Surgical burden of osteomyelitis and factors associated with chronic disease in a rural district of Rwanda

Surgical burden of osteomyelitis and factors associated with chronic disease in a rural district of Rwanda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Surgical burden of osteomyelitis and factors associated with chronic disease in a rural district of Rwanda Jean Paul Nsengiyumva, Schuler Peter This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8590297/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This mixed-methods study assessed the prevalence of osteomyelitis-related surgical procedures and factors associated with chronic osteomyelitis in a rural district of Rwanda. Among 385 analysed surgical cases, 27.8% were related to osteomyelitis, indicating that more than one in four surgical procedures were attributable to this condition. Most patients presented with chronic disease, reflecting substantial delays in diagnosis and referral. Quantitative and qualitative findings identified three key domains associated with chronic osteomyelitis: lack of disease-related knowledge at primary healthcare level, limited awareness among patients and caregivers, and insufficient cooperation between healthcare structures. These results underscore the clinical and socioeconomic relevance of early diagnosis to prevent progression to chronic osteomyelitis. Chronic Osteomyelitis Surgical burdon Prevalence Risk-Factors low- and middle-income countries (LMICs) I. Background Osteomyelitis is an inflammatory disease of bone and bone marrow, most commonly caused by bacterial infection. In children, acute hematogenous osteomyelitis typically affects the metaphyseal regions of long bones and may progress rapidly if not diagnosed and treated early [1,2]. With timely antibiotic therapy and appropriate surgical intervention when indicated, acute osteomyelitis can usually be cured without long-term sequelae [3,4]. In contrast, delayed diagnosis and inadequate treatment frequently lead to chronic osteomyelitis, characterized by sequestrum formation, chronic fistulae, recurrent infection, and functional impairment [5,6]. While chronic osteomyelitis has become relatively rare in high-income countries, it remains highly prevalent in many low- and middle-income countries (LMICs), particularly in sub-Saharan Africa [7–9]. The persistence of chronic osteomyelitis in low-income countries is closely linked to health system constraints. Limited access to diagnostic resources, insufficient disease-related knowledge at primary healthcare level, delayed healthcare-seeking behavior, and fragmented referral pathways have been identified as key contributors to late presentation and disease progression [3,10,11]. As a result, district hospitals in rural settings face a disproportionate surgical burden related to advanced osteomyelitis. Understanding the magnitude of this burden and the underlying system-related causes is essential for the development of effective prevention strategies. This study therefore aims to quantify the surgical burden of osteomyelitis at district hospital level and to explore health system barriers contributing to delayed diagnosis and progression to chronic disease using a mixed-methods approach. II. Material and Methods A. Study Design and Setting A descriptive, retrospective, cross-sectional mixed-methods study with a quantitative and a qualitative component was conducted at Kibogora Hospital and Bushenge Hospital in Nyamasheke District, Western Province of Rwanda. B. Quantitative component a) Study period and population For quantitative analysis hospitals records of all surgical procedures performed between January 1, 2016, and December 31, 2020, were reviewed. During this period, a total of 10,305 surgical operations were performed. b) Sample size calculation The required sample size was calculated using the Yamane formula for finite populations: c) Sampling procedure Systematic random sampling was used to select records proportionally from both hospitals. d) Data extraction Data was extracted using a structured data collection form, including patient demographics, diagnosis (acute or chronic osteomyelitis), residence, health insurance status, transfer time from health centers to hospitals, and prior treatment by traditional healers. C. Qualitative component a) Study design A qualitative approach was chosen to capture perspectives and experiences that could not be adequately assessed through retrospective record review alone, particularly at the level of primary healthcare and patient healthcare-seeking behaviour. The qualitative component was designed as a descriptive exploratory study to complement the quantitative findings and to provide contextual insight into healthcare pathways, decision-making processes, and perceived barriers related to the diagnosis and management of osteomyelitis. b) Participants The qualitative component consisted of in-depth interviews with 12 nurses working at health centers within Nyamasheke District as well as 14 patients with osteomyelitis and/or parents of affected children. Participants were selected purposively. Nurses were eligible for inclusion if they were involved in patient assessment, referral, or follow-up of musculoskeletal infections at primary healthcare level. Patients and parents were eligible if a diagnosis of osteomyelitis had been established at district hospital level. c) Data Collection Data were collected through semi-structured, in-depth interviews using interview guides tailored to each participant group. Interview guides were informed by a review of the literature and by preliminary findings from the quantitative component. Interviews were conducted in a private setting at health centers or hospitals and were carried out in Kinyarwanda or English, depending on participant preference. All interviews were audio-recorded with informed consent and supplemented by field notes. Key topics explored included: • recognition and interpretation of early symptoms • diagnostic confidence and referral