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Subramanian A, Adejuyigbe B, Niknam K, Gomez-Alvarado F, Morshed S, Shearer D. Retrospective cohort study analyzing outcomes of the SIGN Fin Nail in adult femoral fractures using the retrograde approach. J Orthop 2024; 54:103-107. [PMID: 38560590 PMCID: PMC10978453 DOI: 10.1016/j.jor.2024.03.020] [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: 03/04/2024] [Accepted: 03/12/2024] [Indexed: 04/04/2024] Open
Abstract
Purpose There is high burden of long bone fractures in low- and middle-income countries (LMICs). Given a limited availability of fluoroscopy in LMICs, the Surgical Implant Generation Network (SIGN) developed two types of intramedullary nails: the SIGN standard nail and the SIGN Fin Nail. A limited number of studies have analyzed healing outcomes with the SIGN Fin Nail and the current study is the largest one to date. The purpose of this study is to compare outcomes between the SIGN standard nail and SIGN Fin Nails in adult femoral shaft fractures treated with a retrograde approach. Method A retrospective cohort study of adults with femoral shaft fractures was performed using the Sign Online Surgical Database (SOSD). The primary outcome was achieving full painless weight bearing and the secondary outcomes assessed were radiographic healing and infection. A propensity-score adjustment was performed for potential confounders and effect modification due to fracture location was tested using a Mantel-Haenszel test for heterogeneity. Results Of 19,928 adults with femoral shaft fractures, 2,912 (14.7%) had the required 6-month follow-up to be included. The overall propensity score weighted relative risk between the Fin and Standard Nail for achieving painless weight-bearing was 0.99, 95% CI [0.96-1.03] and for radiographical healing was 0.99, 95%CI [0.97-1.02]. The propensity score weighted relative risk for infection was 1.30, 95% [0.85-1.97]. Use of the Fin nail was also significantly associated with shorter surgery times (p < 0.005, effect size = 24 min). Sub-group analysis based on fracture location and injury cause demonstrated no change in relative risk. Conclusion The Fin nail showed no change in relative risk in terms of achieving full painless weightbearing or radiographic healing compared to the standard nail for retrograde nailing of femoral shaft fractures in adults. The heterogeneous nature of the cohort and large sample size allow for generalizability and add to a growing base of literature supporting use of the Fin Nail for retrograde femoral nailing. However, there are limitations as we could not correct for comminution at the fracture site or measure radiographic alignment or shortening.
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Affiliation(s)
- Aditya Subramanian
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, USA
| | - Babapelumi Adejuyigbe
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, USA
| | - Kian Niknam
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, USA
| | - Francisco Gomez-Alvarado
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, USA
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, USA
| | - David Shearer
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, USA
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Hasan AI, Wajahath M, Nasser E, Nasser M, Saleh KJ. Transforming Global Orthopaedic Missions Through Adversity, Lessons Learned, and Sustainable Planning Using Quality Assurance Principles: The FAJR Methodology. J Bone Joint Surg Am 2024; 106:1338-1349. [PMID: 38723017 DOI: 10.2106/jbjs.23.01272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Affiliation(s)
- Ahmad I Hasan
- FAJR Scientific, Ann Arbor, Michigan
- Department of Orthopedic Surgery, Detroit Medical Center, Detroit, Michigan
| | - Muaaz Wajahath
- FAJR Scientific, Ann Arbor, Michigan
- Michigan State University College of Human Medicine, East Lansing, Michigan
| | - Elias Nasser
- FAJR Scientific, Ann Arbor, Michigan
- University of Texas Southwestern Medical School, Dallas, Texas
| | | | - Khaled J Saleh
- FAJR Scientific, Ann Arbor, Michigan
- Michigan State University College of Human Medicine, East Lansing, Michigan
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Adesina SA, Amole IO, Adefokun IG, Adegoke AO, Odekhiran EO, Akinwumi AI, Ojo SA, Durodola AO, Awotunde OT, Ikem IC, Eyesan SU. Reamed intramedullary nailing of diaphyseal multifragmentary femur fractures (AO/OTA 32-C) without fluoroscopy guidance: prospective analysis of methods and short-term outcomes in a low-resource setting. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-04040-3. [PMID: 38963548 DOI: 10.1007/s00590-024-04040-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 06/28/2024] [Indexed: 07/05/2024]
Abstract
PURPOSE To describe the methods and outcomes of reamed intramedullary nailing (IMN) of diaphyseal multifragmentary femur (AO/OTA C2 and C3) fractures (DMFFs) in a low-resource setting without fluoroscopy and fracture table. METHODS The prospective study involved 35 DMFFs among 318 femur fractures treated ≤ 3 weeks post-injury with SIGN nails. The fractures were fixed without fluoroscopy, fracture table and power reaming. Closed, mini-open or open reduction was done. Anatomical length and alignment were ensured using a surgical support triangle during retrograde nailing, and by an assistant during antegrade nailing. Follow-ups were done at 6 weeks, 12 weeks and 6 months. RESULTS DMFFs constituted 11.0% of the 318 fractures. Twenty-four (68.6%) were males. The mean age was 39.0 years (range 17-75 years). About 94.3% were injured in road traffic accidents. Fracture reduction was closed in 18, mini-open in 8 and full-open in 9. The operative times were significantly shorter for closed than open reduction (p = 0.001). Five fractures received a supplemental fixation with plate or lag screws. By the 12th post-operative week, 97.1% demonstrated continuing radiographic healing, 94.1% tolerated painless weight-bearing and 91.2% could squat & smile. There was no infection or noticeable rotational malunion. Five fractures healed with a limb-length discrepancy of < 2 cm. CONCLUSION The study demonstrates the feasibility of reamed IMN of DMFFs without fluoroscopy. The outcomes were satisfactory. Although the small sample size and short follow-up period are limitations, the study could serve as a basis for future larger studies in low-resource settings.
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Affiliation(s)
- Stephen Adesope Adesina
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria.
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria.
| | - Isaac Olusayo Amole
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | | | - Adepeju Olatayo Adegoke
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | | | | | - Simeon Ayorinde Ojo
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | - Adewumi Ojeniyi Durodola
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | - Olufemi Timothy Awotunde
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | - Innocent Chiedu Ikem
- Department of Orthopaedic Surgery and Traumatology, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
| | - Samuel Uwale Eyesan
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
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Mand S, Telfer S. Healthcare segregation in orthopedic surgery: A statewide analysis of American Indian and Alaska Native patients. J Orthop Res 2024; 42:878-885. [PMID: 37849417 DOI: 10.1002/jor.25718] [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: 07/21/2023] [Revised: 10/06/2023] [Accepted: 10/16/2023] [Indexed: 10/19/2023]
Abstract
Significant health disparities have been described for American Indian and Alaska Native (AIAN) patients undergoing various surgical procedures, however, research into healthcare segregation within orthopedic surgery has been limited. In this study, our purpose was to assess if AIAN patients were more likely to be treated by lower-volume surgeons and at lower-volume hospitals. AIAN and White patients who underwent one of four common orthopedic procedures (knee or hip arthroplasty, femur or tibia repair) were identified from a Washington state inpatient database. Demographic, socioeconomic, geographic, and procedure data were surveyed, and volumetric thresholds were established for lower versus higher volume surgeons and hospitals. Adjusted odds ratios were calculated for AIAN patients receiving care from a lower volume surgeon or hospital, including covariates for patient demographics, geographic, and socioeconomic status. AIAN patients were more likely to receive care from a lower-volume surgeon for all procedures except tibial repair. Adjusted odds ratios of 1.53 (95% confidence interval [CI]: 1.22, 1.92) and 1.68 (95% CI: 1.26, 2.21) were found for AIAN patients receiving knee or hip arthroplasty from a lower volume surgeon, respectively. There was no strong evidence of AIAN patients being more likely to receive care at a lower-volume hospital. Finally, AIAN patients having knee arthroplasty at a higher volume hospital were more likely to have their surgery performed by a lower volume surgeon. These data suggest that there may be significant healthcare segregation among AIAN patients across common orthopedic surgical procedures.
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Affiliation(s)
- Simran Mand
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Scott Telfer
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, USA
- RR&D Center for Limb Loss and Mobility, VA Puget Sound, Seattle, Washington, USA
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Twea P, Watkins D, Norheim OF, Munthali B, Young S, Chiwaula L, Manthalu G, Nkhoma D, Hangoma P. The economic costs of orthopaedic services: a health system cost analysis of tertiary hospitals in a low-income country. HEALTH ECONOMICS REVIEW 2024; 14:13. [PMID: 38367132 PMCID: PMC10874068 DOI: 10.1186/s13561-024-00485-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/08/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Traumatic injuries are rising globally, disproportionately affecting low- and middle-income countries, constituting 88% of the burden of surgically treatable conditions. While contributing to the highest burden, LMICs also have the least availability of resources to address this growing burden effectively. Studies on the cost-of-service provision in these settings have concentrated on the most common traumatic injuries, leaving an evidence gap on other traumatic injuries. This study aimed to address the gap in understanding the cost of orthopaedic services in low-income settings by conducting a comprehensive costing analysis in two tertiary-level hospitals in Malawi. METHODS We used a mixed costing methodology, utilising both Top-Down and Time-Driven Activity-Based Costing approaches. Data on resource utilisation, personnel costs, medicines, supplies, capital costs, laboratory costs, radiology service costs, and overhead costs were collected for one year, from July 2021 to June 2022. We conducted a retrospective review of all the available patient files for the period under review. Assumptions on the intensity of service use were based on utilisation patterns observed in patient records. All costs were expressed in 2021 United States Dollars. RESULTS We conducted a review of 2,372 patient files, 72% of which were male. The median length of stay for all patients was 9.5 days (8-11). The mean weighted cost of treatment across the entire pathway varied, ranging from $195 ($136-$235) for Supracondylar Fractures to $711 ($389-$931) for Proximal Ulna Fractures. The main cost components were personnel (30%) and medicines and supplies (23%). Within diagnosis-specific costs, the length of stay was the most significant cost driver, contributing to the substantial disparity in treatment costs between the two hospitals. CONCLUSION This study underscores the critical role of orthopaedic care in LMICs and the need for context-specific cost data. It highlights the variation in cost drivers and resource utilisation patterns between hospitals, emphasising the importance of tailored healthcare planning and resource allocation approaches. Understanding the costs of surgical interventions in LMICs can inform policy decisions and improve access to essential orthopaedic services, potentially reducing the disease burden associated with trauma-related injuries. We recommend that future studies focus on evaluating the cost-effectiveness of orthopaedic interventions, particularly those that have not been analysed within the existing literature.
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Affiliation(s)
- Pakwanja Twea
- University of Bergen, Bergen, Norway.
