Comparison of direct surgical cost and outcomes for unstable elbow injuries: internal joint stabilizer versus external fixation.

Background: Unstable elbow injuries sometimes require External fixation (ExF) or an Internal Joint Stabilizer (IJS) to maintain joint reduction. No studies have compared the clinical outcomes and surgical costs of these 2 treatment modalities. The purpose of this study was to determine whether clinical outcome and surgical encounter total direct costs (SETDCs) differ between ExF and IJS for unstable elbow injuries. Methods: This retrospective study identified adult patients (aged ≥ 18 years) with unstable elbow injures treated by either an IJS or ExF between 2010 and 2019 at a single tertiary academic center. Patients postoperatively completed 3 patient-reported outcome measures (the Disability of the Arm, Shoulder, and Hand, the Mayo Elbow Performance score, and EQ-5D-DL). Postoperative range of motion was measured in all patients, and complications tallied. SETDCs were determined and compared between the 2 groups. Results: A total of 23 patients were identified, with 12 in each group. Clinical and radiographic follow-up for the IJS group averaged 24 months and 6 months, respectively, and for the ExF group, 78 months and 5 months, respectively. The 2 groups had similar final range of motion, the Mayo Elbow Performance score, and 5Q-5D-5L scores; ExF patients had better the Disability of the Arm, Shoulder, and Hand scores. IJS patients had fewer complications and were less likely to require additional surgery. The SETDCs were similar between the 2 groups, but the relative contributors to cost differed significantly between the groups. Conclusions: Patients treated with an ExF or IJS had similar clinical outcomes, but complications and second surgeries were more likely in ExF patients. The overall SETDC was also similar for ExF and IJS, but relative contributions of the cost subcategories differed.

A Novel Prescription Method Reduces Postoperative Opioid Distribution and Consumption: A Randomized Clinical Trial.

BACKGROUND: Prescription opioid abuse in the United States has risen substantially over the past 2 decades. Narcotic prescription refill restrictions may paradoxically be contributing to this epidemic. We investigated a novel, refill-based opioid prescription method to determine whether it would alter postoperative narcotic distribution or consumption. METHODS: In this randomized controlled trial, patients undergoing internal fixation of distal radius fractures or thumb carpometacarpal joint arthroplasty received either a single prescription for all postoperative narcotics (control arm) or the same amount of pain medication divided into 3 equal prescriptions to be filled as needed (experimental arm). Outcomes included total narcotics dispensed, measured in morphine milligram equivalents (MME) through a prescription monitoring program, patient-reported opioid consumption versus opioid not consumed, and a satisfaction survey. RESULTS: Forty-eight participants were enrolled; 25 were randomized to the control arm and 23 to the experimental arm. At 8 weeks post-op, fewer opioids had been dispensed to the experimental arm (177 ± 94 vs 287 ± 123 MME, P = .0025). At 6-week follow-up, the experimental arm reported lower narcotic consumption (124 ± 105 vs 214 ± 110 MME, P = .0131). Subanalysis of the independent surgeries yielded similar results. Some patients reported insurance issues when filling subsequent prescriptions. Consequently, although 100% of control arm patients reported good pain control, only 82.6% of experimental arm patients said likewise (P = .0455). CONCLUSIONS: This randomized clinical trial demonstrated that patients obtained and consumed fewer narcotics when postoperative opioids were given in a refill-based prescription method. More research is needed to determine whether this opioid distribution method is reproducible, translatable, and feasible.

Strength, bulk and surgery time of ex situ versus in situ flexor tendon repair in a cadaveric model.

The purpose of this study was to compare strength, bulk and time of repair of human cadaveric flexor digitorum profundus tendons repaired in situ versus ex situ. Ninety-six human cadaveric flexor digitorum profundus tendons were transected 5 mm distal to the A2-pulley and randomized to 2-strand, 4-strand or 6-strand repairs. We found no significant differences in repair strength between in situ and ex situ repairs, but repair strength increased with increasing number of strands. The cross-sectional area of the repair was not significantly related to the number of strands, but 4- and 6-strand in situ repairs were bulkier than ex situ repairs. In situ repair took longer, and repair time increased with increasing number of strands. We suggest that cadaveric studies of flexor tendon repair should be performed in situ in order to better mimic the clinical reality of tissue handling and repair bulkiness.

