The Socioeconomic Implications of Isolated Tibial and Femoral Fractures from Road Traffic Injuries in Uganda

Global Health Inequities in Orthopaedic Care: Perspectives Beyond the US

PURPOSE OF REVIEW

The burden of musculoskeletal disease is increasing globally and disproportionately affecting people in low and middle income countries (LMIC). We sought to review global access to orthopaedic care, burden of trauma, research infrastructure, impact of surgical mission trips, implant availability, and the effect of COVID-19 upon the delivery of orthopaedic care worldwide.

RECENT FINDINGS

The majority of people in LMIC do not have access to safe, quality surgical care, and there are few fellowship-trained orthopaedic traumatologists. Road traffic accidents are the leading cause of long bone fractures in LMIC and result in significant morbidity and mortality. Of the orthopaedic literature published globally in the last 10 years, less than 15% had authors from LMIC. There has been growth in surgical mission trips to LMIC, but few organizations have established bidirectional partnerships. Among the challenges to delivering quality musculoskeletal care in LMIC is timely access to quality orthopaedic implants. Implant options in LMIC are more limited and subjected to less rigorous testing and regulation than high income countries (HIC). The COVID-19 pandemic dramatically reduced elective surgeries but saw the increase in telemedicine utilization which has prevailed in both HIC and LMIC. Awareness of global inequities in orthopaedic care is growing. Much can be learned through collaborations between orthopaedic surgeons from HIC and LMIC to advance patient care worldwide. There is a need for high quality, accurate data regarding incidence and prevalence of musculoskeletal disease, care utilization/availability, and postoperative outcomes so resources can be allotted to make orthopaedic care more equitable globally.

Predictors of quality of life, economic impact, and loss to follow-up after open tibial shaft fractures in Ghana

Objectives

Open tibia fractures are associated with substantial morbidity and impact on quality of life. Despite increasing incidence in low-resource settings, most open tibia fracture research comes from high-resource settings. This study aimed to assess the impact of socioeconomic status on treatment modality and evaluate predictors of health-related quality of life following open tibia fractures in Ghana.

Design

A single-center prospective observational study was conducted in Kumasi, Ghana, from May 2020 to April 2022. Adults with open tibial shaft fractures presenting within 2 weeks of injury were eligible. Demographics, comorbidities, socioeconomic factors, and hospital course were collected at enrollment. Follow-up was scheduled at 8, 12, 26, and 52 weeks. A telephone survey assessing reasons for loss to follow-up was initiated on enrollment completion.

Results

A total of 180 patients were enrolled. Most patients were employed before injury (79.9%), had government insurance (67.2%), and were from rural areas (59.4%). Fracture classification was primarily Gustilo-Anderson type 3A (49.1%). No relationship between socioeconomic predictors and treatment modality was identified. The largest barriers to follow-up were preference for bonesetter treatment (63.1%), treatment cost (48.8%), and travel cost (29.8%). Of the lost to follow-up patients contacted, 67 (79.8%) reported receiving traditional bonesetter care. Reasons for seeking traditional bonesetter care included ease of access (83.6%), lower cost (77.6%), and familial influence (50.7%).

Conclusion

No association was identified between socioeconomic predictors and choice of treatment. Bonesetter treatment plays a substantial role in the care of open tibia fractures in Ghana, largely because of ease of access and lower cost.

Estimating the economic impact of complications after open tibial fracture: A secondary analysis of the pilot Gentamicin Open Tibia trial (pGO-Tibia)

Objectives

To estimate the indirect economic impact of tibial fractures and their associated adverse events (AEs) in Tanzania.

Design

A secondary analysis of the pilot Gentamicin Open (pGO)-Tibia randomized control trial estimating the indirect economic impact of suffering an AE, defined as a fracture-related infection (FRI) and/or nonunion, after an open tibial fracture in Tanzania.

Setting

The pGO-Tibia trial was conducted from November 2019 to August 2021 at the Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania.

Patients/Participants

One hundred adults with open tibial shaft fractures participated in this study.

Intervention

Work hours were compared between AE groups. Cost data were analyzed using a weighted-average hourly wage and converted into purchasing power parity-adjusted USD.

Main Outcome Measurements

Indirect economic impact was analyzed from the perspective of return to work (RTW), lost productivity, and other indirect economic and household costs. RTW was analyzed using a survival analysis.

