1
|
Abbas S, Chokotho L, Nyamulani N, Oliver VL. The burden of long bone fracture and health system response in Malawi: A scoping review. Injury 2024; 55:111243. [PMID: 38096746 DOI: 10.1016/j.injury.2023.111243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 01/29/2024]
Abstract
OBJECTIVES Fractures pose serious health and socioeconomic consequences for individuals, their families, and societies more broadly. In many low-resource settings, case fatality and long-term sequelae after a fracture remain high due to individual- and system-level barriers affecting timely access to care. This scoping review explored the burden of fractures in Malawi using long bone fracture (LBF) as a case study by examining the epidemiology of these injuries, their consequences, and the accessibility of quality healthcare. Our aim is to not only describe the scale of the issue but to identify specific interventions that can help address the challenges faced in settings with limited resources and healthcare budgets. METHODS A scoping review methodology was adopted with a narrative synthesis of results. We searched five databases to identify relevant literature and applied the "Three Delays" model and the WHO's Building Blocks Framework to analyse findings on the accessibility of fracture care. RESULTS Fractures most often occurred among young males, with falls being the leading cause, constituting between 5 and 35 % of the total burden of injuries. Fractures were typically managed without surgery despite consistent local evidence showing surgical treatment was superior to conservative management in terms of length of hospital stay and bone healing. Poor functional, economic, and social outcomes were noted in fracture patients, especially after conservative treatment. A lack of trust in the health system, financial barriers, poor transport, and road infrastructure, and interfacility transfers were identified as barriers to care-seeking. Factors challenging the provision of appropriate care included governance issues, poor health infrastructure, financial constraints, and shortage of supplies and human resources. CONCLUSIONS To the best of our knowledge, this review represents the first comprehensive examination of the state of LBF and the health system's response in Malawi. The findings underscore the pressing need for a national trauma registry to accurately determine the actual burden of injuries and support a tailored approach to fracture care in Malawi. It is further evident that the health system in Malawi must be strengthen across all six building blocks to address obstacles to equitable access to high-quality fracture care.
Collapse
Affiliation(s)
- Shazra Abbas
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Australia.
| | - Linda Chokotho
- Malawi University of Science and Technology, Mikolongwe, Malawi
| | | | - Victoria L Oliver
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Australia
| |
Collapse
|
2
|
Adesina SA, Amole IO, Akinwumi AI, Adegoke AO, Durodola AO, Owolabi JI, Awotunde OT, Adefokun IG, Ojo SA, Eyesan SU. Follow-up non-attendance after long-bone fractures in a low-resource setting: a prospective study of predictors and interventions to increase attendance rates. BMC Health Serv Res 2023; 23:1405. [PMID: 38093302 PMCID: PMC10720235 DOI: 10.1186/s12913-023-10453-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 12/07/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND While the majority of traumatic injuries occur in low- and middle-income countries, the published literature comes chiefly from high-income countries due to poor follow-up. Clinical and radiographic post-surgical trauma follow-up is essential to high-quality research and objective monitoring for healing and/or complications. This study aimed to identify the predictors of follow-up non-attendance in a low-resource setting and investigate the extent to which interventional efforts based on mobile phone technology (MPT) and home visits improved the follow-up rates for fractures treated with SIGN nails. METHODS This was a prospective study of 594 patients with long-bone fractures. Socio-demographic (e.g. age, gender, marital status, education level, etc.) and clinical (e.g. fracture type, concomitant injuries, comorbidity, etc.) data were collected on each patient. Before discharge, the importance of follow-up was explained to patients and their relations. They were encouraged to attend even if they felt well. Their residential addresses and telephone numbers were validated and securely stored. Patients who missed their appointments were contacted by phone. Those who failed to honour 2 or 3 rescheduled appointments were visited in their home. The patients were divided into those who returned for the primarily scheduled follow-up without prompting (volition group) and those who did not come (non-attenders). Univariate analyses and binary logistic regression were conducted to determine the significant predictors of non-attendance. RESULTS The proportion of patients in the volition group reduced from 96.1% at 6 weeks to 53.0% at 12 weeks and 39.2% at 6 months. However, interventional efforts increased these values to 98.5%, 92.5%, and 72.4% respectively. Walking unaided before the primarily scheduled 12-week appointment was the major reason for not attending the follow-up. Education, occupation, post-operative length of hospital stay (PLOS) and infection were significantly associated with non-attendance but younger age, long distances from the hospital, being separated or divorced, difficulty paying the in-patient care bill, closed fracture, having no (or a non-limb) concomitant injury, achieving painless weight bearing ≤ 6 weeks post-operatively and needing no additional surgery were independent predictors of non-attendance. CONCLUSIONS Our study sheds light on the predictors of follow-up non-attendance and demonstrates how interventional efforts improved attendance rates in a low-resource setting. In addition, efforts that better the socio-economic status of people such as more-encompassing health insurance coverage and greater work flexibility can improve the follow-up attendance rates.
Collapse
Affiliation(s)
- Stephen Adesope Adesina
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria.
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria.
| | - Isaac Olusayo Amole
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | | | - Adepeju Olatayo Adegoke
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | - Adewumi Ojeniyi Durodola
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | - James Idowu Owolabi
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | - Olufemi Timothy Awotunde
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | | | - Simeon Ayorinde Ojo
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | - Samuel Uwale Eyesan
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria
- Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| |
Collapse
|
3
|
Desta T, Lodamo T, Mulat H, Demissie DB, Ayalew K. Prevalence and associated factors of infection after intramedullary nailing of long bone fractures among patients attending St. Paul's Hospital Millennium Medical College, AaBET Hospital, Addis Ababa, Ethiopia. SAGE Open Med 2023; 11:20503121231181648. [PMID: 37342615 PMCID: PMC10278399 DOI: 10.1177/20503121231181648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 05/26/2023] [Indexed: 06/23/2023] Open
Abstract
Objectives The intramedullary nailing of long bone fractures is a major challenge for orthopedic surgeons, with increased risk of infection in third-world countries. Research gaps remain in Ethiopia, determining the magnitude of the problem. This study aimed to determine the prevalence and associated factors of infection after intramedullary nailing of long bone fractures in Ethiopia. Methods This was a descriptive, cross-sectional, retrospective design study with a total census of 227 cases of long bone fractures treated with intramedullary Surgical Implant Generation Network nails at Addis Ababa Burn Emergency and Trauma Hospital from August 2015 to April 2017. Data were collected from 227 patients and descriptive analyses were done to summarize the study variables. Binary and multivariable logistic regression analyses were performed at a p value of 0.05 with a 95% confidence interval and adjusted odds ratio. Results The mean age of patients was 32.9 years, with a male-to-female ratio of 3.5:1. Only 22 (9.3%) of the 227 patients with long bone fractures treated with intramedullary nails developed a surgical site infection, and 8 (3.4%) were developed deep (implant) infections requiring debridement. Road traffic injuries were the leading cause of trauma (60.9%), followed by falls from a height (22.7%). Debridement was done within 24 h for 52 (61.9%) and within 72 h for 69 (82.1%) patients with open fractures. Only 19 (22.4%) and 55 (64.7%) patients with open fractures and tibial long bone fractures received antibiotics within 3 h. Open fractures and tibial fractures had higher percentages of infection, 18.6% and 12.1%, respectively. Previous use of an external fixator (44.4%) and prolonged surgery (12.5%) were associated with higher proportions of infection. Conclusion This study found that the prevalence of infections after intramedullary nailing of long bone fractures in Ethiopia was 44.4% after external fixation, compared to 6.4% after intramedullary nail was inserted directly. Proper control measures are needed to reduce morbidity and complications related to long fracture treatment, such as open fractures, tibial fractures, the use of an external fixator, delayed debridement and skin closure, and prolonged surgery developed surgical site infection rate.