- Ministry of Health, Lilongwe, Malawi.
| | | | | | - Boston Munthali
- Lilongwe Institute of Orthopaedics and Neurosurgery, Lilongwe, Malawi
| | - Sven Young
- Lilongwe Institute of Orthopaedics and Neurosurgery, Lilongwe, Malawi
| | | | | | | | - Peter Hangoma
- University of Bergen, Bergen, Norway
- Chr. Michelson Institute (CMI), Bergen, Norway
- University of Zambia, Lusaka, Zambia
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Almeida BA, Kerluku J, Shapiro LM, Kamal R, Fufa DT. Current Implementation of Quality Measures on American Society for Surgery of the Hand Touching Hands Project Outreach Trips. J Hand Surg Am 2023; 48:1003-1010. [PMID: 37656068 DOI: 10.1016/j.jhsa.2023.06.014] [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: 02/25/2022] [Revised: 05/26/2023] [Accepted: 06/21/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE As hand and upper extremity outreach trips increase, guidelines for assessing quality of care are being established. The Global Quality in Upper Extremity Surgery and Training investigators have published validated quality measures deemed to be essential for outreach trips to low and middle-income countries (LMICs). The purpose of this study was to assess baseline implementation of these quality measures across nine international hand surgery outreach sites to LMICs. Additionally, we investigated barriers and facilitators to implementing quality measures and documentation of their implementation. METHODS We included nine of 12 scheduled 2019 Touching Hands Project trips, excluding independent outreach and teaching mission trips without surgical logs. The team leader from each site received an online questionnaire assessing the documentation and implementation of all 22 quality measures, as well as educational efforts. RESULTS A total of 350 surgeries were performed in 2019 with seven reported minor complications and no major complications or mortalities. For analysis, 20 of 22 quality measures were included. Of 20 included validated quality measures, 10 were implemented across all surgical outreach sites. Two sites (Bolivia, Nepal) implemented all of the validated quality measures. Quality measures with the lowest implementation rates included ensuring availability of continuous electricity and oxygen supply with associated documentation of a backup plan. All outreach sites reported formal educational efforts. CONCLUSIONS Implementation of validated quality measures across surveyed outreach sites is variable, indicating an opportunity for improvement. Standardizing documentation of quality measure implementation for each site, confirming availability of resources, increasing accountability by the visiting teams, and fostering stronger relationships with local health care, may increase quality measure implementation and improve quality health care delivery and patient safety in LMICs. CLINICAL RELEVANCE Benchmarking the implementation of validated quality measures across hand surgical outreach trips provides an opportunity to improve the quality of health care delivered during future hand surgical outreach efforts.
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Affiliation(s)
| | - Jona Kerluku
- Department of Hand Surgery, Hospital for Special Surgery, New York, NY
| | - Lauren M Shapiro
- Department of Orthopedic Surgery, University of California-San Francisco, San Francisco, CA
| | - Robin Kamal
- Robert A. Chase Hand & Upper Limb Center, Stanford Medicine, Stanford, CA
| | - Duretti T Fufa
- Cornell University Weill Cornell Medical College, New York, NY; Department of Hand Surgery, Hospital for Special Surgery, New York, NY
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Welch JM, Kamal RN, Chatterjee M, Shapiro LM. Rates, Barriers, and Facilitators of Outcome Collection on Hand Surgery Outreach to Low- and Middle-Income Countries. Hand (N Y) 2023; 18:875-884. [PMID: 35048744 PMCID: PMC10336811 DOI: 10.1177/15589447211072200] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Global outreach to low- and middle-income countries (LMICs) continues to grow in an effort to improve global health. The practice of quality measurement is empirically lacking from surgical outreach trips to LMICs, which may limit the safety and quality of care provided. Using convergent mixed-methods, we aimed to: (1) identify and evaluate barriers and facilitators to outcome measure collection; and (2) report the sample rate of such collection on hand surgery outreach trips to LMICs. METHODS Surgeons and administrators involved in hand surgery outreach trips completed a survey regarding rates of outcome measure collection and a semi-structured interview to explore barriers and facilitators of outcome collection. Survey data were reported descriptively. Interviews were recorded and transcribed, and excerpts were categorized according to the Pettigrew framework for strategic change (content, process, and context). Results were combined through convergent mixed-methods analysis. RESULTS Thirty-three participants completed the survey, and 21 participated in interviews. Rates of collection were the most common for total case number (83%) and patient mortality (65%). Longitudinal outcomes (eg, patient follow-up or time away from work) were less frequently recorded (9% and 4%, respectively). Content analysis revealed barriers related to each domain of the Pettigrew framework. CONCLUSIONS This analysis demonstrates low levels of outcome collection on outreach trips and identifies priority areas for improvement. Developing context-specific solutions aimed at addressing barriers (eg, resource/database availability) and promoting facilitators (eg, collaborative relationships) may encourage higher rates of collection, which stands to improve patient safety, quality of care, and accountability when conducting outreach trips to LMICs.
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Adesina SA, Amole IO, Oyewusi OO, Adefokun IG, Odekhiran EO, Adeniji DO, Adegoke AO, Ojo SA, Owolabi JI, Eyesan SU. Locked intramedullary nailing of diaphyseal femur fractures without intraoperative fluoroscopy, fracture table and power reaming: retrograde affords greater procedural efficiency than antegrade approach. INTERNATIONAL ORTHOPAEDICS 2023:10.1007/s00264-023-05832-8. [PMID: 37140596 DOI: 10.1007/s00264-023-05832-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 04/28/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE To compare the intraoperative procedural efficiency of antegrade and retrograde locked intramedullary nailing of diaphyseal femur fractures without intraoperative fluoroscopy, power reaming devices and fracture tables. METHODS A secondary analysis of prospectively collected data was conducted on 238 isolated diaphyseal femur fractures fixed with SIGN Standard and Fin nails within three weeks of injury. The data included baseline patient and fracture characteristics, nail type and diameter, fracture reduction methods, operative times and outcome measures. RESULTS There were 84 and 154 fractures in the antegrade and retrograde groups respectively. Both groups were similar vis-a-vis baseline patient and fracture characteristics. Closed reduction of the fractures was significantly easier for retrograde than an antegrade approach. The retrograde approach more readily permitted the use of Fin nails. The mean nail diameter used for retrograde was significantly larger than that for antegrade. The time taken to achieve retrograde nailing was significantly lesser than that of antegrade. There was no statistically significant difference between the outcomes of the two groups. CONCLUSION In the absence of expensive fracture-surgery gadgets, retrograde nailing offers many procedural advantages over antegrade, such as easier closed reduction and canal reaming, the greater possibility of using the Fin nail with fewer interlocking screws and shorter operative times. However, we acknowledge the lack of randomisation and the presence of an unequal number of fractures in the two groups as limitations of this study.
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Affiliation(s)
- Stephen Adesope Adesina
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria.
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria.
| | - Isaac Olusayo Amole
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | | | | | | | | | - Adepeju Olatayo Adegoke
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | - Simeon Ayorinde Ojo
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | - James Idowu Owolabi
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | - Samuel Uwale Eyesan
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
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9
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Adesope Adesina S, Olusayo Amole I, Owolabi JI, Oyewusi OO, Goodness Adefokun I, Uwale Eyesan S. Locked intramedullary nailing of open fractures in resource-poor settings: a prospective observational study of challenges and functional outcomes in 101 fractures at Ogbomoso, Nigeria. BMC Musculoskelet Disord 2023; 24:170. [PMID: 36882725 PMCID: PMC9990318 DOI: 10.1186/s12891-023-06271-7] [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: 11/15/2022] [Accepted: 02/24/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Trauma is now one of the fastest growing epidemics globally but low and middle-income countries (LMICs) are more severely affected in terms of cost, disability and death. The high-energy trauma of road traffic accidents and violence often produces open fractures which can be difficult to manage in resource-poor settings. Adequate stabilization, such as provided by locked nails, has been found to ensure better outcome for open fractures. There is dearth of published studies on the use of locked intramedullary nail in the treatment of open fractures in Nigeria. METHODS This is a prospective observational study of all the 101 open fractures of the humerus, femur and tibia treated over a period of 92 months with Surgical Implant Generation Network (SIGN) nail. Fracture severity was classified according to the modified Gustilo-Anderson system. The intervals between fracture and antibiotics administration, débridement and definitive fixation, as well as surgery duration and method of fracture reduction were noted. Outcomes measured at follow-up included infection, ongoing radiographic healing, knee flexion/shoulder abduction beyond ninety degrees (KF/SA > 900), full weight bearing (FWB), painless squatting (PS&S)/shoulder abduction-external rotation (SAER). RESULTS Most of the patients fall between ages 20 and 49 years; 75.5% of them were males. There were more Gustilo-Anderson type IIIA fractures than other types but nine type IIIB tibia fractures were also nailed. The overall infection rate was 15%, contributed mostly by the type IIIB fractures. By the 12th post-operative week, at least 79% had ongoing radiographic healing and had achieved all of KF/SA > 900, FWB, and PS&S/SAER. CONCLUSION The SIGN nail's solid construct reduces the risk of infection and allows earlier use of the limb, making it particularly suitable in LIMCs where socioeconomic functioning often requires an unhindered use of the limbs.
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Affiliation(s)
| | - Isaac Olusayo Amole
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria.,Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | - James Idowu Owolabi
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria.,Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | | | | | - Samuel Uwale Eyesan
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria.,Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
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10
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Coveney E, Lynam-Loane K, Gorman F, McGrath F, Bennett D, O'Grady P. The benefit of introducing a virtual trauma assessment clinic during a global pandemic. Acta Orthop Belg 2023; 89:1-5. [PMID: 37294978 DOI: 10.52628/89.1.8380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Sars-CoV2/COVID-19 pandemic created a national emergency in Ireland. Our institution implemented a virtual trauma assessment clinic to reduce attendance to our district hospital which was stimulated by the development of 'safe-distanced' care. The audit aimed to evaluate the impact of our trauma assessment clinic on care provision and presentation to hospital. All patients were managed according to the newly implemented virtual trauma assessment clinic protocol. Data was prospectively collected over a 6.5 week period from 23rd March 2020 to 7th May 2020. These referrals were reviewed twice weekly by a Consultant-led multidisciplinary team. 142 patients were referred to the virtual trauma assessment clinic. Mean age of referrals was 33.04 years. 43% (n=61) were male patients. Overall 32.4% (n=46) of new referrals were discharged directly to their family doctor. 30.3% (n=43) were discharged for physiotherapy follow up. 36.6% (n=52) required presentation to the hospital for further clinical review and 0.7% (n=1) was admitted for surgical intervention. Overall, this represents a reduction of 63% of patients attending the hospital. A simple virtual trauma assessment clinic model resulted in significant reduction in unnecessary attendance at face-to-face fracture clinics enhancing patient and staff safety during a global pandemic. This virtual trauma assessment clinic model has allowed the mobilisation of staff to assist with other essential duties in other areas of our hospital without compromising care.
