The burden of musculoskeletal injury in low and middle-income countries: challenges and opportunities

Effect of single versus multiple prophylactic antibiotic doses on prosthetic joint infections following primary total hip arthroplasty in patients with osteoarthritis at public and private hospitals in Denmark: protocol for a nationwide cross-over, cluster randomised, non-inferiority trial [The Pro-Hip-Quality Trial]

INTRODUCTION

A feared complication after total hip arthroplasty (THA) is prosthetic joint infection (PJI), associated with high morbidity and mortality. Prophylactic antibiotics can reduce the risk of PJI. However, there is no consensus on the dosages and current recommendations are based on a low evidence level. The objective is to compare the effect of a single versus multiple doses of prophylactic antibiotics administered within 24 hours on PJI.

METHODS AND ANALYSIS

The study is designed as a cross-over, cluster randomised, non-inferiority trial. All clinical centres use both antibiotic practices (1 year of each intervention). All Danish orthopaedic surgery departments will be involved: Based on quality databases, 2-year cohorts of approximately 20 000 primary THAs conducted at 39 public and private hospitals, will be included.

INCLUSION CRITERIA

age ≥18 years, all indications for THA except patients operated due to acute or sequelae from proximal femoral or pelvic fractures or bone tumour or metastasis. The primary outcome is PJI within 90 days after primary THA. Secondary outcomes include (1) serious adverse events, (2) potential PJI, (3) length of hospitalisation stay, (4) cardiovascular events, (5) hospital-treated infections, (6) community-based antibiotic use, (7) opioid use and (8) use of acetaminophen and non-steroidal anti-inflammatory drugs. All outcome measures will be extracted from national databases. Analyses will be based on the intention-to-treat population. Non-inferiority will be shown if the upper limit of the two-sided 95% CI for the OR is less than 1.32 for the single dose as compared with multiple doses. The results will establish best practice on antibiotic prophylaxis dosages in the future.

ETHICS AND DISSEMINATION

This study has been approved by Committees on Health Research Ethics for The Capital Region of Denmark (21069108) and The Danish Medicines Agency (2021091723). All results will be presented in peer-reviewed medical journals and international conferences.

TRIAL REGISTRATION NUMBER

NCT05530551.

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

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.

Orthopaedic trauma observerships in North America for international surgeons: the visitors' perspective

International observerships are one of many efforts aimed at addressing disparities in orthopaedic trauma care globally. However, their impact on visiting surgeons and their home countries, as well as the challenges faced by participating surgeons, are not well-documented.

Methods

A survey was distributed to overseas surgeons who participated in an orthopaedic trauma observership from 2009 to 2020. Surgeons were identified through North American institutions previously recognized by the authors as having hosted international observerships. Information gathered included participant demographics, details of and perceived impact of the observership, and barriers faced before, during, and after the program. Responses from 148 international surgeons (ISs) from 49 countries were analyzed.

Results

Sixty percent of observerships were at academic programs, 57% lasted 1-3 months, and 60% were self-funded. Participants identified cost and housing as primary barriers. After completing their observership, lack of funding, equipment and support staff, and excessive workload prevented participants from implementing changes at their clinical practice. Most observers believed that they gained relevant clinical (89%) and surgical knowledge (67%) and developed a professional network of North American hosts (63%). The most common suggested changes to the observership were greater hands-on experience in the operating room and structured goal setting relevant to the visiting surgeon.

Conclusions

Visiting surgeons find North American orthopaedic trauma observerships helpful in improving their surgical and clinical skills. However, financial constraints and resource limitations at their clinical practice and limited operative experience during the observership present barriers to maximizing this clinical experience. To enhance the relevance of clinical observerships for ISs and impact global orthopaedic trauma care, the unique needs and challenges facing ISs must be addressed.

Level of Evidence

IV-Cross-Sectional Study.

Context and priorities for health systems strengthening for pain and disability in low- and middle-income countries: a secondary qualitative study and content analysis of health policies

Musculoskeletal (MSK) health impairments contribute substantially to the pain and disability burden in low- and middle-income countries (LMICs), yet health systems strengthening (HSS) responses are nascent in these settings. We aimed to explore the contemporary context, framed as challenges and opportunities, for improving population-level prevention and management of MSK health in LMICs using secondary qualitative data from a previous study exploring HSS priorities for MSK health globally and (2) to contextualize these findings through a primary analysis of health policies for integrated management of non-communicable diseases (NCDs) in select LMICs. Part 1: 12 transcripts of interviews with LMIC-based key informants (KIs) were inductively analysed. Part 2: systematic content analysis of health policies for integrated care of NCDs where KIs were resident (Argentina, Bangladesh, Brazil, Ethiopia, India, Kenya, Malaysia, Philippines and South Africa). A thematic framework of LMIC-relevant challenges and opportunities was empirically derived and organized around five meta-themes: (1) MSK health is a low priority; (2) social determinants adversely affect MSK health; (3) healthcare system issues de-prioritize MSK health; (4) economic constraints restrict system capacity to direct and mobilize resources to MSK health; and (5) build research capacity. Twelve policy documents were included, describing explicit foci on cardiovascular disease (100%), diabetes (100%), respiratory conditions (100%) and cancer (89%); none explicitly focused on MSK health. Policy strategies were coded into three categories: (1) general principles for people-centred NCD care, (2) service delivery and (3) system strengthening. Four policies described strategies to address MSK health in some way, mostly related to injury care. Priorities and opportunities for HSS for MSK health identified by KIs aligned with broader strategies targeting NCDs identified in the policies. MSK health is not currently prioritized in NCD health policies among selected LMICs. However, opportunities to address the MSK-attributed disability burden exist through integrating MSK-specific HSS initiatives with initiatives targeting NCDs generally and injury and trauma care.

Evaluating a novel, low-cost technique for cervical-spine immobilization for application in resource-limited LMICs: a non-inferiority trial

STUDY DESIGN

Non-inferiority trial.

OBJECTIVE

Limited cervical spinal (c-spine) immobilization in resource-limited settings of LMICs suggests alternatives are necessary for patients with traumatic injuries. We propose a novel method of c-spine immobilization using folded towels.

SETTING

Washington University in St. Louis.

METHODS

Using non-inferiority trial design, thirty healthy patients (median age = 22) were enrolled to test the efficacy of folded towels in comparison with rigid cervical collars, foam neck braces, and no immobilization. We measured cervical range of motion (CROM) in six cardinal directions in seated and supine positions. A weighted composite score (CS) was generated to compare immobilization methods. A preserved fraction of 75% was determined for non-inferiority, corresponding to the difference between the median values for CROM between control (no immobilization) and c-collar states.

RESULTS

C-collars reduce median CROM in six cardinal directions in seated and supine positions by an average of -36.83° seated (-17.75° supine) vs. no immobilization. Folded towels and foam neck braces reduced CROM by -27° seated (-16.75° supine) and -14.25° seated (-9.5° supine), respectively. Compared to a 25% non-inferiority margin (permitting an average 9.21° of cervical movement across six cardinal directions), the CS determined folded towels are non-inferior (CS_seated = 0.89, CS_supine = 0.47). Foam neck braces are inferior (CS_seated = 2.35, CS_supine = 2.10). CS > 1 surpassed the non-inferiority margin and were deemed inferior.

CONCLUSIONS

Folded towels are a non-inferior means of immobilizing c-spine in extension and rotation, but not flexion, vs. c-collars. We propose folded towels could be trialed in combination with backboards to deliver affordable and effective prehospital TSCI management in resource-limited settings.

Prognostic factors for surgical site infection following intramedullary nailing of diaphyseal fractures of the femur and tibia in adult patients at a tertiary hospital in Lusaka, Zambia

Our study aimed to identify prognostic factors for surgical site infection following long bone fracture intramedullary nailing at a tertiary hospital in a low-resource setting. This was a longitudinal observational study involving 132 participants enrolled over a one-year period with femoral and tibial diaphyseal fractures scheduled for ORIF. Participant median age was 30 years (range: 26 – 42). The prevalence of surgical site infection was 16%. Male sex (AOR=0.26, 95% CI [0.70–0.98]; p = 0.047) was associated with lower odds of surgical site infection while associated non-musculoskeletal injuries were associated with higher odds of developing surgical site infection. Our study confirms a higher surgical site infection rate than normally accepted. However, intramedullary nailing in our setting is justified as it allows an early return to a pre-injury state. These interventions must be carried out in the best possible circumstances. Future studies could explore alternative methods of fracture fixation.

Functional assessment of long bone fracture healing in Samburu County Referral Hospital (Kenya): the squat and smile challenge

Background:

The burden of musculoskeletal trauma is increasing in low- and middle-income countries. Due to the low clinical follow-up rates in these regions, the Squat-and-Smile test (S&S) has previously been proposed as a proxy to assess bone healing (BH) capacity after surgery involving bone fractures. This study deals with various aspects of using S&S and bone radiography examination to obtain information about an individual's ability to recover after a trauma. In summary, we performed the S&S test to assess the possibility of recovering biomechanical function in lower limbs in a remote area of Kenya (Samburu County).

