A plastic and reconstructive surgery landscape assessment of Malawi: a scoping review of Malawian literature

Plastic and reconstructive surgery (PRS) remains highly relevant to the unmet need for surgery in Malawi. Better understanding the current PRS landscape and its barriers may help address some of these challenges. This scoping review aimed to describe: (1) the scope and focus of the PRS literature being produced in Malawi and (2) the challenges, deficits, and barriers to providing accessible, high-quality PRS in Malawi.

This scoping review was conducted on four databases (SCOPUS, PubMed, Web of Science, EMBASE) from inception through September 1, 2020 following the PRISMA-ScR guidelines.

The database search retrieved 3852 articles, of which 31 were included that examined the burden of PRS-related conditions in Malawi. Of these 31 articles, 25 primarily discussed burn-related care. Burns injuries have a high mortality rate; between 27 and 75% in the studies. The literature revealed that there are only two burn units nationally with one PRS specialist in each unit, compounded by a lack of interest in PRS specialization by Malawian medical students. Congenital anomalies were the only other PRS-related condition examined and reported in the literature, accounting for 23% of all pediatric surgeries in tertiary facilities.

There is a need to increase the country’s capacity to handle burn reconstruction and other PRS-related conditions to reduce overall morbidity and mortality. Additional publicly funded research at the district and community level is warranted to determine the true burden of PRS disease in Malawi to derive health system strengthening and workforce capacity building strategies.

Surgical management of traumatic spinal injuries in Sylvanus Olympio Teaching Hospital

Introduction : Traumatic spinal injuries (TSI) is a global disease burden in low – and middle–income countries (LMIC). The burden of TSI is higher in LMICs than in developed countries. Despite improvements in TSI management, resource-constrained settings have not benefitted from this progress to the same extent as more developed countries.

Hypothese : Spinal implants availability and early surgery are associated with improved neurologic function.

Material and methods: This is a retrospective and descriptive study from November 2017 to October 2020. We included adult patients who presented with traumatic spine injury and who underwent surgery stabilization.

Results: A total of 93 patients were studied. The population was young (35.92 ± 9.68 years old), men (91.4%). Road traffic accidents accounted for 85% of patients. At presentation, 59.1% of patients had an incomplete neurologic deficit (ASIA B-D). The cervical spine was the most common segment injured (57%). The median time from admission to the operating room was 21.06 ± 11.8 days. After surgery, 15.3% improved by at least 1 ASIA grade. Bedsores (14%) and superficial wound infection (10.8%) were the most typical complications in our series after surgery.

Discussion : According to the AANS/CNS guideline, available literature has defined « early » surgery inconsistently, ranging from < 8 hours to < 72 hours. In our series, the median time from admission to the operating room was 21.06 ± 11.8 days (range 2-62). That finding could be explained by the fact that most low-income people have to pay out of their pocket because the rate of medical insurance coverage is low. In the study, only 17.2% of patients have public insurance, and 2.2% private insurance. We performed three types of surgery: anterior cervical discectomy and fusion, anterior cervical corporectomy with tricortical iliac crest graft and plate, and posterolateral thoracic/lumbar fusion. Implant availability for posterior cervical fusion was the principal driver of that decision in our limited resources. Type of study and level of proff: level 3, retrospective cohort study.

Patient Follow-up After Orthopaedic Outreach Trips – Do We Know Whether Patients are Improving?

The burden of traumatic musculoskeletal injuries falls greatest on low- and middle-income countries (LMICs). To help address this burden, organizations host over 6,000 outreach trips annually, 20% of which are orthopaedic. Monitoring post-surgical outcomes is critical to ensuring care quality; however, the implementation of such monitoring is unknown. The purpose of this review is to identify published follow-up practices of short-term orthopaedic surgery outreach trips to LMICs.

We completed a systematic review of Pubmed, Web of Science, EMBASE, and ProQuest following PRISMA guidelines. Follow-up method, rate, duration, and types of outcomes measured along with barriers to follow-up were collected and reported.

The initial search yielded 1,452 articles, 18 of which were eligible. The mean follow-up time was 5.4 months (range: 15 days-7 years). The mean follow-up rate was 65.8% (range: 22%-100%), the weighted rate was 57.5%. Fifteen studies reported follow-up at or after 3 months while eight studies reported follow-up at or after 9 months. Fifteen studies reported follow-up in person, three reported follow-up via phone call or SMS. Outcome reporting varied among mortality, complications, and patient-reported outcomes. The majority (75%) outlined barriers to follow-up, most commonly noting transportation and costs of follow-up to the patient.

There is minimal and heterogeneous public reporting of patient outcomes and follow-up after outreach trips to LMICs, limiting quality assessment and improvement. Future work should address the design and implementation of tools and guidelines to improve follow-up as well as outcome measurement to ensure provision of high-quality care.

