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Sabawo M, Jaffry Z, Chokotho L, Schade AT. An Assessment of Open Fracture Management in Hospitals in Malawi Before and Immediately After Implementing Open Fracture Guidelines. JB JS Open Access 2024; 9:e23.00078. [PMID: 38572496 PMCID: PMC10984658 DOI: 10.2106/jbjs.oa.23.00078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Abstract
Background Open fractures, a common consequence of road traffic collisions, are associated with a high risk of complications. The introduction of standard guidelines has been shown to improve patient care and reduce the risk of complications in several countries. In September 2021, the Malawi Orthopaedic Association/Arbeitsgemeinschaft für Osteosynthesefragen Alliance (MOA/AOA) guidelines and standards for open fracture management were introduced in Malawi. This study aimed to assess the management of open fractures in hospitals in Malawi, before and after implementing a training course on the MOA/AOA open fracture guidelines. Methods This was a descriptive and quantitative, before-and-after study that reviewed the medical files of patients with open fractures at Zomba Central Hospital and Mulanje, Salima, and Mangochi district hospitals over two 3-month periods. Variables included initial assessment; antibiotic prophylaxis; place of debridement; type of anesthesia; treatment of the open fracture in the emergency department, operating room, and wards; and short-term complications requiring hospital treatment. Results A total of 88 open-fracture case files were reviewed; 43 were prior and 45 were subsequent to the implementation of the open fracture guidelines. The overall median patient age was 36 years (interquartile range, 27 to 45 years), and 91% (80) were male. Limb neurovascular status assessment and documentation improved from 26% (11) of the patients before the guidelines to 62% (28) afterward (p = 0.0002). The percentage who underwent debridement in the operating room significantly increased from 19% (8) to 69% (31) (p = 0.01). The percentage who underwent debridement under general or spinal anesthesia significantly increased from 5% (2) to 38% (17) and from 12% (5) to 29% (13), respectively (p= 0.001). The wound infection rate decreased from 21% to 11%, but this was not significant, and there was no change in the overall complication rate (p = 0.152). Conclusions This study suggests that training on the MOA/AOA open fracture management guidelines followed by their implementation can lead to at least temporary improvement in the management of open fractures. Nevertheless, additional studies need to be performed to understand the effect on long-term patient outcomes. Levels of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Zahra Jaffry
- Barts Health NHS Trust, The Royal London Hospital, London, England
| | - Linda Chokotho
- Malawi University of Science and Technology, Mikolongwe, Malawi
| | - Alexander Thomas Schade
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, England
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Jaffry Z, Sabawo M, Harrison WJ, Schade AT. Using a consensus meeting to enhance fracture care education in low income countries. BMC MEDICAL EDUCATION 2023; 23:111. [PMID: 36793036 PMCID: PMC9930265 DOI: 10.1186/s12909-023-04077-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 02/01/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND A key strategy to building surgical capacity in low income countries involves training care providers, particularly in the interventions highlighted by the Lancet Commission for Global Surgery, including the management of open fractures. This is a common injury, especially in areas with a high incidence of road traffic incidents. The aim of this study was to use a nominal group consensus method to design a course on open fracture management for clinical officers in Malawi. METHODS The nominal group meeting was held over two days, including clinical officers and surgeons from Malawi and the UK with various levels of expertise in the fields of global surgery, orthopaedics and education. The group was posed with questions on course content, delivery and evaluation. Each participant was encouraged to suggest an answer and the advantages and disadvantages of each suggestion were discussed before voting through an anonymous online platform. Voting included use of a Likert scale or ranking available options. Ethical approval for this process was obtained from the College of Medicine Research and Ethics Committee Malawi and the Liverpool School of Tropical Medicine. RESULTS All suggested course topics received an average score of greater than 8 out of 10 on a Likert scale and were included in the final programme. Videos was the highest ranking option as a method for delivering pre-course material. The highest ranking methods for each course topic included lectures, videos and practicals. When asked what practical skill should be tested at the end of the course, the highest ranking option was "initial assessment". CONCLUSION This work outlines how a consensus meeting can be used to design an educational intervention to improve patient care and outcomes. Through combining the perspectives of both the trainer and trainee, the course aligns both agendas so that it is relevant and sustainable.
