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Chebli D, Dhaif F, Ridha A, Schade A, Khatri C. A meta-analysis of the incidence of infections following open tibia fractures and the microorganisms that cause them in high-, middle- and low-income countries. Trop Doct 2024; 54:272-281. [PMID: 38410846 DOI: 10.1177/00494755241232171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Open tibia fractures are devastating, life changing injuries, with infection associated with substantial morbidity to the patient. Reducing infection is a research priority, but before interventional studies can be designed, the incidence of infection following this injury needs to be better defined. Our aim was to estimate the global incidence of infection following an open tibia fracture. A systematic review was performed of MEDLINE, EMBASE, Central Register of Controlled Trials (CENTRAL), Web of Science and Global Index Medicus. We included randomised controlled trials with more than ten participants which reported infections after open diaphyseal or distal fractures (AO 42 or 43). Primary outcome was deep infection according to the Centres for Disease Control and Prevention criteria. Secondary outcome included causative micro-organisms. A meta-analysis using a random effects model to assess incidence and between-treatment effects was performed. Thirteen studies including 1463 adults from seven middle-income countries, seven high-income countries and one low-income country were included. The incidence of infection was 12.12 person-years (95% CI 7.95-18.47). A subgroup analysis compared external fixation and intramedullary nailing showed no difference between infection rates. There were limited data on organisms, but Staphylococcus aureus was the most commonly identified. There are limited to no data on antimicrobial resistance.
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Affiliation(s)
- Djenna Chebli
- Medical Student, Warwick Medical School, University of Warwick, Coventry, UK
| | - Fatema Dhaif
- Specialist Registrar, Warwick Orthopaedic Speciality Training Rotation, Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- Academic Foundation Doctor, Department of Trauma & Orthopaedics, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Ali Ridha
- Specialist Registrar, Warwick Orthopaedic Speciality Training Rotation, Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- Academic Foundation Doctor, Department of Trauma & Orthopaedics, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Alexander Schade
- Wellcome Trust PhD Fellow, Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
| | - Chetan Khatri
- Specialist Registrar, Warwick Orthopaedic Speciality Training Rotation, Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- Academic Foundation Doctor, Department of Trauma & Orthopaedics, University Hospitals Coventry and Warwickshire, Coventry, UK
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Schade AT, Sabawo M, Jaffry Z, Nyamulani N, Mpanga CC, Ngoie LB, Metcalfe AJ, Lalloo DG, Harrison WJ, Leather A, MacPherson P. Improving the management of open tibia fractures, Malawi. Bull World Health Organ 2024; 102:255-264. [PMID: 38562195 PMCID: PMC10976873 DOI: 10.2471/blt.23.290755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/21/2023] [Accepted: 01/10/2024] [Indexed: 04/04/2024] Open
Abstract
Objective To assess the impact of an open fracture intervention bundle on clinical management and patient outcomes of adults in Malawi with open tibia fractures. Methods We conducted a before-and-after implementation study in Malawi in 2021 and 2022 to assess the impact of an open fracture intervention bundle, including a national education course for clinical officers and management guidelines for open fractures. We recruited 287 patients with open tibia fractures. The primary outcome was a before-and-after comparison of the self-reported short musculoskeletal function assessment score, a measure of patient function. Secondary outcomes included clinical management; and clinician knowledge and implementation evaluation outcomes of 57 health-care providers attending the course. We also constructed multilevel regression models to investigate associations between clinical knowledge, patient function, and implementation evaluation before and after the intervention. Findings The median patient function score at 1 year was 6.8 (interquartile range, IQR: 1.5 to 14.5) before intervention and 8.4 (IQR: 3.8 to 23.2) after intervention. Compared with baseline scores, we found clinicians' open fracture knowledge scores improved 1 year after the intervention was implemented (mean posterior difference: 1.6, 95% highest density interval: 0.9 to 2.4). However, we found no difference in most aspects of clinicians' open fracture management practice. Conclusion Despite possible improvement in clinician knowledge and positive evaluation of the intervention implementation, our study showed that there was no overall improvement in clinical management, and weak evidence of worsening patient function 1 year after injury, after implementation of the open fracture intervention bundle.
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Affiliation(s)
- Alexander Thomas Schade
- Public Health Department, Malawi-Liverpool-Wellcome Trust, Queen Elizabeth Central Hospital, P.O. Box 30096, Blantyre, Malawi
| | - Maureen Sabawo
- Department of Health Systems and Policy, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Zahra Jaffry
- Trauma and Orthopaedic Department, Bart’s Health NHS Trust, London, England
| | - Nohakhelha Nyamulani
- Trauma and Orthopaedic Department, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | | | - Leonard Banza Ngoie
- Trauma and Orthopaedic Department, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | | | | | - Andrew Leather
- King's Global Health Partnerships, King’s College London, London, England
| | - Peter MacPherson
- School of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
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Abbas S, Chokotho L, Nyamulani N, Oliver VL. The burden of long bone fracture and health system response in Malawi: A scoping review. Injury 2024; 55:111243. [PMID: 38096746 DOI: 10.1016/j.injury.2023.111243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 01/29/2024]
Abstract
OBJECTIVES Fractures pose serious health and socioeconomic consequences for individuals, their families, and societies more broadly. In many low-resource settings, case fatality and long-term sequelae after a fracture remain high due to individual- and system-level barriers affecting timely access to care. This scoping review explored the burden of fractures in Malawi using long bone fracture (LBF) as a case study by examining the epidemiology of these injuries, their consequences, and the accessibility of quality healthcare. Our aim is to not only describe the scale of the issue but to identify specific interventions that can help address the challenges faced in settings with limited resources and healthcare budgets. METHODS A scoping review methodology was adopted with a narrative synthesis of results. We searched five databases to identify relevant literature and applied the "Three Delays" model and the WHO's Building Blocks Framework to analyse findings on the accessibility of fracture care. RESULTS Fractures most often occurred among young males, with falls being the leading cause, constituting between 5 and 35 % of the total burden of injuries. Fractures were typically managed without surgery despite consistent local evidence showing surgical treatment was superior to conservative management in terms of length of hospital stay and bone healing. Poor functional, economic, and social outcomes were noted in fracture patients, especially after conservative treatment. A lack of trust in the health system, financial barriers, poor transport, and road infrastructure, and interfacility transfers were identified as barriers to care-seeking. Factors challenging the provision of appropriate care included governance issues, poor health infrastructure, financial constraints, and shortage of supplies and human resources. CONCLUSIONS To the best of our knowledge, this review represents the first comprehensive examination of the state of LBF and the health system's response in Malawi. The findings underscore the pressing need for a national trauma registry to accurately determine the actual burden of injuries and support a tailored approach to fracture care in Malawi. It is further evident that the health system in Malawi must be strengthen across all six building blocks to address obstacles to equitable access to high-quality fracture care.
