Infection after surgical implant generation network (SIGN) nailing in treatment of long bone shaft fractures in Ethiopia: analysis of a 4-year results

Background
One of the challenge to manage long bone fracture is the risk of infection. Intramedullary nailing is the standard treatment of long bone shaft fractures. Infection from the surgical site during orthopedic management is posing postoperative burdens in different perspectives like patient perspectives and healthcare facilities. However, there is limited information on the magnitude of infection in Ethiopia after surgical implant generation network (SIGN) nailing in the treatment of long bone shaft fractures. Therefore, the current study aimed to assess the prevalence of infection in patients with long bone shaft fractures treated with surgical implant generation network (SIGN) nailing.

Objective
To assess prevalence of infection in patients with long bone shaft fractures treated with SIGN nailing at Felege Hiwot Referral Hospital from January 1, 2015, to December 31, 2018, Bahir Dar, Northwest, Ethiopia.

Methods
This was a retrospective study over a period of 4 years. SIGN surgical-related data, presence or absence of infection from the documented information were collected from the chart/the source. The types of infection were also collected with the standard classification as superficial, deep and deep with osteomyelitis. Age, sex, fracture pattern, nature of fracture, mechanism of injury, prophylaxis antibiotics, nail type, follow-up in weeks and other factors were also extracted from the patients’ charts with structured checklist. Data were analyzed with statistical package for social sciences (SPSS) version 23. The analyzed data were presented with texts, tables and a graph.

Results
Three hundred and eighty-two long bone fractures were treated by locked SIGN intramedullary nailing during the study period. After screening the inclusion criteria, a total of 311 cases were included in this study. A total of 13 (4.2%) patients who treated with SIGN intramedullary nailing developed infection.

Conclusions
We conclude that the overall prevalence of infection with SIGN intramedullary nailing is almost similar with the surgeries done in the developed countries.

Prevalence, Risk Factors, and Microbiological Profile of Early Surgical Site Infection Following Orthopaedic Implant Surgery at Kenyatta National Hospital

