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Orthopaedic Trauma Outcomes in Developing Countries

Commentary on an article by Nathan N. O’Hara, MHA, et al.: “The Socioeconomic Implications of Isolated Tibial and Femoral Fractures from Road Traffic Injuries in Uganda”

Trafton, Peter G., MDa

doi: 10.2106/JBJS.17.01542
Commentary and Perspective
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Department of Orthopaedics, Brown University, Providence, Rhode Island

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This article is a product of the Uganda Sustainable Trauma Orthopaedic Program (USTOP), which began 10 years ago as a collaboration between the University of British Columbia and Makerere University1. USTOP exemplifies the effectiveness of a long-term, multidisciplinary, joint effort to improve orthopaedic trauma care in a country with limited resources. Such carefully planned and executed efforts may be more effective than short-stay volunteer models for both care delivery and capacity building. USTOP also provides an excellent platform for clinical research.

There is a great need to address road traffic injuries (RTIs) in low and middle-income countries, where 90% of fatal injuries occur. Their socioeconomic consequences affect young healthy adults, whose contributions to their families, as well as to the local and national economies, are lost, either temporarily or permanently. Careful study of lost productivity and the costs of care, to the family and to a country’s health-care system, provides a rationale for assigning resources to prevent RTIs and to treat their resulting injuries more effectively. Rigorous documentation of their impact helps to set an accurate disability weight for calculating disability-adjusted life years (DALYs), the preferred measure of the Global Burden of Disease research program2. Valid data provide for fair distribution of limited health-care resources. Studies to further this work (and the work described in the USTOP reports) begin at the level of individual patients, adding immediacy and human considerations to the pictures provided by “big data.” These studies must be done locally because local differences in culture, resources, and economics affect data.

In 2016, O’Hara et al. reported the detrimental socioeconomic effects of lower-extremity injuries in Uganda3. They recruited adults with isolated tibial or femoral fractures who were admitted to Mulago National Referral Hospital, a national orthopaedic referral center, to study cumulative loss of personal income, health-related quality of life (HRQoL), and interruption of school attendance by each patient’s dependent children. The impact at 12 months was profound: there was an 88% loss of income for the year, the EuroQol measurement declined from 0.91 to 0.39, and 93% of children missed at least 1 month of school, with 39% remaining absent. A year after injury, only 35% of the injured had returned to any kind of work.

Because these data were far worse than those of similar injuries reported in western Europe and North America, the authors extended their study for another year, and 95% of the participants successfully completed 2 years of follow-up. The current report by O’Hara et al. reviews the status of the patients at 2 years after injury. In addition to lost income, EuroQol values, and school attendance of dependents, the authors included employment status. Although 63% of the injured had returned to work at 2 years postinjury, only 34% of patients had regained 90% or more of their preinjury income. HRQoL scores continued to improve after the initial 6 months, but only 41% ever approached their preinjury levels, and 38% of dependents remained out of school at 2 years. Ultimately, only 12% of these initially healthy young patients with isolated femoral or tibial fractures had recovered both economically and physically.

Although these patients were admitted to the hospital for surgery, almost half were actually treated nonoperatively. Of the 40 femoral fractures, only 24 received operative treatment, and of the 14 tibial fractures, only 6 did (see Table II of the article). The subgroups are quite small and diverse. Thus, a lack of significance between those treated operatively or nonoperatively is to be expected. We must recognize that these patients were managed with the best care available given the limitations of resources. The study concerned the outcome of the entire group and did not compare treatments. Recognizing that lack of access to surgical treatment is a substantial barrier, Stephens et al. explored what determined surgical access for the patients in this group4. In addition to a demonstrated preference for operative care of femoral fractures, patients who were able to mobilize support from family, friends, or acquaintances who were connected with the hospital were significantly more able to obtain operative care. Only such “social capital” provided significant leverage to promote surgical care. Lack of such connections became the mechanism of rationing.

I believe that all of the studies mentioned above present a clear picture of present outcomes from common injuries in low and middle-income countries. They demonstrate the need for improvement, and set a baseline for future efforts to improve patient care and outcomes.

Disclosure: On the Disclosure of Potential Conflicts of Interest form, which is provided with the online version of the article, the author checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (

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1. OʼHara NN, OʼBrien PJ, Blachut PA. Developing orthopaedic trauma capacity in Uganda: considerations from the Uganda Sustainable Trauma Orthopaedic Program. J Orthop Trauma. 2015 Oct;29(Suppl 10):S20-2.
2. GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017 Sep 16;390(10100):1211-59.
3. O’Hara NN, Mugarura R, Potter J, Stephens T, Rehavi MM, Francois P, Blachut PA, O’Brien PJ, Fashola BK, Mezei A, Beyeza T, Slobogean GP. Economic loss due to traumatic injury in Uganda: the patient’s perspective. Injury. 2016 May;47(5):1098-103. Epub 2015 Dec 11.
4. Stephens T, Mezei A, O’Hara NN, Potter J, Mugarura R, Blachut PA, O’Brien PJ, Beyeza T, Slobogean GP. When surgical resources are severely constrained, who receives care? Determinants of access to orthopaedic trauma surgery in Uganda. World J Surg. 2017 Jun;41(6):1415-9.

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