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

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

Objectives

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

Design

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

Results

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

Conclusion

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

Orthopaedic and trauma research in Tanzania: A scoping review

Tanzania is disproportionately burdened by musculoskeletal injuries as it faces unique challenges when dealing with trauma care. This scoping review aims to summarize and assess the current state of orthopaedic and trauma research in Tanzania. By identifying key themes, trends, and gaps in the literature, this review seeks to guide future research initiatives catered specifically to the needs of Tanzania's healthcare system. Utilizing the PRISMA-ScR protocol, OVID Medline, PubMed, and CINAHL databases were searched from inception to June 17, 2023, using keywords such as "Orthopaedics" "Trauma" and "Tanzania". One hundred and ninety-two eligible studies were included and the Arksey and O'Malley framework for scoping studies was followed. There was a notable growth of relevant publications from 2015 onward, with peaks in growth in the years 2019, 2021, and 2020. The studies employed diverse research methodologies, with cross-sectional (n = 41, 21%) and prospective studies (n = 39, 20%) being the most prevalent, and randomized-controlled trials being the least prevalent methodology, making up eight studies (4.2%). The most common study themes were trauma (n = 101, 52.6%), lower extremity (n = 31, 16%), and spine-related issues (n = 27, 14%). Only three studies looked at work-related injuries (1.6%). Road traffic injuries (RTIs) were the most common mechanism of trauma in 77.0% of the trauma focused studies. Fifty-three percent of the studies were conducted by a majority of Tanzanian authors. This scoping review highlights various trends in orthopaedic and trauma research in Tanzania, with a particular emphasis on road traffic-related injuries. Various gaps are explored, including a lack of research on work-related injuries and a paucity of experimental research. Our findings underline areas where future research is warranted. The future of orthopaedic and trauma care in Tanzania depends on the efforts and collaboration of both local and international stakeholders.

The economic costs of orthopaedic services: a health system cost analysis of tertiary hospitals in a low-income country

BACKGROUND

Traumatic injuries are rising globally, disproportionately affecting low- and middle-income countries, constituting 88% of the burden of surgically treatable conditions. While contributing to the highest burden, LMICs also have the least availability of resources to address this growing burden effectively. Studies on the cost-of-service provision in these settings have concentrated on the most common traumatic injuries, leaving an evidence gap on other traumatic injuries. This study aimed to address the gap in understanding the cost of orthopaedic services in low-income settings by conducting a comprehensive costing analysis in two tertiary-level hospitals in Malawi.

METHODS

We used a mixed costing methodology, utilising both Top-Down and Time-Driven Activity-Based Costing approaches. Data on resource utilisation, personnel costs, medicines, supplies, capital costs, laboratory costs, radiology service costs, and overhead costs were collected for one year, from July 2021 to June 2022. We conducted a retrospective review of all the available patient files for the period under review. Assumptions on the intensity of service use were based on utilisation patterns observed in patient records. All costs were expressed in 2021 United States Dollars.

RESULTS

We conducted a review of 2,372 patient files, 72% of which were male. The median length of stay for all patients was 9.5 days (8-11). The mean weighted cost of treatment across the entire pathway varied, ranging from $195 ($136-$235) for Supracondylar Fractures to $711 ($389-$931) for Proximal Ulna Fractures. The main cost components were personnel (30%) and medicines and supplies (23%). Within diagnosis-specific costs, the length of stay was the most significant cost driver, contributing to the substantial disparity in treatment costs between the two hospitals.

CONCLUSION

This study underscores the critical role of orthopaedic care in LMICs and the need for context-specific cost data. It highlights the variation in cost drivers and resource utilisation patterns between hospitals, emphasising the importance of tailored healthcare planning and resource allocation approaches. Understanding the costs of surgical interventions in LMICs can inform policy decisions and improve access to essential orthopaedic services, potentially reducing the disease burden associated with trauma-related injuries. We recommend that future studies focus on evaluating the cost-effectiveness of orthopaedic interventions, particularly those that have not been analysed within the existing literature.

