An Audit of the effect of Bone Morphogenetic Protein-2 Treatment in patients with non-union of long bone fractures.

OBJECTIVE: To evaluate the outcomes, clinical and radiological application of Bone Morphogenetic Protein-2 alone versus Bone Morphogenetic Protein-2 with autograft in long bone non-unions. METHODS: A prospective review of patients was done with fracture non-union admitted to Aga Khan University Hospital, Karachi, from January 2016 to January 2019. The patients were divided into two groups; those exposed to Bone Morphogenetic Protein-2 alone in group 1, and those exposed to Bone Morphogenetic Protein-2 plus autologous graft in group 2. RESULTS: Background characteristics of both the groups were analysed. Patients were followed up at 6, 12 and 24 weeks through their medical records. The primary outcome was postoperative union at 6, 12 and 24. Union was defined by having the clinical union as well as the radiological union at the same time of assessment. Of the 80 patients enrolled, 13(16.25%) were excluded, and 5(6.25%) were lost to follow-up. The final sample had 62(77.5%) patients; 35(56.5%) in group 1, and 27(43.5%) in group 2. Union at 6 weeks was observed in 13(21%) patients; 8(62%) in group 1, and 5(38%) in group 2. Union at 12 weeks was observed in 38(61%) patients; 20(53%) in group 1, and 18(47%) in group 2. CONCLUSIONS: Results showed that using the adjuvant treatment alone was not worse than using it along with bone autologous graft.

Innovations in surgery between the past and future: A narrative review of targeted literature.

Innovation is the introduction of a new method or technology designed to change the way things are done. History is full of remarkable innovations in surgery over the years as surgeons have always been innovating and pioneering latest techniques and equipment that can benefit the mankind. Though persistent, progress has been far from uniform. Despite all the bells and whistles that these innovations bring to the table, the little acknowledged fact is that they are only accessible to a very small proportion of the global population. Five billion people on this planet do not even have access to an operating room when needed. It has been reported that conditions requiring surgery are responsible for one-third of all the deaths in the world. The current narrative review was planned to focus on the importance of innovations in surgery, to highlight the problems that were faced by resource-restricted countries in the past, and the necessity of innovative solutions to improve global surgical care in the future.

What is the likelihood of nonpulmonary metastasis occurring in the absence of lung metastasis in bone and soft tissue sarcoma? A nested case-control from a sarcoma referral centre.

BACKGROUND AND OBJECTIVES: Nonpulmonary metastases (NPM) are rare, associated with a poorer prognosis, and maybe missed on conventional chest imaging for sarcoma surveillance. We determined (1) the proportion of NPM occurring in isolation or with synchronous or prior pulmonary metastases (PM), and (2) if initial NPM would have been recognized with a standard surveillance protocol. METHODS: Investigators identified patients who developed initial NPM without prior evidence of or concurrent PM from an ongoing cohort of bone and soft tissue sarcoma (STS) patients. Logistic regression at univariate level was done. RESULTS: There were 138/630 (22%) patients with metastasis and 66 (10%) had NPM: 50 (8%) patients had PM presenting first, while 16 (3%) had initial NPM. Malignant peripheral nerve sheath tumor, angiosarcoma, rhabdomyosarcoma, synovial sarcoma, and myxoid liposarcoma were six times more likely to develop initial NPM than other subtypes of STS with odds ratio = 6 (95% confidence interval: 1.93-18.65, p value < 0.01). Chest imaging and physical examination were sufficient to identify NPM in all except three bone sarcoma patients. CONCLUSIONS: Patients who develop initial NPM are rare and demonstrate a predilection towards some subtypes of extremity sarcoma. They develop oligometastatic disease, which may be amenable for surgical excision. All isolated or initial NPM in STS patients were discovered by physical examination and standard chest imaging.

Is local recurrence in bone and soft tissue sarcomas just a local recurrence or does it impact the overall survival, retrospective cohort from a sarcoma referral center.

