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Purpose The purpose of this study was to determine perspectives of surgeons regarding simultaneous surgery in patients undergoing posterior spine instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS). Methods A survey was administered to orthopaedic trainees and faculty regarding simultaneous surgery for primary PSIF for AIS. A five-point Likert scale (1: ‘Strongly Disagree’ to 5: ‘Strongly Agree’) was used to assess agreement with statements about simultaneous surgery. We divided simultaneous surgery into concurrent, when critical portions of operations occur at the same time, and overlapping, when noncritical portions occur at the same time. Results The 72 respondents (78.3% of 92 surveyed) disagreed with concurrent surgery for ‘one of my patients’ (response mean 1.76 (sd 1.03)) but were more accepting of overlapping surgery (mean 3.94 (sd 0.99); p < 0.0001). The rating difference between concurrent and overlapping surgery was smaller for paediatric and spine surgeons (-1.25) than for residents or those who did not identify a subspecialty (-2.17; p = 0.0246) or other subspecialty surgeons (-2.57; p = 0.0026). Respondents were more likely to agree with explicit informed consent for concurrent surgery compared with overlapping (mean 4.32 (sd 0.91) versus 3.44 (sd 1.14); p < 0.001). Conclusion Orthopaedic surgeons disagreed with concurrent but were more accepting of overlapping surgery and anaesthesia for PSIF for AIS. Respondents were in greater agreement that patients should be explicitly informed of concurrence than of overlap. The surgical community's evidence and position regarding simultaneous surgery, in particular overlapping, must be more effectively presented to the public in order to bridge the gap in perspectives. Level of Evidence IV

The accuracy of preoperative patient-reported weight was never evaluated in patients undergoing lower extremity procedures. The purpose of this study was to: (1) compare the disparity between patient-reported and measured weights in patients undergoing lower extremity total joint arthroplasty (LE-TJA) and arthroscopy; and (2) investigate the association between patient-specific factors (patient age, BMI, zip code, and psychiatric comorbidities) and the accuracy of patient-reported weight. Preoperative self-reported weights were retrospectively compared to measured weights in 400 LE-TJA and 85 control arthroscopy patients. The difference between reported and measured weights was calculated. Additionally, the percent of accurate reporting within 0.5, 1, and 5 kg ranges of the measured weight was calculated. Outcomes were compared between surgical modalities as well as between patient-specific factors. There was low disparity (p = 0.838) between patient-reported and measured weights among LE-TJA (mean difference 0.18 ± 3.63 kg; p = 0.446) and that of arthroscopy (0.27 ± 4.08 kg; p = 0.129) patients. Additionally, LE-TJA patients were equally likely to report weights accurately within 0.5 kg of the measured weight (74% vs. 71.76%; p = 0.908). LE-TJA and arthroscopy patients had similar reporting accuracy within 1 and 5 kg of the measured weights (p > 0.05). Preoperative patient-reported weights demonstrated acceptable accuracy in both LE-TJA and lower extremity arthroscopic orthopaedic patient populations making it a potentially reliable parameter of preoperative assessment.

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. publishedVersion

BackgroundFemur 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.ResultsThe average economic burden incurred was $149, 9% of a caregiver’s annual income and positively correlated with patient time in hospital (p

Introduction Although matching lumbar lordosis (LL) with pelvic incidence (PI) is an important surgical goal for adult spinal deformity (ASD), there is concern that overcorrection may lead to proximal junctional kyphosis (PJK). We introduce the upper instrumented vertebra–femoral angle (UIVFA) as a measure of appropriate postoperative position in the setting of lower thoracic to pelvis surgical correction for patients with sagittal imbalance. We hypothesize that a more posterior UIV position in relation to the center of the femoral head is associated with an increased risk of PJK given compensatory hyperkyphosis above the UIV. Methods In this retrospective cohort study, adult patients undergoing lower thoracic (T9–T12) to pelvis correction of ASD with a minimum of 2-year follow-up were included. UIVFA was measured as the angle subtended by a line from the UIV centroid to the femoral head center to the vertical axis. Patients who developed PJK and those who did not were compared with preoperative and postoperative UIVFA as well as change between postoperative and preoperative UIVFA (deltaUIVFA). Results Of 119 patients included with an average 3.6-year follow-up, 51 (42.9%) had PJK and 24 (20.2%) had PJF. Patients with PJK had significantly higher postoperative UIVFA (12.6 ± 4.8° vs. 9.4 ± 6.6°, p = 0.04), deltaUIVFA (6.1 ± 7.6° vs. 2.1 ± 5.6°, p p = 0.04), postoperative lumbar lordosis (47.7 ± 13.9° vs. 42.4 ± 13.1, p = 0.04) and postoperative thoracic kyphosis (44.9 ± 13.2 vs. 31.6 ± 18.8) than patients without PJK. With multivariate logistic regression, postoperative UIVFA and deltaUIVFA were found to be independent risk factors for PJK (p p Conclusion The more posterior the UIV is from the femoral head center after lower thoracic to pelvis surgical correction for ASD, the more patients are at risk for PJK. The greater the magnitude of posterior translation of the UIV from the femoral head center from preop to postop, the greater the likelihood for PJF.

BACKGROUND: Return to work after shoulder arthroplasty for glenohumeral osteoarthritis (OA) is an important consideration for an aging workforce. QUESTIONS/PURPOSES: The aim of this study was to compare the shoulder function, pain levels, and rate of return to work in patients treated with anatomic total shoulder arthroplasty (aTSA) versus humeral hemiarthroplasty (HHA). METHODS: A retrospective review of consecutive HHA patients was performed of our institution’s shoulder arthroplasty registry. Inclusion criteria were pre-operative diagnosis of end-stage OA and more than 2 years’ follow-up. HHA patients were statistically matched to aTSA patients and then screened for pre-operative work status; 26 HHA and 23 aTSA patients worked before surgery. There was no difference in average age (HHA, 62.4 years; aTSA, 61.7 years) or follow-up (HHA, 67.5 months; aTSA, 66.9 months). RESULTS: Average American Shoulder and Elbow Surgeons (ASES) scores (HHA, 37.6 to 70.3; aTSA, 35.6 to 80.1) and visual analogue scale (VAS) for pain scores (HHA, 6.1 to 2.3; aTSA, 6.5 to 0.6) improved in both groups. However, HHA patients had worse final VAS scores, and aTSA patients were more satisfied (100% vs 77%); 61.5% of HHA patients returned to work post-operatively versus 87.0% of aTSA patients. There was no difference in time to return to work (HHA, 1.9 ± 2.3 months; aTSA, 1.3 ± 1.0 months). CONCLUSION: Patients with shoulder OA undergoing aTSA have higher rates of return to work, function, and satisfaction than those undergoing HHA. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-019-09692-0) contains supplementary material, which is available to authorized users.

