Advantages of a New Low-Cost Negative Pressure Wound Therapy Using the "Turtle VAC": A Case Series.

CASE: We present a clinical case and technique guide demonstrating the use and effectiveness of a novel, low-cost negative pressure wound therapy (NPWT) device to achieve soft-tissue coverage in a 34-year-old patient with failed rotational flap and Masquelet technique on infected tibial nonunion. Local debridement was executed, NPWT initiated, and treatment culminated with complete wound healing. CONCLUSION: The "Turtle VAC" offers an effective low-cost alternative to commercially vacuum-assisted closure systems for post-traumatic wounds in low-resource setting of Haiti. Its use of available equipment makes NPWT accessible and can function as a bridge to definitive closure when primary wound closure is not possible and/or between debridement procedures.

Implementation and Impact Evaluation of a Virtual Orthopaedic Continuing Medical Education Conference in a Low-Resource Country.

OBJECTIVE: The Haitian Annual Assembly of Orthopaedic Trauma (HAAOT) is an annual continuing medical education (CME) conference for Haitian orthopedists and trainees converted to a pilot virtual format in 2020 due to the COVID-19 pandemic. We evaluated this virtual format's effectiveness at teaching, facilitating bilingual discussion, and encouraging cross-cultural exchange of experiences - all aimed at improving orthopedic knowledge in a low-resource country like Haiti. DESIGN: Planned collaboratively between North American and Haitian colleagues, the conference involved 4 bilingual weekly Zoom meetings comprised of 4 to 6 prerecorded presentations and live-translated discussion. Pre- and postmeeting knowledge assessments in French (Haitian language of medical instruction) were administered weekly with results compared via 2-sample t-tests. An online postconference survey evaluated attendee satisfaction with the virtual format. SETTING: Virtual. PARTICIPANTS: Weekly attendance involved approximately 50 Haitian orthopedists and trainees, with 20 to 25 completing pre- and postmeeting assessments. RESULTS: Statistically significant increases between pre/post scores were seen during 3 of 4 sessions. Session-wide significant score increases occurred for residents and attending surgeons with <10 years of experience. 85.7% of attendees reported the virtual platform exceeded expectations and 100% indicated likely or extremely likely participation in further virtual events. CONCLUSIONS: The pilot virtual HAAOT was extremely well received with high desire for future sessions. Beyond short-term knowledge retention among attendees, nonmeasurable benefits included collaboration between orthopedists and trainees in the United States, Canada, United Kingdom, Haiti, and Burkina Faso. As COVID-19 spurs online learning in high-income nations, the successful low-resource context adjustments and local partnership underlying this model attest that travel restrictions need not impede delivery of virtual CME conferences in lower-income nations. Attendee learning and the decreased cost and travel requirements allude to this platform's sustainability and reproducibility in facilitating future international education and capacity building. Further studies will assess long-term retention of presented material.

Cross-Cultural Comparison of Nonopioid and Multimodal Analgesic Prescribing in Orthopaedic Trauma.

BACKGROUND: After musculoskeletal injury, US providers prescribe opioids more frequently and at higher dosages than prescribers in the Netherlands and Haiti; however, the extent of variation in nonopioid analgesic prescribing is unknown. The aim of our study was to evaluate how nonopioid prescribing by orthopaedic residents varies by geographic context. METHODS: Orthopaedic residents in three countries in which residents are the primary prescribers of postoperative analgesia in academic medical centers (Haiti, the Netherlands, and the United States) responded to surveys using vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for postdischarge analgesia. We quantified the likelihood and dose of acetaminophen or a nonsteroidal anti-inflammatory drug prescription. We constructed multivariable regressions with generalized estimating equations to describe differences in nonopiate prescription according to country, the resident's sex and training year, and the injury site and age in the test cases. RESULTS: Compared with residents from the United States, residents from Haiti were more likely to prescribe nonopioids (odds ratio, 3.22 [confidence interval, 1.94 to 5.34], P < 0.0001) and residents from the Netherlands nearly always prescribed nonopioids. Of those cases where one or more opioid was prescribed, providers also prescribed a nonopioid (acetaminophen or nonsteroidal anti-inflammatory drug) in 345/603 (57.2%) of US, 152/152 (100%) of Dutch, and 69/97 (71.1%) of Haitian cases (Fisher exact test P value <0.0001). Finally, providers prescribed only nonopioids for pain control in 3/348 (0.86%) of US, 32/184 (17.4%) of Dutch, and 107/176 (60.8%) of Haitian cases (Fisher exact test P < 0.0001). CONCLUSIONS: When comparing multimodal analgesic patterns, US prescribers prescribed nonopioid analgesics less frequently than prescribers in two other countries, one low income and one high income, either in isolation or in conjunction with opioids.

