Improving Management of Adult Ankle Fractures in Malawi

Abstract

Background: The burden of musculoskeletal trauma is increasing worldwide, especially in low-income countries such as Malawi. Ankle fractures are common in Malawi and may receive suboptimal treatment due to inadequate surgical capacity and limited provider knowledge of evidence-based treatment guidelines. Methods: This study was conducted in 3 phases. First, we assessed Malawian orthopaedic providers’ understanding of anatomy, injury identification, and treatment methods. Second, we observed Malawian providers’ treatment strategies for adults with ankle fractures presenting to a central hospital. These patients’ radiographs underwent blinded, post hoc review by 3 U.S.-based orthopaedic surgeons and a Malawian orthopaedic surgeon, whose treatment recommendations were compared with actual treatments rendered by Malawian providers. Third, an educational course addressing knowledge deficits was implemented. We assessed post-course knowledge and introduced a standardized management protocol, specific to the Malawian context. Results: In Phase 1, deficits in injury identification, ideal treatment practices, and treatment standardization were identified. In Phase 2, 17 (35%) of 49 patients met operative criteria but did not undergo a surgical procedure, mainly because of resource limitations and provider failure to recognize unstable injuries. In Phase 3, 51 (84%) of 61 participants improved their overall performance between the pre-course and post-course assessments. Participants answered a mean of 32.4 (66%) of 49 questions correctly pre-course and 37.7 (77%) of 49 questions correctly post-course, a significant improvement of 5.2 more questions (95% confidence interval [CI], 3.8 to 6.6 questions; p < 0.001) answered correctly. Providers were able to identify 1 more injury correctly of 8 injuries (mean, 1.1 questions [95% CI, 0.6 to 1.6 questions]; p < 0.001) and to identify 1 more ideal treatment of the 7 that were tested (mean, 1.0 question [95% CI, 0.5 to 1.4 questions]; p < 0.001). Conclusions: Adult ankle fractures in Malawi were predominantly treated nonoperatively despite often meeting evidence-based criteria for surgery. This was due to resource limitations, knowledge deficits, and lack of treatment standardization. We demonstrated a comprehensive approach to examining the challenges of providing adequate orthopaedic care in a resource-limited setting and the successful implementation of an educational intervention to improve care delivery. This approach can be adapted for other conditions to improve orthopaedic care in low-resource settings.

Epidemiology and Management of Pediatric Fractures in Malawi

“…This suggests that OCOs were less likely than surgeons to recommend surgery for the same injuries, underscoring the importance to train OCOs in evidence-based and standardized guidelines delineating which fractures should be treated conservatively and which should be referred for surgery. 49 To ensure surgical capacity for evidence-based referrals, the training and recruitment of more orthopaedic surgeons must be prioritized.…”

Open tibial shaft fracture management in Argentina: an evaluation of treatment standards in diverse resource settings

“…Given most of the participants’ limited resources and lack of soft-tissue specialists, particularly for Interior Committee groups, a phase 3 study to create a specific didactic and hands-on wound coverage technique course could improve open tibia fracture management and treatment standardization. [ 28 ] Previous studies in LMICs have reported on the efficacy of such courses, including improving patient outcomes and reducing long-term disability. These courses educate orthopedic surgeons on the basic principles and techniques of open fracture management and lower extremity flap reconstruction procedures, with an emphasis on challenges faced in resource-limited settings.…”

“…In addition, of 17 wound care and operating room resources, Negative Pressure Wound Therapy was the only resource that was reported available to more than half of the participants. Given most of the participants’ limited resources and lack of soft-tissue specialists, particularly for Interior Committee groups, a phase 3 study to create a specific didactic and hands-on wound coverage technique course could improve open tibia fracture management and treatment standardization [28] . Previous studies in LMICs have reported on the efficacy of such courses, including improving patient outcomes and reducing long-term disability.…”

Outcomes of Nonoperatively Treated Pediatric Supracondylar Humeral Fractures at the Nkhotakota District Hospital, Malawi

“…There is a need to improve pediatric orthopaedic surgical capacity in Malawi and other similar settings. This will likely require standardization of treatment practices, advanced training of local providers, improved resource procurement, and investment in health-system infrastructure 15,16,[54][55][56][57] . In Malawi, operative orthopaedic surgical capacity is present only in central hospitals.…”