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Background Developing a contextually appropriate curriculum is critical to train physicians who can address surgical challenges in sub-Saharan Africa. An innovative modified Delphi process was used to identify contextually optimized curricular content to meet sub-Saharan Africa and Rwanda's surgical needs. Methods Participants were surgeons from East, Central, Southern, and West Africa and general practitioners with surgical experience. Delphi participants excluded or prioritized surgical topic areas generated from extensive grey and formal literature review. Surgical educators first screened and condensed identified topics. Round 1 screened and prioritized identified topics, with a 75% consensus cut-off based on the content validity index and a prioritization score. Topics that reached consensus were screened again in round 2 and re-prioritized, following controlled feedback. Frequencies for aggregate prioritization scores, experts in agreement, item-level content validity index, universal agreement and scale-level content validity index based on the average method (S-CVI/Ave) using proportion relevance, and intra-class correlation (ICC) (based on a mean-rating, consistency, two-way mixed-effects model) were performed. We also used arithmetic mean values and modal frequency. Cronbach's Alpha was also calculated to ascertain reliability. Results were validated through a multi-institution consensus conference attended by Rwanda-based surgical specialists, general practitioners, medical students, surgical educators, and surgical association representatives using an inclusive, participatory, collaborative, agreement-seeking, and cooperative, a priori consensus decision-making model. Results Two-hundred and sixty-seven broad surgical content areas were identified through the initial round and presented to experts. In round 2, a total of 247 (92%) content areas reached 75% consensus among 31 experts. Topics that did not achieve consensus consisted broadly of small intestinal malignancies, rare hepatobiliary pathologies, and transplantation. In the final round, 99.6% of content areas reached 75% consensus among 31 experts. The highest prioritization was on wound healing, fluid and electrolyte management, and appendicitis, followed by metabolic response, infection, preoperative preparation, antibiotics, small bowel obstruction and perforation, breast infection, acute urinary retention, testicular torsion, hemorrhoids, and surgical ethics. Overall, the consistency and average agreement between panel experts was strong. ICC was 0.856 (95% CI: 0.83-0.87). Cronbach's Alpha for round 2 was very strong (0.985, 95% CI: 0.976-0.991) and higher than round 1, demonstrating strong reliability. All 246 topics from round 4 were verbally accepted by 40 participants in open forum discussions during the consensus conference. Conclusions A modified Delphi process and consensus were able to identify essential topics to be included within a highly contextualized, locally driven surgical clerkship curriculum delivered in rural Rwanda. Other contexts can use similar processes to develop relevant curricula., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Alayande et al.)

Background: The rate of open tibia fractures is rapidly increasing across the globe due to a recent rise in road traffic accidents, predominantly in low- and low-middle-income countries. These injuries are orthopedic emergencies associated with infection rates as high as 40% despite the use of systemic antibiotics and surgical debridement. The use of local antibiotics has shown some promise in reducing the burden of infection in these injuries due to increasing local tissue availability; however, no trial has yet been appropriately powered to evaluate for definitive evidence and the majority of current studies have taken place in a high-resource countries where resources and the bio-burden may be different., Methods: This is a prospective randomized, masked, placebo-controlled superiority trial designed to evaluate the efficacy of locally administered gentamicin versus placebo in the prevention of fracture-related infection in adults (age > 18 years) with primarily closeable Gustillo-Anderson class I, II, and IIIA open tibia fractures. Eight hundred ninety patients will be randomized to receive an injection of either gentamicin (treatment group) or saline (control group) at the site of their primarily closed open fracture. The primary outcome will be the occurrence of a fracture-related infection occurring during the course of the 12-month follow-up., Discussion: This study will definitively assess the effectiveness of local gentamicin for the prevention of fracture-related infections in adults with open tibia fractures in Tanzania. The results of this study have the potential to demonstrate a low-cost, widely available intervention for the reduction of infection in open tibia fractures., Trial Registration: Clinicaltrials.gov NCT05157126. Registered on December 14, 2021., (© 2023. The Author(s).)