Results

Half of patients returned to work at 1-year follow-up, with those experiencing an AE having a significantly lower rate of RTW. Lost productivity was nearly double for those experiencing an AE. There was a significant difference in the mean outside health care costs between groups. The total mean indirect cost was $2385 with an AE, representing 92% of mean annual income and an increase of $1195 compared with no AE. There were significantly more patients with an AE who endorsed difficulty affording household expenses postinjury and who borrowed money to pay for their medical expenses.

Conclusions

This study identified serious economic burden after tibial fractures, with significant differences in total indirect cost between those with and without an AE.

Level of Evidence

II.

Peer-reviewed publications in orthopaedic surgery from lower income countries: A comparative analysis

INTRODUCTION

Musculoskeletal (MSK) disease is a substantial global burden, especially in lower income countries. However, limited research has been published on MSK health by scholars from these countries. We aimed to study the distribution of authorships, including trends in peer-reviewed orthopaedic publications based on each author's affiliated institution's country income status.

METHODS

Based on a bibliometric search, 119 orthopaedic-related journals were identified using the Journal Citation Reports database. Details of all scientific articles published in these journals between 2012 and 2021 were used to study trends and association between each of the author's affiliated institution's country income status, using the World Bank Classification.

RESULTS

Of the 133,718 unique articles, 87.6% had at least one author affiliation from a high-income country (HIC), 7.0% from an upper-middle income country (UMIC), 5.2% from a lower-middle income country (LMIC), and 0.2% from a low-income country (LIC). Overall, these articles were cited 1,825,365 times, with 92.5% of citations from HIC-affiliated authors and < 0.1% from LIC-affiliated authors. Over the 10-year study period, HIC-affiliated articles demonstrated the largest increase in the number of publications (9107-14,619), compared to UMIC-affiliated (495-1214), LMIC-affiliated (406-874), and LIC-affiliated articles (4-28).

CONCLUSIONS

There are large and persistent disparities in orthopaedic research publications based on the country income status of the author's affiliated institution, especially in the higher impact orthopaedic journals. Efforts should be made to increase opportunities for scholars from LICs and LMICs to publish their research in high-impact orthopaedic journals.

Diagnostic Performance of a telephone questionnaire for fracture-related infections (FRIs) in open tibia fracture patients in Tanzania

INTRODUCTION

Fracture-related infections (FRIs) are a major cause of trauma-associated morbidity worldwide. In 2018, an expert group supported by the AO Foundation, European Bone and Joint Infection Society developed a consensus definition of FRI. Still, there is limited knowledge on the applicability of this definition in low- and middle-income countries (LMICs). Given the unique barriers that cause low follow-up rates for orthopaedic trauma patients in LMICs, this study aims to evaluate the diagnostic performance of a telephone questionnaire in identifying patients with FRIs after open tibia fracture fixation in Tanzania.

MATERIALS AND METHODS

Patients from a randomized controlled trial investigating the infection prevention benefit of locally applied gentamycin for open tibial fractures were included. Patients completed FRI based telephone questionnaires 7-10 days prior to scheduled follow-ups at 6 weeks, 3 months, 6 months, 9 months, and 1 year. The questionnaire included two "confirmatory" criteria questions for FRI (i.e., open wound and purulent drainage) and three "suggestive" criteria questions (i.e., wound drainage, fever, and warmth). Contingency tests were performed to identify the sensitivity and specificity between answers and adjudicated FRI diagnoses at the corresponding in-person follow-up. Data was analysed using STATA version 15.0 and MedCalc's online diagnostic test calculator.

RESULTS

There were a total of 234 complete questionnaires and 85 unique patients included. The sensitivity and specificity of having any positive answer in the questionnaire was highest at 6 months (100 % and 92.5 %, respectively). For all time-points pooled, sensitivity was 71.4 % and specificity was 93.0 %. Drainage had the highest sensitivity (71.4 %) while fever had the highest specificity (99.6 %). For confirmatory criteria, sensitivity was 14.3 % and specificity was 96.0 %. Contrastingly, the sensitivity for suggestive criteria was higher (71.4 %), with a similar specificity (93.8 %).

CONCLUSION

Our study indicates that telephone questionnaires have adequate diagnostic performance when assessing FRIs. The presence of drainage identified the majority of patients with FRI, and specificities were high across confirmatory and suggestive criteria. Our study is one of the first to evaluate telephone questionnaires as a diagnostic tool for FRIs in patients with open tibia fractures in a LMIC hospital and validates the FRI consensus definition criteria.

