Bone Mass Changes Following Percutaneous Radiofrequency Ablation, Osteoplasty, Reinforcement, and Internal Fixation of Periacetabular Osteolytic Metastases.

BACKGROUND: The success of orthopedic interventions for periacetabular osteolytic metastases depends on the progression or regression of cancer-induced bone loss. PURPOSE: To characterize relative bone mass changes following percutaneous radiofrequency ablation, osteoplasty, cement reinforcement, and internal screw fixation (AORIF). METHODS: Of 70 patients who underwent AORIF at a single institution, 21 patients (22 periacetabular sites; average follow-up of 18.5 ± 12.3 months) had high-resolution pelvic bone CT scans, with at least one scan within 3 months following their operation (baseline) and a comparative scan at least 6 months post-operatively. In total, 73 CT scans were measured for bone mass changes using Hounsfield Units (HU). A region of interest was defined for the periacetabular area in the coronal, axial, and sagittal reformation planes for all CT scans. For 6-month and 1-year scans, the coronal and sagittal HU were combined to create a weight-bearing HU (wbHU). Three-dimensional volumetric analysis was performed on the baseline and longest available CT scans. Cohort survival was compared to predicted PathFx 3.0 survival. RESULTS: HU increased from baseline post-operative (1.2 ± 1.1 months) to most recent follow-up (20.2 ± 12.1 months) on coronal (124.0 ± 112.3), axial (140.3 ± 153.0), and sagittal (151.9 ± 162.4), p < 0.05. Grayscale volumetric measurements increased by 173.4 ± 166.4 (p < 0.05). AORIF median survival was 27.7 months (6.0 months PathFx3.0 predicted; p < 0.05). At 12 months, patients with >10% increase in wbHU demonstrated superior median survival of 36.5 months (vs. 26.4 months, p < 0.05). CONCLUSION: Percutaneous stabilization leads to improvements in bone mass and may allow for delays in extensive open reconstruction procedures.

Biomechanical restoration of metastatic cancer-induced peri-acetabular bone defects by ablation-osteoplasty-reinforcement-internal fixation technique (AORIF): To screw or not to screw?

BACKGROUND: Minimally invasive percutaneous polymethyl methacrylate cement augmentation procedures offer numerous clinical advantages for patients with periacetabular osteolytic metastatic bone defects in contrast to open reconstructive procedures that are associated with many complications. Several techniques, such as Ablation-Osteoplasty-Reinforcement-Internal Fixation (AORIF), cementoplasty alone, and screw fixation alone are currently used. There is no consensus on optimal skeletal reinforcement of diseased bones. The purpose of this study was to determine the most effective technique of percutaneous acetabular augmentation for joint preservation, with respect to resilience on cyclic loading and fracture pattern at maximal load to failure. METHODS: Five cohorts of hemipelvis composite bones with uniform periacetabular defects and various types of reinforcement techniques were utilized to simulate osteolytic metastasis in the weight bearing dome of the acetabulum. Five groups of hemipelves underwent finite element analysis and biomechanical testing for load to failure, energy absorption to failure, stress relaxation on cyclic loading, and fracture locations. RESULTS: The combination of screws and bone cement augmentation demonstrated significant higher energy absorption than the cement or screw only groups (p < 0.05), and better protection of acetabulum from displaced intraarticular fractures than the screws alone oror cement only groups (p < 0.05). Resilience to cyclic loading was higheest in the screw with cement fixation group than the screw only repair (p < 0.01), though not the cement fixation only group. INTERPRETATION: These data support the hypothesis that cementoplasty combined with screw augmentation such as the AORIF technique provides the best protection of acetabulum from massive metastatic cancer-induced acetabular fractures compared to augmentation with screws or cement alone.

Ablation, Osteoplasty, Reinforcement, and Internal Fixation for Percutaneous Endoskeletal Reconstruction of Periacetabular and Other Periarticular Osteolytic Metastases.

