An Assessment of Open Fracture Management in Hospitals in Malawi Before and Immediately After Implementing Open Fracture Guidelines.

Background: Open fractures, a common consequence of road traffic collisions, are associated with a high risk of complications. The introduction of standard guidelines has been shown to improve patient care and reduce the risk of complications in several countries. In September 2021, the Malawi Orthopaedic Association/Arbeitsgemeinschaft für Osteosynthesefragen Alliance (MOA/AOA) guidelines and standards for open fracture management were introduced in Malawi. This study aimed to assess the management of open fractures in hospitals in Malawi, before and after implementing a training course on the MOA/AOA open fracture guidelines. Methods: This was a descriptive and quantitative, before-and-after study that reviewed the medical files of patients with open fractures at Zomba Central Hospital and Mulanje, Salima, and Mangochi district hospitals over two 3-month periods. Variables included initial assessment; antibiotic prophylaxis; place of debridement; type of anesthesia; treatment of the open fracture in the emergency department, operating room, and wards; and short-term complications requiring hospital treatment. Results: A total of 88 open-fracture case files were reviewed; 43 were prior and 45 were subsequent to the implementation of the open fracture guidelines. The overall median patient age was 36 years (interquartile range, 27 to 45 years), and 91% (80) were male. Limb neurovascular status assessment and documentation improved from 26% (11) of the patients before the guidelines to 62% (28) afterward (p = 0.0002). The percentage who underwent debridement in the operating room significantly increased from 19% (8) to 69% (31) (p = 0.01). The percentage who underwent debridement under general or spinal anesthesia significantly increased from 5% (2) to 38% (17) and from 12% (5) to 29% (13), respectively (p= 0.001). The wound infection rate decreased from 21% to 11%, but this was not significant, and there was no change in the overall complication rate (p = 0.152). Conclusions: This study suggests that training on the MOA/AOA open fracture management guidelines followed by their implementation can lead to at least temporary improvement in the management of open fractures. Nevertheless, additional studies need to be performed to understand the effect on long-term patient outcomes. Levels of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Best Practices for Developing International Academic Partnerships in Orthopaedics.

ABSTRACT: Traumatic and nontraumatic orthopaedic conditions are major contributors to global morbidity and account for the majority of life-years lived with disability worldwide. Additionally, the burden of musculoskeletal injuries has increased substantially over the past 3 decades. Unfortunately, in low and middle-income countries (LMICs), access to orthopaedic care is limited, leading to a disproportionate burden of disease. The Lancet Commission on Global Surgery has emphasized the urgent need for unified international commitment and research collaboration to achieve universal access to safe and affordable surgical care. However, conducting high-quality orthopaedic research in LMICs remains challenging as a result of disparities in training, access to resources, infrastructure, and equipment availability. Partnerships between high-income countries (HICs) and LMICs have emerged in recent decades as an effective approach to combatting some of these challenges. These partnerships aim to bridge the gaps by facilitating collaborative research and knowledge exchange. The establishment of successful partnerships requires a collaborative and reciprocal approach that starts with a clear understanding of mutual research aims and the availability of resources. Despite the potential benefits, various factors can make establishing such partnerships difficult. However, these partnerships can have a substantial impact in delivering quality orthopaedic education and research training, thus improving access to care in resource-limited environments. This paper represents the collaborative effort of multiple international academic orthopaedic surgeons with extensive experience in HIC-LMIC partnerships. Our aims were to outline the best practices for conducting orthopaedic research within these relationships and to provide guidance for future successful collaborations.

Childhood musculoskeletal impairment in Malawi from traumatic and non-traumatic causes: a population- based assessment using the key informant method.