Methods:

Eighty-nine patients (17.9% F; 31.7 ± 18.9 yrs) who underwent intramedullary nail treatment for femur or tibia fractures were enrolled in this study. Both S&S [evaluated by a goal attainment scale (GAS)] and x-ray (evaluated by REBORNE, Bone Healing Score) were performed at 6 and 24 weeks, postoperatively. An acceptable margin for satisfactory S&S GAS scores was determined by assessing its validity, reliability, and sensitivity.

Results:

S&S GAS scores increased over time: 80.2% of patients performed a satisfactory S&S at the 24-weeks follow-up with a complete BH. A high correlation between S&S GAS and REBORNE at the 6- and 24- weeks’ timepoint was found. Facial expression correlated partially with BH. The S&S proved to be accurate at correctly depicting the BH process (75% area fell under the Receiver Operator Curve).

Conclusion:

The S&S provides a possible substitution for bone x-ray during BH assessment. The potential to remotely follow up the BH is certainly appealing in low- and middle-income countries, but also in high-income countries; as was recently observed with the Covid-19 pandemic when access to a hospital is not conceivable.

Population characteristics, outcomes, and centerwide insights of the Zimbabwe national experience with the SIGN intramedullary nail (2013-2020)

PURPOSE

SIGN Fracture international is a non-profit organization that provides intramedullary nails to SIGN centres at no cost for intra-operative fracture fixation in exchange for cases being uploaded to the SIGN Online Surgical Database (SOSD). The SIGN program was introduced in Zimbabwe in 2013 and had expanded to nine hospitals at the end of 2020. This study aimed to evaluate the population characteristics and clinical outcomes of patients who received the SIGN nail in Zimbabwe as well as intranational trends across SIGN centres.

METHODS

We conducted a retrospective review of the SOSD for all cases carried out in Zimbabwe between 2013 and 2020.

RESULTS

A total of 1764 patients received operative fixation over the period. The majority were young (36.83 ± 15.13) years and male (74%). The average time to surgery was 22 ± 20.5 days with over 69% of patients getting surgery after more than ten days. Femur fracture fixation (72%) was the most common procedure with road traffic accidents (RTAs) being the most common cause of fractures (73%). The majority of patients had no follow-up (61%). Of patients with follow-up, 4% reported infection, 2% deformity, and 78% with healing X-rays. There were large differences in volume of patients at different centres with no significant trends in outcomes.

CONCLUSION

The SIGN program allows for safe surgery in Zimbabwe. There are large intranational differences of no particular trend across SIGN centres which may be improved through more intranational knowledge sharing. Improved follow-up would allow for more insights to be gleaned from the database.

Respiratory morbidity and mortality of traumatic cervical spinal cord injury at a level I trauma center in India

STUDY DESIGN

Descriptive retrospective.

OBJECTIVES

To evaluate the burden of respiratory morbidity in terms of ventilator dependence (VD) days and length of stay in neurotrauma ICU (NICU) and hospital, and to determine mortality in patients with traumatic cervical spinal cord injury (CSCI) in a low middle-income country (LMIC).

SETTING

Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi, India.

METHODS

A total of 135 patients admitted with CSCI in the NICU between January 2017 to December 2018 were screened. Information regarding age, gender, American Spinal Injury Association (ASIA) impairment scale (AIS), level of injury, duration of VD, length of NICU, hospital stay, and outcome in terms of mortality or discharge from the hospital were obtained from the medical records.

RESULTS

A total of 106 CSCI patients were analyzed. The mean (SD) age of patients was 40 (±16) years and male: female ratio was 5:1. The duration of VD, duration of NICU, and hospital stay was a median of 8 days (IQR 1127), 6 days (IQR 1118), and 15 days (IQR 3127) respectively. Mortality was 19% (20/106). The mortality was significantly associated with poorer AIS score, VD, and duration of ICU and hospital stay. All patients were discharged to home only after they became ventilator-free.

CONCLUSIONS

The ventilator burden, hospital stay, and mortality are high in patients with CSCI in LMICs. Poor AIS scores, prolonged VD, ICU and hospital stay are associated with mortality. There is a need for comprehensive CSCI rehabilitation programs in LMICs to improve outcome.

Evaluating a Novel Prehospital Emergency Trauma Care Assessment Tool (PETCAT) for Low- and Middle-Income Countries in Sierra Leone

BACKGROUND

WHO recommends training lay first responders (LFRs) as the first step toward formal emergency medical services development, yet no tool exists to evaluate LFR programs.

METHODS

We developed Prehospital Emergency Trauma Care Assessment Tool (PETCAT), a seven-question survey administered to first-line hospital-based healthcare providers, to independently assess LFR prehospital intervention frequency and quality. PETCAT surveys were administered one month pre-LFR program launch (June 2019) in Makeni, Sierra Leone and again 14 months post-launch (August 2020). Using a difference-in-differences approach, PETCAT was also administered in a control city (Kenema) with no LFR training intervention during the study period at the same intervals to control for secular trends. PETCAT measured change in both the experimental and control locations. Cronbach's alpha, point bi-serial correlation, and inter-rater reliability using Cohen's Kappa assessed PETCAT reliability.

RESULTS

PETCAT administration to 90 first-line, hospital-based healthcare providers found baseline prehospital intervention were rare in Makeni and Kenema prior to LFR program launch (1.2/10 vs. 1.8/10). Fourteen months post-LFR program implementation, PETCAT demonstrated prehospital interventions increased in Makeni with LFRs (5.2/10, p < 0.0001) and not in Kenema (1.2/10) by an adjusted difference of + 4.6 points/10 (p < 0.0001) ("never/rarely" to "half the time"), indicating negligible change due to secular trends. PETCAT demonstrated high reliability (Cronbach's α = 0.93, Cohen's K = 0.62).

CONCLUSIONS

PETCAT measures changes in rates of prehospital care delivery by LFRs in a resource-limited African setting and may serve as a robust tool for independent EMS quality assessment.

Pediatric Orthopaedic Observerships in North America for International Surgeons: The Visitor's Perspective

BACKGROUND

There is substantial disparity in access to surgical care worldwide that largely impacts children in resource-limited environments. Although it has been suggested that surgeons in high-income countries work alongside their overseas peers to bridge this gap, there is limited information regarding the impact of pediatric orthopaedic observerships that are available to international surgeons. This study aimed to assess the perceived impact of such visitations on overseas surgeons, including their professional development and clinical practice.

METHODS

A survey was distributed to overseas surgeons who participated in a pediatric orthopaedic observership in North America in the years 2009 to 2019. Details were collected regarding each respondent's demographics and observership program, and the impact of this short-term clinical experience as perceived by the visiting surgeon.

RESULTS

Of the 181 international surgeons from 56 countries who participated in a pediatric orthopaedic observership, most were young male surgeons residing in a middle-income nation. The majority of surgeons observed in outpatient clinics (98%) and in the operating room (96%) and attended educational in-house conferences (92%). Most observers (75%) acknowledged gaining relevant orthopaedic knowledge and clinical skills that improved local patient care, and nearly all (99%) shared the newly acquired knowledge with their peers and trainees. Most (97%) were still living and working in the country that had been their residence at the time of their observership. No noteworthy trends were identified between the income classification of the surgeons' country of residence and their ability to incorporate the acquired skills into their practice.

CONCLUSIONS

Participating in a North American pediatric orthopaedic observership has a positive perceived impact on the majority of visiting surgeons, with potential gains in clinical skills and knowledge that likely benefit their patients, peers, and trainees. Such participation does not contribute to substantial brain drain and may assist with local capacity building. Identifying ways to increase access to such educational opportunities, particularly for surgeons from lower-income countries, should be explored further.

Delay in Initial Debridement for Open Tibial Fractures and Its Possible Impact on Patient Outcomes: A Single-Center Prospective Cohort Study

The current consensus regarding the management of open fracture indicates that the initial debridement should be performed within the first 6 hours after injury. Unfortunately, in Pakistan, the emergency medical services are not well-established and patient arrival at the hospital is delayed the majority of the time. In this study, we present our experience with delayed surgical management of open tibial fractures.

Assessing the Impact of the Pediatric Orthopaedic Society of North America (POSNA) Visiting Scholar Program

BACKGROUND

The primary objective of the Pediatric Orthopaedic Society of North America (POSNA)-Children's Orthopaedics in Underserved Regions (COUR) Visiting Scholar Program is to engage emerging leaders from low-income and middle-income countries (LMICs) in POSNA educational offerings. This study aims to outline the educational and leadership activities pursued by the alumni of the POSNA-COUR Visiting Scholars Program. We hypothesized that there may be a discrepancy between visiting scholar interest level and actual participation in key follow-up educational and leadership activities.

METHODS

A 32-question online survey developed by the POSNA-COUR committee was electronically delivered to the POSNA-COUR visiting scholarship recipients from 2007 to 2019. The survey inquired about scholars' educational background, clinical practice, and academic interests. Respondents also reported educational, research, and leadership activities that occurred following program participation.

