Cross-Sectional Burden Assessment of Proximal Femur Fractures at Three Central Hospitals in a Low-Income Sub-Saharan African Country

Cross-Sectional Burden Assessment of Proximal Femur Fractures at Three Central Hospitals in a Low-Income Sub-Saharan African Country

Emily Powis , Shravya Kakulamarri, Samuel Paek, Damiano Chaula, Boston Munthali, Leonard Banza, Nohakhelha Nyamulani, Cornelius Mukuzunga, Kumbukani Manda, Paul Appleton, Ishaq Ibrahim, Lars Flemming, Kaweme Mwafulirwa, Kiran Agarwal-Harding
Harvard Global Orthopaedics Collaborative, United States; Queen Elizabeth Central Hospital, Malawi; Lilongwe Institute of Orthopaedics and Neurosurgery, Malawi; Beth Israel Deaconess Medical Center, United States; Zomba Central Hospital, Malawi

Purpose:
To examine management of hip fractures in a low-income African country to guide capacity building.

Methods:
We surveyed all adults with proximal femoral fractures at three Central Hospitals over 15 weeks. Radiographs were blindly evaluated post-hoc by an international team of five orthopaedic surgeons. Majority opinion defined the ideal treatment. Predictors of non-ideal treatment were identified using multivariable logistic regression.

Results:
We surveyed 152 patients with 155 proximal femur fractures: average age 58 years, 72% male, and 48% earned less than $5.80 per month. Most common injury mechanism was ground-level fall (38%). Most injuries were treated nonoperatively (68%), with highest surgical rates for subtrochanteric (70%) compared to intertrochanteric (29%) and femoral neck (29%) fractures (p=0.001).

On post-hoc review, 100% of cases were indicated for operative treatment, and surgeons had moderate agreement on ideal treatment (Fleiss’ kappa 0.52, Z=21.7, p<0.001). There was slight agreement between ideal and actual treatment (Cohen’s kappa 0.11, Z=4 .85, p65 years old were 96% less likely to receive surgery compared to 35-to-64-year-olds (p<0.001). Patients treated at Hospital 2 had a 91% lower likelihood of receiving surgery compared to Hospital 1, which has more advanced surgical capacity (p<0.001).

Conclusions:
In this country, proximal femur fractures are common, and the majority are treated nonoperatively. Younger patients may be preferentially treated due to resource rationing. Limited availability of implants may explain low operative rates for intertrochanteric and femoral neck fractures. There is an urgent need to equitably improve hip fracture surgical capacity in resource-limited settings.

Keywords: trauma, proximal femur, hip, orthopaedics, orthopedics, LMIC, LIC