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Background and purpose - In Malawi, both skeletal traction (ST) and intramedullary nailing (IMN) are used in the treatment of femoral shaft fractures, ST being the mainstay treatment. Previous studies have found that IMN has improved outcomes and is less expensive than ST. However, no cost-effectiveness analyses have yet compared IMN and ST in Malawi. We report the results of a cost-utility analysis (CUA) comparing treatment using either IMN or ST.Patients and methods - This was an economic evaluation study, where a CUA was done using a decision-tree model from the government healthcare payer and societal perspectives with an 1-year time horizon. We obtained EQ-5D-3L utility scores and probabilities from a prospective observational study assessing quality of life and function in 187 adult patients with femoral shaft fractures treated with either IMN or ST. The patients were followed up at 6 weeks, and 3, 6, and 12 months post-injury. Quality adjusted life years (QALYs) were calculated from utility scores using the area under the curve method. Direct treatment costs were obtained from a prospective micro costing study. Indirect costs included patient lost productivity, patient transportation, meals, and childcare costs associated with hospital stay and follow-up visits. Multiple sensitivity analyses assessed model uncertainty.Results - Total treatment costs were higher for ST ($1,349) compared with IMN ($1,122). QALYs were lower for ST than IMN, 0.71 (95% confidence interval [CI] 0.66-0.76) and 0.77 (CI 0.71-0.82) respectively. Based on lower cost and higher utility, IMN was the dominant strategy. IMN remained dominant in 94% of simulations. IMN would be less cost-effective than ST at a total procedure cost exceeding $880 from the payers perspective, or $1,035 from the societal perspective.Interpretation - IMN was cost saving and more effective than ST in the treatment of adult femoral shaft fractures in Malawi, and may be an efficient use of limited healthcare resources.

Background: The purpose of this scoping review was to examine the nature and quality of research regarding pediatric supracondylar humerus (SCH) fractures in low and lower-middle income countries (LICs).  Methods: We searched PubMed, Embase, Web of Science, and African Journals Online on January 9, 2018 for studies of SCH fractures in LICs. Studies were categorized by geographic region, Gartland classification of included patients, and study design. We evaluated each study’s methodology and conclusions.Results: Out of 1805 results, we analyzed 105 studies, most of which included Type 3 fractures only (66%). Many were conducted in South Asia (58%) and assessed treatment outcomes (78%). Most of the studies had level IV evidence (67%). Common limitations of research were small sample size (12%) and inadequate follow-up (6%). Epidemiological studies concluded that SCH fractures are more common among male children, are usually secondary to falls, and rarely present with nerve injuries. Most therapeutic studies reported outcomes of surgery (91%). Thirteen studies concluded that all-lateral versus cross-pinning techniques have similar outcomes. Seven studies reported preference for closed reduction over open reduction, when intraoperative fluoroscopy was available. Most common outcome measures were Flynn criteria (77%) and range of motion (53%). None of the papers looked at treatment costs.Conclusions: Our data show a predominance of small level IV studies from LICs, with few studies of higher level of evidence. Many studies examined controversies with surgical technique, similar to studies performed in HICs. Few studies examined non-operative treatment, which is commonly the predominant treatment available for patients in LICs. Further investigation of common treatment modalities and outcomes for SCH fractures in LICs is needed.