BACKGROUND There are few validated instruments that serve as a proxy for fracture-healing after lower-extremity trauma in low-resource settings. The squat-and-smile test (S&S) has been under development by SIGN (Surgical Implant Generation Network) Fracture Care International to monitor outcomes of lower-extremity long-bone fractures after intramedullary nailing in resource-limited settings. The goals of this study were to develop and identify domains of the S&S test. METHODS The S&S domains were developed through an iterative process, and consensus was achieved regarding 3: squat depth, support needed to squat, and facial expression. Adult patients with an OTA/AO type-32 femoral shaft fracture were included in this retrospective study and had the S&S administered at 6 weeks and 3, 6, and 12 months postoperatively. Two authors independently assessed photographs of the patients performing the S&S. S&S domains were correlated with the EuroQol 5-Dimensions (EQ-5D) index score, and comparisons were made between S&S domains and reoperation status. Interrater and test-retest reliability was assessed using the kappa statistic. Sensitivity and specificity analyses were performed. RESULTS Six hundred and nine S&S images were evaluated for 231 patients. Each domain improved over time and correlated positively with EQ-5D scores (p < 0.05). Squat depth and support needed to squat correlated with the need for a reoperation (p ≤ 0.01), and both had high specificity (0.95 and 0.97, respectively) for ruling out the need for a reoperation at 1 year. All 3 domains had high test-retest reliability (κ = 0.95, 0.92, and 0.96). Squat depth and need for support also had strong interrater reliability (κ = 0.75 and 0.78). CONCLUSIONS The S&S is a potential tool for monitoring clinical and functional outcome of femoral shaft fractures in low-resource settings. Our data support the binary assessment of squat depth and need for support, but not facial expression, as a proxy for fracture-healing. Future prospective studies in external populations are warranted to evaluate the validity, reliability, and responsiveness of the S&S. CLINICAL RELEVANCE The S&S provides a valuable proxy for femoral shaft fracture assessment for middle to low-income countries because it is locally relevant (based on squatting), it is easy to administer, and assessment can be performed remotely via mobile telephone or text messaging.

Study Design: Retrospective cohort study. Objective: Overcorrection in adult spinal deformity (ASD) surgery may lead to proximal junctional kyphosis (PJK) because of posterior spinal displacement. The aim of this paper is to determine if the L1 position relative to the gravity line (GL) is associated with PJK. Methods: ASD patients fused from the lower thoracic spine to sacrum by 4 spine surgeons at our hospital were retrospectively studied. Lumbar-only and upper thoracic spine fusions were excluded. Spinopelvic parameters, the L1 plumb line (L1PL), L1 distance to the GL (L1-GL), and Roussouly type were measured. Results: One hundred fourteen patients met inclusion criteria (63 patients with PJK, 51 without). Mean age and follow up was 65.51 and 3.39 years, respectively. There was no difference between the PJK and the non-PJK groups in baseline demographics, pre-operative and immediate post-operative pelvic incidence-lumbar lordosis mismatch, sagittal vertical axis, or coronal Cobb. The immediate postoperative L1-GL was -7.24 cm in PJK and -3.45 cm in non-PJK ( P < 0.001), L1PL was 1.71 cm in PJK and 3.07 cm in non-PJK ( P = 0.004), and PT (23.76° vs 18.90°, P = 0.026) and TK (40.56° vs 31.39°, P < 0.001) were larger in PJK than in non-PJK. After univariate and multivariate analyses, immediate postoperative TK and immediate postoperative L1-GL were independent risk factors for PJK without collinearity. Conclusions: A dorsally displaced L1 relative to the GL was associated with an increased risk of PJK after ASD surgery. The postoperative L1-GL distance may be a factor to consider during ASD surgery.

BACKGROUND CONTEXT Although matching lumbar lordosis (LL) with pelvic incidence (PI) is an important surgical goal for adult spinal deformity (ASD), there is concern that overcorrection may lead to proximal junctional kyphosis (PJK). We introduce the upper instrumented vertebra – femoral angle (UIVFA) as a measure of appropriate postoperative position in the setting of lower thoracic to pelvis surgical correction for patients with sagittal imbalance. We hypothesize that a more posterior UIV position in relation to the center of the femoral head is associated with an increased risk of PJK given compensatory hyperkyphosis above the UIV. PURPOSE The purpose of this study is to evaluate if increased UIVFA is associated with PJK in operative management of ASD. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Adult patients undergoing lower thoracic (T9-T12) to pelvis correction of ASD with a minimum of two-year follow-up were included. OUTCOME MEASURES The primary outcome is PJK and proximal junctional failure (PJF). Methods In this retrospective cohort study, adult patients undergoing lower thoracic (T9-T12) to pelvis correction of ASD with a minimum of two-year follow-up were included. UIVFA was measured as the angle subtended by a line from the UIV centroid to the femoral head center to the vertical axis. UIV posterior to the femoral head center was positive (+) and UIV anterior the femoral head center was negative (-). A >10° kyphotic angle between the UIV and UIV+2 or a >10° increase from preop to postop were used to determine PJK. Patients with PJK that required revision surgery were defined as proximal junctional failure (PJF). Patients who developed PJK and those who did not were compared with preoperative and postoperative UIVFA, change between postoperative and preoperative UIVFA (deltaUIVFA), sagittal vertical axis (SVA), pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), lumbar lordosis (LL), pelvic incidence minus lumbar lordosis (PI-LL), thoracic kyphosis at T5-12 (TK) and the central sacral vertical line (CSVL). Results Of the 119 patients included in the study with an average 3.6-year follow-up, 51 (42.9%) had PJK and 24 (20.2%) had PJF. The average preoperative UIVFA was 7.0±0.7°, the average postoperative UIVFA 10.8±0.6°, and the average deltaUIVFA was 3.8±0.6°. Patients with PJK had significantly higher postoperative UIVFA (12.6±4.8° vs 9.4±6.6°, p=0.04), deltaUIVFA (6.1±7.6° vs 2.1±5.6°, p Conclusions The more posterior the UIV is from the femoral head center after lower thoracic to pelvis surgical correction for ASD, the more patients are at risk for PJK. The greater the magnitude of posterior translation of the UIV from the femoral head center from preop to postop, the greater the likelihood for PJF. Further investigation into the consequences of sagittal overcorrection in the setting of ASD is warranted. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Study Design: Retrospective cohort. Objective: Reoperation to lumbar spinal fusion creates significant burden on patient quality of life and healthcare costs. We assessed rates, etiologies, and risk factors for reoperation following elective 1 to 2 level lumbar fusion. Methods: Patients undergoing elective 1 to 2 level lumbar fusion were identified using the Health Care Utilization Project (HCUP) state inpatient databases from Florida and California. Patients were tracked for 5 years for any subsequent lumbar fusion. Cox proportional hazard analyses for reoperation were assessed using the following covariates: fusion approach type, age, race, Charlson comormidity index, gender, and length of stay. Distribution of etiologies for reoperation was then assessed. Results: 71, 456 patients receiving elective 1 to 2 level lumbar fusion were included. A 5-year reoperation rate of 13.53% and mortality rate of 2.22% was seen. Combined anterior-posterior approaches (HR = 0.904, p < 0.05) and TLIF (HR = 0.867, p < 0.001) were associated with reduced risk of reoperation compared to stand-alone anterior approaches and non-TLIF posterior approaches. Age, gender, and number of comorbidities were not associated with risk of reoperation. From 1 to 5 years, degenerative disease rose from 43.50% to 50.31% of reoperations; mechanical failure decreased from 37.65% to 29.77%. Conclusions: TLIF and combined anterior-posterior approaches for 1 to 2 level lumbar fusion are associated with the lowest rate of reoperation. Number of comorbidities and age are not predictive of reoperation. Primary etiologies leading to reoperation were degenerative disease and mechanical failure. Mortality rate is not increased from baseline following 1 to 2 level lumbar fusion.