BACKGROUND AND OBJECTIVES: Sarcoma local recurrence (LR) is often associated with metastasis, but it is unclear if LR can be a causal event leading to metastasis. We question if LR is best viewed as an independent oncologic event or as a worrisome harbinger threatening a patient's overall survival. METHODS: We identified patients with LR and/or metastasis from an ongoing cohort of 629 patients with primary sarcoma and performed a detailed review to assess the timing of metastasis resulting in the following groups: (1) Isolated LR, (2) LR before metastasis, (3) LR within 6 months of metastasis, (4) LR 6-12 months after metastasis, (5) LR >12 months after metastasis, and (6) metastasis at diagnosis. RESULTS: Overall, 43 patients met the inclusion criteria with an LR rate of 7%. Ten patients (2% of the entire cohort, 23% of LR) developed an LR before or within 6 months of metastasis. For patients without systemic disease preceding LR, 3 of 23 soft tissue sarcoma STS (13%) and 7 of 10 bone sarcoma (70%) subsequently developed metastasis (p < 0.01). CONCLUSION: LR with subsequent metastasis is a rare event. LR appears to be best viewed as a marker of tumor aggressiveness rather than the cause of metastasis and poor survival. LR in bone sarcoma patients should warn providers of a high risk of imminent metastasis.

Intraoperative hypothermia in patients undergoing Total knee arthroplasty: a cross-sectional study from a developing country.

BACKGROUND: Intraoperative hypothermia is associated with various risk factors, morbidity, and mortality in patients undergoing total knee arthroplasty (TKA), increasing the emotional and financial burden on patients. This study aimed to identify risk factors of intraoperative hypothermia in patients undergoing TKA. MATERIALS AND METHODS: All adult patients (⩾18 years) who underwent TKA from January 2016 to December 2017 at a tertiary-care hospital in Pakistan were included in this retrospective, cross-sectional study. Temperature < 36 °C was defined as hypothermia. RESULTS: The study included 286 patients (77.6% female) with a mean age of 61.4 ± 10.4 years. The overall proportion of intraoperative hypothermia was 26.6%. Of the total patients, 66.1% underwent bilateral TKA whereas 33.9% underwent unilateral TKA. 73.8% of the patients were ASA Level 2. Only 13.3% of patients had postoperative hypothermia. CONCLUSION: Intraoperative hypothermia was significantly associated with age, bilateral procedure, ASA level and postoperative hypothermia in patients undergoing TKA. The surgeon and the operative team should be aware of the risk factors and the adverse outcomes associated with intraoperative hypothermia, especially in resource constrained settings to plan preventive strategies. TRIAL REGISTRATION: This study was retrospectively registered on ClinicalTrials.gov on 3rd October 2020. The registration ID is NCT04575246 .

Musculoskeletal tumours throughout history and beyond: Clinical features, imaging, staging and biopsy.

BACKGROUND: Over the last century, there has been a remarkable development in the study of bone and soft tissue sarcomas. This is primarily due to the improved knowledge of the nature of these lesions and the improved imaging technology. In literature there are many protocols that are being used and all of them have reported various advantages and disadvantages of each technique used. However, there is no set guideline and whatever has been proposed has been developed on the basis of the experience of different centres and different surgeons. OBJECTIVE: The current systematic review was planned to thoroughly evaluate the levels of evidence on which we base decisions for surgical management of lower extremity bone tumours. METHODS: The review included descriptive studies published in the English language. Studies included case reports, case series and experiences of different centres for the surgical management of lower extremity bone tumours. Articles reporting all levels of evidence - Level I to V - were included. PubMed, ERIC, MEDLINE, EMBASE and Cochrane Reviews databases from 2002 to 2012 were searched. RESULTS: Information was gathered and thoroughly studied from 63 articles. There were no Level I studies, 2(3.2%) Level II studies, 47(74.6%) Level III, and the remaining 14(22.2%) studies were Level IV and Level V. CONCLUSIONS: Sarcomas are rarely occurring neoplastic conditions which are present in all age groups but commonly affect young age population. Most are asymptomatic but can present with pain or pathological fracture. These lesions are commonly diagnosed with plain radiographs. CT scan and MRI may be used to delineate anatomy and to quantify the extent of soft tissue involvement. Various advantages and disadvantages associated with each aspect in the management of patients starting from the basic history-taking, physical examination, imaging, biopsy principles, peri-operative laboratory work-up and staging of the cancer were studied. Treatment ranges from conservative to en-block resection including extended curettage. Aggressive tumours should be closely followed up for recurrence and metastasis.

In the cost-conscious era: Ilizarov circular frame or uniplanar external fixator for management of complex open tibia shaft fracture, retrospective cohort study from a level-1 trauma center.