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Affiliation(s)
- Shazra Abbas
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Australia.
| | - Linda Chokotho
- Malawi University of Science and Technology, Mikolongwe, Malawi
| | | | - Victoria L Oliver
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Australia
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Schade AT, Sabawo M, Nyamulani N, Mpanga CC, Ngoie LB, Metcalfe AJ, Lalloo DG, Madan JJ, Harrison WJ, MacPherson P. Functional outcomes and quality of life at 1-year follow-up after an open tibia fracture in Malawi: a multicentre, prospective cohort study. Lancet Glob Health 2023; 11:e1609-e1618. [PMID: 37666261 PMCID: PMC10509037 DOI: 10.1016/s2214-109x(23)00346-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/04/2023] [Accepted: 07/11/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Injuries are a major cause of disability globally and injury incidence is rapidly increasing, largely due to road traffic injuries in low-income and middle-income countries. Current estimates of the scale and consequences of disability from injury are largely based on modelling studies, with a scarcity of empirical evidence from severe injuries in low-income countries. We aimed to better understand the outcomes for individuals with open tibia fractures in Malawi. METHODS In this multicentre, prospective cohort study, adults (aged ≥18 years) with open tibia fractures were systematically recruited at six hospitals in Malawi (two tertiary hospitals and four district hospitals). Follow-up lasted at least 1 year, during which in-person follow-up reviews were done at 6 weeks, 3 months, 6 months, and 1 year post-injury. The primary outcome was function at 1 year post-injury, measured by the Short Musculoskeletal Functional Assessment (SMFA) score. Secondary outcomes included quality-adjusted life-years (QALYs; as determined via the European Quality of Life 5-Dimensions 3-Levels [EQ-5D-3L] survey) and fracture-related infection at 1 year post-injury. Multilevel regression models investigated associations between SMFA score, EQ-5D-3L, baseline factors, and orthopaedic management. FINDINGS Between Feb 12, 2021, and March 14, 2022, 287 participants were enrolled (median age 34 years [IQR 25-44]; 84% male). The most common mode of injury was road traffic injuries (194 [68%] of 287). Overall, 268 (93%) participants had debridement; of the 63 participants who were debrided in district hospitals, 47 (75%) had the procedure under local or no anaesthesia. Following substantial declines by 6 weeks after injury, function and quality of life had not recovered by 1 year post-injury for participants with Gustilo grade I-II fractures (posterior mean SMFA at 1 year: 10·5, 95% highest density interval [HDI]: 9·5-11·6; QALYs: 0·73, 95% HDI: 0·66-0·80) nor Gustilo grade III fractures (posterior mean SMFA at 1 year: 14·9, 95% HDI: 13·4-16·6; QALYs: 0·67, 95% HDI: 0·59-0·75). For all fracture grades, intramedullary nailing substantially improved function and quality of life at 1 year post-injury. Delayed definitive fixation after 5 days had 5-times greater odds of infection compared with early management within 2 days (adjusted odds ratio: 5·1, 95% CI 1·8-16·1; p=0·02). INTERPRETATION Adults with open tibia fractures in Malawi have poor function and quality of life in the 1 year following injury. Centralised orthopaedic surgical management, including early definitive fixation and intramedullary nailing for more severe injuries, might improve outcomes. FUNDING Wellcome Trust. TRANSLATION For the Chichewa translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Alexander Thomas Schade
- Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK; Queen Elizabeth Central Hospital, Blantyre, Malawi.
| | | | | | - Chikumbutso Clara Mpanga
- Queen Elizabeth Central Hospital, Blantyre, Malawi; Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | | | | | | | | | - Peter MacPherson
- Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK; University of Glasgow, Glasgow, UK
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Mody KS, Wu HH, Chokotho LC, Mkandawire NC, Young S, Lau BC, Shearer D, Agarwal-Harding KJ. The Socioeconomic consequences of femoral shaft fracture for patients in Malawi. Malawi Med J 2023; 35:141-150. [PMID: 38362293 PMCID: PMC10865065 DOI: 10.4314/mmj.v35i3.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
Background Femoral shaft fractures are common in Malawi, with an annual incidence of 44 per 100,000 people. Inadequate treatment and delayed presentation often result in functional, biopsychosocial, and financial challenges for patients. The purpose of this study was to examine the socioeconomic consequences of femoral shaft fractures for patients in Malawi. Methods This study of 42 patients was part of a larger study that prospectively examined quality of life. Questionnaires were distributed to patients at 1-year follow-up following femoral shaft fracture treatment. Patients reported pre- and post-injury standard of living and financial well-being. Results Patients reported relatively high transportation costs to and from the hospital. One year after injury, 17 patients (40%) had not returned to work. Of the 25 (60%) who had returned, 5 (20%) changed jobs due to their injury, all reported decreased productivity. Household income decreased for 29% of patients. 20 (49%) of 41 patients reported food insecurity in the week prior to questionnaire completion. Many patients reported changing their residence, borrowing money, selling personal property, and unenrolling children from school due to financial hardship caused by their injury. Conclusion While the Malawian public healthcare system is free at the point of care, it lacks the financial risk protection that is essential to universal health coverage (UHC). In this study, we found that the indirect costs of care due to femoral shaft fractures had substantial socioeconomic consequences on the majority of patients and their families. Increased investment of financial and human capital should be made into capacity building and preventative measures to decrease the burden of injury, increase access to care, improve care delivery, and provide financial risk protection for patients with traumatic injuries in Malawi.