decision-making • healthcare-seeking behaviour and treatment pathways • communication between health centers and hospitals • perceived barriers to timely diagnosis and treatment d) Data analysis Audio recordings were transcribed verbatim and, where necessary, translated into English. Transcripts were reviewed for accuracy and anonymised prior to analysis. Qualitative data were analysed using thematic content analysis. An inductive approach was applied, allowing codes and themes to emerge directly from the data. Initial coding was performed independently by two researchers. Codes were then compared, discussed, and refined to develop a shared coding framework. Codes were subsequently grouped into higher-order categories and themes through an iterative analytic process. Discrepancies were resolved through discussion until consensus was achieved. III. Results A. Quantitative results a) Prevalence of osteomyelitis-related surgical procedures During the study period from January 1, 2016, to December 31, 2020, a total of 10,305 surgical procedures were performed at Kibogora Hospital and Bushenge Hospital in Nyamasheke District. Based on the calculated sample size, 385 surgical records were systematically selected and analysed. Among these procedures, 107 operations (27.8%) were related to osteomyelitis, while 278 operations (72.2%) were performed for other indications. Thus, the prevalence of osteomyelitis-related surgical procedures within the analysed sample was 28%. b) Distribution of acute and chronic osteomyelitis Of the 107 osteomyelitis-related operations, 74 patients underwent a single surgical procedure and were included in the detailed patient profile analysis. The remaining patients required multiple surgical interventions. Among these 74 patients: • 9 patients (12.1%) were diagnosed with acute osteomyelitis • 65 patients (87.9%) were diagnosed with chronic osteomyelitis c) Patient characteristics Sex distribution Among the 74 patients analysed, 42 patients (56.8%) were male and 32 patients (43.2%) were female. Age distribution The age distribution showed that osteomyelitis predominantly affected younger individuals. A total of 48 patients (64.9%) were aged 18 years or younger, while 26 patients (35.1%) were older than 18 years. Health insurance status Of the 74 patients: • 65 patients (87.8%) had health insurance • 9 patients (12.2%) had no health insurance Place of residence The majority of patients lived in rural areas: • 58 patients (78.4%) resided in rural areas • 16 patients (21.6%) resided in urban areas Transfer time from health centers to hospitals Transfer time from the first presentation at a health center to admission at a district hospital varied considerably: • 12 patients (16.2%) were transferred within 0–2 weeks • 19 patients (25.7%) were transferred within 2–4 weeks • 9 patients (12.2%) were transferred within 4–6 weeks • 34 patients (45.9%) were transferred after more than 6 weeks Treatment by traditional healers Prior treatment by traditional healers was documented in 24 patients (32.4%), while 50 patients (67.6%) had not received traditional treatment before hospital admission. Among the 24 patients treated by traditional healers, the duration of treatment varied: • 2 patients (8.3%) were treated for up to 10 weeks • 6 patients (25.0%) were treated for 10–20 weeks • 9 patients (37.5%) were treated for 20–30 weeks • 7 patients (29.2%) were treated for more than 30 weeks d) Summary of quantitative findings Overall, the quantitative analysis demonstrates a high prevalence of osteomyelitis-related surgical procedures and a predominance of chronic osteomyelitis at the time of surgery. The majority of affected patients were children or adolescents, lived in rural areas, and experienced prolonged delays before hospital admission. B. Qualitative results The qualitative analysis was based on in-depth interviews conducted with: • 12 nurses working in health centers within Nyamasheke District • 14 patients diagnosed with osteomyelitis and/or parents of affected children All participants were directly involved in the recognition, management, or experience of osteomyelitis care. a) Delayed recognition of osteomyelitis Nurses consistently reported that osteomyelitis is often not recognised at an early stage, particularly during the initial presentation at health centers. Early symptoms were described as unspecific and difficult to distinguish from other common conditions. Several nurses indicated that suspicion of osteomyelitis usually arose only after persistent symptoms, such as prolonged pain, swelling, abscess formation, or non-healing wounds. b) Limited knowledge and diagnostic confidence at primary healthcare level A recurrent theme was limited knowledge and uncertainty regarding the diagnosis of osteomyelitis among healthcare providers at health centers. Nurses reported difficulties in differentiating osteomyelitis from other infections and expressed a lack of formal training on the disease. Some nurses stated that referrals were delayed because of uncertainty about when osteomyelitis should be suspected or referred to hospital level. c) Inconsistent referral and follow-up processes Participants described inconsistencies in referral pathways between health centers and hospitals. Nurses reported that information exchange was often incomplete and that patients were sometimes sent back to health centers without clear treatment plans or scheduled follow-up appointments. This lack of structured communication was perceived as a barrier to continuity of care. d) Healthcare-seeking behaviour and use of traditional medicine Patients and parents frequently described delays in seeking formal medical care. Some reported initial reliance on traditional healers or home-based treatments, particularly in the early phase of the disease. Several participants indicated that medical care was often sought only after symptoms worsened or functional impairment became evident. e) Socioeconomic and logistical barriers to care Both nurses and patients identified