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Background: In Ethiopia, orthopaedic services are limited, and many injured children undergo traditional bonesetting (TBS) despite its association with limb- and life-threatening complications. We sought to identify the risk factors for amputation and a prolonged hospitalization of >7 days in children who presented to hospitals after undergoing TBS., Methods: Over a 15-month period, we prospectively enrolled children who presented to 8 Ethiopian hospitals after undergoing TBS. Separately for each outcome (amputation and prolonged hospitalization), we used multivariable logistic regression to evaluate associations between the outcome and 16 covariates, including demographic and injury characteristics, parent or guardian preference for TBS, and TBS topical treatments and immobilization methods., Results: We enrolled 460 children (mean age, 9.0 ± 4.0 years; 75% male) representing 8 Ethiopian regions and diverse demographic and socioeconomic backgrounds. Elbow injuries (194 patients; 42.2%) and closed fractures and/or dislocations (364 patients; 79.1%) were most common. TBS treatments included topical inorganic (190 patients; 41.3%) or organic (82 patients; 17.8%) material application and rigid (166 patients; 36.1%) or soft (182 patients; 39.6%) immobilization. Twenty-six children (5.7%) underwent an amputation, and 102 (22.2%) had a prolonged hospitalization. The odds of amputation were higher for children from rural communities (adjusted odds ratio [AOR], 6.71; 95% confidence interval [CI], 2.01 to 22.41) and for children with only non-osseous injuries (AOR, 5.76; 95% CI, 1.56 to 21.28). The odds of prolonged hospitalization were higher for children who were 11 to 17 years old (AOR, 2.77; 95% CI, 1.18 to 6.50) and for children with open fractures with a grade of ≥2 (AOR, 4.52; 95% CI, 1.33 to 15.28) but were lower for children from households with secondary education or higher (AOR, 0.40; 95% CI, 0.21 to 0.79). TBS with rigid immobilization increased the odds of amputation (AOR, 5.84; 95% CI, 1.74 to 19.60) and prolonged hospitalization (AOR, 2.20; 95% CI, 1.02 to 4.73). TBS organic topical treatment (with mud, leaves, or butter) increased the odds of amputation (AOR, 3.88; 95% CI, 1.40 to 10.73)., Conclusions: For children who underwent TBS prior to hospital presentation, rigid splinting by bonesetters increased the odds of amputation and prolonged hospitalization. TBS organic topical treatments also increased the odds of amputation. Training bonesetters to avoid these dangerous practices may prevent devastating complications for children in Ethiopia., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: This study was funded by the AO Alliance Foundation. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I418)., (Copyright © 2025 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Bone fractures in low- and middle-income countries are commonly managed by traditional bonesetters (TBSs). Past studies emphasize the potential for improved fracture care through intersectoral cooperation. This review gauged support among stakeholders for intersectoral collaboration and the results of previous initiatives., Methods: Five medical databases were reviewed. Studies focusing on stakeholder perspectives and articles detailing collaborative initiatives were included. Data extraction and synthesis were carried out using the Cochrane Consumers and Communication Review Group's template. Additionally, all studies underwent quality assessment., Results: Of the 3821 identified articles, 16 were included after full-text screening. Twelve articles presented stakeholder perspectives, whereas four discussed collaborative initiatives. The overall article quality was low: articles on stakeholder perspectives scored on average 1.42 out of 4 points, whereas articles on collaborative initiatives scored a mean 1.25 points. In total, 62% of stakeholders (75% of TBSs, 92% of hospital staff, and 52% of patients) expressed support for intersectoral collaboration. The ratio between stakeholders expressing support versus those opposing was 4.4:1. No articles presented data on governmental perspectives. The most mentioned collaborative forms were TBS training (24% of stakeholders) and an integrative model (16% of stakeholders). Interventional studies all consisted of TBS training, reporting improved clinical outcomes and increased practice integration., Conclusion: Despite the limited and low-quality evidence on