Force-Bioreactor for Assessing Pharmacological Therapies for Mechanobiological Targets.

Tissue fibrosis is a major health issue that impacts millions of people and is costly to treat. However, few effective anti-fibrotic treatments are available. Due to their central role in fibrotic tissue deposition, fibroblasts and myofibroblasts are the target of many therapeutic strategies centered primarily on either inducing apoptosis or blocking mechanical or biochemical stimulation that leads to excessive collagen production. Part of the development of these drugs for clinical use involves in vitro prescreening. 2D screens, however, are not ideal for discovering mechanobiologically significant compounds that impact functions like force generation and other cell activities related to tissue remodeling that are highly dependent on the conditions of the microenvironment. Thus, higher fidelity models are needed to better simulate in vivo conditions and relate drug activity to quantifiable functional outcomes. To provide guidance on effective drug dosing strategies for mechanoresponsive drugs, we describe a custom force-bioreactor that uses a fibroblast-seeded fibrin gels as a relatively simple mimic of the provisional matrix of a healing wound. As cells generate traction forces, the volume of the gel reduces, and a calibrated and embedded Nitinol wire deflects in proportion to the generated forces over the course of 6 days while overhead images of the gel are acquired hourly. This system is a useful in vitro tool for quantifying myofibroblast dose-dependent responses to candidate biomolecules, such as blebbistatin. Administration of 50 µM blebbistatin reliably reduced fibroblast force generation approximately 40% and lasted at least 40 h, which in turn resulted in qualitatively less collagen production as determined via fluorescent labeling of collagen.

The association between surgeon grade and risk of revision following total hip arthroplasty : an analysis of National Joint Registry data.

AIMS: Total hip arthroplasties (THAs) are performed by surgeons at various stages in training with varying levels of supervision, but we do not know if this is safe practice with comparable outcomes to consultant-performed THA. Our aim was to examine the association between surgeon grade, the senior supervision of trainees, and the risk of revision following THA. METHODS: We performed an observational study using National Joint Registry (NJR) data. We included adult patients who underwent primary THA for osteoarthritis, recorded in the NJR between 2003 and 2016. Exposures were operating surgeon grade (consultant or trainee) and whether or not trainees were directly supervised by a scrubbed consultant. Outcomes were all-cause revision and the indication for revision up to ten years. We used methods of survival analysis, adjusted for patient, operation, and healthcare setting factors. RESULTS: We included 603,474 THAs, of which 58,137 (9.6%) procedures were performed by a trainee. There was no association between surgeon grade and all-cause revision up to ten years (crude hazard ratio (HR) 1.00 (95% confidence interval (CI) 0.94 to 1.07); p = 0.966), a finding which persisted with adjusted analysis. Fully adjusted analysis demonstrated an association between trainees operating without scrubbed consultant supervision and an increased risk of all-cause revision (HR 1.10 (95% CI 1.00 to 1.21); p = 0.045). There was an association between trainee-performed THA and revision for instability (HR 1.14 (95% CI 1.01 to 1.30); p = 0.039). However, this was not observed in adjusted models, or when trainees were supervised by a scrubbed consultant. CONCLUSION: Within the current training system in England and Wales, appropriately supervised trainees achieve comparable THA survival to consultants. Trainees who are supervised by a scrubbed consultant achieve superior outcomes compared to trainees who are not supervised by a scrubbed consultant, particularly in terms of revision for instability. Cite this article: Bone Joint J 2022;104-B(3):341-351.

Targeted Muscle Reinnervation in the Hand: A Technical Roadmap.