financial constraints, long distances to health facilities, and transportation difficulties as major barriers to timely access to care. Patients reported challenges related to transport costs, loss of income, and difficulties attending follow-up appointments, which contributed to delays in diagnosis and treatment. f) Perceived burden of chronic osteomyelitis Patients and parents described the disease as physically debilitating and socially burdensome. Chronic pain, reduced mobility, prolonged treatment duration, and repeated hospital visits were frequently mentioned. Some participants also reported experiences of social stigma related to chronic wounds and long-term disability. g) Summary of qualitative findings The qualitative results highlight multiple patient-related and healthcare-related factors influencing the recognition and management of osteomyelitis. These findings provide contextual insights into pathways of delayed diagnosis and prolonged disease progression within the study setting. IV. Discussion This mixed-methods study demonstrates that osteomyelitis constitutes a substantial surgical and health system burden in rural Rwanda, with the majority of patients presenting at an advanced, chronic stage of disease. Quantitative analysis showed that osteomyelitis-related procedures accounted for approximately 28% of all surgical interventions performed at district hospital level, indicating that more than one in four surgical procedures were related to osteomyelitis. Importantly, these data reflect an operation-based prevalence and therefore illustrate the burden placed on surgical services rather than population-based incidence. The predominance of chronic osteomyelitis observed in this study is not an inevitable epidemiological phenomenon but rather the consequence of delayed diagnosis and referral. The majority of patients undergoing osteomyelitis-related surgical procedures were children and adolescents, underscoring the disproportionate burden of chronic osteomyelitis in the pediatric population. The study population originated predominantly from rural catchment areas, where long travel distances and limited transport infrastructure may further contribute to delayed presentation at hospital level. Most patients were covered by community-based health insurance; nevertheless, delayed presentation remained common, suggesting that financial coverage alone is insufficient to ensure timely access to care. The qualitative findings provide a coherent explanatory framework for this delay and identify three interrelated system-related barriers: lack of disease-related knowledge, lack of awareness, and lack of cooperation between healthcare structures. Lack of disease-related knowledge at primary healthcare level emerged as a central barrier to early diagnosis. Similar challenges have been reported in other low-resource settings, where early symptoms of acute osteomyelitis are frequently misinterpreted as minor trauma or soft-tissue infection, resulting in delayed referral and inappropriate initial management [3,8]. Limited access to diagnostic tools and insufficient training in musculoskeletal infections further reduce diagnostic confidence among frontline healthcare providers [2,4]. In such contexts, diagnostic uncertainty often leads to prolonged observation rather than timely escalation of care. Lack of awareness among patients and caregivers represents a second major contributor to delayed presentation. Early symptoms such as localized bone pain, swelling, or reduced limb use are frequently underestimated, and healthcare is often sought only when severe pain, fistula formation, or functional impairment occurs. Studies from sub-Saharan Africa describe similar patterns of delayed healthcare-seeking behavior, influenced by sociocultural beliefs, financial constraints, and reliance on traditional healers [6,7,10]. These patient-related delays interact with provider-related delays and substantially increase the risk of progression from acute to chronic disease. The third barrier, lack of cooperation between healthcare structures, reflects broader systemic weaknesses within district health systems. Fragmented referral pathways, limited feedback between health centers and hospitals, and the absence of standardized clinical algorithms hinder continuity of care. Comparable coordination gaps have been described in other low-resource health systems, where communication between levels of care is often informal and inconsistent [5,11]. For osteomyelitis, timely referral within the first four to six weeks is critical; failures at this interface contribute directly to chronic disease development. From a health system perspective, chronic osteomyelitis imposes a disproportionate burden on limited surgical and inpatient resources. Recurrent admissions, repeated surgical debridement, prolonged hospital stays, and long-term antibiotic therapy consume capacity that could otherwise be allocated to other essential surgical conditions [5,6,8]. This reinforces inefficiencies within already constrained district hospital systems. Several limitations should be acknowledged. The quantitative analysis is based on surgical records and therefore reflects the burden of disease among patients requiring operative management rather than population-based incidence. The retrospective nature of the data and reliance on routine documentation may introduce variability in diagnostic classification. Nevertheless, the consistency between quantitative findings and qualitative insights strengthens the validity of the conclusions. In conclusion, chronic osteomyelitis in rural Rwanda is largely driven by delayed diagnosis resulting from modifiable health system barriers. Addressing lack of knowledge, lack of awareness, and lack of cooperation should be central to efforts aimed at reducing disease chronicity and alleviating the associated surgical and socioeconomic burden. Declarations Ethical approval and accordance Ethical approval for this study was obtained from the Rwanda National Ethics