Virtual reality technology in linked orthopaedic training in Ethiopia

We describe the feasibility of delivering a live orthopaedic surgical teaching session with virtual reality (VR) technology simultaneously for trainee surgeons in Ethiopia and the UK.

Forty-three delegates from the Severn Deanery in the UK (n=30) and Bahir Dar in Ethiopia (n=13) attended a live training session in February 2021. During the session, participants watched a surgical operation (recorded earlier that week with a 360° VR camera) alongside live commentary. A qualitative questionnaire was distributed to gauge feasibility, connectivity and educational value of the session as well as its VR component.

The majority of delegates from both the UK and Ethiopia felt that the use of VR technology to aid surgical training is feasible, that it is useful for learning surgical approaches, that it aids surgical performance and that it is superior to conventional resources. Bahir Dar residents strongly agreed that VR simulation videos would allow trainees to supplement reduced learning opportunities as a result of the COVID-19 pandemic and help to counteract their reduced operating experience. For Bahir Dar trainees, a lack of a stable internet connection for large VR files was the predominant issue.

This study demonstrates that there are infrastructure challenges in low and middle income countries (LMICs) in terms of the reliable delivery of VR teaching in orthopaedics at the current time. Despite this, our findings better inform the potential role of VR technology in surgical education, and shed light on the possibility for it to feed into and enrich surgical training in both LMICs and high income countries.

Decolonizing Global Surgery

By bringing health professionals across a variety of disciplines together, we are able to share strategies and create solutions for improving surgical care to these under-serviced regions. The Bethune Round Table 2022 took place virtually, June 16 – 19 and was hosted by BGSC,in co-operation with the Canadian Network for International Surgery. The theme for the BRT 2022 was “Decolonizing Global Surgery”.

The conference program consisted of 28 panelists and speakers and 98 abstracts (46 podium presentations and 52 posters) touching upon diverse aspects of global surgery including women in surgery, indigenous health, and sustainability in global partnerships. All sessions were recorded, including abstracts. All the abstracts presented are contained within this document.

Early detection and treatment of clubfoot in a rural setting in South Africa

Clubfoot is one of the most common musculoskeletal congenital disorders and annually affects around 174 000 babies worldwide. Untreated clubfoot leads to significant permanent impairment and problems with ambulation, thus presenting a potential public health dilemma. Clubfoot can however be corrected with a non-surgical method referred to as the Ponseti method. This gives a child normal, pain free mobility and the potential to grow up as a productive member of society. Treatment for clubfoot needs to be implemented as soon as possible after birth of the child to produce the best results and avoid possible relapse of the clubfoot. Diagnosis and treatment of clubfoot starting at, or later than three months of age, is regarded as late detection and treatment. The purpose of this study was to determine the healthcare-seeking behaviour of guardians of children with clubfoot at or after the age of three months to promote early detection and treatment. A qualitative study was conducted to explore the reasons for seeking healthcare at Ponseti clinics for children that were three months or older; and to describe the challenges that the guardians experienced in seeking healthcare for their children. Data collection was done through semi-structured interviews at two public sector hospitals in KwaZulu Natal Province. Two major themes emerged from the study, namely discovering the clubfoot deformity, and the challenges guardians experienced in seeking healthcare for their children with clubfoot. There is a lack of knowledge about clubfoot resulting in late detection and initiation of treatment; and that clubfoot is a treatable condition which can result in the child leading a normal life if treated with the Ponseti method. Participants attending antenatal care were not informed by health practitioners of clubfoot being a potential birth defect. In some cases, guardians approached health practitioners early, but were referred late to a Ponseti clinic. Guardians in the study experienced several challenges when seeking healthcare for their children, including financial, transport and family responsibility challenges. They described having a child with clubfoot as an emotionally taxing journey. Recommendations are made for education, practice, policy, and research. An information brochure was designed to promote early detection and treatment of clubfoot.

The magnitude and perceived reasons for childhood cancer treatment abandonment in Ethiopia: from health care providers’ perspective

Treatment abandonment is one of major reasons for childhood cancer treatment failure and low survival rate in low- and middle-income countries. Ethiopia plans to reduce abandonment rate by 60% (2019–2023), but baseline data and information about the contextual risk factors that influence treatment abandonment are scarce.

This cross-sectional study was conducted from September 5 to 22, 2021, on the three major pediatric oncology centers in Ethiopia. Data on the incidence and reasons for treatment abandonment were obtained from healthcare professionals. We were unable to obtain data about the patients’ or guardians’ perspective because the information available in the cancer registry was incomplete to contact adequate number of respondents. We used a validated, semi-structured questionnaire developed by the International Society of Pediatric Oncology Abandonment Technical Working Group. We included all (N = 38) health care professionals (physicians, nurses, and social workers) working at these centers who had more than one year of experience in childhood cancer service provision (a universal sampling and 100% response rate).