Collapse
Affiliation(s)
- Tilahun Desta
- Consultant Orthopaedic Surgeon, St. Paul’s Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia
| | - Teshale Lodamo
- Consultant Orthopaedic Surgeon, Sodo University Hospital, Sodo, Wolayita, Ethiopia
| | - Habtewold Mulat
- Consultant Orthopaedic Surgeon, St. Paul’s Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia
| | | | - Kalkidan Ayalew
- Consultant Orthopaedic Surgeon, St. Paul’s Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia
| |
Collapse
|
4
|
Management of Traumatic Femur Fractures: A Focus on the Time to Intramedullary Nailing and Clinical Outcomes. Diagnostics (Basel) 2023; 13:diagnostics13061147. [PMID: 36980455 PMCID: PMC10047428 DOI: 10.3390/diagnostics13061147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/09/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
Background: Femur shaft factures (FSF) are common injuries following high-energy mechanisms mainly involving motor vehicle crashes (MVC). We evaluated the timings of nailing management and analyzed the pattern of fracture union and outcome in a level 1 trauma center. Methods: This was a retrospective observational study of all the admitted trauma patients who sustained femoral fractures between January 2016 and September 2020. Data were analyzed and compared based on time to Intramedullary Nailing (IMN) (<12 h, 12–24 h and >24 h) and outcomes of FSF (union, delayed union and nonunion). Results: A total of 668 eligible patients were included in the study, of which the majority were males (90.9%) with a mean age of 34.5 ± 15.8, and 54% of the injuries were due to MVCs. The chest (35.8%) was the most commonly associated injured body region, followed by the pelvis (25.9%) and spine (25.4%). Most of femur fractures (93.3%) were unilateral, and 84.4% were closed fractures. The complete union of fractures was observed in 76.8% of cases, whereas only 4.2% and 3.3% cases had delayed union and nonunion, respectively, on the clinical follow-up. Patients in the delayed IMN (>24 h) were severely injured, had bilateral femur fracture (p = 0.001) and had higher rate of external fixation, blood transfusion, pulmonary complications and prolonged hospitalization. Non-union proportion was greater in those who had IMN <24 h, whereas a delayed union was greater in IMN done after 24 h (p = 0.5). Those with a nonunion femur fracture were more likely to have bilateral fracture (p = 0.003), frequently had retrograde nailing (p = 0.01), and high-grade femur fracture (AO type C; p = 0.04). Conclusion: This study showed that femur fracture is not uncommon (8.9%), which is manifested with the variety of clinical characteristics, depending on the mechanism, management and outcome in our center. Bilateral fracture, retrograde nailing and AO classification type C were the significant risk factors of non-union in patients with diaphyseal fractures. The timing of IMN has an impact on the fracture union; however, it is not a statistically significant difference. Therefore, the treating physicians should consider the potential risk factors for a better outcome by careful selection of treatment in sub-groups of patients.
Collapse
|
5
|
Adesina S, Amole I, Akinwumi A, Adegoke A, Owolabi J, Adefokun I, Durodola A, Awotunde O, Eyesan S. Infection complicating locked intramedullary nailing of open lower-extremity fractures: incidence, associated risk factors, and lessons for improving outcome in a low-resource setting. J Bone Jt Infect 2023; 8:71-79. [PMID: 38774303 PMCID: PMC11106765 DOI: 10.5194/jbji-8-71-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 01/24/2023] [Indexed: 05/24/2024] Open
Abstract
Introduction: Infection is the chief complication that makes open fractures difficult to treat. Most low- and middle-income countries (LMICs) are missing out on modern management techniques developed to achieve better outcomes in high-income countries (HICs). One of these is the use of locked intramedullary (IM) nails. This study aimed to determine the factors associated with infection of open fractures treated with the surgical implant generation network (SIGN) nail at a Nigerian tertiary hospital. Methods: Data were collected prospectively on 101 open fractures of the femur and tibia over an 8-year period. Active surveillance for infection was done on each patient. Infection was diagnosed as the presence of wound breakdown or purulent discharge from (or near) the wound or surgical incision. Potential risk factors were tested for association with infection. Results: There were 101 fractures in 94 patients with a mean age of 37.76 years. The following treatment-related factors demonstrated significant associations with infection - timings of antibiotic administration (p < 0.001 ) and definitive fracture fixation (p = 0.002 ); definitive wound closure (p < 0.001 ), fracture-reduction methods (p = 0.005 ), and surgery duration (p = 0.007 ). Conclusions: Although this study has limitations precluding the drawing up of final conclusions, the findings suggest that the risk factors for infection of nailed open fractures in LMICs are similar to those in HICs. Consequently, outcomes can potentially improve if LMICs adopt the management principles used in HICs in scientifically sound ways that are affordable and socially acceptable to their people. Further studies are suggested to establish our findings.
Collapse
Affiliation(s)
| | - Isaac O. Amole
- Department of Family Medicine, Bowen University, Iwo, 232102, Nigeria
| | - Akinsola I. Akinwumi
- Department of Family Medicine, Afe Babalola University, Ado-Ekiti,
360101, Nigeria
| | | | | | - Imri G. Adefokun
- Department of Surgery, Bowen University Teaching Hospital, Ogbomoso, 210001, Nigeria
| | | | | | | |
Collapse
|
6
|
Gani MH, Liang K, Muzafar K, Dev B, Bhat KA, Ghani A. Outcomes after primary intramedullary nail fixation of open tibial and femoral fractures in low resource settings. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03329-5. [PMID: 35829964 DOI: 10.1007/s00590-022-03329-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/20/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Open fractures are unique in the urgency they impart to the injury and the therapeutic challenge they pose. Non-union and infection are among the major concerns. Open tibial and femoral shaft fractures are among the commonest orthopaedic urgencies. Primary intramedullary (IM) nailing requires a skillset and knowledge of the principles of open fracture management and also a well-equipped operating room with the necessary implants and instruments. In a low resource setting, one or more of these prerequisites may not be met, and the outcome may thus be affected similarly. The objective of this study was to study these outcomes. METHODS We prospectively studied primary IM nailing of open 1, 2 and 3A tibial and femoral fractures done in our hospital, in a simple non-modular operating room without an image intensifier. RESULTS There were 106 fractures in 104 patients: 93 tibial and 13 femoral. The mean time from injury to surgical debridement was 19.6 h. Mean duration of antibiotics therapy was 4.3 days, and the mean duration of hospital stay was 4.1 days. All patients were followed up to union. Mean time to radiographic union was 6.1 months for the tibia and 5.7 months for the femur. Non-union was seen in 4 tibial and 1 femoral fractures. There were 3 superficial infections but no deep infection. CONCLUSION The outcomes were comparable to, and in some cases better than, those found in existing literature. We conclude that primary IM nailing in open long bone fractures can be performed in austere environments with good success, in expert hands if the principles are adhered to.
