Saving life and limb: limb salvage using external fixation, a multi-centre review of orthopaedic surgical activities in Médecins Sans Frontières

PURPOSE: While the orthopaedic management of open fractures has been well-documented in developed settings, limited evidence exists on the surgical outcomes of open fractures in terms of limb salvage in low- and middle-income countries. We therefore reviewed the Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB) orthopaedic surgical activities in the aftermath of the 2010 Haiti earthquake and in three non-emergency projects to assess the limb salvage rates in humanitarian contexts in relation to surgical staff skills. METHODS: This was a descriptive retrospective cohort study conducted in the MSF-OCB surgical programmes in the Democratic Republic of Congo (DRC), Afghanistan, and Haiti. Routine programme data on surgical procedures were aggregated and analysed through summary statistics. RESULTS: In the emergency post-earthquake response in Haiti, 81 % of open fracture cases were treated by amputation. In a non-emergency project in a conflict setting in DRC, relying on non-specialist surgeons receiving on-site supervision and training by experienced orthopaedic surgeons, amputation rates among open fractures decreased by 100 to 21 % over seven years of operations. In two trauma centres in Afghanistan (national surgical staff supported from the outset by expatriate orthopaedic surgeons) and Haiti (national musculoskeletal surgeons trained in external fixation), amputation rates among long bone open fracture cases were stable at 20 % and <10 %, respectively. CONCLUSIONS: Introduction of and training on the proper use of external fixators reduced the amputation rate for open fractures and consequently increased the limb salvage rates in humanitarian contexts where surgical care was provided.