BACKGROUND: Musculoskeletal impairment (MSI) in children is an under-recognised public health challenge. Although preventable, road injuries and other traumas continue to cause significant impairments to children worldwide. The study aimed to use the Key Informant Method (KIM) to assess prevalence and causes of MSI in children in two districts in Malawi, estimating the associated need for services provision, with a focus on traumatic aetiology. METHODS: The KIM was conducted in the districts of Thyolo (Southern Malawi) and Ntcheu (Central Malawi) in 2013. Five hundred key informants were trained to identify children who may have one of a range of MSI. The identified children were referred to a screening camp where they were examined by medical experts with standardised assessment protocols for diagnosing each form of impairment. RESULTS: 15,000 children were referred to screening camps. 7220 children were assessed (response rate 48%) for an impairment of whom 15.2% (1094) had an MSI. 13% of children developed MSI from trauma, while 54% had a neurological aetiology. For MSI of traumatic origin the most common body part affected was the elbow. Less than half of children with MSI (44.4%) were enrolled in school and none of these children attended schools with resources for disability. More than half of children with MSI (60%) had not received required services and 64% required further physical therapy. CONCLUSIONS: The KIM method was used to identify a high prevalence of MSI among children in two districts of Malawi and estimates an unmet need for dedicated MSI services.

Cost utility analysis of intramedullary nailing and skeletal traction treatment for patients with femoral shaft fractures in Malawi.

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 payer's 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.

Assessing the capacity of Malawi's district and central hospitals to manage traumatic diaphyseal femoral fractures in adults.

BACKGROUND: The burden of musculoskeletal trauma is growing worldwide, disproportionately affecting low-income countries like Malawi. However, resources required to manage musculoskeletal trauma remain inadequate. A detailed understanding of the current capacity of Malawian public hospitals to manage musculoskeletal trauma is unknown and necessary for effective trauma system development planning. METHODS: We developed a list of infrastructure, manpower, and material resources used during treatment of adult femoral shaft fractures-a representative injury managed non-operatively and operatively in Malawi. We identified, by consensus of at least 7 out of 10 experts, which items were essential at district and central hospitals. We surveyed orthopaedic providers in person at all 25 district and 4 central hospitals in Malawi on the presence, availability, and reasons for unavailability of essential resources. We validated survey responses by performing simultaneous independent on-site assessments of 25% of the hospitals. RESULTS: No district or central hospital in Malawi had available all the essential resources to adequately manage femoral fractures. On average, district hospitals had 71% (range 41-90%) of essential resources, with at least 15 of 25 reporting unavailability of inpatient ward nurses, x-ray, external fixators, gauze and bandages, and walking assistive devices. District hospitals offered only non-operative treatment, though 24/25 reported barriers to performing skeletal traction. Central hospitals reported an average of 76% (71-85%) of essential resources, with at least 2 of 4 hospitals reporting unavailability of full blood count, inpatient hospital beds, a procedure room, an operating room, casualty/A&E department clinicians, orthopaedic clinicians, a circulating nurse, inpatient ward nurses, electrocardiograms, x-ray, suture, and walking assistive devices. All four central hospitals reported barriers to performing skeletal traction. Operative treatment of femur fracture with a reliable supply of implants was available at 3/4 hospitals, though 2/3 were dependent entirely on foreign donations. CONCLUSION: We identified critical deficiencies in infrastructure, manpower, and essential resources at district and central hospitals in Malawi. Our findings provide evidence-based guidance on how to improve the musculoskeletal trauma system in Malawi, by identifying where and why essential resources were unavailable when needed.

Validation of Chichewa Short Musculoskeletal Function Assessment (SMFA) questionnaire: A cross-sectional study.

Background: The Short Musculoskeletal Function Assessment (SMFA) tool measures function and quality of life in patients with musculoskeletal conditions. Objective: This study aimed to translate and adapt culturally the SMFA into Chichewa, and assess its clinimetric properties. Methods: The translated Chichewa version was administered to 53 patients with musculoskeletal disorders. To assess repeatability, an additional 20 patients answered the questionnaire twice over a time interval of two weeks. Internal consistency, floor and ceiling effects, and repeatability were tested; construct validity was assessed with the World Health Organization Quality of Life Assessment tool (WHOQOL-BREF). Results: There was good internal consistency for both Dysfunction and Bothersome indices (Cronbach's alpha 0.90) and good construct validity between both indices with the WHOQOL-BREF. Pearson's correlation coefficient and intraclass correlation coefficient (ICC) for repeatability for the Dysfunction Index were 0.941 and 0.922 (95% CI: 0.772, 0.971) respectively, and 0.877 and 0.851 (95% CI: 0.629, 0.941) for the Bothersome Index respectively. Conclusion: The translated Chichewa SMFA is a valid tool for populations that speak the Chichewa language.

