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Glinkowski W, Chelnokov AN. The orthopaedic surgeon's clinical and experimental experience affect methods used for the fracture healing assessment (FHA) - An International Survey. Injury 2021; 52:2205-2214. [PMID: 33836844 DOI: 10.1016/j.injury.2021.03.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 02/02/2023]
Abstract
Detection of fracture healing (FH), which depends on assessment methods, is a crucial factor affecting treatment. The study aimed to examine orthopedic surgeons in terms of practical methods of fracture healing (FHA) assessment (physical, imaging, measurement, and laboratory) and to check whether surgeons participating in clinical and laboratory experiments or only clinical practitioners prefer different FHA methods. An International Survey on Fracture Healing Assessment Methods was developed and distributed through the Web-based survey portal. Ninety-three orthopedic surgeons, on average age 41.46 years, from 24 countries participated in the study. Thirty-one respondents (33.3%) reported dealing with fractures both in the clinic and in experimental studies, six (6.5%) reported dealing with fractures only in laboratory research work, and fifty-six (60.2%) indicated that they dealt with fractures only clinically. The survey's internal consistency was significantly high (Cronbach's alpha coefficients ranged from 0.84 to 0.96). The majority of respondents (80.83%) use specific clinical criteria to define a fracture union. The FHA was mainly based on the physical examination and plain radiograms. Laboratory findings, patient-oriented outcomes scores, and quantitative methods are rarely used. Orthopaedic surgeons dealing with fractures both in the clinic and in laboratory fracture research studies are more likely to use more quantitative FHA methods. Future research is needed to improve the international standard of the FHA methods for use in research, clinical trials, and clinical practice. Using a quantitative, reliable, and standardized approach, including online support, can be valuable for increasing compliance in the orthopedic surgeon population, effectively improving the adherence of fracture healing assessment in clinical conditions, and improving early detection of fracture healing disorders, improving fracture efficiency treatment.
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Affiliation(s)
- Wojciech Glinkowski
- Centre of Excellence "TeleOrto" for Telediagnostics and Treatment of Disorders and Injuries of the Locomotor System, Medical University of Warsaw, 00581 Warsaw, Poland; Department of Medical Informatics and Telemedicine, Medical University of Warsaw, 00581 Warsaw, Poland; Polish Telemedicine and eHealth Society, 03728 Warsaw, Poland; Gabinet Lekarski, 03728 Warsaw, Poland.
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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.
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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
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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] [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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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.
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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.
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