To evaluate internal fixation by intramedullary Kirschner wires as a surgical technique in the treatment of femoral shaft fractures in children by a prospective study.17 femoral shaft fractures at various levels in 16 children aged 2-15 years were treated by closed intramedullary Kirschner wiring under image intensifier control between May 2000 and October 2003. No external splint was used.Fracture union was achieved in 6-14 weeks. Non-weight bearing crutch walking was started 2-3 days after surgery. Full weight bearing started 6-14 weeks. Average operative time was 40 min (range 20-72 min). Wires were removed after 8-22 weeks. There were no infections, no limb length disparity. One child had pin track ulceration. A big child of 14 years had angulation of the fracture.Intramedullary nailing of femoral shaft fractures in children by stainless steel Kirschner wires is an effective method, which compares well with other studies. It is a simple procedure, which can be easily reproduced. Blood loss is minimal, and the operative time short. There is no need pre-bend the wires in a C or S curve. Stainless steel Kirschner wires are cheap, universally available, and can be manufactured locally. The cost of Image intensifiers is affordable in most of the cities of the developing countries. The hospital does not have to maintain a costly inventory. Provides early mobility, return to home and, school. Gives a predictable clinical pathway and reduces occupancy of hospital beds. The technique was successfully applied for internal fixation of other diaphyseal fractures in children and some selected diaphyseal fractures in adults. Based on my experience and a review of the literature, I recommend this technique as a modality for treatment of femoral shaft fractures in children aged 2 to 14 years.
Bone allografting: an Indian experience.
Freeze-drying is considered to be the best technique for allograft preparation and storage. This method is, however, unsuitable for use in developing countries due to high costs. Ethylene oxide sterilization is still controversial because of its effect on osteoinductive capacity. This study involved setting up a bone bank for the first time. Cancellous bone collected from 40 patients was cleaned thoroughly, chemically processed, and sterilized with ethylene oxide gas and stored doubly packed. The grafts were implanted in 11 patients with 14 nonunions. Patients were followed up clinically and radiologically. Thirteen sites were united at the end of 12 months, taking an average of 44.8 weeks to unite. Allograft was also used in 8 benign bone lesions, which showed incorporation of the graft by 29 weeks. This study shows cancellous allograft is suitable for packing cavities in the treatment of benign bone lesions and in treatment of nonunion. There was one deep infection. The low infection rate confirms the efficacy of ethylene oxide as a reliable option for sterilization of bone allograft, and it is also cost effective.
Problems of amputation surgery in a developing country.
We studied prospectively 87 patients who underwent extremity amputation in the National Orthopaedic Hospital in Lagos in 1995-1996. Trauma from road traffic accident was the most common indication (34/87) with peripheral vascular disease being the least encountered (2/87). Traditional bonesetters’ gangrene accounted for 9/87 cases in circumstances that were largely avoidable. Our study revealed that amputation is still being performed as a life-saving procedure, as 44/87 patients presented with gangrene of a limb. The nonavailability of special investigations such as Doppler ultrasound, arteriography, and CT scan was responsible for a delay in definitive treatment in 28 cases. Poor prosthetic services and the absence of a well-coordinated amputee clinic were responsible for some of the unsatisfactory results. We believe that the availability of specialized diagnostic tools and facilities for microvascular surgery, together with a multidisciplinary approach to the management of the amputee, would considerably change the current gloomy picture of amputation in developing countries such as Nigeria.
Surgery in Swaziland.
Surgeons working in less developed countries have to manage a wider range of conditions than their colleagues in Britain. It is suggested that such an experience would be a valuable part of the education of a specialist in Britain. A personal series of surgical operations carried out in Swaziland is presented.
The Orthopedic Trauma Symposium: improving care of orthopedic injuries in Haiti.
