Choices for operative management of fractures in a developing country.

Aims: Operative management of fractures has changed significantly in the 21st century with the introduction of simple but effective devices and procedures to improve fracture care and healing outcomes. This study describes the commonest fractures treated surgically, type of fractures and operative fixation methods used for patients seeking orthopaedic services in two hospitals in Ghana.

Methods: Review of all patients who have had operative fracture fixation at the Cape Coast Teaching Hospital and St. Joseph Orthopaedic Hospital between January 2016 to December 2018. Operation records of 1,168 were reviewed for their age, gender, fractured bone, type of fracture, operative fixation method and devices used for fixation.

Results: A total of 1,168 fractured patients were treated operatively irrespective of age in the 3 year period reviewed. Males (817)compared to females (351) in a ratio of 2.3:1. The 21 – 40 year age group had the highest number of fractures (50% of femur fractures, 52% of tibial and 56% of forearm fractures) managed operatively. Plate osteosynthesis was found to be the most preferred method of fixation for the major long bones; femur 360(66 %), Humerus 69(78% ), radius and ulna 81(78%).

Conclusion: Fractures of the femur and tibial shafts represent an overwhelming majority of operatively managed long bone fractures. Plating as opposed to the gold standard of intramedullary nailing was the most commonly employed fixation method for femur and tibial fractures, so scarce resources should be channelled towards acquiring the requisite instrumentation and skill set for the fixation of these fractures.

Estimation of the National Surgical Needs in India by Enumerating the Surgical Procedures in an Urban Community Under Universal Health Coverage

Background
11% of the global burden of disease requires surgical care or anaesthesia management or both. Some studies have estimated this burden to be as high as 30%. The Lancet Commission for Global Surgery (LCoGS) estimated that 5000 surgeries are required to meet the surgical burden of disease for 100,000 people in LMICs. Studies from LMICs, estimating surgical burden based on enumeration of surgeries, are sparse.

Method
We performed this study in an urban population availing employees’ heath scheme in Mumbai, India. Surgical procedures performed in 2017 and 2018, under this free and equitable health scheme, were enumerated. We estimated the surgical needs for national population, based on age and sex distribution of surgeries and age standardization from our cohort.

Result
A total of 4642 surgeries were performed per year for a population of 88,273. Cataract (22.8%), Caesareans (3.8%), surgeries for fractures (3.27%) and hernia (2.86%) were the commonest surgeries. 44.2% of surgeries belonged to the essential surgeries. We estimated 3646 surgeries would be required per 100,000 Indian population per year. One-third of these surgeries would be needed for the age group 30–49 years, in the Indian population.

Conclusion
A total of 3646 surgeries were estimated annually to meet the surgical needs of Indian population as compared to the global estimate of 5000 surgeries per 100,000 people. Caesarean section, cataract, surgeries for fractures and hernia are the major contributors to the surgical needs. More enumeration-based studies are needed for better estimates from rural as well as other urban areas.

The physical impact of long bone fractures on adults in KwaZulu-Natal

Background: Limb fractures are increasingly common in low-income and middle-income countries due to an increase in motor vehicle and other accidents. Fractures may often lead to physical impairment that affects an individual’s ability to carry out tasks.

Objectives: To assess the physical impact of long bone fractures on adults in KwaZulu-Natal.

Method: A standardised questionnaire pertaining to activities at home and leisure was used to establish patient-reported outcomes at nine public hospitals. English-speaking and isiZulu-speaking participants who had sustained a single long bone fracture in the preceding 4 to 12 weeks at the time of data collection were included. The following activities were evaluated: walking, running, exercising, driving, performing household chores, writing, answering telephones, texting on a cell phone, bathing, using crockery and preparing meals.

Results: A total of 821 participants completed the questionnaire. Ninety-three per cent had closed long bone fractures and 69 per cent were lower limb fractures. Fifty-seven per cent of the fractures were caused by a fall. Female participants (p = 0.19) with lower limb fractures were more likely to have greater difficulty in performing tasks and participants 60 years of age and older (p = 0.001) were significantly more likely to have difficulty performing tasks.