Background: Open tibial fractures have a high risk of infection that can lead to severe morbidity. Antibiotics administered locally at the site of the open wound are a potentially effective preventive measure, but there are limited data evaluating aminoglycoside antibiotics. The objective of this study was to assess the feasibility of a clinical trial to test the efficacy of local gentamicin in reducing the risk of fracture-related infection after open tibial fracture., Methods: This study is a single-center, pilot, masked, randomized controlled trial conducted at the Muhimbili Orthopaedic Institute. Participants were randomized intraoperatively after wound closure to receive gentamicin solution or normal saline solution injected at the fracture site. Follow-ups were completed at 2 weeks, 6 weeks, 3 months, 6 months, 9 months, and 1 year postoperatively. The primary feasibility outcomes were the rate of enrollment and retention. The primary clinical outcome was the occurrence of fracture-related infection., Results: Of 199 patients screened, 100 eligible patients were successfully enrolled and randomized over 9 months (11.1 patients/month). Complete data were recorded at baseline and follow-up for >95% of cases. The rate of follow-up at 6 weeks, 3 months, 6 months, 9 months, and 1 year were 70%, 68%, 69%, 61%, and 80%, respectively. There was no difference in adverse events or any of the measured primary and secondary outcomes., Conclusion: This pilot study is among the first to evaluate locally administered gentamicin in open tibial fractures. Results indicate a rigorous clinical trial with acceptable rates of enrollment and follow-up to address this topic is possible in this setting., Competing Interests: The authors have no conflicts of interest to disclose, (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Background: The burden of disability because of traumatic limb amputation, particularly transfemoral amputation (TFA) is disproportionately carried by low- and middle-income countries. The need for improved access to prosthesis services in these settings is well-documented, but perspectives on the burden imposed by TFA and the challenges associated with subsequent prosthesis provision vary among patients, caregivers and healthcare providers., Objectives: To examine the burden of TFA and barriers to prosthesis provision as perceived by patient, caregiver and healthcare professional, at a single tertiary referral hospital in Tanzania., Method: Data were collected from five patients with TFA and four caregivers recruited via convenience sampling, in addition to 11 purposively sampled healthcare providers. All participants participated in in-depth interviews regarding their perceptions of amputation, prostheses and underlying barriers to improving care for persons with TFA in Tanzania. A coding schema and thematic framework were established from interviews using inductive thematic analysis., Results: All participants noted financial and psychosocial burdens of amputation, and perceived prostheses as an opportunity for return to normality and independence. Patients worried about prosthesis longevity. Healthcare providers noted significant obstacles to prosthesis provision, including infrastructural and environmental barriers, limited access to prosthetic services, mismatched patient expectations and inadequate coordination of care., Conclusion: This qualitative analysis identifies factors influencing prosthesis-related care for patients with TFA in Tanzania which are lacking in the literature. Persons with TFA and their caregivers experience numerous hardships exacerbated by limited financial, social and institutional support., Contribution: This qualitative analysis informs future directions for research into improving prosthesis-related care for patients with TFA in Tanzania., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2023. The Authors.)

Background: Limb loss leads to significant disability. Prostheses may mitigate this disability but are not readily accessible in low- and middle-income countries (LMICs). Cost-effectiveness data related to prosthesis provision in resource-constrained environments such as Tanzania is greatly limited., Objectives: This study aimed to compare the cost-effectiveness of a prosthesis intervention compared with that of no prosthesis for persons with transfemoral amputations in an LMIC., Study Design: This is a prospective cohort study., Methods: Thirty-eight patients were prospectively followed up. Clinical improvement with prosthesis provision was measured using EuroQuol-5D, represented as quality-adjusted life years gained. Direct and indirect costs were measured. The primary outcome was incremental cost per quality-adjusted life year, measured at 1 year and projected over a lifetime using a Markov model. Reference case was set as a single prosthesis provided without replacement from a payer perspective. Additional scenarios included the societal perspective and replacement of the prosthesis. Uncertainty was measured with one-way probabilistic sensitivity analysis., Results: From the payer perspective, the incremental cost-effectiveness ratio (ICER) was $242 for those without prosthetic replacement over a lifetime, and the ICER was $390 for those with prosthetic replacement over a lifeime. From the societal perspective, prosthesis provision was both less expensive and more effective. One-way sensitivity analysis demonstrated the ICER remained below the willingness to pay threshold up to prosthesis costs of $763., Conclusions: These findings suggest prosthesis provision in an LMIC may be cost-effective, but further studies with long-term follow up are needed to validate the results., (Copyright © 2022 International Society for Prosthetics and Orthotics.)