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Xie H, Guo Z, Cao Q, Ye Y, Chen L, Luo N. Effect of individualized comfortable nursing on prognosis of vacuum sealing drainage in patients with orthopedic trauma. Medicine (Baltimore) 2023; 102:e32903. [PMID: 36800609 PMCID: PMC9936052 DOI: 10.1097/md.0000000000032903] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
To explore the effect of individualized comfortable nursing on prognosis of vacuum sealing drainage (VSD) in patients with orthopedic trauma. 110 patients with orthopedic trauma VSD were randomly divided into the control group and the observation group, with 55 patients in each group receiving routine care and comfortable care. The wound healing time, visual analog scale, quality of life score, the level of inflammatory factors, the incidence of complications, and patient satisfaction were compared between the 2 groups. The average time of wound healing in the observation group was significantly lower than that in the control group (P < .01). The satisfaction rate in the observation group was significantly higher than that in the control group (P = .029). Meanwhile, the results showed that visual analog scale and quality of life scores in the observation group was significantly improved than that of the control group after receiving intervention (P < .05). After receiving intervention, the levels of TNF-α and IL-6 of patients in both groups were decreased, and the levels of TNF-α and IL-6 in the observation group were significantly decreased than those in the control group. Moreover, the incidence rate of adverse reaction in the observation group was significantly lower than that in the control group (P < .01). Comfortable nursing can reduce the wound healing time, the postoperative pain level, the incidence of complications, and improve patient satisfaction, which is of great significance for the prognosis of VSD in patients with orthopedic trauma.
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Affiliation(s)
- Huifang Xie
- Department of Hand Surgery, The First People’s Hospital of Jiangxia District, Wuhan city (Union Jiangnan Hospital Huazhong University of Science and Technology), Wuhan, Hubei, China
| | - Zhaodi Guo
- Department of Hand Surgery, The First People’s Hospital of Jiangxia District, Wuhan city (Union Jiangnan Hospital Huazhong University of Science and Technology), Wuhan, Hubei, China
| | - Qin Cao
- Department of Hand Surgery, The First People’s Hospital of Jiangxia District, Wuhan city (Union Jiangnan Hospital Huazhong University of Science and Technology), Wuhan, Hubei, China
| | - Yuan Ye
- Department of Hand Surgery, The First People’s Hospital of Jiangxia District, Wuhan city (Union Jiangnan Hospital Huazhong University of Science and Technology), Wuhan, Hubei, China
| | - Li Chen
- Department of Hand Surgery, The First People’s Hospital of Jiangxia District, Wuhan city (Union Jiangnan Hospital Huazhong University of Science and Technology), Wuhan, Hubei, China
| | - Na Luo
- Department of Hand Surgery, The First People’s Hospital of Jiangxia District, Wuhan city (Union Jiangnan Hospital Huazhong University of Science and Technology), Wuhan, Hubei, China
- * Correspondence: Na Luo, Department of Hand Surgery, The First People’s Hospital of Jiangxia District, Wuhan city (Union Jiangnan Hospital Huazhong University of Science and Technology), Wuhan, Hubei 430200, China (e-mail: )
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12
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Adesina S, Amole I, Akinwumi A, Adegoke A, Owolabi J, Adefokun I, Durodola A, Awotunde O, Eyesan S. Infection complicating locked intramedullary nailing of open lower-extremity fractures: incidence, associated risk factors, and lessons for improving outcome in a low-resource setting. J Bone Jt Infect 2023; 8:71-79. [PMID: 38774303 PMCID: PMC11106765 DOI: 10.5194/jbji-8-71-2023] [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] [Received: 12/08/2022] [Accepted: 01/24/2023] [Indexed: 05/24/2024] Open
Abstract
Introduction: Infection is the chief complication that makes open fractures difficult to treat. Most low- and middle-income countries (LMICs) are missing out on modern management techniques developed to achieve better outcomes in high-income countries (HICs). One of these is the use of locked intramedullary (IM) nails. This study aimed to determine the factors associated with infection of open fractures treated with the surgical implant generation network (SIGN) nail at a Nigerian tertiary hospital. Methods: Data were collected prospectively on 101 open fractures of the femur and tibia over an 8-year period. Active surveillance for infection was done on each patient. Infection was diagnosed as the presence of wound breakdown or purulent discharge from (or near) the wound or surgical incision. Potential risk factors were tested for association with infection. Results: There were 101 fractures in 94 patients with a mean age of 37.76 years. The following treatment-related factors demonstrated significant associations with infection - timings of antibiotic administration (p < 0.001 ) and definitive fracture fixation (p = 0.002 ); definitive wound closure (p < 0.001 ), fracture-reduction methods (p = 0.005 ), and surgery duration (p = 0.007 ). Conclusions: Although this study has limitations precluding the drawing up of final conclusions, the findings suggest that the risk factors for infection of nailed open fractures in LMICs are similar to those in HICs. Consequently, outcomes can potentially improve if LMICs adopt the management principles used in HICs in scientifically sound ways that are affordable and socially acceptable to their people. Further studies are suggested to establish our findings.
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Affiliation(s)
| | - Isaac O. Amole
- Department of Family Medicine, Bowen University, Iwo, 232102, Nigeria
| | - Akinsola I. Akinwumi
- Department of Family Medicine, Afe Babalola University, Ado-Ekiti,
360101, Nigeria
| | | | | | - Imri G. Adefokun
- Department of Surgery, Bowen University Teaching Hospital, Ogbomoso, 210001, Nigeria
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13
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Shapiro LM, Welch JM, Chatterjee M, Katarincic JA, Leversedge FJ, Dyer GSM, Fufa DT, Kozin SH, Chung KC, Fox PM, Chang J, Kamal RN. A Framework and Blueprint for Building Capacity in Global Orthopaedic Surgical Outreach. J Bone Joint Surg Am 2023; 105:e10. [PMID: 35984012 PMCID: PMC10760412 DOI: 10.2106/jbjs.22.00353] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Nongovernmental organizations (NGOs) from high-income countries provide surgical outreach for patients in low and middle-income countries (LMICs); however, these efforts lack a coordinated measurement of their ability to build capacity. While the World Health Organization and others recommend outreach trips that aim to build the capacity of the local health-care system, no guidance exists on how to accomplish this. The objective of this paper is to establish a framework and a blueprint to guide the operations of NGOs that provide outreach to build orthopaedic surgical capacity in LMICs. METHODS We conducted a qualitative analysis of semistructured interviews with 16 orthopaedic surgeons and administrators located in 7 countries (6 LMICs) on the necessary domains for capacity-building; the analysis was guided by a literature review of capacity-building frameworks. We subsequently conducted a modified nominal group technique with a consortium of 10 U.S.-based surgeons with expertise in global surgical outreach, which was member-checked with 8 new stakeholders from 4 LMICs. RESULTS A framework with 7 domains for capacity-building in global surgical outreach was identified. The domains included professional development, finance, partnerships, governance, community impact, culture, and coordination. These domains were tiered in a hierarchical system to stratify the level of capacity for each domain. A blueprint was developed to guide the operations of an organization seeking to build capacity. CONCLUSIONS The developed framework identified 7 domains to address when building capacity during global orthopaedic surgical outreach. The framework and its tiered system can be used to assess capacity and guide capacity-building efforts in LMICs. The developed blueprint can inform the operations of NGOs toward activities that focus on building capacity in order to ensure a measured and sustained impact.
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Affiliation(s)
- Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - Jessica M Welch
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Maya Chatterjee
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | | | | | - George S M Dyer
- Department of Orthopaedics, Harvard Combined Orthopaedics Residency Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Duretti T Fufa
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Scott H Kozin
- Shriners Hospitals for Children–Philadelphia, Philadelphia, Pennsylvania
| | - Kevin C Chung
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Paige M Fox
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, California
| | - James Chang
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, California
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
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14
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Roth V. [Nail osteosynthesis of long bones without image intensifier : SIGN Fracture Care makes it possible in hospitals of the "global south"]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 126:332-336. [PMID: 36583754 DOI: 10.1007/s00113-022-01277-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Volker Roth
- , Außerm Dorf 20, 79713, Bad Säckingen, Deutschland.
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15
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Adesina SA, Eyesan SU, Amole IO, Akinwumi AI, Awotunde OT, Durodola AO, Owolabi JI. Solid locked intramedullary nailing for expeditious return of bone-setting-induced abnormal fracture union victims to work in South-western Nigeria. Sci Rep 2022; 12:21432. [PMID: 36509831 PMCID: PMC9744724 DOI: 10.1038/s41598-022-25862-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
Wage earning in low- and middle-income countries (LMICs) is predominantly through physical labour. Consequently, limb-related disabilities caused by abnormal fracture unions (AFUs) preclude gainful employment and perpetuate the cycle of poverty. Many AFUs result from traditional bone-setting (TBS), a pervasive treatment for long bone fractures in LMICs. The objective of this study was to accentuate the expediency of solid locked intramedullary nail in the early restoration of victims of TBS-induced abnormal fracture unions (AFUs) to their pre-injury functioning, including work. One hundred AFUs in 98 patients treated with a solid locked intramedullary nail in our center over a period of 7 years were prospectively studied. We found the mean age to be 47.97 years. Males constituted 63.9% of the patients' population. Atrophic non-union accounted for 54.1% of the AFUs. The mean fracture-surgery interval was 21.30 months. By the 12th post-operative week, more than 75% of the fractures had achieved knee flexion/shoulder abduction beyond 90°, were able to squat and smile (or do shoulder abduction-external rotation), and were able to bear weight fully. The study demonstrated the expediency of solid locked nail in salvaging TBS-induced abnormal fracture unions in a way that permitted early return to pre-injury daily activities and work, thereby reducing fracture-associated poverty.
