Epidemiology and Treatment of Distal Radius Fractures at Four Public Hospitals in Malawi.

BACKGROUND: Little is known about the burden or management of distal radius fractures (DRFs) in low- and middle-income countries. The purpose of this study was to describe the care of DRFs in Malawi. METHODS: We retrospectively reviewed a registry of all patients with fractures who presented to the orthopaedic departments at four public hospitals in Malawi. RESULTS: Totally, 1,440 patients (14.5%) were with a DRF. Average age was 40, and 888 (62.0%) were male. Surgery was done for 122 patients (9.5%). Patients presenting to Queen Elizabeth Hospital, patients presenting after a fall, and patients initially evaluated by an orthopaedic registrar or orthopaedic clinical officer had lower odds of receiving surgical treatment. Meanwhile, open injuries had the greatest odds of receiving surgery. CONCLUSION: The most common musculoskeletal injury among patients in the Malawi Fracture Registry was fractures of the distal radius. These most affected young adult male patients may benefit from surgery; however, the majority were managed nonsurgically. Lack of access to surgical fixation and conservative follow-up may have long-term functional consequences in a predominantly agrarian society. Outcomes-based research is needed to help guide management decisions and standardize patient care and referral protocols.

Statistical Fragility Analysis of Open Reduction Internal Fixation vs Primary Arthrodesis to Treat Lisfranc Injuries: A Systematic Review.

BACKGROUND: There is a lack of consensus in the use of open reduction internal fixation (ORIF) vs primary arthrodesis (PA) in the management of Lisfranc injuries. Statistical fragility represents the number of events needed to flip statistical significance and provides context to interpret P values of outcomes from conflicting studies. The current study evaluates the statistical fragility of existing research with an outcome-specific approach to provide statistical clarity to the ORIF vs PA discussion. We hypothesized that statistical fragility analysis would offer clinically relevant insight when interpreting conflicting outcomes regarding ORIF vs PA management of Lisfranc injuries. METHODS: All comparative studies, RCTs, and case-series investigating ORIF vs PA management of Lisfranc injuries published through October 5, 2023, were identified. Descriptive characteristics, dichotomous outcomes, and continuous outcomes were extracted. Fragility index and continuous fragility index were calculated by the number of event reversals needed to alter significance. Outcomes were categorized by clinical relevance, and median FI and CFI were reported. RESULTS: A total of 244 studies were screened. Ten studies and 67 outcomes (44 dichotomous, 23 continuous) were included in the fragility analysis. Of the 10 studies, 4 studies claimed PA to correlate with superior outcomes compared to ORIF with regard to functional scores and return to function outcomes. Of these 4 studies, 3 were statistically robust. Six studies claimed PA and ORIF to have no differences in outcomes, in which only 2 studies were statistically robust. CONCLUSION: The overall research regarding ORIF vs PA is relatively robust compared with other orthopaedic areas of controversy. Although the full statistical context of each article must be considered, studies supporting PA superiority with regard to functional scores and return to function metrics were found to be statistically robust. Outcome-specific analysis revealed moderate fragility in several clinically relevant outcomes such as functional score, return to function, and wound complications.

Rotator Cuff Tears to Shoulder Instability: The Relationship Between Acromial Morphology and Shoulder Pathology.

¼ The acromion is a well-studied region of the scapula that has demonstrated substantial relationships to various shoulder pathologies.¼ Abnormal acromial morphology is associated with rotator cuff pathology, and our understanding of this risk factor inspired acromioplasty as an adjunctive treatment for rotator cuff tears.¼ The acromion is linked closely to shoulder kinematics and biomechanics, as it serves as the origin for the deltoid muscle.¼ In degenerative shoulder disease, eccentric glenohumeral osteoarthritis has been associated with a higher, flatter acromial roof.¼ Increasing literature is emerging connecting morphology of the acromion with shoulder instability.

The effect of pre-operative shoulder injections on post-operative opioid use, infection and revision following shoulder arthroplasty.