Conclusion: These findings illustrate the daily limitations in patients’ everyday activities at home, leisure and in activities such as driving.

Clinical implications: This study highlights the difficulty that some individuals, particularly women and individuals 60 years of age and older, face in performing daily tasks after experiencing a long bone fracture.

The EQ-5D-3L administered by text message compared to the paper version for hard-to-reach populations in a rural South African trauma setting: a measurement equivalence study

Introduction
Administering patient-reported outcome measures (PROMs) by text message may improve response rate in hard-to-reach populations. This study explored cultural acceptability of PROMs and compared measurement equivalence of the EQ-5D-3L administered on paper and by text message in a rural South African setting.

Materials and methods
Participants with upper or lower limb orthopaedic pathology were recruited. The EQ-5D was administered first on paper and then by text message after 24 h and 7 days. Differences in mean scores for paper and text message versions of the EQ-5D were evaluated. Test–retest reliability between text message versions was evaluated using Intraclass Correlation Coefficients (ICCs).

Results
147 participants completed a paper EQ-5D. Response rates were 67% at 24 h and 58% at 7 days. There were no differences in means between paper and text message responses for the EQ-5D Index (p = 0.95) or EQ-5D VAS (p = 0.26). There was acceptable agreement between the paper and 24-h text message EQ-5D Index (0.84; 95% Confidence Interval (CI) 0.78–0.89) and EQ-5D VAS (0.73; 95% CI 0.64–0.82) and acceptable agreement between the 24-h and 7-day text message EQ-Index (0.72; CI 0.62–0.82) and EQ-VAS (0.72; CI 0.62–0.82). Non-responder traits were increasing age, Xhosa as first language and lower educational levels.

Conclusions
Text messaging is equivalent to paper-based measurement of EQ-5D in this setting and is thus a viable tool for responders. Non-responders had similar socioeconomic characteristics and attrition rates to traditional modes of administration. The EQ-5D by text message offers potential clinical and research uses in hard-to-reach populations.

Postoperative Pulmonary Complications in Complex Pediatric and Adult Spine Deformity: A Retrospective Review of Consecutive Patients Treated at a Single Site in West Africa

Study Design:
Retrospective review of consecutive series.

Objectives:
This study sought to assess the incidence, risk factors, and outcomes of pulmonary complication following complex spine deformity surgery in a low-resourced setting in West Africa.

Methods:
Data of 276 complex spine deformity patients aged 3 to 25 years who were treated consecutively was retrospectively reviewed. Patients were categorized into 2 groups during data analysis based on pulmonary complication status: group 1: yes versus group 2: no. Comparative descriptive and inferential analysis were performed to compare the 2 groups.

Results:
The incidence of pulmonary complication was 17/276 (6.1%) in group 1. A total of 259 patients had no events (group 2). There were 8 males and 9 females in group 1 versus 100 males and 159 females in group 2. Body mass index was similar in both groups (17.2 vs 18.4 kg/m2, P = .15). Average values (group 1 vs group 2, respectively) were as follows: preoperative sagittal Cobb angle (90.6° vs 88.7°, P = .87.), coronal Cobb angle (95° vs 88.5°, P = .43), preoperative forced vital capacity (45.3% vs 62.0%, P = .02), preoperative FEV1 (forced expiratory volume in 1 second) (41.9% vs 63.1%, P < .001). Estimated blood loss, operating room time, and surgery levels were similar in both groups. Thoracoplasty and spinal osteotomies were performed at similar rates in both groups, except for Smith-Peterson osteotomy. Multivariate logistic regression showed that every unit increase in preoperative FEV1 (%) decreases the odds of pulmonary complication by 9% (OR = 0.91, 95% CI 0.84-0.98, P = .013). Conclusion: The observed 6.1% incidence of pulmonary complications is comparable to reported series. Preoperative FEV1 was an independent predictor of pulmonary complications. The observed case fatality rate following pulmonary complications (17%) highlights the complexity of cases in underserved regions and the need for thorough preoperative evaluation to identify high-risk patients.

