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Haonga BT, O'Marr JM, Ngunyale P, Ngahyoma J, Kessey J, Sasillo I, Rodarte P, Belaye T, Berhaneselase E, Eliezer E, Porco TC, Morshed S, Shearer DW. GO-Tibia: a masked, randomized control trial evaluating gentamicin versus saline in open tibia fractures. Trials 2023; 24:406. [PMID: 37322521 PMCID: PMC10268448 DOI: 10.1186/s13063-023-07410-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/24/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND The rate of open tibia fractures is rapidly increasing across the globe due to a recent rise in road traffic accidents, predominantly in low- and low-middle-income countries. These injuries are orthopedic emergencies associated with infection rates as high as 40% despite the use of systemic antibiotics and surgical debridement. The use of local antibiotics has shown some promise in reducing the burden of infection in these injuries due to increasing local tissue availability; however, no trial has yet been appropriately powered to evaluate for definitive evidence and the majority of current studies have taken place in a high-resource countries where resources and the bio-burden may be different. METHODS This is a prospective randomized, masked, placebo-controlled superiority trial designed to evaluate the efficacy of locally administered gentamicin versus placebo in the prevention of fracture-related infection in adults (age > 18 years) with primarily closeable Gustillo-Anderson class I, II, and IIIA open tibia fractures. Eight hundred ninety patients will be randomized to receive an injection of either gentamicin (treatment group) or saline (control group) at the site of their primarily closed open fracture. The primary outcome will be the occurrence of a fracture-related infection occurring during the course of the 12-month follow-up. DISCUSSION This study will definitively assess the effectiveness of local gentamicin for the prevention of fracture-related infections in adults with open tibia fractures in Tanzania. The results of this study have the potential to demonstrate a low-cost, widely available intervention for the reduction of infection in open tibia fractures. TRIAL REGISTRATION Clinicaltrials.gov NCT05157126. Registered on December 14, 2021.
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Affiliation(s)
- Billy T Haonga
- Muhimbili Orthopaedic Institute, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Jamieson M O'Marr
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA
| | - Patrick Ngunyale
- Muhimbili Orthopaedic Institute, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Joshua Ngahyoma
- Muhimbili Orthopaedic Institute, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Justin Kessey
- Muhimbili Orthopaedic Institute, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Ibrahim Sasillo
- Muhimbili Orthopaedic Institute, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Patricia Rodarte
- Muhimbili Orthopaedic Institute, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Tigist Belaye
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA
| | - Eleni Berhaneselase
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA
| | - Edmund Eliezer
- Muhimbili Orthopaedic Institute, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Travis C Porco
- F.I. Proctor Foundation, University of California San Francisco, 513 Parnassus Avenue, San Francisco, CA, 94122, USA
- Department of Ophthalmology, University of California San Francisco, 10 Koret Way, San Francisco, CA, 94143, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th St. 2nd Floor, San Francisco, CA, 94158, USA
| | - Saam Morshed
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA
| | - David W Shearer
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA.
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Haonga BT, Ngunyale P, von Kaeppler EP, Donnelley CA, Won NY, Eliezer EN, Brown K, Flores M, O'Marr JM, Rodarte P, Urva M, Cortez A, Porco T, Morshed S, Shearer DW. A pilot, masked, randomized controlled trial to evaluate local gentamicin versus saline in open tibial fractures (pGO-Tibia). OTA Int 2023; 6:e268. [PMID: 37719315 PMCID: PMC10503693 DOI: 10.1097/oi9.0000000000000268] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/29/2023] [Indexed: 09/19/2023]
Abstract
Background Open tibial fractures have a high risk of infection that can lead to severe morbidity. Antibiotics administered locally at the site of the open wound are a potentially effective preventive measure, but there are limited data evaluating aminoglycoside antibiotics. The objective of this study was to assess the feasibility of a clinical trial to test the efficacy of local gentamicin in reducing the risk of fracture-related infection after open tibial fracture. Methods This study is a single-center, pilot, masked, randomized controlled trial conducted at the Muhimbili Orthopaedic Institute. Participants were randomized intraoperatively after wound closure to receive gentamicin solution or normal saline solution injected at the fracture site. Follow-ups were completed at 2 weeks, 6 weeks, 3 months, 6 months, 9 months, and 1 year postoperatively. The primary feasibility outcomes were the rate of enrollment and retention. The primary clinical outcome was the occurrence of fracture-related infection. Results Of 199 patients screened, 100 eligible patients were successfully enrolled and randomized over 9 months (11.1 patients/month). Complete data were recorded at baseline and follow-up for >95% of cases. The rate of follow-up at 6 weeks, 3 months, 6 months, 9 months, and 1 year were 70%, 68%, 69%, 61%, and 80%, respectively. There was no difference in adverse events or any of the measured primary and secondary outcomes. Conclusion This pilot study is among the first to evaluate locally administered gentamicin in open tibial fractures. Results indicate a rigorous clinical trial with acceptable rates of enrollment and follow-up to address this topic is possible in this setting.