collaboration initiatives and perspectives, most stakeholders seem supportive of intersectoral collaboration, with training and integration being commonly suggested. Future research efforts exploring the feasibility of embedding TBSs into current primary care systems should ensure the involvement of local and national government., (© 2025 The Author(s). World Journal of Surgery published by John Wiley & Sons Ltd on behalf of International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Aims: HIV and musculoskeletal injuries both disproportionately affect individuals living in low- and middle-income countries (LMICs), leading to a significant number of fractures in HIV-positive patients. Despite this, little is known about the long-term outcomes for these patients. This prospective cohort study investigated whether HIV infection is associated with fracture-related infections (FRIs)., Methods: All adult patients between September 2017 and December 2018 who received intramedullary nail fixation of lower limb fractures in two tertiary referral hospitals in Cape Town, South Africa, were deemed eligible. In total, 358 participants were recruited for this study, 33 of whom were lost to follow-up. Of the 325 participants, 37 (11.4%) developed a total of 39 FRIs over the study period; 25 were early FRIs (64.1%) and 14 were late FRIs (35.9%). Participants were followed up for a minimum of 24 months. Throughout follow-up, participants were monitored for FRIs. These were categorized as early FRIs (< 90 days) and late FRIs (> 90 days)., Results: Overall, 71 participants (21.8%) were HIV-positive and 254 participants were HIV-negative (78.2%). In the HIV-positive population, 15 participants (21.1%) suffered 16 FRIs: seven early FRIs (9.9%) and nine late FRIs (7.0%). In the HIV-negative population, 22 participants (8.7%) experienced 23 FRIs, 18 were early FRIs (7.1%), and five participants experienced late FRIs (2.0%). On univariate and multivariate regression, being HIV-positive increased a participant's likelihood of suffering late FRIs, and FRIs overall. HIV status made no significant difference to early FRI rates., Conclusion: Contrary to recent evidence, this study demonstrates an association between HIV and an increased risk of a patient developing late FRIs. However, there was no significant difference in early FRI rates., Competing Interests: This study was funded by the Wellcome Trust, AOUK, and AO Alliance, as awarded via institutional grants to S. M. Graham. W. J. Harrison is a consultant for AO Alliance – a non-profit developmental foundation with no commercial affiliation to this study. M. Laubscher reports institutional funding from Zimmer Biomet, and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Smith & Nephew and AO Trauma, unrelated to this study. N. Ferreira reports institutional funding from AO, Orthofix, and Smith & Nephew, and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Orthofix and Smith & Nephew, unrelated to this study., (© 2025 The British Editorial Society of Bone & Joint Surgery.)

Decision confidence plays a critical role in humans' ability to make adaptive decisions in a noisy perceptual world. Despite its importance, there is currently little consensus about the computations underlying confidence judgements in perceptual decisions. To better understand these mechanisms, we addressed the extent to which confidence is informed by a naturalistic prior distribution. Contrary to previous research, we did not require participants to internalise parameters of an arbitrary prior distribution. We instead used a novel psychophysical paradigm leveraging probability distributions of low-level image features in natural scenes, which are well-known to influence perception. Participants reported the subjective upright of naturalistic image patches, targets, and then reported their confidence in their orientation responses. We used computational modelling to relate the statistics of the low-level features in the targets to the average distribution of these features across many naturalistic images, a prior. Our results showed that participants' perceptual and importantly, their confidence judgments aligned with an internalised prior for image statistics. Overall, our study highlights the importance of naturalistic task designs that capitalise on existing, long-term priors to further understand the computational basis of confidence., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025. Published by Elsevier Inc.)

