Pain management among adult patients with fractures of long bones at Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage and is one of the leading complaints in emergency departments (EDs). Despite the important and the advantages of pain control, still patients do not receive appropriate attention. The objective of this study was to assess pain management among adult patients with fractures of long bones at Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania. A descriptive Cross-sectional study design (Hospital based) was used.  Total of 250 patients aged 18 – 60 years old with fractures of long bones were recruited from March to June 2008. Structured questionnaires and observation guide were used to collect data. Verbal rating scale was used, to determine the intensity of pain. The study shows that there is no documentation for pain assessment or reassessment at Emergency Department. Slightly above half (54%; 135/250) of patients were not given analgesics. The commonest analgesic given was diclofenac sodium (46%). There was no patient given opioids (pethedine/ morphine). The rate of analgesics administration or splinting before and after admission did not differ between sexes (P=0.314 vs P= 0.230) and (P=0.314 vs P= 0.114), respectively. Almost half (47.0%) of them spent >20 min to 1 hour before the administration of analgesics. After administration of analgesia 76% of the patients continued to have severe to moderate pain. A large proportion (62.4%; N=156/250) of the patients scored their pain as severe. Of these, 28 (17.9%) patients received analgesia within 20 min, 42 (26.9%) after 30-60 min and 73 (46.8%) were not given analgesics at all. In conclusion pain at Moi Orthopaedic Institute is under treated. It is important that this is addressed properly to minimize pains among patients attending hospitals for fracture management

Short-term outcome of patients with closed comminuted femoral shaft fracture treated with locking intramedullary sign nail at Muhimbili Orthopaedic Institute in Tanzania

Background: Comminuted femoral shaft fractures are complex to treat because of increased risk of limb length discrepancies and mal-rotation deformities. Currently the interlocking intramedullary nail using image intensifiers is a suggested treatment for comminuted femoral shaft fractures. This study aimed to evaluate the short-term outcome of patients with closed comminuted femoral shaft fracture treated with locking intramedullary SIGN nail without image intensifiers at Muhimbili Orthopaedic Institute (MOI) in Tanzania.Methods: A prospective hospital base study was conducted on patients with closed comminuted femoral shaft fractures admitted at MOI from March 2011 to February 2012. A total of 91 adult patients (18 to 84 years) were enrolled in the study. Of the total patients, 80 (88%) patients were male, 11 were lost to follow-up, and 80 patients completed follow-ups of 18 weeks post operatively. Structured questionnaires and checklist forms were used to collect information. Operations were carried out either by antegrade or retrograde SIGN nail. Post operatively control radiographs, the lower limb length and mal-rotation deformities were assessed.Results: Comminuted femoral shaft fracture accounted for 20.3% of all adult femoral shaft fractures admitted at MOI. Deep wound infection occurred in 2.5%. Shortening of 2-3cm was seen in 3.8% of the patients. No patient had shortening of more than 3cm. External rotation deformity of more than 20 degrees occurred in 6.3% of the cases. Internal rotation deformity of more than 15 degrees was seen in 7.9%. Knee flexion of less than 90 degree was encountered in 7.5% of patients. By 18th week 95% of the patients had callus formation. Conclusion: SIGN nail appears to be an effective treatment for comminuted femoral shaft fractures in settings where image intensifiers and fracture tables are not readily available. They have excellent to good outcomes in rate of callus formation, limb length and limb alignment outcomes

Estimating the economic impact of complications after open tibial fracture: A secondary analysis of the pilot Gentamicin Open Tibia trial (pGO-Tibia).