For osteolytic metastatic disease in the pelvis and acetabulum of patients with unpredictable and limited lifespans, first-line treatment focuses on targeting the primary cancer with anticancer drugs, osteoclastogenesis inhibitors, analgesics, and radiation therapy. Uncontrolled pain and progressive bone destruction refractory to these interventions often warrant surgical stabilization. Conventional open surgical procedures using metal implants or prostheses may provide immediate biomechanical stability but are associated with various complications without local cancer control. Outcomes of conventional open surgical reconstructive procedures depend on local cancer progression and progressive bone loss. Percutaneous cancer ablation and bone augmentation with polymethyl methacrylate cement alone often lack optimal internal fixation and integration with surrounding bone. The current literature demands a multipurpose minimally invasive surgical intervention that provides local cancer control, bone protection, and stabilization. An overview of new, alternative percutaneous procedure consisting of image-guided ablation, balloon osteoplasty, cement reinforcement, and internal fixation, which offers a minimally invasive percutaneous treatment option for patients with osteolytic metastatic cancers with the advantages of concurrent thermal necrotization of cancers, zoledronate-loaded bone cementoplasty, and surgical stabilization in an ambulatory surgery setting, is warranted. Early clinical results have shown that the ablation, balloon osteoplasty, cement reinforcement, and internal fixation is a safe and effective alternative solution for stabilizing and palliating osteolytic lesions in patients seeking new effective therapies in the era of rapidly evolving oncologic care.

Synovial Myxoma: Found in Canines, Rabbits, and Now Humans Too?: A Case Report.

CASE: A 63 year-old woman presented with a multiple-year history of right knee pain and effusions and pain refractory to numerous knee aspirations and an arthroscopic synovectomy. The patient underwent a 2-incision synovectomy and intralesional resection. A pathologic review of the specimens revealed an infiltrative tumor of basophilic, cluster of differentiation 68-positive synovial cells embedded within a myxoid stroma with low proliferative activity, most consistent with a synovial myxoma. CONCLUSIONS: This case report of a synovial myxoma-a benign, slow growing but locally aggressive mass that is most commonly found in canines-indicates that the lesion may occasionally occur in humans.

Minimally Invasive Image-Guided Ablation, Osteoplasty, Reinforcement, and Internal Fixation (AORIF) for Osteolytic Lesions in the Pelvis and Periarticular Regions of Weight-Bearing Bones.

PURPOSE: To assess early outcome, safety, and complications of an alternative to open surgical treatments of osteolytic lesions in periarticular load-bearing bones. MATERIALS AND METHODS: A single-center, prospective clinical cohort study of 26 lesions in 23 consecutive patients with painful osteolytic skeletal lesions was performed. Patients were followed for an average of 7 mo (1-18 mo). Lesions were targeted from the most intact bone via minimally invasive percutaneous approach for stable anchorage of internal fixation screws using fluoroscopic guidance. Cannulated screws served as universal portals for ablation, balloon osteoplasty, and delivery of bone cement in addition to internal fixation for cement anchoring and prophylactic stabilization of uninvolved bone. RESULTS: There were 19 osteolytic lesions in the pelvis, 4 in the proximal femur, 2 in the proximal tibia, and 1 in the calcaneus. All defects were associated with severe pain or fractures. There were no conversions to open surgery and no infection or bleeding requiring transfusion, embolization, or additional procedures. There was significant improvement in visual analogue scale (VAS) pain score from 8.32 ± 1.70 to 2.36 ± 2.23, combined pain and functional ambulation score from 4.48 ± 2.84 to 7.28 ± 2.76, and Musculoskeletal Tumor Society score from 45% to 68% (P < .05). CONCLUSIONS: Ablation, osteoplasty, reinforcement, and internal fixation is a safe and effective minimally invasive percutaneous image-guided treatment option for functional improvement or palliation of painful osteolytic lesions in the pelvis and periarticular loadbearing bones.

The burden of femoral shaft fractures in Tanzania.