Introduction: The modified Radiographic Union Score for Tibia (RUST) fractures was developed to better describe fracture healing, but its utility in resource-limited settings is poorly understood. This study aimed to determine the validity of mRUST scores in evaluating fracture healing in diaphyseal femur fractures treated operatively at a single tertiary referral hospital in Tanzania., Methods: Radiographs of 297 fractures were evaluated using the mRUST score and compared with outcomes including revision surgery and EuroQol five dimensions questionnaire (EQ-5D) and visual analog scale (VAS) quality-of-life measures. Convergent validity was assessed by correlating mRUST scores with EQ-5D and VAS scores. Divergent validity was assessed by comparing mRUST scores in patients based on revision surgery status., Results: The mRUST score had moderate correlation (Spearman correlation coefficient 0.40) with EQ-5D scores and weak correlation (Spearman correlation coefficient 0.320) with VAS scores. Compared with patients who required revision surgery, patients who did not require revision surgery had higher RUST scores at all time points, with statistically significant differences at 3 months (2.02, P < 0.05)., Discussion: These results demonstrate that the mRUST score is a valid method of evaluating the healing of femoral shaft fractures in resource-limited settings, with high interrater reliability, correlation with widely used quality of life measures (EQ-5D and VAS), and expected divergence in the setting of complications requiring revision surgery., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: The rise of diabetes and traumatic injury has increased limb loss-related morbidity in low- and middle-income countries (LMICs). Despite this, the majority of amputees in LMICs have no access to prosthetic devices, and the magnitude of prosthesis impact on quality of life (QOL ) and function has not been quantified., Objectives: Quantify the impact of prostheses on QOL and function in Tanzanian transfemoral amputees., Method: A prospective cohort study was conducted. Transfemoral amputees at Muhimbili Orthopaedic Institute were assessed twice before and three times after prosthetic fitting using EuroQol-5D-3L (EQ-5D-3L), Prosthetic Limb Users Survey of Mobility (PLUS-M), 2-minute walk test (2MWT) and Physiologic Cost Index (PCI). Data were analysed for change over time. Subgroup analysis was performed for amputation aetiology (vascular or non-vascular) and prosthesis use., Results: Amongst 30 patients, EQ-5D, PLUS-M and 2MWT improved after prosthesis provision ( p < 0.001). EuroQol-5D increased from 0.48 to 0.85 at 1 year ( p < 0.001). EuroQol-5D and 2MWT were higher in non-vascular subgroup ( p < 0.030). At 1-year, 84% of non-vascular and 44% of vascular subgroups reported using their prosthesis ( p = 0.068)., Conclusion: Prosthesis provision to transfemoral amputees in an LMIC improved QOL and function. This benefit was greater for non-vascular amputation aetiologies. Quality of life and function returned to pre-prosthesis levels with discontinued use of prosthesis., Competing Interests: J.A. currently serves as Chief Technology Officer of LegWorks and is the designer of the All-Terrain Knee. E.L. is a cofounder and current member of the board of directors of LegWorks and served as founding Chief Executive Officer of LegWorks from 2014 to 2019. They have disclosed those interests fully and have in place an approved plan for managing any potential conflicts arising from the stated disclosures., (© 2021. The Authors.)