Background: Treatment of glenohumeral osteoarthritis (GHOA) may include conservative management with use of intraarticular injections, prior to considering total shoulder arthroplasty (TSA). The purpose of this study was to assess trends in the use of preoperative cortisone (CO) and hyaluronic acid (HA) injections, as well as investigate the relationship between injection use and infection or revision arthroplasty following TSA. Methods: Pearl Driver was used to identify all patients undergoing TSA for GHOA between 2010 and 2018. Patients were categorized based on the type and number of injections they received. Outcomes of interest included post-operative opioid use, post-operative infection, and risk of revision surgery within 1 year of the index procedure. Results: The incidence of patients receiving a CO or HA injections within 1 year of their TSA decreased by 83% and 54%, respectively. Patients who had received 1 or more steroid injections had higher odds of prolonged opiate use following surgery. Patients that received 1 or 2 CO injection prior to TSA had an increased risk of needing revision surgery. Discussion: Use of intraarticular injections for the management of GHOA has declined. Patients receiving preoperative injections had increased odds of prolonged opiate use and the need for revision surgery.

Short-term outcomes following open gluteus maximus transfer for the management of hip abductor tears.

Tears of the gluteus medius and minimus are an important cause of recalcitrant greater trochanteric pain syndrome. Although endoscopic and open abductor repairs have demonstrated promising outcomes, the success of these techniques is dependent on the size of the tear and the quality of the tissue. In patients presenting with abductor insufficiency and evidence of previous repair failure, large retracted tears, muscle atrophy and/or fatty infiltration, reconstruction/augmentation techniques should be considered. In the present study, we present a retrospective cohort study assessing patient outcomes following open gluteus maximus transfer for irreparable or severely retracted gluteus medius tears. Patients were included in the present study if they underwent open gluteus maximus transfer to address hip abductor tears that a senior surgeon deemed irreparable or at high risk for failure following isolated repair secondary to the following tear characteristics: large tears with >2 cm of retraction, the presence of extensive fatty infiltration (Goutallier Grade 3 or greater) and/or patients requiring revision abductor repair due to primary repair failure with associated pain and a Trendelenburg gait. Patients undergoing a concomitant, or those with a previous history of hip arthroplasty, were excluded from the study. All participants were prospectively enrolled in the study, and both pre- and post-operative patient-reported outcomes were collected at 6 months and 1 year including the modified Hip Harris Score, Visual Analog Score, Hip Outcomes Score of Activities Daily Living, Hip Outcomes Score for Sports-Related Activities and Overall Satisfaction with Hip. Pre-operative scores were compared with post-operative assessments using Student's t-test with a significance level of P < 0.05. Twenty-one patients and 22 hips were included. The average age was 69 (SD ±9.2) and 17 (81%) were females. The average body mass index was 30.0 (±6.2). The outcome scores at both 6 months and 1 year demonstrated significant improvements compared with pre-operative functional assessment. This article reports the utility of gluteus medius/minimus repair augmentation or reconstruction via gluteus maximus transfer demonstrating improvement in patient-reported outcomes at short-term follow-up.

Global Surgery Opportunities for General Surgery Residents: Are We Making Progress?

INTRODUCTION: Global surgery efforts have significantly expanded in the last decade. While an increasing number of general surgery residents are incorporating global surgery experiences and research into their training, few resources are available for residency applicants to evaluate opportunities at programs to which they are applying. MATERIALS AND METHODS: A 17-question survey of all general surgery residency program directors (PDs) was conducted by the Global Surgery Student Alliance through emails to the Association of Program Directors in Surgery listserv. PDs indicated if they wished to remain anonymous or include program information in an upcoming online database. RESULTS: Two hundred fifty eight general surgery PDs were emailed the survey and 45 (17%) responses were recorded. Twenty eight (62%) programs offered formal global surgery experiences for residents, including clinical rotations, research, and advocacy opportunities. Thirty one (69%) programs were developing a global health center. Forty two (93%) respondents indicated that global surgery education was an important aspect of surgical training. Barriers to global surgery participation included a lack of funding, time constraints, low faculty participation, and minimal institutional interest. CONCLUSIONS: While most respondents felt that global surgery was important, less than two-thirds offered formal experiences. Despite the significant increase in public awareness and participation in global surgery, these numbers remain low. While this study is limited by a 17% response rate, it demonstrates that more efforts are needed to bolster training, research, and advocacy opportunities for surgical trainees and promote a global perspective on healthcare.