OBJECTIVES: To estimate the indirect economic impact of tibial fractures and their associated adverse events (AEs) in Tanzania. DESIGN: A secondary analysis of the pilot Gentamicin Open (pGO)-Tibia randomized control trial estimating the indirect economic impact of suffering an AE, defined as a fracture-related infection (FRI) and/or nonunion, after an open tibial fracture in Tanzania. SETTING: The pGO-Tibia trial was conducted from November 2019 to August 2021 at the Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania. PATIENTS/PARTICIPANTS: One hundred adults with open tibial shaft fractures participated in this study. INTERVENTION: Work hours were compared between AE groups. Cost data were analyzed using a weighted-average hourly wage and converted into purchasing power parity-adjusted USD. MAIN OUTCOME MEASUREMENTS: Indirect economic impact was analyzed from the perspective of return to work (RTW), lost productivity, and other indirect economic and household costs. RTW was analyzed using a survival analysis. RESULTS: Half of patients returned to work at 1-year follow-up, with those experiencing an AE having a significantly lower rate of RTW. Lost productivity was nearly double for those experiencing an AE. There was a significant difference in the mean outside health care costs between groups. The total mean indirect cost was $2385 with an AE, representing 92$1195 compared with no AE. There were significantly more patients with an AE who endorsed difficulty affording household expenses postinjury and who borrowed money to pay for their medical expenses. CONCLUSIONS: This study identified serious economic burden after tibial fractures, with significant differences in total indirect cost between those with and without an AE. LEVEL OF EVIDENCE: II

Pain management among adult patients with fractures of long bones at Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage and is one of the leading complaints in emergency departments (EDs). Despite the important and the advantages of pain control, still patients do not receive appropriate attention. The objective of this study was to assess pain management among adult patients with fractures of long bones at Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania. A descriptive Cross-sectional study design (Hospital based) was used. Total of 250 patients aged 18 – 60 years old with fractures of long bones were recruited from March to June 2008. Structured questionnaires and observation guide were used to collect data. Verbal rating scale was used, to determine the intensity of pain. The study shows that there is no documentation for pain assessment or reassessment at Emergency Department. Slightly above half (54%; 135/250) of patients were not given analgesics. The commonest analgesic given was diclofenac sodium (46%). There was no patient given opioids (pethedine/ morphine). The rate of analgesics administration or splinting before and after admission did not differ between sexes (P=0.314 vs P= 0.230) and (P=0.314 vs P= 0.114), respectively. Almost half (47.0%) of them spent >20 min to 1 hour before the administration of analgesics. After administration of analgesia 76% of the patients continued to have severe to moderate pain. A large proportion (62.4%; N=156/250) of the patients scored their pain as severe. Of these, 28 (17.9%) patients received analgesia within 20 min, 42 (26.9%) after 30-60 min and 73 (46.8%) were not given analgesics at all. In conclusion pain at Moi Orthopaedic Institute is under treated. It is important that this is addressed properly to minimize pains among patients attending hospitals for fracture management

Quality of life and complications in lower limb amputees in Tanzania: results from a pilot study

Background: The most common reason for lower extremity amputation in developing countries is trauma, which is an increasingly recognised global epidemic. Despite the rising rates of traumatic injury and the level of disability experienced by amputees, there are few data focusing on this specific population in low-income and middle-income countries (LMICs). The purpose of this study is to investigate the causes and health-related outcomes of lower extremity amputations in Tanzania, and the socioeconomic barriers preventing access to prosthetics. Methods: This was an observational pilot study conducted at the Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania, from 2015 to 2016. Adult patients who had undergone lower extremity amputation less than 1 year before enrolment were included. Baseline data on demographics, socioeconomic factors, and health-related information were collected at enrolment. Patients’ health, health-related quality of life (using the EQ-5D questionnaire), and complication data were recorded 3 and 6 months later. Findings: We enrolled 44 patients, 35 of whom were men, with a mean age of 39·5 years. 39 (89%) of the patients were employed (36 [82%] informally) and 36 (82%) had no health insurance. Below-knee amputations were the most common (23 [52%]) type of amputation. The most common cause of amputation was trauma (29 [66%]), followed by diabetes (7 [16%]), vascular pathology (3 [7%]), and tumours (2 [5%]). Complications including delayed healing, infection, and wound dehiscence were seen in 20 (51%) of the 39 patients who were followed up. Seven patients required reoperation. The average baseline EQ-5D index was 0·912. The population norm based on mean age is 0·889 for the USA and 0·793 for Zimbabwe (the only African country-specific norm available). The average EQ5D index at 3 months and 6 months decreased to 0·714 and 0·847, respectively. Only two amputees (5%) have received a prosthetic. Lack of materials, unsuitable wound, and cost were most commonly cited as barriers to prosthetics. Interpretation: This study demonstrates that amputees in Tanzania experience a high rate of post-operative complications, poor quality of life, and extremely limited access to prosthetics. Educational initiatives to reduce wound-related complications and improved access to lower extremity prosthetics and rehabilitation are needed to address the dearth of knowledge and resources for amputees. Funding: Global Research Initiative