Objectives: Open tibia fractures pose a clinical and economic burden that is disproportionately borne by low-income countries. A randomized trial conducted by our group showed no difference in infection and nonunion comparing 2 treatments: external fixation (EF) and intramedullary nailing (IMN). Secondary outcomes favored IMN. In the absence of clear clinical superiority, we sought to compare costs between EF and IMN., Design: Secondary cost analysis., Setting: Single institution in Tanzania., Patients/participants: Adult patients with acute diaphyseal open tibia fractures who participated in a previous randomized controlled trial., Intervention: SIGN IMN versus monoplanar EF., Main Outcome Measurements: Direct costs of initial surgery and hospitalization and subsequent reoperation: implant, instrumentation, medications, disposable supplies, and personnel costs.Indirect costs from lost productivity of patient and caregiver.Societal (total) costs: sum of direct and indirect costs.All costs were reported in 2018 USD., Results: Two hundred eighteen patients were included (110 IMN, 108 EF). From a payer perspective, costs were $365.83 (95% CI: $332.75-405.76) for IMN compared with $331.25 ($301.01-363.14) for EF, whereas from a societal perspective, costs were $2664.59 ($1711.22-3955.25) for IMN and $2560.81 ($1700.54-3715.09) for EF. The largest drivers of cost were reoperation and lost productivity. Accounting for uncertainty in multiple variables, probabilistic sensitivity analysis demonstrated that EF was less costly than IMN from the societal perspective in only 55% of simulations., Conclusions: Intramedullary nail fixation compared with external fixation of open tibia fractures in a resource-constrained setting is not associated with increased cost from a societal perspective., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

To compare clinical and radiographic outcomes following antegrade versus retrograde intramedullary nailing of infraisthmic femoral shaft fractures., Design: Secondary analysis of prospective cohort study., Setting: Tertiary hospital in Tanzania., Participants: Adult patients with infraisthmic diaphyseal femur fractures., Intervention: Antegrade or retrograde SIGN intramedullary nail., Outcomes: Health-related quality of life (HRQOL), radiographic healing, knee range of motion, pain, and alignment (defined as less than or equal to 5 degrees of angular deformity in both coronal and sagittal planes) assessed at 6, 12, 24, and 52 weeks postoperatively., Results: Of 160 included patients, 141 (88.1%) had 1-year follow-up and were included in analyses: 42 (29.8%) antegrade, 99 (70.2%) retrograde. Antegrade-nailed patients had more loss of coronal alignment ( P  = .026), but less knee pain at 6 months ( P  = .017) and increased knee flexion at 6 weeks ( P  = .021). There were no significant differences in reoperations, HRQOL, hip pain, knee extension, radiographic healing, or sagittal alignment., Conclusions: Antegrade nailing of infraisthmic femur fractures had higher incidence of alignment loss, but no detectable differences in HRQOL, pain, radiographic healing, or reoperation. Retrograde nailing was associated with increased knee pain and decreased knee range of motion at early time points, but this dissipated by 1 year. To our knowledge, this is the first study to prospectively compare outcomes over 1 year in patients treated with antegrade versus retrograde SIGN intramedullary nailing of infraisthmic femur fractures.Level of Evidence: III., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Background: Open tibia fractures are a major source of disability in low- and middle-income countries (LMICs) due to the high incidence of complications, particularly infection and chronic osteomyelitis. One proposed adjunctive measure to reduce infection is prophylactic local antibiotic delivery, which can achieve much higher concentrations at the surgical site than can safely be achieved with systemic administration. Animal studies and retrospective clinical studies support the use of gentamicin for this purpose, but no high-quality clinical trials have been conducted to date in high- or low-income settings., Methods: We describe a protocol for a pilot study conducted in Dar es Salaam, Tanzania, to assess the feasibility of a single-center masked randomized controlled trial to compare the efficacy of locally applied gentamicin to placebo for the prevention of fracture-related infection in open tibial shaft fractures., Discussion: The results of this study will inform the design and feasibility of a definitive trial to address the use of local gentamicin in open tibial fractures. If proven effective, local gentamicin would be a low-cost strategy to reduce complications and disability from open tibial fractures that could impact care in both high- and low-income countries., Trial Registration: ClinicalTrials.gov, Registration # NCT03559400 ; Registered June 18, 2018.