Committee (RNEC) IRB: 00001497 OF OORG 0001100. The study protocol was reviewed and approved in accordance with national ethical guidelines and regulations governing research involving human participants in Rwanda. Permission to access hospital records was granted by the administrations of Kibogora Hospital and Bushenge Hospital. Consent to participate Written informed consent was obtained from all participants involved in the qualitative component of the study. For participants under the age of 18 years, written informed consent was obtained from a parent or legal guardian. Participation was voluntary, and confidentiality and anonymity were assured. Consent to publish Not applicable Data availability statement The datasets generated and/or analyzed during the current study are not publicly available due to ethical and confidentiality restrictions but are available from the corresponding author on reasonable request. Clinical trial number : not applicable. Disclosure statement: We declare no conflict of interest regarding this systematic review. Funding: This study was supported through a Rotary–BMZ partnership grant (Federal Ministry for Economic Cooperation and Development, Germany). The funders had no role in the design of the study, data collection, analysis, interpretation of data, or writing of the manuscrip Authors Jean Paul Nsengiyumva¹*, Peter Schuler² Affiliations ¹ Kibogora Polytechnic, Nyamasheke District, Rwanda ² Department of Orthopaedics and Traumatology, ViDia Kliniken, Karlsruhe, Germany Corresponding author Jean Paul Nsengiyumva Kibogora Polytechnic P.O. Box, Nyamasheke District, Rwanda Email: [email protected] References Peltola H, Pääkkönen M. Acute osteomyelitis in children. N Engl J Med. 2014;370:352–360. Jaramillo D, Dormans JP. Imaging of osteomyelitis in children. Radiol Clin North Am. 2017;55:895–915. Riise ØR, Kirkhus E, Handeland KS, Flato B, Reiseter T, Cvancarova M, et al. Delayed diagnosis of acute osteomyelitis in children: a population-based study. Acta Paediatr. 2008;97:936–940. El-Sobky TA, Mahmoud S. Acute osteomyelitis in children: diagnostic and therapeutic challenges. EFORT Open Rev. 2021;6:207–217. Baldan M, Baggio S, Rovere G, et al. Chronic osteomyelitis: pathophysiology and management. J Bone Joint Infect. 2014;1:1–7. Callistus OO, Ademola SA, Oluwadiya KS, Akinola OO. Chronic osteomyelitis in a developing country. Int Orthop. 2015;39:919–924. Ibingira CBR. Chronic osteomyelitis in rural Uganda. East Afr Med J. 2003;80:242–246. Stanley CM, Rutherford GW, Morshed S. Orthopaedic surgery in low-income countries. Clin Orthop Relat Res. 2010;468:2716–2724. Olivier K, et al. Chronic osteomyelitis in sub-Saharan Africa: a neglected disease. Glob Surg. 2019;5:1–6. Deo P. Economic burden of chronic osteomyelitis management in low-income settings. Int J Health Plann Manage. 2018;33:e432–e439. Tissingh EK, van den Akker M, et al. Referral pathways and coordination in low-resource health systems. BMC Health Serv Res. 2022;22:134. Additional Declarations No competing interests reported. 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Background","content":"\u003cp\u003eOsteomyelitis is an inflammatory disease of bone and bone marrow, most commonly caused by bacterial infection. In children, acute hematogenous osteomyelitis typically affects the metaphyseal regions of long bones and may progress rapidly if not diagnosed and treated early [1,2]. With timely antibiotic therapy and appropriate surgical intervention when indicated, acute osteomyelitis can usually be cured without long-term sequelae [3,4].\u003c/p\u003e\n\u003cp\u003eIn contrast, delayed diagnosis and inadequate treatment frequently lead to chronic osteomyelitis, characterized by sequestrum formation, chronic fistulae, recurrent infection, and functional impairment [5,6]. While chronic osteomyelitis has become relatively rare in high-income countries, it remains highly prevalent in many low- and middle-income countries (LMICs), particularly in sub-Saharan Africa [7\u0026ndash;9].\u003c/p\u003e\n\u003cp\u003eThe persistence of chronic osteomyelitis in low-income countries is closely linked to health system constraints. Limited access to diagnostic resources, insufficient disease-related knowledge at primary healthcare level, delayed healthcare-seeking behavior, and fragmented referral pathways have been identified as key contributors to late presentation and disease progression [3,10,11]. As a result, district hospitals in rural settings face a disproportionate surgical burden related to advanced osteomyelitis.\u003c/p\u003e\n\u003cp\u003eUnderstanding the magnitude of this burden and the underlying system-related causes is essential for the development of effective prevention strategies. This study therefore aims to quantify the surgical burden of osteomyelitis at district hospital level and to explore health system barriers contributing to delayed diagnosis and progression to chronic disease using a mixed-methods approach.\u003c/p\u003e"},{"header":"II. Material and Methods","content":"\u003cp\u003e\u003cstrong\u003eA. Study Design and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA descriptive, retrospective, cross-sectional mixed-methods study with a quantitative and a qualitative component was conducted at Kibogora Hospital and Bushenge Hospital in Nyamasheke District, Western Province of Rwanda.