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

Diab, Mohamed Mustafa; Shearer, David; Kahn, James G.; Wu, Hao-Hua; Lau, Brian C.; Morshed, Saam; Chokotho, Linda

doi:10.1007/s00268-018-4750-3

Cited by 12 publications

(6 citation statements)

References 42 publications

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“…Plating was identified as the most common treatment for the latter (metaphyseal multifragmentary tibial fractures). Consistent with other studies, intramedullary nailing is often the preferred fixation method for low and high-energy open tibial fractures because of its cost-effectiveness, improved function, and shorter length of hospitalization relative to other modalities 9,23-28 . However, the use of intramedullary nails for open tibial fractures has been associated with reoperation rates as high as 44% 29 .…”

Section: Discussionsupporting

confidence: 65%

Open Tibial Fracture Treatment in Argentina

Garabano¹,

MacKechnie²,

Pereira³

et al. 2022

JBJS Open Access

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Background: The purposes of the present study were (1) to characterize open tibial fractures and their treatment in trauma centers located across different regions of Argentina and (2) to evaluate the rates of and indications for reoperation after the surgical treatment of such fractures. Methods: This retrospective multicenter study evaluated open tibial fractures in Argentina that were operatively treated by experienced orthopaedic trauma surgeon-members of the Argentine Association of Orthopedic Trauma (AATO) between January 2015 and June 2020. Data were collected from 13 hospital databases; 8 hospitals were designated as “interior,” and 5 hospitals were designated as “exterior.” The study included 701 skeletally mature patients, all of whom had a minimum of 12 months of follow-up. Information was collected on patient demographics, injury pattern and mechanism, fracture classification, treatment modality, reoperation rates, time between definitive fixation and reoperation, and indications for reoperation. Results: Seventy-six percent of presenting injuries were the result of a high-energy mechanism. Intramedullary nailing represented the most common type of fixation (88%). One hundred and fifty patients (21%) required reoperation. Delayed union/nonunion was the most common indication for reoperation in patients who had been previously treated with intramedullary nail fixation (31%; 39 of 126), and infection was the most common indication for reoperation in patients who had been treated with plate fixation (43%; 3 of 7). The time between the injury and definitive fixation was significantly different between the interior and exterior trauma centers (13.8 versus 4.7 days; p < 0.001), as was the time between definitive fixation and reoperation (69.3 versus 25.2 days; p = 0.004). The reoperation rates for the interior and exterior trauma centers were similar (20% versus 24%; p = 0.2). Infection, delayed union/nonunion, and implant removal were the most common indications for reoperation across groups. Conclusions: An improved understanding of the factors that influence treatment may help to guide future areas for improvement, establish educational goals, and create additional nationwide guidelines for open tibial fracture treatment. Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

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Section: Discussionsupporting

confidence: 65%

Open Tibial Fracture Treatment in Argentina

Garabano¹,

MacKechnie²,

Pereira³

et al. 2022

JBJS Open Access

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“…Our results are consistent with previous studies that found that hospitals in these countries still face widespread deficiencies in trauma capacity, 39 and limited implant availability may be a key contributor. 40 However, these differences in preferred treatment could be because of lack of access to equipment and/or inadequate dissemination of knowledge, as intramedullary nailing has become an increasingly available method of fracture fixation in lowresource settings 41 and has been shown to be cost-effective 42,43 with improved early functional recovery and lower risk of malunion in LMICs. 44 Respondents reported not having sufficient experience with the procedures, not having the necessary equipment, or a combination of both, but our survey was not designed to detect whether one reason was more predominant than the other.…”