RESULTS

Fifty-seven percent (44/77) of the previous scholars participated in the survey. Sixty-eight percent reported that >75% of their practice was comprised of pediatric patients. The COUR scholarship afforded 15 scholars the opportunity to attend their first educational conference in North America. The majority (86%) of respondents consulted POSNA members on care-related issues, 52% organized a POSNA member's visit to their country, and 13% have become members of POSNA. Scholars shared their knowledge with colleagues through lectures (73%), demonstration of surgical skills (63%), mentorship (59%), hosting local courses (43%), and research (14%). There was a significant discrepancy between interest and actual participation in research (98% vs. 16%, P<0.0001), hosting a regional course (98% vs. 43%, P<0.0001), and becoming a member of POSNA (96% vs. 13%, P<0.0001).

CONCLUSIONS

The POSNA-COUR Visiting Scholar Program is effective at providing beneficial educational opportunities to orthopaedic surgeons from LMICs. There is, however, a significant discrepancy between reported scholar interest and actual engagement in leadership endeavors including: research, organization of regional courses, and POSNA membership. The impact of the POSNA-COUR visiting scholar program can be enhanced through collaboration with scholarship alumni in these key areas.

LEVEL OF EVIDENCE

Level IV-case series.

Prevalence, causes and impact of musculoskeletal impairment in Malawi: A national cluster randomized survey

BACKGROUND

There is a lack of accurate information on the prevalence and causes of musculoskeletal impairment (MSI) in low income countries. The WHO prevalence estimate does not help plan services for specific national income levels or countries. The aim of this study was to find the prevalence, impact, causes and factors associated with musculoskeletal impairment in Malawi. We wished to undertake a national cluster randomized survey of musculoskeletal impairment in Malawi, one of the UN Least Developed Countries (LDC), that involved a reliable sampling methodology with a case definition and diagnostic criteria that could clearly be related to the classification system used in the WHO International Classification of Functioning, Disability and Health (ICF).

METHODS

A sample size of 1,481 households was calculated using data from the latest national census and an expected prevalence based on similar surveys conducted in Rwanda and Cameroon. We randomly selected clusters across the whole country through probability proportional to size sampling with an urban/rural and demographic split that matched the distribution of the population. In the field, randomization of households in a cluster was based on a ground bottle spin. All household members present were screened, and all MSI cases identified were examined in more detail by medical students under supervision, using a standardized interview and examination protocol. Data collection was carried out from 1st July to 30th August 2016. Extrapolation was done based on study size compared to the population of Malawi. MSI severity was classified using the parameters for the percentage of function outlined in the WHO International Classification of Functioning (ICF). A loss of function of 5-24% was mild, 25-49% was moderate and 50-90% was severe. The Malawian version of the EQ-5D-3L questionnaire was used, and EQ-5D index scores were calculated using population values from Zimbabwe, as a population value set for Malawi is not currently available. Chi-square test was used to test categorical variables. Odds ratio (OR) was calculated with a linear regression model adjusted for age, gender, location and education.

RESULTS

A total of 8,801 individuals were enumerated in 1,481 households. Of the 8,548 participants that were screened and examined (response rate of 97.1%), 810 cases of MSI were diagnosed of which 18% (108) had mild, 54% (329) had moderate and 28% (167) had severe MSI as classified by ICF. There was an overall prevalence of MSI of 9.5% (CI 8.9-10.1). The prevalence of MSI increased with age, and was similar in men (9.3%) and women (9.6%). People without formal education were more likely to have MSI [13.3% (CI 11.8-14.8)] compared to those with formal education levels [8.9% (CI 8.1-9.7), p<0.001] for primary school and [5.9% (4.6-7.2), p<0.001] for secondary school. Overall, 33.2% of MSIs were due to congenital causes, 25.6% were neurological in origin, 19.2% due to acquired non-traumatic non-infective causes, 16.8% due to trauma and 5.2% due to infection. Extrapolation of these findings indicated that there are approximately one million cases of MSI in Malawi that need further treatment. MSI had a profound impact on quality of life. Analysis of disaggregated quality of life measures using EQ-5D showed clear correlation with the ICF class. A large proportion of patients with moderate and severe MSI were confined to bed, unable to wash or undress or unable to perform usual daily activities.

CONCLUSION

This study has uncovered a high prevalence of MSI in Malawi and its profound impact on a large proportion of the population. These findings suggest that MSI places a considerable strain on social and financial structures in this low-income country. The Quality of Life of those with severe MSI is considerably affected. The huge burden of musculoskeletal impairment in Malawi is mostly unattended, revealing an urgent need to scale up surgical and rehabilitation services in the country.

Using video calling to simulate arthroscopic surgery in a resource-poor setting

There is high demand for arthroscopic procedures in the developing world. Simulation allows trainees to develop basic arthroscopic skills away from theatre, where there may be reduced surgical exposure compared with centres with established arthroscopic practice. Smartphones are widely available and accessible throughout the world. We propose a method to create a low-cost, low-fidelity arthroscopic simulator that can be used at home by using the video call function of smartphones. We used readily available materials from a local market. An adequately sized cardboard box was used to house exercises, LED head torch as a light source, bamboo skewers as probes and a smartphone with video call function allowed visualisation without the need to purchase additional equipment. The whole simulator was constructed using less than 50 ZAR (US$3) of new materials. The arthroscopic simulator can be built simply and is easily portable. Established training exercises can be practised and allow development of basic arthroscopic skills. Our home-made simulator is inexpensive, simple to construct and does not require additional hardware (or software) purchases by the trainee. It is a perfect solution for individuals who want to practise their arthroscopic skills, either at home or at the workplace.

[Prevention of musculoskeletal disorders among nurses of a provincial hospital in Vietnam: Issue and health policy context]

OBJECTIVE

To study the situation of MSDs among nursing staff and the barriers to implementing an MSD preventive intervention in Vietnamese hospitals.

METHODS

A mixed design has been devised. The quantitative component aimed to study the prevalence of MSDs, the associations between MSDs and potential risk factors and consequences of MSDs; the qualitative component focused on the study of facilitators/barriers to the implementation of a MSDs prevention program in Vietnamese hospitals.

RESULTS

The prevalence of lower back, neck and shoulders MSDs, over the past 12 months, was the highest in the neck (59%) and then in lower back (49%), shoulders (40%). Factors associated with these disorders are mainly the presence of stress, being a woman and work intensity. MSD-related pain has an impact on the ability to work and the quality of life. The lack of knowledge on MSDs by health care administrators inside and outside the hospitals and the lack of human resources with expertise in MSD management are important barriers to the implementation of an MSD prevention program in Vietnamese hospitals.

CONCLUSIONS

MSDs represent a serious occupational health problem in hospitals. Reducing the prevalence of MSDs requires not only an increased awareness about this serious problem among administrators, but also the development of expertise in MSD management.

Surgical Implant Generation Network Implant Follow-up: Assessment of Squat and Smile and Fracture Healing

OBJECTIVES

To evaluate the reliability, sensitivity, and specificity of the Squat and Smile (S&S) test, a clinical photographic follow-up, in determination of fracture healing and to assess the extent of continued fracture healing beyond 1-year postoperation.

DESIGN

Retrospective review of the Surgical Implant Generation Network (SIGN) database.

SETTING

The S&S test is utilized in low-resource settings where the SIGN intramedullary nail is used due to unavailability of intraoperative fluoroscopy.

PATIENTS/PARTICIPANTS

One hundred fifty patients undergoing fracture fixation utilizing SIGN intramedullary nails with data available at least 1 year (9-16 months) after surgery.

INTERVENTION

None.

MAIN OUTCOME MEASURES

We extracted clinical data and calculated scores for the S&S photographs and radiographs at the 1-year (9-16 month postoperative) follow-up and last follow-up available beyond that. We analyzed the sensitivity of S&S scoring, using Radiographic Union Scale for Tibia fracture scores as the gold standard for fracture union.

RESULTS

Of the 126 patients analyzed, 21% were found to have incomplete healing at 1 year, whereas 17% of the 64 patients with further follow-up past 1 year had incomplete healing. We found that both S&S and radiographic fracture healing scores had good interrater reliability (k = 0.73-0.78 for S&S and 0.94 for radiographs). The S&S test had poor sensitivity (0.11) and specificity (0.85) in determining fracture healing at the 1-year follow-up.

CONCLUSIONS

The S&S scoring method was reliable but neither sensitive nor specific for determining fracture healing at 1 year. Fractures deemed incompletely healed by radiographic evaluation at 1 year after SIGN implant may still have the potential to heal over time.

LEVEL OF EVIDENCE

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

Diet satisfaction and associated factors among adult surgical orthopaedic inpatients at a teaching hospital in Lusaka province, Zambia; a hospital-based cross-sectional study

Background

Poor quality of food services in hospital contributes to low diet satisfaction among inpatients in both developed and developing countries. However, there is paucity of literature on diet satisfaction in health care facilities in the sub-Saharan region and in particular Zambia. Therefore, this study sought to assess levels of diet satisfaction among adult surgical orthopaedic inpatients at a teaching hospital in Lusaka province, Zambia.