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Affiliation(s)
- Stephen Adesope Adesina
- grid.459398.aDepartment of Family Medicine, Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State Nigeria ,grid.442598.60000 0004 0630 3934Department of Family Medicine, Bowen University, P.M.B 284, Iwo, Osun State Nigeria
| | - Samuel Uwale Eyesan
- grid.459398.aDepartment Surgery, Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State Nigeria ,grid.442598.60000 0004 0630 3934Department Surgery, Bowen University, P.M.B 284, Iwo, Osun State Nigeria
| | - Isaac Olusayo Amole
- grid.459398.aDepartment of Family Medicine, Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State Nigeria ,grid.442598.60000 0004 0630 3934Department of Family Medicine, Bowen University, P.M.B 284, Iwo, Osun State Nigeria
| | - Akinsola Idowu Akinwumi
- grid.448570.a0000 0004 5940 136XDepartment of Family Medicine, Afe Babalola University, km 8.5, Afe Babalola Way, Ado-Ekiti, Ekiti State Nigeria
| | - Olufemi Timothy Awotunde
- grid.459398.aDepartment of Family Medicine, Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State Nigeria ,grid.442598.60000 0004 0630 3934Department of Family Medicine, Bowen University, P.M.B 284, Iwo, Osun State Nigeria
| | - Adewumi Ojeniyi Durodola
- grid.459398.aDepartment of Family Medicine, Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State Nigeria ,grid.442598.60000 0004 0630 3934Department of Family Medicine, Bowen University, P.M.B 284, Iwo, Osun State Nigeria
| | - James Idowu Owolabi
- grid.459398.aDepartment Surgery, Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State Nigeria ,grid.442598.60000 0004 0630 3934Department Surgery, Bowen University, P.M.B 284, Iwo, Osun State Nigeria
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16
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Grisdela P, Williams C, Challa S, Henson P, Agarwal-Harding K, Kwon JY. Screw-only fibular construct for Weber B ankle fractures: A retrospective clinical and cost comparison to assess feasibility for resource-limited settings. Injury 2022; 53:4146-4151. [PMID: 36289020 DOI: 10.1016/j.injury.2022.10.018] [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: 05/17/2022] [Revised: 10/05/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Ankle fractures are one of the most common injuries sustained worldwide, with the majority being isolated lateral malleolus fractures. The majority of the world's population live in Low and Middle Income Countries (LMIC), where implant cost may limit surgical treatment of ankle fractures. We investigate if Weber B ankle fractures could be effectively treated with a lower-cost technique using two screws between the fibula and the tibia to neutralize an interfragmentary lag screw. METHODS After IRB approval, consecutive patients from January 1, 2020 to December 31, 2020 with Weber-B ankle fractures were treated using AO technique (AOT) with plate osteosynthesis neutralizing an interfragmentary screw. Syndesmotic injuries, as well as injuries to the medial malleolus or foot were treated according to the surgeon's preferences. From January 1, 2021 to December 31, 2021 these injuries were treated with a screw-only technique (SOT) with two fibula pro tibia screws to neutralize an interfragmentary screw. Patient demographics including age, sex, BMI, smoking status, associated rheumatoid arthritis, and associated diabetes mellitus were recorded. The primary outcome variable was a stable radiographic mortise at six weeks post-surgery, secondary outcome variables included clinical union, infection, hardware removal, and implant cost for lateral malleolar fixation charged to the hospital. RESULTS Seventeen AOT and 10 SOT constructs were included. Demographic characteristics were similar between groups. All fractures maintained a stable mortise with clinical union at 6 weeks without infection. There was a statistically significant difference in hardware removal (17.6% AOT, 50% SOT, p = 0.012). The average implant cost to the hospital of the lateral malleolar fixation was significantly less in the SOT group ($592 (SD $229)), compared to the AOT group ($1,949.97 (SD $562)), (p < 0.0001). CONCLUSION We introduce proof of concept of a novel lower-cost fixation strategy for Weber B ankle fractures that maintained a stable mortise with clinical union at six weeks post-surgery. However, there was a significantly higher rate of hardware removal following fixation with a screw-only construct.
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Affiliation(s)
- Phillip Grisdela
- Harvard Combined Orthopaedics Residency Program, 55 Fruit St. Boston, MA 02114.
| | - Caroline Williams
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston MA 02215.
| | - Sravya Challa
- Harvard Combined Orthopaedics Residency Program, 55 Fruit St. Boston, MA 02114.
| | - Philip Henson
- Ichan School of Medicine at Mt. Sinai, 1 Gustave L. Levy Pl, New York NY 10029.
| | | | - John Y Kwon
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston MA 02215.
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17
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Ottesen TD, Amick M, Kapadia A, Ziatyk EQ, Joe JR, Sequist TD, Agarwal-Harding KJ. The Unmet Need for Orthopaedic Services Among American Indian and Alaska Native Communities in the United States. J Bone Joint Surg Am 2022; 104:e47. [PMID: 35104253 DOI: 10.2106/jbjs.21.00512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
ABSTRACT Historic and present-day marginalization has resulted in a high burden of disease and worse health outcomes for American Indian and Alaska Native (AI/AN) communities in the United States. Musculoskeletal disease is the leading cause of disability for the general population in the U.S. today. However, few have examined musculoskeletal disease burden and access to orthopaedic surgical care in the AI/AN communities. A high prevalence of hip dysplasia, arthritis, back pain, and diabetes, and a high incidence of trauma and road traffic-related mortality, suggest a disproportionately high burden of musculoskeletal pathology among the AI/AN communities and a substantial need for orthopaedic surgical services. Unfortunately, AI/AN patients face many barriers to receiving specialty care, including long travel distances and limited transportation to health facilities, inadequate staff and resources at Indian Health Service (IHS)-funded facilities, insufficient funding for referral to specialists outside of the IHS network, and sociocultural barriers that complicate health-system navigation and erode trust between patients and providers. For those who manage to access orthopaedic surgery, AI/AN patients face worse outcomes and more complications than White patients. There is an urgent need for orthopaedic surgeons to participate in improving the availability of quality orthopaedic services for AI/AN patients through training and support of local providers, volunteerism, advocating for a greater investment in the IHS Purchased/Referred Care program, expanding telemedicine capabilities, and supporting community-based participatory research activities.
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Affiliation(s)
- Taylor D Ottesen
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- Massachusetts General Hospital/Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Michael Amick
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- Yale University School of Medicine, New Haven, Connecticut
| | - Ami Kapadia
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Elizabeth Q Ziatyk
- Department of Family Medicine, Chinle Comprehensive Healthcare Facility, Chinle, Arizona
| | - Jennie R Joe
- Department of Family and Community Medicine, University of Arizona Health Sciences, Tucson, Arizona
- Native American Research and Training Center, University of Arizona Health Sciences, Tucson, Arizona
| | - Thomas D Sequist
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Healthcare Policy, Harvard Medical School, Boston, Massachusetts
| | - Kiran J Agarwal-Harding
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- Department of Orthopaedic Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
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18
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Miclau T, MacKechnie MC, Born CT, MacKechnie MA, Dyer GSM, Yuan BJ, Dawson J, Lee C, Ishmael CR, Schreiber VM, Tejwani NC, Ulmer T, Shearer DW, Agarwal-Harding KJ, Johal H, Khormaee S, Sprague S, Whiting PS, Roberts HJ, Coughlin R, Gosselin R, Rosenwasser MP, Johnson A, Babu JM, Dworkin M, Makhni MC, McClellan T, Nwachuku CO, Miclau E, Morshed S. International Orthopaedic Volunteer Opportunities in Low and Middle-Income Countries. J Bone Joint Surg Am 2022; 104:e44. [PMID: 34932526 DOI: 10.2106/jbjs.21.00948] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Globally, the burden of musculoskeletal conditions continues to rise, disproportionately affecting low and middle-income countries (LMICs). The ability to meet these orthopaedic surgical care demands remains a challenge. To help address these issues, many orthopaedic surgeons seek opportunities to provide humanitarian assistance to the populations in need. While many global orthopaedic initiatives are well-intentioned and can offer short-term benefits to the local communities, it is essential to emphasize training and the integration of local surgeon-leaders. The commitment to developing educational and investigative capacity, as well as fostering sustainable, mutually beneficial partnerships in low-resource settings, is critical. To this end, global health organizations, such as the Consortium of Orthopaedic Academic Traumatologists (COACT), work to promote and ensure the lasting sustainability of musculoskeletal trauma care worldwide. This article describes global orthopaedic efforts that can effectively address musculoskeletal care through an examination of 5 domains: clinical care, clinical research, surgical education, disaster response, and advocacy.
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Affiliation(s)
- Theodore Miclau
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Madeline C MacKechnie
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Christopher T Born
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael A MacKechnie
- Department of Orthopaedic Surgery, Cleveland Clinic Martin Health, Stuart, Florida
| | - George S M Dyer
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - John Dawson
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas
| | - Cassandra Lee
- Department of Orthopaedic Surgery, University of California at Davis Health, Sacramento, California
| | - Chad R Ishmael
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | | | | | - Todd Ulmer
- Adventist Medical Center, Oregon Health Sciences University, Portland, Oregon
| | - David W Shearer
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Kiran J Agarwal-Harding
- Harvard Global Orthopaedics Collaborative, Massachusetts General Hospital/Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Herman Johal
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Sheila Sprague
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | | | - Heather J Roberts
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Richard Coughlin
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Rich Gosselin
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | | | - Anthony Johnson
- Department of Surgery and Perioperative Care, University of Texas at Austin, Austin, Texas
| | - Jacob M Babu
- Orthopaedic Division of Spine Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Myles Dworkin
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Melvin C Makhni
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Trigg McClellan
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | | | - Elizabeth Miclau
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Saam Morshed
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
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19
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Bilgili F, Sardoğan C, Bozdağ E. Evaluation of a novel semicircular locking external fixator for treating fractures of long bones: Biomechanical comparison with a circular external fixator. Injury 2022; 53:1353-1360. [PMID: 35101257 DOI: 10.1016/j.injury.2021.12.051] [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: 09/11/2021] [Revised: 12/20/2021] [Accepted: 12/30/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE This study aimed to investigate the biomechanical properties of a novel semicircular locking external fixator with locking screw mechanism, shape of trapezoidal corrugations, half- ring designed for greater stability. MATERIALS AND METHODS The novel external fixator had a half-ring with the shape of trapezoidal corrugations and locking screws fixing the bone at different angles in all three planes (sagittal, axial, and coronal). The biomechanical properties of the semicircular locking external fixator (group 1) were compared with those of a standard Ilizarov-type circular external fixator (group 2) (TST, İstanbul, Turkey) in an experimental study design. Five frames were used in each group. Standard PE 1000 (polyethylene) rod models (n = 10) simulating the tibia bone model were used. Both systems were compared biomechanically by applying axial and torsional loads simultaneously. RESULT Two samples in group 2 were damaged before the test ended during axial loading. All of the samples in group 1 completed the tests without damage after 150,000 cycles. The axial stiffness of the semicircular locking external fixator was found to be significantly higher than that of the Ilizarov-type circular external fixator (p < 0.05). No statistically significant difference was found between the two fixators in torsional loading. The application time of semicircular locking external fixator was significantly shorter than Ilizarov-type circular external fixator (p < 0.05). CONCLUSION The novel semicircular locking external fixator was biomechanically stronger than the Ilizarov-type external fixator for treating fractures of long bones. It can be used as a permanent external fixator for the definitive treatment of long bone fractures with soft tissue damage in terms of stability and application time.
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Affiliation(s)
- Fuat Bilgili
- Istanbul University, Istanbul Faculty of Medicine, Department of Orthopaedics and Traumatology, Istanbul, Turkey.
| | - Cansu Sardoğan
- Yeditepe University, Institute of Health Science, Department of Physiotherapy and Rehabilitation, Istanbul, Turkey
| | - Ergun Bozdağ
- Istanbul Technical University, Department of Mechanical Engineering, Biomechanics Laboratory, Istanbul, Turkey
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20
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Donaghy C, Smith N, O'Dea F. Orthopaedic Outreach: An innovative programme for orthopaedic patients in remote areas of Newfoundland and Labrador. CANADIAN JOURNAL OF RURAL MEDICINE 2022; 27:143-147. [DOI: 10.4103/cjrm.cjrm_43_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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21
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von Kaeppler EP, Kramer EJ, Donnelley CA, Wu HH, Marseille E, Eliezer E, Roberts HJ, Shearer D, Morshed S. The Initial Economic Burden of Femur Fractures on Informal Caregivers in Dar es Salaam, Tanzania. Malawi Med J 2021; 33:135-139. [PMID: 34777709 PMCID: PMC8560354 DOI: 10.4314/mmj.v33i2.9] [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] [Indexed: 11/18/2022] Open
Abstract
Background Femur fracture patients require significant in-hospital care. The burden incurred by caregivers of such patients amplifies the direct costs of these injuries and remains unquantified. Aim Here we aim to establish the in-hospital economic burden faced by informal caregivers of femur fracture patients. Methods 70 unique caregivers for 46 femoral shaft fracture patients were interviewed. Incurred economic burden was determined by the Human Capital Approach, using standardized income data to quantify productivity loss (in $USD). Linear regression assessed the relationship between caregiver burden and patient time-in-hospital. Results The average economic burden incurred was $149, 9% of a caregiver's annual income and positively correlated with patient time in hospital (p<0.01). Conclusion Caregivers of patients treated operatively for femur fractures lost a large portion of their annual income, and this loss increased with patient time in hospital. These indirect costs of femur fracture treatment constitute an important component of the total injury burden.