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Affiliation(s)
| | | | - Ericka P. von Kaeppler
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - Claire A. Donnelley
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - Nae Y. Won
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | | | - Kelsey Brown
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - Michael Flores
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - Jamieson M. O'Marr
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - Patricia Rodarte
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - Mayur Urva
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - Abigail Cortez
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - Travis Porco
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Saam Morshed
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - David W. Shearer
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
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Urva M, Donnelley CA, Challa ST, Haonga BT, Morshed S, Shearer DW, Razani N. Transfemoral amputation and prosthesis provision in Tanzania: Patient and provider perspectives. Afr J Disabil 2023; 12:1084. [PMID: 36876024 PMCID: PMC9982473 DOI: 10.4102/ajod.v12i0.1084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 10/10/2022] [Indexed: 02/15/2023] Open
Abstract
Background The burden of disability because of traumatic limb amputation, particularly transfemoral amputation (TFA) is disproportionately carried by low- and middle-income countries. The need for improved access to prosthesis services in these settings is well-documented, but perspectives on the burden imposed by TFA and the challenges associated with subsequent prosthesis provision vary among patients, caregivers and healthcare providers. Objectives To examine the burden of TFA and barriers to prosthesis provision as perceived by patient, caregiver and healthcare professional, at a single tertiary referral hospital in Tanzania. Method Data were collected from five patients with TFA and four caregivers recruited via convenience sampling, in addition to 11 purposively sampled healthcare providers. All participants participated in in-depth interviews regarding their perceptions of amputation, prostheses and underlying barriers to improving care for persons with TFA in Tanzania. A coding schema and thematic framework were established from interviews using inductive thematic analysis. Results All participants noted financial and psychosocial burdens of amputation, and perceived prostheses as an opportunity for return to normality and independence. Patients worried about prosthesis longevity. Healthcare providers noted significant obstacles to prosthesis provision, including infrastructural and environmental barriers, limited access to prosthetic services, mismatched patient expectations and inadequate coordination of care. Conclusion This qualitative analysis identifies factors influencing prosthesis-related care for patients with TFA in Tanzania which are lacking in the literature. Persons with TFA and their caregivers experience numerous hardships exacerbated by limited financial, social and institutional support. Contribution This qualitative analysis informs future directions for research into improving prosthesis-related care for patients with TFA in Tanzania.
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Affiliation(s)
- Mayur Urva
- Department of Orthopedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, United States
| | - Claire A Donnelley
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, United States
| | - Sravya T Challa
- Department of Orthopaedic Surgery, Harvard University, Boston, United States
| | - Billy T Haonga
- Department of Orthopaedic Surgery, Muhimbili Orthopaedic Institute, Dar es Salaam, United Republic of Tanzania
| | - Saam Morshed
- Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, United States
| | - David W Shearer
- Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, United States
| | - Nooshin Razani
- Department of Epidemiology and Biostatistics, University of California, San Francisco, United States
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Donnelley CA, von Kaeppler EP, Hetherington A, Shirley C, Haonga BT, Challa ST, Andrysek J, Lutyens EM, Mamseri L, Mwakasungula G, Morshed S, Shearer DW. Cost-effectiveness analysis of prosthesis provision for patients with transfemoral amputation in Tanzania. Prosthet Orthot Int 2022; 46:523-531. [PMID: 35426873 DOI: 10.1097/pxr.0000000000000129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 02/15/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Limb loss leads to significant disability. Prostheses may mitigate this disability but are not readily accessible in low- and middle-income countries (LMICs). Cost-effectiveness data related to prosthesis provision in resource-constrained environments such as Tanzania is greatly limited. OBJECTIVES This study aimed to compare the cost-effectiveness of a prosthesis intervention compared with that of no prosthesis for persons with transfemoral amputations in an LMIC. STUDY DESIGN This is a prospective cohort study. METHODS Thirty-eight patients were prospectively followed up. Clinical improvement with prosthesis provision was measured using EuroQuol-5D, represented as quality-adjusted life years gained. Direct and indirect costs were measured. The primary outcome was incremental cost per quality-adjusted life year, measured at 1 year and projected over a lifetime using a Markov model. Reference case was set as a single prosthesis provided without replacement from a payer perspective. Additional scenarios included the societal perspective and replacement of the prosthesis. Uncertainty was measured with one-way probabilistic sensitivity analysis. RESULTS From the payer perspective, the incremental cost-effectiveness ratio (ICER) was $242 for those without prosthetic replacement over a lifetime, and the ICER was $390 for those with prosthetic replacement over a lifeime. From the societal perspective, prosthesis provision was both less expensive and more effective. One-way sensitivity analysis demonstrated the ICER remained below the willingness to pay threshold up to prosthesis costs of $763. CONCLUSIONS These findings suggest prosthesis provision in an LMIC may be cost-effective, but further studies with long-term follow up are needed to validate the results.