The lived experience of people with upper limb absence living in Uganda: A qualitative study

Background: The impact of upper limb absence on people’s lived experiences is understudied, particularly in African countries, with implications for policy and service design.
Objectives: The objective of this study was to explore the lived experiences of people with upper limb absence (PWULA) living in Uganda.
Method: Informed by preliminary work, we designed a qualitative study employing semistructured interviews to understand the experience of living with upper limb absence in Uganda. Seventeen adults with upper limb absence were individually interviewed and their interviews were analysed utilising thematic analysis.
Results: Seven themes illustrating the impact on the individual’s life after amputation were identified and categorised into (1) living and adapting to life, (2) productivity and participation and (3) living within the wider environment. This study presents three main findings: (1) PWULA need psychological and occupational support services which are not available in Uganda, (2) PWULA want to work, but face multiple barriers to employment and has limited support, combined with the complex parenting and caring responsibilities, (3) the local Ugandan culture and social structures affect the everyday life of PWULA, both in positive and negative ways.
Conclusion: This study provides information on the lived experiences of PWULA in Uganda which are lacking in the literature. People with upper limb absence face ableism and hardship underpinned by a lack of formal support structures and policies, which may in turn exacerbate the impact of upper limb absence on multiple facets of lif

The impact of socio-economic factors on parental non-adherence to the Ponseti protocol for clubfoot treatment in low- and middle-income countries: A scoping review

The Ponseti treatment is considered the gold standard for clubfoot globally, but requires strong engagement from parents. The aim of this review is to assess the impact of socio-economic factors on the presence of drop-out, relapse or non-compliance during Ponseti treatment in low and middle-income countries (LMICs).

This scoping review includes all articles available from inception until 4.4.2022. All articles describing an association between one or more socio-economic factors and one or more adverse outcomes during the Ponseti treatment in an LMICs were considered for inclusion. Studies were identified by searching Medline/PubMed, Embase, Global Health and Global Index Medicus. Data extraction was done using Covidence extraction 2.0 by two independent reviewers.

A total of 281 unique references were retrieved from the database searches, 59 abstracts were retained for full-text review, of which 19 studies were included in the final review. We grouped the identified socio-economic factors into 4 larger themes: poverty and physical accessibility of clubfoot clinics, presence of support systems, educational level of the parents, and household-level factors and cultural norms. Reduced access to care for girls was considered an important risk factor in South Asia and the Caribbean. Lack of family and community support was an issue raised more often in studies from Eastern Africa. The extreme heterogeneity among collected variables within a small sample of papers made it not possible to perform a meta-analysis.

The identified factors are very similar to the socio-economic factors identified in studies looking at the barriers parents and children face when seeking care initially. Poverty was identified as a cross-cutting risk factor in all 4 domains and the most important socio-economic risk factor based on this review, reconfirming poverty eradication as the challenge for the 21st century.

Solid locked intramedullary nailing for expeditious return of bone-setting-induced abnormal fracture union victims to work in South-western Nigeria

Background: Wage earning in low- and middle-income countries (LMICs) is predominantly through physical labour. Consequently, limb-related disabilities caused by abnormal fracture unions (AFUs) preclude gainful employment and perpetuate the cycle of poverty. Many AFUs result from traditional bone-setting (TBS), a pervasive treatment for long bone fractures in LMICs. The objective of this study was to accentuate the expediency of solid locked intramedullary nail in the early restoration of victims of traditional TBS-induced abnormal fracture unions (AFUs) to their pre-injury functioning, including work.

Methods: One hundred AFUs in 98 patients treated with a solid locked intramedullary nail in our center over a period of 7 years were prospectively studied.

Results: We found the mean age to be 47.97 years. Males constituted 63.9% of the patients’ population. Atrophic non-union accounted for 54.1% of the AFUs. The mean fracture-surgery interval was 21.30 months. By the 12th post-operative week, more than 75% of the fractures had achieved knee flexion/shoulder abduction beyond 900, were able to squat and smile (or do shoulder abduction-external rotation), and were able to bear weight fully.

Conclusion: The study demonstrated the expediency of solid locked nail in salvaging TBS-induced abnormal fracture unions in a way that permitted early return to pre-injury daily activities and work, thereby reducing fracture-associated poverty.

A granular analysis of service delivery for surgical system strengthening: Application of the Lancet indicators for policy development in Colombia

The Lancet Commission on Global Surgery (LCoGS) surgical indicators have given the surgical community metrics for objectively characterizing the disparity in access to surgical healthcare. However, aggregate national statistics lack sufficient specificity to inform strengthening plans at the community level. We performed a second-stage analysis of Colombian surgical system service delivery to inform the development of resource- and context-sensitive interventions to inform a revision of the Decennial Public Health Plan for access inequity resolution.

Data from the year 2016 to inform total operative volume (TOV) and 30-day non-risk adjusted peri-operative mortality (POMR) were collected from the Colombian national health information system. TOV and POMR were sub-characterized by demographics, urgency, service line, disease pathology and facility location.

