Megadactyly with syndactyly of the right toes, a rare case report.

INTRODUCTION AND IMPORTANCE: Megadactyly of the foot is uncommon non hereditary congenital anomalies of the extremities and poses a dilemma on treatment however multiple treatment modalities were developed but is not uniform to all patients with megadactyly. The goal of the surgical treatment is to achieve painless and function of the foot. CASE PRESENTATION: We report a 14 years old male presented with complaints of progressive enlargement 2nd, 3rd, 4th and 5th toes of the right foot since birth, associated with inability to wear shoes. One month prior to admission he experienced gradual onset painful forefoot and toes that was increasing in severity with time associated with inability to walk normally. He is the first born in a family of four children and his other siblings are healthy with no anomalies. On clinical evaluation, he was health with stable vitals, with enlarged 2nd, 3rd, 4th and 5th toes of the right foot with no tenderness with intact neurovascular status. On clinical and radiological evaluation he was diagnosed with congenital megadactyly of the right foot, a multidisciplinary team including orthopedic surgeons and prosthetics team agreed to do trans-metatarsal, then partial foot prosthesis fabrication. He underwent trans-metatarsal amputation of the affected foot and tissue sample was taken for histopathology. The histological findings revealed bone enlargement with increased proliferation of subcutaneous adipose tissues with increased fibrous septae together with thinning of the epidermis, features suggestive of lipomatosis. The wound site healed very well after 14 days stitches were removed and the child was scheduled for follow-up after six weeks, 12 weeks and 6 month post-surgery. On the last visit he was free from pain on his right forefoot and toes, able to wear fabricated partial foot prosthesis and shoes normally, walk with no incapacitation. DISCUSSION: Our case report is unique due to the involvement of the multiple toes of the right foot with syndactyly at third and fourth toes and its management is challenging because there is no uniformity in its surgical treatment, in our case trans-metatarsal amputation was done and the patient progressed well after six months of follow up. CONCLUSION: Foot megadactyly is uncommon congenital malformation, most common on the right foot. Regardless of the dilemma on treatment, the trans-metatarsal amputation and a fabricated prosthesis to our patient fulfilled the goals of painless right foot and able to wear shoes and walk normally with no impairment.

Hospitalized for poverty: orthopaedic discharge delays due to financial hardship in a tertiary hospital in Northern Tanzania.

BACKGROUND: Musculoskeletal injury contributes significantly to the burden of disease in Tanzania and other LMICs. For hospitals to cope financially with this burden, they often mandate that patients pay their entire hospital bill before leaving the hospital. This creates a phenomenon of patients who remain hospitalized solely due to financial hardship. This study aims to characterize the impact of this policy on patients and hospital systems in resource-limited settings. METHODS: A mixed-methods study using retrospective medical record review and semi-structured interviews was conducted at a tertiary hospital in Moshi, Tanzania. Information regarding patient demographics, injury type, days spent in the ward after medical clearance for discharge, and hospital invoices were collected and analyzed for orthopaedic patients treated from November 2016 to June 2017. RESULTS: 346 of the 867 orthopaedic patients (39.9%) treated during this time period were found to have spent additional days in the hospital due to their inability to pay their hospital bill. Of these patients, 72 patient charts were analyzed. These 72 patients spent an average of 9 additional days in the hospital due to financial hardship (range: 1-64 days; interquartile range: 2-10.5 days). They spent an average of 112,958 Tanzanian Shillings (TSH) to pay for services received following medical clearance for discharge, representing 12.3% of the average total bill (916,840 TSH). 646 hospital bed-days were spent on these 72 patients when they no longer clinically required hospitalization. 7 (9.7%) patients eloped from the hospital without paying and 24 (33.3%) received financial assistance from the hospital's social welfare office. CONCLUSIONS: Many patients do not have the financial capacity to pay hospital fees prior to discharge. This reality has added significantly to these patients' overall financial hardship and has taken hundreds of bed-days from other critically ill patients. This single-institution, cross-sectional study provides a deeper understanding of this phenomenon and highlights the need for changes in the healthcare payment structure in Tanzania and other comparable settings.

Patient patronage and perspectives of traditional bone setting at an outpatient orthopaedic clinic in Northern Tanzania.

