Expanding Access to Orthopedic Trauma Care: Evaluation of a Task-Sharing Model With a Remote Quality Assessment Tool for Open Tibia Shaft Fractures in Malawi

Background: Timely care for open tibia fractures remains difficult in low-resource settings. We evaluated a task-sharing model in Malawi in which trained orthopedic clinical officers (OCOs) delivered external fixation supported by a remote quality assessment tool. 

Methods: We conducted a prospective implementation evaluation across one central and four district hospitals (May 2023–July 2024). The intervention bundled OR refurbishment assured external fixator supply, refresher training, mentoring (on-site and remote), national guideline reinforcement, and a novel Fracture Fixation Assessment Tool for External Fixation (FFATEF). OCOs submitted postoperative radiographs and construct photographs for scoring across four domains (reduction, stability, implantation, and surgical impression; total 0–12 and satisfactory ≥ 8). Nonparametric tests compared performance by the hospital type; temporal trends were assessed with Spearman correlation. 

Results: Forty-seven patients (89% male and mean age 32.3 years) were treated (central: n = 28 and district: n = 19). The central hospital managed more severe injuries (Gustilo IIIA/B 69.6% vs. 15.8%). Median FFATEF scores were higher at the central hospital (10.0 [IQR 9–11]) than district hospitals (6.0 [5, 6, 7, 8], p < 0.001). Satisfactory scores (≥ 8) occurred in 93% of central versus 32% of district cases. Central scores improved over time (ρ = 0.52; p = 0.005) whereas district scores were unchanged (ρ = 0.15; p = 0.540). Preoperative antibiotic compliance was 100% at the central versus 47% at district hospitals. 

Conclusions: When embedded within integrated surgical teams and adequate infrastructure, task sharing for open fracture external fixation yielded satisfactory technical performance but lagged district-level implementation despite training. Comprehensive institutional support—mentoring intensity, equipment, supply chains, and referral adherence—is likely required for safe scale-up. Validation of FFATEF against clinical outcomes and economic evaluation of delivery models are priorities.