Background: Supracondylar humerus fractures (SHFs) are common paediatric injuries, with high risk of vascular compromise. Some patients present with a 'pink, pulseless hand', caused by occlusion of brachial artery flow but with collateral circulation preserving distal perfusion. Management of these patients remains controversial, especially when resources may be limited for prolonged hospitalisation and serial monitoring by skilled staff. The aim of this study is to present the intraoperative findings, surgical procedures done and outcomes at 6 weeks for patients with paediatric supracondylar fractures with a pink pulseless hand. Methods: We retrospectively identified 13 patients who presented to a public hospital between January 2019 and May 2023 with a displaced SHF and pink, pulseless hand. All patients underwent an open reduction with an anterior approach allowing for exploration, protection and repair of neurovascular structures. Distal flow was restored in the brachial artery either with topical lidocaine application, thrombectomy or artery reconstruction. Results: Out of 13 patients, all had intact median nerves and 10 had intact arteries (69%), of which seven were interposed at the fracture site and four were in vasospasm. Of the three patients with true arterial injury (23%), two had a crushed artery and one had thrombosis of the artery. Peripheral pulses were restored within an hour of fracture open reduction in all patients. At final follow-up, a mean 6 weeks postoperatively, all patients had recovered without neurovascular deficit, compartment syndrome or Volkmann ischemic contracture. Conclusions: In resource-limited settings, we recommend performing open exploration and reduction for patients with SHFs with pink, pulseless hand. This approach prevents iatrogenic neurovascular injury during closed reduction attempts, allows for immediate repair of a brachial artery injury and avoids unnecessary hospitalisation and serial monitoring. Level of Evidence: Level IV (Therapeutic) [ABSTRACT FROM AUTHOR]

Background Injuries, disorders, and deformities of the hands and upper extremities cause significant morbidity worldwide, but in sub-Saharan Africa, the burden of disease and the availability of appropriate care remain unknown. We sought to characterize disease burden and barriers to care for hand and upper extremity conditions across sub-Saharan Africa, examining differences in burden and access by geographic region and national income level. Methods From 6 June 2020 through 17 March 2021, we surveyed providers of musculoskeletal care in sub-Saharan Africa regarding the provision of care and the most common acute and chronic hand or upper extremity conditions encountered by respondents. Surveys were distributed through professional networks across sub-Saharan Africa. We categorized responses by each respondent’s national income level and geographic region. Then, we examined how frequently various challenges to accessing healthcare, as well as how frequently acute or chronic conditions, were reported. Additionally, we analyzed how these data varied by income level and geographic region. Results We received 193 responses from 39 countries in sub-Saharan Africa. Eighty-eight per cent of respondents reported that general orthopaedic surgeons and orthopaedic traumatologists primarily manage upper extremity conditions. A lack of adequate and timely diagnosis was reported by 142 respondents (74%); late referral for treatment was reported by 149 (77%); and inadequate physical therapy, occupational therapy, and rehabilitation was reported by 149 respondents (77%). The most commonly reported acute conditions were adult and paediatric radius/ulna fractures/dislocations, adult metacarpal/phalangeal fractures/dislocations, soft-tissue injuries (including burns), and paediatric elbow fractures/dislocations. The most commonly reported chronic conditions were tendinitis/tenosynovitis, chronic infections/osteomyelitis, neuropathies, posttraumatic stiff hand, and radius/ulna malunion/nonunion. Neglected trauma (including chronic elbow injuries and burn contractures) was frequently reported, especially in low-income countries. Conclusions Trauma care should be strengthened through training of general orthopaedic surgeons in hand and upper extremity surgery throughout sub-Saharan Africa. Especially in low-income countries, particular training emphasis should be placed on the management of malunion/nonunion, osteomyelitis, acute and chronic elbow injuries, and burn contractures. These findings should inform the development of core competencies in hand surgery for providers managing musculoskeletal conditions in sub-Saharan Africa, as well as guide capacity-building activities on the continent. [ABSTRACT FROM AUTHOR]