Methods

A hospital-based cross-sectional study was conducted over a period of three months. Comprehensive sampling was used to select 98 study participants. A researcher-administered questionnaire adapted from a similar study was used to collect data. The instrument used in this study had 9 aspects of satisfaction. Descriptive statistics such as frequencies, percentages, means and standard deviations were used to analyze the data. Chi-square test was used to test for associations between categorical data. A p-value of less than 0.05 was considered to be statistically significant.

Results

In this study, 64.3% of surgical orthopaedic inpatients were not satisfied with overall quality of hospital food. In addition, 76.5, 96.9, 65.3 and 71.4% of the patients were not satisfied with type, variety, appearance and taste of hospital food respectively. However, patients who were satisfied with portion size, temperature and time of meal distribution were 67.3, 94.9 and 56.1% respectively. There was no significant association between variables of age, sex, education level, marital status, monthly income, days in hospital and overall satisfaction (p > 0.05).

Conclusion

Low diet satisfaction is a global problem associated with poor quality of hospital meals. Although the majority of surgical orthopaedic inpatients were not satisfied with more than half of the dimensions of diet satisfaction, they were satisfied with aspects of portion size, temperature and time of meal distribution. Therefore, an assessment of diet satisfaction can inform hospital administrators and policy makers on the deficiencies in hospital diets and thereby help improve quality of meals.

Electronic supplementary material

The online version of this article (10.1186/s40795-019-0288-5) contains supplementary material, which is available to authorized users.

Cervical spine pathology and treatment: a global overview

Cervical spine pathology is becoming increasingly prevalent with an aging world population and is associated with significant morbidity, affecting all areas of the world. This review was undertaken to provide a global perspective on cervical spine pathology, including epidemiology, burden of disease, access to care, and plan of care in both developed and developing low- and middle-income countries (LMICs). We found that epidemiology, access to care, plan of care, and health outcomes were relatively similar between nations with similar economies. However, these aspects change dramatically when comparing developing nations to LMICs, with LMICs displaying substantial barriers to care and subsequently higher rates of morbidity and mortality. There is currently a need for large-scale, global, prospective multicenter studies that analyze not only the epidemiology and treatment of cervical spine pathology, but also consider patient outcomes.

Assessing the capacity of Malawi's district and central hospitals to manage traumatic diaphyseal femoral fractures in adults

Background

The burden of musculoskeletal trauma is growing worldwide, disproportionately affecting low-income countries like Malawi. However, resources required to manage musculoskeletal trauma remain inadequate. A detailed understanding of the current capacity of Malawian public hospitals to manage musculoskeletal trauma is unknown and necessary for effective trauma system development planning.

Methods

We developed a list of infrastructure, manpower, and material resources used during treatment of adult femoral shaft fractures–a representative injury managed non-operatively and operatively in Malawi. We identified, by consensus of at least 7 out of 10 experts, which items were essential at district and central hospitals. We surveyed orthopaedic providers in person at all 25 district and 4 central hospitals in Malawi on the presence, availability, and reasons for unavailability of essential resources. We validated survey responses by performing simultaneous independent on-site assessments of 25% of the hospitals.

Results

No district or central hospital in Malawi had available all the essential resources to adequately manage femoral fractures. On average, district hospitals had 71% (range 41–90%) of essential resources, with at least 15 of 25 reporting unavailability of inpatient ward nurses, x-ray, external fixators, gauze and bandages, and walking assistive devices. District hospitals offered only non-operative treatment, though 24/25 reported barriers to performing skeletal traction. Central hospitals reported an average of 76% (71–85%) of essential resources, with at least 2 of 4 hospitals reporting unavailability of full blood count, inpatient hospital beds, a procedure room, an operating room, casualty/A&E department clinicians, orthopaedic clinicians, a circulating nurse, inpatient ward nurses, electrocardiograms, x-ray, suture, and walking assistive devices. All four central hospitals reported barriers to performing skeletal traction. Operative treatment of femur fracture with a reliable supply of implants was available at 3/4 hospitals, though 2/3 were dependent entirely on foreign donations.

Conclusion

We identified critical deficiencies in infrastructure, manpower, and essential resources at district and central hospitals in Malawi. Our findings provide evidence-based guidance on how to improve the musculoskeletal trauma system in Malawi, by identifying where and why essential resources were unavailable when needed.

Development of generic Asian pelvic bone models using CT-based 3D statistical modelling

Background/Objective

Artificial bone models (ABMs) are used in orthopaedics for research of biomechanics, development of implants and educational purposes. Most of the commercially available ABMs approximate the morphology of Europeans, but they may not depict the Asian anatomy. Therefore, our aim was to develop the first Asian ABM of the pelvis and compare it with the existing pelvic ABM (Synbone®; Caucasian male).

Methods

One hundred clinical computed tomography (CTs) of adult pelvises (male n ​= ​50, female n ​= ​50) of Malay, Chinese and Indian descent were acquired. CTs were segmented and defined landmarks were placed. Three 3D statistical pelvic model and mean models (overall, male, female) were generated. Anatomical variations were analysed using principal component analysis. To measure gender-related differences and differences to the existing ABM, distances between the anterior superior iliac spines (ASIS), the anterior inferior iliac spines (AIIS), the promontory and the symphysis (conjugate vera, CV) as well as the ischial spines (diameter transversa, DT) were quantified.

Results

Principal component analysis displayed large variability regarding the pelvic shape and size. Female and male statistical models were similar in ASIS (225 ​± ​20; 227 ​± ​13 ​mm; P ​= ​0.4153) and AIIS (185 ​± ​11; 187 ​± ​10 ​mm; P ​= ​0.3982) and differed in CV (116 ​± ​10; 105 ​± ​10 ​mm; P ​< ​0.0001) and DT (105 ​± ​7; 88 ​± ​8 ​mm; P ​< ​0.0001). Comparing the unisex mean model with the pre-existing ABM, the ASIS (226; 275 ​mm; P ​< ​0.0001), the AIIS (186; 209 ​mm; P ​< ​0.0001) and the CV (111; 105 ​mm; P ​< ​0.0001) differed significantly. Both models were similar regarding DT (97; 95 ​mm; P ​= ​0.6927). The analysis revealed notable gender- and size-dependent anatomical variations within the Asian population. Chinese, Malay and Indian descents did not differ notably. The overall Asian model was smaller than the existing ABM.

The translation potential of this article

Owing to the large differences between the Asian ABM and the pre-existing ABM, as well as differences between genders, the use of an Asian- and gender-specific ABM is important to consider in research, biomechanics and implant development for this population.

Risk Factors for Infection After Intramedullary Nailing of Open Tibial Shaft Fractures in Low- and Middle-Income Countries

OBJECTIVES

(1) To determine the infection rate after fixation of open tibial shaft fractures using the Surgical Implant Generation Network (SIGN) intramedullary nail in low- and middle-income countries (LMICs) and (2) to identify risk factors for infection.

DESIGN

Prospective cohort study using an international online database.

SETTING

Multiple hospitals in LMICs worldwide.

PATIENTS/PARTICIPANTS

A total of 1061 open tibia fractures treated with the SIGN nail in LMICs between March 2000 and February 2013.

INTERVENTION

Intravenous antibiotic administration, surgical debridement, and definitive intramedullary nailing within 14 days of injury.

MAIN OUTCOME MEASUREMENTS

Deep or superficial infection at follow-up, implant breakage/loosening, angular deformity >10 degrees, repeat surgery, radiographic union, weight bearing, and ability to kneel.

RESULTS

The overall infection rate was 11.9%. Infection rates by the Gustilo and Anderson classification were type 1: 5.1%, type II: 12.6%, type IIIa: 12.5%, type IIIb: 29.1%, and type IIIc: 16.7% (P = 0.001 between groups). Patients who developed infection had a longer mean time from injury to definitive surgery (4.7 vs. 3.9 days, P = 0.03) and from injury to wound closure (13.7 vs. 3.6 days, P < 0.001). Distal fractures had a higher infection rate than midshaft fractures (13.3% vs. 8.2%, P = 0.03). Infection rates were not associated with time from injury to initial debridement, time from injury to initial antibiotic administration, or total duration of antibiotics.

CONCLUSIONS

Open tibia fractures can be managed effectively using the SIGN intramedullary nail in LMICs with an overall infection rate of 11.9%. Risk factors for infection identified include more severe soft-tissue injury, delayed nailing, delayed wound closure, and distal fracture location.

LEVEL OF EVIDENCE

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

Risk Factors for Delayed Presentation Among Patients with Musculoskeletal Injuries in Malawi

BACKGROUND

The burden of injuries is high in low-income and middle-income countries such as Malawi, where access to musculoskeletal trauma care is limited. Delayed treatment can worsen trauma-related disability. Understanding risk factors for delayed hospital presentation will assist in guiding trauma system development.

METHODS

We examined the records of 1,380 pediatric and adult patients with fractures who presented to the orthopaedic clinics of 2 urban referral hospitals and 2 rural district hospitals in Malawi. We used multivariate Poisson regression to evaluate the association between presentation to a hospital ≥2 days after the injury (delayed presentation) and 11 covariates: age, sex, education level, occupation, season of injury, day of injury, injury mechanism, injury type or extremity of injury, referral status, hospital of presentation, and estimated travel time.