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Affiliation(s)
- Claire A Donnelley
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Ericka P von Kaeppler
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Alexander Hetherington
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Corin Shirley
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Billy T Haonga
- Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Sravya T Challa
- Harvard Combined Orthopedic Residency Program, Boston, MA, USA
| | - Jan Andrysek
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | | | - Leah Mamseri
- Muhimbili Orthopaedic Workshop, Dar es Salaam, Tanzania
| | | | - Saam Morshed
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - David W Shearer
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
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Urva M, Challa ST, Haonga BT, Eliezer E, Working ZM, El Naga A, Morshed S, Shearer DW. Reliability of Modified Radiographic Union Score for Tibia Scores in the Evaluation of Femoral Shaft Fractures in a Low-resource Setting. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202205000-00011. [PMID: 35605095 PMCID: PMC9126518 DOI: 10.5435/jaaosglobal-d-21-00211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 03/15/2022] [Indexed: 06/01/2023]
Abstract
INTRODUCTION The modified Radiographic Union Score for Tibia (RUST) fractures was developed to better describe fracture healing, but its utility in resource-limited settings is poorly understood. This study aimed to determine the validity of mRUST scores in evaluating fracture healing in diaphyseal femur fractures treated operatively at a single tertiary referral hospital in Tanzania. METHODS Radiographs of 297 fractures were evaluated using the mRUST score and compared with outcomes including revision surgery and EuroQol five dimensions questionnaire (EQ-5D) and visual analog scale (VAS) quality-of-life measures. Convergent validity was assessed by correlating mRUST scores with EQ-5D and VAS scores. Divergent validity was assessed by comparing mRUST scores in patients based on revision surgery status. RESULTS The mRUST score had moderate correlation (Spearman correlation coefficient 0.40) with EQ-5D scores and weak correlation (Spearman correlation coefficient 0.320) with VAS scores. Compared with patients who required revision surgery, patients who did not require revision surgery had higher RUST scores at all time points, with statistically significant differences at 3 months (2.02, P < 0.05). DISCUSSION These results demonstrate that the mRUST score is a valid method of evaluating the healing of femoral shaft fractures in resource-limited settings, with high interrater reliability, correlation with widely used quality of life measures (EQ-5D and VAS), and expected divergence in the setting of complications requiring revision surgery.