Abstract: Globally, the burden of musculoskeletal conditions continues to rise, disproportionately affecting low and middle-income countries (LMICs). The ability to meet these orthopaedic surgical care demands remains a challenge. To help address these issues, many orthopaedic surgeons seek opportunities to provide humanitarian assistance to the populations in need. While many global orthopaedic initiatives are well-intentioned and can offer short-term benefits to the local communities, it is essential to emphasize training and the integration of local surgeon-leaders. The commitment to developing educational and investigative capacity, as well as fostering sustainable, mutually beneficial partnerships in low-resource settings, is critical. To this end, global health organizations, such as the Consortium of Orthopaedic Academic Traumatologists (COACT), work to promote and ensure the lasting sustainability of musculoskeletal trauma care worldwide. This article describes global orthopaedic efforts that can effectively address musculoskeletal care through an examination of 5 domains: clinical care, clinical research, surgical education, disaster response, and advocacy. [ABSTRACT FROM AUTHOR]

Background Malawi has a rising burden of musculoskeletal trauma, coupled with insufficient surgical capacity to manage common, debilitating injuries like femoral shaft fractures. Nonoperative treatment remains the standard of care, with surgery available only at central hospitals. We sought to understand how patients navigate the Malawian health system and the barriers they face while seeking care. Methods We performed in-depth, semistructured interviews of 15 adults with closed femoral shaft fractures during their hospitalization at Kamuzu Central Hospital, a public referral hospital in Lilongwe--Malawi's capital city. We additionally interviewed 1 patient who left Kamuzu Central Hospital to seek care at a private hospital. An English-speaking investigator performed all interviews with a Chichewa-speaking medical interpreter. Interviews focused on patients' pathways from injury to present treatment (health system navigation), impressions of the hospital and care received, and the effects of injury and treatment on patients and their families. Interviews were audio recorded, translated, and transcribed in English. We coded the transcripts and performed thematic analysis. Results We identified 6 themes: high variability in health system navigation; frustrations with the biopsychosocial effects of hospitalization; lack of participation in decision-making and uncertainty about treatment course; preference for surgery (vs traction) based on patients' experiences and observations; frustrations with the inequitable provision of surgery; and patients' resignation, acceptance, and resilience in the face of hardship. Many patients receiving nonoperative treatment described the devastating financial burden imposed upon them and their families by their injuries and prolonged hospitalization. These patients viewed nonoperative treatment as inferior to surgery and suspected that richer patients were receiving more timely care. Conclusions This qualitative study suggested a need to standardize care for femoral shaft fractures in Malawi, increase the availability and timeliness of surgery, and increase transparency and communication between providers and patients. These remedies should focus on improving the quality of care and achieving equity in access to care. [ABSTRACT FROM AUTHOR]

Background Diagnostics are foundational to effective health systems but remain widely unavailable worldwide, especially in low-income countries like Malawi. To achieve health equity in Malawi, it is necessary to assess the availability of essential diagnostics. Methods We analysed data collected during a nationwide survey of musculoskeletal trauma care capacity. We analysed the presence, availability, and reasons for unavailability of laboratory testing, vital signs monitoring, electrocardiography, and diagnostic radiology at all 25 district hospitals and 4 central hospitals in Malawi. We used geospatial models to estimate the proportion of the Malawian population with 1-hour and 2-hour access to these resources. Taking 1-hour access to most accurately represent geospatial coverage in the Malawian context, a hypothetical intervention was designed whereby diagnostic capacity improvement would be prioritized at selected hospitals to cover at least 75% of Malawians nationwide. Results Twelve of 29 hospitals had basic laboratory testing available when needed, covering an estimated 58% of Malawians with 1-hour access and 95% with 2-hour access. Vital signs monitoring was available when needed at 18 hospitals, covering an estimated 74% of Malawians with 1-hour access and 97% with 2-hour access. Six hospitals reported that electrocardiography was available when needed, covering an estimated 49% of Malawians with 1-hour access and 91% with 2-hour access. Four hospitals had x-ray capacity of adequate quality to make