Transfemoral amputation and prosthesis provision in Tanzania: Patient and provider perspectives

BackgroundThe burden of disability because of traumatic limb amputation, particularly transfemoral amputation (TFA) is disproportionately carried by low- and middle-income countries. The need for improved access to prosthesis services in these settings is well-documented, but perspectives on the burden imposed by TFA and the challenges associated with subsequent prosthesis provision vary among patients, caregivers and healthcare providers.ObjectivesTo examine the burden of TFA and barriers to prosthesis provision as perceived by patient, caregiver and healthcare professional, at a single tertiary referral hospital in Tanzania.MethodData were collected from five patients with TFA and four caregivers recruited via convenience sampling, in addition to 11 purposively sampled healthcare providers. All participants participated in in-depth interviews regarding their perceptions of amputation, prostheses and underlying barriers to improving care for persons with TFA in Tanzania. A coding schema and thematic framework were established from interviews using inductive thematic analysis.ResultsAll participants noted financial and psychosocial burdens of amputation, and perceived prostheses as an opportunity for return to normality and independence. Patients worried about prosthesis longevity. Healthcare providers noted significant obstacles to prosthesis provision, including infrastructural and environmental barriers, limited access to prosthetic services, mismatched patient expectations and inadequate coordination of care.ConclusionThis qualitative analysis identifies factors influencing prosthesis-related care for patients with TFA in Tanzania which are lacking in the literature. Persons with TFA and their caregivers experience numerous hardships exacerbated by limited financial, social and institutional support.ContributionThis qualitative analysis informs future directions for research into improving prosthesis-related care for patients with TFA in Tanzania

Evaluating reliability and validity of the modified radiographic union scale for tibia (mRUST) among North American and Tanzanian surgeons.

ObjectivesTo determine the international reliability and validity of the modified Radiographic Union Scale for Tibial fracture (mRUST) scoring method for open tibial shaft fractures based on ratings of radiographs by separate groups of North American and Tanzanian surgeons.MethodsSeven North American and 9 Tanzanian surgeons viewed 100 pairs of AP and lateral radiographs of open tibial shaft fractures obtained in Dar Es Salaam, Tanzania. The radiographs showed 25 patients' fractures at 4 time points postfracture after treatment with either external fixation or intramedullary nailing. Surgeons evaluated each fracture using the mRUST scoring method and indicated their confidence that the fracture was healed on a scale from 1 to 10. Reliability of mRUST was determined using inter-rater agreement among North American and Tanzanian surgeons. Validity was determined via analysis of correlation between mRUST scores and EQ-5D-3L index scores at each time point postfracture.ResultsmRUST scores demonstrated strong reliability overall (ICC = 0.64) as well as within each group of North American (ICC = 0.72) and Tanzanian (ICC = 0.69) surgeons. Reliability was stronger for external fixation than for intramedullary nailing cases. mRUST scores were significantly correlated with overall healing confidence at all time points and with quality of life at 6 months and 1 year postfracture. mRUST scores also correlated significantly with patients' quality of life scores (EQ-5D index) at 6 months and 1 year postfracture.ConclusionNorth American and Tanzanian surgeons exhibited strong agreement in rating open tibial shaft fractures. Using mRUST scores is a valid means of assessing radiographic healing of tibial fractures in austere environments like Tanzania