Epidemiological Characteristics of Spinal Cord Injury in Northwest China: A Single Hospital-Based Study

Background: While the cities in China in which spinal cord injury (SCI) studies have been conducted previously are at the forefront of medical care, northwest China is relatively underdeveloped economically, and the epidemiological characteristics of SCI have rarely been reported in this region.

Methods: The SCI epidemiological survey software developed was used to analyze the data of patients treated with SCI from 2014 to 2018. The sociodemographic characteristics of patients, including name, age, sex, and occupation, were recorded. The following medical record data, obtained from physical and radiographic examinations, were included in the study: data on the cause of injury, fracture location, associated injuries, and level of injury. Neurological function was evaluated using the American Spinal Injury Association (ASIA) impairment scale. In addition, the treatment and complications during hospitalization were documented.

Results: A total of 3487 patients with SCI with a mean age of 39.5 ± 11.2 years were identified in this study, and the male to female ratio was 2.57:1. The primary cause of SCI was falls (low falls 47.75%, high falls 37.31%), followed by traffic accidents (8.98%), and impact with falling objects (4.39%). Of all patients, 1786 patients (51.22%) had complications and other injuries. According to the ASIA impairment scale, the numbers of grade A, B, C, and D injuries were 747 (21.42%), 688 (19.73%), 618 (17.72%), and 1434 (41.12%), respectively. During the hospitalization period, a total of 1341 patients experienced complications, with a percentage of 38.46%. Among all complications, pulmonary infection was the most common (437, 32.59%), followed by hyponatremia (326, 24.31%), bedsores (219, 16.33%), urinary tract infection (168, 12.53%), deep venous thrombosis (157, 11.71%), and others (34, 2.53%). Notably, among 3487 patients with SCI, only 528 patients (15.14%) received long-term rehabilitation treatment.

Conclusion: The incidence of SCI in northwest China was on the rise with higher proportion in males; fall and the MCVs were the primary causes of SCI. The occupations most threatened by SCI are farmers and workers. The investigation and analysis of the epidemiological characteristics of SCI in respiratory complications are important factors leading to death after SCI, especially when the SCI occurs in the cervical spinal cord. Finally, the significance of SCI rehabilitation should be addressed.

The global burden of musculoskeletal injury in low and lower-middle income countries

Background:
While the global burden of musculoskeletal injury is increasingly recognized, few epidemiologic studies have specifically recorded its incidence or prevalence, particularly in low- and middle-income countries. Understanding the burden of musculoskeletal injury relative to other health conditions is critical to effective allocation of resources to mitigate the disability that results from trauma. The current study aims to systematically review the existing primary literature on the incidence and prevalence of pelvic and appendicular fractures, a major component of musculoskeletal injury, in low- and lower-middle income countries (LMICs).

Methods:
This study conforms to the systematic review and traditional meta-analysis guidelines outlined in the PRISMA-P statement. Incidence rates were calculated as the occurrence of new fracture cases per 100,000 person-years, and prevalence as total fracture cases per population sample, reported as percentages.

Results:
The literature search yielded 3497 total citations. There were 21 full-text articles, representing 14 different countries, selected for data extraction. Included studies reported a wide range of incidence and prevalence rates, with an overall mean fracture incidence ranging from 779 (95% CI: 483.0–1188.7) to 1574 (95% CI: 1285.1–1915.1) per 100,000 person-years.

Conclusion:
Better understanding the unmet burden of musculoskeletal injury in LMICs is critical to effectively allocating resources and advocating for underserved populations. To address existing gaps and heterogeneity within the literature, future research should incorporate population-based sampling with broader geographic representation in LMICs to more accurately capture the burden of disease.