BACKGROUND: Road traffic injuries disproportionately affect low- and middle-income countries (LMICs) and are associated with femur fractures that lead to long-term disability. Information about these injuries is crucial for appropriate healthcare resource allocation. The purpose of this study is to estimate the incidence of femoral shaft fractures in Tanzania and describe the unmet surgical burden. METHODS: Study sites included six government hospitals across Tanzania. Investigators collected data from hospital admission and procedural logbooks to estimate femoral shaft fracture incidence and their treatment methods. Semi-quantitative interviews were conducted with relevant hospital personnel to validate estimates obtained from hospital records. Investigators gathered road traffic incident (RTI) statistics from national police reports and calculated femur fracture:RTI ratios. RESULTS: Femoral shaft fracture annual incidence rate ranged from 2.1 to 18.4 per 100,000 people. Median low and high femur fracture:RTI ratio were 0.54 and 0.73, respectively. At smaller hospitals, many patients (5-25%) were treated with traction, and a majority (70-90%) are referred to other centers. Barriers to surgery at each hospital include a lack of surgical implants, equipment, and personnel. CONCLUSIONS: The incidence rate is similar to previous estimations, and it is consistent with an increased femoral shaft fracture incidence in Tanzania when compared to higher income countries. The femur fracture:RTI ratio may be a valid tool for estimating femur fracture incidence rates. There is an unmet orthopaedic surgical burden for femur fractures treatment at rural hospitals in Tanzania, and the barriers to treatment could be targets for future interventions.

Validation of Chichewa Short Musculoskeletal Function Assessment (SMFA) questionnaire: A cross-sectional study.

Background: The Short Musculoskeletal Function Assessment (SMFA) tool measures function and quality of life in patients with musculoskeletal conditions. Objective: This study aimed to translate and adapt culturally the SMFA into Chichewa, and assess its clinimetric properties. Methods: The translated Chichewa version was administered to 53 patients with musculoskeletal disorders. To assess repeatability, an additional 20 patients answered the questionnaire twice over a time interval of two weeks. Internal consistency, floor and ceiling effects, and repeatability were tested; construct validity was assessed with the World Health Organization Quality of Life Assessment tool (WHOQOL-BREF). Results: There was good internal consistency for both Dysfunction and Bothersome indices (Cronbach's alpha 0.90) and good construct validity between both indices with the WHOQOL-BREF. Pearson's correlation coefficient and intraclass correlation coefficient (ICC) for repeatability for the Dysfunction Index were 0.941 and 0.922 (95% CI: 0.772, 0.971) respectively, and 0.877 and 0.851 (95% CI: 0.629, 0.941) for the Bothersome Index respectively. Conclusion: The translated Chichewa SMFA is a valid tool for populations that speak the Chichewa language.

Clinical Research Course for International Orthopaedic Surgeons: 2-Year Outcomes.

BACKGROUND: Although orthopaedic trauma occurs at higher rates in low- and middle-income countries (LMICs), most research on this topic is conducted in high-resource settings. Few initiatives exist to promote local research in LMICs. Investigators created the Institute for Global Orthopaedics and Traumatology (IGOT) International Research Symposium to promote local research initiatives by surgeons practicing in low-resource environments. The purpose of this study is to determine the efficacy of this symposium in teaching orthopaedic surgeons practicing in LMICs how to conduct clinical research. METHODS: In this prospective observational study, orthopaedic surgeons from LMICs with no formal research training were recruited to attend the 1-day IGOT International Research Symposium in San Francisco. A survey was administered immediately before and after the symposium to inquire about the participants' confidence in different aspects related to research using a 1-5 Likert scale. A second survey, conducted 2 years later, recorded the attendees' research productivity after the workshop. RESULTS: Forty-three participants representing 10 different LMICs from Africa and Asia attended the 2013 course. At 2 year postcourse, participants reported starting 25 research projects, authored 7 "accepted or published manuscripts" (vs. 1 before the course; P < 0.01), and were selected for 12 podium or poster presentations (vs. 3 before the course; P < 0.01). Two research symposium attendees received "Top International Forum Paper" at the 2015 Orthopaedic Trauma Association Annual Meeting. DISCUSSION: A 1-day research course resulted in increased participant confidence in conducting research. This was associated with greater research productivity by participants 2 years later. These results suggest that the IGOT International Research Symposium can improve the number of initiated research projects by surgeons in LMICs.