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: The Short Musculoskeletal Function Assessment (SMFA) tool measures function and quality of life in patients with musculoskeletal conditions. Objective: This study aimed to translate and adapt culturally the SMFA into Chichewa, and assess its clinimetric properties. Methods: The translated Chichewa version was administered to 53 patients with musculoskeletal disorders. To assess repeatability, an additional 20 patients answered the questionnaire twice over a time interval of two weeks. Internal consistency, floor and ceiling effects, and repeatability were tested; construct validity was assessed with the World Health Organization Quality of Life Assessment tool (WHOQOL-BREF). Results: There was good internal consistency for both Dysfunction and Bothersome indices (Cronbach’s alpha 0.90) and good construct validity between both indices with the WHOQOL-BREF. Pearson’s correlation coefficient and intraclass correlation coefficient (ICC) for repeatability for the Dysfunction Index were 0.941 and 0.922 (95% CI: 0.772, 0.971) respectively, and 0.877 and 0.851 (95% CI: 0.629, 0.941) for the Bothersome Index respectively. Conclusion: The translated Chichewa SMFA is a valid tool for populations that speak the Chichewa language. publishedVersion

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

This review aims to (1) assess the breadth of pediatric orthopaedic research in low- and middle-income countries (LMICs) and (2) determine the impact of academic collaboration (an LMIC and a non-LMIC investigator) in published LMIC research. Pediatric orthopaedic clinical studies conducted in LMICs from 2004 to 2014 were extracted from Embase, Cochrane, and Pubmed databases. Of 22,714 searched studies, 129 met inclusion criteria. 85% generated low-quality evidence (level IV or lower). 21% were collaborative, and these were more likely than non-collaborative papers to generate level III evidence or higher (25% vs 13%, p = 0.141). Pediatric orthopaedic research produced by LMICs rarely achieves level I–III evidence, but collaborative studies are associated with higher levels of evidence. Level of evidence: N/A.

INTRODUCTION Traumatic lower extremity injuries requiring multidisciplinary treatment pose a challenge in low- and middle-income countries, where access to specialists may be limited. The surgical management and reconstructive training (SMART) course teaches orthopaedic surgeons muscle and fasciocutaneous flap procedures to address this scarcity. The purpose of this study is to assess the effectiveness of the SMART course in improving competency and comfort in performing common lower extremity flap procedures among participants. METHODS Sixty-four orthopaedic surgeons from different regions of Nepal and Bhutan participated in the Nepal SMART course in 2016 and 2017. A competency test-consisting of questions from US in-training plastic and orthopaedic surgery examinations-was administered to attendees before and after the course. Thirty-two participants from 2016 were asked to rate their comfort level in performing flap procedures both pre- and postcourse. RESULTS Overall competency test scores, as well as scores in the plastic surgery section, increased significantly after the course (P < 0.01). The precourse competency test scores were higher in 2016 compared with 2017 (P = 0.02). There was a higher increase in overall competency test scores after the course in 2016 compared with 2017 (P = 0.03). The procedure comfort levels reported by attendees increased for all flaps (P < 0.01). CONCLUSIONS These results demonstrate the ability of the SMART course to improve the competency and comfort levels of orthopaedic surgeons in performing common lower extremity flap procedures. Despite the differences in years in practice and previous experience in performing flaps, the course yielded significantly better results in 2017 compared with 2016, showing that the implementation of the course has been improving.

To determine the rate of return to sports and clinical outcomes after anteromedialization (AMZ) tibial tubercle osteotomy (TTO) for patients with patellofemoral pain and/or osteoarthritis.This study is a retrospective case series of consecutive patients who underwent unilateral or staged bilateral AMZ TTO for a primary diagnosis of patellofemoral pain or arthritis. Included were all patients with minimum 1-year follow-up. The indication for surgery was failure of at least 6 months of nonoperative treatment. Simultaneous tubercle distalization or proximal-medial soft-tissue procedures were excluded; however, prior patellar instability procedures did not prohibit inclusion if there was no recurrence. A diagnostic arthroscopy was performed to evaluate the cartilage surfaces; AMZ TTO was performed by use of a freehand technique and two 4.5-mm fully threaded screws for fixation. A gradual return to activities was permitted at 6 months; however, contact sports were prohibited until 9 months postoperatively. Patients were evaluated retrospectively for participation in sports using a questionnaire about the level of participation, return to sporting activities, and Kujala score. Statistical analysis included 1-way analysis of variance and χForty-eight patients played sports within 3 years before surgery. The majority were female patients (84.2%). The average age at surgery was 29.6 years, with an average follow-up period of 4.6 years. The average Kujala score improved from 51.2 to 82.6 (P.0001); the average pain score improved from 4.1 to 1.8 (P.001). Of the patients, 83.3% returned to at least 1 sport on average 7.8 months postoperatively. Of these, 77.5% believed they returned to sports at the same level or a higher level.Patients undergoing AMZ TTO for patellofemoral pain or arthritis had an 83.3% rate of return to 1 or more sporting activities at an average of 7.8 months after surgery, with many patients returning at the same level or a higher level of intensity compared with their preoperative state.Level IV, retrospective case series.

