1
|
Ativor V, Konadu-Yeboah D, O'Marr J, Brown K, Rodarte P, Kumah R, Quartey R, Awariyah D, Konadu P, Baidoo PK, Okike K, Morshed S, Shearer D, Roberts H. Predictors of quality of life, economic impact, and loss to follow-up after open tibial shaft fractures in Ghana. OTA Int 2024; 7:e340. [PMID: 39006124 PMCID: PMC11239167 DOI: 10.1097/oi9.0000000000000340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 04/05/2024] [Accepted: 05/15/2024] [Indexed: 07/16/2024]
Abstract
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.
Collapse
Affiliation(s)
- Vincent Ativor
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana
| | - Dominic Konadu-Yeboah
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana
| | - Jamieson O'Marr
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA
| | - Kelsey Brown
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA
| | - Patricia Rodarte
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA
| | - Ralph Kumah
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana
| | - Ralph Quartey
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana
| | - Dominic Awariyah
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana
| | - Peter Konadu
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana
| | - Paa Kwesi Baidoo
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana
| | - Kanu Okike
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA
| | - Saam Morshed
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA
| | - David Shearer
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA
| | - Heather Roberts
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA
| |
Collapse
|
2
|
Fonkoue L, Tissingh EK, Muluem OK, Kong D, Ngongang O, Tambekou U, Handy D, Cornu O, McNally M. Predictive factors for fracture-related infection in open tibial fractures in a Sub-Saharan African setting. Injury 2023:110816. [PMID: 37246113 DOI: 10.1016/j.injury.2023.05.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/30/2023]
Abstract
INTRODUCTION The management of open tibial fractures (OTF) is challenging in low and middle-income countries (LMICs) where appropriate human resources and infrastructure (including equipment, implants and surgical supplies) are not readily available and medical care is not readily accessible. OTF are not rarely associated with a subsequent fracture-related infection (FRI), which is one of the most devastating and difficult to cure complications in orthopaedic trauma care. The aim of this study was to determine the rate and the predictive factors of FRI in OTF in a limited-resource setting of sub-Saharan Africa. METHODS Patients with OTF who underwent surgery from July 2015 to December 2020 and followed-up for at least 12 months in a tertiary care teaching hospital in Yaoundé (Cameroon) were retrospectively investigated. Diagnosis of FRI was based on the confirmatory criteria of the International FRI Consensus definition. All patients with bone infections, occurring at any time point during follow-up, were included. Logistic regression was used to determine the predictive factors for FRI. RESULTS One hundred and five patients with OTF were studied. With a mean follow-up period of 29.5 ± 16.6 months, 33 patients (31.4%) presented with FRI. Gustilo-Anderson type of OTF, compliance with antibiotics, blood transfusion, time to first washing of the wounds and method of bone fixation were factors associated with the occurrence of FRI. In multivariable logistic regression, 6-hours delay to first washing of the wounds (OR=8.07, 95% CI: 1.43-45.31, p = 0.01), and compliance with antibiotics (OR=11.33, 95%CI: 1.11-115.6, p = 0.04) were the only independent predictors of FRI. CONCLUSION The overall rate of FRI in open tibial fracture is still high in the sub-Saharan African context. For similar low-resources settings, this study supports the recommendations (1) to perform a very early washing-dressing-splinting of OTF on admission of the patient, (2) to administer antibiotics early, and (3) to perform surgery as soon as reasonably possible, once appropriate personnel, equipment, implants and surgical supplies are available.
