Fixation of intertrochanteric femur fractures using the SIGN intramedullary nail augmented by a lateral plate in a resource-limited setting without intraoperative fluoroscopy: assessment of functional outcomes at one-year follow-up at Juba Teaching Hospital

Objectives:
The incidence of hip fracture is high and increasing globally due to an aging population. Morbidity and mortality from these injuries are high at baseline and worse without prompt surgical treatment to facilitate early mobilization. Due to resource constraints, surgeons in low-income countries often must adapt available materials to meet these surgical needs. The objective of this study is to assess functional outcomes after surgical fixation of intertrochanteric femur fractures with the Surgical Implant Generation Network (SIGN) intramedullary nail augmented by a lateral SIGN plate.

Design:
Prospective case series

Setting:
Juba Teaching Hospital, Tertiary Referral Hospital for South Sudan

Participants:
Adult patients with intertrochanteric hip fractures

Intervention:
SIGN nail augmented by a lateral plate

Main Outcome Measurements:
Primary outcome was hip function as measured by a modified Harris Hip Score (mHHS) at 1-year after surgery. Secondary endpoints were the occurrence of reoperation or infection at 1-year after surgery.

Results:
Thirty patients were included, 16 (53%) men and 14 (47%) women, with a mean age of 62 years. Fractures were classified as AO/OTA Type 31A1 in 12 (40%) patients, 31A2 in 15 (50%) patients, and 31A3 in 3 (10%) patients. Mean mHHS at 1-year was 75.10 ± 21.2 with 76% categorized as excellent or good scores. There was 1 (3%) infection and 2 (7%) reoperations.

Conclusions:
The SIGN nail augmented by a lateral plate achieved good or excellent hip function in the majority of patients with intertrochanteric hip fractures. This may be a suitable alternative to conventional implants for hip fracture patients in low-resource settings to allow mobilization.

The evaluation of a surgical task-sharing program in South Sudan

Background: Five billion people lack timely, affordable, and safe surgical services. Sub-Saharan Africa (SSA) is the region with the scarcest access to surgical care. The surgical workforce is crucial in closing this gap. In SSA, South Sudan has one of the lowest surgical workforce density. Task-sharing being a cost-effective training method, in 2019, the University of British Columbia collaborated with Médecins Sans Frontières to create the Essential Surgical Skills program and launched it in South Sudan. This study aims to evaluate this pilot program. Methods: This is a mixed-method prospective cohort study. Quantitative data include pre- and post-training outputs (number and types of surgeries, complication, re-operation, and mortality) and surgical proficiency of the trainees (quiz, Entrustable Professional Activity (EPA), and logbook data), and online survey for trainers. Semi-structured interviews were performed with trainees at the program completion. Results: Since July 2019, trainees performed 385 operations. The most common procedures were skin graft (14.8%), abscess drainage (9.61%), wound debridement and transverse laparotomy (7.79% each). 172 EPAs have been completed, out of which 136 (79%) showed that the trainee could independently perform the procedure. During the training, the operating room and surgical ward mortality remained similar to the pre-training phase. Furthermore, the surgical morbidity decreased from 25% to less than 5%. The pass rate for all quizzes was 100%. Interviews and survey showed that trainees’ surgical knowledge, interprofessional teamwork, trainers’ global insight on surgical training in Low- and Middle-Income Countries (LMICs), and patient care has improved. Also, the program empowered trainees, developed career path, and local acceptance and retention. The modules were relevant to community needs. Conclusions: This study casts light on the feasibility of training surgeons through a virtual platform in under-resourced regions. The COVID-19 global pandemic highlighted the need to make LMICs independent from fly-in trainers and traditional apprenticeship. Knowledge translation of this training platform’s evaluation will hopefully inform Ministries of Health and their partners to develop their National Surgical, Obstetric and Anesthesia Plans (NSOAPs). Furthermore, thanks to its scalability, both across levels of training and geography, it paves the way for virtual surgical education everywhere in the world.

Delivery Mode for Prolonged, Obstructed Labour Resulting in Obstetric Fistula: A Retrospective Review of 4396 Women in East and Central Africa

Objective: To evaluate the mode of delivery and stillbirth rates over time among women with obstetric fistula.

Design: Retrospective record review.

Setting: Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia and Ethiopia.

Population: A total of 4396 women presenting with obstetric fistulas for repair who delivered previously in facilities between 1990 and 2014.

Methods: Retrospective review of trends and associations between mode of delivery and stillbirth, focusing on caesarean section (CS), assisted vaginal deliveries and spontaneous vaginal deliveries.

Main outcome measures: Mode of delivery, stillbirth.

Results: Out of 4396 women with fistula, 3695 (84.1%) delivered a stillborn baby. Among mothers with fistula giving birth to a stillborn baby, the CS rate (overall 54.8%, 2027/3695) rose from 45% (162/361) in 1990-94 to 64% (331/514) in 2010-14. This increase occurred at the expense of assisted vaginal delivery (overall 18.3%, 676/3695), which declined from 32% (115/361) to 6% (31/514).

Conclusions: In Eastern and Central Africa, CS is increasingly performed on women with obstructed labour whose babies have already died in utero. Contrary to international recommendations, alternatives such as vacuum extraction, forceps and destructive delivery are decreasingly used. Unless uterine rupture is suspected, CS should be avoided in obstructed labour with intrauterine fetal death to avoid complications related to CS scars in subsequent pregnancies. Increasingly, women with obstetric fistula add a history of unnecessary CS to their already grim experiences of prolonged, obstructed labour and stillbirth.

Diagnosis and management of 365 ureteric injuries following obstetric and gynecologic surgery in resource-limited settings.

Ureteric injuries are among the most serious complications of pelvic surgery. The incidence in low-resource settings is not well documented.This retrospective review analyzes a cohort of 365 ureteric injuries with ureterovaginal fistulas in 353 women following obstetric and gynecologic operations in 11 countries in Africa and Asia, all low-resource settings. The patients with ureteric injury were stratified into three groups according to the initial surgery: (a) obstetric operations, (b) gynecologic operations, and (c) vesicovaginal fistula (VVF) repairs.The 365 ureteric injuries in this series comprise 246 (67.4%) after obstetric procedures, 65 (17.8%) after gynecologic procedures, and 54 (14.8%) after repair of obstetric fistulas. Demographic characteristics show clear differences between women with iatrogenic injuries and women with obstetric fistulas. The study describes abdominal ureter reimplantation and other treatment procedures. Overall surgical results were good: 92.9% of women were cured (326/351), 5.4% were healed with some residual incontinence (19/351), and six failed (1.7%).Ureteric injuries after obstetric and gynecologic operations are not uncommon. Unlike in high-resource contexts, in low-resource settings obstetric procedures are most often associated with urogenital fistula. Despite resource limitations, diagnosis and treatment of ureteric injuries is possible, with good success rates. Training must emphasize optimal surgical techniques and different approaches to assisted vaginal delivery.