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.

Background: Open tibial fractures are common injuries in low and middle-income countries, but there is no consensus regarding treatment with intramedullary nailing versus external fixation. The purpose of the present study was to compare the outcomes of initial treatment with intramedullary nailing or external fixation in adults with open tibial fractures., Methods: We conducted a randomized clinical trial (RCT) at a tertiary orthopaedic center in Tanzania. Adults with acute diaphyseal open tibial fractures were randomly assigned to statically locked, hand-reamed intramedullary nailing or uniplanar external fixation. The primary outcome was death or reoperation for the treatment of deep infection, nonunion, or malalignment. Secondary outcomes included quality of life as measured with the EuroQol-5 Dimensions (EQ-5D) questionnaire, radiographic alignment, and healing as measured with the modified Radiographic Union Scale for Tibial fractures (mRUST)., Results: Of the 240 patients who were enrolled, 221 (92.1%) (including 111 managed with intramedullary nailing and 110 managed with external fixation) completed 1-year follow-up. There were 44 primary outcome events (with rates of 18.0% and 21.9% in the intramedullary nailing and external fixation groups, respectively) (relative risk [RR] = 0.83 [95% confidence interval (CI), 0.49 to 1.41]; p = 0.505). There was no significant difference between the groups in terms of the rate of deep infection. Intramedullary nailing was associated with a lower risk of coronal malalignment (RR = 0.11 [95% CI, 0.01 to 0.85]; p = 0.01) and sagittal malalignment (RR = 0.17 [95% CI, 0.02 to 1.35]; p = 0.065) at 1 year. The EQ-5D index favored intramedullary nailing at 6 weeks (mean difference [MD] = 0.07 [95% CI = 0.03 to 0.11]; p < 0.001), but this difference dissipated by 1 year. Radiographic healing (mRUST) favored intramedullary nailing at 6 weeks (MD = 1.2 [95% CI = 0.4 to 2.0]; p = 0.005), 12 weeks (MD = 1.0 [95% CI = 0.3 to 1.7]; p = 0.005), and 1 year (MD = 0.8 [95% CI = 0.2 to 1.5]; p = 0.013)., Conclusions: To our knowledge, the present study is the first RCT assessing intramedullary nailing versus external fixation for the treatment of open tibial fractures in sub-Saharan Africa. Differences in primary events were not detected, and only coronal alignment significantly favored the use of intramedullary nailing., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Objective: Predict loss to follow-up in prospective clinical investigations of lower extremity fracture surgery., Design: Secondary analysis of 2 prospective clinical trials., Setting: National public orthopaedic and neurologic trauma tertiary referral hospital in Dar es Salaam, Tanzania, a low-income country in sub-Saharan Africa., Patients/participants: Three hundred twenty-nine femoral shaft and 240 open tibial shaft fracture patients prospectively enrolled in prospective controlled trials of surgical fracture management by external fixation, plating, or intramedullary nailing between June 2015 and March 2017., Intervention: Telephone contact for failure to attend scheduled 1-year clinic visit., Main Outcome Measurements: Ascertainment of primary trial outcome at 1-year from surgery; post-hoc telephone questionnaire for reasons patient did not attend the 1-year clinic visit., Results: One hundred twenty-seven femur fracture (39%) and 68 open tibia fracture (28%) patients did not attend the 1-year clinic visit. Telephone contact significantly improved ascertainment of the primary study outcome by 20% between 6-month and 1-year clinic visits to 82% and 92% respectively at study completion. Multivariable analysis associated unemployment (OR = 2.5 [1.7-3.9], P  < .001), treatment with an external fixator (OR = 1.7 [1.0-2.8], P  = .033), and each additional 20 km