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von Kaeppler EP, Hetherington A, Donnelley CA, Ali SH, Shirley C, Challa ST, Lutyens E, Haonga BT, Morshed S, Andrysek J, Shearer DW. Impact of prostheses on quality of life and functional status of transfemoral amputees in Tanzania. Afr J Disabil 2021; 10:839. [PMID: 34692432 PMCID: PMC8517763 DOI: 10.4102/ajod.v10i0.839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/24/2021] [Indexed: 11/23/2022] Open
Abstract
Background The rise of diabetes and traumatic injury has increased limb loss-related morbidity in low- and middle-income countries (LMICs). Despite this, the majority of amputees in LMICs have no access to prosthetic devices, and the magnitude of prosthesis impact on quality of life (QOL ) and function has not been quantified. Objectives Quantify the impact of prostheses on QOL and function in Tanzanian transfemoral amputees. Method A prospective cohort study was conducted. Transfemoral amputees at Muhimbili Orthopaedic Institute were assessed twice before and three times after prosthetic fitting using EuroQol-5D-3L (EQ-5D-3L), Prosthetic Limb Users Survey of Mobility (PLUS-M), 2-minute walk test (2MWT) and Physiologic Cost Index (PCI). Data were analysed for change over time. Subgroup analysis was performed for amputation aetiology (vascular or non-vascular) and prosthesis use. Results Amongst 30 patients, EQ-5D, PLUS-M and 2MWT improved after prosthesis provision (p < 0.001). EuroQol-5D increased from 0.48 to 0.85 at 1 year (p < 0.001). EuroQol-5D and 2MWT were higher in non-vascular subgroup (p < 0.030). At 1-year, 84% of non-vascular and 44% of vascular subgroups reported using their prosthesis (p = 0.068). Conclusion Prosthesis provision to transfemoral amputees in an LMIC improved QOL and function. This benefit was greater for non-vascular amputation aetiologies. Quality of life and function returned to pre-prosthesis levels with discontinued use of prosthesis.
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Affiliation(s)
- Ericka P von Kaeppler
- Institute of Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, United States of America
| | - Alexander Hetherington
- Institute of Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, United States of America
| | - Claire A Donnelley
- Institute of Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, United States of America
| | - Syed H Ali
- Institute of Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, United States of America
| | - Corin Shirley
- Institute of Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, United States of America
| | - Sravya T Challa
- Institute of Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, United States of America
| | | | - Billy T Haonga
- Department of Orthopaedic Surgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Saam Morshed
- Institute of Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, United States of America
| | - Jan Andrysek
- LegWorks, Inc., Buffalo, United States of America.,Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
| | - David W Shearer
- Institute of Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, United States of America
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Roberts HJ, Donnelley CA, Haonga BT, Kramer E, Eliezer EN, Morshed S, Shearer D. Intramedullary nailing versus external fixation for open tibia fractures in Tanzania: a cost analysis. OTA Int 2021; 4:e146. [PMID: 34746677 PMCID: PMC8568384 DOI: 10.1097/oi9.0000000000000146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/20/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Open tibia fractures pose a clinical and economic burden that is disproportionately borne by low-income countries. A randomized trial conducted by our group showed no difference in infection and nonunion comparing 2 treatments: external fixation (EF) and intramedullary nailing (IMN). Secondary outcomes favored IMN. In the absence of clear clinical superiority, we sought to compare costs between EF and IMN. DESIGN Secondary cost analysis. SETTING Single institution in Tanzania. PATIENTS/PARTICIPANTS Adult patients with acute diaphyseal open tibia fractures who participated in a previous randomized controlled trial. INTERVENTION SIGN IMN versus monoplanar EF. MAIN OUTCOME MEASUREMENTS Direct costs of initial surgery and hospitalization and subsequent reoperation: implant, instrumentation, medications, disposable supplies, and personnel costs.Indirect costs from lost productivity of patient and caregiver.Societal (total) costs: sum of direct and indirect costs.All costs were reported in 2018 USD. RESULTS Two hundred eighteen patients were included (110 IMN, 108 EF). From a payer perspective, costs were $365.83 (95% CI: $332.75-405.76) for IMN compared with $331.25 ($301.01-363.14) for EF, whereas from a societal perspective, costs were $2664.59 ($1711.22-3955.25) for IMN and $2560.81 ($1700.54-3715.09) for EF. The largest drivers of cost were reoperation and lost productivity. Accounting for uncertainty in multiple variables, probabilistic sensitivity analysis demonstrated that EF was less costly than IMN from the societal perspective in only 55% of simulations. CONCLUSIONS Intramedullary nail fixation compared with external fixation of open tibia fractures in a resource-constrained setting is not associated with increased cost from a societal perspective.