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Affiliation(s)
- Ericka P von Kaeppler
- Institute of Global Orthopaedics and Traumatology at the University of California San Francisco
| | | | - Claire A Donnelley
- Institute of Global Orthopaedics and Traumatology at the University of California San Francisco
| | - Hao-Hua Wu
- Institute of Global Orthopaedics and Traumatology at the University of California San Francisco
| | - Elliot Marseille
- Global Health Economics Consortium at the University of California San Francisco
| | | | - Heather J Roberts
- Institute of Global Orthopaedics and Traumatology at the University of California San Francisco
| | - David Shearer
- Institute of Global Orthopaedics and Traumatology at the University of California San Francisco
| | - Saam Morshed
- Institute of Global Orthopaedics and Traumatology at the University of California San Francisco.,Yale University School of Medicine.,Health Strategies International.,Global Health Economics Consortium at the University of California San Francisco.,Muhimbili Orthopaedic Institute
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22
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Shapiro LM, Park MO, Mariano DJ, Welch JM, Kamal RN. Candidate Quality Measures for Orthopaedic Surgery Outreach Trips: A Systematic Review. J Am Acad Orthop Surg 2021; 29:e1068-e1077. [PMID: 34525479 PMCID: PMC8443848 DOI: 10.5435/jaaos-d-20-00263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 09/15/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Up to 30% of the global burden of disease is secondary to surgical conditions, most of which falls on those in low- and middle-income countries (LMICs). Ensuring that the quality of care delivered during outreach trips to address these conditions is foundational. Limited work has been done to develop and implement tools to assess and improve the quality of care for these trips. The purpose of this study was to identify candidate quality measures that address orthopaedic surgery outreach trips in LMICs. METHODS We conducted a systematic review of MEDLINE/PubMed, EMBASE, Web of Science, Google Scholar, and other databases to identify candidate quality measures relevant to orthopaedic surgery outreach to LMICs. Quality measures were then categorized by system management, sustainability, or both system management and sustainability according to the framework and structures, processes, and outcomes of Bido et al according to the Donabedian domains. RESULTS Our initial search yielded 3,891 articles, 22 of which met the inclusion criteria. Seventy-nine candidate quality measures were identified. Regarding the framework of Bido et al, 55 of 79 (70%) were related to system management, 8 (10%) were related to sustainability, and 16 (20%) were related to both system management and sustainability. According to Donabedian domains, 43 of 79 (54%) were structure measures, 25 (32%) were process measures, and 11 (14%) were outcome measures. DISCUSSION Quality measures addressing orthopaedic surgery outreach trips are lacking in quantity and breadth, limiting the ability to assess and improve the safety and quality of care provided. The candidate quality measures identified disproportionately focus on systems management and structures, with few related to sustainability and few addressing outcomes. Patients receiving care on outreach trips would benefit from the implementation of the measures identified in this review and from the development of quality measures that capture all domains of care and emphasize outcomes. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Lauren M Shapiro
- From VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
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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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Koh JL. Not just another ACL paper: the importance of 'Outcomes of single bundle arthroscopic anterior crucial ligament reconstruction in a limited resource setting'. J ISAKOS 2021; 6:185-186. [PMID: 34272292 DOI: 10.1136/jisakos-2020-000580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Jason L Koh
- Orthopaedic Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA .,Orthopaedic Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
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25
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Adesina SA, Eyasan SU, Amole IO, Awotunde OT, Akinwumi AI, Durodola AO, Ikem IC. Closed reduction and locked intramedullary nailing of diaphyseal long bone fractures without intra-operative imaging and fracture table. INTERNATIONAL ORTHOPAEDICS 2021; 46:51-59. [PMID: 34131767 DOI: 10.1007/s00264-021-05091-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Early closed reduction and locked intramedullary (IM) nailing has become the standard treatment for diaphyseal long bone fractures in high income countries. The low and middle income countries (LMICs) are still lagging behind in transiting from open surgical reduction and non-operative modalities to closed reduction due to lack of requisite equipment. However, some surgeons in LMICs are beginning to achieve closed reduction even without the equipment. METHODS A prospective descriptive study was done on a total of 251 fresh diaphyseal fractures of the humerus, femur and tibia fixed with a locked nail over a 5½-year period. The fractures were grouped into those that had open reduction, closed reduction or reduction with a finger. RESULTS Closed reduction was done for 135 (53.8%) fractures belonging to 123 patients. The mean and range of the patients' ages were 41.33 and 13-81 years, respectively. Males constituted 69.9% and mostly (48%) sustained fractures in motorcycle accident. There was a significant negative association between closed reduction and fracture-to-surgery interval (p < 0.001). Closed reduction also had positive associations with: (i) humerus and tibia fractures (p < 0.001), (ii) middle, distal and segmental fractures (p = 0.025), (iii) retrograde approach to femur fracture nailing (p < 0.001), and (iv) wedge or multifragmentary type femur fractures (p = 0.005). CONCLUSION With constant practice, it is possible to achieve closed reduction of many fresh diaphyseal long bone fractures in spite of the limitations imposed on surgeons in LMICs by poor health systems and grossly inadequate fracture care facilities.
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Affiliation(s)
- Stephen Adesope Adesina
- Department of Family Medicine, Bowen University , Iwo, Osun State, Nigeria. .,Department of Family Medicine, Bowen University Teaching Hospital, Ogbomoso, Oyo State, Nigeria.
| | - Samuel Uwale Eyasan
- Department Surgery, Bowen University, Iwo, Osun State, Nigeria.,Department Surgery, Bowen University Teaching Hospital, Ogbomoso, Oyo State, Nigeria
| | - Isaac Olusayo Amole
- Department of Family Medicine, Bowen University , Iwo, Osun State, Nigeria.,Department of Family Medicine, Bowen University Teaching Hospital, Ogbomoso, Oyo State, Nigeria
| | - Olufemi Timothy Awotunde
- Department of Family Medicine, Bowen University , Iwo, Osun State, Nigeria.,Department of Family Medicine, Bowen University Teaching Hospital, Ogbomoso, Oyo State, Nigeria
| | | | - Adewumi Ojeniyi Durodola
- Department of Family Medicine, Bowen University , Iwo, Osun State, Nigeria.,Department of Family Medicine, Bowen University Teaching Hospital, Ogbomoso, Oyo State, Nigeria
| | - Innocent Chiedu Ikem
- Department of Orthopaedic Surgery and Traumatology, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
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26
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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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McDonald CL, Westcott-McCoy S, Weaver MR, Haagsma J, Kartin D. Global prevalence of traumatic non-fatal limb amputation. Prosthet Orthot Int 2021; 45:105-114. [PMID: 33274665 DOI: 10.1177/0309364620972258] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 10/12/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Reliable information on both global need for prosthetic services and the current prosthetist workforce is limited. Global burden of disease estimates can provide valuable insight into amputation prevalence due to traumatic causes and global prosthetists needed to treat traumatic amputations. OBJECTIVES This study was conducted to quantify and interpret patterns in global distribution and prevalence of traumatic limb amputation by cause, region, and age within the context of prosthetic rehabilitation, prosthetist need, and prosthetist education. STUDY DESIGN A secondary database descriptive study. METHODS Amputation prevalence and prevalence rate per 100,000 due to trauma were estimated using the 2017 global burden of disease results. Global burden of disease estimation utilizes a Bayesian metaregression and best available data to estimate the prevalence of diseases and injuries, such as amputation. RESULTS In 2017, 57.7 million people were living with limb amputation due to traumatic causes worldwide. Leading traumatic causes of limb amputation were falls (36.2%), road injuries (15.7%), other transportation injuries (11.2%), and mechanical forces (10.4%). The highest number of prevalent traumatic amputations was in East Asia and South Asia followed by Western Europe, North Africa, and the Middle East, high-income North America and Eastern Europe. Based on these prevalence estimates, approximately 75,850 prosthetists are needed globally to treat people with traumatic amputations. CONCLUSION Amputation prevalence estimates and patterns can inform prosthetic service provision, education and planning.
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Affiliation(s)
- Cody L McDonald
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Sarah Westcott-McCoy
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Marcia R Weaver
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Juanita Haagsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Deborah Kartin
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
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Agarwal-Harding KJ, Kapadia A, Banza LN, Chawinga M, Mkandawire N, Kwon JY. Improving Management of Adult Ankle Fractures in Malawi: An Assessment of Providers' Knowledge and Treatment Strategies. J Bone Joint Surg Am 2021; 103:326-334. [PMID: 33369982 PMCID: PMC8444219 DOI: 10.2106/jbjs.20.00660] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The burden of musculoskeletal trauma is increasing worldwide, especially in low-income countries such as Malawi. Ankle fractures are common in Malawi and may receive suboptimal treatment due to inadequate surgical capacity and limited provider knowledge of evidence-based treatment guidelines. METHODS This study was conducted in 3 phases. First, we assessed Malawian orthopaedic providers' understanding of anatomy, injury identification, and treatment methods. Second, we observed Malawian providers' treatment strategies for adults with ankle fractures presenting to a central hospital. These patients' radiographs underwent blinded, post hoc review by 3 U.S.-based orthopaedic surgeons and a Malawian orthopaedic surgeon, whose treatment recommendations were compared with actual treatments rendered by Malawian providers. Third, an educational course addressing knowledge deficits was implemented. We assessed post-course knowledge and introduced a standardized management protocol, specific to the Malawian context. RESULTS In Phase 1, deficits in injury identification, ideal treatment practices, and treatment standardization were identified. In Phase 2, 17 (35%) of 49 patients met operative criteria but did not undergo a surgical procedure, mainly because of resource limitations and provider failure to recognize unstable injuries. In Phase 3, 51 (84%) of 61 participants improved their overall performance between the pre-course and post-course assessments. Participants answered a mean of 32.4 (66%) of 49 questions correctly pre-course and 37.7 (77%) of 49 questions correctly post-course, a significant improvement of 5.2 more questions (95% confidence interval [CI], 3.8 to 6.6 questions; p < 0.001) answered correctly. Providers were able to identify 1 more injury correctly of 8 injuries (mean, 1.1 questions [95% CI, 0.6 to 1.6 questions]; p < 0.001) and to identify 1 more ideal treatment of the 7 that were tested (mean, 1.0 question [95% CI, 0.5 to 1.4 questions]; p < 0.001). CONCLUSIONS Adult ankle fractures in Malawi were predominantly treated nonoperatively despite often meeting evidence-based criteria for surgery. This was due to resource limitations, knowledge deficits, and lack of treatment standardization. We demonstrated a comprehensive approach to examining the challenges of providing adequate orthopaedic care in a resource-limited setting and the successful implementation of an educational intervention to improve care delivery. This approach can be adapted for other conditions to improve orthopaedic care in low-resource settings.