The Cost of Intramedullary Nailing Versus Skeletal Traction for Treatment of Femoral Shaft Fractures in Malawi: A Prospective Economic Analysis.

BACKGROUND: In many low- and middle-income countries, non-surgical management of femoral shaft fractures using skeletal traction is common because intramedullary (IM) nailing is perceived to be expensive. This study assessed the cost of IM nailing and skeletal traction for treatment of femoral shaft fractures in Malawi. METHODS: We used micro-costing methods to quantify the costs associated with IM nailing and skeletal traction. Adult patients who sustained an isolated closed femur shaft fracture and managed at Queen Elizabeth Central Hospital in Malawi were followed from admission to discharge. Resource utilization and time data were collected through direct observation. Costs were quantified for procedures and ward personnel, medications, investigations, surgical implants, disposable supplies, procedures instruments and overhead. RESULTS: We followed 38 nailing and 27 traction patients admitted between April 2016 and November 2017. Nailing patient's average length of stay (LOS) was 36.35 days (SD 21.19), compared to 61 (SD 18.16) for traction (p = 0.0003). The total cost per patient was $596.97 ($168.81) for nailing and $678.02 (SD $144.25) for traction (p = 0.02). Major cost drivers were ward personnel and overhead; both are directly proportional to LOS. Converting patients from traction to nailing is cost-saving up to day 23 post-admission. CONCLUSION: Savings from IM nailing as compared with skeletal traction were achieved by shortened LOS. Although this study did not assess the effectiveness of either intervention, the literature suggests that traction carries a higher rate of complications than nailing. Investment in IM nailing capacity may yield substantial net savings to health systems, as well as improved clinical outcomes.

Developing Research to Change Policy: Design of a Multicenter Cost-Effectiveness Analysis Comparing Intramedullary Nailing to Skeletal Traction in Malawi.

INTRODUCTION: The purpose of our study is to prospectively evaluate the cost effectiveness of intramedullary nailing compared with skeletal traction in a resource-limited setting where traction remains the most common definitive treatment. METHODS: This multicenter, prospective multicenter investigation was conducted in Malawi at 2 central hospitals and 3 district hospitals. The project was divided into phases. In phase 1, the EuroQol-5D and SMFA were translated and validated in Chichewa. In phase 2, adult patents with OTA/AO 32 femur shaft fractures were prospectively enrolled, and a comparison of quality of life and functional status was made. In phase 3, a cost-effectiveness analysis was performed between those treated with intramedullary nail and those treated with skeletal traction. CONCLUSION: This study serves as an example of an economic study in orthopaedic surgery conducted in a resource-poor environment through academic collaboration.

Correction to: Childhood disability in Malawi: a population based assessment using the key informant method.

Following the publication of this article [1] it was brought to our attention that inadvertently the COSECSA Oxford Orthopaedic Link (COOL) programme was not acknowledged for funding this study.

Childhood disability in Malawi: a population based assessment using the key informant method.

BACKGROUND: Epidemiological data on childhood disability are lacking in Low and Middle Income countries (LMICs) such as Malawi, hampering effective service planning and advocacy. The Key Informant Method (KIM) is an innovative, cost-effective method for generating population data on the prevalence and causes of impairment in children. The aim of this study was to use the Key Informant Method to estimate the prevalence of moderate/severe, hearing, vision and physical impairments, intellectual impairments and epilepsy in children in two districts in Malawi and to estimate the associated need for rehabilitation and other services. METHODS: Five hundred key informants (KIs) were trained to identify children in their communities who may have the impairment types included in this study. Identified children were invited to attend a screening camp where they underwent assessment by medical professionals for moderate/severe hearing, vision and physical impairments, intellectual impairments and epilepsy. RESULTS: Approximately 15,000 children were identified by KIs as potentially having an impairment of whom 7220 (48%) attended a screening camp. The estimated prevalence of impairments/epilepsy was 17.3/1000 children (95% CI: 16.9-17.7). Physical impairment (39%) was the commonest impairment type followed by hearing impairment (27%), intellectual impairment (26%), epilepsy (22%) and vision impairment (4%). Approximately 2100 children per million population could benefit from physiotherapy and occupational therapy and 300 per million are in need of a wheelchair. An estimated 1800 children per million population have hearing impairment caused by conditions that could be prevented or treated through basic primary ear care. Corneal opacity was the leading cause of vision impairment. Only 50% of children with suspected epilepsy were receiving medication. The majority (73%) of children were attending school, but attendance varied by impairment type and was lowest among children with multiple impairments (38%). CONCLUSION: Using the KIM this study identified more than 2500 children with impairments in two districts of Malawi. As well as providing data on child disability, rehabilitation and referral service needs which can be used to plan and advocate for appropriate services and interventions, this method study also has an important capacity building and disability awareness raising component.