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Affiliation(s)
- Heather J Roberts
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA
| | - Claire A Donnelley
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA
| | - Billy T Haonga
- Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Erik Kramer
- Yale University School of Medicine, New Haven, CT
| | | | - Saam Morshed
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA
| | - David Shearer
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA
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von Kaeppler EP, Donnelley C, Ali SH, Roberts HJ, Ibrahim JM, Wu HH, Eliezer EN, Porco TC, Haonga BT, Morshed S, Shearer DW. A study protocol for a Pilot Masked, Randomized Controlled Trial Evaluating Locally-applied Gentamicin versus Saline in Open Tibia Fractures (pGO-Tibia) in Dar es Salaam, Tanzania. Pilot Feasibility Stud 2021; 7:47. [PMID: 33568230 PMCID: PMC7874655 DOI: 10.1186/s40814-021-00766-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 01/06/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Open tibia fractures are a major source of disability in low- and middle-income countries (LMICs) due to the high incidence of complications, particularly infection and chronic osteomyelitis. One proposed adjunctive measure to reduce infection is prophylactic local antibiotic delivery, which can achieve much higher concentrations at the surgical site than can safely be achieved with systemic administration. Animal studies and retrospective clinical studies support the use of gentamicin for this purpose, but no high-quality clinical trials have been conducted to date in high- or low-income settings. METHODS We describe a protocol for a pilot study conducted in Dar es Salaam, Tanzania, to assess the feasibility of a single-center masked randomized controlled trial to compare the efficacy of locally applied gentamicin to placebo for the prevention of fracture-related infection in open tibial shaft fractures. DISCUSSION The results of this study will inform the design and feasibility of a definitive trial to address the use of local gentamicin in open tibial fractures. If proven effective, local gentamicin would be a low-cost strategy to reduce complications and disability from open tibial fractures that could impact care in both high- and low-income countries. TRIAL REGISTRATION ClinicalTrials.gov, Registration # NCT03559400 ; Registered June 18, 2018.
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Affiliation(s)
- Ericka P von Kaeppler
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA
| | - Claire Donnelley
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA
| | - Syed H Ali
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA
| | - Heather J Roberts
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA
| | - John M Ibrahim
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA
| | - Hao-Hua Wu
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA
| | - Edmund N Eliezer
- Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Kalenga Street, Dar es Salaam, Tanzania
| | - Travis C Porco
- F.I. Proctor Foundation, University of California San Francisco, 513 Parnassus Avenue, San Francisco, CA, 94122, USA
- Department of Ophthalmology, University of California San Francisco, 10 Koret Way, San Francisco, CA, 94143, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th St. 2nd Floor, San Francisco, CA, 94158, USA
| | - Billy T Haonga
- Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Kalenga Street, Dar es Salaam, Tanzania
| | - Saam Morshed
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA
| | - David W Shearer
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA.
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Albright PD, Ali SH, Jackson H, Haonga BT, Eliezer EN, Morshed S, Shearer DW. Delays to Surgery and Coronal Malalignment Are Associated with Reoperation after Open Tibia Fractures in Tanzania. Clin Orthop Relat Res 2020; 478:1825-1835. [PMID: 32732563 PMCID: PMC7371086 DOI: 10.1097/corr.0000000000001279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 04/06/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment of diaphyseal open tibia fractures often results in reoperation and impaired quality of life. Few studies, particularly in resource-limited settings, have described factors associated with outcomes after these fractures. QUESTIONS/PURPOSES (1) Which patient demographic, perioperative, and treatment characteristics are associated with an increased risk of reoperation after treatment of open tibia fractures with intramedullary nailing or an external fixation device in Tanzania? (2) Which patient demographic, perioperative, and treatment characteristics are associated with worse 1-year quality of life after treatment of open tibia fractures with intramedullary nailing or an external fixation device in Tanzania? METHODS A prospective study was completed in parallel to a similarly conducted RCT at a tertiary referral center in Tanzania that enrolled adult patients with diaphyseal open tibia fractures from December 2015 to March 2017. Patients were treated with either a statically locked intramedullary nail or external fixator and examined at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year postoperatively. The primary outcome, reoperation, was any deep infection or nonunion