Prevalence and levels of disability post road traffic orthopaedic injuries in Rwanda

Background

Prolonged disability resulting from road traffic injuries (RTIs) contributes significantly to morbidity and disease burden. A good understanding of the prevalence and the level of disability of orthopaedic injuries in developing countries is crucial for improvement; however, such data are currently lacking in Rwanda.

Objectives

To determine the prevalence and levels of disability of 2 years post-road traffic orthopaedic injuries in Rwanda.

Method

A multicentre, cross-sectional study from five Rwandan referral hospitals of 368 adult RTI victims' sustained from accidents in 2019. Between 02 June 2022, and 31 August 2022, two years after the injury, participants completed the World Health Organization Disability Assessment Schedule (WHODAS 2.0) Questionnaire for the degree of impairment and the Upper Extremity Functional Scale and Lower-Extremity Functional Scale forms for limb functional evaluation. Descriptive, inferential statistics Chi-square and multinomial regression models were analysed using R Studio.

Results

The study's mean age of the RTOI victims was 37.5 (±11.26) years, with a sex ratio M: F:3: 1. The prevalence of disability following road traffic orthopedic injury (RTOI) after 2 years was 36.14%, with victims having WHODAS score > 25.0% and 36.31% were still unable to return to their usual activities. Age group, Severe Kampala Trauma Score and lack of rehabilitation contributed to disability. The most affected WHODAS domains were participation in society (33%) and life activities (28%).

Conclusion

The prevalence and levels of disability because of RTOI in Rwanda are high, with mobility and participation in life being more affected than other WHODAS domains. Middle-aged and socio-economically underprivileged persons are the most affected.

Contribution

This study showed that a good rehabilitation approach and economic support for the RTI victims would decrease their disabilities in Rwanda.

Factors affecting social integration after road traffic orthopaedic injuries in Rwanda

Background

Road traffic injuries (RTIs) leading to long-term disability present a significant public health challenge, causing immense personal and societal consequences. Every year, 50 million people are hurt, 1.2 million die, 30% are permanently disabled, and 14% cannot return to work due to road traffic accidents. However, in many developing countries, information on the social integration of patients post-RTI remains limited. This study aimed to identify factors contributing to social integration following road traffic-related orthopedic injuries (RTOI) in Rwanda.

Methodology

A multicenter, cross-sectional study included 369 adult Road traffic orthopedic injuries (RTOI) victims from five Rwandan referral hospitals. Participants completed the IMPACT-S Questionnaire between 2 June 2022, and 31 August 2022, two years after the injury. It measured social integration in terms of activities and paricipation. We used logistic regression statistical analysis with a significance level of p < 0.05 to estimate odds ratios (OR) and 95% confidence intervals (CI). The Institutional Review Board for Health Sciences and Medicine at the University of Rwanda College of Medicine ethically authorized this study. Participants signed a written consent form before participating in the study. The data was kept private and was used only for this study.

Results

The study's findings indicated that the mean age of RTOI victims was 37.5 ± 11.26 years, with a notable male predominance over females. Of the participants, 5.69% were unable to resume normal life activities. The overall mean score on the IMPACT-S scale was moderate, at 77 ± 17. Specifically, participants achieved an average score of 76 ± 16 for "activities" and a higher average of 84 ± 16 for "participation." Certain factors were associated with poor social integration compared to others, including belonging to the age group above 65 years (OR = 8.25, p = 0.02), female sex (OR = 3.26, p = 0.02), lack of rehabilitation (OR = 3.82, p = 0.01), and length of hospital stay >15 days (OR = 4.44, p = 0.02).

Conclusion

The majority of RTOI victims in Rwanda achieved successful reintegration into society; nevertheless, their mobility and community engagement were more significantly impacted compared to other aspects assessed by the IMPACT-S scale. The study emphasized the importance of early management, effective rehabilitation, and prompt patient discharge from the hospital in facilitating a successful return to everyday life after road traffic-related orthopedic injuries.