OBJECTIVE: External fixation is the most commonly used method for temporary management of open fractures of the Tibial shaft followed by internal fixation. This can also be used as a definitive method of fixation. Ilizarov is more superior and can be the primary and definite option where expertise is available. This study was conducted todetermine the outcome of open tibia shaft fracture treated with either Ilizarov or AO External Fixator. METHODS: Anon-commercial retrospective cohort was conducted at Aga Khan University Hospital Karachi on patients operated for isolated open tibia fractures Gustillo type III (A, B, C) stabilized with external fixation either circular or uniplanar external fixator. These two groups were compared in terms of fracture pattern, healing and complications. For fracture healing, Radiographic union score (RUST) for tibial fractures were used. RESULTS: A total of 93 patients were included in the study. Mean age 36.7 +/- 17.3 years comprising 83 males and 10 females. Circular Fixator was used for 46 whereas 47 were treated with uni-planar fixator. Mean new injury severity score was 21 ± 3.4 for circular fixator group and 26 ± 7 in uniplanar fixator group. Mean time fur fracture healing was 6±1months in circular fixator group and 9 months in Uniplanar Fixator group. Mean RUST score for circular fixator was 9.5±1.2.and of uniplanar it was 7.3±1.0. CONCLUSIONS: Circular fixator works as a single stage procedure with acceptable outcomes for Gustilo grade III open tibial shaft fractures as compared to uniplanar external fixator.

A comprehensive basic understanding of pelvis and acetabular fractures after high-energy trauma with associated injuries: Narrative review of targeted literature.

Acetabular fractures are caused by energy trauma which is high enough to cause such a fracture with incidence of 3 patients / 100000. In older individuals, most commonmechanism of injury is fall and, in younger individuals, road traffic accidents. Acetabular fractures are usually associated with visceral injuries and other musculoskeletal injuries (about 50% of patient). In this narrative review of targeted English literature from all level of evidences, which is written and supervised by experienced specialized orthopedic and trauma surgeons who were among the pioneers of conducting pelvis fracture management workshops in the country, we aim to describe the mechanism of injury, assessment principles and associated injuries, decision-making and preoperative planning and indications of non-operative managements.

Sexual dysfunction in men after high energy pelvic fractures: Narrative review of targeted literature.

Pelvic fractures represents high energy trauma with associated other organ injuries including intra-abdominal injuries, haemorrhage and extremity injuries. Anatomical location of genitourinary structures makes them vulnerable to injury with pelvic fracture. Incidence of sexual dysfunction varies in literature with 5% incidence of dysfunction in patients without urethral injury and 42% with urethral injuries. Hence in pelvic fracture, erectile dysfunction may be due to neurogenic, vascular, corporal and psychogenic injury. In this narrative review of targeted English literature from all level of evidences, which is written and supervised by experienced specialized orthopaedic, trauma and urology surgeons who were among the pioneers of conducting pelvis fracture management workshops in the country, we aim to describe the mechanism that can lead to erectile dysfunction after pelvic fracture, assessment principles, decision-making and preoperative planning and indications of operative managements.

Application of 3D printing in orthopaedic surgery. A new affordable horizon for cost-conscious care.

Application of three-dimensional (3D) printing facilities in orthopaedic surgery is getting popular in resourceconstrained countries. It is cost- and resource-efficient to assist in planning and increasing orthopaedic procedures efficienc y. Furthermore, it improves educational training and provides cheaper prosthesis and creation of customised implants for special cases. Moreover, 3D models of computed tomography (CT) and magnetic resonance imaging (MRI) data play a helpful rule for a more hands-on approach for the surgeon. Likeevidence-based medicine practice, researchers are exploring new areas of patient-specific instrumentation in the surgical field, searching for favourable and costeffective results. Three-dimensional printing has shown promising results for quick and cost-effective solutions in several fields. Many fields of application are dependent on various uses of 3D printing, but it has yet to be used widely in medicine and orthopaedics. The current literature review was planned to highlight the advantages of using 3D printing, its scope in surgical field with emphasis on orthopaedic surgery, and the limitations of its use in developing countries.

The need for simulation in surgical education in developing countries. The wind of change. Review article.