Pseudoarthrosis after long adult deformity reconstruction is defined as failure of bony union when surgical arthrodesis is attempted. It accounts for nearly a quarter of reoperation and can present with pain and hardware failure. A thorough work-up, including infectious labs, radiographs, CT, and MRI, should be utilized for treatment planning. Surgery for pseudoarthrosis should correct alignment, improve stiffness of the construct and augment bony healing with use of adjuncts, such as autograft, allograft or BMP.

BACKGROUND CONTEXT There is a dearth of literature on outcomes of fusionless tethering for the correction of skeletally immature idiopathic scoliosis of the thoracolumbar spine. While anterior vertebral body tethering (AVBT) is most commonly performed, combined thoracic anterior and lumbar posterior tethering (TALPT) may offer less perioperative morbidity. PURPOSE The purpose of this study is to compare the perioperative outcomes of AVBT with TALPT in skeletally immature patients with idiopathic scoliosis. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Skeletally immature patients with Lenke 5 or 6 curves of at least 40° with at least two-year follow-up who underwent AVBT or TALPT from 2014-2018 were included. OUTCOME MEASURES The primary outcome is revision. Secondary outcomes include procedure duration, estimated blood loss (EBL), length of stay (LOS), total postoperative opioid morphine equivalent (OME), foley duration, days to solid food, direct cost and 30-day readmission. Methods In this IRB-approved retrospective cohort study, AVBT and TALPT were compared with respect to primary and secondary outcome measures. AVBT was performed lateral decubitus through an open, muscle-sparing approach. TALPT patients underwent a single-stage anterior tethering for the thoracic curve and unilateral posterior tethering on the convexity of the lumbar curve. Results Of 48 enrolled patients, 6 (12.5%) underwent TALPT while 42 (87.5%) underwent AVBT. TALPT and AVBT patients had no difference in revision rate at two-years postoperatively (33% vs 36%, p=0.90). TALPT patients had increased direct cost in USD ($68,365±$17,863 vs $42,157.10±$14,459, p 0.05). Conclusions Skeletally immature idiopathic scoliosis patients who undergo TALPT have equivalent two-year revision rates and perioperative outcome compared to AVBT patients. However, TALPT had significantly increased cost and procedure time. Future research into outcomes of TALPT is warranted. FDA DEVICE/DRUG STATUS Zimmer Spinal Tether (Not approved for this indication)

BACKGROUND CONTEXT In the treatment of skeletally immature idiopathic scoliosis, outcomes for combined Thoracic Anterior and Lumbar Posterior Tethering (TALPT) and posterior spinal fusion and instrumentation (PSF) have never been compared. PURPOSE The purpose of this study is to compare the outcomes of TALPT with PSF in skeletally immature patients with idiopathic scoliosis. STUDY DESIGN/SETTING Retrospective Cohort Study. PATIENT SAMPLE Skeletally immature patients with curves of at least 40 degrees with at least two-year follow-up who underwent TALPT or PSF from 2014-2018 were included. OUTCOME MEASURES The primary outcome is revision. Secondary outcomes include procedure duration, estimated blood loss (EBL), length of stay (LOS), total postoperative opioid morphine equivalent (OME), foley duration, days to solid food, direct cost and 30-day readmission. METHODS In this IRB-approved retrospective cohort study, TALPT and PSF were compared with respect to primary and secondary outcome measures. TALPT patients underwent a single-stage open anterior tethering for the thoracic curve and unilateral posterior tethering on the convexity of the lumbar curve. RESULTS Of 104 enrolled patients, 6 (5.8%) underwent TALPT while 98 (94.2%) underwent PSF. There was no significant difference in revision rate between TALPT and PSF (33% vs 11%, p=0.26). TALPT patients had significantly longer ICU length of stay in hours (18.7±18 vs 4.6±19.1, p 0.05). CONCLUSIONS Skeletally immature idiopathic scoliosis patients who undergo TALPT have equivalent two-year revision rates to PSF patients However, TALPT had significantly increased ICU stay, inpatient OME use on postoperative day 0 and direct cost. FDA DEVICE/DRUG STATUS Zimmer Spinal Tether (Not approved for this indication)

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. publishedVersion

BACKGROUND Although orthopaedic trauma occurs at higher rates in low- and middle-income countries (LMICs), most research on this topic is conducted in high-resource settings. Few initiatives exist to promote local research in LMICs. Investigators created the Institute for Global Orthopaedics and Traumatology (IGOT) International Research Symposium to promote local research initiatives by surgeons practicing in low-resource environments. The purpose of this study is to determine the efficacy of this symposium in teaching orthopaedic surgeons practicing in LMICs how to conduct clinical research. METHODS In this prospective observational study, orthopaedic surgeons from LMICs with no formal research training were recruited to attend the 1-day IGOT International Research Symposium in San Francisco. A survey was administered immediately before and after the symposium to inquire about the participants' confidence in different aspects related to research using a 1-5 Likert scale. A second survey, conducted 2 years later, recorded the attendees' research productivity after the workshop. RESULTS Forty-three participants representing 10 different LMICs from Africa and Asia attended the 2013 course. At 2 year postcourse, participants reported starting 25 research projects, authored 7 "accepted or published manuscripts" (vs. 1 before the course; P < 0.01), and were selected for 12 podium or poster presentations (vs. 3 before the course; P < 0.01). Two research symposium attendees received "Top International Forum Paper" at the 2015 Orthopaedic Trauma Association Annual Meeting. DISCUSSION A 1-day research course resulted in increased participant confidence in conducting research. This was associated with greater research productivity by participants 2 years later. These results suggest that the IGOT International Research Symposium can improve the number of initiated research projects by surgeons in LMICs.

While most patients with an anterior cruciate ligament (ACL) injury indicate satisfaction with surgical intervention, a significant proportion still do not return to pre-injury level of function or sport. Psychiatric comorbidities, such as depression, have recently been associated with poor clinical outcomes after ACL reconstruction (ACLR). To date, no article has yet examined how depression affects ACLR outcomes and how potential screening and intervention for psychological distress may affect postoperative activity level. The purpose of this review is to delineate potential relationships between depression and ACLR outcome, discuss clinical implications and identify future directions for research.