External fixation versus intramedullary nailing for the management of open tibial fracture: meta-analysis of randomized controlled trials

AIM

Tibial shaft fractures are the most common type of long-bone fractures. External fixation (EF) and intramedullary nailing (IMN) are widely used surgical techniques for the definitive fixation of open tibial shaft fractures. The aim of this systematic review and meta-analysis was to compare EF to IMN for the definitive fixation of open tibial fractures.

METHODS

Medline, Embase, and CENTRAL databases were searched for eligible studies. We included randomized controlled trials (RCTs) that compared EF to IMN for skeletally mature adults with open tibial fracture (Gustilo I, II, and III). We evaluated the following outcomes: superficial infection, pin-track infection, deep infection, malunion, nonunion, delayed union, and implant/hardware failure. The risk ratio (RR) was used to represent the desired outcomes. The statistical analysis was performed using the random-effects model.

RESULTS

A total of 12 RCTs that enrolled 1090 participants were deemed eligible for the analysis. EF showed a significantly higher rate of superficial infection, pin track infection, and malunion compared to IMN (RR = 2.30, 95% confidence interval (CI): 1.34 to 3.95; RR = 13.52, 95% CI: 6.16 to 29.66; RR = 2.29, 95% CI 1.41 to 3.73, respectively). No substantial difference was found between EF and IMN in terms of deep infection, nonunion, delayed union, or implant/hardware failure (RR = 1.15, 95% CI 0.67 to 1.98; RR = 0.92, 95% CI 0.77 to 1.10; RR = 1.50, 95% CI 0.98 to 3.33; RR = 0.96, 95% CI 0.36 to 2.60, respectively).

DISCUSSION

The findings of our meta-analysis are consistent with the previous systematic reviews excepts for the implant/hardware failure which was found to be significant in favour of IMN by one of the previous reviews.

CONCLUSION

This meta-analysis confirms that IMN is better than EF with respect to clinical outcomes and complication rate for the definitive fixation of open tibial fracture.

Adequacy of in-mission training to treat tibial shaft fractures in mars analogue testing

Long bone fractures are a concern in long-duration exploration missions (LDEM) where crew autonomy will exceed the current Low Earth Orbit paradigm. Current crew selection assumptions require extensive complete training and competency testing prior to flight for off-nominal situations. Analogue astronauts (n = 6) can be quickly trained to address a single fracture pattern and then competently perform the repair procedure. An easy-to-use external fixation (EZExFix) was employed to repair artificial tibial shaft fractures during an inhabited mission at the Mars Desert Research Station (Utah, USA). Bone repair safety zones were respected (23/24), participants achieved 79.2% repair success, and median completion time was 50.04 min. Just-in-time training in-mission was sufficient to become autonomous without pre-mission medical/surgical/mechanical education, regardless of learning conditions (p > 0.05). Similar techniques could be used in LDEM to increase astronauts' autonomy in traumatic injury treatment and lower skill competency requirements used in crew selection.

Matrix Rhythm Therapy (MRT) Along With Conventional Physiotherapy Proves to Be Beneficial in a Patient With Post-Operative Knee Stiffness in Case of Tibia-Fibula Fracture: A Case Report

Open fractures of the lower extremities are much more serious as compared to those of the upper extremities. Open fractures occur when the damaged bone is exposed to the external environment through injured soft tissue, increasing the risk of infection. The distal tibia can be fractured by a low-energy mechanism, such as rotational strain or perhaps a high-energy mechanism, such as motor vehicle accidents or falls from high altitudes. This case report is of a male individual who underwent an accident that led to a midshaft tibia and fibula fracture with lateral malleolus fracture. For that, he was operated on with open reduction and internal fixation (ORIF) with interlock nailing for a fracture of the tibia on the right side. A thorough physiotherapy protocol was set, which included matrix rhythm therapy (MRT), and improvements were seen in the outcome measures taken. The course of therapy improved the patient's state of well-being. Functional re-education increased the strength and endurance of the muscles. The patient also developed lower limb strength.