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Affiliation(s)
- Kush S Mody
- Rutgers New Jersey Medical School, NJ, USA
- Harvard Global Orthopaedics Collaborative, Boston, MA, USA
| | - Hao-Hua Wu
- Harvard Global Orthopaedics Collaborative, Boston, MA, USA
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | | | - Nyengo C Mkandawire
- Department of Orthopaedics, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Sven Young
- Lilongwe Institute of Orthopaedics and Neurosurgery, Kamuzu Central Hospital, Lilongwe, Malawi
- Department of Orthopedics, Haukeland University Hospital, Bergen, Norway
| | - Brian C Lau
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
- Duke University Department of Orthopaedic Surgery, Durham, NC, USA
| | - David Shearer
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Kiran J Agarwal-Harding
- Harvard Global Orthopaedics Collaborative, Boston, MA, USA
- Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Howard A, Bolton W, Wood A, Hodgson H, Scott J, Jayne D, Bundu I. There is a great variety of orthopaedic conditions presenting to a large hospital in Sierra Leone: a 3-year prospective study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:581-585. [PMID: 36241914 PMCID: PMC10036420 DOI: 10.1007/s00590-022-03380-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/28/2022] [Indexed: 03/25/2023]
Abstract
PURPOSE In Sierra Leone there is a large void in orthopaedic research into the type of orthopaedic injuries, both acute and chronic. Improved data collection is essential in providing insight to guide health care planning and research. This study aims to outline the types of orthopaedic injury sustained. METHOD Data were prospectively collected by local surgeons in the Orthopaedic outpatient department at a large hospital between January 2016 and January 2019. RESULTS The orthopaedic department saw a mean 728 patients per year, with mean age 24.0 years. The workload comprised of 64.92% acute orthopaedic conditions or their complications, with 35.08% elective orthopaedics. Fractures made up the largest proportion of clinical appointments, annually 244.33 fractures; however there was a high incidence of osteomyelitis. CONCLUSION The study gives an important insight into the types and distribution of elective and trauma orthopaedic injuries sustained in Sierra Leone, which has not been previously reported, and highlights key areas where resources may be focused in order to improve clinical outcomes.
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Affiliation(s)
- Anthony Howard
- NDORMS, Oxford University, Oxford, UK.
- LIRMM, Academic Department, Leeds General Infirmary, University of Leeds, Leeds, UK.
| | - William Bolton
- Leeds Institute of Medical Research, St James, University of Leeds, Leeds, UK
| | | | - Harry Hodgson
- LIRMM, Academic Department, Leeds General Infirmary, University of Leeds, Leeds, UK
| | - Julian Scott
- Vascular Institute, Leeds General Infirmary, Leeds, UK
| | - David Jayne
- Leeds Institute of Medical Research, St James, University of Leeds, Leeds, UK
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Schade AT, Sibande W, Kumwenda M, Desmond N, Chokotho L, Karasouli E, Metcalfe A, Harrison WJ. "Don't rush into thinking of walking again": Patient views of treatment and disability following an open tibia fracture in Malawi. Wellcome Open Res 2022; 7:204. [PMID: 36110835 PMCID: PMC9453110 DOI: 10.12688/wellcomeopenres.18063.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 12/05/2022] Open
Abstract
Background: Open tibia fractures are a common injury following road traffic accidents in Malawi and can lead to long term disability. Very little is known about patients' experiences of the healthcare system and the disability in low-income countries following this injury. The aim of the study was to explore patient experiences of treatment and disability following an open tibia fracture in Malawi. Methods: A qualitative study was conducted using semi-structured interviews with ten patients with open tibia fractures at a central hospital in Blantyre, Malawi. A mixed deductive-inductive thematic analysis was used to identify broad themes of treatment and disability. Written informed consent was obtained from all participants. Results: Patient characteristics included an average age of 39.1 years old (22-63) and 80% were male. Broad themes found were delays in receiving treatment, change in individuals' societal role and delayed recovery associated with pain and immobility. Conclusions: Open tibia fractures in Malawi have a devastating impact on patients and their families. Further studies are required to explore the reasons for the delays in open fracture emergency treatment.
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Affiliation(s)
- Alexander Thomas Schade
- Public Health, Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
- Clinical Trials Unit, University of Warwick, Coventry, UK
- Trauma and Orthopaedics, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Wakumanya Sibande
- Public Health, Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Moses Kumwenda
- Public Health, Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nicola Desmond
- Public Health, Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Linda Chokotho
- Trauma and Orthopaedics, Queen Elizabeth Central Hospital, Blantyre, Malawi
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Chokotho L, Croke K, Mohammed M, Mulwafu W, Bertfelt J, Karpe S, Milusheva S. Epidemiology of adult trauma injuries in Malawi: results from a multisite trauma registry. Inj Epidemiol 2022; 9:14. [PMID: 35440067 PMCID: PMC9017418 DOI: 10.1186/s40621-022-00379-5] [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: 11/19/2021] [Accepted: 01/14/2022] [Indexed: 01/12/2023] Open
Abstract
Background Large-scale multisite trauma registries with broad geographic coverage in low-income countries are rare. This lack of systematic trauma data impedes effective policy responses. Methods All patients presenting with trauma at 10 hospitals in Malawi from September 2018 to March 2020 were enrolled in a prospective registry. Using data from 49,241 cases, we analyze prevalence, causes, and distribution of trauma in adult patients, and timeliness of transport to health facilities and treatment. Results Falls were the most common mechanism of injury overall, but road traffic crashes (RTCs) were the most common mechanism of serious injury, accounting for (48%) of trauma admissions. This pattern was consistent across all central and district hospitals, with only one hospital recording < 40% of admissions due to RTCs. 49% of RTC-linked trauma patients were not in motorized vehicles at the time of the crash. 84% of passengers in cars/trucks/buses and 48% of drivers of cars/trucks/buses from RTCs did not wear seatbelts, and 52% of motorcycle riders (driver and passenger) did not wear helmets. For all serious trauma cases (defined as requiring hospital admission), median time to hospital arrival was 5 h 20 min (IQR 1 h 20 min, 24 h). For serious trauma cases that presented on the same day that trauma occurred, median time to hospital arrival was 2 h (IQR 1 h, 11 h). Significant predictors of hospital admission include being involved in an RTC, age > 55, Glasgow Coma Score < 12, and presentation at hospital on a weekend. Conclusions RTCs make up almost half of hospitalized trauma cases in this setting, are equally common in referral and district hospitals, and are an important predictor of injury severity. Pedestrians and cyclists are just as affected as those in vehicles. Many of those injured in vehicles do not take adequate safety precautions. Most trauma patients, including those with serious injuries, do not receive prompt medical attention. Greater attention to safety for both motorized and especially non-motorized road users, and more timely, higher quality emergency medical services, are important policy priorities for Malawi and other developing countries with high burdens of RTC trauma. Supplementary Information The online version contains supplementary material available at 10.1186/s40621-022-00379-5.