Collapse
Affiliation(s)
| | - Kaifeng Liang
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Khalid Muzafar
- Department of Orthopaedics, Government Medical College, Doda, Jammu & Kashmir, India
| | - Bias Dev
- Department of Orthopaedics, Government Medical College Jammu, Jammu, Jammu & Kashmir, India
| | | | - Abdul Ghani
- Department of Orthopaedics, Government Medical College Jammu, Jammu, Jammu & Kashmir, India
| |
Collapse
|
7
|
Tissingh EK, Marais L, Loro A, Bose D, Ferguson J, Morgensten M, McNally M. Management of fracture-related infection in low resource settings: how applicable are the current consensus guidelines? EFORT Open Rev 2022; 7:422-432. [PMID: 35638596 PMCID: PMC9257735 DOI: 10.1530/eor-22-0031] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The global burden of fracture-related infection (FRI) is likely to be found in countries with limited healthcare resources and strategies are needed to ensure the best available practice is context appropriate. This study has two main aims: (i) to assess the applicability of recently published expert guidance from the FRI consensus groups on the diagnosis and management of FRI to low- and middle-income countries (LMICs); (ii) to summarise the available evidence on FRI, with consideration for strategies applicable to low resource settings. Data related to the International Consensus Meeting Orthopaedic Trauma Work Group and the International Fracture Related Infection Consensus Group FRI guidelines were collected including panel membership, country of origin, language of publication, open access status and impact factor of the journal of publication. The recommendations and guidelines were then summarised with specific consideration for relevance and applicability to LMICs. Barriers to implementation were explored within a group of LMIC residents and experienced workers. The authorship, evidence base and reach of the FRI consensus guidelines lack representation from low resource settings. The majority of authors (78.5–100%) are based in high-income countries and there are no low-income country collaborators listed in any of the papers. All papers are in English. The FRI consensus guidelines give a clear set of principles for the optimum management of FRI. Many of these – including the approach to diagnosis, multidisciplinary team working and some elements of surgical management – are achievable in low resource settings. Current evidence suggests that it is important that a core set of principles is prioritised but robust evidence for this is lacking. There are major organisational and infrastructure obstacles in LMICs that will make any standardisation of FRI diagnosis or management challenging. The detail of how FRI consensus principles should be applied in low resource settings requires further work. The important work presented in the current FRI consensus guidelines is relevant to low resource settings. However, leadership, collaboration, creativity and innovation will be needed to implement these strategies for communities who need it the most.
Collapse
Affiliation(s)
- Elizabeth K Tissingh
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK.,King's Global Health Partnerships, School of Life Course and Population Sciences, King's College London, London, UK
| | - Leonard Marais
- Department of Orthopaedic Surgery, School of Clinical Medicine, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Antonio Loro
- Comprehensive Rehabilitation Services for People with Disability in Uganda (CoRSU) Hospital, Kisubi, Uganda
| | - Deepa Bose
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jamie Ferguson
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK.,Oxford Trauma Unit, Oxford University Hospitals, Oxford, UK
| | - Mario Morgensten
- Centre for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| |
Collapse
|
8
|
Telemedicine in Surgical Care in Low- and Middle-Income Countries: A Scoping Review. World J Surg 2022; 46:1855-1869. [PMID: 35428920 PMCID: PMC9012517 DOI: 10.1007/s00268-022-06549-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 12/11/2022]
Abstract
Background Access to timely and quality surgical care is limited in low- and middle-income countries (LMICs). Telemedicine, defined as the remote provision of health care using information, communication and telecommunication platforms have the potential to address some of the barriers to surgical care. However, synthesis of evidence on telemedicine use in surgical care in LMICs is lacking. Aim To describe the current state of evidence on the use and distribution of telemedicine for surgical care in LMICs. Methods This was a scoping review of published and relevant grey literature on telemedicine use for surgical care in LMICs, following the PRISMA extension for scoping reviews guideline. PubMed-Medline, Web of Science, Scopus and African Journals Online databases were searched using a comprehensive search strategy from 1 January 2010 to 28 February 2021. Results A total of 178 articles from 53 (38.7%) LMICs across 11 surgical specialties were included. The number of published articles increased from 2 in 2010 to 44 in 2020. The highest number of studies was from the World Health Organization Western Pacific region (n = 73; 41.0%) and of these, most were from China (n = 69; 94.5%). The most common telemedicine platforms used were telephone call (n = 71, 39.9%), video chat (n = 42, 23.6%) and WhatsApp/WeChat (n = 31, 17.4%). Telemedicine was mostly used for post-operative follow-up (n = 71, 39.9%), patient education (n = 32, 18.0%), provider training (n = 28, 15.7%) and provider-provider consultation (n = 16, 9.0%). Less than a third (n = 51, 29.1%) of the studies used a randomised controlled trial design, and only 23 (12.9%) reported effects on clinical outcomes. Conclusion Telemedicine use for surgical care is emerging in LMICs, especially for post-operative visits. Basic platforms such as telephone calls and 2-way texting were successfully used for post-operative follow-up and education. In addition, file sharing and video chatting options were added when a physical assessment was required. Telephone calls and 2-way texting platforms should be leveraged to reduce loss to follow-up of surgical patients in LMICs and their use for pre-operative visits should be further explored. Despite these telemedicine potentials, there remains an uneven adoption across several LMICs. Also, up to two-thirds of the studies were of low-to-moderate quality with only a few focusing on clinical effectiveness. There is a need to further adopt, develop, and validate telemedicine use for surgical care in LMICs, particularly its impact on clinical outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-022-06549-2.
Collapse
|
9
|
Maharjan R, Shrestha BP, Chaudhary P, Rijal R, Shah Kalawar RP. Functional outcome of patients of tibial fracture treated with solid nail (SIGN nail) versus conventional hollow nail - A randomized trial. J Clin Orthop Trauma 2021; 12:148-160. [PMID: 33716440 PMCID: PMC7920208 DOI: 10.1016/j.jcot.2020.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/05/2020] [Accepted: 07/09/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Trauma related disabilities disproportionately affects low and middle income countries due to lack of resources, skills and optimal implants. Despite adequate animal studies, biomechanical studies, cohort studies and comparison studies we are not aware of any randomized trial to compare the functional outcome of SIGN (Surgical Implant Generation Network, US) solid nailing with a hollow nailing for tibial shaft fracture. METHODS Sixty patients (≥16 years) of closed and Gustilo grade I traumatic fractures of the leg were randomized into SIGN solid nailing or hollow nailing group. Cases with compromised soft tissue and grossly deformed medullary canal were excluded. Functional outcome and need for resurgery were the primary outcomes while the secondary outcomes were duration of surgery, intraoperative blood loss, overall pain (VAS), radiological union (RUST), surgery related complications (infection, malalignment, shortening, nonunion) and pain/range of motion (ROM) of knee/ankle. All SIGN surgery related data were entered and retrieved online from www.signsurgery.org. RESULT The demographical parameters were symmetrically distributed between the groups (p > 0.05). 2 cases in SIGN nailing and 4 cases in hollow nailing needed open reduction. The functional outcome, as assessed by blinded physiotherapist using Johner and Wruh criteria, was excellent in 18 (62.06%), good in 6 (20.68%), fair in 3 (10.34%) and poor in 2 (6.89%) for SIGN nail whereas it was 16 (57.14%), 8 (28.57%), 3 (10.71%) and 1 (3.57%) respectively for hollow nail. There was 1 case of implant failure and 1 case of infection. Intraoperative blood loss (397 ± 94.47 ml versus 350 ± 75.43 ml, p = 0.037) and duration of surgery (94.8 ± 14.57 min versus 82.0 ± 12.36 min, p = 0.001) were significantly more in hollow nailing group. At final follow up, overall pain on weight bearing (VAS score) and radiological union (RUST score) were 2.1 and 11.7 for SIGN nailing while they were 2.7 and 11.3 respectively for hollow nailing.(p = 0.41 and 0.45 respectively) The malrotation (p = 1.000), shortening (p = 1.000), varus-valgus angulation (p = 0.511), AP angulation (p = 0.706), ROM ankle (p = 0.239) and ROM knee (p = 0.086) were similar. CONCLUSION Solid SIGN nailing gives comparable functional outcome as conventional hollow nailing for tibia shaft fracture. For developing world with limited resources, SIGN nail is useful which is supplied freely and is designed to be used without image intensifier and fracture table.
