Objective Musculoskeletal disorders are the second-leading cause of years lived with disability globally. Total Knee Replacement (TKR) offers patients with advanced arthritis relief from pain and the opportunity to return to physical activity. We investigated the impact of TKR on physical activity for patients in a developing nation. Methods We interviewed 18 Dominican patients (78% female) who received TKR as part of the Operation Walk Boston surgical mission program about their level of physical activity after surgery. Qualitative interviews were conducted in Spanish, and English transcripts were analyzed using content analysis. Results Most patients found that TKR increased their participation in physical activities in several life domains such as occupational or social pursuits. Some patients limited their own physical activities due to uncertainty about medically appropriate levels of joint use and post-operative physical activity. Many patients noted positive effects of TKR on mood and mental health. For most patients in the study, religion offered a framework for understanding their receipt of and experience with TKR. Conclusions Our findings underscore the potential of TKR to permit patients in the developing world to return to physical activities. This research also demonstrates the influence of patient education, culture, and religion on patients’ return to physical activity. As the global burden of musculoskeletal disease increases, it is important to characterize the impact of activity limitation on patients’ lives in diverse settings, and the potential for surgical intervention to ease the burden of chronic arthritis.

Objective To determine the reliability of radiographic assessment of knee osteoarthritis (OA) by non-clinician readers compared to an experienced radiologist. Methods The radiologist trained three non-clinicians to evaluate radiographic characteristics of knee OA. The radiologist and non-clinicians read preoperative films of 36 patients prior to total knee replacement. Intra- and inter-reader reliability was measured using the weighted kappa statistic and intra-class correlation coefficient (ICC). Kappa <0.20 indicated slight agreement, 0.21 – 0.40 fair, 0.41 – 0.60 moderate, 0.61 – 0.80 substantial, and 0.81 – 1.0 almost perfect agreement. Results Intra-reader reliability among non-clinicians (kappa) ranged from 0.40 to 1.0 for individual radiographic features and 0.72 to 1.0 for Kellgren-Lawrence (K-L) grade. ICCs ranged from 0.89 to 0.98 for the Osteoarthritis Research Society International (OARSI) Summary Score. Inter-reader agreement among non-clinicians ranged from kappa of 0.45 to 0.94 for individual features, and 0.66 to 0.97 for K-L grade. ICCs ranged from 0.87 to 0.96 for the OARSI Summary Score. Inter-reader reliability between non-clinicians and the radiologist ranged from kappa of 0.56 to 0.85 for KL grade. ICCs ranged from 0.79 to 0.88 for the OARSI Summary Score. Conclusion Intra- and inter-rater agreement was variable for individual radiograph features but substantial for summary KL grade and OARSI Summary Score. Investigators face trade-offs between cost and reader experience. These data suggest that in settings where costs are constrained, trained non-clinicians may be suitable readers of radiographic knee OA, particularly if a summary score (K-L grade or OARSI Score) is used to capture radiographic severity.

BackgroundTo address both the growing burden of joint disease and the gaps in medical access in developing nations, medical relief organizations have begun to launch programs to perform total joint replacement (TJR) on resident populations in developing countries. One outcome of TJR of particular interest is physical activity (PA) since it is strongly linked to general health. This study evaluates the amount of postoperative participation in PA in low-income patients who received total joint replacement in the Dominican Republic and identifies preoperative predictors of postoperative PA level.MethodsWe used the Yale Physical Activity Survey (YPAS) to assess participation in postoperative PA 1–4 years following total knee or hip replacement. We compared the amount of aerobic PA reported by postoperative TJR patients with the levels of PA recommended by the CDC and WHO. We also analyzed preoperative determinants of postoperative participation in aerobic PA in bivariate and multivariate analyses.Results64 patients out of 170 eligible subjects (52/128 TKR and 14/42 THR) who received TJR between 2009–2012 returned for an annual follow-up visit in 2013, with a mean treatment-to-follow-up time of 2.1 years. 43.3% of respondents met CDC/WHO criteria for sufficient participation in aerobic PA. Multivariate analyses including data from 56 individuals identified that patients who were both younger than 65 and at least two years postoperative had an adjusted mean activity dimensions summary index (ADSI) 22.9 points higher than patients who were 65 or older and one year postoperative. Patients who lived with friends or family had adjusted mean ADSI 17.2 points higher than patients living alone. Patients who had the most optimistic preoperative expectations of outcome had adjusted mean ADSI scores that were 19.8 points higher than those who were less optimistic.ConclusionThe TJR patients in the Dominican cohort participate in less PA than recommended by the CDC/WHO. Additionally, several associations were identified that potentially affect PA in this population; specifically, participants who are older than 65, recently postoperative, less optimistic about postoperative outcomes and who live alone participate in less PA.