Critical Adjustments in a Department of Orthopaedics Through the COVID-19 Pandemic

Purpose: SARS-CoV-2’s new scenario has forced health systems to work under extreme stress urging to perform a complete reorganization of the way our means and activities were organized. The orthopaedic and trauma units have rescheduled their activities to help SARS-CoV-2 units, but trauma patients require also treatment, and no standardized protocols have been established.

Methods: A single-centre cross-sectional study was performed in a tertiary hospital. Two different periods of time were analyzed: a two week period of time in March 2019 (pre-SARS-CoV-2) and the same period in March 2020 (SARS-CoV-2 pandemic time). Outpatient’s data, emergency activity, surgical procedures, and admissions were evaluated. Surgeons’ and patient’s opinion was also evaluated using a survey.

Results: A total of ~ 16k (15,953) patients were evaluated. Scheduled clinical appointments decreased by ~ 22%. Urgent consultations and discharge from clinics also descended (~ 37% and ~ 20% respectively). Telemedicine was used in 90% of outpatient clinical evaluations. No elective surgical procedures during SARS-CoV-2 time were scheduled, and subtracting the effect of elective surgeries, there was a reduction of inpatient surgeries, from ~ 85% to ~ 59%. Patients delayed trauma assistance more than 48 hours in 13 cases (35%). Pre-operative admission for hip fractures decreased in ten hours on average. Finally, surveys stated that patients were more in favour than surgeons were to this new way to evaluate orthopaedic and trauma patients based strongly on telemedicine.

Conclusion: Detailed protocols should be standardized for surgical departments during the pandemic. This paper offers a general view in how this virus affects an orthopaedic unit and could serve as a protocol and example for orthopaedic and trauma units. Even in the worst scenario, an orthopaedic and trauma unit could offer an effective, efficient, and quality service. SARS-CoV-2 will set up a new paradigm for health care in orthopaedics and trauma.

The Role of the Orthopaedic Surgeon in the COVID-19 Era: Cautions and Perspectives

The current coronavirus disease 2019 (COVID-19) pandemic has revolutionized global healthcare in an unprecedented way and with unimaginable repercussions. Resource reallocation, socioeconomic confinement and reorganization of production activities are current challenges being faced both at the national and international levels, in a frame of uncertainty and fear. Hospitals have been restructured to provide the best care to COVID-19 patients while adopting preventive strategies not to spread the infection among healthcare providers and patients affected by other diseases. As a consequence, the concept of urgency and indications for elective treatments have been profoundly reshaped. In addition, several providers have been recruited in COVID-19 departments despite their original occupation, resulting in a profound rearrangement of both inpatient and outpatient care. Orthopaedic daily practice has been significantly affected by the pandemic. Surgical indications have been reformulated, with elective cases being promptly postponed and urgent interventions requiring exceptional attention, especially in suspected or COVID-19+ patients. This has made a strong impact on inpatient management, with the need of a dedicated staff, patient isolation and restrictive visiting hour policies. On the other hand, outpatient visits have been limited to reduce contacts between patients and the hospital personnel, with considerable consequences on post-operative quality of care and the human side of medical practice.

In this review, we aim to analyze the effect of the COVID-19 pandemic on the orthopaedic practice. Particular attention will be dedicated to opportune surgical indication, perioperative care and safe management of both inpatients and outpatients, also considering repercussions of the pandemic on resident education and ethical implications.

Orthopedic Healthcare in the Time of COVID-19: Experience of the Orthopedic Surgery Department at Mustapha Bacha Hospital, Algeria

In response to the global health emergency, which has been raised to its highest level as a consequence of the coronavirus disease 2019 (COVID-19), urgent and aggressive actions were taken by health institutions across the world to stop the spread of the disease while ensuring continuity of vital care. This article outlines the urgent measures put in place by the orthopedic surgery department at Mustapha Bacha Hospital in response to the COVID-19 pandemic.