The Harvard Global Orthopaedics Collaborative: Improving Management of Adult Ankle Fractures in Malawi

Malawi is a low-income country in southeastern Africa of about 18 million people. Traumatic musculoskeletal injuries are common, but access to orthopaedic care is limited¹. Most care is provided by orthopaedic clinical officers (OCOs), or non-physician clinicians trained in nonoperative care². Through prior research, we identified that ankle fractures are among the most common adult injuries seen in Malawian public hospitals’ outpatient orthopaedic departments³. Recognizing the large burden of ankle fractures, the limited availability of surgical care, and the many challenges patients may face when seeking surgical care, we set out to understand how ankle fractures are managed in Malawi and whether we could positively influence the quality of care.

First, we assessed Malawian providers’ knowledge of ankle injuries through paper exams. Most of our participants were OCOs, and we found significant knowledge deficits in diagnosis and treatment as well as a lack of treatment standardization. Second, we observed how ankle fracture patients were treated by OCOs at Kamuzu Central Hospital, a public referral hospital with non-operative and operative treatment options. We documented providers’ treatment plans and rationale and compared them to the plans of orthopaedic surgeons. We found that Malawian OCOs were much more likely than surgeons to treat patients non-operatively, even those with unstable ankle fractures that would benefit from surgery. This was primarily due to resource limitations, gaps in provider knowledge, and lack of a standardized treatment protocol.

Above: Ami Kapadia working alongside Orthopaedic Clinical Officers in Malawi to collect data regarding ankle fracture treatment practices.

Next, we assembled a group of orthopaedic surgeons from the US and Malawi to conduct an educational conference in Malawi. There were 61 participants, 85% of whom were OCOs; this group represented 40% of the Malawian orthopaedic workforce. Incorporating the knowledge we gained through our capacity research, we collaboratively designed a standardized treatment protocol for ankle fracture management with our Malawian colleagues. 84% of providers improved their knowledge of ankle fracture diagnosis and treatment after the course.

We found that the success of this project relied heavily on our strong, collaborative partnership between partners from the US and Malawi. What started as “clinical volunteerism,” where members of the Harvard Global Orthopaedics Collaborative (HGOC) worked beside Malawian providers in the clinical setting, matured into a two-way relationship where we could openly discuss challenges faced by Malawian providers. We worked together to identify barriers to care, design studies that investigate these barriers, and introduce appropriate interventions – in this case, an educational one. To truly bring about sustainability, we aim to evaluate the effectiveness of our intervention by conducting studies assessing Malawian providers’ knowledge and adherence to our standardized protocol. We have also created and disseminated a series of ankle fracture videos that cover the same learning objectives as our educational course (links below). Moreover, we at the HGOC were excited to support our Malawian colleagues from a distance as they utilized many of the educational resources we prepared together in 2019 to run the ankle fracture education course on their own in 2020.

Above: Malawian and HGOC faculty with conference participants at the Malawian Orthopaedic Association Annual Meeting 2019 after the ankle fracture course.  

Ultimately, we believe our work demonstrates a comprehensive approach to examining and addressing barriers to orthopaedic care in limited resource settings. We have tried to use education and research as tools to sustainably improve orthopaedic surgical care capacity.

Paper: Improving Management of Adult Ankle Fractures in Malawi: An Assessment of Providers' Knowledge and Treatment Strategies

Ankle Fracture Video Series:

1. Normal Anatomy, Normal Radiographs
2. Pathologic Changes Seen on Radiographs
3. Implications for Stability and Treatment

Sources

1. Agarwal-Harding KJ, Chokotho L, Young S, Mkandawire N, Chawinga M, Losina E, Katz JN. Assessing the capacity of Malawi’s district and central hospitals to manage traumatic diaphyseal femoral fractures in adults. PLoS One. 2019 Nov 20; 14(11):e0225254.
2. Mkandawire N, Ngulube C, Lavy C. Orthopaedic clinical officer program in Malawi: a model for providing orthopaedic care. Clin Orthop Relat Res. 2008;466(10):2385-2391. doi:10.1007/s11999-008-0366-5.
3. Agarwal-Harding KJ, Chokotho LC, Mkandawire NC, Martin C Jr, Losina E, Katz JN. Risk factors for delayed presentation among patients with musculoskeletal injuries in Malawi. J Bone Joint Surg Am. 2019 May 15;101(10): 920-31.

The Harvard Global Orthopaedics Collaborative (HGOC) is a group of Harvard-affiliated orthopaedic faculty and trainees who share a passion for improving access to equitable musculoskeletal care globally. We engage in clinical research, surgical education, care delivery, and health systems development with partners across the globe including Haiti, Colombia, Malawi, Cameroon, and India. Forging long-term, bidirectional partnerships, we work with our partners to develop a research agenda based on the needs identified by providers in the communities we serve. Our research serves as a guide to develop educational materials and design creative interventions to improve musculoskeletal care in low-resource settings. For more information about the HGOC, our projects, and partners please visit our website: https://ortho.hms.harvard.edu/harvard-global-orthopaedics-collaborative

Authors

Ami Kapadia^1,2

Kiran J. Agarwal-Harding¹

Leonard N. Banza³

1. Harvard Global Orthopaedics Collaborative, Boston, MA, USA
2. University of Texas Southwestern School of Medicine, Dallas, Texas
3. Department of Orthopedics, Kamuzu Central Hospital, Lilongwe, Malawi