Collapse
|
10
|
Chokotho L, Wu HH, Shearer D, Lau BC, Mkandawire N, Gjertsen JE, Hallan G, Young S. Outcome at 1 year in patients with femoral shaft fractures treated with intramedullary nailing or skeletal traction in a low-income country: a prospective observational study of 187 patients in Malawi. Acta Orthop 2020; 91:724-731. [PMID: 32698707 PMCID: PMC8023961 DOI: 10.1080/17453674.2020.1794430] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Intramedullary nailing (IMN) is underutilized in low-income countries (LICs) where skeletal traction (ST) remains the standard of care for femoral shaft fractures. This prospective study compared patient-reported quality of life and functional status after femoral shaft fractures treated with IMN or ST in Malawi. Patients and methods - Adult patients with femoral shaft fractures managed by IMN or ST were enrolled prospectively from 6 hospitals. Quality of life and functional status were assessed using EQ-5D-3L, and the Short Musculoskeletal Function Assessment (SMFA) respectively. Patients were followed up at 6 weeks, 3, 6, and 12 months post-injury. Results - Of 248 patients enrolled (85 IMN, 163 ST), 187 (75%) completed 1-year follow-up (55 IMN, 132 ST). 1 of 55 IMN cases had nonunion compared with 40 of 132 ST cases that failed treatment and converted to IMN (p < 0.001). Quality of life and SMFA Functional Index Scores were better for IMN than ST at 6 weeks, 3 and 6 months, but not at 1 year. At 6 months, 24 of 51 patients in the ST group had returned to work, compared with 26 of 37 in the IMN group (p = 0.02). Interpretation - Treatment with IMN improved early quality of life and function and allowed patients to return to work earlier compared with treatment with ST. Approximately one-third of patients treated with ST failed treatment and were converted to IMN.
Collapse
Affiliation(s)
- Linda Chokotho
- Department of Surgery, College of Medicine, University of Malawi
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Hao-Hua Wu
- Institute for Global Orthopedics and Traumatology, Orthopedic Trauma Institute, University of California San Francisco, San Francisco, CA, USA
| | - David Shearer
- Institute for Global Orthopedics and Traumatology, Orthopedic Trauma Institute, University of California San Francisco, San Francisco, CA, USA
| | - Brian C Lau
- Department of Orthopedic Surgery, Duke University Medical Centre, Durham, NC, USA
| | - Nyengo Mkandawire
- Department of Surgery, College of Medicine, University of Malawi
- School of Medicine, Flinders University, Adelaide, Australia
| | - Jan-Erik Gjertsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Geir Hallan
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Sven Young
- Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| |
Collapse
|
11
|
Evaluating Clinical Outcomes for Determining the Optimal Delay to Skin Incision under WALANT: A Prospective Series of 34 Patients from a Low-Resource Tertiary Setting. Adv Orthop 2020; 2020:9351354. [PMID: 32953181 PMCID: PMC7481922 DOI: 10.1155/2020/9351354] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/25/2020] [Accepted: 06/30/2020] [Indexed: 11/18/2022] Open
Abstract
Background Additional studies on clinical outcomes to determine the optimal time delay from injection of local anesthesia to skin incision for WALANT surgeries are needed. The authors aimed to propose the optimal time delay from local injection to skin incision for WALANT surgeries of the hand and wrist by analyzing intraoperative blood loss, postoperative pain scores, and complication rates. Methods Thirty-four patients were consecutively recruited and allocated by either 7-min or 30-min delay for skin incision from local injection of epinephrine with lidocaine. Intraoperative bleeding and postoperative pain scores were analyzed between both groups by Mann–Whitney U-test, while complication rates were compared using Fisher's exact test. Results The present study did not find significant differences in mean intraoperative blood loss (8 ± 5.8 mL vs. 5 ± 2.2 mL, p=0.074), complication rates (18% vs. 0%, p=0.227), and mean pain scores (1.2 ± 0.5 vs. 1.4 ± 0.5, p=0.307) between the 7-min and 30-min groups. Conclusion The authors conclude that a waiting time of 7 min from the injection of local anesthesia is sufficient to achieve comparable clinical outcomes for minor hand and wrist surgeries under WALANT.
Collapse
|
12
|
The Impact of EBM-Manufactured Ti6Al4V ELI Alloy Surface Modifications on Cytotoxicity toward Eukaryotic Cells and Microbial Biofilm Formation. MATERIALS 2020; 13:ma13122822. [PMID: 32585940 PMCID: PMC7344637 DOI: 10.3390/ma13122822] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/19/2020] [Accepted: 06/19/2020] [Indexed: 11/17/2022]
Abstract
Electron beam melting (EBM) is an additive manufacturing technique, which allows forming customized implants that perfectly fit the loss of the anatomical structure of bone. Implantation efficiency depends not only on the implant's functional or mechanical properties but also on its surface properties, which are of great importance with regard to such biological processes as bone regeneration or microbial contamination. This work presents the impact of surface modifications (mechanical polishing, sandblasting, and acid-polishing) of EBM-produced Ti6Al4V ELI implants on essential biological parameters. These include wettability, cytotoxicity toward fibroblast and osteoblast cell line, and ability to form biofilm by Staphylococcus aureus, Pseudomonas aeruginosa, and Candida albicans. Obtained results indicated that all prepared surfaces exhibited hydrophilic character and the highest changes of wettability were obtained by chemical modification. All implants displayed no cytotoxicity against osteoblast and fibroblast cell lines regardless of the modification type. In turn, the quantitative microbiological tests and visualization of microbial biofilm by means of electron microscopy showed that type of implant's modification correlated with the species-specific ability of microbes to form biofilm on it. Thus, the results of the presented study confirm the relationship between such technological aspects as surface modification and biological properties. The provided data are useful with regard to applications of the EBM technology and present a significant step towards personalized, customized implantology practice.
Collapse
|
13
|
von Kaeppler E, Donnelley C, Roberts HJ, O'Hara NN, Won N, Shearer DW, Morshed S. Impact of North American Institutions on Orthopedic Research in Low- and Middle-Income Countries. Orthop Clin North Am 2020; 51:177-188. [PMID: 32138856 DOI: 10.1016/j.ocl.2019.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
Collapse
Affiliation(s)
- Ericka von Kaeppler
- Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
| | - Claire Donnelley
- Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
| | - Heather J Roberts
- Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
| | - Nathan N O'Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Suite 300, 110 South Paca Street, Baltimore, MD 21201, USA
| | - Nae Won
- Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
| | - David W Shearer
- Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA.
| |
Collapse
|
14
|
Travel barriers, unemployment, and external fixation predict loss to follow-up after surgical management of lower extremity fractures in Dar es Salaam, Tanzania. OTA Int 2020; 3:e061. [PMID: 33937685 PMCID: PMC8081490 DOI: 10.1097/oi9.0000000000000061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 12/08/2019] [Indexed: 12/26/2022]
Abstract
Objective: Predict loss to follow-up in prospective clinical investigations of lower extremity fracture surgery. Design: Secondary analysis of 2 prospective clinical trials. Setting: National public orthopaedic and neurologic trauma tertiary referral hospital in Dar es Salaam, Tanzania, a low-income country in sub-Saharan Africa. Patients/Participants: Three hundred twenty-nine femoral shaft and 240 open tibial shaft fracture patients prospectively enrolled in prospective controlled trials of surgical fracture management by external fixation, plating, or intramedullary nailing between June 2015 and March 2017. Intervention: Telephone contact for failure to attend scheduled 1-year clinic visit. Main Outcome Measurements: Ascertainment of primary trial outcome at 1-year from surgery; post-hoc telephone questionnaire for reasons patient did not attend the 1-year clinic visit. Results: One hundred twenty-seven femur fracture (39%) and 68 open tibia fracture (28%) patients did not attend the 1-year clinic visit. Telephone contact significantly improved ascertainment of the primary study outcome by 20% between 6-month and 1-year clinic visits to 82% and 92% respectively at study completion. Multivariable analysis associated unemployment (OR = 2.5 [1.7–3.9], P < .001), treatment with an external fixator (OR = 1.7 [1.0–2.8], P = .033), and each additional 20 km between residence and clinic (OR = 1.03 [1.00–1.06], P = .047] with clinic nonattendance. One hundred eight (55%) nonattending patients completed the telephone questionnaire, reporting travel distance to the hospital (49%), and travel costs to the hospital (46%) as the most prevalent reasons for nonattendance. Sixty-five percent of patients with open tibia fractures cited relocation after surgery as a contributing factor. Conclusions: Relocation during recovery, travel distance, travel cost, unemployment, and use of an external fixator are associated with loss to clinical follow-up in prospective investigations of femur and open tibia fracture surgery in this population. Telephone contact is an effective means to assess outcome.
