Orthopaedic trauma surgery in low-income countries.

This thesis is based on three published papers about complications after intramedullary (IM) nailing of fractures of the long bones in lowand middle-income countries (LMICs). The first two studies were register studies using data from the SIGN online surgical database (SOSD). The third study was a prospective study of patients treated for femoral fractures at Kamuzu Central Hospital in Malawi. The SOSD is, to my knowledge, currently the largest database in the world containing data on orthopaedic trauma surgery in LMICs. It was established to ease communication between SIGN Fracture Care International (SIGN) and surgeons using their IM nail. SIGN provides hospitals in LMICs with IM nails free of charge for the treatment of fractures in poor people. Being operated with an IM nail for a fracture of the thigh bone (femur) will have a patient out of bed in a few days, and this has been the obvious treatment of choice in high-income countries for more than half a century now. In many LMICs, however, femoral fractures are still treated with the patient in bed on traction for one and a half to three months. There are still many myths about the risks of doing surgery in LMICs. We wished to document the results and complications of IM nailing in LMICs so that better informed decisions can be made when planning surgical services in these countries. Lack of sufficient follow-up is a challenge in research in LMICs. We also wished to see how this influences results. We found that returning for follow-up in LIC can be difficult and very expensive for many patients. The motivation for returning for follow-up is therefore very low if a patient does not have any complaints. Insisting on very high follow-up rates in clinical research from low-income countries is unrealistic and can exclude important information from the literature. It does, however, seem as if people in low income countries mostly do return for follow-up if they have a complaint after surgery even if total follow up rates are low. This implies that results based only on the patients that returned for follow-up in LIC will be negatively biased. This should be kept in mind when interpreting results in research from LIC.