Access to operative fracture fixation resources and implants in orthopaedic trauma care in low- and middle-income countries: a systematic review.

Objectives: The burden of orthopaedic trauma has continued to increase with a disproportionate impact on low- and middle-income countries (LMICs), in part due to inadequacy of resources for operative fracture fixation. The objective of this study was to evaluate the available literature regarding the availability of equipment and implants for operative fracture care in LMICs and the barriers to accessing these resources. Data Sources: A comprehensive literature search was conducted in the PUBMED, SCOPUS, EMBASE, and WEB OF SCIENCE databases for the period January 2003 to December 2023 using search terms including "implants," "hardware," "availability," "accessibility," and "access" to identify relevant records published in English. Study Selection: All studies that assessed the availability of implants for operative fracture fixation in LMICs were included. Data Extraction: Articles were critically appraised for their methodological quality using the JBI critical appraisal checklist for qualitative research. Data were manually extracted into a predesigned data extraction template. Data Synthesis: Data were synthesized through basic pooling and summarized using descriptive statistics, including percentages and proportions. Results: Seven hundred twenty-two records were identified, and 11 articles comprising 488 health care facilities from 8 LMICs met the inclusion criteria for analysis. The included studies were all observational, including 8 cross-sectional surveys and 3 qualitative case studies. Findings included little to no capability of performing internal or external fixation at small, community hospitals. Resources were still generally inadequate for treating orthopaedic injuries at larger, tertiary hospitals. Private hospitals and tertiary hospitals with medical schools are the best equipped. Barriers identified included the high cost of implants and reliance on imported implants, lack of government funding and trauma system organization, patients needing to procure their own implants, and even corruption and poor leadership. Solutions proposed included improved funding for trauma care, prioritizing orthopaedic services and providing continuing trauma education, defining essential equipment necessary for orthopaedic care, strengthening resource monitoring and organization, and encouraging local implant manufacturing. Conclusions: Inadequate availability of fracture fixation implants and equipment is a major challenge in LMICs. There is little known about the availability of specific orthopaedic equipment and implants at the specialist level of fracture care. A future study aimed at evaluating the availability of specific orthopaedic equipment and implants necessary for specialized fracture care in these countries is recommended to identify key areas for improvement. Ideally, orthopaedic surgeons working in these settings could be surveyed to determine which resources are most critically lacking and should be prioritized to enhance the delivery of adequate care. Level of Evidence: IV.