Specific preoperative factors increase manipulations under anesthesia following primary TKA.

Background Arthrofibrosis following primary total knee arthroplasty (TKA) can result in pain and limit postoperative range of motion (ROM), jeopardizing clinical outcomes and patient satisfaction. This study aims to identify preoperative risk factors associated with necessitating a manipulation under anesthesia (MUA) following primary TKA. Methods We retrospectively reviewed 950 cases of consecutive primary TKAs performed at one institution by three arthroplasty surgeons between May 2017 and May 2019. Recorded preoperative variables included smoking status, race, preoperative ROM, presence of effusion or positive anterior drawer, and medical comorbidities. Demographic characteristics were compared with Student's t-tests or Chi-squared tests as appropriate. For each preoperative factor, we obtained an odds ratio for MUA risk using multivariate logistic regression. Results Twenty (2.3%) patients underwent MUA following their index primary TKA surgery. History of ipsilateral knee surgery (odds ratio [OR]: 2.727, p=0.047) and diagnosed hypertension (OR: 4.764, p=0.016) were identified as risk factors associated with significantly increased risk of MUA. The greater the preoperative range of motion, the higher likelihood needed of MUA (OR: 1.031, p=0.034). Conclusions Patients who had diagnosed hypertension or a history of prior ipsilateral knee surgery were associated with increased risk of necessitating an MUA following primary TKA. Additionally, a greater total arc of motion preoperatively increased the odds of needing MUA.

Use of The Risk Assessment and Prediction Tool to Predict Same-day Discharge After Primary Hip and Knee Arthroplasty.

INTRODUCTION: The Risk Assessment and Prediction Tool (RAPT) is a preoperative screening tool developed to predict discharge disposition after total hip arthroplasty (THA) and total knee arthroplasty (TKA), but its predictive value for same-day discharge (SDD) has not been investigated. The aims of this study were (1) to assess RAPT's ability to predict SDD after primary THA and TKA and (2) to determine a cutoff RAPT score that may recognize patients appropriate for SDD. METHODS: Data were retrospectively collected from patients undergoing primary THA and TKA at a single tertiary care center between February 2020 and May 2021. A receiver operating characteristic curve was generated to choose a cutoff value to screen for SDD. Logistic regression analysis was done to identify factors including age, BMI, or RAPT score that may be associated with SDD. RESULTS: Three hundred sixty-one patients with preoperative RAPT scores were included in the analysis of whom 147 (42.6%) underwent SDD. A cutoff of ≥9 was identified for TKA and ≥11 for THA. RAPT had a predictive accuracy of only 66.7% for SDD, whereas the discharge plan documented in the preoperative note was 91.7% accurate. DISCUSSION: Although there is a positive association between RAPT and SDD, it is not a useful screening tool given its low predictive accuracy.

Outcomes of Image-Free Robotic Assisted Total Knee Arthroplasty in Patients Who Have Valgus Knee Deformities.

BACKGROUND: Valgus knee deformities pose a unique challenge in total knee arthroplasty (TKA) due to the complexity of achieving ligamentous balance and satisfactory alignment compared to varus or neutral deformities. Robotic-assisted (RA) TKA could aid in achieving improved component alignment and balance. METHODS: We retrospectively evaluated a matched cohort of patients to compare image-free RA-TKA (n = 44) versus conventional manual (CM) TKA (n = 30) techniques in patients who have valgus deformity of 5 to 15 degrees, including radiographic and patient-reported outcomes measures (PROMs) over a 3-year period. The patient reported outcome measures (PROMs) studied to determine outcomes were: Western Ontario McMaster University Arthritis Index, Knee Society Score-Function Score, and Short Form 12-item Survey. RESULTS: Overall, the RA-TKA cohort showed faster improvement in PROMs (37.16 ± 1 8.8 versus 25.74 ± 17.7, P = .02), shorter length of stay (1.41 versus 2.29 days, P = .02), and shorter operating room times (120.79 versus 123.67 minutes, P = .02) than CM-TK). Additionally, there was no difference in the use of primary versus varus-valgus constrained polyethylene liners between the cohorts. CONCLUSIONS: In this investigation, RA-TKA yielded a slightly faster patient recovery, more objective measurements of ligamentous balance, and proved noninferior PROMs compared to CM-TKA for preoperative valgus knee deformities.