BACKGROUND: Much of Sub-Saharan Africa meets the rising rates of musculoskeletal injury with traditional bone setting, especially given limitations in access to allopathic orthopaedic care. Concern for the safety of bone setter practices as well as recognition of their advantages have spurred research to understand the impact of these healers on public health. OBJECTIVES: Our study investigates the role of bone setting in Tanzania through patient utilization and perspectives. METHODS: We surveyed 212 patients at the outpatient orthopaedic clinic at Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania. Surveys were either self-administered or physician-administered. Summary statistics were calculated using XLSTAT. Open responses were analyzed using a deductive framework method. RESULTS: Of all surveys, 6.3% (n=13) reported utilizing traditional bone setting for their injury prior to presenting to KCMC. Of the self-administered surveys, 13.6% (n=6) reported utilizing bone setting compared to 4.3% (n=7) of the physician-administered surveys (p=0.050). Negative perceptions of bone setting were more common than positive perceptions and the main reason patients did not utilize bone setting was concern for competency (35.8%, n=67). CONCLUSION: Our study found lower bone setting utilization than expected considering the reliance of Tanzanians on traditional care reported in the literature. This suggests patients utilizing traditional care for musculoskeletal injury are not seeking allopathic care; therefore, collaboration with bone setters could expand allopathic access to these patients. Patients were less likely to report bone setter utilization to a physician revealing the stigma of seeking traditional care, which may present an obstacle for collaboration.

Practices and Perspectives of Traditional Bone Setters in Northern Tanzania.

Background: Traditional health practitioners remain a critical source of care in Tanzania, more than 50% of Tanzanians frequently using their services. With a severe shortage of orthopaedic surgeons (1:3.3 million Tanzanians) traditional bone setters (TBSs) could potentially expand access to musculoskeletal care and improve outcomes for morbidity as a result of trauma. Objective: We sought to identify the advantages and disadvantages of traditional bone setting in Tanzania and to assess potential for collaboration between TBSs and allopathic orthopaedic surgeons. Methods: Between June and July 2017 we interviewed six TBSs identified as key informants in the regions of Kilimanjaro, Arusha, and Manyara. We conducted semi-structured interviews about practices and perspectives on allopathic healthcare, and analyzed the data using a deductive framework method. Findings: The TBSs reported that their patients were primarily recruited from their local communities via word-of-mouth communication networks. Payment methods for services included bundling costs, livestock barter, and sliding scale pricing. Potentially unsafe practices included lack of radiographic imaging to confirm reduction; cutting and puncturing of skin with unsterile tools; and rebreaking healed fractures. The TBSs described past experience collaborating with allopathic healthcare providers, referring patients to hospitals, and utilizing allopathic techniques in their practice. All expressed enthusiasm in future collaboration with allopathic hospitals. Conclusions: TBSs confer the advantages of word-of-mouth communication networks and greater financial and geographic accessibility. However, some of their practices raise concerns relating to infection, fracture malunion or nonunion, and iatrogenic trauma from manipulating previously healed fractures. A formal collaboration between TBSs and orthopaedic surgeons, based on respect and regular communication, could alleviate concerns through the development of care protocols and increase access to optimal orthopaedic care through a standardized triage and follow-up system.

Psychosocial health of patients receiving orthopaedic treatment in northern Tanzania: A cross-sectional study.

BACKGROUND: Patients with musculoskeletal injuries in Sub-Saharan Africa often receive prolonged inpatient treatment due to limited access to surgical care. Little is known regarding the psychosocial impact of prolonged conservative treatment for orthopaedic injuries, which may add to disability and preclude rehabilitation. METHODS: A cross-sectional, questionnaire study was conducted to characterize the psychosocial health of orthopaedic inpatients at a tertiary hospital in Moshi, Tanzania. Three validated surveys assessing coping strategies, functional social support, and symptoms of depression were orally administered to all orthopaedic patients with a length of stay (LOS) ≥ 6 days by a Tanzanian orthopaedic specialist. RESULTS: Fifty-nine patient surveys were completed, and revealed 92% (54) of patients were more likely to utilize more adaptive than maladaptive coping strategies. Patients with chest or spinal column injuries were more likely to use maladaptive coping strategies (p = 0·027). Patients with head injuries had more social support compared to others (p = 0·009). Lack of insurance, limited education, and rural origins were associated with less functional social support, although this finding did not reach statistical significance. 23·7% (14) of patients had symptoms consistent with mild depression, 33·9% (20) with moderate depression, and 3·4% (2) with moderately-severe depression. LOS was the only significant predictor for depression severity. CONCLUSIONS: 61% (36) of orthopaedic inpatients exhibited depressive symptoms, indicating that the psychosocial health in this population is sub-optimal. Mental health is a crucial element of successful orthopaedic care. Access to timely surgical care would greatly decrease LOS, the most prominent predictor of depressive symptom severity.