An observational cohort study of the adoption of elastic stable intramedullary nailing for the treatment of pediatric femur fractures in Kumasi, Ghana.

BACKGROUND: In high- and middle-income countries, elastic stable intramedullary nailing (ESIN) is the commonest treatment of femur fractures in children 5-11 years of age. At Komfo Anokye Teaching hospital (KATH) in Kumasi, Ghana, prior to this study all pediatric femur fractures were treated with skin traction to union. This study was designed to report the early results and costs of the adoption of ESIN at KATH to provide data to other low- and middle-income sites considering adoption of this surgical technique. METHODS: An observational cohort study that included 84 pediatric patients ages 3-14 years presenting with closed femur fractures and treated with either skin traction or ESIN. Multivariate logistic regression was used to compare the rate of treatment success between treatment groups. RESULTS: Treatment success (coronal and sagittal angulation less than 10 ° and shortening less than 15 mm at osseous union) was achieved in 92 % of the ESIN group versus 67 % of the skin traction group (odds ratio for ESIN group 9.28 (1.6-54.7); p = 0.0138). Average length of stay was significantly lower in the ESIN group (p = 0.001), but charges to patients were higher in the ESIN group (p < 0.001) because of the high cost of implants. CONCLUSIONS: The initial experience of operative treatment of femoral shaft fractures in children using ESIN was positive, with improved rates of treatment success and no surgical complications. Because of the high cost of implants, direct costs of treatment remained higher with ESIN despite reductions in length of hospital stay.

Orthopedic surgery in the developing world: workforce and operative volumes in Ghana compared to those in the United States.

BACKGROUND: Musculoskeletal disease is a growing burden in low- and middle-income countries (LMICs), yet little research exists to describe the problem. The purposes of this study were to characterize orthopedic surgery in an LMIC and compare the findings to those from a developed country. METHODS: The study location was the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana. Orthopedic surgeon, resident, and postgraduate training program numbers were compared to analogous data from a developed nation, the United States. Annual surgical volumes were compared to those at a level I trauma center in the United States, the San Francisco General Hospital (SFGH). RESULTS: There were 24 surgeons in Ghana compared to 23,956 in the United States. There were 7 orthopedic residents and 1 residency program in Ghana versus 3,371 residents and 155 residencies in the United States. Annual case volume was 2,161 at KATH and 2,132 at SFGH. Trauma accounted for 95 % of operations at KATH compared to 65 % at SFGH. The proportion of surgeries devoted to severe fractures was 29 % at KATH compared to 12 % at SFGH. Infections comprised 15 % of procedures at KATH and 5 % at SFGH. CONCLUSIONS: Annual case volume at a referral hospital in an LMIC is equivalent to that of a level I trauma center in an industrialized country. Total case volume is similar, but the LMIC institution manages a disproportionately large number of trauma cases, severe fractures, and infections. There is a large burden of orthopedic disease in the developing nation, and there are too few providers and training programs to address these conditions.