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Elwell Z, Candelo E, Srinivasan T, Nuss S, Zalaquett N, Tuyishimire G, Ncogoza I, Jean‐Gilles PM, Legbo JN, Tollefson T, Shaye D. The State of Craniomaxillofacial Trauma Care in Low- and Middle-Income Countries: A Scoping Review. OTO Open 2024; 8:e70000. [PMID: 39211787 PMCID: PMC11358761 DOI: 10.1002/oto2.70000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 07/19/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024] Open
Abstract
Objective This scoping review aims to contribute a descriptive analysis of the craniomaxillofacial trauma (CMF trauma) literature in low- and middle-income countries (LMICs) to identify knowledge gaps, direct future research, and inform policy. Data Sources PubMed/MEDLINE, Cochrane Review, EMBASE, ClinicalTrials.gov, and Google Scholar from January 1, 2012 to December 10, 2023. Review Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guided reporting, and the PRISMA flowchart documented database searches. Specific, predefined search terms and inclusion criteria were used for screening, and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was used for quality assessment. The search yielded 54 articles, with 13 meeting the inclusion criteria. Key findings were summarized and divided into 7 categories. Results There were 10,420 patients (7739 [74.3%] male, 2681 [25.7%] female) with a male-to-female ratio of 2.9:1. The mean peak age of incidence of CMF trauma was 30.8 years, ranging from 20 to 40 years. Road traffic accidents were the leading cause (60.4%), followed by assault (27.2%) and falls (12.2%). The most common injuries were soft tissue injury (31.7%), isolated mandibular fracture (22.8%), and isolated middle-third of mandible fracture (18.1%). The most common treatments were closed reduction and immobilization (29.5%), conservative management (27.6%), and open reduction and internal fixation (19.6%). Most patients (77.8%) experienced a treatment delay due to a lack of fixation materials (54.8%) or surgeon unavailability (35.7%). Conclusion CMF trauma remains a significant cause of global morbidity, yet there remains a lack of high-quality, CMF trauma-specific data in LMICs. Country-specific investigations are required to enhance knowledge and inform novel interventions. Implementing policy change must be community-specific and account for unique cultural barriers, attitudes, and behaviors to maximize patient care outcomes.
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Affiliation(s)
- Zachary Elwell
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Arizona College of Medicine—TucsonTucsonArizonaUSA
| | - Estephania Candelo
- Department of Otolaryngology–Head and Neck SurgeryMayo Clinic JacksonvilleJacksonvilleFloridaUSA
| | - Tarika Srinivasan
- Department of Otolaryngology–Head and Neck SurgeryMassachusetts Eye and Ear, Harvard Medical SchoolBostonMassachusettsUSA
| | - Sarah Nuss
- Department of Otolaryngology–Head and Neck SurgeryWarren Alpert Medical School at Brown UniversityProvidenceRhode IslandUSA
| | - Nader Zalaquett
- Department of Otolaryngology–Head and Neck SurgeryAmerican University of Beirut Medical CenterBeirutLebanon
| | - Gratien Tuyishimire
- Department of Otolaryngology–Head and Neck SurgeryMedical Business Company HospitalKigaliRwanda
| | - Isaie Ncogoza
- Department of Otolaryngology–Head and Neck SurgeryUniversity Teaching Hospital of KigaliKigaliRwanda
| | - Patrick Marc Jean‐Gilles
- Department of Otolaryngology–Head and Neck SurgeryUniversity Hospital of Port‐au‐PrincePort‐au‐PrinceHaiti
| | - Jacob Ndas Legbo
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck SurgeryUsmanu Danfodiyo University/Teaching HospitalSokotoNigeria
| | - Travis Tollefson
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck SurgeryUniversity of California, DavisSacramentoCaliforniaUSA
| | - David Shaye
- Department of Otolaryngology–Head and Neck SurgeryMassachusetts Eye and Ear, Harvard Medical SchoolBostonMassachusettsUSA
- Department of Otolaryngology–Head and Neck SurgeryUniversity Teaching Hospital of KigaliKigaliRwanda