Collapse
|
15
|
Conway D, Albright P, Eliezer E, Haonga B, Morshed S, Shearer DW. The burden of femoral shaft fractures in Tanzania. Injury 2019; 50:1371-1375. [PMID: 31196597 DOI: 10.1016/j.injury.2019.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/22/2019] [Accepted: 06/02/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Road traffic injuries disproportionately affect low- and middle-income countries (LMICs) and are associated with femur fractures that lead to long-term disability. Information about these injuries is crucial for appropriate healthcare resource allocation. The purpose of this study is to estimate the incidence of femoral shaft fractures in Tanzania and describe the unmet surgical burden. METHODS Study sites included six government hospitals across Tanzania. Investigators collected data from hospital admission and procedural logbooks to estimate femoral shaft fracture incidence and their treatment methods. Semi-quantitative interviews were conducted with relevant hospital personnel to validate estimates obtained from hospital records. Investigators gathered road traffic incident (RTI) statistics from national police reports and calculated femur fracture:RTI ratios. RESULTS Femoral shaft fracture annual incidence rate ranged from 2.1 to 18.4 per 100,000 people. Median low and high femur fracture:RTI ratio were 0.54 and 0.73, respectively. At smaller hospitals, many patients (5-25%) were treated with traction, and a majority (70-90%) are referred to other centers. Barriers to surgery at each hospital include a lack of surgical implants, equipment, and personnel. CONCLUSIONS The incidence rate is similar to previous estimations, and it is consistent with an increased femoral shaft fracture incidence in Tanzania when compared to higher income countries. The femur fracture:RTI ratio may be a valid tool for estimating femur fracture incidence rates. There is an unmet orthopaedic surgical burden for femur fractures treatment at rural hospitals in Tanzania, and the barriers to treatment could be targets for future interventions.
Collapse
Affiliation(s)
- Devin Conway
- Yale School of Medicine, Department of Orthopaedics & Rehabilitation, 800 Howard Avenue, New Haven, CT, USA.
| | - Patrick Albright
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco 2550 23rd Street, Building 9, 3rd Floor, San Francisco, CA, 94110, USA.
| | - Edmund Eliezer
- Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania.
| | - Billy Haonga
- Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania.
| | - Saam Morshed
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco 2550 23rd Street, Building 9, 3rd Floor, San Francisco, CA, 94110, USA.
| | - David W Shearer
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco 2550 23rd Street, Building 9, 3rd Floor, San Francisco, CA, 94110, USA.
| |
Collapse
|
16
|
Mustafa Diab M, Shearer DW, Kahn JG, Wu HH, Lau B, Morshed S, Chokotho L. The Cost of Intramedullary Nailing Versus Skeletal Traction for Treatment of Femoral Shaft Fractures in Malawi: A Prospective Economic Analysis. World J Surg 2019; 43:87-95. [PMID: 30094638 DOI: 10.1007/s00268-018-4750-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND In many low- and middle-income countries, non-surgical management of femoral shaft fractures using skeletal traction is common because intramedullary (IM) nailing is perceived to be expensive. This study assessed the cost of IM nailing and skeletal traction for treatment of femoral shaft fractures in Malawi. METHODS We used micro-costing methods to quantify the costs associated with IM nailing and skeletal traction. Adult patients who sustained an isolated closed femur shaft fracture and managed at Queen Elizabeth Central Hospital in Malawi were followed from admission to discharge. Resource utilization and time data were collected through direct observation. Costs were quantified for procedures and ward personnel, medications, investigations, surgical implants, disposable supplies, procedures instruments and overhead. RESULTS We followed 38 nailing and 27 traction patients admitted between April 2016 and November 2017. Nailing patient's average length of stay (LOS) was 36.35 days (SD 21.19), compared to 61 (SD 18.16) for traction (p = 0.0003). The total cost per patient was $596.97 ($168.81) for nailing and $678.02 (SD $144.25) for traction (p = 0.02). Major cost drivers were ward personnel and overhead; both are directly proportional to LOS. Converting patients from traction to nailing is cost-saving up to day 23 post-admission. CONCLUSION Savings from IM nailing as compared with skeletal traction were achieved by shortened LOS. Although this study did not assess the effectiveness of either intervention, the literature suggests that traction carries a higher rate of complications than nailing. Investment in IM nailing capacity may yield substantial net savings to health systems, as well as improved clinical outcomes.
Collapse
Affiliation(s)
- Mohamed Mustafa Diab
- Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA. .,Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St, San Francisco, CA, 94118, USA.
| | - David W Shearer
- Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA
| | - James G Kahn
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St, San Francisco, CA, 94118, USA.,Global Health Economics Consortium, University of California San Francisco, San Francisco, CA, USA
| | - Hao-Hua Wu
- Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA
| | - Brian Lau
- Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA
| | - Saam Morshed
- Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA.,Global Health Economics Consortium, University of California San Francisco, San Francisco, CA, USA
| | | |
Collapse
|
17
|
Graham SM, Wijesekera MP, Laubscher M, Maqungo S, Held M, Ferreira N, Harrison WJ. Implant-related sepsis in lower limb fractures following gunshot injuries in the civilian population: A systematic review. Injury 2019; 50:235-243. [PMID: 30551865 DOI: 10.1016/j.injury.2018.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 10/16/2018] [Accepted: 12/04/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The management of long bone lower limb fractures secondary to gunshot wounds (GSWs) in the civilian setting are complex and there is currently no consensus regarding the optimal approach to managing such fractures. This study aims to address the relationship of implant related sepsis in fractures secondary to GSWs. METHODS A systematic review of the literature was performed on both Pubmed and Scopus databases that look at fractures caused by GSWs in the lower limb. A total of 14 studies met the inclusion criteria set in this study. RESULTS Current literature suggests that low and high velocity injuries managed with internal fixation, such as intramedullary nails, may carry a low risk of superficial and deep infection, with no obvious risk of osteomyelitis. However, infection was poorly defined across all studies and no study used a validated scoring system for infection making it difficult to draw any valid conclusion on the rate of infection following internal fixation of lower limb fractures following both high and low velocity GSWs. CONCLUSION There is no clear evidence to confirm or refute that internal fixation is the ideal method of management in these complex injuries and guidance is needed due to the high and increasing proportion of patients presenting with these complex injuries worldwide.