An Easy-To-Use External Fixator for All Hostile Environments, from Space to War Medicine: Is It Meant for Everyone's Hands?

Long bone fractures in hostile environments pose unique challenges due to limited resources, restricted access to healthcare facilities, and absence of surgical expertise. While external fixation has shown promise, the availability of trained surgeons is limited, and the procedure may frighten unexperienced personnel. Therefore, an easy-to-use external fixator (EZExFix) that can be performed by nonsurgeon individuals could provide timely and life-saving treatment in hostile environments; however, its efficacy and accuracy remain to be demonstrated. This study tested the learning curve and surgical performance of nonsurgeon analog astronauts (n = 6) in managing tibial shaft fractures by the EZExFix during a simulated Mars inhabited mission, at the Mars Desert Research Station (Hanksville, UT, USA). The reduction was achievable in the different 3D axis, although rotational reductions were more challenging. Astronauts reached similar bone-to-bone contact compared to the surgical control, indicating potential for successful fracture healing. The learning curve was not significant within the limited timeframe of the study (N = 4 surgeries lasting <1 h), but the performance was similar to surgical control. The results of this study could have important implications for fracture treatment in challenging or hostile conditions on Earth, such as war or natural disaster zones, developing countries, or settings with limited resources.

Use of external fixators in developing countries: a short socioeconomic analysis

The use of external fixators (EFs) dates back to 377 BC Hippocrates’ time, and it has a wide range of orthopaedic applications. External fixator has expanded its use in the management of fractures and other musculoskeletal conditions. It is widely used all over the world to manage complex musculoskeletal injuries. It has many advantages as compared to internal fixation in some trauma scenarios. However, the cost of the external fixators presents a dilemma to the healthcare system in developing countries. The goals of this review article are to explain the importance of EFs in developing countries in managing fractures, to determine the problems encountered at present during external fixation by developing countries, to identify solutions that could be used to address these issues, expand the use of external fixation into other domains of treatment, the impact of COVID-19 pandemic on fracture management based on existing literature. In conclusion, EFs are very expensive, researches have been conducted to overcome these barriers in developing countries. However, there are limitations in implementing in developing countries. It is important to have affordable and clinically acceptable EFs available in developing countries.

Value in acute care surgery, Part 1: Methods of quantifying cost

BACKGROUND

With health care expenditures continuing to increase rapidly, the need to understand and provide value has become more important than ever. In order to determine the value of care, the ability to accurately measure cost is essential. The acute care surgeon leader is an integral part of driving improvement by engaging in value increasing discussions. Different approaches to quantifying cost exist depending on the purpose of the analysis and available resources. Cost analysis methods range from detailed microcosting and time-driven activity-based costing to less complex gross and expenditure-based approaches. An overview of these methods and a practical approach to costing based on the needs of the acute care surgeon leader is presented.

Gastrointestinal Tract Colonization Rate of Extended-Spectrum Beta-Lactamase-Producing Gram-Negative Bacteria and Associated Factors Among Orthopaedic Patients in a Tertiary Hospital in Tanzania: Implications for Infection Prevention

Background

The dual burden of road traffic accidents and antimicrobial resistance in orthopaedic infections is challenging already strained health-care systems. Limited information exists in Tanzania on antimicrobial resistance surveillance to delineate the potential sources of multi-drug-resistant bacteria for specific mitigation strategies among orthopaedic patients.

Methods

A longitudinal study was conducted at Bugando Medical Centre in Mwanza city between January and May 2020. It involved the collection of rectal swabs/stools, hand swabs, and environmental sampling to identify extended-spectrum beta-lactamase (ESBL)-producing gram-negative bacteria. Participants’ data were collected using a structured questionnaire and analysed to determine factors associated with ESBL colonization among index orthopaedic patients and correlates with other ESBL sources using OR (95% CI) and a cut-off p-value of ≤0.05.