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck SurgeryMassachusetts Eye and Ear, Harvard Medical SchoolBostonMassachusettsUSA
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Deininger C, Wichlas F, Necchi M, Deluca A, Deininger S, Trieb K, Tempfer H, Kriechbaumer L, Traweger A. Enhancing Cranio-Maxillofacial Fracture Care in Low- and Middle-Income Countries: A Systematic Review. J Clin Med 2024; 13:2437. [PMID: 38673709 PMCID: PMC11050981 DOI: 10.3390/jcm13082437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/11/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Cranio-maxillofacial (CMF) injuries represent a significant challenge in low- and middle-income countries (LMICs), exacerbated by inadequate infrastructure, resources, and training. This systematic review aims to evaluate the current strategies and solutions proposed in the literature to improve CMF fracture care in LMICs, focusing on education, patient transfer, and off-label solutions. Methods: A comprehensive literature search was conducted using PubMed/Medline from January 2000 to June 2023. Studies were selected based on the Preferred Reporting Items for Systematic Review and Meta-analysis Statement (PRISMA). Solutions were categorized into three main areas: education (digital and on-site teaching, fellowships abroad), patient transfer to specialized clinics, and off-label/non-operative solutions. Results: Twenty-three articles were included in the review, revealing a consensus on the necessity for enhanced education and training for local surgeons as the cornerstone for sustainable improvements in CMF care in LMICs. Digital platforms and on-site teaching were identified as key methods for delivering educational content. Furthermore, patient transfer to specialized national clinics and innovative off-label techniques were discussed as immediate solutions to provide quality care despite resource constraints. Conclusions: Effective CMF fracture care in LMICs requires a multifaceted approach, prioritizing the education and training of local healthcare professionals, facilitated patient transfer to specialized centers, and the adoption of off-label solutions to leverage available resources. Collaborative efforts between international organizations, local healthcare providers, and educational institutions are essential to implement these solutions effectively and improve patient outcomes in LMICs.
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Affiliation(s)
- Christian Deininger
- University Clinic for Orthopedics and Traumatology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria; (F.W.); (K.T.); (L.K.)
| | - Florian Wichlas
- University Clinic for Orthopedics and Traumatology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria; (F.W.); (K.T.); (L.K.)
| | - Marco Necchi
- Department of Surgery and Orthopaedics, Hospital Sterzing, Margarethenstraße 24, 39049 Sterzing, Italy;
| | - Amelie Deluca
- Institute of Tendon and Bone Regeneration, Spinal Cord Injury & Tissue Regeneration Center Salzburg, 5020 Salzburg, Austria; (A.D.); (H.T.); (A.T.)
| | - Susanne Deininger
- Department of Urology and Andrology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria;
| | - Klemens Trieb
- University Clinic for Orthopedics and Traumatology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria; (F.W.); (K.T.); (L.K.)
- Department for Orthopaedics and Traumatology, Center for Clinical Medicine, Faculty of Medicine and Dentistry, Danube Private University, 3500 Krems, Austria
| | - Herbert Tempfer
- Institute of Tendon and Bone Regeneration, Spinal Cord Injury & Tissue Regeneration Center Salzburg, 5020 Salzburg, Austria; (A.D.); (H.T.); (A.T.)
| | - Lukas Kriechbaumer
- University Clinic for Orthopedics and Traumatology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria; (F.W.); (K.T.); (L.K.)
| | - Andreas Traweger
- Institute of Tendon and Bone Regeneration, Spinal Cord Injury & Tissue Regeneration Center Salzburg, 5020 Salzburg, Austria; (A.D.); (H.T.); (A.T.)