Section: Discussionmentioning

confidence: 99%

Open tibial shaft fractures: treatment patterns in sub-Saharan Africa

2023

OTA International: The Open Access Journal of Orthopaedic Trauma

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Objective: Open tibial shaft fractures are a leading cause of disability worldwide, particularly in low and middle-income countries (LMICs). Guidelines for these injuries have been developed in many high-income countries, but treatment patterns across Africa are less well-documented.Methods: A survey was distributed to orthopaedic service providers across sub-Saharan Africa. Information gathered included surgeon and practice setting demographics and treatment preferences for open tibial shaft fractures across 3 domains: initial debridement, antibiotic administration, and fracture stabilization. Responses were grouped according to country income level and were compared between LMICs and upper middle-income countries (UMICs).Results: Responses from 261 survey participants from 31 countries were analyzed, with 80% of respondents practicing in LMICs. Most respondents were male practicing orthopaedic surgeons at a tertiary referral hospital. For all respondents, initial debridement occurred most frequently in the operating room (OR) within the first 24 hours, but LMIC surgeons more frequently reported delays due to equipment availability, treatment cost, and OR availability. Compared with their UMIC counterparts, LMIC surgeons less frequently confirmed tetanus vaccination status and more frequently used extended courses of postoperative antibiotics. LMIC surgeons reported lower rates of using internal fixation, particularly for high-grade and late-presenting fractures.Conclusions: This study describes management characteristics of open tibial shaft fractures in sub-Saharan Africa. Notably, there were reported differences in wound management, antibiotic administration, and fracture stabilization between LMICs and UMICs. These findings suggest opportunities for standardization where evidence is available and further research where it is lacking.

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“…Our systematic review identified three key themes for interventions increasing timely access to surgical care: (1) assessment of current capacity, (2) task-shifting and education, and (3) intra-operative tools and surgical techniques. The recurrence of these three themes suggests a multi-pronged approach may be undertaken to improve timely surgical care: capacity assessments laid the framework for potential future interventions in India and Rwanda [5,6]; intraoperative tools and techniques brought certain surgical procedures closer to the patients who need them, reducing the need to transfer patients from district to regional hospitals in countries like Tanzania and Cambodia [7,14,15]; task-shifting and educational initiatives serve to directly increase surgical capacity through training in countries like Kenya [8][9][10][11][12][13]. Each of the interventions identified in this systematic review showcased quality improvement initiatives, demonstrating the importance of placing capacity building initiatives in the context of the existing work and local context.…”

Section: Discussionmentioning

confidence: 99%

“…Economic analysis presents a third method of evaluating time to surgical care [7]. In Malawi, a study demonstrated that there was no difference in time from admission to surgical intervention associated with two different femoral fracture management techniques of varying cost, the lower cost technique being intramedullary nailing (IM nailing), and the higher relative cost technique being skeletal traction.…”

Section: Assessment Of Accessibility To Surgical Carementioning

confidence: 99%

“…Timely surgical care may also be improved through the development of new technologies. Surgical Implant Generation Network (SIGN) implants [7,14] and orthoses made from locally sourced materials both increase access to open fracture reductions and reduce need for amputation [15]. Haonga and Zirkle (2015) document a new quick, low-cost fixation strategy developed using locally available materials [14].…”

Section: Development Of Tools and Surgical Techniquesmentioning

confidence: 99%

See 1 more Smart Citation

Evaluation of Interventions Addressing Timely Access to Surgical Care in Low‐Income and Low‐Middle‐Income Countries as Outlined by the LANCET Commission 2030 Global Surgery Goals: A Systematic Review

et al. 2021

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Background In 2015, the Lancet Commission on Global Surgery published six global surgery goals, one of which was to provide 80% of the world's population with timely access to the Bellwether Surgical procedures. Little is known about the prevalence or efficacy of subsequent interventions implemented in under‐resourced countries to increase timely access to Bellwether surgical procedures. Methods A systematic review of articles and grey literature published in MEDLINE, Embase, Cochrane, CINAHL, and Web of Science databases was conducted. Two independent reviewers evaluated 1923 captured abstracts using explicit inclusion and exclusion criteria. Following a thematic analysis, two reviewers conducted data extraction on the eleven manuscripts included in the final review. Results The studied innovations, sparse in number, centred on improved educational resources, the development of orthopaedic devices, and models for assessing surgical access disparity. Eight papers were centred around timely access to caesarean sections, three around open fracture reduction, and three around laparotomy; all focused on adult populations. Five papers addressed innovations in West Africa, two in East Africa, two in South Asia, and one in Southeast Asia. Common outcome metrics were not used to assess improvements to timely surgical access. Conclusions Few published interventions have been implemented since the publication of the 2015 Lancet Commission on Global Surgery goals that have or will longitudinally increase the availability of timely surgical access in Low and Middle‐Income Countries (LMIC). Tangible outcome measures in existing literature are lacking. An up‐scaling and wider adoption of successful strategies is necessary and possible.

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

Cited by 12 publications

References 42 publications

Open Tibial Fracture Treatment in Argentina

Open Tibial Fracture Treatment in Argentina

Open tibial shaft fractures: treatment patterns in sub-Saharan Africa

Evaluation of Interventions Addressing Timely Access to Surgical Care in Low‐Income and Low‐Middle‐Income Countries as Outlined by the LANCET Commission 2030 Global Surgery Goals: A Systematic Review

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