# Expanding Access to Orthopedic Trauma Care: Evaluation of a Task‐Sharing Model With a Remote Quality Assessment Tool for Open Tibia Shaft Fractures in Malawi

## TL;DR

A task-sharing model for treating open tibia fractures in Malawi showed good results at central hospitals but struggled at district hospitals due to lack of support.

## Contribution

The study introduces a remote quality assessment tool (FFATEF) and evaluates a task-sharing model for orthopedic trauma care in low-resource settings.

## Key findings

- Central hospitals achieved higher FFATEF scores (median 10.0) compared to district hospitals (median 6.0).
- Satisfactory technical performance (≥8 FFATEF score) was 93% at central hospitals but only 32% at district hospitals.
- Preoperative antibiotic compliance was 100% at central hospitals versus 47% at district hospitals.

## Abstract

Timely care for open tibia fractures remains difficult in low‐resource settings. We evaluated a task‐sharing model in Malawi in which trained orthopedic clinical officers (OCOs) delivered external fixation supported by a remote quality assessment tool.

We conducted a prospective implementation evaluation across one central and four district hospitals (May 2023–July 2024). The intervention bundled OR refurbishment assured external fixator supply, refresher training, mentoring (on‐site and remote), national guideline reinforcement, and a novel Fracture Fixation Assessment Tool for External Fixation (FFATEF). OCOs submitted postoperative radiographs and construct photographs for scoring across four domains (reduction, stability, implantation, and surgical impression; total 0–12 and satisfactory ≥ 8). Nonparametric tests compared performance by the hospital type; temporal trends were assessed with Spearman correlation.

Forty‐seven patients (89% male and mean age 32.3 years) were treated (central: n = 28 and district: n = 19). The central hospital managed more severe injuries (Gustilo IIIA/B 69.6% vs. 15.8%). Median FFATEF scores were higher at the central hospital (10.0 [IQR 9–11]) than district hospitals (6.0 [5, 6, 7, 8], p < 0.001). Satisfactory scores (≥ 8) occurred in 93% of central versus 32% of district cases. Central scores improved over time (ρ = 0.52; p = 0.005) whereas district scores were unchanged (ρ = 0.15; p = 0.540). Preoperative antibiotic compliance was 100% at the central versus 47% at district hospitals.

When embedded within integrated surgical teams and adequate infrastructure, task sharing for open fracture external fixation yielded satisfactory technical performance but lagged district‐level implementation despite training. Comprehensive institutional support—mentoring intensity, equipment, supply chains, and referral adherence—is likely required for safe scale‐up. Validation of FFATEF against clinical outcomes and economic evaluation of delivery models are priorities.

When embedded within integrated surgical teams and adequate infrastructure, task sharing for open fracture external fixation yielded satisfactory technical performance but lagged district‐level implementation despite training. Comprehensive institutional support—mentoring intensity, equipment, supply chains, and referral adherence—is likely required for safe scale‐up. Validation of FFATEF against clinical outcomes and economic evaluation of delivery models are priorities.