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Wichlas F, Necchi M, Gruber T, Hofmann V, Deininger S, Deininger SHM, Deluca A, Steidle-Kloc E, Pruszak J, Wittig J, Deininger C. Off-Label Use of an External Hand Fixator for Craniomaxillofacial Fractures-An Anatomical Feasibility Study. Bioengineering (Basel) 2024; 11:279. [PMID: 38534553 DOI: 10.3390/bioengineering11030279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 02/25/2024] [Accepted: 03/11/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND The lack of resources limits the treatment of craniomaxillofacial fractures (CMF) in low-income countries (LIC). Therefore, Barton bandages and/or interdental wiring are considered in these regions. Fracture reduction is maintained by permanent occlusion for 6 weeks, which often leads to limited compliance and dissatisfying results. The aim of this cadaver-based study is to evaluate the feasibility of the use of an external face fixator (EFF) for the treatment of CMF, its biomechanical values and to define the optimal pin insertion points and angles. MATERIALS AND METHODS An AO hand fixator was used. CMF of types Le Fort 1-3 with split fractures of the hard palate were treated with EFF on 13 anatomical specimens. Fractures were created using a chisel, and pins were placed in specific anatomical regions. The maximal pull-out force [N] of pins was analysed by a tensile force gauge, and Fmax of the mandibular pins was evaluated. Computer tomography scans were performed on the healthy, fractured and EFF-treated skulls. RESULTS The pull-out forces for the single pins were mandibular pins (n = 15, median 488.0 N), supraorbital pins (n = 15, median 455.0 N), zygomatic pins (n = 14, median 269.1 N), medial hard palate pins (n = 12, median 208.4 N) and lateral hard palate pins (n = 8, median 49.6 N). CONCLUSIONS The results indicate that the operation technique is feasible, and the stability of the EFF is sufficient for maintaining the reduction. The required pins can safely be inserted into the described areas with good reduction results. Using EFF offers a feasible alternative to the non-surgical treatment of CMF in LIC.
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Affiliation(s)
- Florian Wichlas
- Department of Orthopedics and Traumatology, University Hospital Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
- No Limit Surgery, Ernest-Thun-Strasse 6, 5020 Salzburg, Austria
| | - Marco Necchi
- No Limit Surgery, Ernest-Thun-Strasse 6, 5020 Salzburg, Austria
- Department of Surgery and Orthopaedics, Hospital Sterzing, Margarethenstraße 24, 39049 Sterzing, Italy
| | - Teresa Gruber
- Department of Orthopedics and Traumatology, University Hospital Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Valeska Hofmann
- No Limit Surgery, Ernest-Thun-Strasse 6, 5020 Salzburg, Austria
- BG Trauma Centre, Department of Trauma and Reconstructive Surgery, University of Tübingen, 72076 Tübingen, Germany
| | - Susanne Deininger
- No Limit Surgery, Ernest-Thun-Strasse 6, 5020 Salzburg, Austria
- Department of Urology and Andrology, University Hospital Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
| | | | - Amelie Deluca
- Institute of Tendon and Bone Regeneration, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Eva Steidle-Kloc
- Institute of Anatomy and Cell Biology|Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
- Center of Anatomy and Cell Biology, Salzburg and Nuremberg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Jan Pruszak
- Institute of Anatomy and Cell Biology|Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
- Center of Anatomy and Cell Biology, Salzburg and Nuremberg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Jörn Wittig
- Department of Oral and Maxillofacial Surgery, University Hospital Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Christian Deininger
- Department of Orthopedics and Traumatology, University Hospital Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
- No Limit Surgery, Ernest-Thun-Strasse 6, 5020 Salzburg, Austria
- Institute of Tendon and Bone Regeneration, Paracelsus Medical University, 5020 Salzburg, Austria
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Gadkaree SK, Derakhshan A, Nyabenda V, Ncogoza I, Tuyishimire G, Shaye DA. Wire Osteosynthesis in the Treatment of Mandible Fractures in Low Resource Settings: A Force Study. Craniomaxillofac Trauma Reconstr 2024; 17:13-17. [PMID: 38371214 PMCID: PMC10874206 DOI: 10.1177/19433875221143605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024] Open
Abstract
