David W. Shearer

Arthrofibrosis after anterior cruciate ligament reconstruction in children and adolescents

Introduction: Arthrofibrosis is a known complication after anterior cruciate ligament (ACL) reconstruction. ACL reconstruction is being performed with increased frequency in the pediatric population. The purpose of this study was to determine the prevalence of arthrofibrosis in children and adolescents and to identify risk factors for arthrofibrosis. Methods: The study design was a retrospective case series. Medical records for 1016 consecutive ACL reconstructions in patients aged 7 to18 years old between 1995 to 2008 at a major tertiary care children’s hospital were reviewed to identify cases of postoperative arthrofibrosis. Arthrofibrosis was defined as a loss of 5 degrees or more extension compared with the contralateral knee that required a follow-up procedure or a loss of 15 degrees or more flexion compared with the contralateral knee that required a follow-up procedure. Patient data were recorded and analyzed using bivariate models to identify predictors for arthrofibrosis. Further, we reviewed the clinical course of patients with treated arthrofibrosis to assess functional outcomes of this complication. Results: Nine hundred two patients with 933 knees met the inclusion criteria for this study, of which 60% were female. The mean age at the time of surgery was 15 years (range, 7 to 18 y), and the average follow-up from original ACL reconstruction was 6.3 years (range, 1.6 to 14.2 y). The overall prevalence of arthrofibrosis in our cohort was 8.3%, with 77 of the 933 knees had at least 1 procedure to treat arthrofibrosis after ACL reconstruction. Risk factors for arthrofibrosis were female sex (11.1% females, P=0.0001), patients aged 16 to 18 years [11.6%; odds ratio (OR) 3.51; P=0.007], patellar tendon autograft (OR, 1.7; P=0.026), and concomitant meniscal repair (OR, 2.08; P=0.007). Prior knee surgery and ACL reconstruction within 1 month of injury were not significantly associated with arthrofibrosis after ACL reconstruction. Fifty-three patients had a minimum of 6 months clinical follow-up after the procedure for arthrofibrosis. Of these, 46 patients (86.8%) had full range of motion at follow-up. Thirty-two patients (60.4%) were asymptomatic at final follow-up. Eleven patients (20.8%) complained of some persistent pain. Conclusions: The rate of arthrofibrosis after ACL reconstruction in children and adolescents is 8.3%. Risk factors for arthrofibrosis are female sex, older adolescents, concurrent meniscal repair, and reconstruction with patellar tendon autograft. Surgical treatment for arthrofibrosis after ACL reconstruction in pediatric patients can satisfactorily regain motion in the reconstructed knee; however functional outcome may be compromised. Level of Evidence: Level 4

Common generic measures of health related quality of life in injured patients

The measurement of health-related quality of life (HRQOL) through generic outcome instruments is important for comparisons of populations across disease states and interventions. The growing number of questionnaires available has made selection and interpretation more difficult. Profile instruments such as the SF-36 and Sickness Impact Profile provide insight into various domains of health with established population norms. Preference-based measures, including the EQ-5D, Health Utilities Index, SF-6D, and QWB-SA are used to generate utility scores, which can be used for cost-effectiveness analysis and therefore have particular relevance in health policy. Both types of generic measures have been used in clinical trials in injured populations to assess the relative impact of interventions on quality-of-life. Comparisons of internal consistency and test-retest reliability across measures reveal minimal differences between instruments, and reported values are acceptable for group comparisons but insufficient for individual clinical use. There is a dearth of studies evaluating the validity of these measures in the trauma population, but available data suggest most of the available instruments are acceptable. Populations that may require special consideration are patients with head, spinal cord, and upper-extremity injuries. Practical issues to consider in selecting a questionnaire include time for completion, which ranges from less than 2 min for the EQ-5D to 20-30 min for the Sickness Impact Profile. Selection of the appropriate measure ultimately depends largely on the population to be studied and whether utility-estimation is desired.

The predictors of outcome in total knee arthroplasty for post-traumatic arthritis.