The perceived mean abandonment rate in Ethiopia is 34% (SE 2.5%). The risk of treatment abandonment is dependent on the type of cancer (high for bone sarcoma and brain tumor), the phase of treatment and treatment outcome. The highest risk is during maintenance and treatment failure or relapse for acute lymphoblastic leukemia, and during pre- or post-surgical phase for Wilms tumor and bone sarcoma. The major influencing risk factors in Ethiopia includes high cost of care, low economic status, long travel time to treatment centers, long waiting time, belief in the incurability of cancer and poor public awareness about childhood cancer.

The perceived abandonment rate in Ethiopia is high, and the risk of abandonment varies according to the type of cancer, phase of treatment or treatment outcome. Therefore, mitigation strategies to reduce the abandonment rate should include identifying specific risk factors and prioritizing strategies based on their level of influence, effectiveness, feasibility, and affordability.

Open tibial shaft fracture management in Argentina: an evaluation of treatment standards in diverse resource settings

Argentina is a country with varying access to orthopedic surgical care. The Argentine Association of Trauma and Orthopedics (AATO) “Interior Committee” was developed to address potential regional differences and promote standardization of orthopedic trauma care. The paper assesses the level of national standardization of the management of open tibia fractures across 9 provinces in Argentina.

Utilizing a matched-comparison group design, management of these injuries were assessed and compared between 3 groups: an “AATO Exterior Committee” consisting of surgeons that practice in Buenos Aires, and 2 “Interior Committees,” comprising surgeons that practice in outlying provinces, 1 of which is affiliated with the AATO, and 1 that is not affiliated with the AATO. The study was conducted in 2 phases: phase 1 assessed open tibia fracture management characteristics, and phase 2 evaluated the management of soft-tissue wound coverage following open fractures.

Soft-tissue coverage procedures for Gustilo Anderson Type IIIB fractures were more commonly performed by orthopedic surgeons in Interior Committees than the AATO Exterior Committee. Greater rates of definitive wound coverage within 7 days post-injury were reported in both Interior Committees compared to the Exterior Committee. Plastic surgeons were reported as more available to those in the AATO Exterior Committee group than in the AATO Interior Committees.

While treatment patterns were evident among groups, differences were identified in the management and timing of soft-tissue coverage in Gustilo Anderson Type IIIB fractures between the Exterior Committee and both Interior Committees. Future targeted educational and surgical hands-on training opportunities that emphasize challenges faced in resource-limited settings may improve the management of open tibia fractures in Argentina.

Scarf Injury: a qualitative examination of the emergency response and acute care pathway from a unique mechanism of road traffic injury in Bangladesh

Road traffic injuries (RTI) are the leading cause of death worldwide in children over 5 and adults aged 18–29. Nonfatal RTIs result in 20–50 million annual injuries. In Bangladesh, a new mechanism of RTI has emerged over the past decade known as a ‘scarf injury.’ Scarf injuries occur when scarves, part of traditional female dress, are caught in the driveshaft of an autorickshaw. The mechanism of injury results in novel, strangulation-like cervical spine trauma. This study aimed to understand the immediate emergency response, acute care pathway, and subsequent functional and health outcomes for survivors of scarf injuries.

Key informant interviews were conducted with female scarf injury survivors (n = 12), caregivers (n = 6), and health care workers (n = 15). Themes and subthemes were identified via inductive content analysis, then applied to the three-delay model to examine specific breakdowns in pre-hospital care and provide a basis for future interventions.

Over half of the scarf injury patients were between the ages of 10 and 15. All but two were tetraplegic. Participants emphasized less than optimal patient outcomes were due to unawareness of scarf injuries and spinal cord injuries among the general public and health professionals; unsafe and inefficient bystander first aid and transportation; and high cost of acute health care.

Females in Bangladesh are at significant risk of sustaining serious and life-threatening trauma through scarf injuries in autorickshaws, further worsened through inadequate care along the trauma care pathway. Interventions designed to increase awareness and knowledge of basic SCI care at the community and provider level would likely improve health and functional outcomes

Expanding Access to Microneurosurgery in Low-Resource Settings: Feasibility of a Low-Cost Exoscope in Transforaminal Lumbar Interbody Fusion

Objectives Less than a quarter of the world population has access to microneurosurgical care within a range of 2 hours. We introduce a simplified exoscopic visualization system to achieve optical magnification, illumination, and video recording in low-resource settings.

Materials and Methods We purchased a 48 megapixels industrial microscope camera with a heavy-duty support arm, a wide field c-mount lens, and an LED ring light at a total cost of US$ 125. Sixteen patients with lumbar degenerative disk disease were divided into an exoscope group and a conventional microscope group. In each group we performed four open and four minimally invasive transforaminal lumbar interbody fusion procedures. We further conducted a questionnaire-based assessment of the user experience.