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Affiliation(s)
- Kiran J Agarwal-Harding
- Harvard Global Orthopaedics Collaborative, 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
| | - Ami Kapadia
- University of Texas Southwestern School of Medicine, Dallas, Texas
| | | | - Mabvuto Chawinga
- Department of Orthopedics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Nyengo Mkandawire
- Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - John Y Kwon
- Division of Foot and Ankle Surgery, Department of Orthopaedics, Beth Israel Deaconess Hospital, Boston, Massachusetts
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
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Limb Salvage for Musculoskeletal Tumors in the Austere Environment: Review of the Literature With Illustrative Cases Regarding Considerations and Pitfalls. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:e19.00172. [PMID: 33986213 PMCID: PMC7537826 DOI: 10.5435/jaaosglobal-d-19-00172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 08/15/2020] [Indexed: 11/18/2022]
Abstract
Although there is literature discussing the treatment of acute and chronic trauma in austere environments, no literature or guidelines for the treatment of musculoskeletal tumors exist. This series discusses case examples with considerations and pitfalls of performing limb-salvage surgery in an underserved location. Cases of limb-salvage surgery performed by the same orthopaedic oncologist in Haiti and the Dominican Republic are discussed with a review of the literature on limb salvage for musculoskeletal tumors in developing nations. All patients successfully underwent limb-salvage surgery after considering multiple factors including tumor type and location. Patients with metastatic disease, likelihood of substantial blood loss, and poor health were not candidates for limb-salvage surgery. Medical missions and the development of partnerships with established training programs make limb salvage a greater possibility. Knowledge of the facility, anesthesia support, and instrumentation available is vital. Advanced imaging, blood products, and allograft are likely unavailable or difficult to obtain. Established continuity of care is necessary, and training of the local surgeon should be provided. Surgery should only be considered if it is safe and provides more of a benefit to the patient than an amputation.
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30
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Shapiro LM. Measuring and Improving the Quality of Care During Global Outreach Trips: A Primer for Safe and Sustainable Surgery. J Hand Surg Am 2020; 45:851-856.e2. [PMID: 32680787 DOI: 10.1016/j.jhsa.2020.04.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/13/2020] [Accepted: 04/29/2020] [Indexed: 02/02/2023]
Abstract
Trauma is the leading cause of mortality in patients aged 5 years and older. Globally, trauma kills more people than malaria, tuberculosis, and HIV/AIDs combined. As the number of surgical outreach trips to low- and middle-income countries and resources provided for such trips increase, hand surgeons are uniquely positioned to address this global burden. However, the delivery of surgical care alone is insufficient without effectively evaluating the quality of care delivered. It is critical that the care provided on outreach trips improves patient and population health, does not harm patients, and develops the local health care ecosystem. An estimated 8 million lives could be saved annually in low- and middle-income countries with higher-quality health systems. Currently, data collection systems for evaluating quality during outreach trips are lacking. Insight into current methods of quality assessment and improvement in both developing and developed countries can help inform future efforts to implement innovative data collection systems. Thoughtful and sustainable collaboration with host sites in low- and middle-income countries can ensure that care delivery is culturally competent and improves population health.
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Affiliation(s)
- Lauren M Shapiro
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA.
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31
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Bernstein DN, Agarwal-Harding KJ, Dyer GSM, Rozental TD. Outcomes Measurement in Global Hand Surgery. J Hand Surg Am 2020; 45:865-868. [PMID: 32650956 DOI: 10.1016/j.jhsa.2020.04.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/07/2020] [Accepted: 04/29/2020] [Indexed: 02/02/2023]
Abstract
The global burden of musculoskeletal trauma is high. There is a need to improve access to safe, high-quality surgery in many low- and middle-income countries (LMICs). Numerous initiatives have taken aim at solving this underlying shortage in surgical care, including mission trips, academic programs, and international collaborations. However, much work remains to be done in LMICs compared with high-income countries (HICs). In HICs, the field of hand surgery has grown partially owing to the rigorous application of clinical research to examine outcomes and determine best practices. Patient-reported outcome measures (PROMs) have a key role as a valid patient-centered method of capturing symptoms and well-being. They have substantial promise in LMICs to understand patient symptom severity and quality of life better, monitor treatment success or failure, determine cost-effectiveness of procedures, and guide capacity building. Contextually appropriate PROMs can improve routine follow-up in LMICs and advance the practice and study of hand surgery worldwide.
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Affiliation(s)
| | - Kiran J Agarwal-Harding
- Harvard Global Orthopaedics Collaborative, Harvard Combined Orthopaedic Residency Program, Boston, MA
| | - George S M Dyer
- Department of Orthopaedic Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
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32
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Young JD, Bhashyam AR, Parisien RL, Van der Vliet Q, Qudsi RA, Fils J, Dyer GSM. Cross-Cultural Comparison of Nonopioid and Multimodal Analgesic Prescribing in Orthopaedic Trauma. J Am Acad Orthop Surg Glob Res Rev 2020; 4:e2000051. [PMID: 33970576 PMCID: PMC7434039 DOI: 10.5435/jaaosglobal-d-20-00051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND After musculoskeletal injury, US providers prescribe opioids more frequently and at higher dosages than prescribers in the Netherlands and Haiti; however, the extent of variation in nonopioid analgesic prescribing is unknown. The aim of our study was to evaluate how nonopioid prescribing by orthopaedic residents varies by geographic context. METHODS Orthopaedic residents in three countries in which residents are the primary prescribers of postoperative analgesia in academic medical centers (Haiti, the Netherlands, and the United States) responded to surveys using vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for postdischarge analgesia. We quantified the likelihood and dose of acetaminophen or a nonsteroidal anti-inflammatory drug prescription. We constructed multivariable regressions with generalized estimating equations to describe differences in nonopiate prescription according to country, the resident's sex and training year, and the injury site and age in the test cases. RESULTS Compared with residents from the United States, residents from Haiti were more likely to prescribe nonopioids (odds ratio, 3.22 [confidence interval, 1.94 to 5.34], P < 0.0001) and residents from the Netherlands nearly always prescribed nonopioids. Of those cases where one or more opioid was prescribed, providers also prescribed a nonopioid (acetaminophen or nonsteroidal anti-inflammatory drug) in 345/603 (57.2%) of US, 152/152 (100%) of Dutch, and 69/97 (71.1%) of Haitian cases (Fisher exact test P value <0.0001). Finally, providers prescribed only nonopioids for pain control in 3/348 (0.86%) of US, 32/184 (17.4%) of Dutch, and 107/176 (60.8%) of Haitian cases (Fisher exact test P < 0.0001). CONCLUSIONS When comparing multimodal analgesic patterns, US prescribers prescribed nonopioid analgesics less frequently than prescribers in two other countries, one low income and one high income, either in isolation or in conjunction with opioids.
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Affiliation(s)
- Jason D Young
- From the Harvard Medical School (Mr. Young, Dr. Bhashyam, Dr. Dyer); the Harvard Combined Orthopaedic Residency Program (Dr. Bhashyam, Dr. Dyer); Boston, MA; the Department of Orthopaedic Surgery (Dr. Parisien), University of Pennsylvania; Philadelphia, PA; the Department of Trauma Surgery (Dr. Van der Vliet), University Medical Center Utrecht; Utrecht, the Netherlands; the Department of Orthopaedics, Nemours (Dr. Qudsi)/A.I. duPont Hospital for Children; Wilmington, DE; and the Department of Orthopaedic Surgery (Dr. Fils, Dr. Dyer), Brigham and Women's Hospital, Boston, MA
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33
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Gausden EB, Premkumar A, Bostrom MP. International Collaboration in Total Joint Arthroplasty: A Framework for Establishing Meaningful International Alliances. Orthop Clin North Am 2020; 51:161-168. [PMID: 32138854 DOI: 10.1016/j.ocl.2019.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Despite the increase in utilization of total joint arthroplasty (TJA) throughout high-income countries, there is a lack of access to basic surgical care, including TJA, in low- and middle-income countries (LMICs). Multiple strategies, including short-term surgical trips, establishment of local TJA centers, and education-based international academic collaborations, have been used to bridge the gap in access to quality TJA. The authors review the obstacles to providing TJA in LMICs, the outcomes of the 3 strategies in use to bridge gaps, and a framework for the establishment and maintenance of meaningful international collaborations.
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Affiliation(s)
- Elizabeth B Gausden
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Ajay Premkumar
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Mathias P Bostrom
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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34
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Karhade AV, Qudsi RA, Usoro AO, Dejean CB, Dyer GSM. Education Improves Musculoskeletal Radiology Interpretation by Trainees in a Low-Resource Setting. JOURNAL OF SURGICAL EDUCATION 2019; 76:1605-1611. [PMID: 31221606 DOI: 10.1016/j.jsurg.2019.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/07/2019] [Accepted: 06/01/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The aims of this study were to assess baseline musculoskeletal radiology knowledge among Haitian orthopedists and to determine the impact of an adult and pediatric musculoskeletal radiology lecture series. DESIGN Participants were given lectures reviewing normal and abnormal elbow radiographs and received assessments before and after the intervention. Bivariate and multivariate analyses were used to identify factors associated with baseline and postintervention scores. SETTING This study was carried out as part of the 2018 Haitian Annual Assembly of Orthopaedic Trauma. This is an annual continuing medical educational conference in the capital city of Port-au-Prince open to all Haitian orthopedic surgeons and associated care providers, with a strong focus on resident training. PARTICIPANTS Haitian orthopedic surgery residents and surgeons attending the 2018 Haitian Annual Assembly of Orthopaedic Trauma. RESULTS Thirty-seven residents and faculty consented to participate in this study and 32 (86.5%) were male with a median age of 33 (interquartile rage: 30-35). On multivariate analysis controlling for the title (resident versus attending), total years of orthopedics (beginning of residency and beyond), and formal radiology teaching in medical school or residency, conference attendance in the past was significantly associated with higher preintervention assessment scores (odds ratio = 1.24, 95% confidence interval = 1.06-1.44, p = 0.010]. The mean total preintervention accuracy for correctly identification of pathology, if present, was 70% compared to 83% at the postassessment (p < 0.001). CONCLUSIONS Overall, this study demonstrates that a brief lecture series at a continuing medical conference in Port-au-Prince, Haiti improved upper extremity radiographic interpretation based on pre and postassessments, and that prior conference attendance may be associated with higher baseline scores.