Optimising the Orthopaedic Trauma Society Open Fracture Classification system: a proposal for modification in the context of high civilian gunshot fractures.

OBJECTIVES: Uniformly classifying long bone open fractures is challenging. The purpose of this study was to propose a modified Orthopaedic Trauma Society (OTS) Open Fracture Classification System, developed in a setting with a high incidence of civilian gunshot fractures. METHODS: From our prospectively collected database, we identified all patients with open tibia and femur fractures treated with intramedullary nailing over a 4 year period. All open fractures were retrospectively reclassified from the Gustilo-Anderson Classification system to the OTS Open Fracture Classification System. RESULTS: One hundred and thirty-seven cases were identified. Ninety per cent of subjects were males. Their mean age was 34 years. The most common mechanism of injury was low-velocity civilian gunshot wounds (GSW) in 54.7% of cases. Soft tissue management was primary closure in 23.4% and soft tissue reconstruction in 24.1%. In 52.6% of cases (these all being secondary to civilian GSW), soft tissue management was healing via secondary intention. This is not included as a soft tissue management option in the OTS classification system. Fracture reclassification using the OTS Open Fracture Classification System was only possible in 47.5% of cases (Simple in 23.4%, Complex B in 24.1%). CONCLUSION: We conclude that the OTS Open Fracture Classification System is not inclusive of all open tibia and femur fractures as it does not cater for gunshot fractures. We propose a modification as follows: alter 'wound debridement' to 'appropriate wound care' and to subcategorise 'Simple' into type A and B: healing via secondary intention and primary closure, respectively.

Specific protein interactions between rice members of the GT43 and GT47 families form various central cores of putative xylan synthase complexes.

Members of the glycosyltransferase (GT)43 and GT47 families have been associated with heteroxylan synthesis in both dicots and monocots and are thought to assemble into central cores of putative xylan synthase complexes (XSCs). Currently, it is unknown whether protein-protein interactions within these central cores are specific, how many such complexes exist, and whether these complexes are functionally redundant. Here, we used gene association network and co-expression approaches in rice to identify four OsGT43s and four OsGT47s that assemble into different GT43/GT47 complexes. Using two independent methods, we showed that (i) these GTs assemble into at least six unique complexes through specific protein-protein interactions and (ii) the proteins interact directly in vitro. Confocal microscopy showed that, when alone, all OsGT43s were retained in the endoplasmic reticulum (ER), while all OsGT47s were localized in the Golgi. co-expression of OsGT43s and OsGT47s displayed complexes that form in the ER but accumulate in Golgi. ER-to-Golgi trafficking appears to require interactions between OsGT43s and OsGT47s. Comparison of the central cores of the three putative rice OsXSCs to wheat, asparagus, and Arabidopsis XSCs, showed great variation in GT43/GT47 combinations, which makes the identification of orthologous central cores between grasses and dicots challenging. However, the emerging picture is that all central cores from these species seem to have at least one member of the IRX10/IRX10-L clade in the GT47 family in common, suggesting greater functional importance for this family in xylan synthesis. Our findings provide a new framework for future investigation of heteroxylan biosynthesis and function in monocots.

Higher Sensitivity of Xpert MTB/RIF Ultra Over Tuberculosis Culture for the Diagnosis of Spinal Tuberculosis With Open or Computed Tomography-Guided Biopsies.

Background: Diagnostic specimens for spinal tuberculosis (STB) are mostly collected via open surgery. Percutaneous computed tomography (CT)-guided biopsies are used in times of limited surgical availability. However, poor diagnostic accuracy of Mycobacterium tuberculosis (Mtb) culture has been reported with this method, due to limited sample volume and the paucibacillary nature of STB. We evaluated Xpert MTB/RIF Ultra on open and CT-guided biopsies as compared with the gold standard Mtb culture and histopathology. Methods: We conducted a prospective diagnostic accuracy study of Xpert Ultra, as compared with tuberculosis culture and histopathology, in adults with signs and symptoms of STB at a tertiary academic hospital in South Africa from November 2020 to December 2021. Diagnostic testing was performed on 31 patients with available samples. Results: Xpert Ultra had a sensitivity of 94.7% (95% CI, 75.3%-99.7%) and specificity of 100% (95% CI, 75.7%-100.0%) against a reference standard of Mtb culture and histopathology. Xpert Ultra had high diagnostic accuracy in open and CT-guided biopsy samples with sensitivity and specificity of 100% and 100% (open) and 89% and 100% (CT), respectively. Mtb culture had limited specificity for CT-guided biopsies (43%; 95% CI, 15.8%-74.9%). HIV-1 coinfection did not affect Mtb abundance measures by Xpert Ultra or culture. Xpert Ultra was also superior to culture for STB diagnosis in patients concurrently treated for pulmonary tuberculosis. Conclusions: Xpert Ultra detected more STB cases than culture for CT-guided biopsy samples. There was also no difference in sensitivity for open biopsies, irrespective of HIV-1 status, making it an important tool for rapid diagnosis, especially during times or in locations where open surgery is not possible or concurrent pulmonary tuberculosis treatment is initiated.