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eB. Quantitative component\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea) Study period and population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor quantitative analysis hospitals records of all surgical procedures performed between January 1, 2016, and December 31, 2020, were reviewed. During this period, a total of 10,305 surgical operations were performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb) Sample size calculation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe required sample size was calculated using the Yamane formula for finite populations:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1771237689.png\" width=\"277\" height=\"150\"\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ec) Sampling procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSystematic random sampling was used to select records proportionally from both hospitals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ed) Data extraction\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData was extracted using a structured data collection form, including patient demographics, diagnosis (acute or chronic osteomyelitis), residence, health insurance status, transfer time from health centers to hospitals, and prior treatment by traditional healers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC. Qualitative component\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea) Study design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA qualitative approach was chosen to capture perspectives and experiences that could not be adequately assessed through retrospective record review alone, particularly at the level of primary healthcare and patient healthcare-seeking behaviour.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe qualitative component was designed as a descriptive exploratory study to complement the quantitative findings and to provide contextual insight into healthcare pathways, decision-making processes, and perceived barriers related to the diagnosis and management of osteomyelitis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb) Participants\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe qualitative component consisted of in-depth interviews with 12 nurses working at health centers within Nyamasheke District as well as 14 patients with osteomyelitis and/or parents of affected children. Participants were selected purposively. Nurses were eligible for inclusion if they were involved in patient assessment, referral, or follow-up of musculoskeletal infections at primary healthcare level. Patients and parents were eligible if a diagnosis of osteomyelitis had been established at district hospital level.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ec) Data Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected through semi-structured, in-depth interviews using interview guides tailored to each participant group. Interview guides were informed by a review of the literature and by preliminary findings from the quantitative component. Interviews were conducted in a private setting at health centers or hospitals and were carried out in Kinyarwanda or English, depending on participant preference.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll interviews were audio-recorded with informed consent and supplemented by field notes.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKey topics explored included:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026bull; recognition and interpretation of early symptoms\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026bull; diagnostic confidence and referral decision-making\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026bull; healthcare-seeking behaviour and treatment pathways\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026bull; communication between health centers and hospitals\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026bull; perceived barriers to timely diagnosis and treatment\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ed) Data analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Audio recordings were transcribed verbatim and, where necessary, translated into English. Transcripts were reviewed for accuracy and anonymised prior to analysis. Qualitative data were analysed using thematic content analysis. An inductive approach was applied, allowing codes and themes to emerge directly from the data. Initial coding was performed independently by two researchers. Codes were then compared, discussed, and refined to develop a shared coding framework.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Codes were subsequently grouped into higher-order categories and themes through an iterative analytic process. Discrepancies were resolved through discussion until consensus was achieved.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"III. Results","content":"\u003cp\u003e\u003cstrong\u003eA. Quantitative results\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea) Prevalence of osteomyelitis-related surgical procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the study period from January 1, 2016, to December 31, 2020, a total of 10,305 surgical procedures were performed at Kibogora Hospital and Bushenge Hospital in Nyamasheke District.\u003c/p\u003e\n\u003cp\u003eBased on the calculated sample size, 385 surgical records were systematically selected and analysed. Among these procedures, 107 operations (27.8%) were related to osteomyelitis, while 278 operations (72.2%) were performed for other indications.\u003c/p\u003e\n\u003cp\u003eThus, the prevalence of osteomyelitis-related surgical procedures within the analysed sample was 28%.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb) Distribution of acute and chronic osteomyelitis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 107 osteomyelitis-related operations, 74 patients underwent a single surgical procedure and were included in the detailed patient profile analysis. The remaining patients required multiple surgical interventions.\u003cbr\u003e\u0026nbsp;Among these 74 patients:\u003cbr\u003e\u0026nbsp;\u0026bull; 9 patients (12.1%) were diagnosed with acute osteomyelitis\u003cbr\u003e\u0026nbsp;\u0026bull; 65 patients (87.9%) were diagnosed with chronic osteomyelitis\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003ec) Patient characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSex distribution\u003cbr\u003e\u003c/strong\u003eAmong the 74 patients analysed, 42 patients (56.8%) were male and 32 patients (43.2%) were female.