Collapse
Affiliation(s)
- Loïc Fonkoue
- Department of Orthopedics and Trauma, Yaoundé General Hospital, Yaoundé, Cameroon; Department of surgery and specialties, University of Yaoundé 1, Yaoundé PO Box 5408, Cameroon; Department of Orthopedics and Trauma, Yaoundé Emergency Center, Yaoundé, Cameroon.
| | - Elizabeth K Tissingh
- Royal National Orthopedic Hospital NHS TRUST, United Kingdom of Great Britain and Northern Ireland. United Kingdom; King's Global Health Partnerships, School of Life Course and Population Sciences, King's College London, United Kingdom of Great Britain and Northern Ireland, London, United Kingdom
| | - Olivier Kennedy Muluem
- Department of Orthopedics and Trauma, Yaoundé General Hospital, Yaoundé, Cameroon; Department of surgery and specialties, University of Yaoundé 1, Yaoundé PO Box 5408, Cameroon
| | - Denis Kong
- Department of surgery and specialties, University of Yaoundé 1, Yaoundé PO Box 5408, Cameroon
| | - Olivier Ngongang
- Department of Orthopedics and Trauma, Yaoundé Emergency Center, Yaoundé, Cameroon
| | - Urich Tambekou
- Department of Orthopedics and Trauma, Yaoundé Emergency Center, Yaoundé, Cameroon
| | - Daniel Handy
- Department of surgery and specialties, University of Yaoundé 1, Yaoundé PO Box 5408, Cameroon
| | - Olivier Cornu
- Department of Orthopedics and Trauma, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Martin McNally
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, United Kingdom of Great Britain and Northern Ireland, Oxford, United Kingdom
| |
Collapse
|
3
|
Maurer E, Walter N, Baumgartner H, Histing T, Alt V, Rupp M. Quality of life after fracture-related infection of the foot. Foot Ankle Surg 2022; 28:1421-1426. [PMID: 35987750 DOI: 10.1016/j.fas.2022.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 08/02/2022] [Accepted: 08/14/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Fracture related infection (FRI) of the foot is a serious hazard. Despite successful therapy, the physiological and psychological involvement seems to be high. Therefore, we aim to analyze the impact of an FRI of the foot on the quality of life after successful surgical therapy and infect eradication. METHODS In total, 25 patients from two German hospitals treated for FRI of the foot between March 2011 to January 2020 were retrospectively included. Quality of life was assessed by the German Short Form 36 (SF-36) and the EuroQol five-dimension three-level questionnaire (EQ-5D) as well as the ICD-10 based psychological symptom rating (ISR), and compared to a norm obtained from the general population of Germany. RESULTS 3.0 years (range 0.7-7.9 years) following final surgery after fracture-related infection of the foot, the mean physical health component score (PCS) of the SF-36 was 35.6 ± 12.3, and the mean mental health component score (MCS) of the SF-36 reached a value of 41.3 ± 12.9. Both values were significantly lower than in the general population of Germany (p< .019). The mean scores of the ISR of the cohort crossed the threshold of mild symptom burden in total, as well as for the subscales depression and somatization. The mean EQ-5D VAS rating (62.1 ± 18.6) and the EQ-5D index value (0.66 ± 0.27) were significantly lower in comparison to a score of 72.9 ± 1.0 and 0.88 obtained from an age-matched reference population (p < .01). CONCLUSION FRI of the foot represents a major burden for the patient. Physical and mental well-being of affected patients is restricted albeit successful treatment in terms of infect eradication and bone union has been achieved after a mean follow-up of 3.0 years. A patient-centered treatment approach focusing on improvement of quality of life during and after treatment is therefore warranted.
Collapse
Affiliation(s)
- Elke Maurer
- Department of Trauma and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Nike Walter
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany; Department of Psychosomatic Medicine, University Medical Center Regensburg, Regensburg, Germany
| | - Heiko Baumgartner
- Department of Trauma and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Tina Histing
- Department of Trauma and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany.