RESULTS

Twenty-eight percent of pediatric patients and 34% of adult patients presented late. In the pediatric cohort, fall (relative risk [RR], 1.40 [95% confidence interval (CI), 1.02 to 1.93]), sports injuries (RR, 1.65 [95% CI, 1.09 to 2.49]), tibial or fibular injuries (RR, 1.36 [95% CI, 1.05 to 1.77]), injury over the weekend (RR, 2.30 [95% CI, 1.88 to 2.80]), estimated travel time of ≥20 minutes (RR, 1.45 [95% CI, 1.16 to 1.81]), referral from another facility (RR, 1.46 [95% CI, 1.05 to 2.02]), and presentation to Kamuzu Central Hospital, Mangochi District Hospital, or Nkhata Bay District Hospital (RR, 1.34 [95% CI, 1.07 to 1.69]) independently increased the risk of delayed presentation. In the adult cohort, fall (RR, 1.85 [95% CI, 1.38 to 2.46]), injury over the weekend (RR, 1.80 [95% CI, 1.38 to 2.36]), estimated travel time ≥20 minutes (RR, 1.36 [95% CI, 1.03 to 1.80]), and presentation to Kamuzu Central Hospital (RR, 1.74 [95% CI, 1.30 to 2.33]) independently increased the risk of delayed presentation.

CONCLUSIONS

Delayed presentation to the hospital after a musculoskeletal injury is common in Malawi. Interventions are needed to improve access to musculoskeletal trauma care, especially for pediatric patients with tibial or fibular injuries, all patients after falls, patients injured over the weekend, and patients living far from health facilities.

Limited availability of global health opportunities in US orthopaedic trauma fellowship programs

Purpose

Orthopaedic residents are increasingly seeking international health electives (IHEs) during training, and many such experiences involve providing orthopaedic trauma care. However, little is known about the availability of IHEs during orthopaedic trauma fellowship training. The purpose of our study is to assess the global health opportunities available to US orthopaedic trauma fellows.

Method

We conducted an online, Research Electronic Data Capture (REDCap)-based survey of orthopaedic trauma fellowship program directors (PDs) in the United States. The survey link was sent by the Orthopaedic Trauma Association (OTA) Fellowship Committee to all US OTA-approved orthopaedic trauma fellowship PDs. Follow-up reminder e-mails were delivered at set time intervals from baseline over a period of 4 weeks.

Results

The overall response rate was 80% (43/54). Only 3 of 43 responding programs (7%) offer a structured global health program, but over the last 10 years, 12.5% of the remaining programs (5/40) have had a fellow participate in an IHE during fellowship training. Around 100% of PDs reported fellow satisfaction with their IHEs, and all PDs agreed that the educational experience provided by their fellows' IHE participation was valuable. Among programs with no recent fellow IHE participation and without a structured global health program, 9% of PDs (3/35) expect to institute such a program. Lack of funding, lack of established international partner sites, and fellow time away were the most common perceived barriers to IHE participation. A total of 54% of PDs agree that participation in an IHE during training plays a major role in shaping fellows' future professional and volunteer activities.

Conclusion

There are limited global health opportunities among US orthopaedic trauma fellowship programs, with only 7% (3/43) offering a structured global health program. Perceived barriers include lack of funding, lack of established partner sites, and concerns related to clinical/call coverage. Greater efforts to establish sustainable funding and international partnerships may increase opportunities for IHEs during orthopaedic trauma fellowship training.

Strategies occupational therapists employ to facilitate work-related transitions for persons with hand injuries: a study protocol for a scoping review

INTRODUCTION

Hands make it possible to be employable and productive, to communicate non-verbally and to perform fine motor tasks required in day-to-day activities. Sustaining a hand injury can be detrimental to function including the ability to work. As the literature on work-related transitions is scattered across a range of journals, it is difficult to get a sense of how much literature there is, what is known and where the gaps lie. This scoping study will provide a single source of up-to-date evidence to inform health professionals about the strategies occupational therapists employ to facilitate work-related transitions for people with hand injuries.

METHODS AND ANALYSIS

The methodological framework by Arksey and O'Malley (2005) will form the structure of the scoping review. The search strategy has been developed in collaboration with a subject librarian. The following databases will be searched: EBSCOhost including only Medline, CINAHL and Health Source: Nursing/Academic Edition; PubMed, Scopus, The Cochrane library and Web of Science. Reference lists will be examined, and grey literature sources will be searched to ensure that literature missed in the database searches is included. Covidence will be used to manage the project. Full-texts will be uploaded for literature that meets the inclusion criteria. A process of blind review will be used to ensure that consistency and rigour is upheld.

ETHICS AND DISSEMINATION

The findings of the scoping review will be disseminated in an article, within 2019, to be published in a peer-reviewed journal. The findings will be presented at conferences to ensure the optimal dissemination of the scoping review's conclusions.

Development of Squat-and-Smile Test as Proxy for Femoral Shaft Fracture-Healing in Patients in Dar es Salaam, Tanzania

BACKGROUND

There are few validated instruments that serve as a proxy for fracture-healing after lower-extremity trauma in low-resource settings. The squat-and-smile test (S&S) has been under development by SIGN (Surgical Implant Generation Network) Fracture Care International to monitor outcomes of lower-extremity long-bone fractures after intramedullary nailing in resource-limited settings. The goals of this study were to develop and identify domains of the S&S test.

METHODS

The S&S domains were developed through an iterative process, and consensus was achieved regarding 3: squat depth, support needed to squat, and facial expression. Adult patients with an OTA/AO type-32 femoral shaft fracture were included in this retrospective study and had the S&S administered at 6 weeks and 3, 6, and 12 months postoperatively. Two authors independently assessed photographs of the patients performing the S&S. S&S domains were correlated with the EuroQol 5-Dimensions (EQ-5D) index score, and comparisons were made between S&S domains and reoperation status. Interrater and test-retest reliability was assessed using the kappa statistic. Sensitivity and specificity analyses were performed.

RESULTS

Six hundred and nine S&S images were evaluated for 231 patients. Each domain improved over time and correlated positively with EQ-5D scores (p < 0.05). Squat depth and support needed to squat correlated with the need for a reoperation (p ≤ 0.01), and both had high specificity (0.95 and 0.97, respectively) for ruling out the need for a reoperation at 1 year. All 3 domains had high test-retest reliability (κ = 0.95, 0.92, and 0.96). Squat depth and need for support also had strong interrater reliability (κ = 0.75 and 0.78).

CONCLUSIONS

The S&S is a potential tool for monitoring clinical and functional outcome of femoral shaft fractures in low-resource settings. Our data support the binary assessment of squat depth and need for support, but not facial expression, as a proxy for fracture-healing. Future prospective studies in external populations are warranted to evaluate the validity, reliability, and responsiveness of the S&S.

CLINICAL RELEVANCE

The S&S provides a valuable proxy for femoral shaft fracture assessment for middle to low-income countries because it is locally relevant (based on squatting), it is easy to administer, and assessment can be performed remotely via mobile telephone or text messaging.

Rehabilitation and management outcomes of musculoskeletal injuries in a major referral hospital in Ghana

Background

The devastating impact of musculoskeletal injury (MSI) on human lives, the economy, and health services cannot be overemphasised. This has ignited discussion at international fora, as countries have been exhorted to prioritise management of MSI in order to maintain a healthy society. In the Ghanaian context, the knowledge base management of MSI is very low, which has provided the impetus to explore the management of MSI and the rehabilitation systems at a tertiary hospital in Ghana.

Methods

The study was a retrospective cross-sectional study, using the consecutive sampling method to recruit patients who were discharged after admission at the accident and emergency unit, as well as patients undergoing orthopaedic review, at the St. Joseph’s Orthopaedic Hospital in Koforidua over a six-month period.

Results

A total of 269 musculoskeletal injury patients were recruited for the study. Half of the participants (51%) had had surgery in addition to pain medication. The overall mean recovery days were 26.81 ± 33.94 days, and the average disability days spent in the hospital were estimated at 16.54 ± 27.97 days. Individuals reported financial constraints as a major challenge to their full participation in rehabilitation.

Conclusion

The findings of this study have implications for policymaking in Ghana. Particularly, the need to improve health facilities to enable MSI patients to seek treatment is highlighted. Also, the need to train health professionals who will be able to administer appropriate medication for MSI patients is discussed extensively.

Clinical Outcomes and Complications of the Surgical Implant Generation Network (SIGN) Intramedullary Nail: A Systematic Review and Meta-Analysis

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.

Improving surgical antibiotic prophylaxis adherence and reducing hospital readmissions: a bundle of interventions including health information technologies

OBJECTIVES

Infection following orthopaedic surgery is a feared complication and an indicator of the quality of the hospital. Surgical antibiotic prophylaxis (SAP) guidelines are not always properly followed. Our aim was to describe and evaluate the impact of a multidisciplinary intervention on antibiotic prophylaxis adherence to hospital guidelines and 30-day postoperative outcomes.