Background: Pediatric fractures are common in Malawi, and surgical care, when needed, remains inaccessible to many. Understanding which children in Malawi receive surgery or nonsurgical treatment would help set priorities for trauma system development., Methods: We used multivariate logistic regression to evaluate associations between surgical treatment and age, sex, school enrollment, injury mechanism, fracture type, open fracture, referral status, hospital of presentation, delayed presentation (≥2 days), healthcare provider, and inpatient vs outpatient treatment., Results: From 2016 to 2020, 10,400 pediatric fractures were recorded in the Malawi Fracture Registry. Fractures were most commonly of the wrist (26%), forearm (17%), and elbow (14%). Surgical fixation was performed on 4.0% of patients, and 24 (13.0%) open fractures were treated nonsurgically, without débridement or fixation. Fractures of the proximal and diaphyseal humerus (odds ratio [OR], 3.72; 95% confidence interval [CI], 2.36 to 5.87), knee (OR, 3.16; 95% CI, 1.68 to 5.95), and ankle (OR, 2.63; 95% CI, 1.49 to 4.63) had highest odds of surgery. Odds of surgical treatment were lower for children referred from another facility (OR, 0.62; 95% CI, 0.49 to 0.77)., Conclusions: Most Malawian children with fractures are treated nonsurgically, including many who may benefit from surgery. There is a need to increase surgical capacity, optimize referral patterns, and standardize fracture management in Malawi., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Coordination of goal-directed behavior depends on the brain's ability to recover the locations of relevant objects in the world. In humans, the visual system encodes the spatial organization of sensory inputs, but neurons in early visual areas map objects according to their retinal positions, rather than where they are in the world. How the brain computes world-referenced spatial information across eye movements has been widely researched and debated. Here, we tested whether shifts of covert attention are sufficiently precise in space and time to track an object's real-world location across eye movements. We found that observers' attentional selectivity is remarkably precise and is barely perturbed by the execution of saccades. Inspired by recent neurophysiological discoveries, we developed an observer model that rapidly estimates the real-world locations of objects and allocates attention within this reference frame. The model recapitulates the human data and provides a parsimonious explanation for previously reported phenomena in which observers allocate attention to task-irrelevant locations across eye movements. Our findings reveal that visual attention operates in real-world coordinates, which can be computed rapidly at the earliest stages of cortical processing., Competing Interests: Competing interests statement:The authors declare no competing interest.

Neural oscillations reflect fluctuations in the relative excitation/inhibition of neural systems 1 , 2 , 3 , 4 , 5 and are theorized to play a critical role in canonical neural computations 6 , 7 , 8 , 9 and cognitive processes. 10 , 11 , 12 , 13 , 14 These theories have been supported by findings that detection of visual stimuli fluctuates with the phase of oscillations prior to stimulus onset. 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 However, null results have emerged in studies seeking to demonstrate these effects in visual discrimination tasks, 24 , 25 , 26 , 27 raising questions about the generalizability of these phenomena to wider neural processes. Recently, we suggested that methodological limitations may mask effects of phase in higher-level sensory processing. 28 To test the generality of phasic influences on perception requires a task that involves stimulus discrimination while also depending on early sensory processing. Here, we examined the influence of oscillation phase on the visual tilt illusion, in which a center grating has its perceived orientation biased away from the orientation of a surround grating 29 due to lateral inhibitory interactions in early visual processing. 30 , 31 , 32 We presented center gratings at participants' subjective vertical angle and had participants report whether the grating appeared tilted clockwise or counterclockwise from vertical on each trial while measuring their brain activity with electroencephalography (EEG). In addition to effects of alpha power and aperiodic slope, we observed robust associations between orientation perception and alpha and theta phase, consistent with fluctuating illusion magnitude across the oscillatory cycle. These results confirm that oscillation phase affects the complex processing involved in stimulus discrimination, consistent with its purported role in canonical computations that underpin cognition., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To assess the impact of an open fracture intervention bundle on clinical management and patient outcomes of adults in Malawi with open tibia fractures., Methods: We conducted a before-and-after implementation study in Malawi in 2021 and 2022 to assess the impact of an open fracture intervention bundle, including a national education course for clinical officers and management guidelines for open fractures. We recruited 287 patients with open tibia fractures. The primary outcome was a before-and-after comparison of the self-reported short musculoskeletal function assessment score, a measure of patient function. Secondary outcomes included clinical management; and clinician knowledge and implementation evaluation outcomes of 57 health-care providers attending the course. We also constructed multilevel regression models to investigate associations between clinical knowledge, patient function, and implementation evaluation before and after the intervention., Findings: The median patient function score at 1 year was 6.8 (interquartile range, IQR: 1.5 to 14.5) before intervention and 8.4 (IQR: 3.8 to 23.2) after intervention. Compared with baseline scores, we found clinicians' open fracture knowledge scores improved 1 year after the intervention was implemented (mean posterior difference: 1.6, 95% highest density interval: 0.9 to 2.4). However, we found no difference in most aspects of clinicians' open fracture management practice., Conclusion: Despite possible improvement in clinician knowledge and positive evaluation of the intervention implementation, our study showed that there was no overall improvement in clinical management, and weak evidence of worsening patient function 1 year after injury, after implementation of the open fracture intervention bundle., ((c) 2024 The authors; licensee World Health Organization.)

