The Open fracture National Evaluation (ONE) Study - South Africa: Improving outcomes in the care of open fractures in low resource settings

Lead Research Organisation: University of Oxford
Department Name: Botnar Research Centre


Injuries are the leading cause of death in people aged between 10-49 years. More people die from injuries than from HIV, malaria, and tuberculosis combined. For every person who dies, up to 50 people survive but become disabled.

Open fractures are amongst the most devastating type of MSK injury. An open fracture is a break of a bone where part of the bone comes out through the skin and can result in catastrophic consequences, including high rates of infection and amputation. They most commonly affect people living in poor regions around the world, such as countries in Africa. It is not known how many people in Africa sustain an open fracture, what healthcare services are available to treat them or how best to improve their recovery. Without this fundamental information, it is difficult to know how to improve the care of these complex injuries in resource limited settings.

To improve the outcomes of open fractures in low resource settings.

This project will be undertaken across multiple hospitals in South Africa.

1. Assess current healthcare resources (facilities, equipment, and people) that exist to treat open fractures
2. Determine the number of people affected by an open fracture across South Africa
3. Assess the feasibility to undertake a large-scale clinical study, with the goal of improving the recovery of patients who have experienced an open fracture in a low resource environment

Objectives will be answered through four connect project work packages;
Work Package 1. Define the healthcare resources available for the treatment of open fractures: I will describe the healthcare resources currently available to treat open fractures across South Africa.
Work Package 2. Determine the size of the problem: I will work with a network of collaborating hospitals throughout South Africa to determine how commonly open fractures occur.
Work Package 3: Implement a multi-hospital feasibility study: Through my network of collaborating hospitals, I will undertake a multi-hospital study to 'test' if it is possible to do large-scale research studies of patients suffering from an open fracture.

My research will impact the care of patients in three ways;
1. By understanding current treatment service availability, healthcare managers will be able to identify and fill gaps in service readiness.
2. By knowing the number and type of open fractures presenting to their healthcare centre, clinicians will be able to better allocate resources for open fracture management.
3. By 'testing' if it is possible to do a large-scale research study in open fracture care, clinicians will build the local research capacity and infrastructure for a future nationwide study to improve the care of patients suffering open fractures in low source settings.

In summary, this project will provide key information to help local healthcare workers and policy makers plan future delivery of open fracture care. Without this work it is unlikely, given current limited evidence, that the care of these complex injuries in developing countries will improve.

Technical Summary

Aim: To improve the outcomes of open fractures in low resource settings.

Objectives: This project will evaluate the burden of and available healthcare services for open fracture care across South Africa and assess the feasibility of a randomised controlled trial (RCT) aiming to improve open fracture care in low resource settings.

Study site: Multiple hospitals in South Africa.

Methods: Objectives will be addressed by three connected work packages (WP);
WP 1: Describe the healthcare resources for the treatment of open fractures: I will adapt the World Health Organization Service Availability and Readiness Assessment (SARA) framework to "assess and monitor the service availability and readiness of the health sector and to generate evidence to support the planning and managing of a health system" related to open fracture care.

WP 2: Quantify the incidence of open fractures: I will undertake a "snap-shot" cohort study to determine the nationwide incidence of open fractures across South Africa.

WP 3: Implement a multi-centre feasibility study: I will undertake a multi-centre feasibility study for a future RCT based on one healthcare intervention, prophylactic antibiotic use for the prevention of infection in the management of open fractures in South Africa. This will determine if a RCT is possible in this challenging setting and develop research capacity to undertake clinical trials in trauma surgery in low- and middle-income countries (LMIC).

Scientific & medical impact: This project will contribute valuable knowledge to this significant global health challenge with health, economic and societal impact. It will establish much needed evidence to inform future policy decisions on how best to improve open fracture care across South Africa and other LMIC. Following on from this project I will undertake a full RCT underpinned by the information from the feasibility study and develop a sustainable platform for future collaborative RCTs across LMIC.


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