Can a 2-Day Course Teach Orthopaedic Surgeons Rotational Flap Procedures? An Evaluation of Data From the Nepal SMART Course Over 2 years.

INTRODUCTION: Traumatic lower extremity injuries requiring multidisciplinary treatment pose a challenge in low- and middle-income countries, where access to specialists may be limited. The surgical management and reconstructive training (SMART) course teaches orthopaedic surgeons muscle and fasciocutaneous flap procedures to address this scarcity. The purpose of this study is to assess the effectiveness of the SMART course in improving competency and comfort in performing common lower extremity flap procedures among participants. METHODS: Sixty-four orthopaedic surgeons from different regions of Nepal and Bhutan participated in the Nepal SMART course in 2016 and 2017. A competency test-consisting of questions from US in-training plastic and orthopaedic surgery examinations-was administered to attendees before and after the course. Thirty-two participants from 2016 were asked to rate their comfort level in performing flap procedures both pre- and postcourse. RESULTS: Overall competency test scores, as well as scores in the plastic surgery section, increased significantly after the course (P < 0.01). The precourse competency test scores were higher in 2016 compared with 2017 (P = 0.02). There was a higher increase in overall competency test scores after the course in 2016 compared with 2017 (P = 0.03). The procedure comfort levels reported by attendees increased for all flaps (P < 0.01). CONCLUSIONS: These results demonstrate the ability of the SMART course to improve the competency and comfort levels of orthopaedic surgeons in performing common lower extremity flap procedures. Despite the differences in years in practice and previous experience in performing flaps, the course yielded significantly better results in 2017 compared with 2016, showing that the implementation of the course has been improving.

Developing Research to Change Policy: Design of a Multicenter Cost-Effectiveness Analysis Comparing Intramedullary Nailing to Skeletal Traction in Malawi.

INTRODUCTION: The purpose of our study is to prospectively evaluate the cost effectiveness of intramedullary nailing compared with skeletal traction in a resource-limited setting where traction remains the most common definitive treatment. METHODS: This multicenter, prospective multicenter investigation was conducted in Malawi at 2 central hospitals and 3 district hospitals. The project was divided into phases. In phase 1, the EuroQol-5D and SMFA were translated and validated in Chichewa. In phase 2, adult patents with OTA/AO 32 femur shaft fractures were prospectively enrolled, and a comparison of quality of life and functional status was made. In phase 3, a cost-effectiveness analysis was performed between those treated with intramedullary nail and those treated with skeletal traction. CONCLUSION: This study serves as an example of an economic study in orthopaedic surgery conducted in a resource-poor environment through academic collaboration.

Predictors of lower health-related quality of life after operative repair of diaphyseal femur fractures in a low-resource setting.

BACKGROUND: Little data exists on the negative impact of orthopaedic trauma on quality of life (QOL) in low- and middle-income countries (LMICs). The goal of this study is to investigate the factors associated with lower QOL after operative fixation of femoral shaft fractures in adult patients in a low-resource setting. METHODS: This prospective cohort study followed 272 factures in adults undergoing operative fixation for diaphyseal femur fractures at Tanzania. Patient demographics, injury characteristics, treatment modalities, and functional outcomes up to 1-year post-operatively were evaluated for association with 1-year post-operative EQ-5D QOL scores via univariate linear regression analysis. RESULTS: EQ-5D values were significantly lower at 1 year than at baseline (0.941 vs 0.991, p < 0.0005). CONCLUSIONS: Operative fixation of femoral shaft fractures in LMICs results in return to near baseline QOL. Demographic and treatment factors were not significantly associated with EQ-5D. and several markers of recovery were associated with lower 1 year QOL, including pain, knee stiffness, delayed radiographic healing, complications requiring reoperation. Efforts to reduce perioperative complications may help improve post-operative QOL.

Biomechanical Consequences of Meniscal Tear, Partial Meniscectomy, and Meniscal Repair in the Knee.

UPDATE: This article was updated on April 26, 2018, because of a previous error. On pages 1 and 14, the author name that had read "Alan Z. Zhang, MD" now reads "Alan L. Zhang, MD."