PURPOSE: Targeted muscle reinnervation (TMR) transfers cut the nerve endings to the motor nerves of the nearby muscles to reduce neuroma pain and/or enhance prosthetic function. To guide surgeons, anatomic "roadmaps" describe nerve transfer options for TMR at various locations. This study aimed to landmark and measure motor entry points (MEPs) to the hand interossei muscles in the context of TMR for digital nerve neuroma management. METHODS: Ten fresh-frozen cadaveric hands were dissected to describe the innervation arising from the deep branch of the ulnar nerve to the dorsal interossei (DIs) and palmar interossei (PIs) muscles. The location of MEPs relative to the bone and soft tissue landmarks and the size of the target nerves were measured. RESULTS: The MEPs for the DIs and PIs were found in the central third of the metacarpal. The MEPs to the PIs averaged 23.3-24.7 mm from the median nerve. The length of nerve proximal to the MEP was limited, ranging between 6.5 ± 2.6 mm for the first PI and 10.5 ± 2.7 mm for the second PI. Similarly, minimal nerve proximal to the MEP of the DI was available for mobilization. Access to the first PI innervation required substantial release of the thenar musculature. Motor nerve diameter averaged 0.85-0.97 mm. CONCLUSIONS: In considering TMR for the management or prevention of digital nerve neuromas, the motor branches to the second and third PIs are the most accessible and best approached volarly, whereas motor branches to the DIs take more direct routes into the muscle, making volar exposure difficult. Nerve length proximal to the MEP is short, requiring that most of the nerve length for neurorrhaphy comes from the digital nerve. Size mismatch at the neurorrhaphy site is favorable compared to more proximal TMR. CLINICAL RELEVANCE: Targeted muscle reinnervation in the hand is technically feasible for a patient with a symptomatic neuroma after digital amputation.

Association between surgeon grade and implant survival following hip and knee replacement: a systematic review and meta-analysis.

OBJECTIVE: To investigate the association between surgeon grade (trainee vs consultant) and implant survival following primary hip and knee replacement. DESIGN: A systematic review and meta-analysis of observational studies. DATA SOURCES: MEDLINE and Embase from inception to 6 October 2021. SETTING: Units performing primary hip and/or knee replacements since 1990. PARTICIPANTS: Adult patients undergoing either a primary hip or knee replacement, predominantly for osteoarthritis. INTERVENTION: Whether the surgeon recorded as performing the procedure was a trainee or not. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was net implant survival reported as a Kaplan-Meier survival estimate. The secondary outcome was crude revision rate. Both outcomes were reported according to surgeon grade. RESULTS: Nine cohort studies capturing 4066 total hip replacements (THRs), 936 total knee replacements (TKRs) and 1357 unicompartmental knee replacements (UKRs) were included (5 THR studies, 2 TKR studies and 2 UKR studies). The pooled net implant survival estimates for THRs at 5 years were 97.9% (95% CI 96.6% to 99.2%) for trainees and 98.1% (95% CI 97.1% to 99.2%) for consultants. The relative risk of revision of THRs at 5 and 10 years was 0.88 (95% CI 0.46 to 1.70) and 0.68 (95% CI 0.37 to 1.26), respectively. For TKRs, the net implant survival estimates at 10 years were 96.2% (95% CI 94.0% to 98.4%) for trainees and 95.1% (95% CI 93.0% to 97.2%) for consultants. We report a narrative summary of UKR outcomes. CONCLUSIONS: There is no strong evidence in the existing literature that trainee surgeons have worse outcomes compared with consultants, in terms of the net survival or crude revision rate of hip and knee replacements at 5-10 years follow-up. These findings are limited by the quality of the existing published data and are applicable to countries with established orthopaedic training programmes. PROSPERO REGISTRATION NUMBER: CRD42019150494.

Postoperative care via smartphone following carpal tunnel release.

INTRODUCTION: This study explores a novel smartphone application for postoperative care following carpal tunnel release (CTR). We hypothesized that a software-based 'virtual visit' for CTR could be safe, effective and convenient for the patient. METHODS: Our group developed the software application utilized in this study. Interactive steps with video instructions enabled patients to complete dressing and suture removal, capture a wound photo, answer a question about median nerve symptoms and capture a video of finger range of motion. Adult patients undergoing endoscopic or open CTR were enrolled. Prior to their scheduled postoperative visit, patients received and completed the module using their smartphone. Agreement between findings of the virtual visit and the corresponding in-person clinical visit was assessed using kappa values. RESULTS: Twenty-two patients were contacted regarding study enrolment and 17 patients were enrolled (ages 23-63, mean 48.2, 6M, 11F). Of 16 patients who participated, all completed dressing removal. Ten of 16 patients removed their sutures successfully. Fourteen patients captured a clinically adequate wound photo and 15 patients answered a question about median nerve symptoms. Fourteen patients captured a range of motion video. Software assessments of surgical wounds, nerve symptoms and physical exams agreed strongly with clinical assessments. DISCUSSION: Most patients were able to respond to a question about their symptoms, provide clinical assessment of their wound via a photo and record a video of their range of motion. Suture removal was the most difficult task. More investigation is needed to determine which patients can reliably remove their sutures.