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Affiliation(s)
- Linda Chokotho
- Department of Surgery, College of Medicine, University of Malawi, Mahatma Gandhi, Blantyre, Malawi
| | - Kevin Croke
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, USA.
| | - Meyhar Mohammed
- Development Impact Evaluation, World Bank, 1818 H St NW, Washington, DC, 20433, USA
| | - Wakisa Mulwafu
- Department of Surgery, College of Medicine, University of Malawi, Mahatma Gandhi, Blantyre, Malawi
| | - Jonna Bertfelt
- Development Impact Evaluation, World Bank, 1818 H St NW, Washington, DC, 20433, USA
| | - Saahil Karpe
- Development Impact Evaluation, World Bank, 1818 H St NW, Washington, DC, 20433, USA
| | - Sveta Milusheva
- Development Impact Evaluation, World Bank, 1818 H St NW, Washington, DC, 20433, USA
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Schade AT, Nyamulani N, Banza LN, Metcalfe AJ, Leather A, Madan JJ, Lallloo DG, Harrison WJ, MacPherson P. Protocol for a prospective cohort study of open tibia fractures in Malawi with a nested implementation of open fracture guidelines. Wellcome Open Res 2021; 6:228. [PMID: 35505977 PMCID: PMC9034175 DOI: 10.12688/wellcomeopenres.17145.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Road traffic injury (RTI) is the largest cause of death amongst 15–39-year-old people worldwide, and the burden of injuries such as open tibia fractures are rapidly increasing in Malawi. This study aims to investigate disability and economic outcomes of people with open tibia fractures in Malawi and improve these with locally delivered implementation of open fracture guidelines. Methods: This is a prospective cohort study describing function, quality of life and economic burden of open tibia fractures in Malawi. In total, 160 participants will be recruited across six centres and will be followed-up with face-to-face interviews at six weeks, three months, six months and one year following injury. The primary outcome will be function at one year measured by the short musculoskeletal functional assessment (SMFA) score. Secondary outcomes will include quality of life measured by EuroQol EQ-5D-3L, catastrophic loss of income and implementation outcomes (acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability) at one year. A nested pilot pre-post implementation study of an interventional bundle for all open fractures will be developed based on other implementation studies from low- and middle-income countries (LMICs). Regression analysis will be used to model and investigate associations between SMFA score and fracture severity, infection and the pre- and post-training course period. Outcome: This prospective cohort study will report patient reported outcomes from open tibia fractures in low-resource settings. Subsequent detailed evaluation of both the clinical and implementation components of the study will promote sustainability of improved open fractures management in the study sites and further scale-up of open fracture management guidelines. Ethics: Ethics approval has been obtained from the Liverpool School of Tropical Medicine and College of Medicine Research and Ethics committee.
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Affiliation(s)
- Alexander Thomas Schade
- Public Health, Malawi-Liverpool Wellcome Trust, Blantyre, P.O.Box 30096, Malawi
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Nohakhelha Nyamulani
- Trauma and Orthopaedics surgery, Queen Elizabeth Central Hospital, Blantyre, BOX 95, Malawi
| | - Leonard Ngoe Banza
- Trauma and Orthopaedic surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | - Andrew Leather
- King’s College Centre for Global Health and Health Partnerships, King's College Hospital, London, London, WC2R 2LS, UK
| | - Jason J. Madan
- Warwick medical school, University of Warwick, Coventry, W Midlands, UK
| | | | | | - Peter MacPherson
- Public Health, Malawi-Liverpool Wellcome Trust, Blantyre, P.O.Box 30096, Malawi
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
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Mlinde E, Amlani LM, May CJ, Banza LN, Chokotho L, Agarwal-Harding KJ. Outcomes of Nonoperatively Treated Pediatric Supracondylar Humeral Fractures at the Nkhotakota District Hospital, Malawi. JB JS Open Access 2021; 6:JBJSOA-D-21-00011. [PMID: 34396025 PMCID: PMC8357253 DOI: 10.2106/jbjs.oa.21.00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Displaced supracondylar humeral fractures (SCHFs) benefit from closed reduction and percutaneous pinning. In Malawi, many SCHFs are treated nonoperatively because of limited surgical capacity. We sought to assess clinical and functional outcomes of nonoperatively treated SCHFs in a resource-limited setting. Methods We retrospectively reviewed all patients with SCHFs treated at Nkhotakota District Hospital (NKKDH) in Malawi between January 2014 and December 2016. Patients subsequently underwent clinical and functional follow-up assessment. Results We identified 182 children (54% male, mean age of 7 years) with an SCHF; 151 (83%) of the fractures were due to a fall, and 178 (98%) were extension-type (Gartland class distribution: 63 [35%] type I, 52 [29%] type II, and 63 [35%] type III). Four patients with type-I fractures were treated with an arm sling alone, and 59 were treated with straight-arm traction to reduce swelling and then splint immobilization until union. All 119 of the patients with Gartland type-II and III or flexion-type injuries were treated with straight-arm traction, manipulation under anesthesia without fluoroscopy, and then splint immobilization until union. A total of 137 (75%) of the patients were available for follow-up, at a mean of 3.9 years after injury. The Flynn functional outcome was excellent for 39 (95%) with a type-I fracture, 30 (70%) with type-II, and 14 (29%) with type-III. The Flynn cosmetic outcome was excellent for 40 (98%) with a type-I fracture, 42 (98%) with type-II, and 41 (84%) with type-III. Forty (98%) of the children with a type-I fracture, 41 (95%) with type-II, and 32 (65%) with type-III returned to school without limitation. Controlling for sex, delayed presentation, medical comorbidities, injury mechanism, and skin blistering/superinfection during traction, patients with type-II fractures were 5.82-times more likely (95% confidence interval [CI], 1.71 to 19.85) and those with type-III fractures were 9.81-times more likely (95% CI, 3.00 to 32.04), to have a clinical complication or functional limitation compared with patients with type-I fractures. Conclusions Nonoperative treatment of type-III SCHFs resulted in a high risk of clinical complications or functional impairment. These results illustrate the urgent need to increase surgical capacity in low-income countries like Malawi to improve pediatric fracture care. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Elijah Mlinde
- Department of Orthopedics, Nkhotakota District Hospital, Nkhotakota, Malawi
| | - Lahin M Amlani
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts.,Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Collin J May
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts.,Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Leonard N Banza
- Department of Orthopedics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Linda Chokotho
- Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi
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11
