Publications

BACKGROUND: In Ethiopia, orthopaedic services are limited, and many injured children undergo traditional bonesetting (TBS) despite its association with limb- and life-threatening complications. We sought to identify the risk factors for amputation and a prolonged hospitalization of >7 days in children who presented to hospitals after undergoing TBS.

METHODS: Over a 15-month period, we prospectively enrolled children who presented to 8 Ethiopian hospitals after undergoing TBS. Separately for each outcome (amputation and prolonged hospitalization), we used multivariable logistic regression to evaluate associations between the outcome and 16 covariates, including demographic and injury characteristics, parent or guardian preference for TBS, and TBS topical treatments and immobilization methods.

RESULTS: We enrolled 460 children (mean age, 9.0 ± 4.0 years; 75% male) representing 8 Ethiopian regions and diverse demographic and socioeconomic backgrounds. Elbow injuries (194 patients; 42.2%) and closed fractures and/or dislocations (364 patients; 79.1%) were most common. TBS treatments included topical inorganic (190 patients; 41.3%) or organic (82 patients; 17.8%) material application and rigid (166 patients; 36.1%) or soft (182 patients; 39.6%) immobilization. Twenty-six children (5.7%) underwent an amputation, and 102 (22.2%) had a prolonged hospitalization. The odds of amputation were higher for children from rural communities (adjusted odds ratio [AOR], 6.71; 95% confidence interval [CI], 2.01 to 22.41) and for children with only non-osseous injuries (AOR, 5.76; 95% CI, 1.56 to 21.28). The odds of prolonged hospitalization were higher for children who were 11 to 17 years old (AOR, 2.77; 95% CI, 1.18 to 6.50) and for children with open fractures with a grade of ≥2 (AOR, 4.52; 95% CI, 1.33 to 15.28) but were lower for children from households with secondary education or higher (AOR, 0.40; 95% CI, 0.21 to 0.79). TBS with rigid immobilization increased the odds of amputation (AOR, 5.84; 95% CI, 1.74 to 19.60) and prolonged hospitalization (AOR, 2.20; 95% CI, 1.02 to 4.73). TBS organic topical treatment (with mud, leaves, or butter) increased the odds of amputation (AOR, 3.88; 95% CI, 1.40 to 10.73).

CONCLUSIONS: For children who underwent TBS prior to hospital presentation, rigid splinting by bonesetters increased the odds of amputation and prolonged hospitalization. TBS organic topical treatments also increased the odds of amputation. Training bonesetters to avoid these dangerous practices may prevent devastating complications for children in Ethiopia.

LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: Proximal humerus fractures are common in adults aged 65 and older and provide challenges for osteoporotic patients due to the risk of suboptimal fixation and complications. Locking plates are often utilized to treat two-part fractures; however, ongoing concerns about their stability exist. This pilot study investigates the biomechanical impact of subchondral locking screws compared to unicortical screws in osteoporotic two-part cadaveric proximal humerus fractures.

METHODS: Using dual-energy X-ray absorptiometry (DXA), cadaveric shoulder specimens from eight female Caucasian donors with comparable bone mineral densities were used for the study. Either unicortical or bicortical locking screws (the latter representing subchondral screws in real surgeries) were utilized to fix locking plates. Axial load to failure and cyclic physiologic abduction moments were applied in biomechanical testing.

FINDINGS: The study found no statistically significant difference in interfragmentary displacement between the unicortical and bicortical groups (p = 0.78). The mechanical properties of both groups were found to be comparable in terms of yield (p = 0.59), ultimate (p = 0.86), and fracture strengths (p = 0.70). Furthermore, rigidity analysis did not identify any significant difference between the two groups (p = 0.22).

INTERPRETATION: Our findings indicate that there is little to no difference in the stability of the construct for osteoporotic two-part proximal humerus fractures, in contrast to general recommendations against unicortical screws. This pilot study suggests that the choice between unicortical and subchondral locking screws may not significantly affect biomechanical characteristics in osteoporotic two-part proximal humerus fractures, despite the study's limitations.

BACKGROUND: Achilles tendon rupture treatment has changed substantially in the past decade, with an evolution toward less-invasive techniques and more convenient patient positioning. This review aims to report on the 1-year clinical outcomes of a medially based, mini-open, supine, Achilles tendon repair technique.

METHODS: In this retrospective review, all patients who underwent surgical management of an Achilles tendon rupture were included and analyzed based on approach, including (1) standard open prone technique, (2) mini-open repair, prone, and (3) medial mini-open repair, supine. Primary outcomes were the Patient-Reported Outcome Measures Information Systems (PROMIS) Physical Function, PROMIS Pain Interference, and PROMIS Depression scores. Secondary outcomes of interest were surgical time and complications.