Validation and reliability of the Chichewa translation of the EQ-5D quality of life questionnaire in adults with orthopaedic injuries in Malawi.

BACKGROUND: The EQ-5D is a standardised instrument that measures health-related quality-of-life and explores cost-effectiveness of treatments. Malawi is a low-resource country that would benefit from assessment of quality-of-life among individuals living with chronic conditions. Chichewa is the official native language of Malawi. The Chichewa version of the EQ-5D-3L developed by EuroQoL group has not been validated with Chichewa speakers. The purpose of this study was to evaluate the clinimetric properties of the Chichewa EQ-5D-3L. METHODS: Patients with orthopaedic conditions were recruited in the outpatient orthopaedic clinics and wards at Queen Elizabeth Central Hospital, Blantyre, Malawi. Fifty-three patients with various musculoskeletal problems were administered the Chichewa EQ-5D-3L and World Health Organization quality of life (WHO-QOL) questionnaires. To assess repeatability, a separate test-retest population of 20 patients were also selected from orthopaedic clinics and wards to fill out the questionnaire twice. RESULTS: Convergence validity was determined, with each of the WHO-QOL domains and the EQ-5D descriptive index and visual analogue scale (VAS) having good to moderate correlation (r = 0.3-0.7). Internal consistency was measured for the descriptive index, and the Cronbach's alpha was 0.7. The ceiling effect for the descriptive index and the VAS were 9.4% and 0%, respectively. No respondents reached floor effect for the descriptive index or the VAS. The test-retest intraclass correlation coefficient reliability at 14 days was 0.984 for the VAS and 1 for the descriptive index, with all 20 respondents providing the same responses. CONCLUSIONS: The EuroQoL translated version of the Chichewa EQ-5D-3L was found to demonstrate adequate validity, internal consistency, floor/ceiling effects, and reliability.

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

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

Bipolar Bone Loss in Patients With Anterior Shoulder Dislocation: A Comparison of Adolescents Versus Adult Patients.

PURPOSE: To compare bipolar bone loss by evaluating the degree of glenoid bone loss, Hill-Sachs lesion size, and glenoid track in adolescents and adults with shoulder dislocations. METHODS: We performed a retrospective review between 2012 and 2016 of surgical and nonsurgical patients with a history of anterior shoulder dislocations (primary or recurrent) who underwent magnetic resonance imaging of the affected shoulder. The exclusion criteria included multidirectional instability, prior surgery, and posterior dislocation. Patients were grouped into 2 groups: adolescents (aged 10-19 years) and adults (aged ≥20 years). The groups were compared regarding measures of glenoid bone loss (best-fit circle technique) and Hill-Sachs lesion size (medial margin of rotator cuff footprint to medial margin of Hill-Sachs lesion). If the medial margin of a Hill-Sachs lesion was within the glenoid track, it was defined as on track; if it was more medial than the glenoid track, it was defined as off track. RESULTS: We identified 45 adolescents (mean age, 16.1 years) and 30 adults (mean age, 28.9 years) with anterior shoulder dislocations. There was no significant difference in percentage of bone loss between adolescents (mean, 8.4%) and adults (mean, 9.9%; P = .23). There was no significant difference in Hill-Sachs lesion size between adolescents (mean, 12.7 mm) and adults (mean, 9.9 mm; P = .12). There were 12 patients with off-track lesions. Off-track lesions were present in 11 of 45 adolescents (24.4%) and 1 of 30 adults (3.3%). Adolescents had an increased risk of having an off-track lesion (odds ratio, 9.38; 95% confidence interval, 1.14-77.1). A subgroup analysis identified multiple dislocations as an independent risk factor for an off-track lesion (odds ratio, 4.15; 95% confidence interval, 0.85-20.23). CONCLUSIONS: This study shows that adolescence and a history of multiple dislocations are independent risk factors for a greater likelihood of glenoid off-track lesions. The findings support the use of bipolar assessment of shoulder dislocators, especially in adolescents and multiple dislocators. LEVEL OF EVIDENCE: Level III, retrospective comparative study.