Return to Work Following Intramedullary Nailing of Lower-Limb Long-Bone Fractures in South Africa

BACKGROUND

Injuries are one of the leading causes of global death and disability and commonly have substantial economic implications. The economic impact of injuries is particularly pronounced in low- and middle-income countries, where 90% of injuries occur. In this study, we aimed to assess return-to-work rates of individuals who sustained a lower-limb long-bone fracture in South Africa and to identify factors that influence the ability to return to employment.

METHODS

This prospective cohort study was conducted across 2 tertiary trauma centers in Cape Town, South Africa. Adults who received intramedullary nail fixation for a lower-limb fracture between September 2017 and December 2018 were recruited and followed for 18 months postoperatively. The participants' return to employment was assessed at 6 and 18 months post-injury. Multivariate logistic regression was used to identify factors that influence post-injury employment.

RESULTS

Of the 194 participants enrolled, 192 completed follow-up. The study population had a median age of 33.0 years, and most of the participants (76.6%) were male. Seventy-five percent of the participants were employed before their injury. At 6 and 18 months post-injury, 34.4% and 56.3% of participants, respectively, were employed. Of those employed pre-injury, 70.1% had returned to work at 18 months. Multivariate regression identified increasing age, unemployment prior to injury, and working in the informal employment sector as factors that impede an individual's likelihood of working 18 months post-injury. For those in employment prior to injury, increasing age was the only factor found to impede the likelihood of returning to work following an injury.

CONCLUSIONS

This study highlights the profound effect that lower-limb long-bone fractures may have on an individual's ability to return to work in South Africa, with the potential to cause substantial economic impact on an individual's livelihood and that of their dependents.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Intramedullary Nailing and External Fixation of Open Tibial Fractures: Three to Five-Year Follow-up of a Randomized Clinical Trial

BACKGROUND

While surgeons in low and middle-income countries have increasing experience with intramedullary nailing (IMN), external fixation (EF) continues to be commonly used for the management of open tibial fractures. We examined outcomes with extended follow-up of the participants enrolled in a clinical trial comparing these treatments.

METHODS

Adults who were ≥18 years old with acute AO/OTA type-42 open tibial shaft fractures were randomly assigned to statically locked, hand-reamed IMN or uniplanar EF. These participants were reevaluated 3 to 5 years after treatment. The primary outcome was death or reoperation for the treatment of deep infection, nonunion, or malalignment. Unresolved complications such as persistent fracture-related infection, nonunion, or malalignment were collected and analyzed. Secondary outcomes included the EuroQol-5 Dimension-3 Level (EQ-5D-3L) questionnaire, the Function IndeX for Trauma (FIX-IT) score, radiographic alignment, and the modified Radiographic Union Scale for Tibial fractures (mRUST).

RESULTS

Of the originally enrolled 240 participants,126 (67 managed with IMN and 59 managed with EF) died or returned for follow-up at a mean of 4.0 years (range, 2.9 to 5.2 years). Thirty-two composite primary events occurred, with rates of 23.9% and 27.1% in the IMN and EF groups, respectively. Six of these events (3 in the IMN group and 3 in the EF group) were newly detected after the original 1-year follow-up. Unresolved complications in the form of chronic fracture-related infection or nonunion were present at long-term follow-up in 25% of the participants who sustained a primary event. The EQ-5D-3L index scores were similar between the 2 groups and only returned to preinjury levels after 1 year among patients without complications or those whose complications resolved.

CONCLUSIONS

This observational study extended follow-up for a clinical trial assessing IMN versus EF for the treatment of open tibial fractures in sub-Saharan Africa. At a mean of 4 years after injury, fracture-related infection and nonunion became chronic conditions in nearly a quarter of the participants who experienced these complications, regardless of reintervention.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Unreamed Intramedullary Nailing Versus External Fixation for the Treatment of Open Tibial Shaft Fractures in Uganda: A Randomized Clinical Trial

OBJECTIVE

To compare unreamed intramedullary nailing versus external fixation for the treatment of Gustilo-Anderson type II and IIIA open tibial fractures admitted to a hospital in rural Uganda.

DESIGN

Randomized clinical trial.

SETTING

Regional referral hospital in Uganda.

PATIENTS

Fifty-five skeletally mature patients with a Gustilo-Anderson type II or IIIA open tibia shaft fracture treated within 24 hours of injury between May 2016 and December 2019.

INTERVENTION

Unreamed intramedullary nailing (n = 31) versus external fixation (n = 24).