The burden of trauma at a district hospital in Malawi.

Trauma disproportionately affects low- and middle-income countries, many of which do not have the surveillance systems required to design effective prevention and treatment strategies. The aim of this study was to establish such a system at a district hospital in Malawi. Data on all trauma patients presenting to Mulanje District Hospital from 14 April 2013 to 30 December 2014 were collected using a form based on the core minimum data points for injuries recommended by the World Health Organization and an injury severity assessment. A total of 9073 trauma cases were recorded, accounting for 3.4% of patients that presented at the hospital during this period. Of them, 56.6% were boys/men, with the average age being 22.4 (range, 0.6-98 years). Falls (53.2%), animal bites (16.6%), road traffic injuries (11.1%) and assaults (10.2%) were the most prevalent causes, the majority of the former two taking place at home. Of the patients, 94.8% were treated and sent home, 5.0% were admitted and the remaining were either referred elsewhere or died.

First Responders and Prehospital Care for Road Traffic Injuries in Malawi.

Introduction Road traffic collisions are a common cause of injuries and injury-related deaths in sub-Saharan Africa (SSA). Basic prehospital care can be the difference between life and death for injured drivers, passengers, and pedestrians. Problem This study examined the challenges associated with current first response practices in Malawi. METHODS: In April 2014, focus groups were conducted in two areas of Malawi: Karonga (in the Northern Region) and Blantyre (in the Southern Region; both are along the M1 highway), and a qualitative synthesis approach was used to identify themes. All governmental and nongovernmental first response organizations identified by key informants were contacted, and a checklist was used to identify the services they offer. RESULTS: Access to professional prehospital care in Malawi is almost nonexistent, aside from a few city fire departments and private ambulance services. Rapid transportation to a hospital is usually the primary goal of roadside care because of limited first aid knowledge and a lack of access to basic safety equipment. The key informants recommended: expanding community-based first aid training; emphasizing umunthu (shared humanity) to inspire bystander involvement in roadside care; empowering local leaders to coordinate on-site responses; improving emergency communication systems; equipping traffic police with road safety gear; and expanding access to ambulance services. CONCLUSION: Prehospital care in Malawi would be improved by the creation of a formal network of community leaders, police, commercial drivers, and other lay volunteers who are trained in basic first aid and are equipped to respond to crash sites to provide roadside care to trauma patients and prepare them for safe transport to hospitals. Chokotho L , Mulwafu W , Singini I , Njalale Y , Maliwichi-Senganimalunje L , Jacobsen KH . First responders and prehospital care for road traffic injuries in Malawi. Prehosp Disaster Med. 2017;32(1):14-19.

A review of existing trauma and musculoskeletal impairment (TMSI) care capacity in East, Central, and Southern Africa.