Results

We found that 47.2% (125/265) of index patients, 77.8% (14/18) of neighbouring patients, 8.3% (2/24) of health-care workers, 72.2% (13/18) of non-medical caregivers, and 31.4% (27/86) of samples taken from the hospital environment had ESBL producers. Escherichia coli and Klebsiella spp. predominated among participants and Acinetobacter spp. predominated in the environmental samples. Patients with open fractures had increased odds of being colonized with ESBL producers [OR (95% CI): 2.08 (1.16–3.75); p=0.015]. The floor below patients’ beds was commonly contaminated; however, the odds of environmental contamination decreased on the third round of sampling [OR (95% CI: 0.16 (0.04–0.67); p=0.012], apparently as a result of parallel infection prevention and control responsive measures against coronavirus disease 2019 (COVID-19).

Conclusion

We found a high occurrence of ESBL colonization among participants and in the environmentat this tertiary hospital. The importance of routine ESBL surveillance among orthopaedic patients with open fractures on admission and strengthened decontamination of health-care premises is reiterated.

Monoplanar external fixation of comminuted open tibial shaft fractures predicts loss of alignment by one year compared to a statically locked intramedullary SIGN nail

AIMS

This investigation develops a predictive model for loss of alignment (LOA) following fixation of open tibia fractures.

PATIENTS/METHODS

An analysis was performed of adults with diaphyseal open tibia fractures randomized to intramedullary nailing (IMN) or external fixation (EF) followed at 6, 12, 24, and 52 weeks postoperatively. Demographic data were collected at baseline. Pre-injury and follow-up EuroQol 5-Dimensions (EQ-5D) and pain score were measured. Radiographs, taken postoperatively and in follow-up, were assessed for coronal and sagittal angulation, and used to calculate the modified Radiographic Union Scale for Tibia fractures (mRUST). LOA was defined as an increase in angulation >5° by one year follow-up. Fracture comminution was defined using AO/OTA classification. Putative risk factors were assessed for association with LOA using bivariate logistic regression. Adjusted associations with LOA were estimated using multivariable logistic regression and marginal analysis.

RESULTS

Analyses included 129 patients (70 IMN, 59 EF), majority male, of mean age 33 years (range 17.7-73) and body mass index (BMI) 25.2 (range 15.5-45.1), with 48% Type A, 41% Type B, and 11% Type C fractures (AO/OTA classification). The likelihood of LOA with EF increased with greater fracture comminution; 45.21% (p<0.001), 77.50% (p<0.001), and 100% LOA for Type A, B, and C fractures respectively. Relative risk of LOA for EF compared to IMN was 3.87 (95% CI 1.36, 11.02), 3.75 (95% CI 1.77, 7.92), and 5.76 for Type A, B, and C fractures, respectively. Compared to patients who lost alignment, patients without LOA had improved fracture healing (p = 0.003) and higher EQ-5D scores (p = 0.03) at one year.

CONCLUSION

Increasing age and BMI are associated with LOA and segmental fracture amplifies the protective effect of IMN versus EF. The importance of LOA as a surrogate outcome after operative treatment of open tibial fractures is supported by its association with inferior radiographic and functional patient outcomes.

Global Volunteering in Orthopaedics: Availability and Implementation Considerations

The World Health Organization describes traumatic injuries as a "neglected epidemic" in developing countries, accounting for more deaths annually than HIV/AIDS, malaria, and tuberculosis combined. Low- and middle-income countries rely on volunteer assistance to address the growing surgical disease burden of traumatic injuries. Efforts to increase the availability of international electives for orthopaedic trainees can help with the short-term need for surgical personnel abroad and facilitate sustainability through capacity building, maximizing long-term benefits for all parties. The volunteer invariably benefits from this cross-cultural experience with many citing improved skills in communication, clinical diagnostics, appreciation of equality and diversity, and cost-consciousness. A consolidated discussion regarding barriers and implementation strategies can assist interested individuals and institutions plan for future volunteering endeavors.

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

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