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Recker AJ, Danelson K, Coates KE. Forward Surgical Teams as a Model for Humanitarian Orthopedic Surgical Care: A Review of Current Literature. Mil Med 2021; 186:e505-e511. [PMID: 33210715 DOI: 10.1093/milmed/usaa451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/31/2020] [Accepted: 10/14/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Orthopedic trauma is a significant portion of global burden of disease in low- and middle-income countries (LMICs). This has led the World Health Organization to advocate for increased surgical intervention in LMICs. The two largest barriers to orthopedic surgical care for LMICs are cost of procedure and geographic access to centers with appropriate surgical capabilities. There is no current consensus on how to structure surgical interventional teams. The overall objective of this study is to describe the composition of a forward surgical team (FST), including its abilities and limitations. It is hypothesized that an FST is an effective model for orthopedic surgical relief efforts in LMICs. METHODS A narrative literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis standards published by the National Academies of Medicine. Studies were evaluated by structured review procedures to identify an FST's capacity for orthopedic surgery, as well as applicability for humanitarian care. Articles detailing FST logistics, types of orthopedic treatment provided, and instances of humanitarian care while deployed in austere environments were included for review. RESULTS The FST is a military surgical unit operating with a small crew of surgeons and supporting staff who use tents or trailers that can be positioned near points of conflict, often in remote or austere environments. FSTs were designed to treat traumatic injuries, including orthopedic trauma from RTIs. If used as a sponsored humanitarian aid mission, FSTs can provide surgical care at free or greatly reduced costs. Because FSTs carry limited supplies and personnel, they are highly mobile surgical units that can be transported via truck. CONCLUSION FSTs are effective models for humanitarian orthopedic surgery in LMICs. FSTs were designed to treat orthopedic trauma, the largest burden of orthopedic care in LMICs. Efficient use of limited equipment allows FSTs to be cost effective for funding sources and highly mobile to reduce the geographic barrier to care. Further research is needed to determine the cost to operate an FST and ethical consideration for military intervention for foreign humanitarian aid.
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Affiliation(s)
- Andrew J Recker
- Wake Forest School of Medicine, Bowman Gray Center for Medical Education, Winston-Salem, NC 27101, USA
| | - Kerry Danelson
- Department of Orthopedics, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Kevin E Coates
- Department of Orthopedics, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA
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12
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Agwu C, Purcell LN, Gallaher J, Young S, Banza L, Mansfield AJ, Charles A. Cost-Effectiveness analysis of the surgical management of fractures in Malawi: An economic evaluation of a high and low-income country surgical collaboration. Injury 2021; 52:767-773. [PMID: 33162013 PMCID: PMC8084876 DOI: 10.1016/j.injury.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/14/2020] [Accepted: 11/01/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Cost-effectiveness is an essential tool for identifying high-value interventions in resource-limited settings. This study aims to evaluate the cost-effectiveness of the surgical management of fractures by surgical residents at Kamuzu Central Hospital (KCH). Currently, the 5-year surgical training program is supported by the Malawi Ministry of Health, and two universities in the United States and Norway. METHODS We performed a modeled cost-effectiveness analysis (CEA) from a public health sector perspective. Cost data were collected from the current residency program and effectiveness data estimated from clinical data derived from operative interventions for fractures between 2013 and 2017 at KCH. Three patient groups were used as the base case; (1) patients of all ages, (2) patients age ≥18 years, and (3) patients who were <18 years. A Monte Carlo simulation of 10,000 trials was conducted for the probabilistic sensitivity analysis. RESULTS The estimated average lifetime cost of training and compensating residency-trained surgeons over a 35-year career was $448,600 (SD $31,167). The incremental cost-effectiveness ratio (ICER) for providing surgical care to patients of all ages was $215 (SD $3,666) per disability-adjusted life-year (DALY), which is below the willingness-to pay-threshold (WTP) of $1,170 per DALY and highly cost-effective at a WTP threshold of $390. Each surgeon is estimated to avert approximately 5,570 DALYs during their career when performing operations to treat fractures. CONCLUSION The KCH surgical training program is highly cost-effective at reducing disability at an incremental cost of $215 per averted DALY. This CEA demonstrates that the current surgical training program is cost-effective in reducing morbidity among individuals with fractures.
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Affiliation(s)
- Chidera Agwu
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management
| | - Laura N. Purcell
- University of North Carolina at Chapel Hill, School of Medicine, Department of Surgery
| | - Jared Gallaher
- University of North Carolina at Chapel Hill, School of Medicine, Department of Surgery
| | - Sven Young
- Department of Orthopedics, Haukeland University, Bergen, Norway
| | - Leonard Banza
- Department of Surgery, Kamuzu Central Hospital, Malawi
| | - Alyssa J. Mansfield
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management
| | - Anthony Charles
- University of North Carolina at Chapel Hill, School of Medicine, Department of Surgery
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13
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Schade AT, Yesaya M, Bates J, Martin C, Harrison WJ. The Malawi Orthopaedic Association/AO Alliance guidelines and standards for open fracture management in Malawi: a national consensus statement. Malawi Med J 2021; 32:112-118. [PMID: 33488981 PMCID: PMC7812144 DOI: 10.4314/mmj.v32i3.2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Background Open fractures are common injuries in Malawi that pose a large burden on the healthcare system and result in long-term disability. Aim Establishing a multiprofessional agreement on the management of open fractures in Malawi from a consensus meeting. Methods AO Alliance convened a consensus meeting to build an agreement on the management of open fractures in Malawi. Eighteen members from different professions and various regions of Malawi participated in a 1-day consensus meeting on 7 September 2019. Prior to the meeting the British Orthopaedic Audit Standards for Trauma (BOAST) for open fractures, as well as relevant systematic reviews and seminal literature were circulated. Panel members gave presentations on open fracture management, followed by an open discussion meeting. At the 1-day consensus meeting panel members developed statements for each standard and guideline. Panel members then voted to accept or reject the statements. Results Substantial agreement (no rejections) was reached for all 17 guidelines and the associated terminology was agreed on. These guidelines were then presented to the members of the Malawi Orthopaedic Association (MOA) at their annual general meeting on 28 September 2019 and all participants agreed to adopt them. Conclusions These MOA/AO Alliance guidelines aim to set a standard for open fracture management that can be regularly measured and audited in Malawi to improve care for these patients.