BACKGROUND CONTEXT There remains a need for practical radiographic parameters to help predict risk of proximal junctional kyphosis (PJK) in adult patients undergoing multilevel posterior fusion. The upper instrumented vertebral pelvic angle (UIVPA) is a novel measure of sagittal alignment that is easy to measure and can account for both spinal inclination and pelvic retroversion. We hypothesize that the further the UIV is from the center of gravity, the higher the risk of PJK. PURPOSE The purpose of this study is to evaluate the association between UIVPA and risk of PJK in adult patients undergoing 6-level fusion. STUDY DESIGN/SETTING Retrospective cohort study at single academic institution. PATIENT SAMPLE Adult patients with minimum two-year follow-up who underwent ≥6 level posterior spinal fusion. OUTCOME MEASURES PJK, proximal junctional failure (PJF). METHODS In this retrospective cohort study, adult patients with two-year follow-up and ≥6 levels of posterior fusion for spinal deformity were included. The UIVPA was measured between a line from the UIV centroid to the center of the femoral head to a line from the center of the sacrum to the center of the femoral head. PJK was defined as a >10° kyphotic angle between the UIV and the vertebra 2 levels above. Proximal junctional failure (PJF) was defined as PJK that required surgery. Patients who developed PJK and those who did not were compared with respect to UIVPA, T1 pelvic angle (T1PA), pelvic tilt, sagittal vertical axis and central sacral vertical line. RESULTS There were 291 patients with an average 3.0 years follow-up enrolled in the study. Fifty (17%) patients were diagnosed with PJK and 29 (10%) qualified for PJF. The average UIVPA for all patients was 19.5° preop. Patients with PJK had significantly higher preoperative UIVPA than those without PJK or PJF (25.6 vs 16.2 p CONCLUSIONS UIV pelvic angle correlates well with established measures of sagittal spinopelvic alignment, such as T1PA, SVA and pelvic tilt. Patients with PJK and PJF at least two years from surgery were more likely to have a significantly higher preoperative UIVPA than their counterparts. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Purpose: There are an estimated 1.2 million deaths from road traffic injuries annually, disproportionately affecting patients in low- resource settings. The purpose of this scoping review is to identify knowledge gaps in global orthopaedic trauma in an effort to help prioritize future research. Methods: Using the 6-stage Arksey and O’Malley framework for conducting a scoping review, orthopaedic trauma literature was reviewed over a ten-year period from 2004 to 2014. Studies from low-resource settings were included and categorized by geographic location, anatomic region, study type, and level of evidence. Results: Of 548 included studies, 51.4% were from low- and middle-income countries in South Asia and 33.7% were from sub- Saharan Africa. Therapeutic (53.3%), epidemiologic (26.4%), and qualitative (8.9%) studies were most common. Only 10.2% of the studies were considered high level of evidence, whereas the vast majority (89.8%) was level 3 or below. Overall, lower extremity injuries were much more frequently represented in the literature compared with upper extremity injuries (233 vs. 78). Pelvic and acetabular fractures were the least studied anatomic region of the lower extremity (3.4%). Conclusions: Our study identified a lack of cost-effectiveness analyses pertaining to injury and intervention, paucity of high- quality research, and under-representation of pelvic, acetabular, and upper extremity injuries. Improved and prioritized research in low- and middle-income countries may help optimize care and inform policy makers of how to reduce the global burden of musculoskeletal trauma.

Introduction The purpose of our study is to prospectively evaluate the cost effectiveness of intramedullary nailing compared with skeletal traction in a resource-limited setting where traction remains the most common definitive treatment. Methods This multicenter, prospective multicenter investigation was conducted in Malawi at 2 central hospitals and 3 district hospitals. The project was divided into phases. In phase 1, the EuroQol-5D and SMFA were translated and validated in Chichewa. In phase 2, adult patents with OTA/AO 32 femur shaft fractures were prospectively enrolled, and a comparison of quality of life and functional status was made. In phase 3, a cost-effectiveness analysis was performed between those treated with intramedullary nail and those treated with skeletal traction. Conclusion This study serves as an example of an economic study in orthopaedic surgery conducted in a resource-poor environment through academic collaboration.

In many low- and middle-income countries, non-surgical management of femoral shaft fractures using skeletal traction is common because intramedullary (IM) nailing is perceived to be expensive. This study assessed the cost of IM nailing and skeletal traction for treatment of femoral shaft fractures in Malawi. We used micro-costing methods to quantify the costs associated with IM nailing and skeletal traction. Adult patients who sustained an isolated closed femur shaft fracture and managed at Queen Elizabeth Central Hospital in Malawi were followed from admission to discharge. Resource utilization and time data were collected through direct observation. Costs were quantified for procedures and ward personnel, medications, investigations, surgical implants, disposable supplies, procedures instruments and overhead. We followed 38 nailing and 27 traction patients admitted between April 2016 and November 2017. Nailing patient’s average length of stay (LOS) was 36.35 days (SD 21.19), compared to 61 (SD 18.16) for traction (p = 0.0003). The total cost per patient was $596.97 ($168.81) for nailing and $678.02 (SD $144.25) for traction (p = 0.02). Major cost drivers were ward personnel and overhead; both are directly proportional to LOS. Converting patients from traction to nailing is cost-saving up to day 23 post-admission. Savings from IM nailing as compared with skeletal traction were achieved by shortened LOS. Although this study did not assess the effectiveness of either intervention, the literature suggests that traction carries a higher rate of complications than nailing. Investment in IM nailing capacity may yield substantial net savings to health systems, as well as improved clinical outcomes.

As the number of anatomic total shoulder arthroplasties performed on younger patients continues to grow, return to work after surgery becomes increasingly important. The purpose of this study was to evaluate the ability of anatomic total shoulder arthroplasty to return patients 55 years or younger to work postoperatively. A retrospective review was performed of consecutive anatomic total shoulder arthroplasty patients. Inclusion criteria were age 55 years or younger at surgery, greater than 2 years of follow-up, and employment within 3 years of surgery. Employment was stratified by intensity of work (sedentary, light, moderate, or heavy). Return to work status and time out of work were also evaluated. Fifty-two patients worked before surgery. Average age was 48.4 years, with average follow-up of 5.4 years. Seventy-three percent were male, and average body mass index was 28.0 kg/m 2 . Average visual analog scale score improved from 5.5 to 0.9 ( P P P Orthopedics. 2018; 41(3):e310–e315.]

Background Arthroplasty outcomes and patient risk factors have not been studied in detail in safety net hospital settings. This study examines the relationship between selected risk factors and short-term complications in such a population, including a large subgroup with treated substance abuse. Methods This retrospective cohort study contains 486 consecutive patients after primary hip and knee arthroplasty. One hundred three of these had a history of substance abuse and completed a 1-year sobriety pathway preoperatively. Primary outcomes included the presence of any complication, deep infection, and reoperation. Bivariable analyses were used to compare outcomes with demographic and health risk factors. A multivariate analysis was performed to identify independent risk factors. Results Adverse outcomes were more common in patients with higher rates of substance abuse, mental illness, and infection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV). Substance abuse alone was not an independent risk factor for the occurrence of complications, but infections with HIV and HCV were. In the substance abuse subgroup, with its higher prevalence of risk factors, complications were more frequent (31.1% vs 16.4%, P = .0009), and, in particular, deep infections (5.8% vs 1.8%, P = .0256). Conclusions Specific risk factors were associated with short-term complications in safety net arthroplasty patients. Despite having completed a preoperative sobriety pathway, substance abuse patients had more complications than did others. However, substance abuse alone was not an independent risk factor for adverse surgical outcomes. Other factors, notably HCV and HIV infection that were more common in patients with substance abuse, were most closely associated with adverse outcomes.