Sulfasalazine Resolves Joint Stiffness in a Rabbit Model of Arthrofibrosis.

Joint stiffness due to fibrosis/capsule contracture is a seriously disabling complication of articular injury that surgical interventions often fail to completely resolve. Fibrosis/contracture is associated with the abnormal persistence of myofibroblasts, which over-produce and contract collagen matrices. We hypothesized that intra-articular therapy with drugs targeting myofibroblast survival (sulfasalazine), or collagen production (ß-aminopropionitrile and cis-hydroxyproline), would reduce joint stiffness in a rabbit model of fibrosis/contracture. Drugs were encapsulated in poly[lactic-co-glycolic] acid pellets and implanted in joints after fibrosis/contracture induction. Capsule α-smooth muscle actin (α-SMA) expression and intimal thickness were evaluated by immunohistochemistry and histomorphometry, respectively. Joint stiffness was quantified by flexion-extension testing. Drawer tests were employed to determine if the drugs induced cruciate ligament laxity. Joint capsule fibroblasts were tested in vitro for contractile activity and α-SMA expression. Stiffness in immobilized joints treated with blank pellets (control) was significantly higher than in non-immobilized, untreated joints (normal) (p = 0.0008), and higher than in immobilized joints treated with sulfasalazine (p = 0.0065). None of the drugs caused significant cruciate ligament laxity. Intimal thickness was significantly lower than control in the normal and sulfasalazine-treated groups (p = 0.010 and 0.025, respectively). Contractile activity in the cells from controls was significantly increased versus normal (p = 0.001). Sulfasalazine and ß-aminopropionitrile significantly inhibited this effect (p = 0.005 and 0.0006, respectively). α-SMA expression was significantly higher in control versus normal (p = 0.0021) and versus sulfasalazine (p = 0.0007). These findings support the conclusion that sulfasalazine reduced stiffness by clearing myofibroblasts from fibrotic joints. Statement of clinical significance: The results provide proof-of-concept that established joint stiffness can be resolved non-surgically. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:629-638, 2020.

Evidence of Selection Bias and Non-Response Bias in Patient Satisfaction Surveys.

Background: Patient satisfaction surveys are increasingly utilized to measure the patient experience and as a tool to assess the quality of care delivered by medical providers. Press Ganey (PG) is the largest provider of tools for patient satisfaction measurement and analysis. The purpose of this study was to determine if patient satisfaction surveys were subject to selection and/ or nonresponse bias. Methods: Patients seen in an outpatient academic orthopedic clinic were included in this retrospective cohort study. Demographic data included age, race, gender, marital status, primary payer, and native language. All surveys were administered by PG Associates per internal protocols adhering to exclusion criteria within the institutional contract with PG Associates. Results: 3.5% of outpatient encounters generated PG survey data, which were generated by 9.1% of all patients evaluated. The population of patients who were administered as well as patients who responded to the patient satisfaction survey represented a unique population with regards to age, race, gender, marital status, insurance status, and native language. Conclusions: Demographically, patients who were administered and patients who responded to PG surveys differed from the overall population of patients seen in an outpatient orthopedic setting, evidencing both selection and non-response bias. Because of these differences, and considering the small number of survey returned, caution should be exercised when interpreting and applying these data.Level of Evidence: III.

The Effect of Workers' Compensation Status on the Patient Experience.