BACKGROUND The outcomes of total knee arthroplasty (TKA) for post-traumatic arthritis are less reliable than for idiopathic osteoarthritis. These patients tend to be younger, present with varying degrees of deformity, and often have a history of prior surgery, resulting in a wide spectrum of pathology. We hypothesized that preoperative variables, in particular the location of deformity, would predict pain and functional outcomes. METHODS The outcomes of total knee arthroplasty for post-traumatic arthrosis were studied in 47 knees treated at our institution. All patients were administered the Knee Society Score (KSS) preoperatively and at follow-up (mean 52months, range 16 to 124). We classified the defects into four categories: intra-articular, metaphyseal, diaphyseal, and combined femoral and tibial deformities. RESULTS There was a significant improvement in KSS scores for pain (p<0.0001) and a trend toward higher function (p=0.06) comparing preoperative scores to final follow-up. The largest improvements in pain and functional scores were in patients with isolated articular deformities, while patients with combined tibial and femoral deformities did not have significant improvements in pain or function. Soft-tissue defects requiring flap coverage were associated with worsening in the pain score (p=0.027). CONCLUSIONS The location of post-traumatic deformity and compromise of the soft-tissue envelope influence the pain and functional outcomes of total knee arthroplasty for post-traumatic arthritis. Specifically, isolated articular deformities have the largest improvement in pain and function while patients with combined tibial and femoral deformities as well as patients with soft-tissue compromise experience poor outcomes. LEVEL OF EVIDENCE IV-Retrospective Case Series.

Population Characteristics and Clinical Outcomes From the SIGN Online Surgical Database

Summary: There are over 26,000 cases recorded in the SIGN Online Surgical Database (SOSD). Though follow-up is limited, there is an abundance of data describing the population being treated and the resultant outcomes. Furthermore, given the lack of evidence available, the clinical outcomes reported in the database are a first step toward understanding the safety and efficacy of Surgical Implant Generation Network (SIGN) nailing. Methods: All data from the SOSD from 2003 to August 2009 were included in the study. The primary outcome considered was the rate of deep infection. Results: The majority of patients were young men. Over 20% of patients had a delay of greater than 10 days from the time of the injury to surgery, and more than 5% were considered a nonunion preoperatively. Femoral shaft fractures were the most common indication for SIGN nailing. The infection rate was less than 2% for closed fractures and between 5% to 7% for open fractures. The number of patients with documented full painless weight bearing increased dramatically with more recent surgery. Discussion: Operative intervention has significant potential to reduce the burden of long-bone fractures at the familial and societal level. The infection rate was comparable to studies published in the Western literature. The weight bearing data are unlikely to be of clinical significance. Conclusion: There is a tremendous amount of data regarding patients treated with SIGN nails in the SOSD. With improvement in clinical follow-up, this will be invaluable in assessing the safety and efficacy of SIGN nailing and addressing important clinical questions.

Short-term Complications Have More Effect on Cost-effectiveness of THA than Implant Longevity