Background:Recent literature has recognized a correlation with depression and poor self-reported functional outcome after orthopaedic procedures. However, the effect of depression on anterior cruciate ligament reconstruction (ACLR) outcome has never been studied.Purpose:To quantify the incidence of major depressive disorder (MDD) and correlate depression symptoms with patient-rated knee function in patients undergoing ACLR.Study Design:Cohort study; Level of evidence, 2.Methods:In this multicenter prospective cohort study, 64 consecutive adult patients undergoing primary ACLR were given the 16-item self-report Quick Inventory of Depressive Symptomatology (QIDS) to assess MDD symptoms preoperatively and at 6 weeks, 12 weeks, 24 weeks, and 1 year postoperatively. Lysholm and International Knee Documentation Committee (IKDC) subjective scores were obtained at the same time points to assess self-reported knee function. A QIDS score ≥6 served as a validated threshold for diagnosis of MDD. MDD and non-MDD group assignment was based on preoperative QIDS score. Student t test analysis was performed to compare ACLR outcomes between MDD and non-MDD patients. Correlation among QIDS, Lysholm, and IKDC scores was determined with Spearman r value.Results:A total of 27 patients (42%) were categorized in the MDD group. At baseline, the MDD group reported mean Lysholm (50.8) and IKDC (43.7) scores that were significantly lower than those (64.9 and 57.0, respectively) reported by the non-MDD group ( P < .05). Both cohorts showed similar and significant absolute improvement from baseline to 1 year postoperatively (MDD vs non-MDD, increase in mean Lysholm: +24.4 vs +23.5 [ P = .63]; MDD vs non-MDD, increase in mean IKDC: +28.1 vs +32.3 [ P = .21]). While Lysholm and IKDC scores improved in both groups, at 1-year follow-up, MDD patients reported significantly lower mean Lysholm (75.2 vs 88.4; P = .04) and mean IKDC (71.8 vs 89.3; P = .001) scores as compared with their non-MDD counterparts. In addition, a moderate inverse correlation was found between QIDS and Lysholm scores ( r = −0.50) and between QIDS and IKDC scores ( r = −0.54). Interestingly, 4 patients experienced complications in the MDD cohort (15%), while there were no complications in the non-MDD group.Conclusion:This study suggests that ACLR may be an equally effective intervention for MDD and non-MDD patients, given their similar significant absolute improvements in functional scores from baseline to 1 year after ACLR. However, MDD patients still reported significantly lower self-reported functional scores at baseline and 1 year postoperatively.

Introduction In many low and middle-income countries (LMICs) SIGN nail is commonly used for antegrade femoral intramedullary (IM) nailing, using a start site either at the tip of the greater trochanter or piriformis fossa. While a correct start site is considered an essential technical step; few studies have evaluated the impact of using an erroneous start site. This is particularly relevant in settings with limited access to fluoroscopy to aid in creating a nail entry point. The purpose of this study was to evaluate the impact of antegrade SIGN IM nailing start site on radiographic alignment and health-related quality of life. Methods In this prospective cohort study, adult patients with proximal femur fractures (OTA 32, subtrochanteric zone) treated with antegrade IM SIGN nail at Muhimbili Orthopaedic Institute (MOI), Dar es Salaam, Tanzania were enrolled. Start site was determined on the immediate postoperative X-ray and was graded on a continuous scale based on distance of the IM nail center from the greater trochanteric tip. The primary outcome measurement was coronal alignment on the post-operative x-ray. The secondary outcomes were reoperation rates, RUST scores and EQ5D scores at one year follow-up. Results Seventy-nine patients were enrolled. 50 of them (63.3%) had complete data at 1 year and were included in the final data analysis. Of the fifty patients, nine (18%) had IM nails placed laterally, 26 (52%) medially and 15 (30%) directly over the tip of the greater trochanter. Compared to a start site at the tip or medial to the greater trochanter, a lateral start site was 9 times more likely to result in a varus malalignment (95% CI: 1.42–57.70, p = 0.021). Conclusions Lateral start site was associated with varus malalignment. Although lateral start site was not significantly associated with reoperation, varus deformity was associated with higher reoperation rates. Surgeons should consider avoiding a start site lateral to the tip of the greater trochanter or allow the nail to rotate to avoid malalignment when using the SIGN nail for proximal femur fractures.

Background: The EQ-5D is a standardised instrument that measures health-related quality-of-life and explores cost-effectiveness of treatments. Malawi is a low-resource country that would benefit from assessment of quality-of-life among individuals living with chronic conditions. Chichewa is the official native language of Malawi. The Chichewa version of the EQ-5D-3L developed by EuroQoL group has not been validated with Chichewa speakers. The purpose of this study was to evaluate the clinimetric properties of the Chichewa EQ-5D-3L. Methods: Patients with orthopaedic conditions were recruited in the outpatient orthopaedic clinics and wards at Queen Elizabeth Central Hospital, Blantyre, Malawi. Fifty-three patients with various musculoskeletal problems were administered the Chichewa EQ-5D-3L and World Health Organization quality of life (WHO-QOL) questionnaires. To assess repeatability, a separate test–retest population of 20 patients were also selected from orthopaedic clinics and wards to fill out the questionnaire twice. Results: Convergence validity was determined, with each of the WHO-QOL domains and the EQ-5D descriptive index and visual analogue scale (VAS) having good to moderate correlation (r = 0.3–0.7). Internal consistency was measured for the descriptive index, and the Cronbach’s alpha was 0.7. The ceiling effect for the descriptive index and the VAS were 9.4% and 0%, respectively. No respondents reached floor effect for the descriptive index or the VAS. The test retest intraclass correlation coefficient reliability at 14 days was 0.984 for the VAS and 1 for the descriptive index, with all 20 respondents providing the same responses. Conclusions: The EuroQoL translated version of the Chichewa EQ-5D-3L was found to demonstrate adequate validity, internal consistency, floor/ ceiling effects, and reliability.