between residence and clinic (OR = 1.03 [1.00-1.06], P  = .047] with clinic nonattendance. One hundred eight (55%) nonattending patients completed the telephone questionnaire, reporting travel distance to the hospital (49%), and travel costs to the hospital (46%) as the most prevalent reasons for nonattendance. Sixty-five percent of patients with open tibia fractures cited relocation after surgery as a contributing factor., Conclusions: Relocation during recovery, travel distance, travel cost, unemployment, and use of an external fixator are associated with loss to clinical follow-up in prospective investigations of femur and open tibia fracture surgery in this population. Telephone contact is an effective means to assess outcome., Competing Interests: DWS received grants from the Orthopaedic Research and Education Foundation (OREF) and Orthopaedic Trauma Association (OTA) exclusively to support the Tanzania Femur Trial; and grants from Wyss Medical Foundation and Doris Duke Charitable Foundation exclusively to support the Tanzania Open Tibia Study. SM is a board or committee member of the OTA. JTP, PDA, JHJ, ENE, BTH, certify that they have no financial conflict of interest (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) in connection with this article. The authors have no conflicts of interest to disclose., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Introduction: Surgical fixation of distal diaphyseal femur fractures remains a major challenge in developing countries given limited availability of fluoroscopy. The Surgical Implant Generation Network (SIGN) Standard Intramedullary Nail and SIGN Fin Nail are two modalities developed to address this challenge; the Fin Nail additionally avoids needing to place proximal interlocking screws. While efficacy of the Standard Nail has been established, outcomes following fixation with the Fin Nail are unknown. In this study, we compare outcomes of distal diaphyseal femur fractures treated with each implant., Methods: A prospective cohort study was conducted from 2012 to 2013 at a single tertiary-referral center in Tanzania. Skeletally mature patients with distal diaphyseal femur fractures treated with either retrograde SIGN Standard Nail or Fin Nail were included. Patients followed-up at 6, 12, 26, and 52 weeks post-operatively. The primary outcome was all-cause reoperation. Secondary outcomes included infection, non-union, malalignment, quality of life (EQ-5D score), pain (VAS score), radiographic healing (RUST score), and function (pain with weight bearing, knee range of motion, and Squat and Smile score)., Results: 74 (85%) of 85 enrolled patients completed the minimum 1-year follow-up. There was no difference in rate of reoperation (p = 1.00), infection (p = 1.00), limb length discrepancy (p = 0.47), non-union (p = 1.00), or coronal or sagittal malalignment (p = 1.00, p = 0.55 respectively) at 1 year. There was furthermore no difference in mean EQ-5D (p = 0.82), VAS pain score (p = 0.43), RUST score (p = 0.44), maximum knee flexion (p = 0.52) and extension (p = 1.00), or Squat and Smile function (p = 1.00) between cohorts at 1 year., Discussion: Outcomes associated with the SIGN Fin Nail are comparable to those associated with the SIGN Standard Intramedullary Nail at 1 year. The SIGN Fin Nail may be useful as an alternative to Standard locked IM nails for fixation of distal diaphyseal femur fractures., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: There are few validated instruments that serve as a proxy for fracture-healing after lower-extremity trauma in low-resource settings. The squat-and-smile test (S&S) has been under development by SIGN (Surgical Implant Generation Network) Fracture Care International to monitor outcomes of lower-extremity long-bone fractures after intramedullary nailing in resource-limited settings. The goals of this study