Developing an antibiogram for empiric antibiotic prescribing for adult non-spinal orthopaedic infections in a developing world setting.

PURPOSE: Empiric antibiotic strategies in the treatment of fracture-related infections, chronic osteomyelitis, prosthetic joint infection, and septic arthritis should be based on local microbiological antibiograms. This study aims to describe the microbiology and review the antibiogram profiles of bacterial isolates from patients undergoing surgical treatment for non-spinal orthopaedic infections, to identify the most appropriate empiric antibiotic strategy. METHODS: A retrospective review was performed of all cases of non-spinal orthopaedic infections treated surgically from 1 January 2018 to 31 December 2018. The National Health Laboratory Service microbiology database was used to identify all intra-operative microbiological specimens obtained from orthopaedic patients, and data were correlated with the orthopaedic surgical database. Cases were divided into fracture-related infections, chronic osteomyelitis, prosthetic joint infection, and septic arthritis. Antibiotic susceptibility data were used to predict the efficacy of different empiric antibiotic regimens. RESULTS: A total of 107 cases were included in the study; 184 organisms were cultured. Overall, the most common organism cultured was Staphylococcus aureus (25%) followed by Acinetobacter baumannii (9%), Enterococcus faecalis (7%) and Enterobacter cloacae (5%). Across all categories the oral antibiotic combination with the highest effectiveness (81%) would have been a combination of co-trimoxazole, ciprofloxacin and amoxicillin. The most effective intravenous antibiotic combination would have been either piperacillin-tazobactam, amikacin and vancomycin or meropenem and vancomycin; 90% of tested isolates were susceptible to either of these combinations. CONCLUSION: Antibiogram profiles can serve to guide to empiric antibiotic choice in the management of different categories of non-spinal orthopaedic infections.

Knockout of eight hydroxyproline-O-galactosyltransferases cause multiple vegetative and reproductive growth defects.

Arabinogalactan-proteins (AGPs) are a family of hyperglycosylated hydroxyproline-rich cell wall proteins found throughout the plant kingdom. To date, eight Hydroxyproline-galactosyltransferases (Hyp-GALTs), named GALT2-GALT9, are known to catalyze the addition of the first galactose sugar to Hyp residues in AGP protein cores. The generation and characterization of galt23456789 octuple mutants using CRISPR-Cas9 gene editing technology, provided strong reverse genetic evidence that AG glycans are essential for normal vegetative and reproductive growth, as these mutants demonstrated stunted growth, greatly delayed flowering and significant defects in floral organ development and morphogenesis. Compared to the lower seed set of galt25789 quintuple mutants being more so contributed by female gametophytic defects, dramatically low seed-set of octuple mutants was largely due to impaired male reproductive function, specifically due to shorter filaments, delayed anther dehiscence, and large decreases in pollen quantity and viability. Octuple mutant pollen had severely distorted reticulate exine, tectum patterning and intine thickness. Reduced amounts of galactose and arabinose in overall lower amounts of ß-Yariv precipitated AGPs illustrated how biological functions of AGPs are affected by abnormal glycosylation.

Is human immunodeficiency virus a risk factor for the development of nonunion?-a case-control study.