RESULTS: Seventy-eight patients were included in this study who underwent Achilles tendon repair and were seen in follow-up at least 1-year postoperatively. Demographics are displayed in Table 1. No statistical difference was observed regarding sex, laterality, age, and mechanism between those with 1-year follow-up data and those who were lost to follow-up before the 1-year mark. Primary outcomes were notable for statistically significant difference in the PROMIS Depression score between the mini-open repair, prone group, and the mini-open repair, supine group. The remainder of the primary outcomes of interest were not statistically significant. Secondary outcomes were notable for markedly shorter surgical time for the mini-open repair, supine group compared with both the standard open prone and mini-open repair, prone groups, with times being 89, 72, and 58 minutes, respectively. Surgical time was defined as starting from the time the patient was anesthetized in the room and included positioning and time up until extubation.

CONCLUSION: The medial mini-open repair, supine technique shows promise as a noninferior surgical option for acute Achilles tendon rupture repair with markedly decreased operating room time and 1-year outcomes with comparable results to both open and mini-open prone techniques.

➢ Musculoskeletal injuries constitute a substantial proportion of worldwide disease, with access limited to many due to the availability and cost of devices. A multifaceted approach is needed to improve system-level access to care.➢ Although a number of procurement policies are utilized, providers in low and middle-income countries often struggle with inconsistent supply chains, leading to delays in care or less desirable management strategies.➢ Partnerships between governments, academic institutions, and nongovernmental agencies are needed to improve access to devices by providing funds for patients and creating regulatory bodies to ensure product quality and availability.➢ There should be a focus on local and regional manufacturing as well as job creation within low and middle-income countries to achieve sustainable access to orthopaedic devices.➢ High-quality research initiatives are needed to provide evidence-based solutions. This includes a focus on outcomes-based studies to determine best management practices within the low and middle-income countries' context and operations research to optimize systems for device procurement.

This retrospective case series investigates the efficacy of integrating vascularized fibula flaps in ankle arthrodesis procedures, focusing on clinical outcomes including union rate, postoperative infection rate, and patient function. Four male patients between the ages of 53 and 71 years underwent ankle arthrodesis in conjunction with a vascularized fibula bone flap. Comorbidities included hypertension, rheumatoid arthritis, and type II diabetes. Two flaps were pedicled; the other 2 were transferred as free flaps. One patient experienced a postoperative infection, successfully treated with hardware removal. Union was achieved in all cases.

Although spine surgery has been shown to be an effective treatment for many spinal disorders, perioperative complications can increase patient morbidity and lead to poorer surgical outcomes. Nutritional status is a modifiable factor that affects spine surgery results. Malnutrition can negatively influence inflammatory pathways and can change circulating stress hormones. Perioperative nutrition status can be evaluated by both clinical and laboratory parameters, with nutritional indices allowing for determination of perioperative risk. Perioperative nutritional optimization has been attempted and has been associated with improved outcomes, for patients undergoing spine surgery. Additional investigation is needed to determine effective perioperative nutritional protocols.

CASE: A 59-year-old man sustained a fall onto his head and was found to have dense bilateral upper extremity weakness worse than lower extremity and radiographic cervical cord compression. He underwent emergent decompression and presented a few days after discharge with a Salmonella surgical site infection (SSI).

CONCLUSION: Central cord syndrome is the most common type of incomplete spinal cord injury. Early decompression is associated with the best outcomes. However, infection represents a problematic complication, contributing to overall morbidity. Salmonella can be a very rare contributor to SSI. This is the first report of Salmonella SSI after spine surgery in an immunocompetent patient.

PURPOSE: Educational mobile apps have been studied in multiple surgical disciplines, evaluating a wide range of possible benefits with varying success in improving overall quality of life after surgery. We hypothesize that utilization of a mobile health app in the perioperative setting will be easy to use and will improve patient satisfaction with care for patients undergoing hand surgery.

METHODS: Patients were given access to a mobile app at their initial visit to access content about their diagnosis, treatment options, and care instructions for cubital tunnel syndrome, carpal tunnel syndrome, distal radius fracture, trigger finger, or carpometacarpal arthritis. At their initial visit, patients were administered the Short-Form-12 (SF-12) survey to assess subjects' physical component summary (score-12) and mental component summary (score-12)health score, with higher scores indicating better function and with the United States average score at 50. At their 4-week postoperative visit, the participating patients were administered two surveys: the mHealth App Usability Questionnaire (mAUQ) to address the usability and utility of mobile health care apps and SF-12. The mAUQ comprises 21 items rated from 1 (strongly disagree) to 7 (strongly agree).

RESULTS: Of the 162 patients enrolled, 120 patients completed all survey items. Patients scored the mAUQ an average 6.2 of 7 regarding ease of use, 5.9 of 7 for system information arrangement, and 4.8 of 7 for usefulness. Comparing pre- to postsurgery SF-12 scores at 4 week follow-up, the patients demonstrated stable physical component summary (score-12) and a trend toward slightly worse mental component summary (score-12).

CONCLUSIONS AND CLINICAL RELEVANCE: Overall, the patients found the mobile app easy to use, could sufficiently navigate the app, and found the information presented useful to their care. However, the patients did not find improvement in their mental health scores with the app.