METHODS

The study was carried out from January to May 2016 and consisted of creating a multidisciplinary team, updating institutional guidelines and embedding the recommendations in the computerised physician order entry system which is linked to dose and renal function alerts, educational activities and pharmaceutical bedside care of patients in the orthopaedic department. A prospective pre-post study was carried out in accordance with the Declaration of Helsinki. The following information was recorded: patient and surgery characteristics, adherence to SAP guidelines, surgical site infections, length of hospital stay and rate of readmission 30 days after discharge. Statistical analyses were performed using SPSS 18.0.

RESULTS

Eighty three orthopaedic patients of mean±SD age 68.2±17.0 years (44.6% male, 40 in the pre-intervention group and 43 in the intervention group) were included. Cefazolin was the recommended and most commonly administered antibiotic agent. In the intervention group, an improvement in global adherence to guidelines was achieved (76.7% vs 89.9%; p=0.039): antibiotic duration (75.0% vs 97.7%), correct dosage post-surgery (55.0% vs 76.7%), timing of administration (57.5% vs 72.1%), antibiotic pre-surgery prescription (92.5% vs 97.7%). Three surgical site infections were detected in the pre-intervention group and none in the intervention group (p>0.05). Length of hospital stay was reduced by 1 day and readmission decreased by 15% (p=0.038).

CONCLUSIONS

SAP is used in daily practice in most orthopaedic patients. The implementation of a multidisciplinary programme based on health technology improved the adherence to guidelines and appeared to reduce the readmission rate.

The Global Spine Care Initiative: model of care and implementation

PURPOSE

Spine-related disorders are a leading cause of global disability and are a burden on society and to public health. Currently, there is no comprehensive, evidence-based model of care for spine-related disorders, which includes back and neck pain, deformity, spine injury, neurological conditions, spinal diseases, and pathology, that could be applied in global health care settings. The purposes of this paper are to propose: (1) principles to transform the delivery of spine care; (2) an evidence-based model that could be applied globally; and (3) implementation suggestions.

METHODS

The Global Spine Care Initiative (GSCI) meetings and literature reviews were synthesized into a seed document and distributed to spine care experts. After three rounds of a modified Delphi process, all participants reached consensus on the final model of care and implementation steps.

RESULTS

Sixty-six experts representing 24 countries participated. The GSCI model of care has eight core principles: person-centered, people-centered, biopsychosocial, proactive, evidence-based, integrative, collaborative, and self-sustaining. The model of care includes a classification system and care pathway, levels of care, and a focus on the patient's journey. The six steps for implementation are initiation and preparation; assessment of the current situation; planning and designing solutions; implementation; assessment and evaluation of program; and sustain program and scale up.

CONCLUSION

The GSCI proposes an evidence-based, practical, sustainable, and scalable model of care representing eight core principles with a six-step implementation plan. The aim of this model is to help transform spine care globally, especially in low- and middle-income countries and underserved communities. These slides can be retrieved under Electronic Supplementary Material.

A scoping review of biopsychosocial risk factors and co-morbidities for common spinal disorders

OBJECTIVE

The purpose of this review was to identify risk factors, prognostic factors, and comorbidities associated with common spinal disorders.

METHODS

A scoping review of the literature of common spinal disorders was performed through September 2016. To identify search terms, we developed 3 terminology groups for case definitions: 1) spinal pain of unknown origin, 2) spinal syndromes, and 3) spinal pathology. We used a comprehensive strategy to search PubMed for meta-analyses and systematic reviews of case-control studies, cohort studies, and randomized controlled trials for risk and prognostic factors and cross-sectional studies describing associations and comorbidities.

RESULTS

Of 3,453 candidate papers, 145 met study criteria and were included in this review. Risk factors were reported for group 1: non-specific low back pain (smoking, overweight/obesity, negative recovery expectations), non-specific neck pain (high job demands, monotonous work); group 2: degenerative spinal disease (workers' compensation claim, degenerative scoliosis), and group 3: spinal tuberculosis (age, imprisonment, previous history of tuberculosis), spinal cord injury (age, accidental injury), vertebral fracture from osteoporosis (type 1 diabetes, certain medications, smoking), and neural tube defects (folic acid deficit, anti-convulsant medications, chlorine, influenza, maternal obesity). A range of comorbidities was identified for spinal disorders.

CONCLUSION

Many associated factors for common spinal disorders identified in this study are modifiable. The most common spinal disorders are co-morbid with general health conditions, but there is a lack of clarity in the literature differentiating which conditions are merely comorbid versus ones that are risk factors. Modifiable risk factors present opportunities for policy, research, and public health prevention efforts on both the individual patient and community levels. Further research into prevention interventions for spinal disorders is needed to address this gap in the literature.

"That's what you do for people you love": A qualitative study of social support and recovery from a musculoskeletal injury

Background

Social support has been identified as a significant factor in facilitating better health outcomes following injury. However, research has primarily focused on the role of social support from the perspective of the person experiencing an injury. Limited research has examined the experiences of the family members and friends of a person with injury. This study aims to explore the perceptions and experiences of social support and recovery following a transport-related musculoskeletal injury (MSI) in a population of injured persons and their family members and friends.

Methods

This study was conducted using a phenomenological qualitative research design. In-depth semi-structured interviews were conducted with ten persons with MSI, recruited via the Transport Accident Commission (TAC) in Victoria, Australia. Seven family members and friends were also interviewed. The data was analysed using constant comparative method and thematic analysis.

Results

Several themes were identified including: (1) key sources and types of support received, (2) relationship development and (3) challenges of providing and receiving support. Participants with MSI reported stories about how the social network provided emotional and tangible support. Family members and friends confirmed the supportive acts provided to the participants with MSI. Positive iterative changes in relationships were reported by the participants with MSI. Participants with MSI, their family members and friends described several difficulties including loss of independence, feeling like a burden, and the impact of caring on health and well-being.

Conclusions

The role of social support is complex given the multitude of people involved in the recovery process. The findings of this study suggest that persons with MSI may benefit from support groups and maintenance of existing support networks. Furthermore, family members and friends engaged in the recovery process may benefit from support in this role.

Characteristics and status of Korean medicine use in whiplash-associated disorder patients

Background

Patients are free to choose conventional or Korean medicine treatment under the dual medical system in Korea, and the prevalence of patients who choose Korean medicine treatment for whiplash-associated disorders (WADs) is high. This study analyzed the sociodemographic characteristics and medical service use in this population to provide healthcare providers with basic usage information of complementary and alternative medicine for WAD.

Methods

A total of 8291 outpatients who registered under automobile insurance coverage and visited the main branch of Jaseng Hospital of Korean Medicine from April 1, 2014 to August 10, 2016 were included. Data on sociodemographic characteristics, symptoms, and accident and treatment-related details were collected from electronic medical records. Univariate and multivariate regression analyses were performed to identify baseline factors predictive of total treatment duration.

Results

The most prevalent demographic of patients who chose Korean medicine for WAD treatment was males in their thirties whose initial visit to the hospital was 16.1 ± 94.1 days from the accident. Neck pain accompanied by low back pain (57.0%) was the most common complaint, and for singular pain, neck pain (13.5%) was the most prevalent. Baseline numeric rating scale (NRS) pain levels were generally moderate (4–6) regardless of area. Patients received 7.2 ± 10.2 sessions of treatment for 32.6 ± 55.3 days. The most commonly prescribed treatment modalities in order of highest frequency were acupuncture, cupping, pharmacopuncture, and herbal medicine, which collectively accounted for > 90% of treatments. Acupuncture was administered 29.0 ± 40.8 times, and cupping 14.0 ± 18.7 times as the two highest frequency treatments. In multivariate regression analysis, longer treatment periods were found to be associated with higher NRS, older age, and delayed initial visits at baseline.

Conclusions

This study highlights the characteristics and Korean medicine use of WAD patients. These results are particularly relevant and informative for consideration of personal preferences and effective prioritization in further insurance coverage.

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

BACKGROUND

The purpose of this study was to determine the socioeconomic implications of isolated tibial and femoral fractures caused by road traffic injuries in Uganda.

METHODS

This prospective longitudinal study included adult patients who were admitted to Uganda's national referral hospital with an isolated tibial or femoral fracture. The primary outcome was the time to recovery following injury. We assessed recovery using 4 domains: income, employment status, health-related quality of life (HRQoL) recovery, and school attendance of the patients' dependents.

RESULTS

The majority of the study participants (83%) were employed, and they were the main income earner for their household (74.0%) at the time of injury, earning a mean annual income of 2,375 U.S. dollars (USD). All of the patients had been admitted with the intention of surgical treatment; however, because of resource constraints, only 56% received operative treatment. By 2 years postinjury, only 63% of the participants had returned to work, and 34% had returned to their previous income level. Overall, the mean monthly income was 62% less than preinjury earnings, and participants had accumulated 1,069 USD in debt since the injury; 41% of the participants had regained HRQoL scores near their baseline, and 62% of school-aged dependents, enrolled at the time of injury, were in school at 2 years postinjury.