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Affiliation(s)
| | | | - William J Harrison
- Countess of Chester Hospital NHS Trust, London, UK
- AO Alliance Africa, Davos, Switzerland
| | - Alexander T Schade
- Malawi- Liverpool Wellcome Trust, Blantyre, Malawi.
- Liverpool School of Tropical Medicine, Liverpool, UK.
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MacKechnie MC, Albright PD, Garabano G, Bidolegui F, Pereira S, Pesciallo CA, Miclau T. Open tibial shaft fracture management in Argentina: an evaluation of treatment standards in diverse resource settings. OTA Int 2022; 5:e209. [PMID: 36425094 PMCID: PMC9580262 DOI: 10.1097/oi9.0000000000000209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/20/2022] [Indexed: 06/16/2023]
Abstract
Background Argentina is a country with varying access to orthopedic surgical care. The Argentine Association of Trauma and Orthopedics (AATO) "Interior Committee" was developed to address potential regional differences and promote standardization of orthopedic trauma care. The paper assesses the level of national standardization of the management of open tibia fractures across 9 provinces in Argentina. Methods Utilizing a matched-comparison group design, management of these injuries were assessed and compared between 3 groups: an "AATO Exterior Committee" consisting of surgeons that practice in Buenos Aires, and 2 "Interior Committees," comprising surgeons that practice in outlying provinces, 1 of which is affiliated with the AATO, and 1 that is not affiliated with the AATO. The study was conducted in 2 phases: phase 1 assessed open tibia fracture management characteristics, and phase 2 evaluated the management of soft-tissue wound coverage following open fractures. Results Soft-tissue coverage procedures for Gustilo Anderson Type IIIB fractures were more commonly performed by orthopedic surgeons in Interior Committees than the AATO Exterior Committee. Greater rates of definitive wound coverage within 7 days post-injury were reported in both Interior Committees compared to the Exterior Committee. Plastic surgeons were reported as more available to those in the AATO Exterior Committee group than in the AATO Interior Committees. Conclusion While treatment patterns were evident among groups, differences were identified in the management and timing of soft-tissue coverage in Gustilo Anderson Type IIIB fractures between the Exterior Committee and both Interior Committees. Future targeted educational and surgical hands-on training opportunities that emphasize challenges faced in resource-limited settings may improve the management of open tibia fractures in Argentina.
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Affiliation(s)
- Madeline C MacKechnie
- Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Patrick D Albright
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America
| | | | | | | | | | - Theodore Miclau
- Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
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Holler JT, Cortez A, Challa S, Eliezer E, Hoanga B, Morshed S, Shearer DW. Risk Factors for Delayed Hospital Admission and Surgical Treatment of Open Tibial Fractures in Tanzania. J Bone Joint Surg Am 2022; 104:716-722. [PMID: 35442248 DOI: 10.2106/jbjs.21.00727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Open fractures, especially of the tibia, require prompt intervention to achieve optimal patient outcomes. While open tibial shaft fractures are common injuries in low- and middle-income countries (LMICs), there is a dearth of literature examining delays to surgery for these injuries in low-resource settings. This study investigated risk factors for delayed management of open tibial fractures in Tanzania. METHODS We conducted an ad hoc analysis of adult patients enrolled in a prospective observational study at a tertiary referral center in Tanzania from 2015 to 2017. Multivariable models were utilized to analyze risk factors for delayed hospital presentation of ≥2 hours, median time from injury to the treatment hospital, and delayed surgical treatment of ≥12 hours after admission among patients with diaphyseal open tibial fractures. RESULTS Two hundred and forty-nine patients met the inclusion criteria. Only 12% of patients used an ambulance, 41% were delayed ≥2 hours in presentation to the first hospital, 75% received an interfacility referral, and 10% experienced a delay to surgery of ≥12 hours after admission. After adjusting for injury severity, having insurance (adjusted odds ratio [aOR] = 0.48; 95% confidence interval [CI] = 0.24 to 0.96) and wounds with approximated skin edges (aOR = 0.37; 95% CI = 0.20 to 0.66) were associated with a decreased risk of delayed hospital presentation. Interfacility referrals (2.3 hours greater than no referral; p = 0.015) and rural injury location (10.9 hours greater than urban location; p < 0.001) were associated with greater median times to treatment hospital admission. Older age (aOR = 0.54 per 10 years; 95% CI = 0.31 to 0.95), single-person households (aOR = 0.12 compared with ≥8 people; 95% CI = 0.02 to 0.96), and an education level greater than pre-primary (aOR = 0.16; 95% CI = 0.04 to 0.62) were associated with fewer delays to surgery of ≥12 hours after admission. CONCLUSIONS Prehospital network and socioeconomic characteristics are associated with delays to open tibial fracture care in Tanzania. Reducing interfacility referrals and implementing surgical cost-reduction strategies may help to reduce delays to open fracture care in LMICs. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jordan T Holler
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California.,Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Abigail Cortez
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - Sravya Challa
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Edmund Eliezer
- Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Billy Hoanga
- Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - David W Shearer
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
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Management of soft-tissue coverage of open tibia fractures in Latin America: Techniques, timing, and resources. Injury 2022; 53:1422-1429. [PMID: 35101259 DOI: 10.1016/j.injury.2022.01.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/13/2022] [Accepted: 01/15/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE This study examined soft-tissue coverage techniques of open tibia fractures, described soft-tissue treatment patterns across income groups, and determined resource accessibility and availability in Latin America. METHODS A 36-question survey was distributed to orthopaedic surgeons in Latin America through two networks: national orthopaedic societies and the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR). Demographic information was collected, and responses were stratified by income groups: high-income countries (HICs) and middle-income countries (MICs). RESULTS The survey was completed by 469 orthopaedic surgeons, representing 19 countries in Latin America (2 HICs and 17 MICs). Most respondents were male (89%), completed residency training (96%), and were fellowship-trained (71%). Only 44% of the respondents had received soft-tissue training. Respondents (77%) reported a strong interest in attending a soft-tissue training course. Plastic surgeons were more commonly the primary providers for Gustilo Anderson (GA) Type IIIB injuries in HICs than in MICs (100% vs. 47%, p<0.01) and plastic surgeons were more available (<24 h of patient presentation to the hospital) in HICs than MICs (63% vs. 26%, p = 0.05), demonstrating statistically significant differences. In addition, respondents in HICs performed free flaps more commonly than in MICs for proximal third (55% vs. 10%, p<0.01), middle third (36% vs. 9%, p = 0.02), and distal third (55% vs. 10%, p<0.01) lower extremity wounds. Negative Pressure Wound Therapy (NPWT or Wound VAC) was the only resource available to more than half of the respondents. Though not statistically significant, surgeons reported having more access to plastic surgeons at their institutions in HICs than MICs (91% vs. 62%, p = 0.12) and performed microsurgical flaps more commonly at their respective institutions (73% vs. 42%, p = 0.06). CONCLUSIONS The study demonstrated that most orthopaedic surgeons in Latin America have received no soft-tissue training, HICs and MICs have differences in access to plastic surgeons and expectations for flap type and timing to definitive coverage, and most respondents had limited access to necessary soft-tissue surgical resources. Further investigation into differences in the clinical outcomes related to soft-tissue coverage methods and protocols can provide additional insight into the importance of timing and access to specialists.