accurate diagnoses when needed, covering an estimated 39% of Malawians with 1-hour access and 86% with 2-hour access. Broken machinery, inadequate supplies, and inadequate staff training were common reasons for resource unavailability. Conclusions Essential diagnostics were found to be unavailable for many Malawians. By prioritizing capacity improvements for all 4 central hospitals and 11 district hospitals, over three-quarters of Malawians could have 1-hour access to laboratory testing, vital signs monitoring, electrocardiography, and diagnostic x-ray. These capacity improvements are essential to meet the needs of a growing population, especially in the context of the current COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Aims: Lower limb fractures are common in low- and middle-income countries (LMICs) and represent a significant burden to the existing orthopaedic surgical infrastructure. In high income country (HIC) settings, internal fixation is the standard of care due to its superior outcomes. In LMICs, external fixation is often the surgical treatment of choice due to limited supplies, cost considerations, and its perceived lower complication rate. The aim of this systematic review protocol is identifying differences in rates of infection, nonunion, and malunion of extra-articular femoral and tibial shaft fractures in LMICs treated with either internal or external fixation., Methods: This systematic review protocol describes a broad search of multiple databases to identify eligible papers. Studies must be published after 2000, include at least five patients, patients must be aged > 16 years or treated as skeletally mature, and the paper must describe a fracture of interest and at least one of our primary outcomes of interest. We did not place restrictions on language or journal. All abstracts and full texts will be screened and extracted by two independent reviewers. Risk of bias and quality of evidence will be analyzed using standardized appraisal tools. A random-effects meta-analysis followed by a subgroup analysis will be performed, given the anticipated heterogeneity among studies, if sufficient data are available., Conclusion: The lack of easily accessible LMIC outcome data, combined with international clinical guidelines that are often developed by HIC surgeons for use in HIC environments, makes the clinical decision-making process infinitely more difficult for surgeons in LMICs. This protocol will guide research on surgical management, outcomes, and complications of lower limb shaft fractures in LMICs, and can help guide policy development for better surgical intervention delivery and improve global surgical care., Competing Interests: M. Pigeolet received publication support for this article from the Belgian University Foundation (WA-0544) and the Harvard Global Orthopaedic Collaboration. M. Pigeolet received a grant from the Belgian Kids’ Fund for Pediatric Research, which had had no influence on any aspect of this article. J. K. Agarwal-Harding, M. R. Askew, S. R. Bradley, and A. Shah received publication support for this article from the Harvard Global Orthopaedic Collaborative., (© 2024 Pigeolet et al.)

Musculoskeletal injuries are common in Cameroon. Negative pressure wound therapy (NPWT) can effectively manage complex wounds including open fractures, however high cost and unavailability prevent its widespread use. We sought to evaluate the feasibility and efficacy in Cameroon of a low-cost NPWT (LCNPWT) device built from an aquarium pump costing less than $100. We performed a prospective case series including all patients with musculoskeletal injuries managed with LCNPWT at Baptist Hospital Mutengene, Mutengene, Cameroon from 15 th March 2021 to 15 th March 2022. Patient demographics, wound characteristics, and wound photographs were collected at intake and at each dressing change (performed every 3 days). All treatment was provided inpatient, and outcomes were recorded at hospital discharge. Forty-one patients (mean age 40 years, 58% male) received LCNPWT. The most common injury mechanisms were road traffic-related accidents (n=16, 42%) and gunshots (n=8, 21%). Wound characteristics were recorded for 38 patients of which 24 (63%) had infected wounds and 3 were bacteremic (13%) on presentation. All patients received antibiotics. The average duration of LCNPWT was 5.9 days (standard deviation 3.1 days). For 15 patients with documented outcome data, LCNPWT was successful in achieving wound closure in 12 (80%). Five patients failed limb salvage, with 4 receiving amputations and 1 dying during hospitalization. Eighty-three percent of providers (15 providers) reported LCNPWT as beneficial in managing wounds. Low-cost NPWT device was effective for managing contaminated and complex wounds in a resource-limited setting., Competing Interests: The authors declare no competing interests., (Copyright: Lahin Amlani et al.)