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Affiliation(s)
| | | | - Jeremy Bates
- Queen Elizabeth Central Hospital, Blantyre, Malawi
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14
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Varela C, Young S, Groen RS, Banza L, Mkandawire N, Moen BE, Viste A. Deaths from surgical conditions in Malawi - a randomised cross-sectional Nationwide household survey. BMC Public Health 2020; 20:1456. [PMID: 32977777 PMCID: PMC7519556 DOI: 10.1186/s12889-020-09575-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 09/21/2020] [Indexed: 12/21/2022] Open
Abstract
Background Relatively little is known about deaths from surgical conditions in low- and middle- income African countries. The prevalence of untreated surgical conditions in Malawi has previously been estimated at 35%, with 24% of the total deaths associated with untreated surgical conditions. In this study, we wished to analyse the causes of deaths related to surgical disease in Malawi and where the deaths took place; at or outside a health facility. Methods The study is based on data collected in a randomised multi-stage cross-sectional national household survey, which was carried out using the Surgeons Overseas Assessment of Surgical Need (SOSAS) tool. Randomisation was done on 48,233 settlements, using 55 villages from each district as data collection sites. Two to four households were randomly selected from each village. Two members from each household were interviewed. A total of 1479 households (2909 interviewees) across the whole country were visited as part of the survey. Results The survey data showed that in 2016, the total number of reported deaths from all causes was 616 in the 1479 households visited. Data related to cause of death were available for 558 persons (52.7% male). Surgical conditions accounted for 26.9% of these deaths. The conditions mostly associated with the 150 surgical deaths were body masses, injuries, and acute abdominal distension (24.3, 21.5 and 18.0% respectively). 12 women died from child delivery complications. Significantly more deaths from surgical conditions or injuries (55.3%) occurred outside a health facility compared to 43.6% of deaths from other medical conditions, (p = 0.0047). 82.3% of people that died sought formal health care and 12.9% visited a traditional healer additionally prior to their death. 17.7% received no health care at all. Of 150 deaths from potentially treatable surgical conditions, only 21.3% received surgical care. Conclusion In Malawi, a large proportion of deaths from possible surgical conditions occur outside a health facility. Conditions associated with surgical death were body masses, acute abdominal distention and injuries. These findings indicate an urgent need for scale up of surgical services at all health care levels in Malawi.
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Affiliation(s)
- Carlos Varela
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi.,Department of Surgery, University of Malawi, College of Medicine, Lilongwe, Malawi.,Department of Clinical Medicine, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Sven Young
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi.,Department of Surgery, University of Malawi, College of Medicine, Lilongwe, Malawi.,Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Reinou S Groen
- Department of Obstetrics and Gynaecology, Johns Hopkins Medicine, Baltimore, USA.,Department of Obstetrics and Gynaecology, Alaska Native Medical Centre, Anchorage, USA
| | - Leonard Banza
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi.,Department of Surgery, University of Malawi, College of Medicine, Lilongwe, Malawi.,Department of Clinical Medicine, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Nyengo Mkandawire
- Department of Surgery, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Bente Elisabeth Moen
- Department of Clinical Medicine, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Asgaut Viste
- Department of Clinical Medicine, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway. .,Department of Research and Development, Haukeland University Hospital, Bergen, Norway.
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15
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von Kaeppler E, Donnelley C, Roberts HJ, O'Hara NN, Won N, Shearer DW, Morshed S. Impact of North American Institutions on Orthopedic Research in Low- and Middle-Income Countries. Orthop Clin North Am 2020; 51:177-188. [PMID: 32138856 DOI: 10.1016/j.ocl.2019.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
There exists an unmet need for locally relevant and sustainable orthopedic research in low- and middle-income countries. Partnerships between high-income countries and low- and middle-income countries can bridge gaps in resources, knowledge, infrastructure, and skill. This article presents a select list of models for high-income countries/low- and middle-income countries research partnerships including academic partnerships, international research consortia, professional society-associated working groups, and nongovernmental organization partnerships. Models that produce research with lasting legacy are those that promote mutually beneficial partnerships over individual gains.
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Affiliation(s)
- Ericka von Kaeppler
- Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
| | - Claire Donnelley
- Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
| | - Heather J Roberts
- Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
| | - Nathan N O'Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Suite 300, 110 South Paca Street, Baltimore, MD 21201, USA
| | - Nae Won
- Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
| | - David W Shearer
- Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA.