Collapse
Affiliation(s)
- Simon Matthew Graham
- Liverpool School of Tropical Medicine, Liverpool, UK; Orthopaedic Research Unit, Department of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | | | - Maritz Laubscher
- Orthopaedic Research Unit, Department of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Sithombo Maqungo
- Orthopaedic Research Unit, Department of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Michael Held
- Orthopaedic Research Unit, Department of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Nando Ferreira
- Division of Orthopaedics, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - William J Harrison
- Division of Orthopaedics, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; Countess of Chester Hospital, Chester, UK
| |
Collapse
|
18
|
Chang Y, Bhandari M, Zhu KL, Mirza RD, Ren M, Kennedy SA, Negm A, Bhatnagar N, Naji FN, Milovanovic L, Fei Y, Agarwal A, Kamran R, Cho SM, Schandelmaier S, Wang L, Jin L, Hu S, Zhao Y, Lopes LC, Wang M, Petrisor B, Ristevski B, Siemieniuk RA, Guyatt GH. Antibiotic Prophylaxis in the Management of Open Fractures. JBJS Rev 2019; 7:e1. [DOI: 10.2106/jbjs.rvw.17.00197] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
|
19
|
Varela C, Young S, Groen R, Banza L, Mkandawire NC, Viste A. Untreated surgical conditions in Malawi: A randomised cross-sectional nationwide household survey. Malawi Med J 2018; 29:231-236. [PMID: 29872512 PMCID: PMC5811994 DOI: 10.4314/mmj.v29i3.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Noncommunicable diseases, such as surgical conditions have received little attention from public health planners in low income countries (LIC) like Malawi. Though increasingly recognised as a growing global health problem, the burden of surgical pathologies and access to surgical care has not been adequately identified in many LIC. Information on the spectrum and burden of surgical disease in Malawi is important to uncover the unmet need for surgery and for planning of the National Health Service. Methods This was a multistage random cluster sampling national survey. Households were selected from clusters using probability proportional to size method. 1448 households and 2909 interviewees were analysed. The Surgeons Overseas Assessment of Surgical need (SOSAS) tool was used to collect data. This electronic tablet based questionnaire tool included general information and a dual personalised head to toe inquiry on surgical conditions. The general information included number of household members, and inquired on any death within the past twelve months, and if any of the deaths in the family had a suspected surgical condition leading to that death. Data was collected by specially trained third year medical students. Results Out of 1480 selected households, 1448 (98%) agreed to participate, with 2909 interviewed individuals included in the study. The median household size was 6 individuals (range 1 – 47). Median age of interviewed persons was 35 years (range 0.25 – 104 years). 1027 out of 2909 (35%) of the interviewed people reported to be living with a condition requiring surgical consultation or intervention, whereas 146 of 616 (24%) of the total deaths reported to have occurred in the preceding 12 months were reported to have died from a surgically related condition. Most individuals did not seek health care due to lack of funds for transportation to the health facility. Only 3.1% of those that reported a surgical condition had surgical intervention. Conclusions There is a large unmet need for surgical care in Malawi. A third of the population is living with a condition needing surgical consultation or intervention, and a quarter of all deaths are potentially avoidable with surgery. Urgent scale up of surgical services and training are needed to reduce this huge gap in public health planning in the country.
Collapse
Affiliation(s)
- Carlos Varela
- Kamuzu Central Hospital, Lilongwe, Malawi.,Lilongwe Campus, College of Medicine, University of Malawi, Lilongwe, Malawi.,Institute of Clinical Sciences (K1 and Centre for International Health, University of Bergen, Bergen, Norway
| | - Sven Young
- Kamuzu Central Hospital, Lilongwe, Malawi.,Lilongwe Campus, College of Medicine, University of Malawi, Lilongwe, Malawi.,Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Reinou Groen
- Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Department of Obstetrics and Gynaecology, Alaska Native Medical Center, Anchorage, Alaska, USA
| | - Leonard Banza
- Kamuzu Central Hospital, Lilongwe, Malawi.,Lilongwe Campus, College of Medicine, University of Malawi, Lilongwe, Malawi.,Institute of Clinical Sciences (K1 and Centre for International Health, University of Bergen, Bergen, Norway
| | | | - Asgaut Viste
- Institute of Clinical Sciences (K1 and Centre for International Health, University of Bergen, Bergen, Norway.,Department of Acute and Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
20
|
Woelber E, Martin A, Van Citters D, Luplow C, Githens M, Kohn C, Kim YJ, Oy H, Gollogly J. Complications in patients with intramedullary nails: a case series from a single Cambodian surgical clinic. INTERNATIONAL ORTHOPAEDICS 2018; 43:433-440. [PMID: 29806054 DOI: 10.1007/s00264-018-3966-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 04/30/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE Since its development in 1999, the SIGN nail has been used in over 190,000 surgeries spanning 55 countries. To date, however, evaluation of SIGN nail outcomes has been limited to small prospective studies or large retrospective studies using SIGN's online database. This study uses the experience of a single, independent Cambodian surgical clinic to characterize common complications, provide commentary on ways to reduce the risk of those complications, and determine whether several observed nail fractures were due to metallurgic defects. METHODS Clinic medical records were queried to identify complications in patients with SIGN nails. Data was abstracted including age, sex, mechanism of injury, and latency between injury, primary implantation, and presentation with a complication. Two nails that fractured in vivo were analyzed by light microscopy, scanning electron microscopy, and polarized light microscopy after chemical etching. RESULTS Fifty-four complications in 51 patients were identified. The most common complications were non-union (n = 26, 48%), infection (n = 16, 30%), flexion limitation (n = 11, 20%), nail fracture (n = 4, 7%), delayed union (n = 4, 7%), and malunion (n = 4, 7%). Other complications included broken or floating screws. Fractography revealed that two of the fractured nails most likely failed by fatigue followed by fast fracture at the site of non-union. We found no evidence of intrinsic nail defects. We identified multiple inconsistencies between SIGN's database and independent clinic records. CONCLUSIONS Non-union and infection were common relative to all complications. Based on radiographic review, risk for non-union and malunion can be minimized by selecting an appropriate nail diameter, using multiple interlocking screws, and employing the correct implant and approach for fracture morphology when using SIGN nails. Nail fractures were unlikely to be caused by metallurgical flaws. Further study is necessary to determine the appropriate management of non-unions based on radiographic and clinical factors.
Collapse
Affiliation(s)
- Erik Woelber
- University of Washington School of Medicine, Seattle, WA, USA.
- Department of Orthopedics, OHSU, 3147 S.W. Sam Jackson Park Road, Portland, OR, 97239, USA.
| | - Audrey Martin
- Dartmouth Biomedical Engineering Center, Hanover, NH, USA
| | | | - Craig Luplow
- Duke University Department of Surgery, Durham, NC, USA
| | - Michael Githens
- University of Washington Department of Orthopaedic Surgery, Seattle, WA, USA
| | | | - Yong Jun Kim
- Children's Surgical Centre, Phnom Penh, Cambodia
| | - Heang Oy
- Children's Surgical Centre, Phnom Penh, Cambodia
| | - Jim Gollogly
- Children's Surgical Centre, Phnom Penh, Cambodia
| |
Collapse
|
21
|
McQuillan TJ, Cai LZ, Corcoran-Schwartz I, Weiser TG, Forrester JD. Surgical Site Infections after Open Reduction Internal Fixation for Trauma in Low and Middle Human Development Index Countries: A Systematic Review. Surg Infect (Larchmt) 2018; 19:254-263. [DOI: 10.1089/sur.2017.273] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Lawrence Z. Cai
- Stanford University School of Medicine, Stanford, California
| | - Ian Corcoran-Schwartz
- Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Thomas G. Weiser
- Department of General Surgery, Stanford University, Stanford, California
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, Scotland
| | | |
Collapse
|
22
|
Parkes RJ, Parkes G, James K. A systematic review of cost-effectiveness, comparing traction to intramedullary nailing of femoral shaft fractures, in the less economically developed context. BMJ Glob Health 2017; 2:e000313. [PMID: 29018580 PMCID: PMC5623315 DOI: 10.1136/bmjgh-2017-000313] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/16/2017] [Accepted: 05/19/2017] [Indexed: 01/20/2023] Open
Abstract
Introduction Femoral shaft fractures carry considerable morbidity and are increasingly common in less economically developed countries (LEDCs). Treatment options include traction and intramedullary (IM) nailing but in a limited-resource environment; cost-effectiveness is fundamental to policy development. The objective herein was to evaluate the cost-effectiveness of moving from traction to IM nailing for femoral shaft fractures, in adults, in LEDCs. Incorporating a systematic review of complications and functional outcomes and a cost-minimization analysis. Methods PubMed, EMBASE, Africa Journals Online and the Cochrane Library were searched from inception using the terms: femur* AND fracture AND traction AND (sign OR nail* OR intramedullary) AND (cost-effectiveness OR cost* OR outcome OR function) NOT paed* NOT child* NOT elastic NOT neck NOT intertrochanteric NOT periprosthetic (where asterisks indicate an unlimited truncation strategy). Abstracts were reviewed for all titles returned and full texts obtained as indicated. References of all relevant papers were also examined for further studies. Results IM nailing has been successfully used in several institutions and reported infection, union and reoperation rates are encouraging, although no randomised control trials were identified. Three studies assessed the cost aspect and all found IM nailing to be the cheaper strategy. Conclusion To date, the improved complication profile and reduced cost of treatment suggest that IM nailing is more cost-effective than traction. Evidence, however, is limited and the necessity for appropriate training and audit with the introduction of new techniques must be emphasised.