Objective: Human immunodeficiency virus (HIV) infection has been suggested to be associated with an increased risk of the development of nonunion after a fracture. This prospective matched case-control study in South Africa investigated common risk factors, including HIV status, that influence the development of a nonunion after a femur or tibia fracture. Methods: Adult participants (cases) with established nonunions of the femur or tibia shaft were recruited over a 16-month period, between December 2017 and April 2019. They were matched for (1) age; (2) sex; (3) fracture site; and (4) fracture management type, with "control" participants who progressed to fracture union within 6 months of injury. All participants were tested for HIV. Multivariable logistic regression models were constructed to investigate associations between known risk factors for the development of nonunion and impaired fracture healing. Results: A total of 57 cases were matched with 57 "control" participants (44/57 male, 77.2% vs. 13/57 female, 22.8%, median age 36 years). HIV status was not associated with the development of nonunion after the management of tibia and femur fractures, on both univariate (odds ratio, 0.40; confidence interval, 0.10-1.32; P = 0.151) or multivariable (odds ratio, 0.86; confidence interval, 0.18-3.73; P = 0.831) analysis. No other confounding factors were shown to have any statistically significant impact on the odds of developing nonunion in this study cohort. Conclusion: This study demonstrates that HIV does not seem to increase the risk of the development of nonunion and HIV-positive individuals who sustain a fracture can be managed in the same manner as those who are HIV negative.

Methods for detection and identification of beer-spoilage microbes.

It is critical that breweries of all sizes routinely monitor the microbiome of their process to limit financial losses due to microbial contamination. Contamination by beer-spoiling microbes (BSMs) at any point during the brewing process may lead to significant losses for breweries if gone undetected and allowed to spread. Testing and detection of BSMs must be routine and rapid, and because even small breweries need the capability of BSM detection and identification, the method also needs to be affordable. Lactic acid bacteria (LAB) are responsible for most spoilage incidents, many of which have been shown to enter the viable but nonculturable (VBNC) state under conditions present in beer such as cold or oxidative stress. These bacteria are invisible to traditional methods of detection using selective media. This article describes several methods of BSM detection and identification that may be useful in the majority of craft breweries. While there are several genomic methods that meet some or many qualifications of being useful in craft breweries, real-time quantitative polymerase chain reaction (qPCR) currently best meets the desired method characteristics and holds the most utility in this industry, specifically SYBR Green qPCR. qPCR is a targeted method of detection and identification of microbes that is affordable, rapid, specific, sensitive, quantitative, and reliable, and when paired with valid DNA extraction techniques can be used to detect BSMs, including those in the VBNC state.

Supine Lobenhoffer Approach Optimizes PCL Reconstruction with Tibial Inlay in Knee Dislocations: A Case Report.

CASE: A 47-year-old man suffered a knee dislocation while skiing with associated damage to the anterior cruciate, posterior cruciate, medial collateral, and medial patellofemoral ligaments. The patient underwent a multiple-ligament knee reconstruction using the supine Lobenhoffer approach, which resulted in remarkable outcomes that persisted throughout the 56-month follow-up period. CONCLUSION: The utilization of this approach can prevent inappropriate graft tension and iatrogenic damage, reduce surgical time, and minimize airway complications by eliminating the need for the prone position. Optimizing these factors enhances the patient's chances for long-term outcomes; thus, surgeons should consider this approach in managing multiple-ligament knee injuries.

Establishing a Consensus Definition of a Knee Fracture-Dislocation (Schenck Knee Dislocation V) Using a Global Modified Delphi Method.

BACKGROUND: Knee fracture-dislocations are complex injuries; however, there is no universally accepted definition of what constitutes a fracture-dislocation within the Schenck Knee Dislocation (KD) V subcategory. The purpose of this study was to establish a more precise definition for fracture patterns included within the Schenck KD V subcategory. METHODS: A series of clinical scenarios encompassing various fracture patterns in association with a bicruciate knee ligament injury was created by a working group of 8 surgeons. Utilizing a modified Delphi technique, 46 surgeons from 18 countries and 6 continents with clinical and academic expertise in multiligamentous knee injuries undertook 3 rounds of online surveys to establish consensus. Consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree" for a positive consensus or "strongly disagree" or "disagree" for a negative consensus. RESULTS: There was a 100% response rate for Rounds 1 and 2 and a 96% response rate for Round 3. A total of 11 fracture patterns reached consensus for inclusion: (1) nondisplaced articular fracture of the femur; (2) displaced articular fracture of the femur; (3) tibial plateau fracture involving the weight-bearing surface (with or without tibial spine involvement); (4) tibial plateau peripheral rim compression fracture; (5) posterolateral tibial plateau compression fracture, Bernholt type IIB; (6) posterolateral tibial plateau compression fracture, Bernholt type IIIA; (7) posterolateral tibial plateau compression fracture, Bernholt type IIIB; (8) Gerdy's tubercle avulsion fracture with weight-bearing surface involvement; (9) displaced tibial tubercle fracture; (10) displaced patellar body fracture; and (11) displaced patellar inferior pole fracture. Fourteen fracture patterns reached consensus for exclusion from the definition. Two fracture patterns failed to reach consensus for either inclusion or exclusion from the definition. CONCLUSIONS: Using a modified Delphi technique, this study established consensus for specific fracture patterns to include within or exclude from the Schenck KD V subcategory. LEVEL OF EVIDENCE: Prognostic Level V . See Instructions for Authors for a complete description of levels of evidence.

