Research Summary Research topic:
Comparing re-operation rates for femoral fracture patients in Dar es Salaam, Tanzania who are treated with intramedullary nailing to those who are treated by open reduction internal fixation with a dynamic compression plate.
Determinination of the most efficacious and cost-effective surgical treatment for femoral shaft fracture patients in Dar es Salaam, Tanzania and identification of potentially modifiable risk factors for treatment failure.
Patient care application of results:
Patients in developing countries, where road traffic injures are an emerging health crisis, receive the most effective, locally appropriate treatment for femoral shaft fractures.
Simplified patient care application:
Patients in developing countries receive the optimal treatment for femoral shaft fractures.
Improving outcomes where the need is greatest
OREF grant recipient seeks optimal treatment for patients with femoral fractures in Tanzania
David W. Shearer, MD, MPH, has trained, treated patients and performed research in some of the world’s most advanced medical environments. His goal, though, is to apply his skills and experience to achieve better outcomes for underserved patients in developing countries, starting with Sub-Saharan Africa.
In his fifth year of his residency at the University of California, San Francisco (UCSF), Dr. Shearer secured funding from the Orthopaedic Research and Education Foundation (OREF) for a prospective clinical trial that will investigate the optimal surgical treatment for femoral shaft fractures in Dar es Salaam, Tanzania. The results, he said, will resonate worldwide.
Still, he considered his bid for the 2012 OREF/Zimmer Young Investigator Grant a longshot.
“Global health funding tends to go to infectious disease investigators, and orthopaedic funding tends to support research in developed countries,” Dr. Shearer explained. “I hoped OREF would appreciate the novel outcomes data—data that will impact clinical care on a global scale. Fortunately, it did. We’re so pleased to have the grant.”
Addressing unmet needs
Dr. Shearer said he has been looking for a way to work at the intersection of orthopaedic surgery and global health since medical school. The need for just such a specialization is growing sharply. Approximately 1.24 million people die every year on the world’s roads, over 90 percent of which are in low and middle-income countries. There are another 20 to 50 million that sustain non-fatal injuries as a result of road traffic crashes.1
“If you go to Southeast Asia or Africa, it’s just flat out unsafe on the roads,” Dr. Shearer said. “Orthopaedic care providers are overwhelmed.”
Specialty societies have begun to address the need to improve the quality of musculoskeletal care in developing countries. Dr. Shearer highlighted the work of AAOS and OTA (Orthopaedic Trauma Association) international relations committees.
But research is needed, too.
“The dearth of research establishing optimal management protocols in developing countries is really compelling,” Dr. Shearer said.
Nailing versus plating
Dr. Shearer’s study will track approximately 300 adult patients with diaphyseal femur fractures and no prior surgeries or infections. The team will compare re-operation rates for patients treated with intramedullary nailing and, still commonplace in the region, open reduction internal fixation with a dynamic compression plate. Patients will be examined: at 6 weeks, 3 months, 6 months and 1 year after surgery.
Secondarily, the study will identify predictors of clinical and radiographic unions, return to work and quality-of-life assessments as measured by the EQ-5D instrument. The study will also identify prognostic factors that predict poor outcomes.
All patient enrollment, treatment, evaluation and data collection will occur at Dar es Salaam’s Muhimbili Orthopaedic Institute (MOI), a tertiary hospital and academic center. MOI is an established partner with UCSF through its Institute for Global Orthopaedic Traumatology, which cultivates academic partnerships to promote the exchange of knowledge and ideas.
Images of plain radiographs are sent from Tanzania to UCSF for review using cell phone technology. Investigators comminicate through twice monthly web conferences.
Achieving valid and sustainable results
“Our goal is 80 percent follow-up at the one-year mark—a benchmark for a good study in the U.S., but virtually unheard of in Africa,” Dr. Shearer said.
Through qualitative research with prospective participants, the team found a range of barriers including long clinic waiting times and inadequate transportation. Among the incentives the team devised to achieve 80 percent participation are:
- No cost for follow-up clinic visits
- A dedicated research clinic on Saturdays to minimize waiting time
- Text message reminders in advance of each appointment followed by a direct call to participants’ cell phones
- Transportation to the clinic for the 1 year follow up appointment
In addition to establishing sound clinical guidance, Dr. Shearer hopes to lay the groundwork for better health care policy-making. He expects the quality of life data will shed light on a number of policy questions, minimally those related to cost-effectiveness and resource allocation. Further, the study is designed to build capacity at MOI so that similar research can continue.
Dr. Shearer believes his fellow AAOS members will agree that research like his contributes to the Academy’s commitment to encouraging leadership and collaboration, and promoting quality care.
“By far the best part of the experience has been the collaborative spirit of the study and the strong personal relationship that has developed between the investigators— Billy Haonga and Edmund Eliezer in Tanzania, and at UCSF mentors Saam Morshed and Rick Coughlin and research coordinators Joshua Ngahyoma and Justin Kessy.
In addition, nurturing relationships with colleagues in Dar es Salaam is helping them take a leadership role in their country and in their hospital—and helping them get plugged into organizations here. Plus, they’re transforming the way they practice and conduct research to deliver better care. It’s deeply satisfying.”
Dr. Shearer also hopes the orthopaedic community will continue to invest in future research efforts and continue to reap the rewards.
“OREF supports research that potentially changes how all of us practice. Whether you do research or not, a contribution to OREF advances the breadth of orthopaedics and gives each of us a chance to have a positive impact on patients at large. What a tremendous opportunity.”
1 Global Status Report on Road Safety 2013: supporting a decade of action. Geneva: World Health Organization. 2013, 308 p.