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Wichlas F, Hofmann V, Moursy M, Strada G, Deininger C. No implant, no solution, lost cases to surgery: orthopedic trauma triage for surgery in an NGO hospital in Sierra Leone. Arch Orthop Trauma Surg 2022; 142:805-811. [PMID: 33459821 PMCID: PMC7811951 DOI: 10.1007/s00402-020-03747-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 12/19/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION In low-income countries (LIC), international surgeons face the fact that there are patients they cannot treat. The goal of this study was to identify and analyze patients lost to treatment. MATERIAL AND METHODS We analyzed retrospectively the data of 282 trauma victims from a non-governmental organizational (NGO) hospital in Sierra Leone, Africa. During a 3-month period (10.10.2015-08.01.2016), these patients had 367 injuries and underwent 263 orthopedic surgeries. Despite a clear indication, some patients did not receive surgical treatment. We identified these injuries and the reason why they could not be operated. The anatomic region of the injury was evaluated and if they had a bone or soft tissue defect or were infected. RESULTS We identified 95 (25.89%) injuries in 70 patients (47 males; 23 females) that were not be operated. The reasons were lack of specific implants (no implant group; N = 33), no treatment strategy for the injury (no solution group; N = 29), and patients that were lost (lost patient group; N = 33), almost equally distributed by 1/3. In the no implant group were mainly closed fractures and fractures of the pelvis and the proximal femur. The implants needed were locking plates (N = 19), proximal femoral nails (N = 8), and implants for pelvic surgery (N = 6). In the no solution group were nearly all bone (P < 0.0000), soft tissue defects (P < 0.00001) and infections (P = 0.00003) compared to the rest and more open fractures (P < 0.00001). In the lost patients group, most fractures were closed (24 out of 33, P = 0.033). These fractures were mostly not urgent and were postponed repeatedly. CONCLUSION One quarter of the patients did not receive the surgical treatment needed. Besides acquisition of implants, surgical skills and expertise could be a solution for this issue. Nevertheless, these skills must be passed to local surgeons.
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Affiliation(s)
- F Wichlas
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria.
- No Limit Surgery, Ernest-Thun-Strasse 6, 5020, Salzburg, Austria.
| | - V Hofmann
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria
- No Limit Surgery, Ernest-Thun-Strasse 6, 5020, Salzburg, Austria
| | - M Moursy
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria
| | | | - C Deininger
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria
- No Limit Surgery, Ernest-Thun-Strasse 6, 5020, Salzburg, Austria
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Holler JT, MacKechnie MC, Albright PD, Morshed S, Shearer DW, Terry MJ. The Impact of Inadequate Soft-tissue Coverage following Severe Open Tibia Fractures in Tanzania. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3272. [PMID: 33425587 PMCID: PMC7787316 DOI: 10.1097/gox.0000000000003272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/01/2020] [Indexed: 12/31/2022]
Abstract
Managing lower extremity fractures complicated by large soft-tissue defects is challenging for surgeons in low- and middle-income countries, and long-term quality of life (QOL) for these patients is unclear. METHODS We examined QOL, surgical complications, and longitudinal outcomes in 10 patients with Gustilo-Anderson Classification Type IIIB open tibia fractures seen at an orthopedic institute in Tanzania, from December 2015 to March 2017. Patients completed follow-up at 2-, 6-, 12-, 26-, and 52-week time points, and returned for qualitative interviews at 2.5 years. The primary outcome was QOL, as measured using EuroQoL-5D scores and qualitative semi-structured interview responses. The secondary outcome was rate of complication, as defined by reoperation for deep infection or nonunion. RESULTS Ten patients enrolled in the study and 7 completed 1-year follow-up. All fractures were caused by road traffic accidents and treated by external fixation. No patients received initial soft-tissue (flap) coverage of the wound. All patients developed an infected nonunion. No patients returned to work at 6 weeks, 3 months, or 6 months. EQ-5D index scores at 1 year were poor (0.71 ± 0.09). Interview themes included ongoing medical complications, loss of employment, reduced income, and difficulty with activities of daily living. CONCLUSIONS Patients in low- and middle-income countries with IIIB open tibia fractures not treated with appropriate soft-tissue coverage experience poor QOL, high complication rates, and severe socioeconomic effects as a result of their injuries. These findings illustrate the need for resources and training to build capacity for extremity soft-tissue reconstruction in LMICs.
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Affiliation(s)
- Jordan T. Holler
- From the UCSF School of Medicine, University of California, San Francisco, Calif
| | - Madeline C. MacKechnie
- Institute for Global Orthopedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Calif
| | - Patrick D. Albright
- Department of Orthopaedic Surgery, University of Minnesota – Medical School, Minneapolis, Minn
| | - Saam Morshed
- Institute for Global Orthopedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Calif
| | - David W. Shearer
- Institute for Global Orthopedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Calif
| | - Michael J. Terry
- Division of Plastic and Reconstructive Surgery, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, Calif
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