

Background: The functional disability after amputation is tremendous and imposes a high economic burden on patients and health systems. The current literature on the costs of amputation has been limited to the index hospitalization or a short time window around the amputation procedure, which covers a small percentage of the total costs.

Methods: We conducted a retrospective cohort study of patients who underwent lower extremity amputations at a single urban public level 1 trauma hospital. Resource utilization and healthcare costs 1 year before and 1 year after the index amputation were examined. Hospitalization costs were estimated using cost center-based cost-to-charge ratios for the 2-year follow-up.

Results: The sample comprised 90 patients (73 men and 17 women) with a mean age of 55.9 years (SD, 9.9). Most amputations were secondary to diabetes (74%) and vascular disease in the absence of diabetes (22%). During the 2-year window around the index amputation, patients had an average of 2.7 admissions (SD, 2.3), mean index length of stay of 14.6 days (SD, 22.3), and a mean cumulative length of stay of 31.3 days (SD, 43.4). The patients had a mean of 2.3 (SD, 3.2) additional procedures performed on their amputated limb. Twenty-one patients (23%) required additional proximal amputations, with an average change of 2.2 (SD, 1.6) levels. The mean cost, per patient, of the index hospitalization was $51,481. Over the 2-year period, the mean cost of hospitalizations was $114,292 per patient with a total cost, summed over the cohort, of $10,286,250. Approximately 64% of the total cost went uncompensated.

Discussion: Over a 2-year window, amputees endured multiple procedures, readmissions, and reamputations, leading to high healthcare costs. Further research into resource-conscious interventions and programs is needed to control the burdens faced by amputees and the health systems that care for them.
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http://dx.doi.org/10.5435/JAAOS-D-21-00293DOI Listing
January 2022

Timing of Flap Coverage With Respect to Definitive Fixation in Open Tibia Fractures.

Authors:
Casey Kuripla Paul Tornetta Clary J Foote Justin Koh Andrew Sems Tayseer Shamaa Heather Vallier Debra Sorg Hassan R Mir Benjamin Streufert Clay Spitler Brian Mullis Brian McGowan John Weinlein Lisa Cannada Jonathan Charlu Emily Wagstrom Jerald Westberg Saam Morshed Abigail Cortez Peter Krause Andrew Marcantonio Gillian Soles Jason Lipof

J Orthop Trauma 2021 08;35(8):430-436

Strong Memorial Hospital, Rochester, NY.

Objectives: We conducted a large, U.S wide, observational study of type III tibial fractures, with the hypothesis that delays between definitive fixation and flap coverage might be a substantial modifiable risk factor associated with nosocomial wound infection.

Design: A retrospective analysis of a multicenter database of open tibial fractures requiring flap coverage.

Setting: Fourteen level-1 trauma centers across the United States.

Patients: Two hundred ninety-six (n = 296) consecutive patients with Gustilo III open tibial fractures requiring flap coverage at 14 trauma centers were retrospectively analyzed from a large orthopaedic trauma registry. We collected demographics and the details of surgical care. We investigated the patient, and treatment factors leading to infection, including the time from various points in care to the time of soft-tissue coverage.

Intervention: Delay definitive fixation and flap coverage in tibial type III fractures.

Main Outcome Measurements: (1) Results of multivariate regression with time from injury to coverage, debridement to coverage, and definitive fixation to coverage in the model, to determine which delay measurement was most associated with infection. (2) A second multivariate model, including other factors in addition to measures of flap delay, to provide the estimate between delay and infection after adjustment for confounding.

Results: Of 296 adults (227 M: 69 F) with open Gustilo type III tibial fractures requiring flap coverage, 96 (32.4%) became infected. In the multivariate regression, the time from definitive fixation to flap coverage was most predictive of subsequent wound infection (odds ratio 1.04, 95% confidence interval 1.01 to 1.08, n = 260, P = 0.02) among the time measurements. Temporary internal fixation was not associated with an increased risk of infection in both univariate (P = 0.59) or multivariate analyses (P = 0.60). Flap failure was associated with the highest odds of infection (odds ratio 6.83, 95% confidence interval 3.26 to 14.27, P < 0.001).

Conclusion: Orthoplastic teams that are dedicated to severe musculoskeletal trauma, that facilitate coordination of definitive fixation and flap coverage, will reduce the infection rates in Gustilo type III tibial fractures.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002033DOI Listing
August 2021

Accuracy of institutional orthopedic trauma databases: a retrospective chart review.

Authors:
Aman Chopra Abigail C Cortez Ashraf El Naga Anthony Ding Saam Morshed

J Orthop Surg Res 2021 Jun 7;16(1):363. Epub 2021 Jun 7.

Orthopaedic Trauma Institute, UCSF Department of Orthopaedic Surgery, 2550 23rd St, San Francisco, CA, 94110, USA.

Introduction: Academic trauma institutions rely on fracture databases as research and quality control tools. Frequently, these databases are populated by trainees, but the completeness and accuracy of such databases has not yet been evaluated. The purpose of this study is to determine the capture rate of a resident-populated database in collecting extremity fractures and to determine the accuracy of assigned Orthopaedic Trauma Association (OTA) classifications.

Materials And Methods: A retrospective study was performed at a level 1 trauma center of all adult patients who underwent treatment for extremity fractures after an emergency department or inpatient consultation. A 20% random sample was taken from these entries and compared to a resident-populated fracture database designed to capture the same patients. For all matching records containing a resident-assigned OTA classification, relevant imaging was blindly reviewed by a trauma fellowship-trained orthopedic attending surgeon for fracture pattern classification. Resident OTA classifications were compared to this gold standard to determine overall accuracy rate.

Results: Three hundred eighteen (80%) out of 400 entries were captured by the resident-populated database. Two hundred thirty-one of these 318 entries contained an OTA classification. One hundred fifty-three (66%) of these 231 entries demonstrated concordance between resident and attending assigned OTA classifications. On subgroup analysis, 133 (70%) of the 190 lower extremity classifications were accurately identified as compared to just 20 (49%) of the 41 upper extremity classifications (p = 0.009). Seventy-nine (65%) of the 121 end segment fractures showed agreement versus 42 (67%) of the 63 diaphyseal injury patterns (p = 0.85). Accuracy of classification did not significantly vary by resident year of training (p = 0.142).

Conclusion: Trainee generated databases at academic institutions may be subject to incomplete data entry and inaccurate fracture classifications. Quality control measures should be instituted to ensure accuracy in such databases if efforts are invested with the expectation of useful information.
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http://dx.doi.org/10.1186/s13018-021-02478-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182920PMC
June 2021
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