title: Orthopaedic surgery in natural disaster and conflict settings: how can quality care be ensured?
abstract: OBJECTIVE
  Médecins sans Frontières (MSF) is one of the main providers of orthopaedic surgery in natural disaster and conflict settings and strictly imposes a minimum set of context-specific standards before any surgery can be performed. Based on MSF's experience of performing orthopaedic surgery in a number of such settings, we describe: (a) whether it was possible to implement the minimum standards for one of the more rigorous orthopaedic procedures--internal fixation--and when possible, the time frame, (b) the volume and type of interventions performed and (c) the intra-operative mortality rates and postoperative infection rates.
  
  
  METHODS
  We conducted a retrospective review of routine programme data collected between 2007 and 2014 from three MSF emergency surgical interventions in Haiti (following the 2010 earthquake) and three ongoing MSF projects in Kunduz (Afghanistan), Masisi (Democratic Republic of the Congo) and Tabarre (Haiti).
  
  
  RESULTS
  The minimum standards for internal fixation were achieved in one emergency intervention site in Haiti, and in Kunduz and Tabarre, taking up to 18 months to implement in Kunduz. All sites achieved the minimum standards to perform amputations, reductions and external fixations, with a total of 9,409 orthopaedic procedures performed during the study period. Intraoperative mortality rates ranged from 0.6 to 1.9 % and postoperative infection rates from 2.4 to 3.5 %.
  
  
  CONCLUSIONS
  In settings affected by natural disaster or conflict, a high volume and wide repertoire of orthopaedic surgical procedures can be performed with good outcomes when minimum standards are in place. More demanding procedures like internal fixation may not always be feasible.
authors.affiliation: Médecins sans Frontières - Operational Centre Brussels (MSF-OCB), Brussels, Belgium.
authors.forename: Oscar
authors.initials: O
authors.lastname: Alvarado
authors.affiliation: Médecins sans Frontières - Operational Centre Brussels (MSF-OCB), Brussels, Belgium.|MSF-OCB Surgery, Anaesthesia, Gynaecology, and Emergency Medicine Unit, Brussels, Belgium.
authors.forename: Miguel
authors.initials: M
authors.lastname: Trelles
authors.affiliation: Médecins sans Frontières - Operational Centre Brussels (MSF-OCB), Brussels, Belgium. katietaylersmith@gmail.com.|MSF-OCB, Operational Research Unit, MSF-Luxembourg, Luxembourg, Luxembourg. katietaylersmith@gmail.com.
authors.forename: Katie
authors.initials: K
authors.lastname: Tayler-Smith
authors.affiliation: Médecins sans Frontières - Operational Centre Brussels (MSF-OCB), Brussels, Belgium.|Tabarre Referral Centre for Surgical and Orthopaedic Care, Port-au-Prince, Haiti.
authors.forename: Holdine
authors.initials: H
authors.lastname: Joseph
authors.affiliation: Médecins sans Frontières - Operational Centre Brussels (MSF-OCB), Brussels, Belgium.|Tabarre Referral Centre for Surgical and Orthopaedic Care, Port-au-Prince, Haiti.
authors.forename: Rodné
authors.initials: R
authors.lastname: Gesline
authors.affiliation: Médecins sans Frontières - Operational Centre Brussels (MSF-OCB), Brussels, Belgium.|Tabarre Referral Centre for Surgical and Orthopaedic Care, Port-au-Prince, Haiti.
authors.forename: Thélusma Eli
authors.initials: TE
authors.lastname: Wilna
authors.affiliation: Médecins sans Frontières - Operational Centre Brussels (MSF-OCB), Brussels, Belgium.|Kunduz Trauma Centre, Kunduz, Afghanistan.
authors.forename: Mohammad Karim
authors.initials: MK
authors.lastname: Mohammad Omar
authors.affiliation: Médecins sans Frontières - Operational Centre Brussels (MSF-OCB), Brussels, Belgium.|Kunduz Trauma Centre, Kunduz, Afghanistan.
authors.forename: Niaz Mohammad
authors.initials: NM
authors.lastname: Faiz Mohammad
authors.affiliation: Médecins sans Frontières - Operational Centre Brussels (MSF-OCB), Brussels, Belgium.|Masisi General Referral Hospital, North Kivu, Democratic Republic of the Congo.
authors.forename: John
authors.initials: J
authors.lastname: Muhima Mastaki
authors.affiliation: Médecins sans Frontières - Operational Centre Brussels (MSF-OCB), Brussels, Belgium.|Masisi General Referral Hospital, North Kivu, Democratic Republic of the Congo.
authors.forename: Richard
authors.initials: R
authors.lastname: Chingumwa Buhu
authors.affiliation: Médecins sans Frontières - Operational Centre Brussels (MSF-OCB), Brussels, Belgium.|MSF-OCB Infection Control Unit, Brussels, Belgium.
authors.forename: An
authors.initials: A
authors.lastname: Caluwaerts
authors.affiliation: Médecins sans Frontières - Operational Centre Brussels (MSF-OCB), Brussels, Belgium.|MSF-OCB Surgery, Anaesthesia, Gynaecology, and Emergency Medicine Unit, Brussels, Belgium.
authors.forename: Lynette
authors.initials: L
authors.lastname: Dominguez
mesh_terms: D000346:Afghanistan; D003223:Congo; D004190:Disasters / Q000706:statistics & numerical data*; D055866:Earthquakes; D006205:Haiti; D006801:Humans; D019637:Orthopedic Procedures / Q000009:adverse effects / Q000379:methods / Q000592:standards*; D011183:Postoperative Complications; D011785:Quality Assurance, Health Care / Q000592:standards*; D011787:Quality of Health Care / Q000592:standards*; D012189:Retrospective Studies
keywords: Internal fixation; Minimum standards; Natural disaster and conflict settings; Orthopaedic surgery