Study Design Cadaveric investigation. Objective Rigid internal fixation (RIF) using plates and screws is often not feasible in low and middle-income countries due to limited resources. Interosseous wiring to achieve semi-rigid fixation is often used, but lacks biomechanical force data. Herein we aim to quantitatively compare interosseous wiring to RIF. Methods Cadaveric mandibles were fractured at the parasymphysis and angle. Fixation was achieved using interosseous wiring in both single wire loop and figure-of-eight formations, as well as plate and screw fixation (n = 5 for each fixation type at each fracture site). A force gauge was used to measure the number of Newtons (N) required to achieve diastasis and complete failure at the fixation site. Results For angle fractures, the mean force required for initial diastasis was 4.1, 5.9, and 10.9 N for single wire, figure-of-eight wiring, and plating respectively (P < .001). Complete failure was achieved with 152.9, 168.9, and 237.6 N of force for the three methods, respectively (P < .001). Complete failure was achieved for parasymphyseal fractures with 197.7, 263.0, and 262.8 N of force for single wire, figure-of-eight wiring, and plating respectively (P = .002). Forces to achieve initial diastasis for parasymphyseal fractures were not statistically significant among the three fixation methods (P = .29). Conclusions Figure-of-eight interosseous wiring resists comparable forces across mandibular fractures compared to the gold standard of plating. In resource-limited settings when plates and screws are not available, this technique can be considered to achieve semi-rigid fixation of mandibular fractures.
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Affiliation(s)
- Shekhar K. Gadkaree
- Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, MA, USA
- Department of Otolaryngology Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, MA, USA
| | - Adeeb Derakhshan
- Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, MA, USA
- Department of Otolaryngology Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, MA, USA
| | - Victor Nyabenda
- Department of Otolaryngology – Head & Neck Surgery, University Teaching Hospital of Kigali, Rwanda
| | - Isaie Ncogoza
- Department of Otolaryngology – Head & Neck Surgery, University Teaching Hospital of Kigali, Rwanda
| | - Gratien Tuyishimire
- Department of Otolaryngology – Head & Neck Surgery, University Teaching Hospital of Kigali, Rwanda
| | - David A. Shaye
- Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, MA, USA
- Department of Otolaryngology Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, MA, USA
- Department of Otolaryngology – Head & Neck Surgery, University Teaching Hospital of Kigali, Rwanda
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Matic D, Cheng JS, Gauthier O, Harder Y, Lettieri SC, Chatterjee S, Chen M, Volgas D. Generation of Cross-Specialty Consensus Statements on Soft Tissue Management via a Modified Delphi Method. World J Surg 2022; 46:2174-2188. [PMID: 35831713 PMCID: PMC9334401 DOI: 10.1007/s00268-022-06627-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Soft tissue management (STM) training programs for surgeons are largely tradition based, and substantial differences exist among different surgical specialties. The lack of comprehensive and systematic clinical evidence on how surgical techniques and implants affect soft tissue healing makes it difficult to develop evidence-based curricula. As a curriculum development group (CDG), we set out to find common grounds in the form of a set of consensus statements to serve as the basis for surgical soft tissue education. METHODS Following a backward planning process and Kern's six-step approach, the group selected 13 topics to build a cross-specialty STM curriculum. A set of statements based on the curriculum topics were generated by the CDG through discussions and a literature review of three topics. A modified Delphi process including one round of pilot voting through a face-to-face CDG meeting and two rounds of web-based survey involving 22 panelists were utilized for the generation of consensus statements. RESULTS Seventy-one statements were evaluated, and 56 statements reached the 80% consensus for "can be taught as is." CONCLUSIONS Using a modified Delphi method, a set of cross-specialty consensus statements on soft tissue management were generated. These consensus statements can be used as a foundation for multi-specialty surgical education. Similar methods that combine expert experience and clinical evidence can be used to develop specialty-specific consensus on soft tissue handling.