Operative skills are the heart and soul of surgical practice. An extensive amount of literature has been devoted to the art and science of acquiring these skills which start by mastering basic skills until automaticity has been achieved. The current model of surgical education is purely based on sheer volume of patients, restrictions in the maximum number of working hours for trainees and increased pressures of operating room efficiency. This leads to limited teaching time. Adding to the scenario is the emphasis on patient safety and greater awareness of medico-legal consequences following medical errors. All this has significantly hampered the learning experience of surgical trainees and limited the expert surgeon's ability to fulfil trainees' learning needs during complex procedures. Thus, learning strategies outside the operating room were required to provide an ideal environment for learning without putting patients' health at risk. This has led to increased use of simulators in modern surgical training. The situation is even more worrisome in developing countries where the availability of these facilities is either extremely limited or nonexistent. The current narrative review was planned to go over the importance of simulation in surgical education and to question its utility in developing countries.

Low cost reconstructive options after musculoskeletal tumour resection in developing countries. Affordable, effective and durable alternatives.

Over the last two, three decades, the overall survival rates for non-metastatic malignant tumours of the bone have dramatically improved. This has become possible due to the recent advances and multidisciplinary approach towards these diseases, specifically the advent of multi-agent chemotherapy and radiotherapy. Limb salvage has now become the norm in the treatment of musculoskeletal tumours without compromising on the overall survival and recurrence of the disease. In the era of metal, prosthetic reconstruction has become the standard procedure specifically in the large tumours which involve the joints as this method of reconstruction helps in joint mobility and early weight-bearing. Considering the costs and resource constraints, multiple cost-effective, stable, durable reconstruction options have evolved over the last decade and these have also shown favourable func tional outcomes without compromising on the amount of resection and risk of local recurrence. The current literature review was planned to discuss various cost-effective, durable reconstructive options and their advantages and disadvantages. These include Van ness rotationplasty, allograft, autograft, devitalised tumour bone and Masqueletor induced membrane technique . .

Inflammatory arthritis and Mycobacterium Tuberculosis infection: a diagnostic and management challenge for Knee arthroplasty in endemic areas.

Tuberculosis continues to be one of the most challenging health problems more prevalent in developing countries. Pakistan ranks 5th in tuberculosis prevalence among the high-burden countries. Prosthetic joint infection of the knee by acid fast bacilli is a rare and distressing complication, occurring in nearly 1% of primary joint arthroplasties requiring prolonged medical treatment and multiple surgeries. A recent publication extensively reviewed English literature from 1952 to 2016, and repor ted only 64 prosthetic joint infec tion with tuberculosis, of which 27 cases involved the knee. Tuberculosis is a global health problem adding to the challenges that arthroplasty surgeons face in our resource-constrained setting. Furthermore, it presents as other inflammatory arthritis with almost same laboratory and radiological findings. The current paper was planned to highlight the preoperative and postoperative challenges that the arthroplasty surgeon may have in diagnosis and management of this rare infection. We included studies from 1996 to date which reported knee tuberculosis prosthetic joint infection that were managed by medication alone or with surgical intervention in patients who had undergone arthroplasty.

Does pin tract infection after external fixator limits its advantage as a cost-effective solution for open fractures in low-middle income countries, a prospective cohort study.

OBJECTIVE: To determine the frequency of pin tract infection in external fixator tibia and its effects on the definite fracture fixation and bone healing. Methods: The prospective study was conducted at Lady Reading Hospital, Peshawar, Pakistan, from August 2017 to July 2018, and comprised patients regardless of age and gender with open fracture tibia Gustillo-Anderson type II and type IIIA. Pin tract infection was assessed following the application of locally made external fixation of tibia open fractures. Follow-up was done fortnightly till soft tissue healing, removal of external fixator and definite fracture healing. Pin tract infection was classifiedand treated according to the Checketts-Otterburn classification system. SPSS 20 was used for data analysis. Results: Of the 117 patients, 95(81%) were males and 22(19%) were females with an overall mean age of 24.7±9.35 years. Pin tract infection was documented in 28(23.9%) patients. Minor and major pin tract infections were reported in 27(96.4%) and 1(3.5%) patient respectively. Soft tissues healed in 27(96.4%) cases. Conclusion: External fixator for initial stabilisation of open tibial fractures in all patients is recommended..