CONCLUSIONS

At 2 years postinjury, only 12% of our cohort of Ugandan patients who had sustained an isolated tibial or femoral fracture from a road traffic injury had recovered both economically and physically.

LEVEL OF EVIDENCE

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

The Ankle Injury Management (AIM) trial: a pragmatic, multicentre, equivalence randomised controlled trial and economic evaluation comparing close contact casting with open surgical reduction and internal fixation in the treatment of unstable ankle fractures in patients aged over 60 years

BACKGROUND

Close contact casting (CCC) may offer an alternative to open reduction and internal fixation (ORIF) surgery for unstable ankle fractures in older adults.

OBJECTIVES

We aimed to (1) determine if CCC for unstable ankle fractures in adults aged over 60 years resulted in equivalent clinical outcome compared with ORIF, (2) estimate cost-effectiveness to the NHS and society and (3) explore participant experiences.

DESIGN

A pragmatic, multicentre, equivalence randomised controlled trial incorporating health economic evaluation and qualitative study.

SETTING

Trauma and orthopaedic departments of 24 NHS hospitals.

PARTICIPANTS

Adults aged over 60 years with unstable ankle fracture. Those with serious limb or concomitant disease or substantial cognitive impairment were excluded.

INTERVENTIONS

CCC was conducted under anaesthetic in theatre by surgeons who attended training. ORIF was as per local practice. Participants were randomised in 1 : 1 allocation via remote telephone randomisation. Sequence generation was by random block size, with stratification by centre and fracture pattern.

MAIN OUTCOME MEASURES

Follow-up was conducted at 6 weeks and, by blinded outcome assessors, at 6 months after randomisation. The primary outcome was the Olerud-Molander Ankle Score (OMAS), a patient-reported assessment of ankle function, at 6 months. Secondary outcomes were quality of life (as measured by the European Quality of Life 5-Dimensions, Short Form questionnaire-12 items), pain, ankle range of motion and mobility (as measured by the timed up and go test), patient satisfaction and radiological measures. In accordance with equivalence trial US Food and Drug Administration guidance, primary analysis was per protocol.

RESULTS

We recruited 620 participants, 95 from the pilot and 525 from the multicentre phase, between June 2010 and November 2013. The majority of participants, 579 out of 620 (93%), received the allocated treatment; 52 out of 275 (19%) who received CCC later converted to ORIF because of loss of fracture reduction. CCC resulted in equivalent ankle function compared with ORIF at 6 months {OMAS 64.5 points [standard deviation (SD) 22.4 points] vs. OMAS 66.0 points (SD 21.1 points); mean difference -0.65 points, 95% confidence interval (CI) -3.98 to 2.68 points; standardised effect size -0.04, 95% CI -0.23 to 0.15}. There were no differences in quality of life, ankle motion, pain, mobility and patient satisfaction. Infection and/or wound problems were more common with ORIF [29/298 (10%) vs. 4/275 (1%)], as were additional operating theatre procedures [17/298 (6%) vs. 3/275 (1%)]. Malunion was more common with CCC [38/249 (15%) vs. 8/274 (3%); p < 0.001]. Malleolar non-union was lower in the ORIF group [lateral: 0/274 (0%) vs. 8/248 (3%); p = 0.002; medial: 3/274 (1%) vs. 18/248 (7%); p < 0.001]. During the trial, CCC showed modest mean cost savings [NHS mean difference -£644 (95% CI -£1390 to £76); society mean difference -£683 (95% CI -£1851 to £536)]. Estimates showed some imprecision. Incremental quality-adjusted life-years following CCC were no different from ORIF. Over common willingness-to-pay thresholds, the probability that CCC was cost-effective was very high (> 95% from NHS perspective and 85% from societal perspective). Experiences of treatments were similar; both groups endured the impact of fracture, uncertainty regarding future function and the need for further interventions.

LIMITATIONS

Assessors at 6 weeks were necessarily not blinded. The learning-effect analysis was inconclusive because of limited CCC applications per surgeon.

CONCLUSIONS

CCC provides a clinically equivalent outcome to ORIF at reduced cost to the NHS and to society at 6 months.

FUTURE WORK

Longer-term follow-up of trial participants is under way to address concerns over potential later complications or additional procedures and their potential to impact on ankle function. Further study of the patient factors, radiological fracture patterns and outcomes, treatment responses and prognosis would also contribute to understanding the treatment pathway.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN04180738.

FUNDING

The National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 75. See the NIHR Journals Library website for further project information. This report was developed in association with the National Institute for Health Research Oxford Biomedical Research Unit funding scheme. The pilot phase was funded by the AO Research Foundation.

Perioperative Antibiotic Prophylaxis Has No Effect on Time to Positivity and Proportion of Positive Samples: a Cohort Study of 64 Cutibacterium acnes Bone and Joint Infections

If a bone or joint infection is suspected, perioperative antibiotic prophylaxis is frequently withheld until intraoperative microbiological sampling has been performed. This practice builds upon the hypothesis that perioperative antibiotics could render culture results negative and thus impede tailored antibiotic treatment of infections. We aimed to assess the influence of antibiotic prophylaxis within 30 to 60 min before surgery on time to positivity of microbiological samples and on proportion of positive samples in Cutibacterium acnes bone and joint infections. Patients with at least one sample positive for C. acnes between January 2005 and December 2015 were included and classified as having an "infection" if at least 2 samples were positive; otherwise they were considered to have a sample "contamination." Kaplan-Meier curves were used to illustrate time to culture positivity. We found 64 cases with a C. acnes infection and 46 classified as having a C. acnes contamination. Application of perioperative prophylaxis significantly differed between the infection and contamination groups (72.8% versus 55.8%; P < 0.001). Within the infection group, we found no difference in time to positivity between those who had or had not received a perioperative prophylaxis (7.07 days; 95% confidence interval [CI], 6.4 to 7.7, versus 7.11 days; 95% CI, 6.8 to 7.5; P = 0.3). Also, there was no association between the proportion of sample positivity and the application of perioperative prophylaxis (71.6% versus 65.9%; P = 0.39). Since perioperative prophylaxis did not negatively influence the microbiological yield in C. acnes infections, antibiotic prophylaxis can be routinely given to avoid surgical site infections.

A review of local antibiotic implants and applications to veterinary orthopaedic surgery

In the face of increasing incidence of multidrug resistant implant infections, local antibiotic modalities are receiving increased attention for both infection prophylaxis and treatment. Local antibiotic therapy that achieves very high antibiotic drug concentrations at the site of the implant may represent an avenue for treatment of biofilmforming bacterial pathogens. Randomized controlled trials in human patients have demonstrated an infection risk reduction when antibiotic-impregnated cement is used for infection prophylaxis in implanted joint prostheses, and when a gentamicin-impregnated collagen sponge is used for infection prophylaxis in midline sternotomy. The other modalities discussed have for the most part yet to be evaluated in randomized controlled trials in veterinary or human patients. In general, the in vivo pharmacokinetics and appropriate dosing profiles for local antibiotic modalities have yet to be elucidated. Toxicity is possible, and attention to the dose applied is warranted.

A Systematic Review of Economic Analysis of Surgical Mission Trips Using the World Health Organization Criteria

BACKGROUND

Although the World Health Organization (WHO) has developed tools to standardize economic evaluations of global health interventions, little is known about the cost-effectiveness of surgical mission trips and their economic values. Our objective was to systematically evaluate the current literature on surgical volunteering trips to measure their adherence to WHO CHOosing Interventions that are cost-effective (WHO-CHOICE). We hypothesized that the majority of studies use some type of cost-effectiveness analysis that do not adhere to these standards.

METHODS

A systematic review of Pubmed, Medline, and Embase databases was performed in accordance with PRISMA guidelines, with inclusion criteria set a priori. Of the 908 publications screened, 72 were selected for full text review; 17 met inclusion criteria.

RESULTS

Only 17 out of 72 studies reported some type of economic analysis. We categorized the studies into service, educational, and combination (service and educational) surgical trips. Although seven of the service studies calculated the cost per disability-adjusted life year averted, the results were not based on WHO-CHOICE standards to facilitate comparisons among alternative options. Furthermore, none of the three educational trips calculated the value of the education provided, but only published cost estimates of the resources used during the trip.

CONCLUSIONS

Although a few studies performed some type of economic analysis, owing to their non-adherence to WHO-CHOICE standards, the results were not comparable to other studies. International surgical trips are expensive. To improve the efficacy and optimal use of limited resources, studies on surgical trips should follow the guidelines set by the WHO-CHOICE.

State of Pelvic and Acetabular Surgery in the Developing World: A Global Survey of Orthopaedic Surgeons at Surgical Implant Generation Network (SIGN) Hospitals

OBJECTIVES

To document the current state of pelvic and acetabular surgery in the developing world and to identify critical areas for improvement in the treatment of these complex injuries.

DESIGN

A 50-question online survey.

SETTING

International, multicenter.

