Norwegian Open Fracture Management System: Outcomes After 10 Years Working in Low-Resource Settings in Cambodian Hospitals.

INTRODUCTION: The treatment of open lower limb fractures represents a major challenge for any trauma surgeon, and this even more so in resource-limited areas. The aim of the study is to describe the intervention, report the treatment plan, and observe the effectiveness of the Norwegian Open Fracture Management System in saving lower limbs in rural settings. MATERIALS AND METHODS: A retrospective and prospective interventional study was carried out in the period 2011 through 2017 in six rural hospitals in Cambodia. The fractures were managed with locally produced external fixators and orthosis developed in 2007. Based on skills and living locations, two local surgeons and one paramedic without reconstructive surgery experience were selected to reach the top of the reconstructive ladder and perform limb salvage surgeries. This study evaluated 56 fractures using the Ganga Hospital Open Injury Score (GHOIS) for Gustilo-Anderson Type IIIA and Type IIIB open fracture classification groups. RESULTS: The primary success rate in open tibia fractures was 64.3% (95% CI, 50.3 - 76.3). The average treatment time to complete healing for all of the patients was 39.6 weeks (95% CI, 34.8 - 44.4). A percentage of 23.2% (95% CI, 13.4 - 36.7) experienced a deep infection. Fifteen of the patients had to undergo soft tissue reconstruction and 22 flaps were performed. Due to non-union, a total of 15 bone grafts were performed. All of the 56 patients in the study gained limb salvage and went back to work. CONCLUSION: The given fracture management program proves that low-resource countries are able to produce essential surgical tools at high quality and low price. Treatment with external fixation and functional bracing, combined with high-level training of local surgeons, demonstrates that a skilled surgical team can perform advanced limb salvage surgery in low-resource settings.

Open Fracture Management in Low-Resource Settings: A Medical Training Experience in Cambodian Hospitals.

INTRODUCTION: A prospective interventional study has been carried out on the teaching effect and sustainability of low-cost trauma training program in open tibia fracture management for health workers. MATERIALS AND METHODS: In 2007, an external fixator and a patella-bearing orthosis were developed at a rural workshop in Cambodia. From 2010 to 2016, a core group of nine Cambodian health workers was trained in open fracture management by Norwegian senior surgeons, using the locally made fixator and brace. The training outcome was also assessed by a questionnaire comprising of assertions regarding theoretical understanding, technical skills and self-confidence in understanding the biomechanical properties of locally made external fixator and its application; the use of handmade orthosis and principle in covering of soft-tissue defects. RESULTS: The students managed 23 cases with the new technique with a primary healing rate of 70% (95% CI 48.1-85.5). A significant increase in self-reported technical skills, understanding, and self-confidence was reported. CONCLUSION: This study demonstrates that the capacity building of reconstructive surgery in low-resource settings by local doctors and paramedics is clearly a reasonable option that may substantially reduce amputation of the limbs.

Reconstructive surgery including free flap transfers can be performed in low-resource settings: experiences from a wartime scenario.

BACKGROUND: Severe wartime injuries often require microsurgical reconstruction or pedicle flap transfer. The aim of the study is to explore if such reconstructive surgery can be performed under low-resource conditions in a rural area. METHODS: A clinical intervention study was performed at rural hospital in a war scenario in the Balkans. RESULTS: Thirty-four patients underwent microsurgical postinjury reconstructions for land mine or blast injuries. Five different types of flaps were used. Three patients developed postoperative complications and was reoperated (8.3%, 95% CI 1.8-22.5%). CONCLUSIONS: The actual intervention demonstrates that skilled surgical teams can perform advanced reconstructive surgery in low-resource settings. The experience is not only relevant for wartime scenarios, but also in civilian trauma where decentralization of microsurgical service may be feasible.