treated with a secondary intervention. The secondary outcome was the 1-year EuroQol-5D (EQ-5D) index score. There were 394 patients screened and ultimately, 267 patients enrolled in the study (240 from the primary RCT and 27 followed for the purposes of this study). Of these, 90% (240 of 267) completed 1-year follow-up and were included in the final analysis. This group comprised 110 patients who underwent IMN and 130 who had external fixation; follow-up was similar between study groups. Patients were an average of 33 years old and were primarily males who sustained road traffic injuries resulting in AO/Orthopaedic Trauma Association (OTA) classification type A or B fractures. There were 51 reoperations. For the purposes of analysis, all patients were pooled to identify all other factors, in addition to treatment type, associated with increased risk of reoperation and 1-year quality of life. An exploratory bivariable analysis identifying various factors associated with reoperation risk and EQ-5D was subsequently included in a multivariate modeling procedure to control for confounding of effect on our primary outcome. Multivariable modeling was performed using standard hierarchical modeling simplification procedures with log-likelihood ratios. Alpha levels were set to 0.05. RESULTS After controlling for potentially confounding variables such as gender, smoking status, mechanism of injury, and treatment type, the following factors were independently associated with reoperation: Time from hospital presentation to surgery more than 24 hours (odds ratio 7.7 [95% confidence interval 2.1 to 27.8; p = 0.002), AO/OTA fracture classification Type 42C fracture (OR 4.2 [95% CI 1.2 to 14.0]; p = 0.02), OTA-Open Fracture Classification muscle loss (OR 7.5 [95% CI 1.3 to 42.2]; p = 0.02), and varus coronal angle on an immediate postoperative AP radiograph (OR 4.8 [95% CI 1.2 to 14.0]; p = 0.002). After again controlling for confounding variables such as gender, smoking status, mechanism of injury, and treatment type factors independently associated with worse 1-year EQ-5D scores included: Wound length ≥ 10 cm (ß = [change in EQ-5D score] -0.081 [95% CI -0.139 to -0.023]; p = 0.006), OTA-Open Fracture Classification muscle loss (ß = -0.133 [95% CI -0.215 to -0.051]; p = 0.002), and OTA-Open Fracture Classification bone loss (ß = -0.111 [95% CI -0.208 to -0.013]; p = 0.03). We observed a modest, but independent association between reoperation and worse 1-year EQ-5D scores (ß = -0.113 [95% CI -0.150 to -0.077]; p < 0.001). CONCLUSIONS We found two potentially modifiable factors associated with the risk of reoperation: reducing time to surgical treatment and avoiding varus coronal angulation during definitive stabilization. Hospitals may be able to minimize time to surgery, and thus, reoperation, by increasing the number of available operative personnel and space and emphasizing the importance of open tibia fractures as an injury requiring emergent orthopaedic management. Given the lack of fluoroscopy in the study setting and similar settings, surgeons should emphasize appropriate fracture alignment, even into slight valgus, to avoid varus angulation and subsequent reoperation risk. LEVEL OF EVIDENCE Level II, therapeutic study.
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Affiliation(s)
- Patrick D Albright
- P. D. Albright, S. H. Ali, H. Jackson, S. Morshed, D. W. Shearer, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Syed Haider Ali
- P. D. Albright, S. H. Ali, H. Jackson, S. Morshed, D. W. Shearer, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Hunter Jackson
- P. D. Albright, S. H. Ali, H. Jackson, S. Morshed, D. W. Shearer, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Billy T Haonga
- B. T. Haonga, E. N. Eliezer, Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Dar Es Salaam, Tanzania
| | - Edmund Ndalama Eliezer
- B. T. Haonga, E. N. Eliezer, Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Dar Es Salaam, Tanzania
| | - Saam Morshed
- P. D. Albright, S. H. Ali, H. Jackson, S. Morshed, D. W. Shearer, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
- S. Morshed, Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - David W Shearer
- P. D. Albright, S. H. Ali, H. Jackson, S. Morshed, D. W. Shearer, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
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Haonga BT, Liu M, Albright P, Challa ST, Ali SH, Lazar AA, Eliezer EN, Shearer DW, Morshed S. Intramedullary Nailing Versus External Fixation in the Treatment of Open Tibial Fractures in Tanzania: Results of a Randomized Clinical Trial. J Bone Joint Surg Am 2020; 102:896-905. [PMID: 32028315 PMCID: PMC7508278 DOI: 10.2106/jbjs.19.00563] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Open tibial fractures are common injuries in low and middle-income countries, but there is no consensus regarding treatment with intramedullary nailing versus external fixation. The purpose of the present study was to compare the outcomes of initial treatment with intramedullary nailing or external fixation in adults with open tibial fractures. METHODS We conducted a randomized clinical trial (RCT) at a tertiary orthopaedic center in Tanzania. Adults with acute diaphyseal open tibial fractures were randomly assigned to statically locked, hand-reamed intramedullary nailing or uniplanar