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Affiliation(s)
- Damir Matic
- Division of Plastic and Reconstructive Surgery, Department of Surgery, London Health Science Center, Victoria Hospital, Western University, 800 Commissioners Rd E, London, ON N6A5W9 Canada
| | - Joseph S. Cheng
- Department of Neurosurgery, University of Cincinnati College of Medicine, P.O. Box 670515, Cincinnati, OH 45267-0515 USA
| | - Olivier Gauthier
- Department of Small Animal Surgery and Anesthesia, Food Science and Engineering, ONIRIS Nantes-Atlantic College of Veterinary Medicine, Site de la Chantrerie, 101 route de Gachet - CS 40706, 44307 Nantes cedex 3, France
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale Di Lugano, Sede Ospedale Italiano, Ente Ospedaliero Cantonale (EOC), Via Capelli, CH-6962 Viganello - Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana (USI), Via Buffi 13, 6900 Lugano, Switzerland
| | | | - Sandipan Chatterjee
- AO Education Institute, AO Foundation, Stettbachstrasse 6, 8600 Dübendorf, Switzerland
| | - Maio Chen
- AO Innovation Translation Center, AO Foundation, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - David Volgas
- Department of Orthopaedic Surgery, University of Missouri – Columbia, 3800 S National Ave Suite 600, Springfield, MO 65807 USA
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Stanford-Moore GB, Niyigaba G, Tuyishimire G, Yau J, Kulkrani A, Nyabyenda V, Ncogoza I, Shaye DA. Effect of Delay of Care for Patients with Craniomaxillofacial Trauma in Rwanda. OTO Open 2022; 6:2473974X221096032. [PMID: 35480144 PMCID: PMC9036345 DOI: 10.1177/2473974x221096032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/22/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives Craniomaxillofacial (CMF) trauma represents a significant proportion of global surgical disease burden, disproportionally affecting low- and middle-income countries where care is often delayed. We investigated risk factors for delays to care for patients with CMF trauma presenting to the highest-volume trauma hospital in Rwanda and the impact on complication rates. Study Design This prospective cohort study comprised all patients with CMF trauma presenting to the University Teaching Hospital of Kigali, Rwanda, between June 1 and October 1, 2020. Setting Urban referral center in resource-limited setting. Methods Epidemiologic data were collected, and logistic regression analysis was undertaken to explore risk factors for delays in care and complications. Results Fifty-four patients (94.4% men) met criteria for inclusion. The mean age was 30 years. A majority of patients presented from a rural setting (n = 34, 63%); the most common cause of trauma was motor vehicle accident (n = 18, 33%); and the most common injury was mandibular fracture (n = 28, 35%). An overall 78% of patients had delayed treatment of the fracture after arrival to the hospital, and 81% of these patients experienced a complication (n = 34, P = .03). Delay in treatment was associated with 4-times greater likelihood of complication (odds ratio, 4.25 [95% CI, 1.08-16.70]; P = .038). Conclusion Delay in treatment of CMF traumatic injuries correlates with higher rates of complications. Delays most commonly resulted from a lack of surgeon and/or operating room availability or were related to transfers from rural districts. Expansion of the CMF trauma surgical workforce, increased operative capacity, and coordinated transfer care efforts may improve trauma care.