"It's a precious gift, not to waste": is routine cross matching necessary in orthopedics surgery? Retrospective study of 699 patients in 9 different procedures.

BACKGROUND: Orthopedic surgeries are usually associated with excessive blood loss which leads surgeons to overestimate need for blood transfusions and over ordering of blood. The cross matched blood, when not used, leads to the wastage of blood bank resources in terms of time, money and manpower. The objective of this study was to investigate the compliance to previously proposed MSBOS and to provide updated recommendations for all orthopedic procedures. METHODS: A retrospective analysis was conducted between 1st June 2015 and 31st May 2016. Patients admitted to the orthopedic surgery service for whom blood products were requested were included. Cross Match/Transfusion (CT) Ratio, Transfusion Index and Transfusion Probability were calculated. Values of < 2.5, > 0.5 and > 30% respectively, were taken as standards. Maximum Surgical Blood Ordering Schedule (MSBOS) was proposed based upon these calculations using Mead's criteria. RESULTS: Six hundred and ninety-nine patients were sampled after implementing exclusion criteria. The overall CT ratio was 4.87, transfusion index was 0.55 and transfusion probability was 25%. A compliance rate of 24.6% was observed with the reference CT ratio of 2.5. Highest CT ratio was calculated for arthroscopic procedures while tumor resection had the lowest ratio. Age, procedure performed, ASA status and use of tourniquet were found to be significantly associated with CT ratio being greater or less than 2.5. CONCLUSION: Results showed significant wastage of blood products and non-compliance with blood ordering guidelines. Hence there is need for large scale prospective studies to establish MSBOS and ensure its compliance.

Benign tumours and tumour like lesions of bone.

Over the last century, there has been a remarkable development in the study of benign bone tumours. This is primarily due to the improved knowledge of the nature of these lesions and improved imaging technology. They present as a diverse group of clinical and pathological entities, which vary in their clinical behaviour and aggressiveness and, hence, multidisciplinary approach is necessary in their management. Combined opinion from an orthopaedic surgeon, radiologist and a pathologist is therefore required. Incidence of these tumours is debatable because they are often asymptomatic. Many protocols have been reported in studies with respect to the management of these tumours based on the experience of different centres and different surgeons with no set guidelines. English-language studies, including case reports, case series and systemic reviews, from PubMed, ERIC, MEDLINE, EMBASE and Cochrane Reviews databases from 2002 to 2016 were included in the current. Articles reporting all levels of evidence - Level I to V - were included.

Characteristics and Long-Term Outcome of Surgically Managed High-Grade Extremity Chondrosarcoma.