Cross-Cultural Comparison of Postoperative Discharge Opioid Prescribing After Orthopaedic Trauma Surgery.

BACKGROUND: The extent of variation in analgesic prescribing following musculoskeletal injury among countries and cultural contexts is poorly understood. Such an understanding can inform both domestic prescribing and future policy. The aim of our survey study was to evaluate how opioid prescribing by orthopaedic residents varies by geographic context. METHODS: Orthopaedic residents in 3 countries in which residents are the primary prescribers of postoperative analgesia in academic medical centers (Haiti, the Netherlands, and the U.S.) responded to surveys utilizing vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for post-discharge analgesia. We standardized opioid prescriptions in the surveys by conversion to morphine milligram equivalents (MMEs). We then constructed multivariable regressions with generalized estimating equations to describe differences in opiate prescription according to country, the resident's sex and training year, and the injury site and age in the test cases. RESULTS: U.S. residents prescribed significantly more total MMEs per case (mean [95% confidence interval] = 383 [331 to 435]) compared with residents from the Netherlands (229 [160 to 297]) and from Haiti (101 [52 to 150]) both overall (p < 0.0001) and for patients treated for injuries of the femur (452 [385 to 520], 315 [216 to 414], and 103 [37 to 169] in the U.S., the Netherlands, and Haiti, respectively), tibial plateau (459 [388 to 531], 280 [196 to 365], and 114 [46 to 183]), tibial shaft (440 [380 to 500], 294 [205 to 383], and 141 [44 to 239]), wrist (239 [194 to 284], 78 [36 to 119], and 63 [30 to 95]), and ankle (331 [270 to 393], 190 [100 to 280], and 85 [42 to 128]) (p = 0.0272). U.S. residents prescribed significantly more MMEs for patients <40 years old (432 [374 to 490]) than for those >70 years old (327 [270 to 384]) (p = 0.0019). CONCLUSIONS: Our results demonstrate greater prescribing of postoperative opioids at discharge in the U.S. compared with 2 other countries, 1 low-income and 1 high-income. Our findings highlight the high U.S. reliance on opioid prescribing for postoperative pain control after orthopaedic trauma. CLINICAL RELEVANCE: Our findings point toward a need for careful reassessment of current opioid prescribing habits in the U.S. and demand reflection on how we can maximize effectiveness in pain management protocols and reduce provider contributions to the ongoing opioid crisis.

Education Improves Musculoskeletal Radiology Interpretation by Trainees in a Low-Resource Setting.

OBJECTIVE: The aims of this study were to assess baseline musculoskeletal radiology knowledge among Haitian orthopedists and to determine the impact of an adult and pediatric musculoskeletal radiology lecture series. DESIGN: Participants were given lectures reviewing normal and abnormal elbow radiographs and received assessments before and after the intervention. Bivariate and multivariate analyses were used to identify factors associated with baseline and postintervention scores. SETTING: This study was carried out as part of the 2018 Haitian Annual Assembly of Orthopaedic Trauma. This is an annual continuing medical educational conference in the capital city of Port-au-Prince open to all Haitian orthopedic surgeons and associated care providers, with a strong focus on resident training. PARTICIPANTS: Haitian orthopedic surgery residents and surgeons attending the 2018 Haitian Annual Assembly of Orthopaedic Trauma. RESULTS: Thirty-seven residents and faculty consented to participate in this study and 32 (86.5%) were male with a median age of 33 (interquartile rage: 30-35). On multivariate analysis controlling for the title (resident versus attending), total years of orthopedics (beginning of residency and beyond), and formal radiology teaching in medical school or residency, conference attendance in the past was significantly associated with higher preintervention assessment scores (odds ratio = 1.24, 95% confidence interval = 1.06-1.44, p = 0.010]. The mean total preintervention accuracy for correctly identification of pathology, if present, was 70% compared to 83% at the postassessment (p < 0.001). CONCLUSIONS: Overall, this study demonstrates that a brief lecture series at a continuing medical conference in Port-au-Prince, Haiti improved upper extremity radiographic interpretation based on pre and postassessments, and that prior conference attendance may be associated with higher baseline scores.