| |
Collapse
|
4
|
Cortez A, Urva M, Haonga B, Donnelley CA, von Kaeppler EP, Roberts HJ, Shearer DW, Morshed S. Outcomes of Intramedullary Nailing and External Fixation of Open Tibial Fractures: Three to Five-Year Follow-up of a Randomized Clinical Trial. J Bone Joint Surg Am 2022; 104:1877-1885. [PMID: 35980080 DOI: 10.2106/jbjs.22.00016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND While surgeons in low and middle-income countries have increasing experience with intramedullary nailing (IMN), external fixation (EF) continues to be commonly used for the management of open tibial fractures. We examined outcomes with extended follow-up of the participants enrolled in a clinical trial comparing these treatments. METHODS Adults who were ≥18 years old with acute AO/OTA type-42 open tibial shaft fractures were randomly assigned to statically locked, hand-reamed IMN or uniplanar EF. These participants were reevaluated 3 to 5 years after treatment. The primary outcome was death or reoperation for the treatment of deep infection, nonunion, or malalignment. Unresolved complications such as persistent fracture-related infection, nonunion, or malalignment were collected and analyzed. Secondary outcomes included the EuroQol-5 Dimension-3 Level (EQ-5D-3L) questionnaire, the Function IndeX for Trauma (FIX-IT) score, radiographic alignment, and the modified Radiographic Union Scale for Tibial fractures (mRUST). RESULTS Of the originally enrolled 240 participants,126 (67 managed with IMN and 59 managed with EF) died or returned for follow-up at a mean of 4.0 years (range, 2.9 to 5.2 years). Thirty-two composite primary events occurred, with rates of 23.9% and 27.1% in the IMN and EF groups, respectively. Six of these events (3 in the IMN group and 3 in the EF group) were newly detected after the original 1-year follow-up. Unresolved complications in the form of chronic fracture-related infection or nonunion were present at long-term follow-up in 25% of the participants who sustained a primary event. The EQ-5D-3L index scores were similar between the 2 groups and only returned to preinjury levels after 1 year among patients without complications or those whose complications resolved. CONCLUSIONS This observational study extended follow-up for a clinical trial assessing IMN versus EF for the treatment of open tibial fractures in sub-Saharan Africa. At a mean of 4 years after injury, fracture-related infection and nonunion became chronic conditions in nearly a quarter of the participants who experienced these complications, regardless of reintervention. LEVEL OF EVIDENCE Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Abigail Cortez
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California.,Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Mayur Urva
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Billy Haonga
- Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Claire A Donnelley
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Ericka P von Kaeppler
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Heather J Roberts
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - David W Shearer
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - 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
| |
Collapse
|
5
|
Holler JT, Cortez A, Challa S, Eliezer E, Hoanga B, Morshed S, Shearer DW. Risk Factors for Delayed Hospital Admission and Surgical Treatment of Open Tibial Fractures in Tanzania. J Bone Joint Surg Am 2022; 104:716-722. [PMID: 35442248 DOI: 10.2106/jbjs.21.00727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Open fractures, especially of the tibia, require prompt intervention to achieve optimal patient outcomes. While open tibial shaft fractures are common injuries in low- and middle-income countries (LMICs), there is a dearth of literature examining delays to surgery for these injuries in low-resource settings. This study investigated risk factors for delayed management of open tibial fractures in Tanzania. METHODS We conducted an ad hoc analysis of adult patients enrolled in a prospective observational study at a tertiary referral center in Tanzania from 2015 to 2017. Multivariable models were utilized to analyze risk factors for delayed hospital presentation of ≥2 hours, median time from injury to the treatment hospital, and delayed surgical treatment of ≥12 hours after admission among patients with diaphyseal open tibial fractures. RESULTS Two hundred and forty-nine patients met the inclusion criteria. Only 12% of patients used an ambulance, 41% were delayed ≥2 hours in presentation to the first hospital, 75% received an