\u003cbr\u003e\u003cstrong\u003eAge distribution\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eThe age distribution showed that osteomyelitis predominantly affected younger individuals.\u003cbr\u003e\u0026nbsp;A total of 48 patients (64.9%) were aged 18 years or younger, while 26 patients (35.1%) were older than 18 years.\u003cbr\u003e\u003cstrong\u003eHealth insurance status\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eOf the 74 patients:\u003cbr\u003e\u0026nbsp;\u0026bull; 65 patients (87.8%) had health insurance\u003cbr\u003e\u0026nbsp;\u0026bull; 9 patients (12.2%) had no health insurance\u003cbr\u003e\u003cstrong\u003ePlace of residence\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eThe majority of patients lived in rural areas:\u003cbr\u003e\u0026nbsp;\u0026bull; 58 patients (78.4%) resided in rural areas\u003cbr\u003e\u0026nbsp;\u0026bull; 16 patients (21.6%) resided in urban areas\u003cbr\u003e\u003cstrong\u003eTransfer time from health centers to hospitals\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Transfer time from the first presentation at a health center to admission at a district hospital varied considerably:\u003cbr\u003e\u0026nbsp;\u0026bull; 12 patients (16.2%) were transferred within 0\u0026ndash;2 weeks\u003cbr\u003e\u0026nbsp;\u0026bull; 19 patients (25.7%) were transferred within 2\u0026ndash;4 weeks\u003cbr\u003e\u0026nbsp;\u0026bull; 9 patients (12.2%) were transferred within 4\u0026ndash;6 weeks\u003cbr\u003e\u0026nbsp;\u0026bull; 34 patients (45.9%) were transferred after more than 6 weeks\u003cbr\u003e\u003cstrong\u003eTreatment by traditional healers\u003cbr\u003e\u0026nbsp;\u003c/strong\u003ePrior treatment by traditional healers was documented in 24 patients (32.4%), while 50 patients (67.6%) had not received traditional treatment before hospital admission. Among the 24 patients treated by traditional healers, the duration of treatment varied:\u003cbr\u003e\u0026nbsp;\u0026bull; 2 patients (8.3%) were treated for up to 10 weeks\u003cbr\u003e\u0026nbsp;\u0026bull; 6 patients (25.0%) were treated for 10\u0026ndash;20 weeks\u003cbr\u003e\u0026nbsp;\u0026bull; 9 patients (37.5%) were treated for 20\u0026ndash;30 weeks\u003cbr\u003e\u0026nbsp;\u0026bull; 7 patients (29.2%) were treated for more than 30 weeks\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ed) Summary of quantitative findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, the quantitative analysis demonstrates a high prevalence of osteomyelitis-related surgical procedures and a predominance of chronic osteomyelitis at the time of surgery. The majority of affected patients were children or adolescents, lived in rural areas, and experienced prolonged delays before hospital admission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB. Qualitative results\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003eThe qualitative analysis was based on in-depth interviews conducted with:\u003cbr\u003e\u0026nbsp;\u0026bull; 12 nurses working in health centers within Nyamasheke District\u003cbr\u003e\u0026nbsp;\u0026bull; 14 patients diagnosed with osteomyelitis and/or parents of affected children\u003cbr\u003e\u0026nbsp;All participants were directly involved in the recognition, management, or experience of osteomyelitis care.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003ea) Delayed recognition of osteomyelitis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNurses consistently reported that osteomyelitis is often not recognised at an early stage, particularly during the initial presentation at health centers. Early symptoms were described as unspecific and difficult to distinguish from other common conditions. Several nurses indicated that suspicion of osteomyelitis usually arose only after persistent symptoms, such as prolonged pain, swelling, abscess formation, or non-healing wounds.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003cstrong\u003eb) Limited knowledge and diagnostic confidence at primary healthcare level\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eA recurrent theme was limited knowledge and uncertainty regarding the diagnosis of osteomyelitis among healthcare providers at health centers. Nurses reported difficulties in differentiating osteomyelitis from other infections and expressed a lack of formal training on the disease. Some nurses stated that referrals were delayed because of uncertainty about when osteomyelitis should be suspected or referred to hospital level.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003ec) Inconsistent referral and follow-up processes\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eParticipants described inconsistencies in referral pathways between health centers and hospitals. Nurses reported that information exchange was often incomplete and that patients were sometimes sent back to health centers without clear treatment plans or scheduled follow-up appointments. This lack of structured communication was perceived as a barrier to continuity of care.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003cstrong\u003ed) Healthcare-seeking behaviour and use of traditional medicine\u003cbr\u003e\u0026nbsp;\u003c/strong\u003ePatients and parents frequently described delays in seeking formal medical care. Some reported initial reliance on traditional healers or home-based treatments, particularly in the early phase of the disease.\u003cbr\u003e\u0026nbsp;Several participants indicated that medical care was often sought only after symptoms worsened or functional impairment became evident.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003cstrong\u003ee) Socioeconomic and logistical barriers to care\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Both nurses and patients identified financial constraints, long distances to health facilities, and transportation difficulties as major barriers to timely access to care. Patients reported challenges related to transport costs, loss of income, and difficulties attending follow-up appointments, which contributed to delays in diagnosis and treatment.