external fixation. The primary outcome was death or reoperation for the treatment of deep infection, nonunion, or malalignment. Secondary outcomes included quality of life as measured with the EuroQol-5 Dimensions (EQ-5D) questionnaire, radiographic alignment, and healing as measured with the modified Radiographic Union Scale for Tibial fractures (mRUST). RESULTS Of the 240 patients who were enrolled, 221 (92.1%) (including 111 managed with intramedullary nailing and 110 managed with external fixation) completed 1-year follow-up. There were 44 primary outcome events (with rates of 18.0% and 21.9% in the intramedullary nailing and external fixation groups, respectively) (relative risk [RR] = 0.83 [95% confidence interval (CI), 0.49 to 1.41]; p = 0.505). There was no significant difference between the groups in terms of the rate of deep infection. Intramedullary nailing was associated with a lower risk of coronal malalignment (RR = 0.11 [95% CI, 0.01 to 0.85]; p = 0.01) and sagittal malalignment (RR = 0.17 [95% CI, 0.02 to 1.35]; p = 0.065) at 1 year. The EQ-5D index favored intramedullary nailing at 6 weeks (mean difference [MD] = 0.07 [95% CI = 0.03 to 0.11]; p < 0.001), but this difference dissipated by 1 year. Radiographic healing (mRUST) favored intramedullary nailing at 6 weeks (MD = 1.2 [95% CI = 0.4 to 2.0]; p = 0.005), 12 weeks (MD = 1.0 [95% CI = 0.3 to 1.7]; p = 0.005), and 1 year (MD = 0.8 [95% CI = 0.2 to 1.5]; p = 0.013). CONCLUSIONS To our knowledge, the present study is the first RCT assessing intramedullary nailing versus external fixation for the treatment of open tibial fractures in sub-Saharan Africa. Differences in primary events were not detected, and only coronal alignment significantly favored the use of intramedullary nailing. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Billy T. Haonga
- Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Dar es Salaam, Tanzania,Email address for B.T. Haonga:
| | - Max Liu
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California,Email address for M. Liu:
| | - Patrick Albright
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California,Email address for P. Albright:
| | - Sravya T. Challa
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California,Email address for S.T. Challa:
| | - Syed H. Ali
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California,Email address for S.H. Ali:
| | - Ann A. Lazar
- Division of Oral Epidemiology, School of Dentistry, University of California San Francisco, San Francisco, California,Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California,Email address for A.A. Lazar:
| | - Edmund N. Eliezer
- Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Dar es Salaam, Tanzania,Email address for E.N. Eliezer:
| | - David W. Shearer
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California,Email address for D.W. Shearer:
| | - Saam Morshed
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California,Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California,Email address for S. Morshed:
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Haonga BT, Areu MMM, Challa ST, Liu MB, Elieza E, Morshed S, Shearer D. Early treatment of open diaphyseal tibia fracture with intramedullary nail versus external fixator in Tanzania: Cost effectiveness analysis using preliminary data from Muhimbili Orthopaedic Institute. SICOT J 2019; 5:20. [PMID: 31204649 PMCID: PMC6572994 DOI: 10.1051/sicotj/2019022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 05/31/2019] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Open tibia fractures are some of the most common types of Orthopedics injuries in low- and middle-income countries (LMICs). In Tanzania, open tibia fractures are treated either conservatively by prolonged cast or surgically by external fixation (EF) or intramedullary nail (IMN) when available. The cost of treatment and amount of time patients spend away from work are major economic concerns with prolonged casting and EF. The goal of this study was to determine the cost effectiveness of IMN versus EF in the treatment of open diaphyseal tibia fractures at Muhimbili Orthopaedic Institute (Dar es Salaam, Tanzania). METHODS This is a prospective randomized control study conducted of patients with a closeable AO/OTA 42 open diaphyseal tibia fracture. The patients underwent surgical fixation with either IMN or EF at Muhimbili Orthopaedic Institute (MOI), and were followed up at 2, 6, and 12 weeks postoperatively. A micro-costing method was used to estimate the fixed and variable costs of IMN and EF of the open diaphyseal tibial fracture. RESULTS The mean total cost per patient was lower for the IMN group ($425.8 ± 38.4) compared to the EF group ($559.6 ± 70.5, p < 0.001), with savings of $133.80 per patient for the IMN group. The mean hospital stay was 2.72 ± 1.40 days for the IMN group and 2.44 ± 1.47 days for the EF group (p = 0.5). Quality-adjusted life years (QALYs) were 0.26 per patient for the IMN group and 0.24 in the EF group at 12 weeks (p = 0.8). Ninety-two percent of patients in the IMN group achieved fracture union versus 60% in the EF group at three months postoperatively (p = 0.03). CONCLUSION IM nailing of a closeable open diaphyseal tibial fracture is more cost effective than EF. In addition, IM nailing has better union rates at three months compared to EF.
