Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California.
Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts.
J Bone Joint Surg Am. 2022 Apr 20;104(8):716-722. doi: 10.2106/JBJS.21.00727. Epub 2022 Feb 1.
Open fractures, especially of the tibia, require prompt intervention to achieve optimal patient outcomes. While open tibial shaft fractures are common injuries in low- and middle-income countries (LMICs), there is a dearth of literature examining delays to surgery for these injuries in low-resource settings. This study investigated risk factors for delayed management of open tibial fractures in Tanzania.
We conducted an ad hoc analysis of adult patients enrolled in a prospective observational study at a tertiary referral center in Tanzania from 2015 to 2017. Multivariable models were utilized to analyze risk factors for delayed hospital presentation of ≥2 hours, median time from injury to the treatment hospital, and delayed surgical treatment of ≥12 hours after admission among patients with diaphyseal open tibial fractures.
Two hundred and forty-nine patients met the inclusion criteria. Only 12% of patients used an ambulance, 41% were delayed ≥2 hours in presentation to the first hospital, 75% received an interfacility referral, and 10% experienced a delay to surgery of ≥12 hours after admission. After adjusting for injury severity, having insurance (adjusted odds ratio [aOR] = 0.48; 95% confidence interval [CI] = 0.24 to 0.96) and wounds with approximated skin edges (aOR = 0.37; 95% CI = 0.20 to 0.66) were associated with a decreased risk of delayed hospital presentation. Interfacility referrals (2.3 hours greater than no referral; p = 0.015) and rural injury location (10.9 hours greater than urban location; p < 0.001) were associated with greater median times to treatment hospital admission. Older age (aOR = 0.54 per 10 years; 95% CI = 0.31 to 0.95), single-person households (aOR = 0.12 compared with ≥8 people; 95% CI = 0.02 to 0.96), and an education level greater than pre-primary (aOR = 0.16; 95% CI = 0.04 to 0.62) were associated with fewer delays to surgery of ≥12 hours after admission.
Prehospital network and socioeconomic characteristics are associated with delays to open tibial fracture care in Tanzania. Reducing interfacility referrals and implementing surgical cost-reduction strategies may help to reduce delays to open fracture care in LMICs.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
开放性骨折，尤其是胫骨骨折，需要及时干预，以达到最佳的患者预后。虽然胫骨骨干开放性骨折在中低收入国家（LMICs）很常见，但在资源匮乏的环境下，针对这些损伤手术延迟的文献很少。本研究调查了坦桑尼亚开放性胫骨骨折延迟管理的风险因素。
我们对 2015 年至 2017 年在坦桑尼亚一家三级转诊中心参加前瞻性观察研究的成年患者进行了一项特别分析。利用多变量模型分析了胫骨骨干开放性骨折患者在 2 小时以上延迟就诊、从受伤到治疗医院的中位时间以及入院后 12 小时以上延迟手术治疗的风险因素。
249 名患者符合纳入标准。只有 12%的患者使用了救护车，41%的患者首次就诊延迟≥2 小时，75%的患者接受了医院间转诊，10%的患者在入院后 12 小时以上接受了手术延迟治疗。在调整损伤严重程度后，有保险（调整后的优势比[aOR] = 0.48；95%置信区间[CI] = 0.24 至 0.96）和伤口边缘接近皮肤（aOR = 0.37；95%CI = 0.20 至 0.66）与降低医院就诊延迟风险相关。医院间转诊（比无转诊长 2.3 小时；p = 0.015）和农村受伤地点（比城市地点长 10.9 小时；p < 0.001）与到达治疗医院的中位时间更长相关。年龄较大（每增加 10 岁，aOR = 0.54；95%CI = 0.31 至 0.95）、单人家庭（aOR = 0.12 比≥8 人；95%CI = 0.02 至 0.96）和教育程度高于学前（aOR = 0.16；95%CI = 0.04 至 0.62）与入院后 12 小时以上手术延迟减少相关。
院前网络和社会经济特征与坦桑尼亚开放性胫骨骨折治疗的延迟有关。减少医院间转诊和实施手术成本降低策略可能有助于减少 LMIC 中开放性骨折治疗的延迟。
预后 III 级。有关证据水平的完整描述，请参见作者说明。