International Orthopaedic Volunteer Opportunities in Low and Middle-Income Countries.

ABSTRACT: Globally, the burden of musculoskeletal conditions continues to rise, disproportionately affecting low and middle-income countries (LMICs). The ability to meet these orthopaedic surgical care demands remains a challenge. To help address these issues, many orthopaedic surgeons seek opportunities to provide humanitarian assistance to the populations in need. While many global orthopaedic initiatives are well-intentioned and can offer short-term benefits to the local communities, it is essential to emphasize training and the integration of local surgeon-leaders. The commitment to developing educational and investigative capacity, as well as fostering sustainable, mutually beneficial partnerships in low-resource settings, is critical. To this end, global health organizations, such as the Consortium of Orthopaedic Academic Traumatologists (COACT), work to promote and ensure the lasting sustainability of musculoskeletal trauma care worldwide. This article describes global orthopaedic efforts that can effectively address musculoskeletal care through an examination of 5 domains: clinical care, clinical research, surgical education, disaster response, and advocacy.

Sepsis in two hospitals in Rwanda: A retrospective cohort study of presentation, management, outcomes, and predictors of mortality.

PURPOSE: Few studies have assessed the presentation, management, and outcomes of sepsis in low-income countries (LICs). We sought to characterize these aspects of sepsis and to assess mortality predictors in sepsis in two referral hospitals in Rwanda. MATERIALS AND METHODS: This was a retrospective cohort study in two public academic referral hospitals in Rwanda. Data was abstracted from paper medical records of adult patients who met our criteria for sepsis. RESULTS: Of the 181 subjects who met eligibility criteria, 111 (61.3%) met our criteria for sepsis without shock and 70 (38.7%) met our criteria for septic shock. Thirty-five subjects (19.3%) were known to be HIV positive. The vast majority of septic patients (92.7%) received intravenous fluid therapy (median = 1.0 L within 8 hours), and 94.0% received antimicrobials. Vasopressors were administered to 32.0% of the cohort and 46.4% received mechanical ventilation. In-hospital mortality for all patients with sepsis was 51.4%, and it was 82.9% for those with septic shock. Baseline characteristic mortality predictors were respiratory rate, Glasgow Coma Scale score, and known HIV seropositivity. CONCLUSIONS: Septic patients in two public tertiary referral hospitals in Rwanda are young (median age = 40, IQR = 29, 59) and experience high rates of mortality. Predictors of mortality included baseline clinical characteristics and HIV seropositivity status. The majority of subjects were treated with intravenous fluids and antimicrobials. Further work is needed to understand clinical and management factors that may help improve mortality in septic patients in LICs.

Fostering Trauma and Emergency Research Capacity in Rwanda Through Collaboration.

OBJECTIVES: Access to effective emergent care would prevent 45% of all deaths in LMICs, however, trauma and emergency care remain largely neglected. Our collaboration in Rwanda to build prehospital trauma care led us to create a research mentorship program to enhance the ability of the local team to evaluate their system. METHODS: NIH grant funding had been previously obtained to establish standards for prehospital trauma care in Rwanda and build local research capacity. We created a research mentorship program that involved a surgical resident embedded locally tasked with 1) giving lectures on research, study design, interpretation, and writing, 2) providing mentorship for data interpretation and 3) supporting the development of abstracts, presentations, and publications. RESULTS: Four research teams identified high priority areas for quality improvement research. Research group meetings were held and involved mentored literature searches, critical review of published works, basics of study design, abstract writing and manuscript development. Abstracts were submitted and accepted to three international conferences. At this time 3 manuscripts have been accepted and are in production, 2 abstracts and 1 manuscript has been published. Eleven staff enrolled in master's degree programs in critical and nursing, epidemiology, public health and global health equity across three institutions. CONCLUSIONS: Responsive health care systems need capacity for ongoing quality improvement and research. This is especially true to address the massive global burden of disease of trauma and emergency conditions. US academic surgical collaborations have tremendous research expertise that can contribute to improving health system capacity globally. Such collaborations offer the opportunity to set up the foundations of future academic productivity.

