Using a consensus meeting to enhance fracture care education in low income countries.

BACKGROUND: A key strategy to building surgical capacity in low income countries involves training care providers, particularly in the interventions highlighted by the Lancet Commission for Global Surgery, including the management of open fractures. This is a common injury, especially in areas with a high incidence of road traffic incidents. The aim of this study was to use a nominal group consensus method to design a course on open fracture management for clinical officers in Malawi. METHODS: The nominal group meeting was held over two days, including clinical officers and surgeons from Malawi and the UK with various levels of expertise in the fields of global surgery, orthopaedics and education. The group was posed with questions on course content, delivery and evaluation. Each participant was encouraged to suggest an answer and the advantages and disadvantages of each suggestion were discussed before voting through an anonymous online platform. Voting included use of a Likert scale or ranking available options. Ethical approval for this process was obtained from the College of Medicine Research and Ethics Committee Malawi and the Liverpool School of Tropical Medicine. RESULTS: All suggested course topics received an average score of greater than 8 out of 10 on a Likert scale and were included in the final programme. Videos was the highest ranking option as a method for delivering pre-course material. The highest ranking methods for each course topic included lectures, videos and practicals. When asked what practical skill should be tested at the end of the course, the highest ranking option was "initial assessment". CONCLUSION: This work outlines how a consensus meeting can be used to design an educational intervention to improve patient care and outcomes. Through combining the perspectives of both the trainer and trainee, the course aligns both agendas so that it is relevant and sustainable.

The economic burden of open tibia fractures: A systematic review.

BACKGROUND: Open tibia fractures are a common injury following road traffic collisions and place a large economic burden on patients and healthcare systems. Summarising their economic burden is key to inform policy and help prioritise treatment. METHODS: All studies were identified from a systematic search of Medline, Embase and the Cochrane Central Register of Controlled Trials. We included any human with a diagnosed open tibia fracture, following any intervention. The primary outcome was any costs reported or patient return to work status. Secondary outcomes included average length of stay, wage loss, absenteeism and complications such as infection, amputation and nonunion. Data was extracted and we performed a descriptive narrative summary. RESULTS: We reviewed 1,204 studies from our searches. A total of 34 studies were included from 14 different countries. The average age was 37.7 years old and 76% of the patients were male. 6.5% were Gustilo I, 12% Gustilo II and 82% Gustilo III. Initial direct hospitalisation costs were reported to be between £356 to £126,479 with an average length of stay of 56 days (3.1-244). 89% of participants were working pre-injury, 60% fully returned to work, 17% returned to work part time or changed profession and 22% did not return to work at one-year. The most common complications reported were 22% infection, 11% nonunion and 16% amputation. Mean follow-up duration for the studies was 25 months. CONCLUSION: The economic burden of open tibia fractures varies greatly, but it is costly for both hospitals and patients. The current evidence is predominantly from high-income countries (HICs), especially the USA. Further research is required to investigate the costs of open tibia fractures using validated costing tools, especially in low-income countries (LICs), to help inform and direct policy.

Systematic review of patient reported outcomes from open tibia fractures in low and middle income countries.

BACKGROUND: Open tibia fractures are a common cause of admission following road traffic accidents in low and middle income countries (LMICs), resulting in substantial mortality and disability. It is important to summarise the clinical course of this injury using patient reported scores in order to assess best treatment in LMICs. OBJECTIVES: To summarise the disability after sustaining an open tibia fracture in LMICs METHODS: All studies were identified from a systematic search of Medline, Embase and the Cochrane Central Register of Controlled Trials. We included any human with a diagnosed open tibia fracture, following any intervention. Studies were performed in a low or middle income country. The primary outcome was any validated patient reported outcome score reported after three months. Secondary outcomes included economic impact and complications such as infection, non-union and amputation. Data was extracted and summarised. RESULTS: We reviewed 3,593 articles from our search. A total of 18 studies were included from 10 countries with 8 different outcome scores. The average age was 35 years old and 86% of the patients were male. Thirty-one percent were Gustilo I, 28% Gustilo II, 19% Gustilo IIIA, 17% Gustilo IIIB and 5% Gustilo IIIC. The most common complications reported were 18% infection, 15% non-union and 15% amputation. Economic impact was reported in only one study with 100% patients working pre-injury and 20% post-injury at 12 months. Mean follow-up duration for outcome scores was 19.8 months. There was heterogeneity between the studies in terms of subject of the studies, outcome criteria, fracture type, surgical technique and length of follow-up. Therefore, no meta-analysis could be performed. CONCLUSION: The clinical history of open tibia fractures in low or middle income countries remains largely unknown in terms of patient reported outcomes. Further studies are required to define these outcomes in open tibia fractures before best treatments can be assessed.