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Affiliation(s)
- Gaelen B. Stanford-Moore
- Department of Otolaryngology–Head and Neck Surgery, University of California–San Francisco, San Francisco, California, USA
| | - Gilbert Niyigaba
- Department of ENT, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Gratien Tuyishimire
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Jenny Yau
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye & Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Amol Kulkrani
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Victor Nyabyenda
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Isaie Ncogoza
- Department of ENT, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - David A. Shaye
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye & Ear, Harvard Medical School, Boston, Massachusetts, USA
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Off-Label Treatment for Severe Craniomaxillofacial Fractures in Low-Income Countries-A Novel Operation Method with the External Face Fixator. J Clin Med 2022; 11:jcm11061488. [PMID: 35329814 PMCID: PMC8956088 DOI: 10.3390/jcm11061488] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 02/01/2023] Open
Abstract
Introduction: Craniomaxillofacial fractures (CMF) are common in low-income countries (LIC). Due to limited resources, treatment of these fractures usually consists of interdental wiring or immobilization with a Barton bandage to maintain the reduction by permanent occlusion. These non-surgical treatment methods often lead to unsatisfactory results, such as a disturbed dental occlusion and lockjaw. The aim of this study is to present an off-label treatment option for CMF by applying a hand fixator as external face fixator (EFF) and to demonstrate the surgical method in detail. Materials and Methods: The feasibility and postoperative outcomes of this new off-label operation technique were evaluated by analyzing patients with CMF (n = 13) treated at an NGO hospital in Sierra Leone between 2015 and 2019. Results: The application of the EFF was feasible. The biggest advantage compared to the conventional non-operative methods was, that a dynamic occlusion was still possible during the 6 weeks healing period. Hence, patients could eat and drink almost normally and perform dental hygiene with the EFF in place. We did not discover pintrack infections or other complications. Three patients developed an oronasal fistula due to traumatic a palatal bone loss of about 7–8 mm which was treated by a palatal mucoperiosteal flap 15–20 days after the first operation. Discussion and Conclusions: In LIC, where plate osteosynthesis for CMF cannot be performed due to limited resources the application of an EFF is a promising alternative for a better outcome and an improved quality of life for the patients.
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Trauma Training Courses and Programs in Low- and Lower Middle-Income Countries: A Scoping Review. World J Surg 2021; 45:3543-3557. [PMID: 34486080 PMCID: PMC8572832 DOI: 10.1007/s00268-021-06283-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 12/03/2022]
Abstract
Background Injury is the leading cause of morbidity and mortality in low- and lower middle-income countries (LMICs). Trauma training is a cost-effective way to improve injury outcomes. Several trauma programs have been implemented in LMICs; however, their scope and effectiveness remain unclear. In this review, we sought to describe and assess the current state of trauma training in LMICs. Methods We searched MEDLINE, Embase, Global Health, Cochrane Library, and ProQuest Dissertations & Theses Global for trauma training courses in LMICs. An additional gray literature search was conducted on university, governmental, and non- governmental organizations’ websites to identify trauma-related postgraduate medical education (PGME) opportunities. Results Most studies occurred in sub-Saharan Africa and participants were primarily physicians/surgeons, medical students/residents, and nurses. General and surgical trauma management courses were most common, followed by orthopedic trauma or plastic surgery trauma/burn care courses. 32/45 studies reported on participant knowledge and skills, 27 of which had minimal follow-up. Of the four studies commenting on cost of courses, only one demonstrated cost-effectiveness. Three articles evaluated post-course effects on patient outcomes, two of which failed to demonstrate significant improvements. Overall, 43.0% of LMICs have PGME programs with defined trauma competency requirements. Conclusions Current studies on trauma training in LMICs do not clearly demonstrate sustainability, cost-effectiveness, nor improved outcomes. Trauma training programs should be in response to a need, championed locally, and work within a cohesive system to demonstrate concrete benefits. We recommend standardized and contextualized trauma training with recertifications in LMICs for lasting and improved trauma care. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-021-06283-1.