The Initial Prehospital Management of Traumatic Brain Injuries in Kigali, Rwanda.

INTRODUCTION: Traumatic brain injuries (TBIs) are an important cause of mortality and disability around the world. Early intervention and stabilization are necessary to obtain optimal outcomes, yet little is written on the topic in low- and middle-income countries (LMICs). The aim is to provide a descriptive analysis of patients with TBI treated by Service d'Aide Medicale Urgente (SAMU), the prehospital ambulance service in Kigali, Rwanda. HYPOTHESIS/PROBLEM: What is the incidence and nature of TBI seen on the ambulance in Kigali, Rwanda? METHODS: A retrospective descriptive analysis was performed using SAMU records captured on an electronic database from December 2012 through May 2016. Variables included demographic information, injury characteristics, and interventional data. RESULTS: Patients with TBIs accounted for 18.0% (n = 2,012) of all SAMU cases. The incidence of TBIs in Kigali was 234 crashes per 100,000 people. The mean age was 30.5 (SD = 11.5) years and 81.5% (n = 1,615) were men. The most common mechanisms were road traffic incidents (RTIs; 78.5%, n = 1,535), assault (10.7%, n=216), and falls (7.8%, n=156). Most patients experienced mild TBI (Glasgow Coma Score [GCS] ≥ 13; 83.5%, n = 1,625). The most common interventions were provision of pain medications (71.0%, n = 1,429), placement of a cervical collar (53.6%, n = 1,079), and administration of intravenous fluids (48.7%, n = 979). In total, TBIs were involved in 67.0% of all mortalities seen by SAMU. CONCLUSION: Currently, TBIs represent a large burden of disease managed in the prehospital setting of Kigali, Rwanda. These injuries are most often caused by RTIs and were observed in 67% of mortalities seen by SAMU. Rwanda has implemented several initiatives to reduce the incidence of TBIs with a specific emphasis on road safety. Further efforts are needed to better prevent these injuries. Countries seeking to develop prehospital care capacity should train providers to manage patients with TBIs.

Ankle and Lower Leg Injuries in Professional Baseball Players.

BACKGROUND: Ankle and lower leg injuries are very common in sports, and numerous studies have discussed their diagnosis and management. Our study differs in that we report lower leg injuries in professional baseball players spanning the 2011-2016 seasons by utilizing a comprehensive injury surveillance system developed by Major League Baseball (MLB). PURPOSE: To determine the injury characteristics of ankle and lower leg injuries in professional baseball players during the 2011-2016 seasons by utilizing the MLB injury surveillance system. STUDY DESIGN: Descriptive epidemiology study. METHODS: Our study is a descriptive epidemiological evaluation through a retrospective review of injury data from the MLB Health and Injury Tracking System (HITS) since its implementation in 2010. We included any professional baseball player (MLB and Minor League Baseball [MiLB]) who was identified as having an ankle or lower leg injury between January 1, 2011, and February 28, 2017. RESULTS: Over the study period, there were a total of 4756 injuries, of which 763 (16%) occurred in MLB players and 3993 (84%) occurred in MiLB players. The mean number of days missed for all players was 27.8 ± 141.4 days, with a median of 3 days. From 2011 through 2016, it was estimated that there were 414,912 athlete exposures (AEs) in MLB and 1,796,607 AEs in MiLB. Of the 4756 injuries recorded, 550 (12%) took place during the MLB regular season, and 3320 (70%) took place during the MiLB regular season. Injuries in MLB players, however, were 1.7 times more likely to require surgery (P < .001). Additionally, rates of injury to the lower leg were stratified by position, with infield players experiencing injuries at a 1.6 times greater rate than any other position (P < .001). CONCLUSION: In conclusion, this is the only epidemiological study to focus primarily on ankle and lower leg injuries in professional baseball players, utilizing an injury surveillance system developed by MLB.