were to develop and identify domains of the S&S test., Methods: The S&S domains were developed through an iterative process, and consensus was achieved regarding 3: squat depth, support needed to squat, and facial expression. Adult patients with an OTA/AO type-32 femoral shaft fracture were included in this retrospective study and had the S&S administered at 6 weeks and 3, 6, and 12 months postoperatively. Two authors independently assessed photographs of the patients performing the S&S. S&S domains were correlated with the EuroQol 5-Dimensions (EQ-5D) index score, and comparisons were made between S&S domains and reoperation status. Interrater and test-retest reliability was assessed using the kappa statistic. Sensitivity and specificity analyses were performed., Results: Six hundred and nine S&S images were evaluated for 231 patients. Each domain improved over time and correlated positively with EQ-5D scores (p < 0.05). Squat depth and support needed to squat correlated with the need for a reoperation (p ≤ 0.01), and both had high specificity (0.95 and 0.97, respectively) for ruling out the need for a reoperation at 1 year. All 3 domains had high test-retest reliability (κ = 0.95, 0.92, and 0.96). Squat depth and need for support also had strong interrater reliability (κ = 0.75 and 0.78)., Conclusions: The S&S is a potential tool for monitoring clinical and functional outcome of femoral shaft fractures in low-resource settings. Our data support the binary assessment of squat depth and need for support, but not facial expression, as a proxy for fracture-healing. Future prospective studies in external populations are warranted to evaluate the validity, reliability, and responsiveness of the S&S., Clinical Relevance: The S&S provides a valuable proxy for femoral shaft fracture assessment for middle to low-income countries because it is locally relevant (based on squatting), it is easy to administer, and assessment can be performed remotely via mobile telephone or text messaging.

Introduction: Open tibia fractures are some of the most common types of Orthopedics injuries in low- and middle-income countries (LMICs). In Tanzania, open tibia fractures are treated either conservatively by prolonged cast or surgically by external fixation (EF) or intramedullary nail (IMN) when available. The cost of treatment and amount of time patients spend away from work are major economic concerns with prolonged casting and EF. The goal of this study was to determine the cost effectiveness of IMN versus EF in the treatment of open diaphyseal tibia fractures at Muhimbili Orthopaedic Institute (Dar es Salaam, Tanzania)., Methods: This is a prospective randomized control study conducted of patients with a closeable AO/OTA 42 open diaphyseal tibia fracture. The patients underwent surgical fixation with either IMN or EF at Muhimbili Orthopaedic Institute (MOI), and were followed up at 2, 6, and 12 weeks postoperatively. A micro-costing method was used to estimate the fixed and variable costs of IMN and EF of the open diaphyseal tibial fracture., Results: The mean total cost per patient was lower for the IMN group ($425.8 ± 38.4) compared to the EF group ($559.6 ± 70.5, p < 0.001), with savings of $133.80 per patient for the IMN group. The mean hospital stay was 2.72 ± 1.40 days for the IMN group and 2.44 ± 1.47 days for the EF group (p = 0.5). Quality-adjusted life years (QALYs) were 0.26 per patient for the IMN group and 0.24 in the EF group at 12 weeks (p = 0.8). Ninety-two percent of patients in the IMN group achieved fracture union versus 60% in the EF group at three months postoperatively (p = 0.03)., Conclusion: IM nailing of a closeable open diaphyseal tibial fracture is more cost effective than EF. In addition, IM nailing has better union rates at three months compared to EF., (© The Authors, published by EDP Sciences, 2019.)