Background: Little is known about the burden or management of distal radius fractures (DRFs) in low- and middle-income countries. The purpose of this study was to describe the care of DRFs in Malawi., Methods: We retrospectively reviewed a registry of all patients with fractures who presented to the orthopaedic departments at four public hospitals in Malawi., Results: Totally, 1,440 patients (14.5%) were with a DRF. Average age was 40, and 888 (62.0%) were male. Surgery was done for 122 patients (9.5%). Patients presenting to Queen Elizabeth Hospital, patients presenting after a fall, and patients initially evaluated by an orthopaedic registrar or orthopaedic clinical officer had lower odds of receiving surgical treatment. Meanwhile, open injuries had the greatest odds of receiving surgery., Conclusion: The most common musculoskeletal injury among patients in the Malawi Fracture Registry was fractures of the distal radius. These most affected young adult male patients may benefit from surgery; however, the majority were managed nonsurgically. Lack of access to surgical fixation and conservative follow-up may have long-term functional consequences in a predominantly agrarian society. Outcomes-based research is needed to help guide management decisions and standardize patient care and referral protocols., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Humans have well-documented priors for many features present in nature that guide visual perception. Despite being putatively grounded in the statistical regularities of the environment, scene priors are frequently violated due to the inherent variability of visual features from one scene to the next. However, these repeated violations do not appreciably challenge visuo-cognitive function, necessitating the broad use of priors in conjunction with context-specific information. We investigated the trade-off between participants' internal expectations formed from both longer-term priors and those formed from immediate contextual information using a perceptual inference task and naturalistic stimuli. Notably, our task required participants to make perceptual inferences about naturalistic images using their own internal criteria, rather than making comparative judgements. Nonetheless, we show that observers' performance is well approximated by a model that makes inferences using a prior for low-level image statistics, aggregated over many images. We further show that the dependence on this prior is rapidly re-weighted against contextual information, even when misleading. Our results therefore provide insight into how apparent high-level interpretations of scene appearances follow from the most basic of perceptual processes, which are grounded in the statistics of natural images., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Our study assessed the effectiveness of a traditional bonesetter (TBS) educational program that was designed to increase knowledge, reduce complications, and promote the referral of patients to local hospitals by TBSs when necessary., Methods: From April to December 2021, TBSs from the Northern Sector (the Northern, Savannah, and North East regions) and the Ashanti region of Ghana underwent a 4-day training course that had been designed to teach basic principles of fracture care with the use of local tools. We assessed the levels of knowledge of the TBSs both before and after training. The change in practice of the trained TBSs also was assessed at 6 months using a structured questionnaire and a checklist., Results: In total, 157 TBSs were trained in 5 training sessions over a 9-month period. There was an improvement in knowledge in all of the modules of training, with an overall knowledge gain of 19.7% (from 67.2% to 86.9%). At 6 months of follow-up, the practices of TBSs that had most improved were record-keeping, hand hygiene, and patient rehabilitation. As a result of the referral system that was established by the training project, a total of 37 patients were referred to local hospitals in the 6 months following the training., Conclusions: Formal training for TBSs that was provided by a multidisciplinary team with use of a locally developed curriculum and tools was effective in improving the practice and outcomes of treatment by TBSs. There was marked knowledge retention by the trained TBSs at 6 months after training in fracture management., Clinical Relevance: Education, training, and the establishment of referral pathways between TBSs and local hospitals could improve trauma care in