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Wu CA, Dutta R, Virk S, Roy N, Ranganathan K. The need for craniofacial trauma and oncologic reconstruction in global surgery. J Oral Biol Craniofac Res 2021; 11:563-567. [PMID: 34430193 DOI: 10.1016/j.jobcr.2021.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022] Open
Abstract
The global burden of surgical disease is concentrated in low- and middle-income countries and primarily consists of injuries and malignancies. While global reconstructive surgery has a long and well-established history, efforts thus far have been focused on addressing congenital anomalies. Craniofacial trauma and oncologic reconstruction are comparatively neglected despite their higher prevalence. This review explores the burden, management, and treatment gaps of craniofacial trauma and head and neck cancer reconstruction in low-resource settings. We also highlight successful alternative treatments used in low-resource settings and pearls that can be learned from these areas.
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Affiliation(s)
| | - Rohini Dutta
- WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, BARC Hospital (Government of India), Mumbai, India.,Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Sargun Virk
- Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
| | - Nobhojit Roy
- WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, BARC Hospital (Government of India), Mumbai, India
| | - Kavitha Ranganathan
- Harvard Medical School, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
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Calero-Martinez SA, Matula C, Peraud A, Biroli F, Fernández-Alén J, Bierschneider M, Cunningham M, Hawryluk GWJ, Babu M, Bullock MR, Rubiano AM. Development and assessment of competency-based neurotrauma course curriculum for international neurosurgery residents and neurosurgeons. Neurosurg Focus 2021; 48:E13. [PMID: 32114549 DOI: 10.3171/2019.12.focus19850] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 12/31/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic brain injuries (TBIs) are a significant disease burden worldwide. It is imperative to improve neurosurgeons' training during and after their medical residency with appropriate neurotrauma competencies. Unfortunately, the development of these competencies during neurosurgeons' careers and in daily practice is very heterogeneous. This article aimed to describe the development and evaluation of a competency-based international course curriculum designed to address a broad spectrum of needs for taking care of patients with neurotrauma with basic and advanced interventions in different scenarios around the world. METHODS A committee of 5 academic neurosurgeons was involved in the task of building this course curriculum. The process started with the identification of the problems to be addressed and the subsequent performance needed. After this, competencies were defined. In the final phase, educational activities were designed to achieve the intended learning outcomes. In the end, the entire process resulted in competency and outcomes-based education strategy, including a definition of all learning activities and learning outcomes (curriculum), that can be integrated with a faculty development process, including training. Further development was completed by 4 additional academic neurosurgeons supported by a curriculum developer specialist and a project manager. After the development of the course curriculum, template programs were developed with core and optional content defined for implementation and evaluation. RESULTS The content of the course curriculum is divided into essentials and advanced concepts and interventions in neurotrauma care. A mixed sample of 1583 neurosurgeons and neurosurgery residents attending 36 continuing medical education activities in 30 different cities around the world evaluated the course. The average satisfaction was 97%. The average usefulness score was 4.2, according to the Likert scale. CONCLUSIONS An international competency-based course curriculum is an option for creating a well-accepted neurotrauma educational process designed to address a broad spectrum of needs that a neurotrauma practitioner faces during the basic and advanced care of patients in different regions of the world. This process may also be applied to other areas of the neurosurgical knowledge spectrum. Moreover, this process allows worldwide standardization of knowledge requirements and competencies, such that training may be better benchmarked between countries regardless of their income level.
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Affiliation(s)
| | - Christian Matula
- 3Department of Neurosurgery, Medical University of Vienna, Austria
| | | | | | | | | | | | | | - Maya Babu
- 10Massachusetts General Hospital, Boston, Massachusetts
| | | | - Andrés M Rubiano
- 1Meditech Foundation, Cali, Colombia.,12Universidad El Bosque, Bogota, Colombia; and.,13Global Neuro Foundation, Davos, Switzerland
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Andenmatten K, Provence F, Cunningham M, Sepehri A, Perka C, Ylänkö P, Masri BA. Development and Implementation of International Curricula for Joint Replacement and Preservation. Orthop Clin North Am 2021; 52:27-39. [PMID: 33222982 DOI: 10.1016/j.ocl.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The number of patients undergoing joint replacement and preservation procedures continues to increase worldwide. Globally, there is no standardized educational pathway, training program, or recognized certification program for surgeons in these procedures. Development and implementation of new competency-based curricula to deliver specific educational events and resources may help trainees and practicing surgeons be able to perform these procedures more effectively and therefore improve patient outcomes in their respective countries. Ideally, a curriculum would be globally standardized and professionally designed to interactively meet the needs of surgeons. A competency-based approach with built-in assessment and evaluation processes is today's educational standard.