In 2016, aggregate national mortality was 0·87%, while mortality attributable to elective and emergency surgery was 0·73% and 1·30%, respectively. The elderly experienced a 5·6-fold higher mortality, with 4·2% undergoing an operation within 30 days of dying. Individuals undergoing hepatobiliary, thoracic, cardiac, and neurosurgical operations experienced the highest mortality rates while obstetrics, general surgery, orthopaedics, and urology performed the largest procedure volume. Finally, analysis of operation and service line specific POMR reveals opportunities for improvement.

This granular second-stage analysis provides actionable data which is fundamental to the development of resource and context-sensitive interventions to address gaps and inequities in surgical system service delivery. Furthermore, this analysis validates the modeling underlying development of the LCoGS indicators. These data will inform the assessment of implementation priorities and revision of the Colombian Decennial Public Health Plan

High value and cheap musculoskeletal health care interventions: lessons for low- and middle-income countries

To the Editor,

The Global Burden of Disease Study 2019 reported low back pain and other musculoskeletal disorders constitute the top ten cause of disability-adjusted life-year and are common from teenage years into old age [1]. The number of people experiencing musculoskeletal conditions in the coming decades will increase in low- and middle-income countries (LMICs) [2]. In addition to the likelihood of risk factors such as increased life expectancy and obesity associated with musculoskeletal conditions in high-income countries becoming more common in LMICs, the burden of musculoskeletal conditions will increase as a result of physically demanding agrarian work, and arduous portering due to poor access to modern transportation system [2].

In the past decades, the largest increase in disability due to low back pain occurred in LMICs, including Asia, Africa, and the Middle East region [2], where resource-constrained health and social systems are stressed by other burdens including infectious diseases, child and maternal health, and non-communicable diseases. The Lancet series on low back pain reported healthcare professionals in LMICs are providing wrong care for low back pain [3], resulting not only in burdens to individuals, communities, and health care systems but also contravening the 2010 Declaration of Montreal, which recognises pain relief as fundamental human right. Therefore, LMICs should develop innovative health policies to address this concern with fiscally cheaper but high value care. In this paper, the musculoskeletal conditions refer to the chronic, non-traumatic musculoskeletal pain disorders.

Survival rate of pediatric osteosarcoma in Indonesia: a single center study

Background Over the years, the survival rate of children with osteosarcoma has increased with improved management. However, survival tends to be lower in low-middle-income countries.

Objective To report the survival rate of children with osteosarcoma in a single center in Indonesia and to evaluate the outcomes of treatment modalities currently used.

Methods We performed a retrospective analysis of the medical records of pediatric osteosarcoma patients in Cipto Mangunkusumo Hospital from 2015 to 2019. Patients were categorized based on age group, sex, primary tumor location, treatment modalities, disease metastasis, and disease outcome.

Results We included 83 children with osteosarcoma, with an age range of 4-17 years (median 13 years). Mean estimated overall survival and event-free survival were 28 (95%CI 24 to 32) months and 10 (95%CI 8 to 13) months, respectively. Overall survival duration between treatment modality groups was significantly different (P<0.05). The mean estimated overall duration of survival was 9 (95%CI 3 to 15) months for chemotherapy, 18 (95%CI 14 to 22) months for chemotherapy with surgery, and 21 (95%CI 14 to 27) months for chemotherapy with surgery and radiation.

Conclusion The survival rate of childhood osteosarcoma in Indonesia remains low. The current treatment option currently used in our center may contribute to the low rate of survival.

The role of digital health for post-surgery care of older patients with hip fracture: A scoping review

Digital health interventions can potentially improve the integration of the health care systems. Hip fracture is a serious injury for older people and integrated post-surgery care is vital for good recovery.

We aimed to characterise digital health interventions used for hip fracture post-surgery care, and further to examine the extent to which of these interventions address the World Health Organisation (WHO) integrated care for older people (ICOPE) framework.

A scoping review was conducted, by searching the literature from English and Chinese databases and trial registries. Keywords included hip fracture, post-surgery care and digital health interventions. Interventional, observational, qualitative studies and case reports were included. We used a combined framework, WHO ICOPE and WHO digital health intervention classifications, to support data synthesis.

A total of 4,542 articles were identified, of which 39 studies were included in the analysis. We identified only six randomised controlled trials. Digital health interventions were mainly used to help doctors provide clinical care and facilitate service delivery between the patients and healthcare providers. No studies focused on health workforce, financial policy or the development of infrastructure. The primary users were healthcare providers and patients, without healthcare managers or the use of data services. Most digital health interventions focused on physical therapy, bone protection and falls prevention. Limited interventions were implemented in low-and middle-income countries.

A stronger evidence base is needed to expand the use of digital health for post-surgery care of hip fracture patients, including high-quality larger-scale studies, more focus in resource-constrained settings, expanding to more users and capabilities of interventions, and exploring the role of digital health for the integrated care model to mitigate health system challenges.