Background. There are no established guidelines for fixation of posterior malleolus fractures (PMFs). However, fixation of PMFs appears to be increasing with growing evidence demonstrating benefits for stability, alignment, and early functional outcomes. The purpose of this study was to determine the risk to anatomic structures utilizing a percutaneous technique for posterior to anterior (PA) screw fixation of PMFs. Methods. Percutaneous PA screw placement was carried out on 10 fresh frozen cadaveric ankles followed by dissection to identify soft tissue and neurovascular structures at risk. The distance from the guidewire to each anatomic structure of interest was measured. The correlation between the mean distances from the guidewire to each structure was calculated. Results. The sural nerve was directly transected in 1/10 specimens (10%) and in contact with the wire in a second specimen (10%). There was a significant correlation between the proximity of the guidewire to the apex of Volkmann’s tubercle and its proximity to the sural nerve. The flexor hallucis longus (FHL) muscle belly was perforated by the guidewire 40% of the time but was not tethered or entrapped by the screw. Conclusions. Percutaneous PA screw placement is a safe technique which can be improved with several modifications. A mini-open technique is recommended to protect the sural nerve. There may be potential for tethering of the FHL with use of a washer or large screw head. Risk to the anterior and posterior neurovascular bundles is minimal. Levels of Evidence: Level V

Level IV- retrospective case series.

PurposeIn Honduras, the breast cancer burden is high, and access to women’s health services is low. This project tested the connection of community-based breast cancer detection with clinical diagnosis and treatment in a tightly linked and quickly facilitated format.MethodsThe Norris Cotton Cancer Center at Dartmouth College partnered with the Honduran cancer hospital La Liga Contra el Cancer to expand a cervical cancer screening program, which included self-breast exam (SBE) education and clinical breast exams (CBEs), to assess patient attitudes about and uptake of breast cancer education and screening services. The cervical cancer screening event was held in Honduras in 2013; 476 women from 31 villages attended.ResultsHalf of the women attending elected to receive a CBE; most had concerns about lactation. Clinicians referred 12 women with abnormal CBEs to La Liga Contra el Cancer for additional evaluation at no cost. All referred patients were compliant with the recommendation and received follow-up care. One abnormal follow-up mammogram/ultrasound result was negative on biopsy. One woman with an aggressive phyllodes tumor had a mastectomy within 60 days. Multimodal education about breast cancer screening maximized delivery of women’s health services in a low-tech rural setting.ConclusionThe addition of opportunistic breast cancer education and screening to a cervical cancer screening event resulted in high uptake of services at low additional cost to program sponsors. Such novel strategies to maximize delivery of women’s health services in low-resource settings, where there is no access to mammography, may result in earlier detection of breast cancer. Close follow-up of positive results with referral to appropriate treatment is essential.

Syndesmotic instability is a source of significant pain and disability. Both subtle instability and gross diastasis, whether acute or chronic, require stabilization and may benefit from reconstruction with ligamentous augmentation. The use of nonabsorbable suture-tape has emerged as a promising operative strategy, allowing surgeons to anatomically reconstruct the syndesmosis, in particular the anterior inferior tibiofibular ligament. The current work provides a detailed description of the technique and preliminary results of a patient cohort treated using nonabsorbable suture-tape for syndesmotic augmentation. Level of Evidence: Level V, expert opinion.

A pelvic fracture with entrapment of the urinary bladder in the fracture site is a rare pattern of injury. As the “team captains” in the trauma bay and in the care of polytraumatized patients, trauma surgeons must be aware of this entity and its implications. We report a case of acute bladder entrapment in the fracture site of a lateral compression pelvic fracture. A review of the English literature yielded four previous reports, including two patients with delayed diagnosis (Ghuman et al., 2014; Kumar et al., 1980; Wright and Taitsman, 1996; Min et al., 2010 [1–4]). Kumar and colleagues first documented bladder entrapment by a pelvic fracture in 1980 (Kumar et al., 1980 [2]). Ghuman et al. described a similar case treated with fixation of the pelvic fracture (Ghuman et al., 2014 [1]). Wright and colleagues treated a patient with bladder perforation due to entrapment diagnosed two weeks after a pelvic ring fracture (Wright and Taitsman, 1996 [3]). In this case the bladder injury was repaired, but internal fixation of the pelvis fracture was avoided due to fear of contamination. Finally, Min et al. documented a case of bladder entrapment and perforation presenting six months after non-operative management of a pelvic ring fracture. The female patient developed recurrent UTIs and dyspareunia, and imaging revealed fracture malunion with the bladder entrapped in the fracture site (Min et al., 2010 [4]). This collection of case reports demonstrates the potential for acute or delayed bladder injury even in seemingly benign pelvic fractures. A high index of suspicion is required to intervene and prevent morbidity from bladder injuries in pelvic trauma. Entrapment of the bladder may require surgical intervention even when the injury pattern would not normally dictate surgery for the pelvis or bladder alone (Bryk and Zhao, 2016 [5]). We describe the diagnosis and surgical management of bladder entrapment and present a brief review of bladder injuries associated with pelvic fractures.