Ghana., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H644 )., (Copyright © 2023 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Background: Injuries are a major cause of disability globally and injury incidence is rapidly increasing, largely due to road traffic injuries in low-income and middle-income countries. Current estimates of the scale and consequences of disability from injury are largely based on modelling studies, with a scarcity of empirical evidence from severe injuries in low-income countries. We aimed to better understand the outcomes for individuals with open tibia fractures in Malawi., Methods: In this multicentre, prospective cohort study, adults (aged ≥18 years) with open tibia fractures were systematically recruited at six hospitals in Malawi (two tertiary hospitals and four district hospitals). Follow-up lasted at least 1 year, during which in-person follow-up reviews were done at 6 weeks, 3 months, 6 months, and 1 year post-injury. The primary outcome was function at 1 year post-injury, measured by the Short Musculoskeletal Functional Assessment (SMFA) score. Secondary outcomes included quality-adjusted life-years (QALYs; as determined via the European Quality of Life 5-Dimensions 3-Levels [EQ-5D-3L] survey) and fracture-related infection at 1 year post-injury. Multilevel regression models investigated associations between SMFA score, EQ-5D-3L, baseline factors, and orthopaedic management., Findings: Between Feb 12, 2021, and March 14, 2022, 287 participants were enrolled (median age 34 years [IQR 25-44]; 84% male). The most common mode of injury was road traffic injuries (194 [68%] of 287). Overall, 268 (93%) participants had debridement; of the 63 participants who were debrided in district hospitals, 47 (75%) had the procedure under local or no anaesthesia. Following substantial declines by 6 weeks after injury, function and quality of life had not recovered by 1 year post-injury for participants with Gustilo grade I-II fractures (posterior mean SMFA at 1 year: 10·5, 95% highest density interval [HDI]: 9·5-11·6; QALYs: 0·73, 95% HDI: 0·66-0·80) nor Gustilo grade III fractures (posterior mean SMFA at 1 year: 14·9, 95% HDI: 13·4-16·6; QALYs: 0·67, 95% HDI: 0·59-0·75). For all fracture grades, intramedullary nailing substantially improved function and quality of life at 1 year post-injury. Delayed definitive fixation after 5 days had 5-times greater odds of infection compared with early management within 2 days (adjusted odds ratio: 5·1, 95% CI 1·8-16·1; p=0·02)., Interpretation: Adults with open tibia fractures in Malawi have poor function and quality of life in the 1 year following injury. Centralised orthopaedic surgical management, including early definitive fixation and intramedullary nailing for more severe injuries, might improve outcomes., Funding: Wellcome Trust., Translation: For the Chichewa translation of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests We declare no competing interests. AJM is an investigator on three National Institute for Health and Care Research-funded trials (Chief Investigator for START:REACTS and RACER-Knee and co-investigator for RACER-Hip), for which Stryker, a medical device company, fund some treatment costs and some imaging costs. For all these studies, the full independence of the study team is protected by legal agreements and they have no bearing on the presented study., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Perception is often modelled as a process of active inference, whereby prior expectations are combined with noisy sensory measurements to estimate the structure of the world. This mathematical framework has proven critical to understanding perception, cognition, motor control, and social interaction. While theoretical work has shown how priors can be computed from environmental statistics, their neural instantiation could be realised through multiple competing encoding schemes. Using a data-driven approach, here we extract the brain's representation of visual orientation and compare this with simulations from different sensory coding schemes. We found that the tuning of the human visual system is highly conditional on stimulus-specific variations in a way that is not predicted by previous proposals. We further show that the adopted encoding scheme effectively embeds an environmental prior for natural image statistics within the sensory measurement, providing the functional architecture necessary for optimal inference in the earliest stages of cortical processing., (© 2023. Springer Nature Limited.)