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Affiliation(s)
| | - Rameez A Qudsi
- Department of Orthopaedic Surgery, Nemours A.I. duPont Hospital for Children, Wilmington, Delaware
| | - Andrew O Usoro
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | | | - George S M Dyer
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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35
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Abstract
Carefully planned, long-term partnerships can build surgical capacity in developing countries, which can save lives and alleviate suffering. Good partnerships are built around the goal of educating local staff. They involve consistent engagement with the same local hosts over time. Teaching is directed more broadly than just to surgeons; anesthesia, nursing, sterile processing, and biomedical engineering are also important partners.
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36
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Mattson P, Nteziryayo E, Aluisio AR, Henry M, Rosenberg N, Mutabazi ZA, Nyinawankusi JD, Byiringiro JC, Levine AC, Karim N. Musculoskeletal Injuries and Outcomes Pre- and Post- Emergency Medicine Training Program. West J Emerg Med 2019; 20:857-864. [PMID: 31738712 PMCID: PMC6860388 DOI: 10.5811/westjem.2019.7.41448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 07/31/2019] [Indexed: 12/03/2022] Open
Abstract
Introduction Musculoskeletal injuries (MSI) comprise a large portion of the trauma burden in low- and middle-income countries (LMIC). Rwanda recently launched its first emergency medicine training program (EMTP) at the University Teaching Hospital-Kigali (UTH-K), which may help to treat such injuries; yet no current epidemiological data is available on MSI in Rwanda. Methods We conducted this pre-post study during two data collection periods at the UTH-K from November 2012 to July 2016. Data collection for MSI is limited and thus is specific to fractures. We included all patients with open, closed, or mixed fractures, hereafter referred to as MSI. Gathered information included demographics and outcomes including death, traumatic complications, and length of hospital stay, before and after the implementation of the EMTP. Results We collected data from 3609 patients. Of those records, 691 patients were treated for fractures, and 674 of them had sufficient EMTP data measured for inclusion in the analysis of results (279 from pre-EMTP and 375 from post-EMTP). Patient demographics demonstrate that a majority of MSI cases are male (71.6% male vs 28.4% female) and young (64.3% below 35 years of age). Among mechanisms of injury, major causes included road traffic accidents (48.1%), falls (34.2%), and assault (6.0%). There was also an observed association between EMTP and trends of the three primary outcomes: a reduction of death in the emergency department (ED) from those with MSI by 89.9%, from 2.51% to 0.25% (p = 0.0077); a reduction in traumatic complications for MSI patients by 71.7%, from 3.58% to 1.01% (p = 0.0211); and a reduction in duration of stay in the ED among those with MSI by 52.7% or 2.81 days on average, from 5.33 to 2.52 days (p = 0.0437). Conclusion This study reveals the current epidemiology of MSI morbidity and mortality for a major Rwandan teaching hospital and the potential impacts of EM training implementation among those with MSI. Residency training programs such as EMTP appear capable of reducing mortality, complications, and ED length of stay among those with MSI caused by fractures. Such findings underscore the efficacy and importance of investments in educating the next generation of health professionals to combat prevalent MSI within their communities.
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Affiliation(s)
- Peter Mattson
- Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
| | | | - Adam R Aluisio
- Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
| | - Michael Henry
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Noah Rosenberg
- Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
| | | | | | | | - Adam C Levine
- Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
| | - Naz Karim
- Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
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Young JD, Bhashyam AR, Qudsi RA, Parisien RL, Shrestha S, van der Vliet QM, Fils J, Losina E, Dyer GS. Cross-Cultural Comparison of Postoperative Discharge Opioid Prescribing After Orthopaedic Trauma Surgery. J Bone Joint Surg Am 2019; 101:1286-1293. [PMID: 31318808 PMCID: PMC6641112 DOI: 10.2106/jbjs.18.01022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The extent of variation in analgesic prescribing following musculoskeletal injury among countries and cultural contexts is poorly understood. Such an understanding can inform both domestic prescribing and future policy. The aim of our survey study was to evaluate how opioid prescribing by orthopaedic residents varies by geographic context. METHODS Orthopaedic residents in 3 countries in which residents are the primary prescribers of postoperative analgesia in academic medical centers (Haiti, the Netherlands, and the U.S.) responded to surveys utilizing vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for post-discharge analgesia. We standardized opioid prescriptions in the surveys by conversion to morphine milligram equivalents (MMEs). We then constructed multivariable regressions with generalized estimating equations to describe differences in opiate prescription according to country, the resident's sex and training year, and the injury site and age in the test cases. RESULTS U.S. residents prescribed significantly more total MMEs per case (mean [95% confidence interval] = 383 [331 to 435]) compared with residents from the Netherlands (229 [160 to 297]) and from Haiti (101 [52 to 150]) both overall (p < 0.0001) and for patients treated for injuries of the femur (452 [385 to 520], 315 [216 to 414], and 103 [37 to 169] in the U.S., the Netherlands, and Haiti, respectively), tibial plateau (459 [388 to 531], 280 [196 to 365], and 114 [46 to 183]), tibial shaft (440 [380 to 500], 294 [205 to 383], and 141 [44 to 239]), wrist (239 [194 to 284], 78 [36 to 119], and 63 [30 to 95]), and ankle (331 [270 to 393], 190 [100 to 280], and 85 [42 to 128]) (p = 0.0272). U.S. residents prescribed significantly more MMEs for patients <40 years old (432 [374 to 490]) than for those >70 years old (327 [270 to 384]) (p = 0.0019). CONCLUSIONS Our results demonstrate greater prescribing of postoperative opioids at discharge in the U.S. compared with 2 other countries, 1 low-income and 1 high-income. Our findings highlight the high U.S. reliance on opioid prescribing for postoperative pain control after orthopaedic trauma. CLINICAL RELEVANCE Our findings point toward a need for careful reassessment of current opioid prescribing habits in the U.S. and demand reflection on how we can maximize effectiveness in pain management protocols and reduce provider contributions to the ongoing opioid crisis.
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Affiliation(s)
| | - Abhiram R. Bhashyam
- Harvard Medical School, Boston, Massachusetts,Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Rameez A. Qudsi
- Harvard Medical School, Boston, Massachusetts,Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts,Orthopaedic & Arthritis Center for Outcomes Research (R.A.Q., S.S., and E.L.) and Department of Orthopaedic Surgery (J.F. and G.S.M.D.), Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Swastina Shrestha
- Orthopaedic & Arthritis Center for Outcomes Research (R.A.Q., S.S., and E.L.) and Department of Orthopaedic Surgery (J.F. and G.S.M.D.), Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Jacky Fils
- Orthopaedic & Arthritis Center for Outcomes Research (R.A.Q., S.S., and E.L.) and Department of Orthopaedic Surgery (J.F. and G.S.M.D.), Brigham and Women’s Hospital, Boston, Massachusetts
| | - Elena Losina
- Harvard Medical School, Boston, Massachusetts,Orthopaedic & Arthritis Center for Outcomes Research (R.A.Q., S.S., and E.L.) and Department of Orthopaedic Surgery (J.F. and G.S.M.D.), Brigham and Women’s Hospital, Boston, Massachusetts
| | - George S.M. Dyer
- Harvard Medical School, Boston, Massachusetts,Orthopaedic & Arthritis Center for Outcomes Research (R.A.Q., S.S., and E.L.) and Department of Orthopaedic Surgery (J.F. and G.S.M.D.), Brigham and Women’s Hospital, Boston, Massachusetts
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Pean CA, Premkumar A, Pean MA, Ihejirika-Lomedico R, Woolley PM, McLaurin T, Israelski R, Schwarzkopf R, Caplan A, Egol K. Global Orthopaedic Surgery: An Ethical Framework to Prioritize Surgical Capacity Building in Low and Middle-Income Countries. J Bone Joint Surg Am 2019; 101:e64. [PMID: 31274729 DOI: 10.2106/jbjs.18.01358] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | | | - Marc-Alain Pean
- Department of Orthopedics and Traumatology, La Paix University Hospital, Port-au-Prince, Haiti
| | | | - Pierre-Marie Woolley
- Department of Orthopedics and Traumatology, La Paix University Hospital, Port-au-Prince, Haiti
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A Novel Traction Frame for Femur Fracture Management in Developing Countries: Technique and Outcomes. J Orthop Trauma 2019; 33:e203-e206. [PMID: 31008820 DOI: 10.1097/bot.0000000000001407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Fractures of the femur have long been a major cause of morbidity and mortality in developing countries and are most frequently caused by road traffic accidents. Intramedullary nail fixation has become the gold standard of care for diaphyseal fractures of the femur. However, modern techniques require proper implants, access to imaging, and accessible operating room facilities, all of which have limited availability in the developing world. We describe a new technique for assembly of a polyvinyl chloride traction frame for treatment of femur fractures in resource-poor settings. Our report includes a retrospective review of patients treated with polyvinyl chloride traction frames in the Dominican Republic and Haiti.
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A multicenter observational study on the distribution of orthopaedic fracture types across 17 low- and middle-income countries. OTA Int 2019; 2:e026. [PMID: 33937655 PMCID: PMC7997096 DOI: 10.1097/oi9.0000000000000026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 12/03/2018] [Indexed: 11/29/2022]
Abstract
Objectives: To describe the regional distribution of fractures sustained by women and health care system characteristics across 17 low- and middle-income countries (LMICs). Methods: The INternational ORthopaedic MUlticentre Study in fracture care (INORMUS) is an observational study collecting data on patients in LMICs who sustained a fracture or musculoskeletal injury. As a planned analysis for the INORMUS study, we explored differences in fracture locations and demographics reported among 9878 female patients who sustained a fracture within 17 LMICs in 5 regions (China, Africa, India, Other Asia, and Latin America). Results: Half of our study population (49.6%) was ≥60 years of age. Across all regions, 58.3% of patients possessed health insurance. Latin America possessed the highest proportion (88.8%) of health insurance, while in Africa, patients possessed the lowest (18.0%). Falls from standing were the most prevalent mechanism of injury (51.7%) followed by falls from height (12.8%) and motorcycle-related road traffic injuries (9.7%). The majority of the fractures (65.6%) occurred in patients aged 50 and older. Hip fractures were the most common fracture (26.8%), followed by tibia/fibula (12.6%) and spine fractures (9.7%). Open fractures accounted for 7.6% of fractures and were most commonly tibia/fibula fractures (35.1%). Despite these severe injuries, less than one-third (28.8%) of patients were transported for care after sustaining a fracture by ambulance. Regionally, a majority of female patients in Africa were working age and suffered tibia/fibula (21.6%) and femur fractures (14.0%). Patients in the regional category Other Asia, suffered the highest frequencies of open fractures (9.6% low grade, 7.1% high grade), and disproportionately from motorcycle road traffic injuries (29.9%). Conclusion: Across all regions, the most significant source of fracture burden was in the elderly, and included common fragility fractures, such as hip fractures. Notable regional deviations in fracture distributions were observed within Africa, and Other Asia. Across all studied LMICs, ambulance usage was low, and health insurance coverage was particularly low in Africa and India.
