{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T14:35:50Z","timestamp":1787754950750,"version":"build-2784847793"},"reference-count":24,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"4","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2021,2,17]]},"abstract":"<jats:sec>\n                    <jats:title>Background:<\/jats:title>\n                    <jats:p>The burden of musculoskeletal trauma is increasing worldwide, especially in low-income countries such as Malawi. Ankle fractures are common in Malawi and may receive suboptimal treatment due to inadequate surgical capacity and limited provider knowledge of evidence-based treatment guidelines.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>This study was conducted in 3 phases. First, we assessed Malawian orthopaedic providers\u2019 understanding of anatomy, injury identification, and treatment methods. Second, we observed Malawian providers\u2019 treatment strategies for adults with ankle fractures presenting to a central hospital. These patients\u2019 radiographs underwent blinded, post hoc review by 3 U.S.-based orthopaedic surgeons and a Malawian orthopaedic surgeon, whose treatment recommendations were compared with actual treatments rendered by Malawian providers. Third, an educational course addressing knowledge deficits was implemented. We assessed post-course knowledge and introduced a standardized management protocol, specific to the Malawian context.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>In Phase 1, deficits in injury identification, ideal treatment practices, and treatment standardization were identified. In Phase 2, 17 (35%) of 49 patients met operative criteria but did not undergo a surgical procedure, mainly because of resource limitations and provider failure to recognize unstable injuries. In Phase 3, 51 (84%) of 61 participants improved their overall performance between the pre-course and post-course assessments. Participants answered a mean of 32.4 (66%) of 49 questions correctly pre-course and 37.7 (77%) of 49 questions correctly post-course, a significant improvement of 5.2 more questions (95% confidence interval [CI], 3.8 to 6.6 questions; p &lt; 0.001) answered correctly. Providers were able to identify 1 more injury correctly of 8 injuries (mean, 1.1 questions [95% CI, 0.6 to 1.6 questions]; p &lt; 0.001) and to identify 1 more ideal treatment of the 7 that were tested (mean, 1.0 question [95% CI, 0.5 to 1.4 questions]; p &lt; 0.001).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions:<\/jats:title>\n                    <jats:p>Adult ankle fractures in Malawi were predominantly treated nonoperatively despite often meeting evidence-based criteria for surgery. This was due to resource limitations, knowledge deficits, and lack of treatment standardization. We demonstrated a comprehensive approach to examining the challenges of providing adequate orthopaedic care in a resource-limited setting and the successful implementation of an educational intervention to improve care delivery. This approach can be adapted for other conditions to improve orthopaedic care in low-resource settings.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.2106\/jbjs.20.00660","type":"journal-article","created":{"date-parts":[[2020,12,24]],"date-time":"2020-12-24T15:56:38Z","timestamp":1608825398000},"page":"326-334","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":6,"title":["Improving Management of Adult Ankle Fractures in Malawi"],"prefix":"10.2106","volume":"103","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1485-5950","authenticated-orcid":false,"given":"Kiran J.","family":"Agarwal-Harding","sequence":"first","affiliation":[{"name":"Harvard Global Orthopaedics Collaborative, Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts"},{"name":"The Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women\u2019s Hospital, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9452-1522","authenticated-orcid":false,"given":"Ami","family":"Kapadia","sequence":"additional","affiliation":[{"name":"University of Texas Southwestern School of Medicine, Dallas, Texas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2107-2615","authenticated-orcid":false,"given":"Leonard Ngoie","family":"Banza","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Kamuzu Central Hospital, Lilongwe, Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6002-1482","authenticated-orcid":false,"given":"Mabvuto","family":"Chawinga","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Kamuzu Central Hospital, Lilongwe, Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1357-8173","authenticated-orcid":false,"given":"Nyengo","family":"Mkandawire","sequence":"additional","affiliation":[{"name":"Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi"},{"name":"College of Medicine, University of Malawi, Blantyre, Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7639-2202","authenticated-orcid":false,"given":"John Y.","family":"Kwon","sequence":"additional","affiliation":[{"name":"Division of Foot and Ankle Surgery, Department of Orthopaedics, Beth Israel Deaconess Hospital, Boston, Massachusetts"},{"name":"Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2020,12,24]]},"reference":[{"issue":"9859","key":"bib2-20250502","doi-asserted-by":"crossref","first-page":"2095","DOI":"10.1016\/S0140-6736(12)61728-0","article-title":"Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010","volume":"380","author":"Lozano","year":"2012","journal-title":"Lancet."},{"issue":"3","key":"bib3-20250502","doi-asserted-by":"crossref","first-page":"e91862","DOI":"10.1371\/journal.pone.0091862","article-title":"Health and economic benefits of improved injury prevention and trauma care worldwide","volume":"9","author":"Kotagal","year":"2014","journal-title":"PLoS One."},{"issue":"9859","key":"bib4-20250502","doi-asserted-by":"crossref","first-page":"2163","DOI":"10.1016\/S0140-6736(12)61729-2","article-title":"Years lived with disability 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