Background: Little data exists on the negative impact of orthopaedic trauma on quality of life (QOL) in low- and middle-income countries (LMICs). The goal of this study is to investigate the factors associated with lower QOL after operative fixation of femoral shaft fractures in adult patients in a low-resource setting., Methods: This prospective cohort study followed 272 factures in adults undergoing operative fixation for diaphyseal femur fractures at Tanzania. Patient demographics, injury characteristics, treatment modalities, and functional outcomes up to 1-year post-operatively were evaluated for association with 1-year post-operative EQ-5D QOL scores via univariate linear regression analysis., Results: EQ-5D values were significantly lower at 1 year than at baseline (0.941 vs 0.991, p < 0.0005)., Conclusions: Operative fixation of femoral shaft fractures in LMICs results in return to near baseline QOL. Demographic and treatment factors were not significantly associated with EQ-5D. and several markers of recovery were associated with lower 1 year QOL, including pain, knee stiffness, delayed radiographic healing, complications requiring reoperation. Efforts to reduce perioperative complications may help improve post-operative QOL., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: The optimal treatment for femoral shaft fractures in low-resource settings has yet to be established, in part, because of a lack of data supporting operative treatment modalities. We aimed to determine the reoperation rate among femoral fractures managed operatively and to identify risk factors for reoperation at a hospital in a Sub-Saharan country., Methods: We conducted a prospective clinical study at a single tertiary care center in Tanzania, enrolling all skeletally mature patients with diaphyseal femoral fractures managed operatively from July 2012 to July 2013. Patients were followed at regular intervals for 1 year postoperatively. The primary outcome was a complication requiring reoperation for any reason. Secondary outcomes were scores on the EuroQol (EQ)-5D, radiographic union score for tibial fractures (RUST), and squat-and-smile test., Results: There were a total of 331 femoral fractures (329 patients) enrolled in the study, with a follow-up rate at 1 year of 82.2% (272 of 331). Among the patients with complete follow-up, 4 injuries were managed with plate fixation and 268 were managed with use of an intramedullary nail. The reoperation rate for plate fixation was 25% (1 of 4) compared with 5.2% (14 of 268) for intramedullary nailing (p = 0.204). As found in a multivariate logistic regression, a small nail diameter, a Winquist type-3 fracture pattern, and varus malalignment of proximal fractures were associated with reoperation. The mean EQ-5D score at 1 year was 0.95 for patients who did not require reoperation compared with 0.83 for patients who required reoperation (p = 0.0002)., Conclusions: Intramedullary nailing for femoral shaft fractures was associated with low risk of reoperation and a nearly full return to baseline health-related quality of life at 1 year of follow-up. There are potentially modifiable risk factors for reoperation that can be identified and addressed through education and dissemination of these findings., Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Surgeons in low-resource settings manage an increasing number of patients presenting with high-energy fractures. The number of surgeons and the operating time available are frequently not adequate to treat these fractures in a timely manner. A common cause of delay in treating fractures is waiting for the patient to accumulate sufficient funding to pay for the surgery, including the surgical implant. The donation of the SIGN intramedullary nail interlocking screw system obviates a major delay in timing of surgery. The SIGN intramedullary nail has been designed to be used in low-resource settings as it can be placed without fluoroscopy or electricity. The SIGN-trained surgeons are very skillful in hand reaming the canal, placing the nail, and interlocking screws without fluoroscopy. As more is learned about fracture healing, the SIGN system continues to evolve. The SIGN system is expanding to include deformity correction and soft tissue coverage.

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage and is one of the leading complaints in emergency departments (EDs). Despite the important and the advantages of pain control, still patients do not receive appropriate attention. The objective of this study was to assess pain management among adult patients with fractures of long bones at Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania. A descriptive Cross-sectional study design (Hospital based) was used. A total of 250 patients aged 18-60 years old with fractures of long bones were recruited from March to June 2008. Structured questionnaires and observation guide were used to collect data. Verbal rating scale was used, to determine the intensity of pain. The study shows that there is no documentation for pain assessment or reassessment at Emergency Department. Slightly above half (54%; 135/250) of patients were not given analgesics. The commonest analgesic given was diclofenac sodium (46%). There was no patient given opioids (pethedine/ morphine). The rate of analgesics administration or splinting before and after admission did not differ between sexes (P=0.314 vs. P= 0.230) and (P=0.314 vs. P= 0.114), respectively. Almost half (47.0%) of them spent >20 min to 1 hour before the administration of analgesics. After administration of analgesia 76% of the patients continued to have severe to moderate pain. A large proportion (62.4%; N=156/250) of the patients scored their pain as severe. Of these, 28 (17.9%) patients received analgesia within 20 min, 42 (26.9%) after 30-60 min and 73 (46.8%) were not given analgesics at all. In conclusion pain at Muhimbili Orthopaedic Institute is under treated. It is important that this is addressed properly to minimize pains among patients attending hospitals for fracture management.