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003ef) Perceived burden of chronic osteomyelitis\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Patients and parents described the disease as physically debilitating and socially burdensome. Chronic pain, reduced mobility, prolonged treatment duration, and repeated hospital visits were frequently mentioned. Some participants also reported experiences of social stigma related to chronic wounds and long-term disability.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eg) Summary of qualitative findings\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eThe qualitative results highlight multiple patient-related and healthcare-related factors influencing the recognition and management of osteomyelitis. These findings provide contextual insights into pathways of delayed diagnosis and prolonged disease progression within the study setting.\u003c/p\u003e"},{"header":"IV. Discussion","content":"\u003cp\u003eThis mixed-methods study demonstrates that osteomyelitis constitutes a substantial surgical and health system burden in rural Rwanda, with the majority of patients presenting at an advanced, chronic stage of disease.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative analysis\u003c/strong\u003e showed that osteomyelitis-related procedures accounted for approximately 28% of all surgical interventions performed at district hospital level, indicating that more than one in four surgical procedures were related to osteomyelitis. Importantly, these data reflect an operation-based prevalence and therefore illustrate the burden placed on surgical services rather than population-based incidence. The predominance of chronic osteomyelitis observed in this study is not an inevitable epidemiological phenomenon but rather the consequence of delayed diagnosis and referral.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe majority of patients undergoing osteomyelitis-related surgical procedures were children and adolescents, underscoring the disproportionate burden of chronic osteomyelitis in the pediatric population. The study population originated predominantly from rural catchment areas, where long travel distances and limited transport infrastructure may further contribute to delayed presentation at hospital level. Most patients were covered by community-based health insurance; nevertheless, delayed presentation remained common, suggesting that financial coverage alone is insufficient to ensure timely access to care.\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;\u003cstrong\u003equalitative findings\u003c/strong\u003e provide a coherent explanatory framework for this delay and identify three interrelated system-related barriers: lack of disease-related knowledge, lack of awareness, and lack of cooperation between healthcare structures.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Lack of disease-related knowledge at primary healthcare level emerged as a central barrier to early diagnosis. Similar challenges have been reported in other low-resource settings, where early symptoms of acute osteomyelitis are frequently misinterpreted as minor trauma or soft-tissue infection, resulting in delayed referral and inappropriate initial management [3,8]. Limited access to diagnostic tools and insufficient training in musculoskeletal infections further reduce diagnostic confidence among frontline healthcare providers [2,4]. In such contexts, diagnostic uncertainty often leads to prolonged observation rather than timely escalation of care.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Lack of awareness among patients and caregivers represents a second major contributor to delayed presentation. Early symptoms such as localized bone pain, swelling, or reduced limb use are frequently underestimated, and healthcare is often sought only when severe pain, fistula formation, or functional impairment occurs. Studies from sub-Saharan Africa describe similar patterns of delayed healthcare-seeking behavior, influenced by sociocultural beliefs, financial constraints, and reliance on traditional healers [6,7,10]. These patient-related delays interact with provider-related delays and substantially increase the risk of progression from acute to chronic disease.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;The third barrier, lack of cooperation between healthcare structures, reflects broader systemic weaknesses within district health systems. Fragmented referral pathways, limited feedback between health centers and hospitals, and the absence of standardized clinical algorithms hinder continuity of care. Comparable coordination gaps have been described in other low-resource health systems, where communication between levels of care is often informal and inconsistent [5,11]. For osteomyelitis, timely referral within the first four to six weeks is critical; failures at this interface contribute directly to chronic disease development.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;From a health system perspective, chronic osteomyelitis imposes a disproportionate burden on limited surgical and inpatient resources. Recurrent admissions, repeated surgical debridement, prolonged hospital stays, and long-term antibiotic therapy consume capacity that could otherwise be allocated to other essential surgical conditions [5,6,8]. This reinforces inefficiencies within already constrained district hospital systems.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Several limitations should be acknowledged. The quantitative analysis is based on surgical records and therefore reflects the burden of disease among patients requiring operative management rather than population-based incidence. The retrospective nature of the data and reliance on routine documentation may introduce variability in diagnostic classification. Nevertheless, the consistency between quantitative findings and qualitative insights strengthens the validity of the conclusions.