MAIN OUTCOME MEASUREMENTS

The primary outcome was function within 12 months of injury, measured using the Function IndeX for Trauma (FIX-IT) score. Secondary outcomes included health-related quality of life (HRQoL) using the 3-level version of the 5-dimension EuroQol instrument (EQ-5D-3L), radiographic healing using the Radiographic Union Scale for Tibia (RUST) fractures score, and clinical complications.

RESULTS

Treatment with an intramedullary nail resulted in a 1.0-point higher [95% credible intervals (CrI), 0.1 to 1.9] FIX-IT score compared with external fixation. Results were similar for the secondary patient-reported outcomes, EQ-5D-3L and the visual analog scale component of the EuroQol instrument (EQ-VAS). RUST scores were not different between groups at any time point. Treatment with an intramedullary nail was associated with a 22.1% (95% CrI, -42.6% to 1.7%) lower rate of malunion and a 20.8% (95% CrI, -44.0% to 2.9%) lower rate of superficial infection.

CONCLUSION

In rural Uganda, treatment of open tibial shaft fractures with an unreamed intramedullary nail results in marginal clinically important improvements in functional outcomes, although there is likely an important reduction in malunion and superficial infection.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

"Trauma-the forgotten pandemic?"

Global annual deaths from Trauma are greater than any other single cause in the global working population, and, more than all contagious diseases added together including COVID-19. The number of people injured, either temporarily or permanently, is greater than any other medical condition. This problem affects Low and Middle Income Countries (LMICs) disproportionately. The numbers are so great as to cause "zone out" and present a human rights issue. This is a particular issue as Trauma presently receives less than 1% of global healthcare funding. This article will highlight and discuss many of the issues and raise some uncomfortable arguments showing that improvement is needed, necessary and achievable.

The Impact of Musculoskeletal Injuries Sustained in Road Traffic Crashes on Work-Related Outcomes: A Systematic Review

Musculoskeletal injuries occur frequently after road traffic crashes (RTCs), and the effect on work participation is not fully understood. The primary aim of this review was to determine the impact of sustaining a musculoskeletal injury during an RTC on the rate of return to work (RTW), sick leave, and other work outcomes. The secondary aim was to determine factors associated with these work-related outcomes. An electronic search of relevant databases to identify observational studies related to work and employment, RTC, and musculoskeletal injuries was conducted. Where possible, outcome data were pooled by follow-up period to answer the primary aim. Fifty-three studies were included in this review, of which 28 were included in meta-analyses. The pooled rate of RTW was 70% at 1 month, 67% at 3 months, 76% at 6 months, 83% at 12 months, and 70% at 24 months. Twenty-seven percent of participants took some sick leave by one month follow-up, 13% by 3 months, 23% by 6 months, 36% by 12 months, and 22% by 24 months. Most of the factors identified as associated with work outcomes were health-related, with some evidence also for sociodemographic factors. While 70% of people with RTC-related musculoskeletal injury RTW shortly after accident, many still have not RTW two years later.

Economic impact of surgery on households and individuals in low income countries: A systematic review

BACKGROUND

Surgical disease in Low Income Countries (LIC) is common, and overall provision of surgical care is poor. A key component of surgical health systems as part of universal health coverage (UHC) is financial risk protection (FRP) - the need to protect individuals from financial hardship due to accessing healthcare. We performed a systematic review to amalgamate current understanding of the economic impact of surgery on the individual and household. Our study was registered on Research registry (www.researchregistry.com).

METHODS

We searched Pubmed and Medline for articles addressing economic aspects of surgical disease/care in low income countries. Data analysis was descriptive in light of a wide range of methodologies and reporting measures. Quality assessment and risk of bias analysis was performed using study design specific Joanna-Briggs Institute checklists. This study has been reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines.

RESULTS

31 full text papers were identified for inclusion; 22 descriptive cross-sectional studies, 4 qualitative studies and 5 economic analysis studies of varying quality. Direct medical, direct non-medical and indirect costs were variably reported but were substantial, resulting in catastrophic expenditure. Costs had far reaching economic impacts on individuals and households, who used entire savings, took out loans, reduced essential expenditure and removed children from school to meet costs.

CONCLUSION

Seeking healthcare for surgical disease is economically devastating for individuals and households in LICs. Policies directed at strengthening surgical health systems must seek ways to reduce financial hardship on individuals and households from both direct and indirect costs and these should be monitored and measured using defined instruments from the patient perspective.

