How can the outcomes of open tibia fractures be improved in a low-income country?

Abstract

Overall, my thesis aims to understand the outcomes of patents with open tibia fractures and identify improvements in the quality of open tibia fracture care in a low-income country. In Chapter 1, I provided an up to date comprehensive overview of open tibia fractures in low-income countries by conducting a literature review, two systematic reviews and two consensus meetings prior to the thesis. I critiqued the conceptual underpinnings and evidence base for my thesis and identified any relevant research priorities that needed to be addressed.

In Chapter 2, I summarised the burden, characteristics and operative management of 23,734 participants in one of the largest fracture care registry studies in any low-income country.

The main study finding was that most fractures were treated non-operatively by non-physician orthopaedic clinical officers including a proportion of severe fractures, such as open fractures. This implies there are major gaps in operative management of patents with

severe fractures. Chapter 3 describes a prospective cohort study of 287 adults with open tibia fractures across six hospitals in Malawi and found that people with open tibia fractures in Malawi have very poor function and quality of life in the year following injury, which may

be improved by early referral to tertiary hospitals for definitive fixation. Chapter 4, this nested economic analysis in the prospective cohort study found that open tibia fractures result in substantial societal costs in the year after injury. This new evidence implies that

open tibia fractures drives poor people further into poverty.

In Chapter 5, an open fracture intervention bundle was designed, implemented, and evaluated to improve patent-reported outcomes following an open tibia fracture. The main finding of this Chapter is that, despite sustained improvements at one-year post-intervention

in knowledge and positive evaluation of the intervention by health workers that attended the training, the implementation of an open fracture interventional bundle did not lead to improved patent functional outcomes or an overall change in the clinical process one year after injury. Future open fracture interventions could improve the hospital environment such as establishing orthopaedic theatres and regular district hospital visits from specialists in each region to improve patent-reported outcomes in the year following open tibia fractures.

The Chapter 6 summarises the findings of the thesis, compares them to the existing evidence and discusses the strengths and limitations of the empirical research. This Chapter identifies research priorities including potential future studies (including technology innovations) and explores in detail policy and health system implications.