The mechanisms that enable humans to evaluate their confidence across a range of different decisions remain poorly understood. To bridge this gap in understanding, we used computational modelling to investigate the processes that underlie confidence judgements for perceptual decisions and the extent to which these computations are the same in the visual and auditory modalities. Participants completed two versions of a categorisation task with visual or auditory stimuli and made confidence judgements about their category decisions. In each modality, we varied both evidence strength, (i.e., the strength of the evidence for a particular category) and sensory uncertainty (i.e., the intensity of the sensory signal). We evaluated several classes of computational models which formalise the mapping of evidence strength and sensory uncertainty to confidence in different ways: 1) unscaled evidence strength models, 2) scaled evidence strength models, and 3) Bayesian models. Our model comparison results showed that across tasks and modalities, participants take evidence strength and sensory uncertainty into account in a way that is consistent with the scaled evidence strength class. Notably, the Bayesian class provided a relatively poor account of the data across modalities, particularly in the more complex categorisation task. Our findings suggest that a common process is used for evaluating confidence in perceptual decisions across domains, but that the parameter settings governing the process are tuned differently in each modality. Overall, our results highlight the impact of sensory uncertainty on confidence and the unity of metacognitive processing across sensory modalities., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 West et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Injuries are one of the leading causes of global death and disability and commonly have substantial economic implications. The economic impact of injuries is particularly pronounced in low- and middle-income countries, where 90% of injuries occur. In this study, we aimed to assess return-to-work rates of individuals who sustained a lower-limb long-bone fracture in South Africa and to identify factors that influence the ability to return to employment., Methods: This prospective cohort study was conducted across 2 tertiary trauma centers in Cape Town, South Africa. Adults who received intramedullary nail fixation for a lower-limb fracture between September 2017 and December 2018 were recruited and followed for 18 months postoperatively. The participants' return to employment was assessed at 6 and 18 months post-injury. Multivariate logistic regression was used to identify factors that influence post-injury employment., Results: Of the 194 participants enrolled, 192 completed follow-up. The study population had a median age of 33.0 years, and most of the participants (76.6%) were male. Seventy-five percent of the participants were employed before their injury. At 6 and 18 months post-injury, 34.4% and 56.3% of participants, respectively, were employed. Of those employed pre-injury, 70.1% had returned to work at 18 months. Multivariate regression identified increasing age, unemployment prior to injury, and working in the informal employment sector as factors that impede an individual's likelihood of working 18 months post-injury. For those in employment prior to injury, increasing age was the only factor found to impede the likelihood of returning to work following an injury., Conclusions: This study highlights the profound effect that lower-limb long-bone fractures may have on an individual's ability to return to work in South Africa, with the potential to cause substantial economic impact on an individual's livelihood and that of their dependents., Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H427 )., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Aim: Our aim is to establish and analyse the first year of trauma registry data from Hawassa University Comprehensive Specialised Hospital (HUCSH)-an Ethiopian tertiary referral centre. We plan to identify possible trends in injury patterns, access to health care and referral pathways and establish if our observations are in keeping with data published from other sub-Saharan LMIC's., Methods: Prospective data collection using the WHO trauma registry dataset. All trauma patients presenting to HUCSH between November 2019 and November 2020 were included. Military patients were excluded., Dataset: Age, sex, region of residence, mode of transport to hospital, referral centre, time from injury to arrival in HUCSH, arrival triage category, Kampala Trauma Score (KTS), mechanism of injury, injury type, closed/open fracture and 24 h outcomes. Data statistical analysis was performed to calculate frequencies of the above variables., Results: There were a total of 1919 cases. Fifty-three per cent were caused by road traffic collision and 49% were fracture/dislocations. Public transport was the most common mode to hospital-40%. Seventy-seven per cent of all trauma admissions were referred from other centres, 69% had a mild KTS. A total of 376 patients presented with an open fracture-76% had a low KTS and 67% remained in ED for > 24 h. Sixty-five per cent of ambulances were utilised for mild KTS patients, only 25% of ambulances transported moderate and severe injuries., Conclusion: We have shown that a 'one size fits all approach' should not be adopted for LMIC's as trends vary between regions and countries. Improvements are needed in ambulance utilisation, the use of appropriate triaging tools to facilitate initial basic trauma care and appropriate, timely referrals and the management of open fractures., (© 2022. The Author(s).)

