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Introduction: Spondylodiscitis (SD) is an infection of the intervertebral disc with involvement of the adjacent vertebral bodies. Diagnostic tests with CT-guided biopsy only provide a positive yield in 14%–48% of cases. Percutaneous endoscopic debridement and drainage (PEDD) has recently shown promise in the treatment of spondylodiscitis. Research question: The purpose of this study is to determine differences in pathogen identification and clinical outcomes for PEDD versus CT-guided needle biopsy in SD patients. Materials and methods: We conducted a systematic review of the literature using PRISMA guidelines to determine differences in positive microbiology results, perioperative complications, pain control, and long-term clinical outcomes for PEDD vs. CT-guided needle biopsy in SD patients. Results: 1078 studies were evaluated, 87 of which underwent full review. 15 studies met the inclusion and exclusion criteria, including 7 PEDD, 7 CT-guided biopsy, and 1 CT-guided biopsy vs. PEDD article, for a total of 192 PEDD patients and 604 CT-guided biopsy patients. We found 36.59% of CT-guided biopsy patients had positive microbiology results, compared to 84.38% of PEDD patients. No major perioperative complications occurred as a result of the PEDD procedure. Of the five PEDD studies that reported pain outcomes, greater than 80% of patients experienced relief after intervention. Discussion and conclusion: These results suggest that PEDD may improve pathogen identification while simultaneously reducing pain compared to CT-guided needle biopsy in SD. Although current treatment guidelines recommend CT-guided biopsy, in patients with severe back pain and suspected SD, PEDD can be considered an alternative intervention.

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

Abstract Background Open tibia fractures are a major source of disability in low- and middle-income countries (LMICs) due to the high incidence of complications, particularly infection and chronic osteomyelitis. One proposed adjunctive measure to reduce infection is prophylactic local antibiotic delivery, which can achieve much higher concentrations at the surgical site than can safely be achieved with systemic administration. Animal studies and retrospective clinical studies support the use of gentamicin for this purpose, but no high-quality clinical trials have been conducted to date in high- or low-income settings. Methods We describe a protocol for a pilot study conducted in Dar es Salaam, Tanzania, to assess the feasibility of a single-center masked randomized controlled trial to compare the efficacy of locally applied gentamicin to placebo for the prevention of fracture-related infection in open tibial shaft fractures. Discussion The results of this study will inform the design and feasibility of a definitive trial to address the use of local gentamicin in open tibial fractures. If proven effective, local gentamicin would be a low-cost strategy to reduce complications and disability from open tibial fractures that could impact care in both high- and low-income countries. Trial registration ClinicalTrials.gov, Registration # NCT03559400 ; Registered June 18, 2018.

Background: For the surgical treatment of single-level degenerative spondylolisthesis (DS), patients can be treated with either an anterior or posterior interbody fusion. Prior studies have shown that patients with symptomatic degenerative spondylolisthesis treated surgically maintain substantially greater pain relief and improvement in function when compared to those treated non-operatively, but no consensus has emerged between which approach results in the best outcomes. Methods: The PearlDiver MARINER database was queried for patients with single-level DS who underwent either an anterior or posterior lumbar interbody fusion. Both populations were compared on multiple outcomes, including reoperation, post-operative complications, and readmission rates at 90 days, as well as rates of reoperation and cauda equina syndrome two-years postoperatively. Results: At 90 days patients who underwent anterior interbody were found to have higher rates of DVT (OR 2.53, 95% CI 1.74 – 3.70, p

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

A prospective observational cohort of 20 primary total hip arthroplasty (n = 12) and total knee arthroplasty (n = 8) patients (mean age: 63 ± 6 years) was passively monitored with a consumer-level wearable activity sensor before and 6 weeks after surgery. Patients were clustered by minimal change or decreased activity using sensor data. Decreased postoperative activity was associated with greater pain reduction (−5.5 vs −2.0, P = .03). All patients surpassed minimal clinical benefit thresholds of total joint arthroplasty (TJA) (Hip Disability and Osteoarthritis Score Junior 30.5 vs 20.8, P = .23; Knee Injury and Osteoarthritis Outcome Score Junior 23.3 vs 18.2, P = .77) within 6 weeks. Patients who objectively “take it easy” after TJA may experience less pain with no difference in early subjective outcome. Remote, passive analysis of outpatient wearable sensor data may permit real-time detection of early problems after TJA. Keywords: Hip arthroplasty, Knee arthroplasty, Activity tracking, Sensors, Wearable, Pain

BackgroundThe burden of complex orthopedic trauma in low- and middle-income countries (LMICs) is exacerbated by soft-tissue injuries, which can often lead to amputations. This study's purpose was to create and evaluate the Surgical Management and Reconstruction Training (SMART) course to help orthopedic surgeons from LMICs manage soft-tissue defects and reduce the rate of amputations.MethodsIn this prospective observational study, orthopedic surgeons from LMICs were recruited to attend a 2-day SMART course taught by plastic surgery faculty in San Francisco. Before the course, participants were asked to assess the burden of soft-tissue injury and amputation encountered at their respective sites of practice. A survey was then given immediately and 1-year postcourse to evaluate the quality of instructional materials and the course's effect in reducing the burden of amputation, respectively.ResultsFifty-one practicing orthopedic surgeons from 25 countries attended the course. No participant reported previously attempting a flap reconstruction procedure to treat a soft-tissue defect. Before the course, participants cumulatively reported 580-970 amputations performed annually as a result of soft-tissue defects. Immediately after the course, participants rated the quality and effectiveness of training materials to be a mean of ≥4.4 on a Likert scale of 5 (Excellent) in all 14 instructional criteria. Of the 34 (66.7%) orthopedic surgeons who completed the 1-year postcourse survey, 34 (100%, 'P' < 0.01) reported performing flaps learned at the course to treat soft-tissue defects. Flap procedures prevented 116 patients from undergoing amputation; 554 (93.3%) of the cumulative 594 flaps performed by participants 1 year after the course were reported to be successful. Ninety-seven percent of course participants taught flap reconstruction techniques to colleagues or residents, and a self-reported estimate of 28 other surgeons undertook flap reconstruction as a result of information dissemination by 1 year postcourse.ConclusionThe SMART Course can give orthopedic surgeons in LMICs the skills and knowledge to successfully perform flaps, reducing the self-reported incidence of amputations. Course participants were able to disseminate flap reconstructive techniques to colleagues at their home institution. While this course offers a collaborative, sustainable approach to reduce global surgical disparities in amputation, future investigation into the viability of teaching the SMART course in LMICs is warranted.