Extensor Mechanism Disruption Impacts Treatment of Dislocated and Multiligament Injured Knees: Treatment and Schenck Classification Recommendations Based on a Global Delphi Method.

BACKGROUND: Multiligament knee injury (MLKI) with associated extensor mechanism (EM) involvement is a rare injury, with limited evidence to guide optimal treatment. The purpose of this study was to identify areas of consensus among a group of international experts regarding the treatment of patients with MLKI and concomitant EM injury. METHODS: Utilizing a classic Delphi technique, an international group of 46 surgeons from 6 continents with expertise in MLKI undertook 3 rounds of online surveys. Participants were presented with clinical scenarios involving EM disruption in association with MLKI, classified using the Schenck Knee-Dislocation (KD) Classification. Positive consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree," and negative consensus was defined as ≥70% agreement with "strongly disagree" or "disagree." RESULTS: There was a 100% response rate for rounds 1 and 2 and a 96% response rate for round 3. There was strong positive consensus (87%) that an EM injury in combination with MLKI significantly alters the treatment algorithm. For an EM injury in conjunction with a KD2, KD3M, or KD3L injury, there was positive consensus to repair the EM injury only and negative consensus regarding performing concurrent ligamentous reconstruction at the time of initial surgery. CONCLUSIONS: In the setting of bicruciate MLKI, there was overall agreement on the significant impact of EM injury on the treatment algorithm. We therefore recommend that the Schenck KD Classification be updated with the addition of the modifier suffix "-EM" to highlight this impact. Treatment of the EM injury was judged to have the highest priority, and there was consensus to treat the EM injury only. However, given the lack of clinical outcome data, treatment decisions need to be made on a case-by-case basis with consideration of the numerous clinical factors that are encountered. CLINICAL RELEVANCE: Little clinical evidence exists to guide the surgeon on the management of EM injury in the setting of a multiligament injured or dislocated knee. This survey highlights the impact that EM injury has on the treatment algorithm and provides some guidance for management until a further large case series or prospective studies are undertaken.

Arabinogalactan Structures of Repetitive Serine-Hydroxyproline Glycomodule Expressed by Arabidopsis Cell Suspension Cultures.

Arabinogalactan-proteins (AGPs) are members of the hydroxyproline-rich glycoprotein (HRGP) superfamily. They are heavily glycosylated with arabinogalactans, which are usually composed of a ß-1,3-linked galactan backbone with 6-O-linked galactosyl, oligo-1,6-galactosyl, or 1,6-galactan side chains that are further decorated with arabinosyl, glucuronosyl, rhamnosyl, and/or fucosyl residues. Here, our work with Hyp-O-polysaccharides isolated from (Ser-Hyp)32-EGFP (enhanced green fluorescent protein) fusion glycoproteins overexpressed in transgenic Arabidopsis suspension culture is consistent with the common structural features of AGPs isolated from tobacco. In addition, this work confirms the presence of ß-1,6-linkage on the galactan backbone identified previously in AGP fusion glycoproteins expressed in tobacco suspension culture. Furthermore, the AGPs expressed in Arabidopsis suspension culture lack terminal-rhamnosyl residues and have a much lower level of glucuronosylation compared with those expressed in tobacco suspension culture. These differences not only suggest the presence of distinct glycosyl transferases for AGP glycosylation in the two systems, but also indicate the existence of minimum AG structures for type II AG functional features.

A comparison of pin site complications between large and small pin diameters in robotic-assisted total knee arthroplasty.