BACKGROUND: We conducted an assessment of orthopaedic surgical capacity in the following countries in East, Central, and Southern Africa: Burundi, Ethiopia, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. METHODS: We adapted the WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care with questions specific to trauma and orthopaedic care. In May 2013-May 2014, surgeons from the College of Surgeons of East, Central and Southern Africa (COSECSA) based at district (secondary) and referral (tertiary) hospitals in the region completed a web-based survey. COSECSA members contacted other eligible hospitals in their country to collect further data. FINDINGS: Data were collected from 267 out of 992 (27%) hospitals, including 185 district hospitals and 82 referral hospitals. Formal accident and emergency departments were present in 31% of hospitals. Most hospitals had no general or orthopaedic surgeons or medically-qualified anaesthetists on staff. Functioning mobile C-arm X-ray machines were available in only 4% of district and 27% of referral hospitals; CT scanning was available in only 3% and 26%, respectively. Closed fracture treatment was offered in 72% of the hospitals. While 20% of district and 49% of referral hospitals reported adequate instruments for the surgical treatment of fractures, only 4% and 10%, respectively, had a sustainable supply of fracture implants. Elective orthopaedic surgery was offered in 29% and Ponseti treatment of clubfoot was available at 42% of the hospitals. INTERPRETATION: The current capacity of hospitals in sub-Saharan Africa to manage traumatic injuries and orthopaedic conditions is significantly limited. In light of the growing burden of trauma and musculoskeletal impairment within this region, concerted efforts should be made to improve hospital capacity with equipment, trained personnel, and specialist clinical services.

Prioritisation of Surgery in the National Health Strategic Plans of Africa: A Systematic Review.

INTRODUCTION: Disease amenable to surgical intervention accounts for 11-15 % of world disability and there is increasing interest in surgery as a global public health issue. National Health Strategic Plans (NHSPs) reflect countries' long-term health priorities, plans and targets. These plans were analysed to assess the prioritisation of surgery as a public health issue in Africa. METHODS: NHSPs of 43 independent Sub-Saharan African countries available in the public domain in March 2014 in French or English were searched electronically for key terms: surg*, ortho*, trauma, cancer, appendic*, laparotomy, HIV, tuberculosis, malaria. They were then searched manually for disease prevalence, targets, and human resources. RESULTS: 19 % of NHSPs had no mention of surgery or surgical conditions. 63 % had five or less mentions of surgery. HIV and malaria had 3772 mentions across all the policies, compared to surgery with only 376 mentions. Trauma had 239 mentions, while the common surgical conditions of appendicitis, laparotomy and hernia had no mentions at all. Over 95 % of NHSPs specifically mentioned the prevalence of HIV, tuberculosis, malaria, infant mortality and maternal mortality. Whereas, the most commonly mentioned surgical condition for which a prevalence was given was trauma, in only 47 % of policies. All NHSPs had plans and measurable targets for the reduction of HIV and tuberculosis. Of the total 4064 health targets, only 2 % were related to surgical conditions or surgical care. 33 % of policies had no surgical targets. DISCUSSION: NHSPs are the best available measure of health service and planning priorities. It is clear from our findings that surgery is poorly represented and that surgical conditions and surgical treatment are not widely recognised as a public health priority. Greater prioritisation of surgery in national health strategic policies is required to build resilient surgical systems.

The burden of trauma in four rural district hospitals in Malawi: a retrospective review of medical records.

BACKGROUND: Few injury surveillance systems collect data in sub-Saharan Africa. This medical record review of four rural hospitals provides baseline data on the burden of trauma in Malawi. METHODS: We reviewed all outpatient, inpatient, and mortuary records for one full year at four of the 28 district hospitals in Malawi: Dedza in central Malawi, Mangochi in the east, Nkhata Bay in the north, and Thyolo in the south. We used descriptive and comparative statistics to examine characteristics of patients and the data file. RESULTS: During 2012, 18,735 trauma patients were treated at the four district hospitals. Trauma cases accounted for 3.5% of the 541,170 patient visits. In total, 60.8% of trauma patients were male; 39.1% were 0­14 years old and 50.4% were 15­49 years old. The logbooks were missing information about the primary type of injury for 44.9% of patients and about injury cause for 82.7%. Of the recorded trauma diagnoses, the most common injuries were soft tissue injuries, fractures, and sprains. The most commonly reported causes of injuries were animal bites (mostly dog bites), road traffic injuries, assaults, burns, and falls. CONCLUSIONS: The development and implementation of improved methods for acquiring more complete, accurate, and useful trauma data in Malawi and other low-income countries requires addressing difficulties that might result in missing data. Increased injury surveillance is critical for improving trauma care and meeting the emerging global demand for burden of disease data.