Collapse
Affiliation(s)
- Rebekah J Parkes
- School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Gary Parkes
- Department of Surgery, United Mission Hospital Tansen, Tansen, Nepal
| | - Kyle James
- Department of Orthopaedics, Beit CURE International Malawi, Blantyre, Malawi
| |
Collapse
|
23
|
Young S, Banza L. Neglected traumatic anterior dislocation of the hip. Open reduction using the Bernese trochanter flip approach - a case report. Acta Orthop 2017; 88:348-350. [PMID: 28056583 PMCID: PMC5434607 DOI: 10.1080/17453674.2016.1272375] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
|
24
|
Moodley Y, Govender K. An HIV-positive status and short term perioperative mortality – a systematic review. S Afr J Infect Dis 2017. [DOI: 10.1080/23120053.2016.1192822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
25
|
Eliezer EN, Haonga BT, Morshed S, Shearer DW. Predictors of Reoperation for Adult Femoral Shaft Fractures Managed Operatively in a Sub-Saharan Country. J Bone Joint Surg Am 2017; 99:388-395. [PMID: 28244909 DOI: 10.2106/jbjs.16.00087] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The optimal treatment for femoral shaft fractures in low-resource settings has yet to be established, in part, because of a lack of data supporting operative treatment modalities. We aimed to determine the reoperation rate among femoral fractures managed operatively and to identify risk factors for reoperation at a hospital in a Sub-Saharan country. METHODS We conducted a prospective clinical study at a single tertiary care center in Tanzania, enrolling all skeletally mature patients with diaphyseal femoral fractures managed operatively from July 2012 to July 2013. Patients were followed at regular intervals for 1 year postoperatively. The primary outcome was a complication requiring reoperation for any reason. Secondary outcomes were scores on the EuroQol (EQ)-5D, radiographic union score for tibial fractures (RUST), and squat-and-smile test. RESULTS There were a total of 331 femoral fractures (329 patients) enrolled in the study, with a follow-up rate at 1 year of 82.2% (272 of 331). Among the patients with complete follow-up, 4 injuries were managed with plate fixation and 268 were managed with use of an intramedullary nail. The reoperation rate for plate fixation was 25% (1 of 4) compared with 5.2% (14 of 268) for intramedullary nailing (p = 0.204). As found in a multivariate logistic regression, a small nail diameter, a Winquist type-3 fracture pattern, and varus malalignment of proximal fractures were associated with reoperation. The mean EQ-5D score at 1 year was 0.95 for patients who did not require reoperation compared with 0.83 for patients who required reoperation (p = 0.0002). CONCLUSIONS Intramedullary nailing for femoral shaft fractures was associated with low risk of reoperation and a nearly full return to baseline health-related quality of life at 1 year of follow-up. There are potentially modifiable risk factors for reoperation that can be identified and addressed through education and dissemination of these findings. LEVEL OF EVIDENCE Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Edmund N Eliezer
- 1Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania 2Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, San Francisco General Hospital, San Francisco, California 3Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | | | | | | |
Collapse
|
26
|
High morbidity and mortality after lower extremity injuries in Malawi: A prospective cohort study of 905 patients. Int J Surg 2017; 39:23-29. [DOI: 10.1016/j.ijsu.2017.01.047] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 12/19/2016] [Accepted: 01/11/2017] [Indexed: 10/20/2022]
|
27
|
Young S, Banza L, Munthali BS, Manda KG, Gallaher J, Charles A. The impact of the increasing burden of trauma in Malawi on orthopedic trauma service priorities at Kamuzu Central Hospital. Acta Orthop 2016; 87:632-636. [PMID: 27587339 PMCID: PMC5119448 DOI: 10.1080/17453674.2016.1228413] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The burden of road traffic injuries globally is rising rapidly, and has a huge effect on health systems and development in low- and middle-income countries. Malawi is a small low-income country in southeastern Africa with a population of 16.7 million and a gross national income per capita of only 250 USD. The impact of the rising burden of trauma is very apparent to healthcare workers on the ground, but there are very few data showing this development. Patients and methods - The annual number of femoral fracture patients admitted to Kamuzu Central Hospital (KCH) in the Capital of Malawi, Lilongwe, from 2009 to 2014 was retrieved from the KCH trauma database. Linear regression curve estimation was used to project the growth in the burden of femoral fractures and the number of operations performed for femoral fractures over the same time period. Results - 992 patients with femoral fractures (26% of all admissions for fractures) presented at KCH from 2009 through 2014. In this period, there was a 132% increase in the annual number of femoral fractures admitted to KCH. In the same time period, the total number of operations more than doubled, but there was no increase in the number of operations performed for femoral fractures. Overall, there was a 7% mortality rate for patients with femoral fractures. Interpretation - The burden of femoral fractures in Malawi is rising rapidly, and the surgical resources available cannot keep up with this development. Limited funds for orthopedic trauma care in Malawi should be invested in central training hospitals, to develop a sustainable number of orthopedic surgeons and improve current infrastructure and equipment. The centralization of orthopedic surgical care delivery at the central training hospitals will lead to better access to surgical care and early return of patients to local district hospitals for rehabilitation, thus increasing surgical throughput and efficiency in a more cost-effective manner, with the goal of expanding the future orthopedic surgical workforce to meet the national need.