Background: The prevalence of surgical site infections (SSI) in orthopaedic surgery has been on the rise especially in low and middle-income countries (LMIC). This has been attributed to the increased number of trauma patients due to the increased incidence of motor vehicle and motor cycle crashes. Kenya has witnessed a similar increase, more so from motor cycle related crashes, leading to an increase in the number of fractures treated operatively. Time to ORIF, duration of surgery, antibiotic prophylaxis are some of the risk factors for SSI, however, data on prevalence and risk factors of SSI within our population to inform preventive strategies remain scarce. Study objective: To determine the prevalence, risk factors and causative bacterial pathogens using microscopy culture and antibiotic sensitivity patterns of SSI following surgery for long bone fractures at level 6 referral hospital Kenyatta(KNH). Study design: Prospective observational analytic . Study setting: The study was carried out in orthopaedic clinic (OC) and wards (OW) at the Kenyatta National Hospital (KNH) between 11th February 2022 and 2nd May 2022 Patients and methods: The collected data were transferred from password-coded data digital collection sheets into analysis software for data cleaning and coding prior to analysis. Data was stored in password-protected computer folders to maintain anonymity of the study subjects. Data analysis was carried out using the Prism 7 (GraphPad Software, San Diego, CA, USA) and SPSS (IBM Statistics Software Version 25, Armonk, New York, USA). Categorial data was reported as frequencies (%). Continuous data were subjected to normality tests (histogram and Q-Q plots with Kolmogorov-Smirnov test) and reported as mean and standard deviation (SD). Comparison of patient and fracture characteristics between patients with and without SSI was carried out using the Independent Student’s-t test (continuous variables) and Chi-square xii statistic (categorical variables). Multivariate logistic regression analysis was performed to identify risk factors for SSI, adjusting for the age,BMI ,sex and comorbidities, and to calculate adjusted odds ratios (ORs) with the corresponding 95% Wald CI. Throughout the analysis, a p<0.05 was considered statistically significant at a 95% confidence interval. Results: A total of 130 patients were recruited into this study. They were generally young (mean age: 33±12.8 years) with a male predominance (83%). The mean body mass index (BMI) was 23.7±2.1 Kg/M2, with 13 (10%) having diabetes mellitus (DM). The most fractured bone was femur (n=66 patients, 50.8%). The mean injury severity score (ISS), pre-operative hospital stay and ASA (American Society of Anaesthesiology) score were 21.6±11.2, 12±9.2 days 1.0±0.1 and respectively. A total of 18 patients (13.8%) developed surgical site infection (SSI). Compared to those without SSI, patients with SSI were predominantly male (p=0.007), had higher BMI (p=0.003) and diabetes mellitus (DM) (p=0.007), had higher incidence of open fractures (p=0.046), higher ISS (p=0.008), and were more likely to require pre-operative blood transfusion (p<0.001) and ICU admission (p<0.001). In the multivariate adjusted logistic regression model, female sex (OR= 5.52, 95% CI 1.15-26.65, p=0.033), presence of diabetes (OR= 9.72, 95% CI 1.83-51.76, p=0.008), higher BMI (OR= 1.31, 95% CI 1.02-1.69, p=0.033), need for pre-operative blood transfusion (OR= 68.21, 95% CI 5.42-858.32, p<0.001) and need for ICU admission (OR= 8.10, 95% CI 5.18-12.65, p<0.001) were significant predictors of development of SSI. The commonest organism isolated was staphylococcus aureus (SA) (70%). Conclusion: The burden of surgical site infections (SSI) following orthopaedic surgery remains high. Diabetes mellitus (DM), higher body mass index (BMI), pre-operative blood transfusion and intensive care unit admission were associated as risk factors for SSI in this study cohort. Commonest isolated organism was Staphylococcus aureus (n= 7patients,70%). Culture isolates display a concerning trend of increased resistance to commonly prescribed antibiotics. Recommendation: 1.Increased SSI surveillance mearures in Orthopaedic patients with diabetes and obesity comorbidities 2. Routine establishment of sensitivity patterns of SSI isolates to guide antimicrobial selection is recommended.

Healthcare utilization by children with neurological impairments and disabilities in rural Kenya: a retrospective cohort study combined with secondary analysis of audit data

Background: There is a paucity of data on healthcare utilization by children with neurological impairments (NI) in sub-Saharan Africa. We determined the rate, risk factors, causes, and outcomes of hospital admission and utilization patterns for rehabilitative care among children with NI in a defined rural area in Kenya.
Methods: We designed two sub-studies to address the primary objectives. Firstly, we retrospectively observed 251 children aged 6–9 years with NI and 2162 age-matched controls to determine the rate, causes and outcomes of hospitalization in a local referral hospital. The two cohorts were identified from an epidemiological survey conducted in 2015 in a defined geographical area. Secondly, we reviewed hospital records to characterize utilization patterns for rehabilitative care.
Results: Thirty-four in-patient admissions occurred in 8503 person-years of observation (PYO), yielding a crude rate of 400 admissions per 100 000 PYO (95% confidence interval (Cl): 286–560). The risk of admission was similar between cases and controls (rate ratio=0.70, 95%CI: 0.10–2.30, p = 0.31). The presence of electricity in the household was associated with reduced odds of admission (odds ratio=0.32, 95% Cl: 0.10–0.90, p < 0.01). Seizures and malaria were the main causes of admission. We confirmed six (0.3%) deaths during the follow-up period. Over 93% of outpatient paediatric visits for rehabilitative care were related to cerebral palsy and intellectual developmental delay. Health education (87%), rehabilitative exercises (79%) and assistive technology (64%) were the most common interventions. Conclusions: Surprisingly, the risk of hospitalization was not different between children with NI and those without, possibly because those with severe NI who died before this follow-up were under seclusion and restraint in the community. Evidence-based and tailored rehabilitative interventions are urgently required based on the existing secondary data.