Background: Dedifferentiated chondrosarcoma (DCS) is a highly malignant variant that portends a poor prognosis. Although factors such as clinico-pathological characteristics, surgical margin, and adjuvant modalities likely play a role in overall survival, debate continues with varying results on the importance of these indicators. The purpose of this study is (1) To delineate the characteristics, local recurrence (LR), and survival of patients with intermediate (IGCS), high (HGCS) and dedifferentiated (DCS) chondrosarcoma of the extremity by utilizing detailed cases at one tertiary institution. (2) To assess survival between high grade chondrosarcoma and DCS utilizing a less detailed but large cohort from the Surveillance, Epidemiology, and End Results (SEER) database. Methods: Twenty-six cases of high-grade (conventional FNCLCC grades 2 and 3, dedifferentiated) chondrosarcoma were identified from an ongoing prospective cohort of 630 sarcoma patients managed surgically at a tertiary referral university hospital between 9/1/2010-12/30/2019. A retrospective review of demographics, tumor characteristics, surgical procedure, treatment course, and survival data was performed to determine prognostic factors for survival. An additional 516 cases of chondrosarcoma were identified from the SEER database. Using the Kaplan-Meier method, both the large database and case series were evaluated, and estimated cause-specific survival was calculated at 1, 2, and 5 years. Results: There were 12 IGCS, 5 HGCS, and 9 DCS patients in the single institution cohort. DCS had a higher stage at diagnosis (p=0.04). Limb salvage was the most common procedure performed in every group (11/12 IGCS, 5/5 HGCS, and 7/9 DCS; p=0.56). Margins included 8/12 wide and 3/12 intralesional for IGCS. For HGCS, there were 3/5 wide, 1/5 marginal, and 1/5 intralesional. A majority of DCS margins were wide (8/9) with only 1 marginal. There was no difference of associated margins between the groups (p=0.85), however there was a difference when margins were classified based on numerical measurement (IGCS: 0.125cm (0.1-0.35); HGCS: 0cm (0-0.1); DCS: 0.2cm (0.1-0.5); p=0.03). The overall median follow-up was 26 months (IQR:16.1-70.8). The time interval from resection to death was lower in DCS (11.5 months (10.7-12.2)), followed by IGCS (30.3 months (16.2-78.2)), and HGCS (55.1 months (32.0-78.2; p=0.047). LR occurred in 5/9 DCS, 1/5 HGCS, and 1/14 IGCS patients. Of the DCS patients only 2/6 who received systemic therapy had LR, while all 3/3 who did not receive systemic therapy had LR. Overall systemic therapy and radiation did not impact incidence of LR (p=0.67; p=0.34). However, patients who had LR were 17.5 times more likely to die within one year (HR=17.5, 95%CI (1.01-303.7), p=0.049), after adjusting for the age at the surgery. There was no correlation with the utilization of systemic therapy, radiation therapy, or margin and overall survival (p=0.63, p=0.52, p=0.74). In the SEER patient cohort, 149 cases (28.9%) were DCS and 367 (71.1%) were HGCS. At final follow-up, 49.6% (n=256) of the cohort had a cause of death due to chondrosarcoma. HGCS was associated with higher chance of 1-year survial (p<0.001), 2-year survival (p<0.001), 5-year survival (p<0.001), and overall survival (p<0.001). Additionally, decreased survival was associated with metastatic disease at presentation (p=0.01). Overall limb salvage was most utilized for both HGCS (76.5%) and DCS (74.3%). In regard to limb salvage vs. amputation, there was no difference in survival at 1 year (p=0.10) or 2 year (p=0.13) between the groups, however those who underwent limb salvage procedure had a significantly better chance of survival at 5 years when compared to amputation (HR=1.49 (1.11-1.99); p=0.002). Conclusion: High-grade chondrosarcoma remains a fatal disease in many patients, particularly if associated with dedifferentiated subtype. Interestingly, all (100%) DCS patients who did not receive systemic therapy had LR. However, chemotherapy and radiation did not significantly increase survival. In this case series and large database study, HGCS had the smallest surgical margin, but with the longest time interval for both LR and death. Additionally, using the SEER database, DCS and amputation had worse prognosis at the 5-year survival time. Further studies on valuable prognostic influences as well as earlier identification of this rare disease may help in developing better management options. Level of Evidence: III.

Web-Based Patient Educational Material on Osteosarcoma: Quantitative Assessment of Readability and Understandability.

BACKGROUND: Patients often turn to web-based resources following the diagnosis of osteosarcoma. To be fully understood by average American adults, the American Medical Association (AMA) and National Institutes of Health (NIH) recommend web-based health information to be written at a 6th grade level or lower. Previous analyses of osteosarcoma resources have not measured whether text is written such that readers can process key information (understandability) or identify available actions to take (actionability). The Patient Education Materials Assessment Tool (PEMAT) is a validated measurement of understandability and actionability. OBJECTIVE: The purpose of this study was to evaluate web-based osteosarcoma resources using measures of readability, understandability, and actionability. METHODS: Using the search term "osteosarcoma," two independent Google searches were performed on March 7, 2020 (by AGS), and March 11, 2020 (by TRG). The top 50 results were collected. Websites were included if they were directed at providing patient education on osteosarcoma. Readability was quantified using validated algorithms: Flesh-Kincaid Grade Ease (FKGE), Flesch-Kincaid Grade-Level (FKGL). A higher FKGE score indicates that the material is easier to read. All other readability scores represent the US school grade level. Two independent PEMAT assessments were performed with independent scores assigned for both understandability and actionability. A PEMAT score of 70% or below is considered poorly understandable or poorly actionable. Statistical significance was defined as P≤.05. RESULTS: Two searches yielded 53 unique websites, of which 37 (70%) met the inclusion criteria. The mean FKGE and FKGL scores were 40.8 (SD 13.6) and 12.0 (SD 2.4), respectively. No website scored within the acceptable NIH or AHA recommended reading level. Only 4 (11%) and 1 (3%) website met the acceptable understandability and actionability threshold. Both understandability and actionability were positively correlated with FKGE (ρ=0.55, P<.001; ρ=0.60, P<.001), but were otherwise not significantly associated with other readability scores. There were no associations between readability (P=.15), understandability (P=.20), or actionability (P=.31) scores and Google rank. CONCLUSIONS: Overall, web-based osteosarcoma patient educational materials scored poorly with respect to readability, understandability, and actionability. None of the web-based resources scored at the recommended reading level. Only 4 achieved the appropriate score to be considered understandable by the general public. Authors of patient resources should incorporate PEMAT and readability criteria to improve web-based resources to support patient understanding.