interfacility referral, and 10% experienced a delay to surgery of ≥12 hours after admission. After adjusting for injury severity, having insurance (adjusted odds ratio [aOR] = 0.48; 95% confidence interval [CI] = 0.24 to 0.96) and wounds with approximated skin edges (aOR = 0.37; 95% CI = 0.20 to 0.66) were associated with a decreased risk of delayed hospital presentation. Interfacility referrals (2.3 hours greater than no referral; p = 0.015) and rural injury location (10.9 hours greater than urban location; p < 0.001) were associated with greater median times to treatment hospital admission. Older age (aOR = 0.54 per 10 years; 95% CI = 0.31 to 0.95), single-person households (aOR = 0.12 compared with ≥8 people; 95% CI = 0.02 to 0.96), and an education level greater than pre-primary (aOR = 0.16; 95% CI = 0.04 to 0.62) were associated with fewer delays to surgery of ≥12 hours after admission. CONCLUSIONS Prehospital network and socioeconomic characteristics are associated with delays to open tibial fracture care in Tanzania. Reducing interfacility referrals and implementing surgical cost-reduction strategies may help to reduce delays to open fracture care in LMICs. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Jordan T Holler
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California.,Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Abigail Cortez
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - Sravya Challa
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Edmund Eliezer
- Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Billy Hoanga
- Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - David W Shearer
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| |
Collapse
|
6
|
Foote CJ, Tornetta P, Reito A, Al-Hourani K, Schenker M, Bosse M, Coles CP, Bozzo A, Furey A, Leighton R. A Reevaluation of the Risk of Infection Based on Time to Debridement in Open Fractures: Results of the GOLIATH Meta-Analysis of Observational Studies and Limited Trial Data. J Bone Joint Surg Am 2021; 103:265-273. [PMID: 33298796 DOI: 10.2106/jbjs.20.01103] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Open fractures are one of the leading causes of disability worldwide. The threshold time to debridement that reduces the infection rate is unclear. METHODS We searched all available databases to identify observational studies and randomized trials related to open fracture care. We then conducted an extensive meta-analysis of the observational studies, using raw and adjusted estimates, to determine if there was an association between the timing of initial debridement and infection. RESULTS We identified 84 studies (18,239 patients) for the primary analysis. In unadjusted analyses comparing various "late" time thresholds for debridement versus "early" thresholds, there was an association between timing of debridement and surgical site infection (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 1.11 to 1.49, p < 0.001, I2 = 30%, 84 studies, n = 18,239). For debridement performed between 12 and 24 hours versus earlier than 12 hours, the OR was higher in tibial fractures (OR = 1.37, 95% CI = 1.00 to 1.87, p = 0.05, I2 = 19%, 12 studies, n = 2,065), and even more so in Gustilo type-IIIB tibial fractures (OR = 1.46, 95% CI = 1.13 to 1.89, p = 0.004, I2 = 23%, 12 studies, n = 1,255). An analysis of Gustilo type-III fractures showed a progressive increase in the risk of infection with time. Critical time thresholds included 12 hours (OR = 1.51, 95% CI = 1.28 to 1.78, p < 0.001, I2 = 0%, 16 studies, n = 3,502) and 24 hours (OR = 2.17, 95% CI = 1.73 to 2.72, p < 0.001, I2 = 0%, 29 studies, n = 5,214). CONCLUSIONS High-grade open fractures demonstrated an increased risk of infection with progressive delay to debridement. LEVEL OF EVIDENCE Prognostic Level IV. See Instruction for Authors for a complete description of the levels of evidence.
Collapse
Affiliation(s)
| | - Paul Tornetta
- Department of Orthopedics, Boston University Medical Center, Boston, Massachusetts
| | - Aleksi Reito
- Tampere University Hospital (TAUH), Tampere, Finland
| | - Khalid Al-Hourani
- Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Mara Schenker
- Orthopedic Trauma Research Unit, Emory University, Atlanta, Georgia
| | - Michael Bosse
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Chad P Coles
- Division of Orthopaedics, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Andrew Furey
- Division of Orthopaedics, Memorial University, St. John's, Newfoundland, Canada
| | - Ross Leighton
- Division of Orthopaedics, Dalhousie University, Halifax, Nova Scotia, Canada
| | | |
Collapse
|