Background: Pediatric fractures are common in Malawi, and surgical care, when needed, remains inaccessible to many. Understanding which children in Malawi receive surgery or nonsurgical treatment would help set priorities for trauma system development., Methods: We used multivariate logistic regression to evaluate associations between surgical treatment and age, sex, school enrollment, injury mechanism, fracture type, open fracture, referral status, hospital of presentation, delayed presentation (≥2 days), healthcare provider, and inpatient vs outpatient treatment., Results: From 2016 to 2020, 10,400 pediatric fractures were recorded in the Malawi Fracture Registry. Fractures were most commonly of the wrist (26%), forearm (17%), and elbow (14%). Surgical fixation was performed on 4.0% of patients, and 24 (13.0%) open fractures were treated nonsurgically, without débridement or fixation. Fractures of the proximal and diaphyseal humerus (odds ratio [OR], 3.72; 95% confidence interval [CI], 2.36 to 5.87), knee (OR, 3.16; 95% CI, 1.68 to 5.95), and ankle (OR, 2.63; 95% CI, 1.49 to 4.63) had highest odds of surgery. Odds of surgical treatment were lower for children referred from another facility (OR, 0.62; 95% CI, 0.49 to 0.77)., Conclusions: Most Malawian children with fractures are treated nonsurgically, including many who may benefit from surgery. There is a need to increase surgical capacity, optimize referral patterns, and standardize fracture management in Malawi., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: Little is known about the burden or management of distal radius fractures (DRFs) in low- and middle-income countries. The purpose of this study was to describe the care of DRFs in Malawi., Methods: We retrospectively reviewed a registry of all patients with fractures who presented to the orthopaedic departments at four public hospitals in Malawi., Results: Totally, 1,440 patients (14.5%) were with a DRF. Average age was 40, and 888 (62.0%) were male. Surgery was done for 122 patients (9.5%). Patients presenting to Queen Elizabeth Hospital, patients presenting after a fall, and patients initially evaluated by an orthopaedic registrar or orthopaedic clinical officer had lower odds of receiving surgical treatment. Meanwhile, open injuries had the greatest odds of receiving surgery., Conclusion: The most common musculoskeletal injury among patients in the Malawi Fracture Registry was fractures of the distal radius. These most affected young adult male patients may benefit from surgery; however, the majority were managed nonsurgically. Lack of access to surgical fixation and conservative follow-up may have long-term functional consequences in a predominantly agrarian society. Outcomes-based research is needed to help guide management decisions and standardize patient care and referral protocols., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Displaced supracondylar humeral fractures (SCHFs) benefit from closed reduction and percutaneous pinning. In Malawi, many SCHFs are treated nonoperatively because of limited surgical capacity. We sought to assess clinical and functional outcomes of nonoperatively treated SCHFs in a resource-limited setting., Methods: We retrospectively reviewed all patients with SCHFs treated at Nkhotakota District Hospital (NKKDH) in Malawi between January 2014 and December 2016. Patients subsequently underwent clinical and functional follow-up assessment., Results: We identified 182 children (54% male, mean age of 7 years) with an SCHF; 151 (83%) of the fractures were due to a fall, and 178 (98%) were extension-type (Gartland class distribution: 63 [35%] type I, 52 [29%] type II, and 63 [35%] type III). Four patients with type-I fractures were treated with an arm sling alone, and 59 were treated with straight-arm traction to reduce swelling and then splint immobilization until union. All 119 of the patients with Gartland type-II and III or flexion-type injuries were treated with straight-arm traction, manipulation under anesthesia without fluoroscopy, and then splint immobilization until union. A total of 137 (75%) of the patients were available for follow-up, at a mean of 3.9 years after injury. The Flynn functional outcome was excellent for 39 (95%) with a type-I fracture, 30 (70%) with type-II, and 14 (29%) with type-III. The Flynn cosmetic outcome was excellent for 40 (98%) with a type-I fracture, 42 (98%) with type-II, and 41 (84%) with type-III. Forty (98%) of the children with a type-I fracture, 41 (95%) with type-II, and 32 (65%) with type-III returned to school without limitation. Controlling for sex, delayed presentation, medical comorbidities, injury mechanism, and skin blistering/superinfection during traction, patients with type-II fractures were 5.82-times more likely (95% confidence interval [CI], 1.71 to 19.85) and those with type-III fractures were 9.81-times more likely (95% CI, 3.00 to 32.04), to have a clinical complication or functional limitation compared with patients with type-I fractures., Conclusions: Nonoperative treatment of type-III SCHFs resulted in a high risk of clinical complications or functional impairment. These results illustrate the urgent need to increase surgical capacity in low-income countries like Malawi to improve pediatric fracture care., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A310)., (Copyright © 2021 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)