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16
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Agarwal-Harding KJ, Chokotho L, Young S, Mkandawire N, Chawinga M, Losina E, Katz JN. Assessing the capacity of Malawi's district and central hospitals to manage traumatic diaphyseal femoral fractures in adults. PLoS One 2019; 14:e0225254. [PMID: 31747420 PMCID: PMC6867700 DOI: 10.1371/journal.pone.0225254] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 10/26/2019] [Indexed: 12/18/2022] Open
Abstract
Background The burden of musculoskeletal trauma is growing worldwide, disproportionately affecting low-income countries like Malawi. However, resources required to manage musculoskeletal trauma remain inadequate. A detailed understanding of the current capacity of Malawian public hospitals to manage musculoskeletal trauma is unknown and necessary for effective trauma system development planning. Methods We developed a list of infrastructure, manpower, and material resources used during treatment of adult femoral shaft fractures–a representative injury managed non-operatively and operatively in Malawi. We identified, by consensus of at least 7 out of 10 experts, which items were essential at district and central hospitals. We surveyed orthopaedic providers in person at all 25 district and 4 central hospitals in Malawi on the presence, availability, and reasons for unavailability of essential resources. We validated survey responses by performing simultaneous independent on-site assessments of 25% of the hospitals. Results No district or central hospital in Malawi had available all the essential resources to adequately manage femoral fractures. On average, district hospitals had 71% (range 41–90%) of essential resources, with at least 15 of 25 reporting unavailability of inpatient ward nurses, x-ray, external fixators, gauze and bandages, and walking assistive devices. District hospitals offered only non-operative treatment, though 24/25 reported barriers to performing skeletal traction. Central hospitals reported an average of 76% (71–85%) of essential resources, with at least 2 of 4 hospitals reporting unavailability of full blood count, inpatient hospital beds, a procedure room, an operating room, casualty/A&E department clinicians, orthopaedic clinicians, a circulating nurse, inpatient ward nurses, electrocardiograms, x-ray, suture, and walking assistive devices. All four central hospitals reported barriers to performing skeletal traction. Operative treatment of femur fracture with a reliable supply of implants was available at 3/4 hospitals, though 2/3 were dependent entirely on foreign donations. Conclusion We identified critical deficiencies in infrastructure, manpower, and essential resources at district and central hospitals in Malawi. Our findings provide evidence-based guidance on how to improve the musculoskeletal trauma system in Malawi, by identifying where and why essential resources were unavailable when needed.
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Affiliation(s)
- Kiran J. Agarwal-Harding
- Harvard Combined Orthopaedic Residency Program, Boston, MA, United States of America
- The Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women’s Hospital, Boston, MA, United States of America
- * E-mail:
| | - Linda Chokotho
- Department of Orthopedics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Sven Young
- Department of Orthopedics, Haukeland University Hospital, Bergen, Norway
- Department of Orthopedics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Nyengo Mkandawire
- Department of Orthopedics, Queen Elizabeth Central Hospital, Blantyre, Malawi
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Mabvuto Chawinga
- Department of Orthopedics, Kamuzu Central Hospital, Lilongwe, Malawi
- Department of Clinical Services, Malawi Ministry of Health, Lilongwe, Malawi
| | - Elena Losina
- The Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women’s Hospital, Boston, MA, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States of America
| | - Jeffrey N. Katz
- The Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women’s Hospital, Boston, MA, United States of America
- Departments of Epidemiology and Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
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17
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Conway D, Albright P, Eliezer E, Haonga B, Morshed S, Shearer DW. The burden of femoral shaft fractures in Tanzania. Injury 2019; 50:1371-1375. [PMID: 31196597 DOI: 10.1016/j.injury.2019.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/22/2019] [Accepted: 06/02/2019] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Devin Conway
- Yale School of Medicine, Department of Orthopaedics & Rehabilitation, 800 Howard Avenue, New Haven, CT, USA.
| | - Patrick Albright
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco 2550 23rd Street, Building 9, 3rd Floor, San Francisco, CA, 94110, USA.
| | - Edmund Eliezer
- Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania.
| | - Billy Haonga
- Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania.
| | - Saam Morshed
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco 2550 23rd Street, Building 9, 3rd Floor, San Francisco, CA, 94110, USA.
| | - David W Shearer
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco 2550 23rd Street, Building 9, 3rd Floor, San Francisco, CA, 94110, USA.
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18
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Agarwal-Harding KJ, Chokotho LC, Mkandawire NC, Martin C, Losina E, Katz JN. Risk Factors for Delayed Presentation Among Patients with Musculoskeletal Injuries in Malawi. J Bone Joint Surg Am 2019; 101:920-931. [PMID: 31094984 PMCID: PMC6530973 DOI: 10.2106/jbjs.18.00516] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The burden of injuries is high in low-income and middle-income countries such as Malawi, where access to musculoskeletal trauma care is limited. Delayed treatment can worsen trauma-related disability. Understanding risk factors for delayed hospital presentation will assist in guiding trauma system development. METHODS We examined the records of 1,380 pediatric and adult patients with fractures who presented to the orthopaedic clinics of 2 urban referral hospitals and 2 rural district hospitals in Malawi. We used multivariate Poisson regression to evaluate the association between presentation to a hospital ≥2 days after the injury (delayed presentation) and 11 covariates: age, sex, education level, occupation, season of injury, day of injury, injury mechanism, injury type or extremity of injury, referral status, hospital of presentation, and estimated travel time. RESULTS Twenty-eight percent of pediatric patients and 34% of adult patients presented late. In the pediatric cohort, fall (relative risk [RR], 1.40 [95% confidence interval (CI), 1.02 to 1.93]), sports injuries (RR, 1.65 [95% CI, 1.09 to 2.49]), tibial or fibular injuries (RR, 1.36 [95% CI, 1.05 to 1.77]), injury over the weekend (RR, 2.30 [95% CI, 1.88 to 2.80]), estimated travel time of ≥20 minutes (RR, 1.45 [95% CI, 1.16 to 1.81]), referral from another facility (RR, 1.46 [95% CI, 1.05 to 2.02]), and presentation to Kamuzu Central Hospital, Mangochi District Hospital, or Nkhata Bay District Hospital (RR, 1.34 [95% CI, 1.07 to 1.69]) independently increased the risk of delayed presentation. In the adult cohort, fall (RR, 1.85 [95% CI, 1.38 to 2.46]), injury over the weekend (RR, 1.80 [95% CI, 1.38 to 2.36]), estimated travel time ≥20 minutes (RR, 1.36 [95% CI, 1.03 to 1.80]), and presentation to Kamuzu Central Hospital (RR, 1.74 [95% CI, 1.30 to 2.33]) independently increased the risk of delayed presentation. CONCLUSIONS Delayed presentation to the hospital after a musculoskeletal injury is common in Malawi. Interventions are needed to improve access to musculoskeletal trauma care, especially for pediatric patients with tibial or fibular injuries, all patients after falls, patients injured over the weekend, and patients living far from health facilities.