BackgroundOutcomes research in THA has focused largely on long-term implant survivorship as a primary outcome and emphasized the development of new implant technologies. In contrast, strategies to improve short-term outcomes, such as the frequencies of periprosthetic joint infections and unplanned readmissions, have received less attention.Questions/purposesWe asked whether reductions in periprosthetic joint infections and early readmissions would have greater influence on the net monetary benefit (a summation of lifetime cost and quality of life) for THA compared with equivalent reductions in aseptic loosening.MethodsA Markov model was created using decision-analysis software with six health states and death to represent seven major potential outcomes of THA. We compared the effect of a 10% reduction in each of the following outcomes: (1) periprosthetic joint infection, (2) hospital readmission, and (3) aseptic loosening. Procedure costs (not charges) were derived from our hospital cost-accounting system. Probabilities were derived primarily from the Australian Orthopaedic Association National Joint Replacement Registry, and utilities were estimated from a previous study at our institution using the time trade-off method. The primary outcome of the study is the net monetary benefit, which combines the reductions in cost and improvement in health-related quality of life in a single metric. Quality of life is expressed in quality-adjusted life years (QALYs), which are calculated by multiplying the utility of a health state (ranging from 0 to 1) by the duration of time in the health state. The cost and QALYs are reported separately as secondary outcomes. One-way and multivariate sensitivity analyses were performed including a probabilistic sensitivity analysis to account for uncertainty in model inputs.ResultsThe net monetary benefit for a 10% reduction in periprosthetic joint infections was USD 278 (95% CI, USD 239–295) per index procedure compared with USD 174 (95% CI, USD 150–185) and USD 113 (95% CI, USD 94–129) for reductions in aseptic loosening and early readmission, respectively. Compared with the base case, reductions in cost associated with a 10% reduction in periprosthetic joint infections, early readmissions, and aseptic loosening were USD 98, USD 93, and USD 75 per index procedure, respectively. The increase in QALYs for an equivalent reduction in periprosthetic joint infections, aseptic loosening, and early readmissions were 0.0036, 0.002, and 0.0004 QALYs, respectively. Results were most sensitive to age, baseline rate of readmission, periprosthetic joint infection, aseptic loosening, and the costs of readmission and revision THA.ConclusionsStrategies to reduce periprosthetic joint infections may have a greater effect on the cost and long-term effectiveness of THA than further enhancements in implant longevity. Reductions in the rate of readmission resulted in greater reductions in cost but not quality-of-life, and therefore had smaller effect on the net monetary benefit compared with aseptic loosening. Surgeons preferentially should engage in strategies focusing on periprosthetic joint infections to improve the value of THA care.Level of EvidenceLevel II, economic and decision analysis.

Collaborative Partnerships and the Future of Global Orthopaedics

The body of evidence illustrating the impact of injury and musculoskeletal disease on global health continues to grow. The 2010 Global Burden of Disease study [11] estimated that injury accounted for 11% of disability-adjusted life years globally, with the majority occurring in low- and middle-income countries as a result of road-traffic injuries. There are an estimated 1.2 million deaths and an additional 20 to 50 million nonfatal injuries from road-traffic injuries [14]. Appropriately, the WHO declared 2011 to 2020 a Decade of Action for road traffic safety [8]. This public health effort to promote injury prevention is likely to have an enormous long-term impact. However, while awaiting effective policy and infrastructure changes, orthopaedic surgeons in low- and middle-income countries are managing an overwhelming volume of musculoskeletal injuries with limited resources.

Predictors of Reoperation for Adult Femoral Shaft Fractures Managed Operatively in a Sub-saharan Country

Background: The optimal treatment for femoral shaft fractures in low-resource settings has yet to be established, in part, because of a lack of data supporting operative treatment modalities. We aimed to determine the reoperation rate among femoral fractures managed operatively and to identify risk factors for reoperation at a hospital in a Sub-Saharan country. Methods: We conducted a prospective clinical study at a single tertiary care center in Tanzania, enrolling all skeletally mature patients with diaphyseal femoral fractures managed operatively from July 2012 to July 2013. Patients were followed at regular intervals for 1 year postoperatively. The primary outcome was a complication requiring reoperation for any reason. Secondary outcomes were scores on the EuroQol (EQ)-5D, radiographic union score for tibial fractures (RUST), and squat-and-smile test. Results: There were a total of 331 femoral fractures (329 patients) enrolled in the study, with a follow-up rate at 1 year of 82.2% (272 of 331). Among the patients with complete follow-up, 4 injuries were managed with plate fixation and 268 were managed with use of an intramedullary nail. The reoperation rate for plate fixation was 25% (1 of 4) compared with 5.2% (14 of 268) for intramedullary nailing (p = 0.204). As found in a multivariate logistic regression, a small nail diameter, a Winquist type-3 fracture pattern, and varus malalignment of proximal fractures were associated with reoperation. The mean EQ-5D score at 1 year was 0.95 for patients who did not require reoperation compared with 0.83 for patients who required reoperation (p = 0.0002). Conclusions: Intramedullary nailing for femoral shaft fractures was associated with low risk of reoperation and a nearly full return to baseline health-related quality of life at 1 year of follow-up. There are potentially modifiable risk factors for reoperation that can be identified and addressed through education and dissemination of these findings. Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