Global orthopaedic trauma surgeons highlight telenomics during the COVID-19 era: A case for advancing telemedicine in orthopaedics

The Coronavirus (COVID-19) pandemic sparked rapid widespread adoption of telemedicine throughout specialties, including orthopaedics. A succession of factors, starting with payers, followed by provider adoption, and reciprocated by patient approval, created newly accepted telehealth practices that have moved from trial to norm in a short time span. Orthopaedic surgeons believe telehealth will endure as a permanent change to their practice beyond the COVID-19 era, however, many permanent changes must take place by payers, providers, and patients to sustain telehealth into the future. The goal of this paper is to highlight the indelibility of telemedicine adoption in orthopaedic practices globally, characterize the chain of events that led to its large-scale adoption, and catalyze discussion around actionable next steps to sustain its benefits.

Epidemiology of injured patients in rural Uganda: A prospective trauma registry's first 1000 days

Trauma is a leading cause of morbidity and mortality worldwide. Data characterizing the burden of injury in rural Uganda is limited. Hospital-based trauma registries are a critical tool in illustrating injury patterns and clinical outcomes. This study aims to characterize the traumatic injuries presenting to Soroti Regional Referral Hospital (SRRH) in order to identify opportunities for quality improvement and policy development. From October 2016 to July 2019, we prospectively captured data on injured patients using a locally designed, context-relevant trauma registry instrument. Information regarding patient demographics, injury characteristics, clinical information, and treatment outcomes were recorded. Descriptive, bivariate, and multivariate statistical analyses were conducted. A total of 4109 injured patients were treated during the study period. Median age was 26 years and 63% were male. Students (33%) and peasant farmers (31%) were the most affected occupations. Falls (36%) and road traffic injuries (RTIs, 35%) were the leading causes of injury. Nearly two-thirds of RTIs were motorcycle-related and only 16% involved a pedestrian. Over half (53%) of all patients had a fracture or a sprain. Suffering a burn or a head injury were significant predictors of mortality. The number of trauma patients enrolled in the study declined by five-fold when comparing the final six months and initial six months of the study. Implementation of a context-appropriate trauma registry in a resource-constrained setting is feasible. In rural Uganda, there is a significant need for injury prevention efforts to protect vulnerable populations such as children and women from trauma on roads and in the home. Orthopedic and neurosurgical care are important targets for the strengthening of health systems. The comprehensive data provided by a trauma registry will continue to inform such efforts and provide a way to monitor their progress moving forward.

Prognostic factors for predicting health-related quality of life after intramedullary nailing of tibial fractures: a randomized controlled trial

Aims

Using tibial shaft fracture participants from a large, multicentre randomized controlled trial, we investigated if patient and surgical factors were associated with health-related quality of life (HRQoL) at one year post-surgery.

Methods

The Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) trial examined adults with an open or closed tibial shaft fracture who were treated with either reamed or unreamed intramedullary nails. HRQoL was assessed at hospital discharge (for pre-injury level) and at 12 months post-fracture using the Short Musculoskeletal Functional Assessment (SMFA) Dysfunction, SMFA Bother, 36-Item Short Form 36 (SF-36) Physical, and SF-36 Mental Component scores. We used multiple linear regression analysis to determine if baseline and surgical factors, as well as post-intervention procedures within one year of fracture, were associated with these HRQoL outcomes. Significance was set at p < 0.01. We hypothesize that, irrespective of the four measures used, prognosis is guided by both modifiable and non-modifiable factors and that patients do not return to their pre-injury level of function, nor HRQoL.

Results

For patient and surgical factors, only pre-injury quality of life and isolated fracture showed a statistical effect on all four HRQoL outcomes, while high-energy injury mechanism, smoking, and race or ethnicity, demonstrated statistical significance for three of the four HRQoL outcomes. Patients who did not require reoperation in response to infection, the need for bone grafts, and/or the need for implant exchanges had statistically superior HRQoL outcomes than those who did require intervention within one year after initial tibial fracture nailing.

Conclusion

We identified several baseline patient factors, surgical factors, and post-intervention procedures within one year after intramedullary nailing of a tibial shaft fracture that may influence a patient’s HRQoL.

Cite this article: Bone Jt Open 2021;2(1):22–32.

