The Burden of Orthopaedic Disease in Sub-Saharan Africa: A Focus on Tanzania

Background As road trac crashes (RTCs) continue to rise in the developing world, the current growth rate and true burden of orthopaedic injuries are unknown. In 2015, we characterized the orthopaedic burden at Kilimanjaro Christian Medical Center (KCMC) in Tanzania. In this study, we re-evaluated the burden and growth-rate over three years in the absence of any system level changes. Additionally, we calculated the percentage of orthopaedic patients that received denitive xation for their orthopaedic injury when surgery was indicated. Methods We prospectively collected data for 190 patients admitted to the orthopaedic ward at KCMC during June/July 2018. We also retrospectively reviewed available records for patients presenting to the KCMC emergency department, orthopaedic outpatient clinic and orthopaedic ward. Results Prospective data: RTC (48.6%) was the most common etiology and femur fractures (31.0%) the most common type of injury. Almost 96% of admitted patients were indicated for surgical xation, but only 44.5% received denitive fracture treatment. Retrospective data: KCMC treated an average of 15,117 orthopaedic patients per year, representing a 35.3% growth in the orthopaedic burden compared to 2015.


Background
The burden of musculoskeletal disease in low-and middle-income countries (LMIC) continues to increase mainly due to road tra c crashes (RTC). Globally, RTCs constitute over 1.35 million deaths annuallymore deaths than HIV/AIDS, tuberculosis and diarrheal diseases combined, and represent the third leading cause of disability for people aged . (1,2) Traumatic musculoskeletal injuries often necessitate orthopaedic surgical treatment. However, in LMICs, even at tertiary referral centers, de nitive care is not readily accessible for most patients.
Countries in Sub-Saharan East-Africa are no exception to this scenario. In 2017, Tanzania experienced 17,840 deaths due to RTCs, the 9th highest mortality rate from RTCs worldwide. (2) For its population of almost 50 million people, there are 45 consultant orthopaedic surgeons; only one orthopaedic surgeon for every 1.1 million Tanzanians.(3) Given this massive discrepancy, the current workforce is unable to address the demand for orthopaedic services.
Our group previously characterized the orthopaedic burden at Kilimanjaro Christian Medical Center (KCMC) in northern Tanzania. At this tertiary referral center, the orthopaedic volume is comparable to that of a level one trauma center in the United States of America (USA), and only 10% of the catchment area population have access to orthopaedic surgical care. (4,5) As RTCs continue to rise in the developing world, the current growth rate and true burden of orthopaedic injuries is still unknown. (1) In this study, we calculated the percentage of orthopaedic patients that received de nitive xation for their orthopaedic injury when surgery was indicated. We also re-evaluated KCMC's orthopaedic burden and documented the growth-rate since 2015 in the absence of any system level changes. We hypothesized that the number of patients that received de nitive treatment of their musculoskeletal injury would be less than previously reported and that the burden of disease at KCMC would grow considerably over a three-year period.

Methods
Setting KCMC is a 700-bed facility in northern Tanzania and is one of the country's four large tertiary referral centers. Its catchment area covers 12.5 million people from ve surrounding regions (Fig. 1). Each year, the institution treats 110,000 outpatients and admits approximately 25,000 patients for inpatient care. KCMC has limited material and personnel resources, including just four full-time equivalent orthopaedic surgeons, 17 orthopaedic residents and 16 trained nurses (equating to three nurses per shift). The orthopaedic ward consists of 66 total beds: three 12-bed rooms, three 4-bed rooms, four 2-bed "private" rooms, and one 10-bed pediatric room. There are ve operating theaters of which only one is dedicated to orthopaedic surgery. A second operating theater is shared with the general surgery and obstetrics and gynecology departments and is used approximately twice weekly for septic orthopaedic cases. There is one full-time anesthesiologist and 11 nurse anesthetists shared between all departments across the ve operating theaters. There is no established pre-hospital emergency response system in northern Tanzania, and most patients reach the hospital via personal transportation or ambulance reserved for inter-facility transfer of critically ill patients.(4) Study Design We prospectively collected data for all patients admitted to the orthopaedic ward at KCMC from June 2018 to July 2018(4). We also retrospectively reviewed all available records for patients presenting to the KCMC emergency department (ED), orthopaedic outpatient clinic and orthopaedic ward (Table 1). This study received KCMC Clinical Research Ethical Review Committee approval prior to data collection and analysis. All patients, except those with isolated spine injuries, admitted to the orthopaedic ward during the six- week study period were included for prospective data collection ( Table 2). When available, admission and post-operative radiographs were collected and reviewed by two senior orthopaedic surgery resident authors (AP and CP). The authors classi ed each admission radiograph according to the 2018 AO/OTA Fracture and Dislocation Guidelines and determined if surgical xation was indicated.(6) Post-operative radiographs were evaluated for the presence of de nitive surgical xation. Patients who received open reduction and internal xation (ORIF) or intramedullary nailing were categorized as having undergone de nitive surgical fracture treatment; cases for which external xation was used as de nitive treatment were individually assessed for appropriateness. Implant removal procedures were also categorized as de nitive treatment. All available ED, outpatient clinic and orthopaedic ward records were reviewed by two authors (WH and MJ). Review of ED records established the total number of orthopaedic consultations. Outpatient analysis determined the total number of evaluated clinic patients and the percentage of patients presenting with health insurance. Retrospective review of orthopaedic ward data determined the number of ward admissions, diagnoses and discharge status (including deaths). Deaths were cross-referenced with hospital mortality reports.