Prevalence and Risk Factors Associated with Serious Injuries among in-school Adolescents in Samoa: A population based cross-sectional study

Introduction
Injuries form one of the leading causes of death and disability among human populations. Notwithstanding the growing evidence of injuries worldwide, little is known about the case of adolescents in Samoa. The study aimed to explore the prevalence and risk factors associated with serious injuries among adolescents in Samoa.

Methods
The 2017 Global School-Based Student Health Survey data from Samoa was analysed using the Chi-square test and binomial logistic regression analysis with an adjusted odds ratio (AOR) at a 95% confidence interval (CI).

Results
The prevalence of serious injury among in-school adolescents in Samoa is 46.8%. Sex (male) (AOR = 1.60, CI = 1.29–1.98) was a significant predictor of serious injuries among adolescents in Samoa. Other predictors of serious injuries included physical attack (AOR = 2.21, CI = 1.66–2.94), Physical fights (AOR = 2.27, CI = 1.84–2.80) and being bullied (AOR = 1.59, CI = 1.28–1.99).

Conclusion
Samoa’s serious injury rate among in-school adolescents requires multidisciplinary programmes like anti-bullying campaigns, violence-free relationship education and policies.

Healthcare Services for the Physically Challenged Persons in Africa: Challenges and Way Forward

This chapter is based on persons with physical disabilities in Africa, their challenges, and how it affects their health-seeking behaviors. We noticed that physical challenge has a substantial long-term adverse effect on one’s ability to carry out normal day-to-day activities. Both the causes and the consequences of physical disability vary throughout the world, especially in Africa. Environmental, technical, and attitudinal barriers and consequent social exclusion reduce the opportunities for physically challenged persons to contribute productively to the household and the community and further increase the risk of falling into poverty and poor healthcare services. The inability of the physically challenged persons to perceive the lack of points of interest of government has intensified to make significant recommendations and possible solutions. This is appalling because the rate to which a community provides and funds restoration is a way of grading how much interest it has, and importance it connects to the quality of life of its citizens. We advocate and recommend swift actions and disability inclusiveness to accommodate persons with physical disabilities in Africa for them to have a good perception of life.

Musculoskeletal health complaints: A growing concern that should be investigated elaborately in Bangladesh

Evidence from the past few decades suggests that the most increases in disability-related musculoskeletal health complaints (MHC) have occurred in low-income and middle-income countries (LMICs). Past studies identified long sitting, higher commute time to the office, and traffic congestion predictors of MHC in Bangladesh. Additionally, post-acute COVID-19 patients reported MHC at a higher rate in Bangladesh. Further studies are needed to recommend exclusive initiatives from authorities to tackle the upcoming tsunami of MHC in LMICs, for example, in Bangladesh.

Alliance for the development of the Argentinian Hip Fracture Registry

Summary
Age expectancy has significantly increased over the last 50 years, as well as some age-related health conditions such as hip fractures. The development of hip fracture registries has shown enhanced patient outcomes through quality improvement strategies. The development of the Argentinian Hip Fracture Registry is going in the same direction.

Introduction
Age expectancy has increased worldwide in the last 50 years, with the population over 64 growing from 4.9 to 9.1%. As fractures are an important problem in this age group, specific approaches such as hip fracture registries (HFR) are needed. Our aim is to communicate the Argentinian HFR (AHFR) development resulting from an alliance between Fundación Trauma, Fundación Navarro Viola, and the Argentinian Network of Hip Fracture in the elderly.

Methods
Between October 2020 and May 2021, an iterative consensus process involving 5 specialty-focused meetings and 8 general meetings with more than 20 specialists was conducted. This process comprised inclusion criteria definitions, dataset proposals, website deployment with data protection and user validation, the definition of hospital-adjusted registry levels, implementation planning, and sustainability strategies.