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;In conclusion, chronic osteomyelitis in rural Rwanda is largely driven by delayed diagnosis resulting from modifiable health system barriers. Addressing lack of knowledge, lack of awareness, and lack of cooperation should be central to efforts aimed at reducing disease chronicity and alleviating the associated surgical and socioeconomic burden.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and accordance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Rwanda National Ethics Committee (RNEC) IRB: 00001497 OF OORG 0001100. The study protocol was reviewed and approved in accordance with national ethical guidelines and regulations governing research involving human participants in Rwanda. Permission to access hospital records was granted by the administrations of Kibogora Hospital and Bushenge Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants involved in the qualitative component of the study. For participants under the age of 18 years, written informed consent was obtained from a parent or legal guardian. Participation was voluntary, and confidentiality and anonymity were assured.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to ethical and confidentiality restrictions but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe declare no conflict of interest regarding this systematic review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003cbr\u003e\u003c/strong\u003eThis study was supported through a Rotary\u0026ndash;BMZ partnership grant (Federal Ministry for Economic Cooperation and Development, Germany). The funders had no role in the design of the study, data collection, analysis, interpretation of data, or writing of the manuscrip\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003cbr\u003e\u003c/strong\u003eJean Paul Nsengiyumva\u0026sup1;*, Peter Schuler\u0026sup2;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eAffiliations\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u0026sup1; Kibogora Polytechnic, Nyamasheke District, Rwanda\u003cbr\u003e\u0026nbsp;\u0026sup2; Department of Orthopaedics and Traumatology, ViDia Kliniken, Karlsruhe, Germany\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Jean Paul Nsengiyumva\u003cbr\u003e\u0026nbsp;Kibogora Polytechnic\u003cbr\u003e\u0026nbsp;P.O. Box, Nyamasheke District, Rwanda\u003cbr\u003e\u0026nbsp;Email: [email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePeltola H, P\u0026auml;\u0026auml;kk\u0026ouml;nen M. Acute osteomyelitis in children. N Engl J Med. 2014;370:352\u0026ndash;360.\u003c/li\u003e\n\u003cli\u003eJaramillo D, Dormans JP. Imaging of osteomyelitis in children. Radiol Clin North Am. 2017;55:895\u0026ndash;915.\u003c/li\u003e\n\u003cli\u003eRiise \u0026Oslash;R, Kirkhus E, Handeland KS, Flato B, Reiseter T, Cvancarova M, et al. Delayed diagnosis of acute osteomyelitis in children: a population-based study. Acta Paediatr. 2008;97:936\u0026ndash;940.\u003c/li\u003e\n\u003cli\u003eEl-Sobky TA, Mahmoud S. Acute osteomyelitis in children: diagnostic and therapeutic challenges. EFORT Open Rev. 2021;6:207\u0026ndash;217.\u003c/li\u003e\n\u003cli\u003eBaldan M, Baggio S, Rovere G, et al. Chronic osteomyelitis: pathophysiology and management. J Bone Joint Infect. 2014;1:1\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eCallistus OO, Ademola SA, Oluwadiya KS, Akinola OO. Chronic osteomyelitis in a developing country. Int Orthop. 2015;39:919\u0026ndash;924.\u003c/li\u003e\n\u003cli\u003eIbingira CBR. Chronic osteomyelitis in rural Uganda. East Afr Med J. 2003;80:242\u0026ndash;246.\u003c/li\u003e\n\u003cli\u003eStanley CM, Rutherford GW, Morshed S. Orthopaedic surgery in low-income countries. Clin Orthop Relat Res. 2010;468:2716\u0026ndash;2724.\u003c/li\u003e\n\u003cli\u003eOlivier K, et al. Chronic osteomyelitis in sub-Saharan Africa: a neglected disease. Glob Surg. 2019;5:1\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eDeo P. Economic burden of chronic osteomyelitis management in low-income settings. Int J Health Plann Manage. 2018;33:e432\u0026ndash;e439.\u003c/li\u003e\n\u003cli\u003eTissingh EK, van den Akker M, et al. Referral pathways and coordination in low-resource health systems. BMC Health Serv Res. 2022;22:134.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Chronic Osteomyelitis, Surgical burdon, Prevalence, Risk-Factors, low- and middle-income countries (LMICs)","lastPublishedDoi":"10.21203/rs.3.rs-8590297/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8590297/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis mixed-methods study assessed the prevalence of osteomyelitis-related surgical procedures and factors associated with chronic osteomyelitis in a rural district of Rwanda. Among 385 analysed surgical cases, 27.8% were related to osteomyelitis, indicating that more than one in four surgical procedures were attributable to this condition. Most patients presented with chronic disease, reflecting substantial delays in diagnosis and referral. Quantitative and qualitative findings identified three key domains associated with chronic osteomyelitis: lack of disease-related knowledge at primary healthcare level, limited awareness among patients and caregivers, and insufficient cooperation between healthcare structures. These results underscore the clinical and socioeconomic relevance of early diagnosis to prevent progression to chronic osteomyelitis.\u003c/p\u003e","manuscriptTitle":"Surgical burden of osteomyelitis and factors associated with chronic disease in a rural district of Rwanda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-16 10:32:02","doi":"10.21203/rs.3.rs-8590297/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8e3292ed-9b08-439e-ab10-0a6efe08cf91","owner":[],"postedDate":"February 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T10:11:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-16 10:32:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8590297","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8590297","identity":"rs-8590297","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}