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Introduction: Ankle fractures are one of the most common injuries sustained worldwide, with the majority being isolated lateral malleolus fractures. The majority of the world's population live in Low and Middle Income Countries (LMIC), where implant cost may limit surgical treatment of ankle fractures. We investigate if Weber B ankle fractures could be effectively treated with a lower-cost technique using two screws between the fibula and the tibia to neutralize an interfragmentary lag screw., Methods: After IRB approval, consecutive patients from January 1, 2020 to December 31, 2020 with Weber-B ankle fractures were treated using AO technique (AOT) with plate osteosynthesis neutralizing an interfragmentary screw. Syndesmotic injuries, as well as injuries to the medial malleolus or foot were treated according to the surgeon's preferences. From January 1, 2021 to December 31, 2021 these injuries were treated with a screw-only technique (SOT) with two fibula pro tibia screws to neutralize an interfragmentary screw. Patient demographics including age, sex, BMI, smoking status, associated rheumatoid arthritis, and associated diabetes mellitus were recorded. The primary outcome variable was a stable radiographic mortise at six weeks post-surgery, secondary outcome variables included clinical union, infection, hardware removal, and implant cost for lateral malleolar fixation charged to the hospital., Results: Seventeen AOT and 10 SOT constructs were included. Demographic characteristics were similar between groups. All fractures maintained a stable mortise with clinical union at 6 weeks without infection. There was a statistically significant difference in hardware removal (17.6% AOT, 50% SOT, p = 0.012). The average implant cost to the hospital of the lateral malleolar fixation was significantly less in the SOT group ($592 (SD $229)), compared to the AOT group ($1,949.97 (SD $562)), (p < 0.0001)., Conclusion: We introduce proof of concept of a novel lower-cost fixation strategy for Weber B ankle fractures that maintained a stable mortise with clinical union at six weeks post-surgery. However, there was a significantly higher rate of hardware removal following fixation with a screw-only construct., Competing Interests: Declaration of Competing Interest John Kwon, MD serves as a consultant for and receives royalties from Paragon 28, Denver Colorado. There are no other declarations of interest from the remaining authors., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: The burden of musculoskeletal trauma is increasing worldwide, especially in low-income countries such as Malawi. Ankle fractures are common in Malawi and may receive suboptimal treatment due to inadequate surgical capacity and limited provider knowledge of evidence-based treatment guidelines., Methods: This study was conducted in 3 phases. First, we assessed Malawian orthopaedic providers' understanding of anatomy, injury identification, and treatment methods. Second, we observed Malawian providers' treatment strategies for adults with ankle fractures presenting to a central hospital. These patients' radiographs underwent blinded, post hoc review by 3 U.S.-based orthopaedic surgeons and a Malawian orthopaedic surgeon, whose treatment recommendations were compared with actual treatments rendered by Malawian providers. Third, an educational course addressing knowledge deficits was implemented. We assessed post-course knowledge and introduced a standardized management protocol, specific to the Malawian context., Results: In Phase 1, deficits in injury identification, ideal treatment practices, and treatment standardization were identified. In Phase 2, 17 (35%) of 49 patients met operative criteria but did not undergo a surgical procedure, mainly because of resource limitations and provider failure to recognize unstable injuries. In Phase 3, 51 (84%) of 61 participants improved their overall performance between the pre-course and post-course assessments. Participants answered a mean of 32.4 (66%) of 49 questions correctly pre-course and 37.7 (77%) of 49 questions correctly post-course, a significant improvement of 5.2 more questions (95% confidence interval [CI], 3.8 to 6.6 questions; p < 0.001) answered correctly. Providers were able to identify 1 more injury correctly of 8 injuries (mean, 1.1 questions [95% CI, 0.6 to 1.6 questions]; p < 0.001) and to identify 1 more ideal treatment of the 7 that were tested (mean, 1.0 question [95% CI, 0.5 to 1.4 questions]; p < 0.001)., Conclusions: Adult ankle fractures in Malawi were predominantly treated nonoperatively despite often meeting evidence-based criteria for surgery. This was due to resource limitations, knowledge deficits, and lack of treatment standardization. We demonstrated a comprehensive approach to examining the challenges of providing adequate orthopaedic care in a resource-limited setting and the successful implementation of an educational intervention to improve care delivery. This approach can be adapted for other conditions to improve orthopaedic care in low-resource settings., Competing Interests: Disclosure: This project was supported by a grant from Paragon 28, Inc. K.J.A.-H. and L.N.B. received grant support from the AO Alliance Foundation. K.J.A.-H. was supported by the Clinical Orthopedic and Musculoskeletal Education and Training Program at Brigham and Women’s Hospital (NIH AR-T32-055885). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G264)., (Copyright © 2020 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction/Purpose: The burden of trauma is growing worldwide, especially in low-income countries. In Malawi, ankle fractures are common and may receive inadequate treatment due to limited surgical capacity and provider knowledge of evidencebased treatment guidelines. We sought to examine ankle fracture management in Malawi, identify providers' knowledge gaps, and address these knowledge gaps in ways that were relevant to the Malawian context. Methods: This study had three phases. First, we performed a baseline assessment of orthopaedic providers' knowledge of anatomy, injury identification, and ideal treatment methods. Second, we observed providers' treatment strategies while they cared for adult patients with ankle fractures over a five-week period at a large central hospital. We performed blinded, post-hoc reviews of patient x-rays and compared our treatment recommendations to the plans and rationales of Malawian providers. Third, we implemented an educational course addressing the knowledge gaps we identified, performed pre- and post-course knowledge assessments, and launched a standardized protocol for ankle fracture management in Malawi. Results: In our baseline assessment, we identified significant knowledge gaps in identification of common injuries on x-ray and ideal treatment practices. In our observations of treatment practices, 17/49 patients (35%) met operative criteria based on evidence-based guidelines but did not receive operative treatment by Malawian providers. For 7/17 (41%) of these patients, Malawian providers believed nonoperative treatment was ideal. In our educational course, 51/61 participants (84%) performed better between the pre- and post-course assessments. Overall scores improved from a mean of 66% to 77%, an improvement of 5.2/49 questions (95% CI 3.8-6.6, p<0.001). Providers could identify one more injury correctly out of 6 that were tested (95% CI 0.6-1.6, p<0.001), and identify one more ideal treatment out of 7 (95% CI 0.5-1.4, p<0.001). Conclusion: In Malawi, ankle fractures are common, and most are treated non-operatively. This is partly due to resource limitations, but also due to gaps in provider knowledge and lack of treatment standardization. Here we demonstrated a comprehensive approach to examining the challenges to providing adequate care, as well as the successful implementation of an intervention to improve care capacity nationwide. [ABSTRACT FROM AUTHOR]