Objective: Human immunodeficiency virus (HIV) infection has been suggested to be associated with an increased risk of the development of nonunion after a fracture. This prospective matched case-control study in South Africa investigated common risk factors, including HIV status, that influence the development of a nonunion after a femur or tibia fracture., Methods: Adult participants (cases) with established nonunions of the femur or tibia shaft were recruited over a 16-month period, between December 2017 and April 2019. They were matched for (1) age; (2) sex; (3) fracture site; and (4) fracture management type, with "control" participants who progressed to fracture union within 6 months of injury. All participants were tested for HIV. Multivariable logistic regression models were constructed to investigate associations between known risk factors for the development of nonunion and impaired fracture healing., Results: A total of 57 cases were matched with 57 "control" participants (44/57 male, 77.2% vs. 13/57 female, 22.8%, median age 36 years). HIV status was not associated with the development of nonunion after the management of tibia and femur fractures, on both univariate (odds ratio, 0.40; confidence interval, 0.10-1.32; P = 0.151) or multivariable (odds ratio, 0.86; confidence interval, 0.18-3.73; P = 0.831) analysis. No other confounding factors were shown to have any statistically significant impact on the odds of developing nonunion in this study cohort., Conclusion: This study demonstrates that HIV does not seem to increase the risk of the development of nonunion and HIV-positive individuals who sustain a fracture can be managed in the same manner as those who are HIV negative., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Background: A key strategy to building surgical capacity in low income countries involves training care providers, particularly in the interventions highlighted by the Lancet Commission for Global Surgery, including the management of open fractures. This is a common injury, especially in areas with a high incidence of road traffic incidents. The aim of this study was to use a nominal group consensus method to design a course on open fracture management for clinical officers in Malawi., Methods: The nominal group meeting was held over two days, including clinical officers and surgeons from Malawi and the UK with various levels of expertise in the fields of global surgery, orthopaedics and education. The group was posed with questions on course content, delivery and evaluation. Each participant was encouraged to suggest an answer and the advantages and disadvantages of each suggestion were discussed before voting through an anonymous online platform. Voting included use of a Likert scale or ranking available options. Ethical approval for this process was obtained from the College of Medicine Research and Ethics Committee Malawi and the Liverpool School of Tropical Medicine., Results: All suggested course topics received an average score of greater than 8 out of 10 on a Likert scale and were included in the final programme. Videos was the highest ranking option as a method for delivering pre-course material. The highest ranking methods for each course topic included lectures, videos and practicals. When asked what practical skill should be tested at the end of the course, the highest ranking option was "initial assessment"., Conclusion: This work outlines how a consensus meeting can be used to design an educational intervention to improve patient care and outcomes. Through combining the perspectives of both the trainer and trainee, the course aligns both agendas so that it is relevant and sustainable., (© 2023. The Author(s).)

In order to synthesise the existing evidence of Traditional Bone Setters' (TBS) treatment and its associated complications in Low and Middle Income Countries (LMICs), we conducted a literature search following PRISMA guidelines. The keywords "traditional bone setter", "traditional bone healer", "traditional bone setting", "fracture", "complication", "low income country"," low to middle income country", "poor outcome" and "death" were searched in PubMed. Articles included in the review demonstrated complications associated with treatment by TBS for Musculoskeletal injury in LMICs. Out of 878 papers screened, twelve studies were finally included for review. Seven were prospective, and five retrospective studies. All were observational studies with all but one hospital based, the remaining being community based, and investigated the outcomes of treatment of fractures by traditional bonesetters published between 1999 and 2020 in LMICs. In total, this review covers 833 participants with 691 complications of TBS treatment. We identify a significant number of limb and life-threatening complications including mortality associated with the treatment by TBS. However, recent studies have shown that TBS are willing and keen to engage with local orthodox services and training courses. As shown in many countries, this can lead to a reduction in complications including mortality and can form a favourable environment where TBS and orthodox services can work side by side.

Aims: Prior to the availability of vaccines, mortality for hip fracture patients with concomitant COVID-19 infection was three times higher than pre-pandemic rates. The primary aim of this study was to determine the 30-day mortality rate of hip fracture patients in the post-vaccine era., Methods: A multicentre observational study was carried out at 19 NHS Trusts in England. The study period for the data collection was 1 February 2021 until 28 February 2022, with mortality tracing until 28 March 2022. Data collection included demographic details, data points to calculate the Nottingham Hip Fracture Score, COVID-19 status, 30-day mortality, and vaccination status., Results: A total of 337 patients tested positive for COVID-19. The overall 30-day mortality in these patients was 7.7%: 5.5% in vaccinated patients and 21.7% in unvaccinated patients. There was no significant difference between post-vaccine mortality compared with pre-pandemic 2019 controls (7.7% vs 5.0%; p = 0.068). Independent risk factors for mortality included unvaccinated status, Abbreviated Mental Test Score ≤ 6, male sex, age > 80 years, and time to theatre > 36 hours, in decreasing order of effect size., Conclusion: The vaccination programme has reduced 30-day mortality rates in hip fracture patients with concomitant COVID-19 infection to a level similar to pre-pandemic. Mortality for unvaccinated patients remained high.Cite this article: Bone Joint J  2022;104-B(12):1362-1368.