Collapse
Affiliation(s)
- Sven Young
- Department of Surgery, Kamuzu Central Hospital, Lilongwe;,Department of Surgery, College of Medicine, University of Malawi, Blantyre, Malawi;,Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway;,Correspondence:
| | - Leonard Banza
- Department of Surgery, Kamuzu Central Hospital, Lilongwe;,Department of Surgery, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | | | - Jared Gallaher
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| |
Collapse
|
28
|
Selimi V, Heang O, Kim Y, Woelber E, Gollogly J. Chronic hip dislocations: a rarity. How should we treat them? J Orthop 2016; 13:431-436. [PMID: 27698547 DOI: 10.1016/j.jor.2016.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 07/22/2016] [Accepted: 09/02/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Chronically dislocated hips (>6 weeks) are usually the consequence of difficulties accessing appropriate healthcare in a timely fashion after dislocation; this explains why they are more common in developing countries. Due to a lack of research, there is currently no consensus on the best treatment available for patients presenting with this condition. Therefore, it is important to assess the treatments available so as to ensure that doctors adequately manage those presenting with this debilitating condition in the future. OBJECTIVE To identify the best treatment strategy for chronic hip dislocations based on the treatment outcomes achieved by a free surgical clinic in Phnom Penh, Cambodia. PATIENTS AND METHOD A retrospective analysis of the surgical centre's electronic records was conducted. Patients presenting with hips dislocated for >6 weeks were included whilst congenitally dislocated hips were excluded. Treatment outcomes, based on follow up notes, were then assessed. Data abstracted during chart review was analysed using descriptive and comparative statistics. RESULTS 72 patients presented to the clinic with chronic hip dislocations. 42 patients received recorded treatment and 32 were followed up. Among patients with follow-up, 63% experienced 'good' outcomes after treatment. Open reductions, the most common treatment, were successful 65% of the time. The use of preoperative traction increased the success of open reductions by 13%, however, this result was not statistically significant (p = 0.64). CONCLUSION Open reductions with pre-operative traction seem to be an acceptable treatment in this setting.
Collapse
Affiliation(s)
- V Selimi
- University of Cambridge, Cambridge, England, United Kingdom
| | - O Heang
- Children's Surgical Centre, Phnom Penh, Cambodia
| | - Y Kim
- Children's Surgical Centre, Phnom Penh, Cambodia
| | - E Woelber
- WWAMI (Washington, Alaska, Montana and Idaho), USA
| | - J Gollogly
- Children's Surgical Centre, Phnom Penh, Cambodia
| |
Collapse
|
29
|
Haug L, Wazakili M, Young S, Van den Bergh G. Longstanding pain and social strain: patients' and health care providers' experiences with fracture management by skeletal traction; a qualitative study from Malawi. Disabil Rehabil 2016; 39:1714-1721. [PMID: 27440263 DOI: 10.1080/09638288.2016.1207109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
Collapse
Affiliation(s)
- Lise Haug
- a Department of Occupational Therapy, Physiotherapy and Radiography , Bergen University College , Bergen , Norway
| | | | - Sven Young
- c Department of Surgery , Kamuzu Central Hospital , Lilongwe , Malawi.,d Department of Orthopaedic Surgery , Haukeland University Hospital , Bergen , Norway
| | - Graziella Van den Bergh
- a Department of Occupational Therapy, Physiotherapy and Radiography , Bergen University College , Bergen , Norway
| |
Collapse
|
30
|
Treatment With the SIGN Nail in Closed Diaphyseal Femur Fractures Results in Acceptable Radiographic Alignment. Clin Orthop Relat Res 2015; 473:2394-401. [PMID: 25894807 PMCID: PMC4457748 DOI: 10.1007/s11999-015-4290-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 03/27/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND The burden of orthopaedic trauma in the developing world is substantial and disproportionate. SIGN Fracture Care International is a nonprofit organization that has developed and made available to surgeons in resource-limited settings an intramedullary interlocking nail for use in the treatment of femoral and tibial fractures. Instrumentation also is donated with the nail. A prospectively populated database collects information on all procedures performed using this nail. Given the challenging settings and numerous surgeons with varied experience, it is important to document adequate alignment and union using the device. QUESTIONS/PURPOSES The primary aim of this research was to assess the adequacy of operative reduction of closed diaphyseal femur fractures using the SIGN interlocking intramedullary nail based on radiographic images available in the SIGN database. The secondary aims were to assess correlations between postoperative alignment and several associated variables, including fracture location in the diaphysis, degree of fracture site comminution, and time to surgery. The tertiary aim was to assess the functionality of the SIGN database for radiographic analyses. METHODS A review of the prospectively populated SIGN database was performed for patients with a diaphyseal femur fracture treated with the SIGN nail, which at the time of the study totaled 32,362 patients. After study size calculations, a random number generator was used to select 500 femur fractures for analysis. Exclusion criteria included open fractures and those without radiographs during the early postoperative period. The following information was recorded: location of the fracture in the diaphysis; fracture classification (AO/Orthopaedic Trauma Association [OTA] classification); degree of comminution (Winquist and Hansen classification); time from injury to surgery; and patient demographics. Measurements of alignment were obtained from the AP and lateral radiographs with malalignment defined as deformity in either the sagittal or coronal plane greater than 5°. Measurements were made manually by the four study authors using on-screen protractor software and interobserver reliability was assessed. RESULTS The frequency of malalignment greater than 5° observed on postoperative radiographs was 51 of 501 (10%; 95% CI, 6.5-11.5), and malalignment greater than 10° occurred in eight of 501 (1.6%) of the femurs treated with this nail. Fracture location in the proximal or distal diaphysis was strongly correlated with risk of malalignment, with an odds ratio (OR) of 3.7 (95% CI, 1.5-9.3) for distal versus middle diaphyseal fractures and an OR of 4.7 (95% CI, 1.9-11.5) for proximal versus middle fractures (p < 0.001). Time from injury to surgery greater than 4 weeks also was strongly correlated with risk of malalignment (p < 0.001). Inherent fracture stability, based on fracture site comminution as per the Winquist and Hansen classification (Class 0-1 stable versus 2-4 unstable) showed an OR of 2.3 (95% CI, 1.2-4.3) for malalignment in unstable fractures. Interobserver reliability showed agreement of 88% (95% CI, 83-93) and mean kappa of 0.81 (95% CI, 0.65-0.87). The SIGN database of radiographic images was found to be an excellent source for research purposes with 92% of reviewed radiographs of acceptable quality. CONCLUSIONS The frequency of malalignment in closed diaphyseal femoral fractures treated with the SIGN nail closely approximated the incidence reported in the literature for North American trauma centers. Increased time from injury to surgery was correlated with increased frequency of malalignment; as humanitarian distribution of the SIGN nail increases, local barriers to timely care should be assessed and improved as possible. Prospective clinical study with followup, despite its inherent challenges in the developing world, would be of great benefit in the future. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
|
31
|
Ayana B, Klungsøyr PJ. Good results after Ponseti treatment for neglected congenital clubfoot in Ethiopia. A prospective study of 22 children (32 feet) from 2 to 10 years of age. Acta Orthop 2014; 85:641-5. [PMID: 25175659 PMCID: PMC4259042 DOI: 10.3109/17453674.2014.957085] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Neglected clubfoot deformity is a major cause of disability in low-income countries. Most children with clubfoot have little access to treatment in these countries, and they are often inadequately treated. We evaluated the effectiveness of Ponseti's technique in neglected clubfoot in children in a rural setting in Ethiopia. PATIENTS AND METHODS A prospective study was conducted from June 2007 through July 2010. 22 consecutive children aged 2-10 years (32 feet) with neglected clubfoot were treated by the Ponseti method. The deformity was assessed using the Pirani scoring system. The average follow-up time was 3 years. RESULTS A plantigrade functional foot was obtained in all patients by Ponseti casting and limited surgical intervention. 2 patients (4 feet) had recurrent deformity. They required re-manipulation and re-tenotomy of the Achilles tendon and 1 other patient required tibialis anterior transfer for dynamic supination deformity of the foot. INTERPRETATION This study shows that the Ponseti method with some additional surgery can be used successfully as the primary treatment in neglected clubfoot, and that it minimizes the need for extensive corrective surgery.
Collapse
Affiliation(s)
- Birhanu Ayana
- St. Luke Catholic General Hospital, Wolliso, Ethiopia; Orthopaedic Department, Ålesund, Helse Møre and Romsdal, Norway
| | - Peter J Klungsøyr
- St. Luke Catholic General Hospital, Wolliso, Ethiopia; Orthopaedic Department, Ålesund, Helse Møre and Romsdal, Norway
| |
Collapse
|