Although single-trip volunteer medical teams can provide much-needed acute trauma care following natural disasters, their ability to leave a legacy of improved care in the region is often limited. One way to improve treatment of traumatic injuries is through conference-based teaching, such as the Orthopedic Trauma Symposium (OTS), which took place in Haiti in 2014. However, there is little research evaluating the effectiveness of such teaching tools. We evaluated the OTS and the potential benefits of future iterations of the course.A survey consisting of 5-point Likert scale questions as well as qualitative open feedback assessed respondents’ opinions regarding the value, content and delivery of the OTS. Respondents were classified dichotomously in terms of their role in the OTS (instructor v. participant) to measure any meaningful difference in feedback.In total, 84% of all participants agreed that course content was clearly communicated, and 98% agreed that instructors were knowledgeable in the topics covered. Moreover, 87% of all participants responded that they would apply the training in their medical practices going forward.Haitian physicians, residents and medical students responded favourably to the OTS. Open-ended questions offered concise, attainable improvements for future iterations of the course. Organizations committed to improving medical care in low- and middle-income countries should take note of these findings while continuing to develop the OTS and similar initiatives globally.Les équipes médicales bénévoles qui font des interventions ponctuelles sont en mesure de prodiguer des soins essentiels en traumatologie aigüe après des désastres naturels, mais elles laissent souvent un héritage limité pour ce qui est de l’amélioration des soins dans la région touchée. Or, il est possible d’améliorer le traitement des blessures post-traumatismes par le biais de conférences didactiques, telles que le Symposium de traumatologie-orthopédie (STO) tenu en Haïti en 2014. Peu de recherches ont toutefois mesuré l’efficacité de ce type d’outil didactique. Nous avons voulu faire un bilan du STO et des avantages potentiels qu’il y aurait à répéter l’expérience.Un questionnaire prenant la forme d’une échelle de Likert en 5 points, ainsi que des questions qualitatives ouvertes, ont permis de recueillir l’opinion des répondeurs au sujet de l’utilité, du contenu et du déroulement du STO. Nous avons scindé les répondeurs en 2 groupes en fonction de leur rôle lors du STO (soit instructeurs, soit participants) pour mesurer les différences notables sur le plan des perceptions.En tout, 84 % de l’ensemble des participants ont affirmé que le contenu du cours avait été clairement communiqué et 98 % ont affirmé que les instructeurs connaissaient les thèmes abordés. En outre, 87 % de tous les participants ont répondu avoir l’intention d’appliquer dorénavant la formation à leur pratique médicale.Les médecins, résidents et étudiants en médecine haïtiens ont répondu favorablement au STO. Les questions ouvertes ont suscité des suggestions concises et réalistes pour améliorer les futures éditions du cours. Les organisations vouées à l’amélioration des soins médicaux dans les pays à revenu faible et moyen devraient prendre note de ces observations tout en continuant d’exploiter la formule des STO et autres initiatives similaires ailleurs dans le monde.
Simplified Negative Pressure Wound Therapy Device for Application in Low-Resource Settings.
Negative pressure wound therapy (NPWT) provides proven wound healing benefits and is often a desirable wound treatment methodology. Unfortunately, NPWT devices are not widely available in low-resource settings. To overcome the identified NPWT barriers, a simplified NPWT (sNPWT) system was designed and iteratively improved during field-based testing. The sNPWT technology, our device design iterations, and the design-based results of our field tests are described in this article. The sNPWT system includes a bellows hand pump, an occlusive drape, and a tube with tube connectors, connecting the drape to the pump. The most critical property of an sNPWT system is that it must be airtight. The details of the design iterations, which are needed to achieve an occlusive system, are explained. During the design process, the sNPWT system was tested during the earthquake relief in Haiti. This testing found that a liquid sealant was necessary to seal the drape to the periwound skin. A study conducted in Rwanda verified that a liquid latex sealant was safe to use, and that the tube connector must be connected to the drape with an airtight method during the manufacturing process. This work has shown that sNPWT is feasible in low-resource settings. Since the completion of the clinical testing, the design has been further evolved, and the developers are working with contract manufacturers to produce the final design and preparing for regulatory approval applications.
Developing a sustainable hip service in Cambodia
Initial report on establishment of a hip service in Phnom Penh, Cambodia at Children’s Surgical Centre. We describe indications for total hip replacement (THR) and initial results.
A database was established to collect data and track patients for follow up. Initial data collected included; diagnosis, implant used, post-operative complications. As the service developed, pre- and postoperative Harris hip scores were included.
High rate of avascular necrosis (AVN) as the initial diagnosis. Five years post initiation of the hip service, 95 patients have received 116 THRs; including 10 revisions, 12 bilateral procedures. Complications/failures requiring revision involved four prosthetic femoral neck fractures, two aseptic acetabular component, two late infections, one instability. One failure, a periprosthetic acetabular fracture, required removal of all prosthetics. Complications not requiring revision, included three post-op foot drops, three superficial wound infections, one Vancouver B1 periprosthetic femur fracture. Average age was 41. Overall implant survival is 85% at three years.