Haitian Annual Conference on Orthopaedic Traumatology: Building Surgical Capacity Through Academic Collaboration.

The Assemblée Annuelle Haitienne de Traumatologie Orthopedique (Haitian Annual Conference on Orthopaedic Traumatology) is an international orthopaedic conference, conducted each Spring in Haiti in French and English. It brings together most of Haiti's practicing orthopaedic surgeons, trainees from Haiti's 3 residency training programs, and a visiting faculty from overseas. The Haitian Annual Conference on Orthopaedic Traumatology has become an unexpected cornerstone of 1 program to support and nurture the development of orthopaedic surgery in that country.

Short-Term Performance Improvement of a Continuing Medical Education Program in a Low-Income Country.

BACKGROUND: The Haitian Annual Assembly for Orthopaedic Trauma (HAAOT) is a CME conference designed to help Haitian orthopaedic surgeons improve their knowledge and skills. The effectiveness of international CME conferences has not been studied. We hypothesized that HAAOT improves participants' short-term performance on knowledge-based assessments. METHODS: Data were prospectively collected from 57 Haitian and 21 foreign orthopaedic surgeons and residents who attended HAAOT using pre- and post-presentation questions. An audience response system was used to capture responses to 40 questions. Five additional demographic questions were used to train participants and to record unique audience member responses. Questions were projected in English and in French. Two-sided paired t tests were used to compare pre- and post-test scores. ANOVA with post-hoc unpaired t tests was used to compare among demographic groups. RESULTS: Response rate Median response rate was 77.4 % per day (Range: 76.5-85.9 % per day). Pre-test scores Pre-test scores averaged 21 % for Haitians and 39 % for foreigners (p < 0.0001), and were similar among Haitian attendings and residents. Pre-post differences Scores improved by 8 % for Haitians (p < 0.0001) and 10 % for foreigners (p < 0.01) after didactic presentations. Among sub-groups, Haitian attendings improved on average by 18 % compared to 6 % for residents (p < 0.0001). Haitian attending improvement trended toward significance when compared to foreign attendings (p < 0.08). CONCLUSIONS: Our study is the first to show improved short-term knowledge performance using an audience response system during a CME conference in a low-income country. CME conferences in low-income countries can be an effective tool to increase surgeon knowledge, and audience response systems can help engage participants and track outcomes.

A novel approach for needs assessment to build global orthopedic surgical capacity in a low-income country.

OBJECTIVE: Visiting surgical teams are a vital aspect of capacity-building continuing medical education (CME) in low-income countries like Haiti. Imperfect understanding of the genuine needs of local surgeons limit CME initiatives. Previous paper-based needs assessment efforts have been unsuccessful because of low response rates. We explored using an electronic audience response system (ARS) during a Haitian CME conference to improve the response rates and better assess needs. METHODS: Data were prospectively collected using an ARS from 78 conference participants (57 Haitian and 21 foreign) about current and desired knowledge of 7 topic and 8 skill areas using a 5-point Likert scale presented in English and in French. The response rates using ARS vs a similar paper survey were compared using a 2-sample test of proportions. The current and desired knowledge levels were compared using paired t tests. Analysis of variance and post hoc unpaired t tests were used to compare between demographic groups. RESULTS: The response rates were significantly greater for ARS vs a paper survey (87.7 vs 63.2%, p = 0.002). The 4 areas of least self-confidence for Haitians were pelvic and articular injury, joint dislocation, and osteomyelitis. The 4 skills of least self-confidence for Haitians were arthroscopy, open reduction and internal fixation-plate, external fixation, and fasciotomy. Haitians desired improvements in knowledge and management of articular, diaphyseal, and pelvic injury, joint dislocation, and osteomyelitis to a greater extent than foreigners (p < 0.05). Participants who previously attended the conference on open fractures felt more knowledgeable about open fractures as a topic (p < 0.05), but not in its management. CONCLUSIONS: We are the first to show that an ARS improves response rates to allow for better characterization of surgeon needs in the developing world. We also demonstrate the importance of skill building paired with topic area teaching. Lastly, we show how a CME conference is an effective tool to build surgical capacity and increase confidence level.