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Clinical Outcomes and Complications of the Surgical Implant Generation Network (SIGN) Intramedullary Nail: A Systematic Review and Meta-Analysis. J Orthop Trauma 2019; 33:42-48. [PMID: 30277978 DOI: 10.1097/bot.0000000000001328] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study is a systematic review and meta-analysis of the clinical outcomes and pooled complication rate of femoral, tibial, and humeral fracture fixation using SIGN nails. We aimed at comparing the pooled rate of adverse events based on the country of study origin, acute versus delayed fracture fixation, and length of follow-up. METHODS We searched PubMed/MEDLINE/Cochrane databases from 2000 to 2016 for English language studies. There was substantial heterogeneity among included studies. Therefore, we used subgroup analysis of varying adverse events and removal of potential outlier studies based on the "remove one" sensitivity analysis to address the heterogeneity across studies. A funnel plot was drawn and inspected visually to assess publication bias. We reported pooled complication rates for each adverse event with 95% prediction interval. RESULTS There were 14 studies with 47,169 cases across 58 different low- and middle-income countries. The average age was 33 ± 14 years, with 83% men and 17% women. Sixty percent of SIGN nails used in these 14 studies were used in femur fracture fixation, 38% in tibial shaft fractures, and the remaining 2% for humeral shaft fractures. Approximately 23% of patients had follow-up data recorded. All studies that measured clinical outcome indicated that >90% achieved full weight-bearing status, favorable range of motion (knee range of motion >90 degrees according to the SIGN database), and radiographic or clinical union depending on the specific variable(s) measured in each study. The overall complication rate was 5.2% (4.4%-6.4%). Malalignment (>5 degrees of angulation in any plane) was the most common complication (7.6%), followed by delayed/nonunion (6.9%), infection (5.9%), and hardware failure, (3.2%). CONCLUSIONS Overall, the use of SIGN nails in fixing femoral, tibial, and humeral shaft fractures demonstrates good results with a high rate of return to full weight-bearing and radiographic/clinical union. The most common complications when using the SIGN nail are malalignment, delayed/nonunion, infection, and hardware failure. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Role of North-South Partnership in Trauma Management: Uganda Sustainable Trauma Orthopaedic Program. J Orthop Trauma 2018; 32 Suppl 7:S21-S24. [PMID: 30247395 DOI: 10.1097/bot.0000000000001290] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Uganda, as do many low-middle income countries, has an overwhelming volume of orthopaedic trauma injuries. The Uganda Sustainable Trauma Orthopaedic Program (USTOP) is a partnership between the University of British Columbia, McMaster University and Makerere University that was initiated in 2007. The goal of the project is to reduce the disabilities that occur secondary to musculoskeletal trauma in Uganda. USTOP works with local collaborators to build orthopaedic trauma capacity through teaching, innovation, and research. USTOP has maintained a multidisciplinary approach to training, involving colleagues in anesthesia, nursing, rehabilitation, and sterile reprocessing. The project was initiated at the invitation of the Department of Orthopaedics at Makerere University and Mulago Hospital in Kampala. The project is a collaboration between Canadian and Ugandan orthopaedic surgeons and is driven by the needs identified by the Ugandan surgeons. The program has also worked with collaborators to develop several technologies aimed at reducing the cost of providing orthopaedic care without compromising quality. As orthopaedic trauma capacity in Uganda advances, USTOP strives to continually evolve and provide relevant support to colleagues in Uganda to ensure that changes result in sustainable improvements in patient care.
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Haitian Annual Conference on Orthopaedic Traumatology: Building Surgical Capacity Through Academic Collaboration. J Orthop Trauma 2018; 32 Suppl 7:S16-S17. [PMID: 30247393 DOI: 10.1097/bot.0000000000001291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The Assemblée Annuelle Haitienne de Traumatologie Orthopedique (Haitian Annual Conference on Orthopaedic Traumatology) is an international orthopaedic conference, conducted each Spring in Haiti in French and English. It brings together most of Haiti's practicing orthopaedic surgeons, trainees from Haiti's 3 residency training programs, and a visiting faculty from overseas. The Haitian Annual Conference on Orthopaedic Traumatology has become an unexpected cornerstone of 1 program to support and nurture the development of orthopaedic surgery in that country.
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Can a 2-Day Course Teach Orthopaedic Surgeons Rotational Flap Procedures? An Evaluation of Data From the Nepal SMART Course Over 2 years. J Orthop Trauma 2018; 32 Suppl 7:S38-S42. [PMID: 30247399 DOI: 10.1097/bot.0000000000001298] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Traumatic lower extremity injuries requiring multidisciplinary treatment pose a challenge in low- and middle-income countries, where access to specialists may be limited. The surgical management and reconstructive training (SMART) course teaches orthopaedic surgeons muscle and fasciocutaneous flap procedures to address this scarcity. The purpose of this study is to assess the effectiveness of the SMART course in improving competency and comfort in performing common lower extremity flap procedures among participants. METHODS Sixty-four orthopaedic surgeons from different regions of Nepal and Bhutan participated in the Nepal SMART course in 2016 and 2017. A competency test-consisting of questions from US in-training plastic and orthopaedic surgery examinations-was administered to attendees before and after the course. Thirty-two participants from 2016 were asked to rate their comfort level in performing flap procedures both pre- and postcourse. RESULTS Overall competency test scores, as well as scores in the plastic surgery section, increased significantly after the course (P < 0.01). The precourse competency test scores were higher in 2016 compared with 2017 (P = 0.02). There was a higher increase in overall competency test scores after the course in 2016 compared with 2017 (P = 0.03). The procedure comfort levels reported by attendees increased for all flaps (P < 0.01). CONCLUSIONS These results demonstrate the ability of the SMART course to improve the competency and comfort levels of orthopaedic surgeons in performing common lower extremity flap procedures. Despite the differences in years in practice and previous experience in performing flaps, the course yielded significantly better results in 2017 compared with 2016, showing that the implementation of the course has been improving.
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Chan Y, Banza L, Martin C, Harrison WJ. Essential fracture and orthopaedic equipment lists in low resource settings: consensus derived by survey of experts in Africa. BMJ Open 2018; 8:e023473. [PMID: 30224399 PMCID: PMC6144338 DOI: 10.1136/bmjopen-2018-023473] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Low/middle-income countries (LMICs) have a growing need for trauma and orthopaedic (T&O) surgical interventions but lack surgical resources. Part of this is due to the high amount of road traffic accidents in LMICs. We aimed to develop recommendations for an essential list of equipment for three different levels of care providers. METHODS The Delphi method was used to achieve consensus on essential and desirable T&O equipment for LMICs. Twenty experts with T&O experience from LMICs underwent two rounds of questionnaires. Feedback was given after each round of questionnaires. The first round of questionnaire consisted of 45 items graded on a Likert scale with the second round consisting of 50 items. We used an electronic questionnaire to collect our data for three different levels of care: non-operative-based provider, specialist provider with operative fracture care and tertiary provider with operative fracture care and orthopaedics. RESULTS After two rounds of questionnaires, recommendations for each level of care in LMICs included 4 essential equipment items for non-operative-based providers; 27 essential equipment items for specialist providers with operative fracture care and 46 essential equipment items for tertiary providers with operative fracture care and orthopaedic care. CONCLUSION These recommendations can facilitate in planning of appropriate equipment required in an institution which in turn has the potential to improve the capacity and quality of T&O care in LMICs. The essential equipment lists provided here can help direct where funding for equipment should be targeted. Our recommendations can help with planning and organising national T&O care in LMICs to achieve appropriate capacity at all relevant levels of care.
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Affiliation(s)
- Yuen Chan
- Department of Trauma and Orthopaedics, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Leonard Banza
- Department of Orthopaedics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Claude Martin
- AO Alliance, AO Alliance Foundation, Davos, Switzerland
| | - William J Harrison
- Department of Trauma and Orthopaedics, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
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Premkumar A, Ying X, Mack Hardaker W, Massawe HH, Mshahaba DJ, Mandari F, Pallangyo A, Temu R, Masenga G, Spiegel DA, Sheth NP. Access to Orthopaedic Surgical Care in Northern Tanzania: A Modelling Study. World J Surg 2018; 42:3081-3088. [DOI: 10.1007/s00268-018-4630-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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McQuillan TJ, Cai LZ, Corcoran-Schwartz I, Weiser TG, Forrester JD. Surgical Site Infections after Open Reduction Internal Fixation for Trauma in Low and Middle Human Development Index Countries: A Systematic Review. Surg Infect (Larchmt) 2018; 19:254-263. [DOI: 10.1089/sur.2017.273] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Lawrence Z. Cai
- Stanford University School of Medicine, Stanford, California
| | - Ian Corcoran-Schwartz
- Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Thomas G. Weiser
- Department of General Surgery, Stanford University, Stanford, California
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, Scotland
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Conway DJ, Coughlin R, Caldwell A, Shearer D. The Institute for Global Orthopedics and Traumatology: A Model for Academic Collaboration in Orthopedic Surgery. Front Public Health 2017; 5:146. [PMID: 28713803 PMCID: PMC5491941 DOI: 10.3389/fpubh.2017.00146] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 06/09/2017] [Indexed: 01/15/2023] Open
Abstract
In 2006, surgeons at the University of California, San Francisco (UCSF) established the Institute for Global Orthopedics and Traumatology (IGOT), an initiative within the department of orthopedic surgery. The principal aim of IGOT is to create long-term, sustainable solutions to the growing burden of musculoskeletal injury in low- and middle-income countries (LMICs) through academic partnership. IGOT currently has relationships with teaching hospitals in Ghana, Malawi, Tanzania, Nicaragua, and Nepal. The organizational structure of IGOT is built on four pillars: Global Surgical Education (GSE), Global Knowledge Exchange (GKE), Global Research Initiative (GRI), and Global Leadership and Advocacy. GSE focuses on increasing surgical knowledge and technical proficiency through hands-on educational courses. The GKE facilitates the mutual exchange of surgeons and trainees among IGOT and its partners. This includes a global resident elective that allows UCSF residents to complete an international rotation at one of IGOT's partner sites. The GRI strives to build research capacity and sponsor high-quality clinical research projects that address questions relevant to local partners. The fourth pillar, Global Leadership and Advocacy aims to increase awareness of the global impact of musculoskeletal injury through national and international courses and events, such as the Bay Area Global Health Film Festival. At the core of each tenet is the collaboration among IGOT and its international partners. Over the last decade, IGOT has experienced tremendous growth and maturation in its partnership model based on cumulative experience and the needs of its partners.
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Affiliation(s)
- Devin James Conway
- University of California San Francisco, San Francisco, CA, United States
| | - Richard Coughlin
- University of California San Francisco, San Francisco, CA, United States
| | - Amber Caldwell
- University of California San Francisco, San Francisco, CA, United States
| | - David Shearer
- University of California San Francisco, San Francisco, CA, United States
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