BACKGROUND: Rating the patient experience is an increasingly important component of value-based health care. Generation of lower ratings on validated functional assessments by patients with Workers' Compensation is well known; however, the relationship between Workers' Compensation status and patient satisfaction is poorly described in orthopaedic patient populations. METHODS: All orthopaedic outpatient patient satisfaction surveys (Press Ganey) generated over an 18-month period at a U.S. academic tertiary care center were included in this study. Data with regard to the primary payer, demographic characteristics, orthopaedic subspecialty, and planned surgical interventions with the provider for whom the survey was completed were analyzed in conjunction with patient satisfaction data. RESULTS: During the study period, 3,720 consecutive patient satisfaction surveys were generated, and 244 surveys were generated by 215 patients with Workers' Compensation. Satisfied patients with Workers' Compensation were more likely to be male (p = 0.0007), to have higher mental health self-assessments (p = 0.004), and to be scheduled for surgical intervention (p = 0.03). Scheduling a surgical procedure was independently associated with improved patient satisfaction, whereas Workers' Compensation status was independently associated with dissatisfaction when adjusting for sex, language, race, and marital status. Across all patient satisfaction domains, patients with Workers' Compensation gave significantly lower scores (p < 0.05) compared with all other patients. Patients with Workers' Compensation were more likely to rate their overall health as lower compared with other patients (p < 0.0001). Patients with Workers' Compensation were more likely to give lower ratings to providers on a 1-to-10 scale (p < 0.0001) and were less likely to recommend the practice to others (p < 0.0001). CONCLUSIONS: Workers' Compensation status is a non-modifiable independent predictor of dissatisfaction with health care compared with other primary payer groups. Further research is warranted to understand the factors influencing patient satisfaction ratings.

Intercarpal Ligament Injuries Associated With Distal Radius Fractures.

Injuries to the scapholunate (SL) and lunotriquetral (LT) interosseous ligaments occur in approximately one third of distal radius fractures. The diagnosis of these injuries is challenging because plain radiographs are not reliably diagnostic. Wrist arthroscopy may be the most accurate way to examine and diagnose soft-tissue injuries of the carpus adjacent to a distal radius fracture. Treatment options for SL and LT ligament injuries include open repair and/or percutaneous pinning. Because the natural history of these injuries is unclear, the necessity of diagnosing and treating these SL and LT interosseous ligament defects remains speculative.

A Retrospective Comparative Cohort Study Comparing Temporary Internal Fixation to External Fixation at the First Stage Debridement in the Treatment of Type IIIB Open Diaphyseal Tibial Fractures.

OBJECTIVES: To compare the rates of deep infection, flap failure, and nonunion after temporary internal fixation (TIF) with temporary external fixation (ex-fix) in the management of Gustilo-Anderson type IIIB open tibia fractures. DESIGN: Retrospective comparative cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Sixty-four consecutive patients with a Gustilo-Anderson type IIIB open diaphyseal tibia fracture (OTA/AO 42) were treated between May 2014 and May 2016. Forty-seven patients (TIF = 24; ex-fix = 23) met the inclusion criteria and underwent 2-stage reconstruction. Definitive fixation was with an intramedullary nail. INTERVENTION: Temporary fracture stabilization at the first-stage debridement was achieved with either TIF with a plate or ex-fix. MAIN OUTCOME MEASUREMENT: The main outcome measure was deep infection. RESULTS: There were 4 complications in the ex-fix group (3 infection and 1 nonunion) and 2 complications in the TIF group (1 infection and 1 flap failure). Multiple regression modeling revealed that infection (P = 0.610), nonunion (P = 0.918), and flap failure (P = 0.112) were not significantly associated with the mode of temporary fixation or other demographic and treatment variables. The odds ratio of patients treated with TIF developing an infection compared with those treated with an ex-fix was 0.29 (95% confidence interval, 0.03-3.01). CONCLUSIONS: TIF of type IIIB open diaphyseal tibial fractures seems to be a safe alternative to conventional external fixation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Preoperative fasting in the department of plastic surgery.

Preoperative fasting is necessary to reduce the risk of regurgitation of gastric contents and pulmonary aspiration in patients undergoing general anaesthetic and procedural sedation. Excessive fasting is associated with metabolic, cardiovascular and gastrointestinal complications and patient discomfort. We aimed to reduce the fasting time for patients on the plastic surgery trauma list. Adult inpatients awaiting surgery were asked to complete a preoperative assessment sheet. Questions included the length of preoperative fasting, clarity of instructions and wellness scores. Three cycles of data collection were performed over a 12-month period, patients who declined to participate or were unable to consent were excluded. The first cycle revealed the need for significant improvement. Interventions included staff education, patient information sheets, preoperative drinks, greater availability of ward snacks and improved communication between the ward staff and surgical team through our electronic trauma database. The initial audit of 15 patients revealed a mean fasting time of 16.3 hours for fluid (range 10-22) and a mean of 19.3 hours for solid food (range 10-24). The mean wellness score was 6/10 (10 being very well), 67% of patients felt they were given clear information. The final cycle demonstrated clear improvement in all domains. The mean fasting time declined to 5.1 hours for fluid (range 3-10 hours) and 13 hours for solid food (range 7.5-17 hours). The mean wellness score (10=very well) increased from 6 to 8, the mean thirst score declined from 6.1 to 5.1 and 100% patients felt they had been given clear information. Removal of the traditional 'NBM from midnight', patient education, a clear fasting routine with preoperative drinks and improved communication between the full multidisciplinary team has led to a reduction in the fasting times on our trauma list.