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Affiliation(s)
- Billy T Haonga
- Department of Orthopaedic and Traumatology, Muhimbili University of Health and Allied Sciences, Kalenga street 11000, Dar es Salaam, Tanzania
| | - Mapuor M M Areu
- Department of Orthopaedic and Traumatology, Muhimbili University of Health and Allied Sciences, Kalenga street 11000, Dar es Salaam, Tanzania
| | - Sravya T Challa
- Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, San Francisco, CA 94110, USA
| | - Max B Liu
- Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, San Francisco, CA 94110, USA
| | - Edmund Elieza
- Department of Orthopaedic and Traumatology, Muhimbili University of Health and Allied Sciences, Kalenga street 11000, Dar es Salaam, Tanzania
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, San Francisco, CA 94110, USA
| | - David Shearer
- Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, San Francisco, CA 94110, USA
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Wu HH, Liu M, Challa ST, Morshed S, Eliezer EN, Haonga BT, Zirkle L, Shearer DW. Development of Squat-and-Smile Test as Proxy for Femoral Shaft Fracture-Healing in Patients in Dar es Salaam, Tanzania. J Bone Joint Surg Am 2019; 101:353-359. [PMID: 30801374 DOI: 10.2106/jbjs.18.00387] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Hao-Hua Wu
- University of California San Francisco, San Francisco, California
| | - Max Liu
- Stanford University, Stanford, California
| | - Sravya T Challa
- University of California San Francisco, San Francisco, California
| | - Saam Morshed
- University of California San Francisco, San Francisco, California
| | - E N Eliezer
- Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Billy T Haonga
- Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Lewis Zirkle
- SIGN Fracture Care International, Richland, Washington
| | - David W Shearer
- University of California San Francisco, San Francisco, California
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Ibrahim JM, Conway D, Haonga BT, Eliezer EN, Morshed S, Shearer DW. Predictors of lower health-related quality of life after operative repair of diaphyseal femur fractures in a low-resource setting. Injury 2018; 49:1330-1335. [PMID: 29866624 DOI: 10.1016/j.injury.2018.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 05/17/2018] [Accepted: 05/22/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Little data exists on the negative impact of orthopaedic trauma on quality of life (QOL) in low- and middle-income countries (LMICs). The goal of this study is to investigate the factors associated with lower QOL after operative fixation of femoral shaft fractures in adult patients in a low-resource setting. METHODS This prospective cohort study followed 272 factures in adults undergoing operative fixation for diaphyseal femur fractures at Tanzania. Patient demographics, injury characteristics, treatment modalities, and functional outcomes up to 1-year post-operatively were evaluated for association with 1-year post-operative EQ-5D QOL scores via univariate linear regression analysis. RESULTS EQ-5D values were significantly lower at 1 year than at baseline (0.941 vs 0.991, p < 0.0005). CONCLUSIONS Operative fixation of femoral shaft fractures in LMICs results in return to near baseline QOL. Demographic and treatment factors were not significantly associated with EQ-5D. and several markers of recovery were associated with lower 1 year QOL, including pain, knee stiffness, delayed radiographic healing, complications requiring reoperation. Efforts to reduce perioperative complications may help improve post-operative QOL.
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Affiliation(s)
- John M Ibrahim
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA, 94110, USA.
| | - Devin Conway
- Tulane University School of Medicine, New Orleans, LA, USA
| | - Billy T Haonga
- Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | | | - Saam Morshed
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA, 94110, USA
| | - David W Shearer
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA, 94110, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Haonga BT, Makupa JE, Muhina RI, Nungu KS. Pain management among adult patients with fractures of long bones at Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania. ACTA ACUST UNITED AC 2011; 13:107-11. [DOI: 10.4314/thrb.v13i4.56959] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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