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

Background: Little is known about the quality of orthopaedic investigations conducted in low- and middle-income countries (LMICs). Academic collaboration is one model to build research capacity and improve research quality. Our study aimed to determine (1) the quality of clinical orthopaedic research conducted in LMICs, (2) the World Bank Regions and LMICs that publish the highest quality studies, (3) the pattern of collaboration among investigators and (4) whether academic collaboration between LMIC and non-LMIC investigators is associated with studies that have higher levels of evidence. Methods: Orthopaedic studies from 2004 to 2014 conducted in LMICs were extracted from multiple electronic databases. The World Bank Region, level of evidence and author country-affiliation were recorded. Collaboration was defined as a study that included an LMIC with non-LMIC investigator. Results: There were 958 studies that met inclusion criteria of 22,714 searched. Ninety-seven (10.1%) of included studies achieved Level 1 or 2 evidence, but case series (52.3%) were the most common. Collaboration occurred in 14.4% of studies and the vast majority of these (88.4%) were among academic institutions. Collaborative studies were more likely to be Level 1 or 2 (20.3% vs. 8.4%, p < 0.01), prospective (34.8% vs. 22.9% p = 0.04) and controlled (29.7% vs. 14.4%, p < 0.01) compared to non-collaborative studies. Conclusions: Although orthopaedic studies in LMICs rarely reach Level 1 or 2 evidence, studies published through academic collaboration between LMIC and non-LMIC investigators are associated with higher levels of evidence and more prospective, controlled designs.

The Institute for Global Orthopedics and Traumatology: A Model for Academic Collaboration in Orthopedic Surgery

In 2006, surgeons at the University of California, San Francisco (UCSF) established the Institute for Global Orthopedics and Traumatology (IGOT), an initiative within the department of orthopedic surgery. The principal aim of IGOT is to create long-term, sustainable solutions to the growing burden of musculoskeletal injury in low- and middle-income countries (LMICs) through academic partnership. IGOT currently has relationships with teaching hospitals in Ghana, Malawi, Tanzania, Nicaragua, and Nepal. The organizational structure of IGOT is built on four pillars: Global Surgical Education (GSE), Global Knowledge Exchange (GKE), Global Research Initiative (GRI), and Global Leadership and Advocacy. GSE focuses on increasing surgical knowledge and technical proficiency through hands-on educational courses. The GKE facilitates the mutual exchange of surgeons and trainees among IGOT and its partners. This includes a global resident elective that allows UCSF residents to complete an international rotation at one of IGOT’s partner sites. The GRI strives to build research capacity and sponsor high-quality clinical research projects that address questions relevant to local partners. The fourth pillar, Global Leadership and Advocacy aims to increase awareness of the global impact of musculoskeletal injury through national and international courses and events, such as the Bay Area Global Health Film Festival. At the core of each tenet is the collaboration among IGOT and its international partners. Over the last decade, IGOT has experienced tremendous growth and maturation in its partnership model based on cumulative experience and the needs of its partners.

The Cost of Intramedullary Nailing for Femoral Shaft Fractures in Dar es Salaam, Tanzania

BackgroundFemoral shaft fractures are one of the most common injuries seen by surgeons in low- and middle-income countries (LMICs). Surgical repair in LMICs is often dismissed as not being cost-effective or unsafe, though little evidence exists to support this notion. Therefore, the goal of this study is to determine the cost of intramedullary nailing of femoral shaft fractures in Tanzania.MethodsWe used micro-costing methods to estimate the fixed and variable costs of intramedullary nailing of femoral shaft fractures. Variable costs assessed included medical personnel costs, ward personnel costs, implants, medications, and single-use supplies. Fixed costs included costs for surgical instruments and administrative and ancillary staff.Results46 adult femoral shaft fracture patients admitted to Muhimbili Orthopaedic Institute between June and September 2014 were enrolled and treated with intramedullary fixation. The total cost per patient was