Prospective Cohort
During the study period, 231 patients were admitted to the orthopaedic ward. Forty-one (17.7%) isolated spine patients were excluded, leaving 190 patients in the nal study cohort. The majority of admitted patients were male and under the age of 45 years (Table 3). Males tended to be younger (mean age 37.8, range 3 to 98 years, SD 23.7) than females (mean age 43.9, range 2 to 94 years, SD 21.5) (p = 0.108).
(data not shown) The most common occupations were farmer, businessman and student, which together accounted for over 50% of patient reported jobs. Of the 190 patients prospectively followed during the sixweek study period, 138 (72.6%) were discharged home, 45 (23.7%) were still admitted at the end of the data collection period and seven (3.7%) died as an inpatient.
Statistical Analysis Statistical analysis was performed using the R: a language and environment for statistical computing (R Foundation for Statistical Computing, http://www.R-project.org). Student t-tests were performed for continuous data and χ 2 or Fisher exact tests were performed for categorical data. Two-tailed p values < 0.05 were considered statistically signi cant. Cohen's Kappa statistic was calculated to assess interobserver agreement of prospective de nitive treatment designations and inter-observer agreement of retrospective data abstraction.   The average time from admission to surgical intervention was 4.2 days (range, 0 to 40 days, SD 6.2). Of the patients who were discharged during the study period, the mean hospital length of stay was 11.6 days and the median length of stay was 6 days (range, 1 to 46 days, SD 7.0). Few non-surgical patients were admitted during the study period (8/190, 4.2%); the majority were pediatric patients with a mid-shaft femur fracture that were treated with Plaster of Paris casting. Among patients indicated for surgical intervention, less than half received de nitive fracture treatment (Fig. 2).  Legend: 2018 data represents annualized data from the corresponding retrospective data collection periods.