Simultaneous Fractures of the Ipsilateral Scaphoid and Distal Radius.

Background Ipsilateral fractures of the distal radius and scaphoid are rare, with few reports describing mechanisms of injury, fracture patterns, and treatment approaches. Purpose This article describes the clinical and radiographic features of ipsilateral distal radius and scaphoid fractures occurring simultaneously. Materials and Methods Electronic databases from 2007 to 2017 at a single Level 1 trauma center were reviewed for patients with concurrent fractures of the distal radius and scaphoid. Patient demographics, injury mechanism, scaphoid and distal radius fracture pattern, treatment approach, and radiographic healing were studied. Results Twenty-three patients were identified. Nineteen of the 23 (83%) were males, and 19 of 23 (83%) of the injury mechanisms were considered high energy. Twenty-two of the 23 (96%) scaphoid fractures were nondisplaced, all treated with screw fixation. Most distal radius fractures were displaced and comminuted, 17 of 23 (74%) were intra-articular. All distal radius fractures were treated surgically with internal and/or external fixation. Three patients were lost to follow-up. Average follow-up of the remaining 20 was to 19.8 weeks. Nineteen of the 20 (95%) scaphoids healed, one scaphoid went on to nonunion with avascular necrosis. All 20 radius fractures healed, 16 of 20 (80%) in anatomic alignment. Conclusion Ipsilateral fractures of the distal radius and scaphoid are rare and are usually result of high-energy mechanisms. The scaphoid fracture is usually a nondisplaced fracture at the waist. The distal radius fracture pattern varies but most are displaced and comminuted. The union rate of the scaphoid is high, even if subjected to radiocarpal distraction required for distal radius management. Level of Evidence Therapeutic level IV study.

Estimating the impact of the US President's Emergency Plan for AIDS Relief on HIV treatment and prevention programmes in Africa.

BACKGROUND: Since 2004, the US President's Emergency Plan for AIDS Relief (PEPFAR) has supported the tremendous scale-up of HIV prevention, care and treatment services, primarily in sub-Saharan Africa. We evaluate the impact of antiretroviral treatment (ART), prevention of mother-to-child transmission (PMTCT) and voluntary medical male circumcision (VMMC) programmes on survival, mortality, new infections and the number of orphans from 2004 to 2013 in 16 PEPFAR countries in Africa. METHODS: PEPFAR indicators tracking the number of persons receiving ART for their own health, ART regimens for PMTCT and biomedical prevention of HIV through VMMC were collected across 16 PEPFAR countries. To estimate the impact of PEPFAR programmes for ART, PMTCT and VMMC, we compared the current scenario of PEPFAR-supported interventions to a counterfactual scenario without PEPFAR, and assessed the number of life years gained (LYG), number of orphans averted and HIV infections averted. Mathematical modelling was conducted using the SPECTRUM modelling suite V.5.03. RESULTS: From 2004 to 2013, PEPFAR programmes provided support for a cumulative number of 24 565 127 adults and children on ART, 4 154 878 medical male circumcisions, and ART for PMTCT among 4 154 478 pregnant women in 16 PEPFAR countries. Based on findings from the model, these efforts have helped avert 2.9 million HIV infections in the same period. During 2004-2013, PEPFAR ART programmes alone helped avert almost 9 million orphans in 16 PEPFAR countries and resulted in 11.6 million LYG. CONCLUSIONS: Modelling results suggest that the rapid scale-up of PEPFAR-funded ART, PMTCT and VMMC programmes in Africa during 2004-2013 led to substantially fewer new HIV infections and orphaned children during that time and longer lives among people living with HIV. Our estimates do not account for the impact of the PEPFAR-funded non-biomedical interventions such as behavioural and structural interventions included in the comprehensive HIV prevention, care and treatment strategy used by PEPFAR countries. Therefore, the number of HIV infections and orphans averted and LYG may be underestimated by these models.