Results
By June 2021, we were able to (1) outline data fields, including epidemiological, clinical, and functional dimensions for the pre-admission, hospitalization, discharge, and follow-up stages; (2) define three levels: basic (53 fields), intermediate (85), and advanced (99); (3) identify 21 benchmarking indicators; and (4) make a correlation scheme among fracture classifications. Simultaneously, we launched a fundraising campaign to implement the AHFR in 30 centers, having completed 18.

Conclusion
AHFR development was based on four pillars: (1) representativeness and support, (2) solid definitions from onset, (3) committed teams, and (4) stable funding. This tool may contribute to the design of evidence-based health policies to improve patient outcomes, and we hope this experience will help other LMICs to develop their own tailored-to-their-needs registries.

Patient-Reported Outcome Measures for Acetabular Fractures Treated Operatively without a C-Arm in Ethiopia

Background:
There is little evidence describing the open treatment of displaced acetabular fractures in low-resource environments. We endeavored to determine the results of the operative management of acetabular fractures without intraoperative C-arm use in a developing nation, through the assessment of patient-reported outcome measures.

Methods:
This was a prospective, single-surgeon, consecutive case series conducted in a tertiary referral hospital in Ethiopia, a high-population, low-income country. The primary author performed fixation without the use of a C-arm in 108 patients from among a total of 202 patients presenting with acetabular fracture. The modified Harris hip score (mHHS) and Short-Form Health Survey (SF)-36 at a minimum of 2 years postoperatively were used to assess the outcome.

Results:
Of the 108 patients potentially available for analysis, 92 (85%) were available for 2-year follow-up (mean age of 35 years; range, 15 to 70 years). The mean duration from injury to surgery was 16 days (range, 1 to 204 days). Seventy-three (78.5%; n = 93) of the patients had associated fracture patterns. The most common fractures were associated both-column type (22%) and transverse-plus-posterior-wall type (22%). The mean mHHS was 91; 88% of the patients had a score of ≥80, and 12% had a score of ≤79. SF-36 scores were in alignment with the mHHS. The majority (approximately 90%) of our cohort returned to work. We did not find a significant difference in the mean mHHS between patients with or without anatomic reduction (p = 0.31). However, 2-year radiographic outcomes were strongly associated with the mean mHHS (p < 0.001). Predictors of a lower mHHS included older age, cartilage damage, and lack of secondary congruence. Conclusions: Good functional outcomes were achieved at 2 years among patients with acetabular fractures surgically treated without the use of a C-arm in a limited-resource setting. Surgical congruence of the femoral head under the acetabular roof, rather than the absolute residual gap, seems essential in determining clinical outcomes. This information can help in planning increased access to care for individuals who experience traumatic injuries in low- and middle-income countries.

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.

Virtual reality technology in linked orthopaedic training in Ethiopia

Introduction
We describe the feasibility of delivering a live orthopaedic surgical teaching session with virtual reality (VR) technology simultaneously for trainee surgeons in Ethiopia and the UK.

Methods
Forty-three delegates from the Severn Deanery in the UK (n=30) and Bahir Dar in Ethiopia (n=13) attended a live training session in February 2021. During the session, participants watched a surgical operation (recorded earlier that week with a 360° VR camera) alongside live commentary. A qualitative questionnaire was distributed to gauge feasibility, connectivity and educational value of the session as well as its VR component.

Results
The majority of delegates from both the UK and Ethiopia felt that the use of VR technology to aid surgical training is feasible, that it is useful for learning surgical approaches, that it aids surgical performance and that it is superior to conventional resources. Bahir Dar residents strongly agreed that VR simulation videos would allow trainees to supplement reduced learning opportunities as a result of the COVID-19 pandemic and help to counteract their reduced operating experience. For Bahir Dar trainees, a lack of a stable internet connection for large VR files was the predominant issue.

Conclusions
This study demonstrates that there are infrastructure challenges in low and middle income countries (LMICs) in terms of the reliable delivery of VR teaching in orthopaedics at the current time. Despite this, our findings better inform the potential role of VR technology in surgical education, and shed light on the possibility for it to feed into and enrich surgical training in both LMICs and high income countries.