Discussion
The need for timely, safe, and affordable basic surgical services in Sub-Saharan Africa is clear. We found that over 95% of prospective patients admitted to the orthopaedic ward at KCMC were indicated for operative intervention; this is in line with our previous ndings.(4) In 2015, 57.9% of surgical candidates were taken to the operating room for treatment. However, this group included both patients who received temporizing treatments such as bedside irrigation or traction pin placement and those that received de nitive treatment (ORIF, intramedullary nailing or removal of implant). In the current study, we subcategorized patients into two groups: temporizing treatment and de nitive xation. While over 70% of surgical candidates were taken to the operating room for any surgical treatment, only 44.5% of the total received de nitive treatment for their fracture. We believe that by excluding procedures that did not provide de nitive treatment, this percentage is a more accurate re ection of the current surgical system's ability to de nitively treat orthopaedic patients.
Several surgical system constraints prevent the delivery of de nite fracture treatment including: 1) the patient's inability to pay for surgery, 2) a lack of a steady supply of expensive orthopaedic implants and 3) an inadequate number of operating theaters, which compromises surgical capacity. The lack of affordability is a major constraint. For the operative procedure alone, the out of pocket cost at KCMC is over $100 (230,000 TZS as per the foreign exchange rate on 5/26/2020), signi cantly more than the average Tanzanian monthly income. Additional fees for implants, imaging, medications, and hospital stay nancially overwhelm patients and their family. Our group's previous work at KCMC revealed that nearly 75% of orthopaedic patients reported catastrophic healthcare expenditures when seeking care for their injuries -without making care affordable, de nitive fracture treatment will never be readily available. (8,9) With local government's inability to dedicate required resources to improve road safety laws, infrastructure and road safety education, injuries from RTCs will continue to rise as motorized transport becomes the mainstay in the developing world. As in 2015, RTC was the most common mechanism of injury for admitted patients in the current study. Motorcycles, a very common form of inexpensive transport, represented over two-thirds of RTC injuries; patients sustained their injuries either as a driver, passenger or pedestrian. The majority of patients were admitted for fracture care, with nearly 84% having at least one lower extremity fracture and more than 75% were male. Untreated lower extremity fractures confer a great deal of long-term morbidity as the lack of infrastructure result in most LMICs being nonwheelchair accessible. The high prevalence of injured males signi cantly impacts the Tanzanian economy as most patients do not return to the work force without de nitive surgical xation. (9) Analysis of the retrospective data revealed a 35% increase in the overall orthopaedic disease burden between 2015 and 2018. When assessing the individual components, the ED exhibited a 35.1% decrease in consultations, the outpatient clinic demonstrated a 76.6% increase in the patients evaluated and orthopaedic ward admissions increased by 16.9%. These ndings re ect an increase in clinic capacity; KCMC increased the frequency of outpatient clinics from two weekly in 2015 to ve weekly in 2018. With the increased outpatient clinic capacity, many patients historically seen in the ED were redirected to the orthopaedic outpatient clinic for evaluation. Over the study period, 1,179 fewer patients were evaluated in the ED in 2018 compared to 2015. Even if these patients were preferentially seen in the outpatient clinic, this transfer did not account for the additional 3,700 patients seen in 2018 compared to 2015. The exhibited increase in inpatient ward admissions represents the overall increased demand for orthopaedic services -the musculoskeletal disease burden at KCMC is persistent and growing.
Potential non-epidemiological causes for the increase in musculoskeletal disease burden at KCMC were considered. However, there were no closures of hospitals in the region that provided orthopaedic surgery, nor was there any signi cant improvement in road infrastructure in the area -both of which might have resulted in an increased burden of disease presenting to KCMC.
Our secondary analysis demonstrated that of the 3,802 patients seen as an outpatient, 61.3% (2,330) had some form of health insurance. This was an increase from 2015, where only 42.6% (227/532) of patients were insured. This is a favorable trend for Tanzania, where Universal Health Coverage (UHC) has been a goal since the World Health Organization advocated for UHC in every country by 2030. However, these percentages far exceed the level of national health insurance coverage in Tanzania, reported to be 16-32%. (10,11) Other studies support the disproportionately high health insurance utilization among patients who voluntarily seek surgical services.(8, 12) In our study, nearly 40% of patients paid out of pocket for outpatient services, and it is speculated that potential patients without insurance may avoid seeking care due to perceived or real costs associated with treatment. Regardless, the Tanzanian Government has rea rmed its commitment to UHC, announcing new insurance packages for the National Health Insurance Fund (NHIF), with the stated goal of increasing enrollment to over 50% by the end of 2020. (11) Among the strengths of this study is that it provides actual country speci c data on the burden of musculoskeletal disease in a LMIC. Such data remains scarce, with most burden of surgical disease estimates extrapolated from indirect methods, such as demographic surveillance systems, household surveys and a combination of models. (13,14) An important limitation to this study is that it only includes patients that present to a tertiary care center -patients in the region that sustain orthopaedic injuries may never seek care due to system constraints (lack of transportation, travel distance and unaffordability). In addition, alternative healers continue to be common in northern Tanzania. Other Sub-Saharan African studies have reported that as many as 85% of people who suffer an acute fracture rst visit alternative healers (including traditional "bone setters") for care. (15) Further work has been undertaken by our research team to more accurately characterize the utilization and role of alternative healers in northern Tanzania. Identifying ways to collaborate with alternative healers will aid in the awareness of allopathic medical centers and the provision of services. (16) Regarding the retrospective arm of this study, our conclusions were limited by patient record availability.
Shortcomings in record keeping in this setting usually lead to the omission of patients and/or cases, rather than the inclusion of patients and cases that did not exist. The ultimate result of these data shortcomings would be the underestimation of disease burden. For this reason, we feel comfortable reporting the increasing trend in musculoskeletal disease burden in this region.
This study also excluded orthopaedic spine patients. At the time of this study, resources were unavailable at KCMC to treat these patients surgically. The inclusion of spine injured patients would have increased the total number of musculoskeletal patients seen at KCMC as well as signi cantly increase the number of patients who did not receive surgery but for whom surgery was indicated. In addition, the de nition of "de nitive treatment" was subjective. If intramedullary nailing or ORIF was performed, the procedure was deemed to be de nitive, but the xation technique, surgical approach, implant used, or other technical criteria were not used to evaluate the reconstruction. Furthermore, de nitive treatment does not guarantee a favorable outcome; preliminary investigation into post-operative rehabilitation services available via KCMC have shown this to be an area in need of substantial development. With known resource limitations in implant availability, the percentage of orthopaedic injuries effectively treated with surgery is likely lower than our calculations suggest.
Surgical candidates who did not receive surgery received skeletal traction. While we believe this treatment option likely leads to long-term deleterious outcomes, we have as of yet been unable to design a strategy and protocol to capture this data, which can be elusive due to prohibitively poor follow up in these patients. Collecting this data remains an important goal of our research team.

Conclusions
The Global Burden of Disease 2017 study predicts a 26.0% increase in worldwide road tra c injuries by 2030; this study supports this projection. (17) The burden of orthopaedic surgical disease seen at KCMC is dominated by trauma and is increasing at a rate similar to or above that of global estimates. (4) Signi cantly fewer available resources leaves a growing burden of neglected orthopaedic surgical disease. Without new strategies to address this worsening situation, the discrepancy between supply and demand for musculoskeletal surgical care in the developing world will continue to grow.
Collaborative efforts are underway to develop an Orthopaedic Center of Excellence at KCMC. Volunteer surgeons at leading international academic institutions will provide year-round surgical services, specialty training, sustainable access to implants, and a mechanism by which to address post-operative complications. (18, 19) This venture's nancial structure is devised to deliver democratized orthopaedic care -patients would have access to care regardless of their ability to pay. The foundation of this longterm partnership with KCMC is based on education at every level -a critical component of creating a approval prior to data collection and analysis. As all clinical data was de-identi ed and no protected health information for any patient was disclosed, informed consent was waived. Consent for publication Not applicable.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.