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Affiliation(s)
- Kokeb Andenmatten
- AO Foundation - AO Education Institute, Stettbachstrasse 6, Dübendorf 8600, Switzerland
| | | | - Michael Cunningham
- AO Foundation - AO Education Institute, Stettbachstrasse 6, Dübendorf 8600, Switzerland
| | - Aresh Sepehri
- Department of Orthopaedics, University of British Columbia, Diamond Health Care Centre, 11th Floor - 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada
| | - Carsten Perka
- Charité, University Medicine Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Pipsa Ylänkö
- AO Recon, Clavadelerstrasse 8, Davos Platz 7270, Switzerland
| | - Bassam A Masri
- Department of Orthopaedics, Complex Joint Reconstruction Clinic, Gordon & Leslie Diamond Health Care Centre, University of British Columbia, 3rd Floor, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada.
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Deptula P, Chang K, Chang J. Teaching Hand Surgery in the Developing World: Utilizing Educational Resources in Global Health. Hand Clin 2019; 35:411-419. [PMID: 31585601 DOI: 10.1016/j.hcl.2019.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The development of surgical capacity in the developing world is essential to address the global burden of surgical disease. Training local surgeons in low-income and middle-income countries is critical in this endeavor. The challenges to teaching hand surgery in the developing world include a shortage of local faculty, absence of a defined curriculum, no competency-based evaluation systems, few subspecialty training opportunities, and lack of financial support. To teach hand surgery in the developing world effectively, the authors suggest principles and components of a global training curriculum.
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Affiliation(s)
- Peter Deptula
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, CA 94304, USA.
| | | | - James Chang
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, CA 94304, USA
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Update on the management of craniomaxillofacial trauma in low-resource settings. Curr Opin Otolaryngol Head Neck Surg 2019; 27:274-279. [PMID: 31274568 DOI: 10.1097/moo.0000000000000545] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Craniomaxillofacial (CMF) trauma is a common cause of global morbidity and mortality. Although in high resource settings the management of CMF trauma has improved substantially over the past several decades with internal rigid fixation technology; these advancements have remained economically unviable and have not yet reached low and middle-income countries (LMICs) en masse. The purpose of this review is to discuss the current management of CMF injuries in low-resource settings. RECENT FINDINGS Trauma injuries remain a global epidemic with head and neck injuries among the most common. CMF trauma injuries largely occur in LMICs, with motor vehicle trauma being a common cause. Patients present in a delayed fashion which increases complications. Diagnostic methods are often limited to plain radiographs as computed tomography is not always available. In low-resource settings, CMF trauma continues to be treated primarily by closed reduction, maxillomandibular fixation, and transosseous wiring, yielding acceptable results through affordable methods. With the advent of less expensive plating systems, internal fixation with plates and screws are gradually finding their place in the management of facial trauma in low-resource settings. A shortage of CMF surgeons in LMICs is a recognized problem and is being addressed by targeted curricula. SUMMARY CMF trauma is a major cause of morbidity and mortality globally that remains poorly addressed. Currently, conventional methods of treating CMF trauma in low-resource settings have evolved to meet resource constraints. The education of CMF surgeons remains a key leverage point in improving CMF trauma care globally.
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Affiliation(s)
- David A. Shaye
- Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston
- Department of Otolaryngology, Central University Teaching Hospital, Kigali, Rwanda
- Doctors Without Borders, Amsterdam, Holland
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