Assessing Lower Limb Orthopaedic Function in Patients With Muskuloskeletal Disorders and Injuries in Northern Tanzania

Evgeny Bulat MA 1, Sonya Davey MPhil 1, Amani Lupenza MD 2, Honest Massawe MD 2, Anthony Pallangyo MD 2, Ajay Premkumar MD MPH 3, Neil Sheth MD 4

1 Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; 2 Department of Orthopaedics and Traumatology, Killimanjaro Christian Medical Center, Moshi, Tanzania3 Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA; 4 Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA

Methods•  A cross-sectional survey conducted over 3 weeks and 5

consecutive, bi-weekly outpatient orthopaedics clinic days at KCMC in June/July 2016

•  Approved by KCMC’s research ethics committee•  Survey was translated into Swahili and assessed both

socioeconomic and functional orthopaedic outcomes.•  All patients presenting to the clinic were solicited for study

participation after being informed that it is entirely voluntary, would not affect their care, and is without preference towards age, sex, disability, or socioeconomic status.

•  200 out of an estimated 335 patients (60%) agreed to participate in the survey, with a 91-95% estimated completion rate.

Introduction•  While over 40% of the

world’s population lives inLMICs, fewer than 5% of allsurgeries take place there.

•  Only about 12% of Northern Tanzanians haveaccess to musculoskeletal(MSK) surgical care.

•  In general, LMICs likeTanzania are under-represented in clinical and quality improvement research, especially using patient-reported outcomes measurements (PROMs).

•  Goal: To apply the HOOS JR and KOOS JR outcomes instruments to examine the hip and knee functional health status of patients in the outpatient orthopaedic clinic at Kilimanjaro Christian Medical Center.

•  Broader impact: An improved understanding of patient-reported outcomes for the LMIC orthopaedic/MSK patient population that would inform future quality improvement.

Results

Discussion•  Main idea: The HOOS JR and KOOS JR instruments

may be effective in capturing PROMs regarding functional hip and knee orthopaedic/MSK outcomes in the Northern Tanzanian oupatient population.

•  Study limitations:1)  Cross-sectional survey design without follow-up2)  Participation bias in terms of literacy, familiarity with

the survey format, and either degree of injury or physical ability

3)  Not a formal validation study•  Future directions: Perform a formal validation study to

establish normal score distributions, and use the instruments to research and track orthopaedic/MSK treatment outcomes after healthcare innovation.

•  Acknowledgements: Ms. Halima Said for assistance with translation and data entry.

Table 1: Study cohort demographics.  N   N

Age  195

Injury location (%)  

197

Mean (SD) 44 (20) Neck 6 (3) Median (IQR) 47 (30.5) Arm 34 (17)

  Back 49 (25) Sex (%)  

196 Hip 40 (20)

Male 110 (56) Leg 107 (54) Female 86 (44) Knee 31 (16)

  Lower limb (hip, leg, knee) 149 (76) Reason for visit (%)  

183

Multiple injuries 43 (22) Chronic condition 75 (41)   Acute injury 27 (15) Ability to perform daily tasks (%)  

193 Follow-up post-treatment 81 (44) Worsened as a result of injury 115 (60)  Not worsened as a result of injury 78 (40)

Time since injury in months  172

  Mean (SD) 49 (85) Treatment status (%)  

170 Median (IQR) 12 (48) Both operative and non-operative 20 (12)

  Only operative 35 (21) Only non-operative 34 (20) No treatment 81 (48)

Figure 1: Non-parametric comparison of functional hip outcomes (HOOS JR, left) and functional knee outcomes (KOOS JR, right) across hip and knee injury statuses. Higher scores indicate greater functional impairment.

Take-away: Both the HOOS JR and KOOS JR may be sensitive to hip and knee injury, respectively, although their specificity may be more limited and the scores have to be taken in the context of clinical presentation.

Group 1 Group 2 Comparison P-value Hip injured Hip not injured < 0.001 Hip injured Knee injured 0.02 Hip injured Knee not injured < 0.001

Group 1 Group 2 Comparison P-value Knee injured Knee not injured 0.02 Knee injured Hip injured 0.72 Knee injured Hip not injured 0.03

Table 2: Multivariate modeling of HOOS JR and KOOS JR outcomes based on select study population variables.  HOOS JR KOOS JR Variable Weight coefficient P-value Weight coefficient P-value Hip injury 4.02 0.04 3.28 0.28 Knee injury 1.07 0.52 6.06 0.01 Back injury 4.10 0.02 3.35 0.21 Leg injury 0.94 0.49 3.89 0.05 >1 injury 0.76 0.74 2.56 0.48 Age of injury 0.02 0.06 0.01 0.50 Age 0.07 0.03 0.07 0.10 Female sex 0.46 0.69 3.82 0.02 Decreased daily task ability 3.16 0.01 4.18 0.02

Note: Generalized normal linear regression analysis was used for modeling purposes. A positiveweight suggests that either the presence (binary) or increasing value (non-binary) of a variablepredicts higher HOOS JR/KOOS JR scores (i.e. greater functional hip or knee impairment).

Take-away: For functional hip outcomes, hip injury and back injury were the strongest predictors of worse outcomes, followed by a decreased ability to complete daily tasks and, to a small degree, the patient’s age. For functional knee outcomes, knee injury was the strongest predictor of worse outcomes, followed by a decreased ability to complete daily tasks and female sex.