PURPOSE: Robotic-assisted total knee arthroplasty typically necessitates use of tracking pins, which can vary in diameter. Complications such as infections and fractures at the pin-site have been observed, but clarification of the effect of pin diameter on complication is needed. The aim of this study is to compare the pin-related complication rates following robotic-assisted total knee arthroplasty between 4.5 mm and 3.2 mm diameter pins. METHODS: In this retrospective cohort study, 90-day pin-site complication rates after robotic-assisted total knee arthroplasty were compared between 4.5 mm diameter and 3.2 mm diameter groups. In total, 367 patients were included: 177 with large pin diameter and 190 with small pin diameter. All four pin sites were evaluated using postoperative radiographs. Cases without orthogonal views or visualization of all four pin tracts were noted. Multivariate logistic regression was used to control for age, which differed between the two cohorts. RESULTS: The rate of pin-site complications was 5.6% in the large pin diameter cohort and 2.6% in the small pin diameter cohort, with no statistically significant difference between the groups. The adjusted odds ratio for complications in small compared to large diameter group was 0.48, with a p-value of 0.18. The most common pin-site complication was infection/persistent drainage, found in 1.9% of patients, followed by intraoperative fracture of the second cortex in 1.4%. Intraoperative fracture could not be ruled out in 96 cases due to inadequate radiographic visualization of all pin sites. There was one postoperative pin-site fracture in the large diameter cohort, which required operative fixation. CONCLUSION: This study demonstrates no statistically significant difference in pin-site complication rates after robotic-assisted total knee arthroplasty between 4.5 mm and 3.2 mm pin diameter cohorts, although there was a trend towards increased intraoperative and postoperative pin-site fractures in the 4.5 mm group.

Type II arabinogalactans initiated by hydroxyproline-O-galactosyltransferases play important roles in pollen-pistil interactions.

Arabinogalactan-proteins (AGPs) are hydroxyproline-rich glycoproteins containing a high sugar content and are widely distributed in the plant kingdom. AGPs have long been suggested to play important roles in sexual plant reproduction. The synthesis of their complex carbohydrates is initiated by a family of hydroxyproline galactosyltransferase (Hyp-GALT) enzymes which add the first galactose to Hyp residues in the protein backbone. Eight Hyp-GALT enzymes have been identified so far, and in the present work a mutant affecting five of these enzymes (galt2galt5galt7galt8galt9) was analyzed regarding the reproductive process. The galt25789 mutant presented a low seed set, and reciprocal crosses indicated a significant female gametophytic contribution to this mutant phenotype. Mutant ovules revealed abnormal callose accumulation inside the embryo sac and integument defects at the micropylar region culminating in defects in pollen tube reception. In addition, immunolocalization and biochemical analyses allowed the detection of a reduction in the amount of glucuronic acid in mutant ovary AGPs. Dramatically low amounts of high-molecular-weight Hyp-O-glycosides obtained following size exclusion chromatography of base-hydrolyzed mutant AGPs compared to the wild type indicated the presence of underglycosylated AGPs in the galt25789 mutant, while the monosaccharide composition of these Hyp-O-glycosides displayed no significant changes compared to the wild-type Hyp-O-glycosides. The present work demonstrates the functional importance of the carbohydrate moieties of AGPs in ovule development and pollen-pistil interactions.

Return to Work Following Intramedullary Nailing of Lower-Limb Long-Bone Fractures in South Africa.

BACKGROUND: Injuries are one of the leading causes of global death and disability and commonly have substantial economic implications. The economic impact of injuries is particularly pronounced in low- and middle-income countries, where 90% of injuries occur. In this study, we aimed to assess return-to-work rates of individuals who sustained a lower-limb long-bone fracture in South Africa and to identify factors that influence the ability to return to employment. METHODS: This prospective cohort study was conducted across 2 tertiary trauma centers in Cape Town, South Africa. Adults who received intramedullary nail fixation for a lower-limb fracture between September 2017 and December 2018 were recruited and followed for 18 months postoperatively. The participants' return to employment was assessed at 6 and 18 months post-injury. Multivariate logistic regression was used to identify factors that influence post-injury employment. RESULTS: Of the 194 participants enrolled, 192 completed follow-up. The study population had a median age of 33.0 years, and most of the participants (76.6%) were male. Seventy-five percent of the participants were employed before their injury. At 6 and 18 months post-injury, 34.4% and 56.3% of participants, respectively, were employed. Of those employed pre-injury, 70.1% had returned to work at 18 months. Multivariate regression identified increasing age, unemployment prior to injury, and working in the informal employment sector as factors that impede an individual's likelihood of working 18 months post-injury. For those in employment prior to injury, increasing age was the only factor found to impede the likelihood of returning to work following an injury. CONCLUSIONS: This study highlights the profound effect that lower-limb long-bone fractures may have on an individual's ability to return to work in South Africa, with the potential to cause substantial economic impact on an individual's livelihood and that of their dependents. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Establishing a consensus on research priorities in orthopaedic trauma within South Africa.

