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Jia Q, Peng Z, Huang A, Jiang S, Zhao W, Xie Z, Ma C. Is fracture management merely a physical process? Exploring the psychological effects of internal and external fixation. J Orthop Surg Res 2024; 19:231. [PMID: 38589910 PMCID: PMC11000308 DOI: 10.1186/s13018-024-04655-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/02/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Internal and external fixation are common surgical procedures for treating fractures. However, the impact of different surgical approaches (including internal and external fixations) on patients' psychological status and Quality of Life (QoL) is rarely examined. Herein, we aimed to investigate the effects of internal and external fixation on anxiety, depression, insomnia, and overall mental and physical health in Distal Radius Fractures (DRF) patients. METHODS We performed a retrospective study on 96 fracture patients who underwent internal fixation (57 patients) or external fixation (39 patients). The Visual Analog Scale (VAS), the Hospital Anxiety and Depression Scale (HADS), the Athens Insomnia Scale (AIS), and the Medical Outcomes Study Short Form 36 (SF-36) questionnaire were used to assess the patients' pain, anxiety, depression, sleep, and QoL before surgery and at seven days, one month, and three months post-surgery. RESULTS The VAS scores were significantly lower in the Internal Fixation Group (IFG) than in the External Fixation Group (EFG) on the seventh day and one month postoperatively (P < 0.05). Although both groups showed no significant anxiety, depression, or insomnia before surgery (P > 0.05), the EFG showed significantly higher HADS-A, HADS-D, and AIS scores than the IFG at seven days and one and three months postoperatively (P < 0.05). Additionally, changes in HADS-A, HADS-D, and AIS scores were most significant at day seven post-surgery in the EFG (P < 0.05). Furthermore, no significant difference was found between the two groups in the average Physical Component Summary (PCS) and Mental Component Summary (MCS) scores before surgery (P > 0.05). However, both groups showed positive changes in PCS and MCS scores at postoperative day seven and one and three months postoperatively, with the IFG having significantly higher average PCS and MCS scores compared to the EFG (P < 0.05). CONCLUSION Compared to external fixation, internal fixation did not significantly impact patients' emotions regarding anxiety and depression in the early postoperative period, and physical and mental health recovery was better during the postoperative rehabilitation period. Furthermore, when there are no absolute indications, the impact on patients' psychological well-being should be considered as one of the key factors in the treatment plan during surgical approach selection.
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Affiliation(s)
- Qiyu Jia
- Department of Trauma Orthopedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Zhenlei Peng
- Xinjiang Clinical Research Center for Mental Health, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Anqi Huang
- Nanjing Brain Hospital, Clinical Teaching Hospital of Medical School, Child Mental Health Research Center, Nanjing University, Nanjing, China
| | - Shijie Jiang
- Xinjiang Clinical Research Center for Mental Health, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Wen Zhao
- Department of Orthopedics, Beijing Aerospace General Hospital, Beijing, China.
- Department of Orthopedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China.
| | - Zengru Xie
- Department of Trauma Orthopedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China.
| | - Chuang Ma
- Department of Trauma Orthopedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China.
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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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Lam AW, Richardson D, Kang KK. Technique for Extraction and Revision of a Bent Intramedullary Nail for a Subtrochanteric Femur Fracture: A Case Report. JBJS Case Connect 2023; 13:01709767-202303000-00031. [PMID: 36763704 DOI: 10.2106/jbjs.cc.22.00453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
CASE A 17-year-old adolescent boy presented 2 months after initial intramedullary nail (IMN) fixation of a comminuted subtrochanteric fracture with refracture at the previous site and approximately 20° varus angulation of the nail. The bent femoral nail was successfully extracted using an open technique using Lohman bone-holding clamps and a broad plate. At the 1-year follow-up, fracture union was achieved. CONCLUSIONS Removal of a deformed IMN is rare. No standardized protocol exists in guiding orthopaedic surgeons. A thorough review of techniques is discussed on this unusual complication.
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Affiliation(s)
- Aaron W Lam
- Maimonides Medical Center, Brooklyn, New York
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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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Schade AT, Mbowuwa F, Chidothi P, MacPherson P, Graham SM, Martin C, Harrison WJ, Chokotho L. Epidemiology of fractures and their treatment in Malawi: Results of a multicentre prospective registry study to guide orthopaedic care planning. PLoS One 2021; 16:e0255052. [PMID: 34347803 PMCID: PMC8336825 DOI: 10.1371/journal.pone.0255052] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 07/08/2021] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Injuries cause 30% more deaths than HIV, TB and malaria combined, and a prospective fracture care registry was established to investigate the fracture burden and treatment in Malawi to inform evidence-based improvements. OBJECTIVE To use the analysis of prospectively-collected fracture data to develop evidence-based strategies to improve fracture care in Malawi and other similar settings. DESIGN Multicentre prospective registry study. SETTING Two large referral centres and two district hospitals in Malawi. PARTICIPANTS All patients with a fracture (confirmed by radiographs)-including patients with multiple fractures-were eligible to be included in the registry. EXPOSURE All fractures that presented to two urban central and two rural district hospitals in Malawi over a 3.5-year period (September 2016 to March 2020). MAIN OUTCOME(S) AND MEASURE(S) Demographics, characteristics of injuries, and treatment outcomes were collected on all eligible participants. RESULTS Between September 2016 and March 2020, 23,734 patients were enrolled with a median age of 15 years (interquartile range: 10-35 years); 68.7% were male. The most common injuries were radius/ulna fractures (n = 8,682, 36.8%), tibia/fibula fractures (n = 4,036, 17.0%), humerus fractures (n = 3,527, 14.9%) and femoral fractures (n = 2,355, 9.9%). The majority of fractures (n = 21,729, 91.6%) were treated by orthopaedic clinical officers; 88% (20,885/2,849) of fractures were treated non-operatively, and 62.7% were treated and sent home on the same day. Open fractures (OR:53.19, CI:39.68-72.09), distal femoral fractures (OR:2.59, CI:1.78-3.78), patella (OR:10.31, CI:7.04-15.07), supracondylar humeral fractures (OR:3.10, CI:2.38-4.05), ankle fractures (OR:2.97, CI:2.26-3.92) and tibial plateau fractures (OR:2.08, CI:1.47-2.95) were more likely to be treated operatively compared to distal radius fractures. CONCLUSIONS AND RELEVANCE The current model of fracture care in Malawi is such that trained orthopaedic surgeons manage fractures operatively in urban referral centres whereas orthopaedic clinical officers mainly manage fractures non-operatively in both district and referral centres. We recommend that orthopaedic surgeons should supervise orthopaedic clinical officers to manage non operative injuries in central and district hospitals. There is need for further studies to assess the clinical and patient reported outcomes of these fracture cases, managed both operatively and non-operatively.