Barriers to Surgical Care at a Tertiary Hospital in Kigali, Rwanda.

BACKGROUND: The disproportionate distribution of surgical resources across the globe has left many in low- and middle-income countries without proper care. Patients often have complex surgical problems that are worsened by delayed presentation. We aim to describe barriers to surgical care at a tertiary hospital in Kigali, Rwanda. MATERIALS AND METHODS: A prospective review of all patients undergoing general and orthopedic surgery was performed at a tertiary hospital in Rwanda. Patients completed a questionnaire regarding their presurgical interactions with the health-care system. RESULTS: Over a 3-wk period, there were 24 (33%) general and 49 (67%) orthopedic surgery patients. Patients reported delays seeking care (n = 21, 29%), reaching care (n = 28, 38.5%), and receiving care (n = 44, 60%). The median number of days from first symptom to surgery was 7.3 d and was significantly longer for patients reporting at least 1 barrier to care (P < 0.001). Barriers reported during the care-seeking time period had the largest impact on time to surgery (51.5 d versus 5.7 d, P = 0.01). Meanwhile, the most frequently reported barriers included not knowing care was needed (n = 17, 23%), transportation issues (n = 25, 34%), and surgical staff availability (n = 23, 32.5%). CONCLUSIONS: Initiatives are needed to address common barriers to surgical care in Rwanda. Educational programs designed to help patients identify key symptoms could encourage earlier presentation to health-care providers. System-based projects to improve transportation could facilitate patient transfers within the health-care system. Finally, increasing surgical staff at hospitals throughout the country would reduce delays and improve access.

Prehospital epidemiology and management of injured children in Kigali, Rwanda.

INTRODUCTION: Paediatric injuries are a major cause of mortality and disability worldwide, yet little information exists regarding its epidemiology or prehospital management in low-income and middle-income countries. We aimed to describe the paediatric injuries seen and managed by the prehospital ambulance service, Service d'Aide Medicale d'Urgence (SAMU), in Kigali, Rwanda over more than 3 years. METHODS: A retrospective, descriptive analysis was conducted of all injured children managed by SAMU in the prehospital setting between December 2012 and April 2016. RESULTS: SAMU responded to a total of 636 injured children, 10% of all patients seen. The incidence of paediatric injury in Kigali, Rwanda was 140 injuries per 100 000 children. 65% were male and the average age 13.5 (±5.3). Most patients were between 15 and 19 years old (56%). The most common causes of injuries were road traffic incidents (RTIs) (447, 72%), falls (70, 11%) and assaults (50, 8%). Most RTIs involved pedestrians (251, 56%), while 15% (65) involved a bicycle. Anatomical injuries included trauma to the head (330, 52%), lower limb (280, 44%) and upper limb (179, 28%). Common interventions included provision of pain medications (445, 70%), intravenous fluids (217, 34%) and stabilisation with cervical collar (190, 30%). CONCLUSION: In Kigali, RTIs were the most frequent cause of injuries to children requiring prehospital response with most RTIs involving pedestrians. Rwanda has recently instituted several programmes to reduce the impact of paediatric injuries especially with regard to RTIs. These include changes in traffic laws and increased road safety initiatives.

Effects of Operating Room Size on Surgical Site Infection Following Lumbar Fusion Surgery.

