Functional outcomes and quality of life at 1-year follow-up after an open tibia fracture in Malawi: a multicentre, prospective cohort study

Alexander Thomas Schade, Maureen Sabawo, Nohakhelha Nyamulani, Chikumbutso Clara Mpanga, Leonard Banza Ngoie, Andrew John Metcalfe, David G Lalloo, Jason J Madan, William James Harrison, Peter MacPherson, Alexander Thomas Schade, Maureen Sabawo, Nohakhelha Nyamulani, Chikumbutso Clara Mpanga, Leonard Banza Ngoie, Andrew John Metcalfe, David G Lalloo, Jason J Madan, William James Harrison, Peter MacPherson

Abstract

Background: Injuries are a major cause of disability globally and injury incidence is rapidly increasing, largely due to road traffic injuries in low-income and middle-income countries. Current estimates of the scale and consequences of disability from injury are largely based on modelling studies, with a scarcity of empirical evidence from severe injuries in low-income countries. We aimed to better understand the outcomes for individuals with open tibia fractures in Malawi.

Methods: In this multicentre, prospective cohort study, adults (aged ≥18 years) with open tibia fractures were systematically recruited at six hospitals in Malawi (two tertiary hospitals and four district hospitals). Follow-up lasted at least 1 year, during which in-person follow-up reviews were done at 6 weeks, 3 months, 6 months, and 1 year post-injury. The primary outcome was function at 1 year post-injury, measured by the Short Musculoskeletal Functional Assessment (SMFA) score. Secondary outcomes included quality-adjusted life-years (QALYs; as determined via the European Quality of Life 5-Dimensions 3-Levels [EQ-5D-3L] survey) and fracture-related infection at 1 year post-injury. Multilevel regression models investigated associations between SMFA score, EQ-5D-3L, baseline factors, and orthopaedic management.

Findings: Between Feb 12, 2021, and March 14, 2022, 287 participants were enrolled (median age 34 years [IQR 25-44]; 84% male). The most common mode of injury was road traffic injuries (194 [68%] of 287). Overall, 268 (93%) participants had debridement; of the 63 participants who were debrided in district hospitals, 47 (75%) had the procedure under local or no anaesthesia. Following substantial declines by 6 weeks after injury, function and quality of life had not recovered by 1 year post-injury for participants with Gustilo grade I-II fractures (posterior mean SMFA at 1 year: 10·5, 95% highest density interval [HDI]: 9·5-11·6; QALYs: 0·73, 95% HDI: 0·66-0·80) nor Gustilo grade III fractures (posterior mean SMFA at 1 year: 14·9, 95% HDI: 13·4-16·6; QALYs: 0·67, 95% HDI: 0·59-0·75). For all fracture grades, intramedullary nailing substantially improved function and quality of life at 1 year post-injury. Delayed definitive fixation after 5 days had 5-times greater odds of infection compared with early management within 2 days (adjusted odds ratio: 5·1, 95% CI 1·8-16·1; p=0·02).

Interpretation: Adults with open tibia fractures in Malawi have poor function and quality of life in the 1 year following injury. Centralised orthopaedic surgical management, including early definitive fixation and intramedullary nailing for more severe injuries, might improve outcomes.

Funding: Wellcome Trust.

Translation: For the Chichewa translation of the abstract see Supplementary Materials section.

Conflict of interest statement

Declaration of interests We declare no competing interests. AJM is an investigator on three National Institute for Health and Care Research-funded trials (Chief Investigator for START:REACTS and RACER-Knee and co-investigator for RACER-Hip), for which Stryker, a medical device company, fund some treatment costs and some imaging costs. For all these studies, the full independence of the study team is protected by legal agreements and they have no bearing on the presented study.

Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.

Figures

Figure 1
Figure 1
Study profile Participants lost to follow-up are shown at each stage (non-cumulative). The greater loss to follow-up at 6 weeks was due to the fact that, early in the study, some participants were not successfully traced. Once identified, the necessary measures were implemented to trace the participants, obtain their updated contact details, and ensure proper follow-up for the remaining study period, meaning that they attended later assessments.
Figure 2
Figure 2
Empirical SMFA and EQ-5D-3L scores at 1 year post-injury in participants with open tibia fracture Scatterplot of SMFA-dysfunction index scores and EQ-5D-3L scores for participants with Gustilo grade I and II injuries (A and C) and Gustilo grade III injuries (B and D). EQ-5D-3L=European Quality of Life 5-Dimensions 3-Levels. SMFA=Short Musculoskeletal Functional Assessment.
Figure 3
Figure 3
Modelled cumulative impact of open tibia fracture and orthopaedic management on function and quality of life Posterior predictions from Bayesian multilevel regression model, with age held constant at its mean, and days to initial surgical intervention at its median, plus participant-level random effects. AUC=area under the curve. EQ-5D-3L=European Quality of Life 5-Dimensions 3-Levels. HDI=highest density interval. POP=plaster of Paris. QALY=quality-adjusted life-year. SMFA=Short Musculoskeletal Functional Assessment.

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Source: PubMed

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