Background: Young, active candidates for total shoulder arthroplasty (TSA) are a unique group of patients. Not only do they demand longevity and improved function, but they also desire a return to physical activities. Purpose: To determine the rate of return to sports in patients aged ≤55 years undergoing TSA. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective review of consecutive patients who underwent anatomic TSA at a single institution. Exclusion criteria included age at the time of surgery >55 years and Results: From 70 eligible patients, 59 patients (61 shoulders) were included with an average follow-up of 61.0 months (range, 25-103 months) and average age at the time of surgery of 48.9 years (range, 25-55 years). The average VAS score improved from 5.6 to 0.9 ( P < .001), and the average ASES score improved from 39.3 to 88.4 ( P < .001). Forty-nine procedures (80.3%) were performed for a primary diagnosis of osteoarthritis. Four shoulders returned to the operating room; none were for glenoid loosening. There was a 93.2% satisfaction rate, and 67.7% of patients (n = 40) stated that they underwent their surgery to return to sports. Moreover, patients in 96.4% of shoulders (55/57) restarted at least 1 sport at an average of 6.7 months. Direct rates of return were as follows: fitness sports (97.2%), golf (93.3%), singles tennis (87.5%), swimming (77.7%), basketball (75.0%), and flag football (66.7%). Patients in 47 shoulders (82.4%) returned to a similar or higher level of sports; 90.3% returned to high-demand sports, and 83.8% returned to high upper extremity sports. There was no significant difference in rates of return to sports by body mass index, sex, age, preoperative diagnosis, revision status, and dominant extremity. Conclusion: In patients aged ≤55 years undergoing TSA, there was a 96.4% rate of return to ≥1 previous sports at an average of 6.7 months. Furthermore, at an average follow-up of 61.0 months, no patients needed revision of their glenoid component, despite an 83.8% rate of return to high upper extremity sports. While caution should still be advised in young, active patients undergoing TSA, these results demonstrate a high satisfaction rate and improved ability to return to most sports after surgery.

Introduction: Prophylactic surgical drains are commonly used in Nigeria following intramedullary nailing (IMN) of long bone diaphyseal fractures. However, evidence in the literature suggests that drains do not confer any benefit and predispose clean wounds to infection. This study compares outcomes between patients treated with and without prophylactic surgical drainage following diaphyseal long bone fractures treated with IMN.Methods: A prospective cohort study with randomization was conducted at a tertiary referral center in Enugu, Nigeria. Investigators included skeletally mature patients with diaphyseal long bone (femur, tibia, humerus) fractures treated with SIGN IMN. Patients followed-up at 5, 14, and 30 days post-operatively. The primary outcome was surgical site infection (SSI) rate. Secondary outcomes included post-operative pain at 6 and 12 h, need for blood transfusion, wound characteristics (swelling, ecchymosis, and gaping), need for dressing changes, and length of hospital stay.Results: Of the enrolled patients, 76 (96%) of 79 completed 30-day follow-up. SSI rate was associated with patients who received a prophylactic drain versus those who did not (23.7% vs. 10.5%,p = 0.007). There were no significant differences in transfusion need (p = 0.22), wound swelling (p = 0.74), wound ecchymosis (p = 1.00), wound gaping (p = 1.00), dressing change need (p = 0.31), post-operative pain at 6 h (p = 0.25) or 12 h (p = 0.57), or length of stay (p = 0.95).Discussion: Surgical drain placement following IMN of diaphyseal long bone fractures is associated with a significantly higher risk of SSI. Reducing surgical drain use following orthopaedic injuries in lower resource settings may translate to reduced infection rates.

Background: Little is known about the quality of orthopaedic investigations conducted in low- and middle-income countries (LMICs). Academic collaboration is one model to build research capacity and improve research quality. Our study aimed to determine (1) the quality of clinical orthopaedic research conducted in LMICs, (2) the World Bank Regions and LMICs that publish the highest quality studies, (3) the pattern of collaboration among investigators and (4) whether academic collaboration between LMIC and non-LMIC investigators is associated with studies that have higher levels of evidence. Methods: Orthopaedic studies from 2004 to 2014 conducted in LMICs were extracted from multiple electronic databases. The World Bank Region, level of evidence and author country-affiliation were recorded. Collaboration was defined as a study that included an LMIC with non-LMIC investigator. Results: There were 958 studies that met inclusion criteria of 22,714 searched. Ninety-seven (10.1%) of included studies achieved Level 1 or 2 evidence, but case series (52.3%) were the most common. Collaboration occurred in 14.4% of studies and the vast majority of these (88.4%) were among academic institutions. Collaborative studies were more likely to be Level 1 or 2 (20.3% vs. 8.4%, p

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.

The return to work of young patients undergoing shoulder arthroplasty is increasingly important. Whereas studies have shown superior outcomes of reverse total shoulder arthroplasty (RTSA) compared with humeral hemiarthroplasty (HHA), no prior literature has compared RTSA with HHA in regard to return to work.A retrospective review of a prospectively collected shoulder arthroplasty registry was performed to analyze all patients who underwent RTSA or HHA at a single institution. A validated questionnaire evaluating return to work postoperatively was administered at baseline and at follow-up in addition to the American Shoulder and Elbow Surgeons and visual analog scale (VAS) pain surveys.The study included 40 RTSA and 41 HHA patients. The average age at surgery was 68.6 years in the RTSA group and 60.8 years in the HHA group (P .001). Postoperatively, 65% of RTSA patients returned to work compared with 70.7% of HHA patients (P = .64). There was no significant difference in the time to return to work between the RTSA (2.3 months) and HHA (3.1 months) groups (P = .46). Both groups had statistically significant improvements in both the American Shoulder and Elbow Surgeons and VAS scores. The improvement in pain on the VAS for patients undergoing RTSA (-5.6) trended toward significance compared with HHA (-4.2) (P = .056).Roughly two-thirds of patients undergoing either HHA or RTSA were able to return to work postoperatively, with no significant difference found between the 2 groups in terms of time to return to work, despite that patients undergoing RTSA were significantly older.

Background: Short-term outcomes for patients with large, engaging Hill-Sachs lesions who underwent remplissage have demonstrated good results. However, limited data are available for longer term outcomes. Purpose: To evaluate the long-term outcomes of remplissage and determine the long-term rate of return to specific sports postoperatively. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective review of patients treated with the remplissage procedure from 2007 to 2013. All underwent preoperative magnetic resonance imaging demonstrating large Hill-Sachs lesions by the Rowe criteria and glenoid bone loss Results: A total of 50 patients (51 shoulders) were included in the study. The average patient age at surgery was 29.8 years (range, 15.0-72.4 years), and the average follow-up time was 60.7 months (range, 25.5-97.6 months); 20.0% of patients underwent previous surgery on their shoulder. The average postoperative WOSI score was 79.5%, and the average ASES score was 89.3. Six shoulders had dislocation events (11.8%) postoperatively: 3 were traumatic, and 3 were atraumatic. Increased preoperative dislocations led to a greater risk of a postoperative dislocation ( P < .001). There was also a trend toward higher postoperative dislocation rates in patients who underwent revision ( P = .062). The average loss of external rotation was 5.26° ( P = .13). The rate of return to ≥1 sports was 95.5% of patients at an average of 7.0 months postoperatively; 81.0% returned to their previous intensity and level of sport. Of patients who played a throwing sport, 65.5% (n = 19) stated that they had problems throwing, and 58.6% (n = 17) felt that they could not normally wind up throwing a ball. Direct rates of return to overhead sports were volleyball, 100%; basketball, 69%; baseball, 50%; and football, 50%. Conclusion: The redislocation rate after remplissage was 11.8% at an average of 5 years, with 95.5% of patients returning to full sports at an average of 7 months. For throwing sports, 65.5% of patients complained of decreased range of motion during throwing. The results should be considered preoperatively in candidates for remplissage who are engaged in throwing sports.