BACKGROUND: Surgical site infections (SSIs) represent a devastating complication after spine surgery. Many factors have been identified, but the influence of operating room (OR) size on infection rate has not been assessed. METHODS: Two thousand five hundred and twenty-three patients who underwent open lumbar spine fusion at a single institution between 2010 and 2016 were included. Patients were dichotomized into large versus small groups based on OR volume. Bivariate logistic regression and a final multivariate model following a multicollinearity check were used to calculate odds of infection for all variables. RESULTS: A total of 63 patients (2.5%) developed SSIs with 46 (73%) in the larger OR group and 17 (27%) in the smaller OR group. The rate of SSIs in larger ORs was 3.02% compared with 1.81% in smaller ORs. Significant parameters impacting SSI in bivariate analysis included an earlier year of surgery, BMI > 30, more comorbidities, more levels decompressed and fused, smoking, and larger OR volumes. Multivariate analysis identified BMI > 30, Elixhauser scores, smoking, and increasing levels decompressed as significant predictors. Topical vancomycin was found to significantly decrease rate of infection in both analyses. CONCLUSIONS: OR size (large versus small) was ultimately not a significant predictor of infection related to rates of SSIs, although it did show a clinical trend toward significance, suggesting association. Future prospective analysis is warranted. LEVEL OF EVIDENCE: 3.

What Factors Predict Failure of Nonsurgical Management of a Lumbar Surgical Site Infection?

BACKGROUND: One of the most frequent complications of invasive lumbar spine surgery is postoperative surgical site infections (SSIs). Although there are absolute criteria for surgical intervention (progressive neurologic deficit, sepsis, failure of medical management), the treatment of routine, uncomplicated SSIs remains somewhat unclear. The purpose of this study was to evaluate the outcome of a series of patients with postoperative surgical site infections who were treated with or without surgical intervention. The primary clinical outcome was the assessment of whether medical management alone would be sufficient to eradicate the infection. METHODS: A retrospective review of consecutive patients who underwent lumbar surgery complicated by spine infection between 2011 and 2017 was performed in order to determine what factors, if any, resulted in the need for additional surgical management. Medical records were reviewed for various demographic (e.g., age), clinical (e.g., organism), and surgical (e.g., presence of instrumentation) factors. A regression analysis was performed to identify what variables significantly increased the risk for SSI. RESULTS: During the 6-year period studied, a total of 74 patients met the inclusion criteria and were included in the study. There were 13 patients who failed medical management and required additional surgical management, which included irrigation and debridement. Thus, overall, medical management alone was effective in 82% of patients. In the final multivariate logistic regression analysis model, revision primary surgery had the strongest association with SSI that would require a washout. In addition, diabetes had a strong association with the occurrence of an infection. CONCLUSIONS: Identification of risk factors associated with the need for additional surgical management may benefit from aggressive antibiotic therapy to reduce the likelihood of reoperation. Clinicians should be aware of the identified risk factors, which may help with postoperative management in at-risk individuals.

Adherence to Inpatient Venous Thromboembolism Prophylaxis: A Single Institution's Concurrent Review.

Hospital-acquired venous thromboembolism (VTE) affects morbidity and mortality and increases health care costs. Poor adherence to recommended prophylaxis may be a potential cause of ongoing events. This study aims to identify institutional adherence rates and barriers to optimal VTE prophylaxis. The authors performed patient and nurse interviews and a concurrent review of clinical documentation, utilizing a cloud-based, HIPAA-compliant tool, on a convenience sample of hospitalized patients. Adherence and agreement between different assessment modalities were calculated. Seventy-six patients consented for participation. Nurse documented adherence was 66% (29/44), 44% (27/61), and 89% (50/56) for mechanical, ambulatory, and chemoprophylactic prophylaxis, respectively. Patient report and nurse documentation showed moderate agreement for mechanical and no agreement for ambulatory adherence (κ = 0.51 and 0.07, respectively). Concurrent review using a cloud-based tool can provide robust, timely, and relevant information on adherence to recommended VTE prophylaxis. Iterative concurrent reviews can guide efforts to improve adherence and reduce rates of hospital-acquired VTE.