BACKGROUND: Musculoskeletal (MSK) injuries are one of the leading causes of disability worldwide. Despite improvements in trauma-related morbidity and mortality in high-income countries over recent years, outcomes following MSK injuries in low- and middle-income countries, such as South Africa (SA), have not. Despite governmental recognition that this is required, funding and research into this significant health burden are limited within SA. This study aims to identify research priorities within MSK trauma care using a consensus-based approach amongst MSK healthcare practitioners within SA. METHOD: Members from the Orthopaedic Research Collaboration in Africa (ORCA), based in SA, collaborated using a two round modified Delphi technique to form a consensus on research priorities within orthopaedic trauma care. Members involved in the process were orthopaedic healthcare practitioners within SA. RESULTS: Participants from the ORCA network, working within SA, scored research priorities across two Delphi rounds from low to high priority. We have published the overall top 10 research priorities for this Delphi process. Questions were focused on two broad groups-clinical effectiveness in trauma care and general trauma public health care. Both groups were represented by the top two priorities, with the highest ranked question regarding the overall impact of trauma in SA and the second regarding the clinical treatment of open fractures. CONCLUSION: This study has defined research priorities within orthopaedic trauma in South Africa. Our vision is that by establishing consensus on these research priorities, policy and research funding will be directed into these areas. This should ultimately improve musculoskeletal trauma care across South Africa and its significant health and socioeconomic impacts.

Evaluating Basic Knee Arthroscopy Skills in Orthopaedic Trainees in a Limited-Resource Setting.

Orthopaedic training in Southern Africa is largely focused on trauma, although elective procedures, such as knee arthroscopy, are increasing. This is especially true in the private sector where most trainees will practice. The primary aim of this study was to assess the arthroscopic competency of orthopaedic trainees in a setting of limited resources. Methods: A prospective observational cohort study was conducted. Orthopaedic trainees of a Southern African university hospital performed basic arthroscopy on a knee model. Their surgical competency was assessed by 2 surgeons proficient in arthroscopy using the modified Basic Knee Arthroscopy Skill Scoring System (mBAKSSS). Results: A total of 16 trainees (12 male) were included (6 junior and 10 senior trainees). The median age of participants was 36 (34.8-37) years. The median mBAKSSS was 28.0 (20.3-32.5) but showed a large variability (12.0-42.5). The overall reliability was excellent with Cronbach's alpha of 0.91 and interclass correlation of 0.91 (95% confidence interval 0.75-0.97). Conclusions: The average knee arthroscopy proficiency of our trainees is comparable with that of international training programs, but there was great variability with inconsistent skills among the trainees. This calls for improved and reproducible arthroscopy training and skills transfer, exposure to procedures, and ongoing assessment. Level of Evidence: II (prospective observational cohort study).

The reuse of circular external fixator components: an assessment of safety and potential savings.

PURPOSE: Cost-saving strategies are important, especially in a resource-constrained environment. One such strategy well supported in the literature is the reuse of temporary monolateral external fixator components, a strategy we utilize at our institution. The aim of the study was to determine the safety and cost saving associated with the reuse of definitive circular external fixator components in a resource-constrained environment. METHOD: We performed a retrospective review of all adult patients who were treated with either new or reused circular external fixators from a single manufacturer between January and December 2017. Reused circular external fixator components, excluding half pins and wires, were subjected to an in-house reprocessing protocol. Cost savings were calculated as the difference between the price of a completely new frame and the amount invoiced for new components only in a reused frame. RESULTS: Thirty-three patients were included in the study with an average age of 31.9 years. The mean duration of treatment with a circular external fixator was 5.8 months. No mechanical failure events were recorded during the study period. Our institution saved approximately 52% (R717 503.89) and 63% (R136 568.19) of expected total cost for hexapod and Ilizarov frames, respectively. CONCLUSION: The strategy of reusing circular external fixator components is unconventional, and this study was conducted to evaluate the safety and potential savings in a resource-constrained environment. We demonstrated this practice to be reasonably safe and to result in significant cost savings which might be relevant in low-and-middle-income countries.