PATIENTS/PARTICIPANTS

One hundred eighty-one orthopaedic surgeons at Surgical Implant Generation Network (SIGN) hospitals, which represent a cross-section of institutions in low- and middle-income countries that treat high-energy musculoskeletal trauma.

INTERVENTIONS

Administration and analysis of 50-question survey.

MAIN OUTCOME MEASURES

Surgeon training and experience; hospital resources; volume and patterns of pelvic/acetabular fracture management; postoperative protocols and resources for rehabilitation; financial responsibilities for patients with pelvic/acetabular fractures.

RESULTS

Complete surveys were returned by 75 institutions, representing 61.8% of the global SIGN nail volume. Although 96% of respondents were trained in orthopaedic surgery, 53.3% have no formal training in pelvic or acetabular surgery. Emergency access to the operating room is available at all responding sites, but computed tomography scanners are available at only 60% of sites, and a mere 21% of sites have access to angiography for pelvic embolization. Cannulated screws (53.3%) and pelvic reconstruction plates (56%) are available at just over half of the sites, and 68% of sites do not have pelvic reduction clamps and retractors. 21.3% of sites do not have access to intraoperative fluoroscopy. Responding hospitals see an average of 38.8 pelvic ring injuries annually, with 24% of sites treating them all nonoperatively. Sites treated an average of 22.5 acetabular fractures annually, with 34.7% of institutions treating them all nonoperatively. Patients travel up to 1000 km or 20 hours for pelvic/acetabular treatment at some sites. Although 78.7% of sites have inpatient physical or occupational therapy services, only 17% report access to home physical therapy, and only 9% report availability of nursing or rehabilitation facilities postdischarge. At over 80% of hospitals, patients and their families are at least partially responsible for payment of surgical, implant, hospital, and outpatient fees. Government aid is available for inpatient fees at over 40% of sites, but outpatient services are subsidized at only 28% of sites.

CONCLUSIONS

We report the current state of pelvic and acetabular surgery in low- and middle-income countries. Our results identify significant needs in surgeon training, hospital resources, availability of instruments and implants, and access to appropriate postoperative rehabilitation services for pelvic and acetabular surgery in the developing world. Targeted programs designed to overcome these barriers are required to advance the care of pelvic and acetabular fractures in the developing world.

The Burden of Spine Fractures in India: A Prospective Multicenter Study

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

The objectives of this study were (1) to determine the characteristics of patients sustaining spinal trauma in India and (2) to explore the association between patient or injury characteristics and outcomes after spinal trauma.

METHODS

In affiliation with the ongoing INternational ORthopaedic MUlticentre Study (INORMUS), 192 patients with spinal injuries were recruited during an 8-week period (November 2011 to June 2012) from 14 hospitals in India and followed for 30-days. The primary outcome was a composite of mortality, complications, and reoperation. This was regressed on a set of 13 predictors in a multiple logistic regression model.

RESULTS

Most patients were middle-aged (mean age = 51.0 years; median age = 55.5 years; range = 18.0 to 72.0 years), male (60.4%), injured from falls (72.4%), and treated in a private setting (59.9%). Fractures in the lumbar region (51.0%) were most common, followed by thoracic (30.7%) and cervical (18.2%). More than 1 in 5 (21.6%) patients experienced a treatment delay greater than 24 hours, and 36.5% arrived by ambulance. Thirty-day mortality and complication rates were 2.6% and 10.0%, respectively. Care in the public hospital system (odds ratio [OR] = 6.7, 95% CI = 1.1-41.6), chest injury (OR = 11.1, 95% CI = 1.8-66.9), and surgical intervention (OR = 4.8, 95% CI = 1.2-19.6) were independent predictors of major complications.

CONCLUSIONS

Treatment in the public health care system, increased severity of injury, and surgical intervention were associated with increased risk of major complications following spinal trauma. The need for a large-scale, prospective, multicenter study taking into account spinal stability and neurologic status is feasible and warranted.

Barriers to Clinical Research in Latin America

Enhancing health research capacity in developing countries is a global health priority. Understanding the orthopedic burden of disease in Latin America will require close partnership between more-developed and less-developed countries. To this end, the Osteosynthesis and Trauma Care Foundation assembled a research consortium of Latin-American orthopedic leaders. Prior to the meeting, we surveyed attendees on perceived barriers to conducting research at their institutions. During the event, working groups discussed these barriers, developed strategies for addressing them, and planned future steps for collaboration. The participants established the need for global relationships that allow colleagues from Latin America to access to training and established investigational infrastructure of North American centers to address research questions relevant to their communities. As a result of the discussion, the International Orthopaedic Multicenter Study (INORMUS) in Fracture Care was initiated. Since then, an expanded international working group, Associación de Cirujanos Traumatológicos en las Americas (ACTUAR), has been created with the purpose of promoting increased global partnership for research capacity development.

Understanding and Addressing the Global Need for Orthopaedic Trauma Care

➤The burden of musculoskeletal trauma is high worldwide, disproportionately affecting the poor, who have the least access to quality orthopaedic trauma care.➤Orthopaedic trauma care is essential, and must be a priority in the horizontal development of global health systems.➤The education of surgeons, nonphysician clinicians, and ancillary staff in low and middle income countries is central to improving access to and quality of care.➤Volunteer surgical missions from rich countries can sustainably expand and strengthen orthopaedic trauma care only when they serve a local need and build local capacity.➤Innovative business models may help to pay for care of the poor. Examples include reducing costs through process improvements and cross-subsidizing from profitable high-volume activities.➤Resource-poor settings may foster innovations in devices or systems with universal applicability in orthopaedics.

Longstanding pain and social strain: patients' and health care providers' experiences with fracture management by skeletal traction; a qualitative study from Malawi

AIM

The aim of the study is to contribute to a more holistic evidence based on lower limb fracture management in low-income settings, by exploring the perspectives of those actually experiencing and administering skeletal traction in Malawi.

METHODS

The study took place at Queen Elizabeth Central Hospital in Blantyre and Kamuzu Central Hospital in Lilongwe, the two largest public hospitals of Malawi. Qualitative data were collected by participant observation, individual interviews with eight patients, two orthopedic surgeons, one physiotherapist, and two focus group discussions with multidisciplinary teams.

RESULTS

Patients experienced physical and psychological pain from the prolonged traction treatment in bed. Anxiety, indignity and emotional distress in the ward environment were commonly observed. Patients emphasized the negative impact on their families and the significant economic consequences due to prolonged hospitalization. Health care providers identified the major obstacles for quality treatment due to the lack of staff, equipment, specialized knowledge and skills. Rehabilitation services were nearly absent, thus little effort was made to maintain function and enhance recovery during and after long-term bed confinement.

CONCLUSION

The use of long-term skeletal traction has a devastating impact on the patients and families, and causes major frustrations to health workers involved with fracture management in a low-resource setting. Implications for Rehabilitation As stated by various health care providers, there is a need to improve trauma care, strengthen rehabilitation services and educate more rehabilitation staff so they can take up the different roles and functions required in treatment and rehabilitation after injuries and other debilitating conditions. In the current situation, sufficient pain relief for patients is required. This should go hand in hand with the empowerment of patients so as to fulfill their rights to quality health services. For health care providers, multidisciplinary teamwork, enhanced specialized education and skills, improved access to adequate equipment and developing standardized procedures appear essential in order to improve fracture management. With injuries representing a growing portion of the global burden of disease, and in the changing demographic panorama with aging populations in Africa and the world at large, injury prevention, trauma care- and rehabilitation need a stronger focus in public health globally.

Reduction in post-operative acute kidney injury following a change in antibiotic prophylaxis policy for orthopaedic surgery: an observational study

OBJECTIVES

Evidence has shown that a prophylactic antibiotic regimen of flucloxacillin and gentamicin for orthopaedic surgery was associated with increased rates of post-operative acute kidney injury (AKI). This resulted in changes in the national antibiotic policy recommendation for orthopaedic surgical prophylaxis. This study aimed to assess whether this change from flucloxacillin and gentamicin to co-amoxiclav was associated with changes in the rates of AKI and Clostridium difficile infection (CDI).

METHODS

An observational study and interrupted time series analyses were used to assess rates of post-operative AKI separately in patients undergoing neck of femur (NOF) repair and other orthopaedic operations that required antibiotic prophylaxis. Incidence rate ratios were used to evaluate changes in CDI rates.

RESULTS

Following the change in policy, from flucloxacillin and gentamicin to co-amoxiclav, there was a relative change in rates of post-operative AKI of -63% (95% CI -77% to -49%) at 18 months in the other orthopaedic operations group. In the NOF repair group, there was no change in the rate of post-operative AKI [-10% (95% CI -35%-15%)] at 18 months. The incident rate ratio for CDI in the other orthopaedic operations group was 0.29 (95% CI 0.09-0.96) and in the NOF repair group was 0.76 (95% CI 0.28-2.08).

CONCLUSIONS

The use of co-amoxiclav for antibiotic prophylaxis in orthopaedic surgery was associated with a decreased rate of post-operative AKI compared with flucloxacillin and gentamicin and was not associated with increased rates of CDI.