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Affiliation(s)
- Alexander Thomas Schade
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | | | - Peter MacPherson
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene and Tropical Medicine, Blantyre, United Kingdom
| | - Simon Matthew Graham
- Institute of Population Health Sciences, University of Liverpool, Liverpool, United Kingdom
- Department of Orthopaedic and Trauma Surgery, Liverpool University Teaching Hospital Trust, Liverpool, United Kingdom
| | | | - William James Harrison
- AO-Alliance Foundation, Blantyre, Malawi
- Department of Orthopaedic and Trauma Surgery, Liverpool University Teaching Hospital Trust, Liverpool, United Kingdom
- Countess of Chester NHS Foundation Trust, Blantyre, Malawi
| | - Linda Chokotho
- AO-Alliance Foundation, Blantyre, Malawi
- Department of Surgery, College of Medicine, University of Malawi, Blantyre, Malawi
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Chokotho L, Donnelley CA, Young S, Lau BC, Wu HH, Mkandawire N, Gjertsen JE, Hallan G, Agarwal-Harding KJ, Shearer D. Cost utility analysis of intramedullary nailing and skeletal traction treatment for patients with femoral shaft fractures in Malawi. Acta Orthop 2021; 92:436-442. [PMID: 33757393 PMCID: PMC8428269 DOI: 10.1080/17453674.2021.1897927] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - In Malawi, both skeletal traction (ST) and intramedullary nailing (IMN) are used in the treatment of femoral shaft fractures, ST being the mainstay treatment. Previous studies have found that IMN has improved outcomes and is less expensive than ST. However, no cost-effectiveness analyses have yet compared IMN and ST in Malawi. We report the results of a cost-utility analysis (CUA) comparing treatment using either IMN or ST.Patients and methods - This was an economic evaluation study, where a CUA was done using a decision-tree model from the government healthcare payer and societal perspectives with an 1-year time horizon. We obtained EQ-5D-3L utility scores and probabilities from a prospective observational study assessing quality of life and function in 187 adult patients with femoral shaft fractures treated with either IMN or ST. The patients were followed up at 6 weeks, and 3, 6, and 12 months post-injury. Quality adjusted life years (QALYs) were calculated from utility scores using the area under the curve method. Direct treatment costs were obtained from a prospective micro costing study. Indirect costs included patient lost productivity, patient transportation, meals, and childcare costs associated with hospital stay and follow-up visits. Multiple sensitivity analyses assessed model uncertainty.Results - Total treatment costs were higher for ST ($1,349) compared with IMN ($1,122). QALYs were lower for ST than IMN, 0.71 (95% confidence interval [CI] 0.66-0.76) and 0.77 (CI 0.71-0.82) respectively. Based on lower cost and higher utility, IMN was the dominant strategy. IMN remained dominant in 94% of simulations. IMN would be less cost-effective than ST at a total procedure cost exceeding $880 from the payer's perspective, or $1,035 from the societal perspective.Interpretation - IMN was cost saving and more effective than ST in the treatment of adult femoral shaft fractures in Malawi, and may be an efficient use of limited healthcare resources.
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Affiliation(s)
- Linda Chokotho
- Department of Surgery, College of Medicine, University of Malawi; ,Department of Clinical Medicine, University of Bergen, Bergen, Norway; ,Correspondence:
| | - Claire A Donnelley
- Institute for Global Orthopedics and Traumatology, Orthopedic Trauma Institute, University of California San Francisco, San Francisco, CA, USA;
| | - Sven Young
- Department of Surgery, College of Medicine, University of Malawi; ,Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway; ,Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi;
| | - Brian C Lau
- Department of Orthopedic Surgery, Duke University Medical Centre, Durham, NC, USA;
| | - Hao-Hua Wu
- Institute for Global Orthopedics and Traumatology, Orthopedic Trauma Institute, University of California San Francisco, San Francisco, CA, USA;
| | - Nyengo Mkandawire
- Department of Surgery, College of Medicine, University of Malawi; ,School of Medicine, Flinders University, Adelaide, Australia;
| | - Jan-Erik Gjertsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; ,Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway;
| | - Geir Hallan
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; ,Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway;
| | - Kiran J Agarwal-Harding
- Harvard Global Orthopaedics Collaborative, Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, MA, USA
| | - David Shearer
- Institute for Global Orthopedics and Traumatology, Orthopedic Trauma Institute, University of California San Francisco, San Francisco, CA, USA;
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