AVN was the most common indication for THR: many patients had a history of hip trauma, and/or prolonged steroids from traditional healers for pain. Problems with specific implants were addressed by the company. A different stem is now routinely used, no further fractures have been reported. Acetabular loosening, thought to be due to poor technique, has been addressed by focused training. Infection rate is monitored, and microbiology resources are improving.
Developing an affordable hip arthroplasty service in a country like Cambodia is challenging. Developing a local registry has helped to identify complications and modify techniques.
Surgical Site Infection Rates in Seven Cities in Vietnam: Findings of the International Nosocomial Infection Control Consortium
Background: Surgical site infections (SSIs) are the most common healthcare-associated infections (HAI) in lower-income countries. This is the first study to report the results of surveillance on SSI stratified by surgical procedure in seven Vietnamese cities.
Methods: This was a prospective, active SSI surveillance study conducted from November 2008–December 2010 in seven hospitals using the U.S. Centers for Disease Control and Prevention’s National Healthcare Safety Network (CDC-NHSN) definitions and methods. Surgical procedures (SPs) were classified into 26 types according to the International Classification of Diseases Edition 9 criteria.
Results: We recorded 241 SSIs, associated with 4,413 SPs (relative risk [RR] 5.5%; 95% confidence interval [95% CI] 4.8–6.2). The highest SSI rates were found for limb amputation (25%), colon surgery (33%), and small bowel surgery (21%). Compared with CDC-NHSN SSI report, our SSI rates were higher for the following SPs: Limb amputation (25% vs. 1.3%; RR 20.0; p = 0.001); appendix surgery (8.8% vs. 3.5%; RR 2.54; 95% CI 1.3–5.1; p = 0.001); gallbladder surgery (13.7% vs. 1.7%; RR 7.76; 95% CI 1.9–32.1; p = 0.001); colon surgery (18.2% vs. 4.0%; RR 4.56; 95% CI 2.0–10.2; p = 0.001); open reduction of fracture (15.8% vs. 3.4%; RR 4.70, 95% CI 1.5–15.2; p = 0.004); gastric surgery (7.3% vs. 1.7%; RR 4.26; 95% CI 2.2–8.4, p = 0.001); kidney surgery (8.9% vs. 0.9%; RR 10.2; 95% CI 3.8–27.4; p = 0.001); prostate surgery (5.1% vs. 0.9%; RR 5.71; 95% CI 1.9–17.4; p = 0.001); small bowel surgery (20.8% vs. 6.7%; RR 3.07; 95% CI 1.7–5.6; p = 0.001); thyroid or parathyroid surgery (2.4% vs. 0.3%; RR 9.27; 95% CI 1.0–89.1; p = 0.019); and vaginal hysterectomy (14.3% vs. 1.2%; RR 12.3; 95% CI 1.7–88.4; p = 0.001).
Conclusions: Our SSIs rates were significantly higher for 11 of the 26 types of SPs than for the CDC-NHSN. This study advances our knowledge of SSI epidemiology in Vietnam and will allow us to introduce targeted interventions.
Limb versus life—the outcomes of osteosarcoma in Cambodia
Osteosarcoma (OS) is a serious disease affecting mainly children and young adults. In a resource poor setting the treatment options are limited and further obstacles can be found with respect to late presenting pathology, access to modern treatment modalities such as effective chemotherapy, and cultural reluctance to undergo certain treatments. Clinical outcome studies and epidemiology for this disease in developing countries are scarce.
We report on the outcomes of 30 patients treated by the CSC, a rehabilitative surgery centre in Cambodia, from 2002 to present. Enneking staging, location, and treatment protocols were evaluated. Outcome measures were months of survival, EDQ5S life quality scores and clinically relevant inquiries. Kaplan-Meier analysis estimates and the Wilcoxon chi-square test were used for statistical inferences.
We find a grim prognosis for patients diagnosed with OS in Cambodia, 53 % survive the first year after presentation and the five-year survival stands at 8 %. There is a higher mean age for presentation of OS compared to Western norms, namely, 18.8 years and 21.7 years for females and males, respectively.
Most patients opted for surgical treatment without adjuvant chemotherapy, which is not within the means of many Cambodian patients. Acceptance of amputation, earlier diagnosis, patient education, and access to standardized chemotherapy needs to be enhanced if Cambodian patients are to have a fighting chance.