Background: With an active aging population, more patients expect to return to previous activities and work after surgery. Purpose: To determine the rate and timing to return of sports and employment after shoulder hemiarthroplasty. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective review of consecutive patients who underwent shoulder hemiarthroplasty from 2007 to 2013. Follow-up consisted of a patient-reported questionnaire regarding physical fitness, sporting activities, and work status. Results: From 105 patients screened, 79 were available for follow-up. The average follow-up time was 63.1 months, and the average age at follow-up was 69 years. Scores on the visual analog scale for pain improved from 6.2 to 2.1 ( P < .001) postoperatively, and those on the American Shoulder and Elbow Surgeons (ASES) shoulder assessment improved from 34.6 to 71.3 ( P < .001). Patients older than 65 years had significantly lower absolute postoperative ASES scores ( P = .041) but experienced similar improvement from their preoperative baseline ( P = .158) compared with patients younger than 65 years. There were 58 patients who played sports preoperatively, and 67.2% of these restarted at least 1 of their previous sports postoperatively. The average time to return to full sports was 6.5 months for those who returned. Direct rates of return were as follows: fitness sports (69%), swimming (65%), running (64%), cycling (63%), and doubles tennis (57%). Younger age was associated with highest demand level achieved ( P = .023). Forty-nine patients worked preoperatively, with 69.4% returning to previous employment after surgery; the average time to return to work was 1.4 months. In comparative analysis, patients who did not return to work had a higher mean body mass index (32 ± 7 vs 27 ± 5 kg/m2; P < .008). Conclusion: In this hemiarthroplasty cohort, there was a 67.2% rate of return to 1 or more sports at an average of 6.5 months postoperatively. Patients older than 65 years experienced similar improvements in ASES scores compared with patients younger than 65 years, although absolute scores were lower on average. Those who returned to higher demand sports were younger on average. Of patients working preoperatively, 69.4% returned to their previous employment at an average of 1.4 months. Patients who did not return to employment had significantly higher body mass index on average. These findings will help surgeons manage expectations of shoulder hemiarthroplasty candidates preoperatively.

Traditionally, fewer postoperative sport restrictions are imposed on hemiarthroplasty (HHA) patients on than reverse total shoulder arthroplasty (RTSA) patients. However, functional outcomes have been shown to be superior in RTSA. No direct comparison of RTSA vs HHA has been done on rates of return to sports in patients with glenohumeral arthritis and rotator cuff dysfunction, proximal humeral fractures, or rheumatoid arthritis.This is a retrospective review of consecutive RTSA and HHA patients collected from our institution's shoulder arthroplasty registry. All patients playing sports preoperatively with minimum 1-year follow-up were included. Final follow-up included an additional patient-reported questionnaire with questions regarding physical fitness and sport activities.The study included 102 RTSA and 71 HHA patients. Average age at surgery was 72.3 years for RTSA compared with 65.6 years for HHA (P .001). Patients undergoing RTSA had improved visual analog scale scores compared with HHA (-5.6 vs -4.2, P = .007), returned to sports after RTSA at a significantly higher rate (85.9% vs 66.7%, P = .02), and were more likely to be satisfied with their ability to play sports (P = .013). HHA patients were also more likely to have postoperative complaints than RTSA patients (63% vs 29%, P .0001). No sports-related complications occurred. Female sex, age70 years, surgery on the dominant extremity, and a preoperative diagnosis of arthritis with rotator cuff dysfunction predicted a higher likelihood of return to sports for patients undergoing RTSA compared with HHA.Despite traditional sport restrictions placed on RTSA, patients undergoing RTSA can return to sports at rates higher than those undergoing HHA, with fewer postoperative complaints.

Background: Return to activity is a commonly used indication for shoulder hemiarthroplasty (HA) compared with total shoulder arthroplasty (TSA). Despite clinical studies demonstrating better functional outcomes after TSA, the literature has failed to show a difference in return to sports. Purpose: To compare rates of return to sports in a matched cohort of TSA and HA patients with a preoperative diagnosis of glenohumeral osteoarthritis (OA). Study Design: Cohort study; Level of evidence, 3. Methods: A prospectively collected registry was queried retrospectively for consecutive patients who underwent HA. Inclusion criteria were preoperative diagnosis of OA and more than 2 years of follow-up. After meeting the inclusion criteria, all HA patients were statistically matched to a TSA patient. All patients had end-stage OA with significant glenohumeral joint space narrowing. Results: At final follow-up, 40 HA patients and 40 TSA patients were available. The average (±SD) age at surgery was 65.7 ± 10.5 years and 66.2 ± 9.6 years for the HA and TSA groups, respectively ( P = .06). Average follow-up was 62.0 months and 61.1 months for the HA and TSA groups, respectively ( P = .52). Average American Shoulder and Elbow Surgeons scores improved from 36.3 to 70.2 for HA patients and from 34.0 to 78.5 for TSA patients ( P < .001 for both); final scores were not significantly different between groups ( P = .21). Average visual analog scale pain scores improved from 6.3 to 2.2 for HA patients and from 6.1 to 0.6 for TSA patients ( P < .001 for both). HA patients had significantly worse final visual analog scale scores compared with the TSA group ( P = .002). Significantly more TSA patients were satisfied with their surgery compared with HA patients (100% vs 70%) ( P = .01). Of both groups, 65.5% of HA patients (19 of 29) returned to at least 1 sport postoperatively compared with 97.3% of TSA patients (36 of 37) ( P < .001). Average timing for return to full sports was 5.5 ± 4.2 months and 5.4 ± 3.1 months for the HA and TSA groups, respectively ( P = .92). Significantly more TSA patients returned to higher upper extremity use sports ( P = .01). Conclusion: In patients with OA, rate of return to sports was significantly better after TSA compared with HA. HA patients had significantly more pain, worse surgical satisfaction, and decreased ability to return to high upper extremity use sports. For patients with OA who wish to return to sporting activities, these results help manage expectations.