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Affiliation(s)
- Kiran J. Agarwal-Harding
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts,The Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Nyengo C. Mkandawire
- Department of Orthopedics, Queen Elizabeth Central Hospital, Blantyre, Malawi,College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Elena Losina
- The Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts,Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Jeffrey N. Katz
- The Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts,Departments of Epidemiology and Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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19
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Sharma V, Bhardwaj N, Khurana S, Aggarwal R, Sharma N, Mathur P. Impact of monocytic cytokines in polytrauma patients with orthopedics injures. J Clin Orthop Trauma 2019; 10:750-754. [PMID: 31316249 PMCID: PMC6611960 DOI: 10.1016/j.jcot.2018.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 08/02/2018] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Orthopedic injuries are a growing epidemic affecting predominantly, the young population, after trauma. Polytrauma patients with a femoral fracture and with Injury Severity Score of >15 are of special concern because of complications like Systemic inflammatory response syndrome (SIRS), Multi-organ dysfunction syndrome (MODS) and sepsis. Against this background. We aimed to assess the role of monocytic cytokines in the development of complications in patients, having isolated diapheseal fracture of femur as compared to those having diapheseal fracture of femur along with ISS score >15. METHODOLOGY Patients were divided into to two groups: in first group, only those patients who had isolated femur fracture were included (named as 'Group A'). In the second groups patients having femur fracture along with ISS >15 at the time of admission (named as 'Group B'), were included. The study used flowcytometry based intracellular cytokine assay to circumvent the problem associated with extracellular cytokine assay. RESULTS AND CONCLUSION A total of 20 patients aged between 20 and 55 years, presenting to the emergency department within 24 h of injury were enrolled in Group 'A' and 'B' as per criteria mentioned above. Intracellular expression of cytokines in isolated femur fracture tends to normalize towards healthy control in the late phase of trauma. Elevated levels of IL-8 and IL-6 levels in late phase (Day 10) of trauma. IL-8 and IL-6 may increases to compensate the higher levels of IL-1β. The effect of cytokines on the severity of injury was observed. This complex action of immune cells and proinflammatory cytokines were seen in initial and later stage of trauma.
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Affiliation(s)
- Vijay Sharma
- Department of Orthopaedics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Nidhi Bhardwaj
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Surbhi Khurana
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Richa Aggarwal
- Department of Neuroanesthesia, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Neelu Sharma
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Purva Mathur
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, 110029, India,Corresponding author
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Chokotho LC, Mulwafu W, Nyirenda M, Mbomuwa FJ, Pandit HG, Le G, Lavy C. Establishment of trauma registry at Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi and mapping of high risk geographic areas for trauma. World J Emerg Med 2019; 10:33-41. [PMID: 30598716 DOI: 10.5847/wjem.j.1920-8642.2019.01.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Less attention is directed toward gaining a better understanding of the burden and prevention of injuries, in low and middle income countries (LMICs). We report the establishment of a trauma registry at the Adult Emergency and Trauma Centre (AETC) at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi and identify high risk geographic areas. METHODS We devised a paper based two-page trauma registry form. Ten data clerks and all AETC clinicians were trained to complete demographic and clinical details respectively. Descriptive data, regression and hotspot analyses were done using STATA 15 statistical package and ArcGIS (16) software respectively. RESULTS There were 3,747 patients from May 2013 to May 2015. The most common mechanisms of injury were assault (38.2%), and road traffic injuries (31.6%). The majority had soft tissue injury (53.1%), while 23.8% had no diagnosis indicated. Fractures (OR 19.94 [15.34-25.93]), head injury and internal organ injury (OR 29.5 [16.29-53.4]), and use of ambulance (OR 1.57 [1.06-2.33]) were found to be predictive of increased odds of being admitted to hospital while assault (OR 0.69 [0.52-0.91]) was found to be associated with less odds of being admitted to hospital. Hot spot analysis showed that at 99% confidence interval, Ndirande, Mbayani and Limbe were the top hot spots for injury occurrence. CONCLUSION We have described the process of establishing an integrated and potentially sustainable trauma registry. Significant data were captured to provide details on the epidemiology of trauma and insight on how care could be improved at AETC and surrounding health facilities. This approach may be relevant in similar poor resource settings.
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Affiliation(s)
| | - Wakisa Mulwafu
- Department of Surgery, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Mulinda Nyirenda
- Adult Emergency and Trauma Center, Queen Elizabeth Central Hospital, Ministry of Health, Blantyre, Malawi
| | | | | | - Grace Le
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Christopher Lavy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Banza LN, Gallaher J, Dybvik E, Charles A, Hallan G, Gjertsen JE, Mkandawire N, Varela C, Young S. The rise in road traffic injuries in Lilongwe, Malawi. INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2017.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
BACKGROUND The small developing countries in the Pacific are grouped together as Small Island Development States (SIDS) because they face similar problems which they cannot cope with nationally. They are developing countries, so-called low and lower middle income countries (LMIC), are economically weak and the islands of the different nations are widely scattered. Approximately 80% of the 10 million inhabitants live in rural regions. EPIDEMIOLOGY AND SURGICAL CAPACITY Over 40% of patients in the surgical departments of hospitals are hospitalized for injuries, and this tendency is increasing. Fractures of the upper extremities are relatively more frequent in the Pacific than in the countries of the North. Long distances, lack of possibilities for treatment and lack of transport often cause complications, such as infected open fractures, pseudarthrosis and posttraumatic malformations. There are too few hospitals with sufficiently competent surgeons, anesthetists and obstetricians (SAO) and appropriate equipment. PACIFIC ISLANDS ORTHOPEDIC ASSOCIATION (PIOA) The PIOA was founded in Honiara, Solomon Islands, and offers surgeons of the Pacific SIDS a comprehensive, structured trauma and orthopedic surgery training in their own countries. It lasts 4 years and leads to an M‑Med (orthopaedic surgery) diploma and to a Fellowship of the International College of Surgeons (FICS), which are both recognized by the participating hospitals. It is free for participants. THE AO ALLIANCE FOUNDATION (AOAF) The AOAF is an independent organization with the only aim to enhance trauma surgery capacity in LMICs. The AOAF supports the PIOA program together with the Wyss Medical Foundation. Currently, 18 trainees from 8 Pacific SIDS are participating in the PIOA training program.
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Affiliation(s)
- H Oberli
- National Referral Hospital, Honiara, Guadalcanal, Solomon Islands.
- , Dorfmatt 7, 3286, Muntelier, Schweiz.
| | - C Martin
- AO Alliance Foundation, Clavadelerstrasse 8, 7270, Davos, Schweiz
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