Impact of North American Institutions on Orthopedic Research in Low- and Middle-Income Countries

There exists an unmet need for locally relevant and sustainable orthopedic research in low- and middle-income countries. Partnerships between high-income countries and low- and middle-income countries can bridge gaps in resources, knowledge, infrastructure, and skill. This article presents a select list of models for high-income countries/low- and middle-income countries research partnerships including academic partnerships, international research consortia, professional society-associated working groups, and nongovernmental organization partnerships. Models that produce research with lasting legacy are those that promote mutually beneficial partnerships over individual gains.

The Development of a Surgical Mission in the Peruvian Amazon: A 15-Year Expedition

Musculoskeletal disorders and injuries represent a substantial proportion of the global burden of disease. This burden is particularly prevalent in low and middle-income countries that already have insufficient health-care resources. The purpose of this paper is to highlight the vision, the history, the implementation, and the challenges in establishing an orthopaedic surgical mission in a developing nation to help address the epidemic of musculoskeletal trauma.Scalpel At The Cross (SATC) is a nonprofit Christian orthopaedic surgical mission organization that sends teams of 10 to 20 members to Pucallpa, Peru, a rural town in the Amazon, to evaluate patients with musculoskeletal conditions, many that require surgery. The organization employs 4 full-time staff members and has included over 400 medical volunteers in 32 surgical campaigns since 2005. SATC has provided approximately 8.1 million U.S. dollars in total medical care, while investing approximately 2.2 million U.S. dollars in implementation and overhead.Given the projected increase in trauma in low and middle-income countries, the SATC model may be increasingly relevant as a possible blueprint for other medical professionals to take on similar endeavors. This paper also highlights the importance of continued research into the effectiveness of various organizational models to advance surgical services in these countries.

The willingness of orthopaedic trauma patients in Uganda to accept financial loans following injury

Background:

Early access to a monetary loan may mitigate some of the socioeconomic burden associated with surgical treatment and lost wages following injury. The primary objective of this study was to determine the willingness of orthopaedic trauma patients in Uganda to accept a formal financial loan shortly after their time of injury.

Methods:

A consecutive sample of adult orthopaedic trauma patients admitted to Uganda's national referral hospital was included in the survey. The primary outcome was the self-reported willingness to accept a financial loan. Secondary outcomes included the preferred loan terms, fracture treatment costs, and the factors associated with loan willingness.

Results:

Of the 40 respondents (mean age, 40 years; 58% male), the median annual income was $582 United States dollars (USD) (range: $0–$6720). Around 50% reported a willingness to accept a loan with any terms. Patients requested loans with a median principal of $500 USD and a median interest rate of 5% with 12 months to pay back. Patients had received loans with a median principal of $142 USD, an interest rate of 10%, and payback of 6 months. These received loans covered a mean of 63% of the treatment costs. Patients with higher median incomes ($857 USD vs $342 USD) were more willing to accept a loan.

Conclusion:

This study demonstrated a limited interest of orthopaedic trauma patients in Uganda to procure loans through formalized lending. This observed resistance must be overcome in future programs that rely on mechanisms such as conditional cash transfers or microfinancing to improve clinical and socioeconomic outcomes after injury.

Orthopaedic Trauma in Low-resource Settings: Measuring Value

There is increasing recognition of both the impact and value of trauma care in low- and middle-income countries (LMICs). However, data supporting the value of musculoskeletal trauma care specifically are lacking. This review discusses methods of economic analysis relevant to low-resource settings and provides a review of cost studies related to orthopaedic trauma care in these settings. In general, microcosting methods are preferred in LMICs because of the lack of databases with aggregate cost data. It is important that studies use a societal perspective that includes the indirect costs of treatment in addition to direct costs of medical care. Cost-effectiveness studies most commonly report cost per disability-adjusted life year, particularly in LMICs, but quality-adjusted life years are an acceptable alternative that is based on more empiric data. There are solid economic data supporting potential cost savings and improved outcomes with intramedullary nailing for femoral shaft fractures. Trauma care hospitals and educational initiatives have also been found to be highly cost-effective. However, very little data exist to support other interventions in orthopaedic trauma. Orthopaedic surgeons should strive to understand these methodologies and support the conduct of rigorous economic analysis to better establish the value of musculoskeletal trauma care in LMICs.

Role of North-South Partnership in Trauma Management: Uganda Sustainable Trauma Orthopaedic Program

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.