Does more testing in routine preoperative evaluation benefit the orthopedic patient? Case control study from a resource-constrained setting.

BACKGROUND: Routine preoperative tests in healthy patients not only cause extra anxiety, but may delay treatment without influencing surgical plan. This has worse impact in resource-constrained settings where fee for service rather than health insurance is the usual norm. Investigators aim to determine if "routine" pre-operative tests are justified in healthy orthopedic patients. METHODS: We conducted a non-commercialized, non-funded matched case control study in tertiary care university hospital and a level-1 trauma centre for healthy patients (ASA-1&2) admitted from January 2014-December 2016 for elective orthopedic intermediate and major procedures. Cases (patient who had a change in his/her surgical plan after admission) and controls were selected independently of the exposure of interest then matched randomly to cases on age, gender and procedure type. Primary exposure was the routine preoperative lab tests, as defined by the American Society of Anesthesiologist, which included 13 blood tests. Analysis was done using Principle Component Analysis and Conditional logistic regression at univariate and multivariable levels reporting matched adjusted Odds Ratios. The data was reported in line with STROCSS criteria. RESULTS: Overall, 7610 preoperative tests were done for 670 patients with 62% men among cases and 53% men among controls with mean age of 49.9 ± 22.5 years and 41.1 ± 23.0 years, respectively. There were 1076 (14%) abnormal result that influenced surgical plan in 0.96% cases only. Matched adjusted OR with 95% confidence interval of primary exposure was insignificant. CONCLUSION: Routine preoperative tests were superfluous and did not influence the surgical plan when adjusted for other variables in the model as well as after matching on potential confounders. This study would be amongst first steps to move towards an evidence based surgical practice for preoperative evaluation.

Novel Scoring Criteria for Preoperative Prediction of Neoadjuvant Chemotherapy Response in Osteosarcoma.

Background: The extent of tumor necrosis after neoadjuvant chemotherapy is an important predictive factor of survival in osteosarcoma. However, the response to chemotherapy is not known until after the definitive resection and limits the utility of this information for operative planning. Our study questions include: 1) Are there clinical and radiographic factors following neoadjuvant chemotherapy, but prior to the tumor resection, that may aid in predicting response to treatment? 2) Can we combine these criteria into a predictive composite score that can identify good and poor responders to chemotherapy? Methods: We identified consecutive patients diagnosed with osteosarcoma and managed with neoadjuvant chemotherapy prior to surgical resection. We assessed post-chemotherapy tumor ossification, tumor size and growth, and the presence of pain to devise a scoring criteria to predict the percent necrosis on the final histologic specimen. Bivariate analyses were done, and a receiver operating characteristic curve was constructed to determine predictive capacity. Results: Out of the 40 patients included in this study, 15 (38%) had a good response (≥ 90% necrosis) to treatment and ten patients (25%) had a poor response with ≤ 50% necrosis. Tumor size, growth and increase in ossification were significantly associated with a good response to treatment. For good responders, a composite score of 6 was seen to attain the highest sensitivity and specificity, 100% and 84%, respectively. Tumor size, no change in ossification, and post-chemotherapy pain were significantly associated with a poor response to treatment. For poor responders, a composite score of 7 was seen to have the highest sensitivity and specificity, 100% and 63%, respectively. Conclusion: Compared to the use of one single factor, our combined scoring criteria demonstrated a far improved accuracy in identifying good responders to neoadjuvant chemotherapy, where a score of 6 or less is predictive of a good response. However, the specificity of this scoring criteria to predict poor responders was low, indicating that this criterion may not be the most accurate method to identify poor responders. The utility of this score has implications regarding pre-operative counseling of the patient and operative planning.Level of Evidence: III.