Results The overall user experience was positive. The exoscope achieved similar postoperative improvement with comparable blood loss and operating time as the conventional microscope. It provided a similar image quality, magnification and illumination. Yet, the lack of stereoscopic perception and the cumbersome adjustability of the camera position and angle resulted in a shallow learning curve. Most users strongly agreed that the exoscope would significantly improve surgical teaching. Over 75% reported they would recommend the exoscope to colleagues and all users saw its great potential for low-resource environments.

Conclusion Our low-budget exoscope is technically non-inferior to the conventional binocular microscope and purchasable at a significantly lower price. It may thus help expand access to neurosurgical care and training worldwide.

Establishing Sustainable Arthroscopy Capacity in Low- and Middle-Income Countries (LMICs) through High-Income Country/LMIC Partnerships

Disparities exist in treatment modalities, including arthroscopic surgery, for orthopaedic injuries between high-income countries (HICs) and low- and middle-income countries (LMICs). Arthroscopy training is a self-identified goal of LMIC surgeons to meet the burden of musculoskeletal injury. The aim of this study was to determine the necessary “key ingredients” for establishing arthroscopy centers in LMICs in order to build capacity and expand training in arthroscopy in lower-resource settings.

This study utilized semi-structured interviews with orthopaedic surgeons from both HICs and LMICs who had prior experience establishing arthroscopy efforts in LMICs. Participants were recruited via referral sampling. Interviews were qualitatively analyzed in duplicate via a coding schema based on repeated themes from preliminary interview review. Subgroup analysis was conducted between HIC and LMIC respondents.

We identified perspectives shared between HIC and LMIC stakeholders and perspectives unique to 1 group. Both groups were motivated by opportunities to improve patients’ lives; the LMIC respondents were also motivated by access to skills and equipment, and the HIC respondents were motivated by teaching opportunities. Key ingredients identified by both groups included an emphasis on teaching and the need for high-cost equipment, such as arthroscopy towers. The LMIC respondents reported single-use materials as a key ingredient, while the HIC respondents reported local champions as crucial. The LMIC respondents cited the scarcity of implants and shaver blades as a barrier to the continuity of arthroscopy efforts.

Incorporation of the identified key ingredients, along with leveraging the motivations of the host and the visiting participant, will allow future international arthroscopy partnerships to better match proposed interventions with the host-identified needs.

Context and Priorities for Health Systems Strengthening for Pain and Disability in Low- and Middle-Income Countries: A Secondary Qualitative Study and Content Analysis of Health Policies

Musculoskeletal (MSK) health impairments contribute substantially to the pain and disability burden in low- and middle-income countries (LMICs), yet health systems strengthening (HSS) responses are nascent. We aimed to explore the contemporary context, framed as challenges and opportunities, for improving population-level prevention and management of MSK health in LMICs using secondary qualitative data from a previous study exploring HSS priorities for MSK health globally; and (2) to contextualize these findings through an analysis of health policies for integrated management of noncommunicable diseases (NCDs) in select LMICs. Part 1: 12 transcripts of interviews with LMIC-based key informants (KIs) were inductively analysed. Part 2: systematic content analysis of health policies for integrated care of NCDs where KIs were resident (Argentina, Bangladesh, Brazil, Ethiopia, India, Kenya, Malaysia, Philippines, South Africa). A thematic framework of LMIC-relevant challenges and opportunities was empirically-derived, organized around 5 meta-themes: (1) MSK health is a low priority; (2) social determinants adversely affect MSK health; (3) healthcare system issues de-prioritize MSK health; (4) economic constraints restrict system capacity to direct and mobilize resources to MSK health; (5) build research capacity. Twelve policy documents were included, describing explicit foci on cardiovascular disease (100%), diabetes (100%), respiratory conditions (100%) and cancer (89%); none explicitly focussed on MSK health. Policy strategies were coded into three categories: (1) general principles for people-centred NCD care; (2) service delivery; (3) system strengthening. Four policies described strategies to address MSK health in some way, mostly related to injury care. Priorities and opportunities for HSS for MSK health identified by KIs aligned with broader strategies targeting NCDs identified in the policies. MSK health is not currently prioritized in NCD health policies among selected LMICs. However, opportunities to address the MSK-attributed disability burden exist through integrating MSK-specific HSS initiatives with initiatives targeting NCDs generally and injury and trauma care.

High quality care following orthopaedic injury in Zambia: A qualitative, patient-centred study

Injuries are a significant cause of mortality and morbidity, particular in low- and middle-income countries (LMICs). While there is a focus on increasing injury care capacity, less attention is given to assessing, improving, and understanding the quality of care provided, especially from a patient perspective. This study therefore aims to understand what patients from a Zambian orthopaedic ward believe good quality care to be, to identify its key components, and contribute to better understanding what patients believe local healthcare priorities could be.

Patients admitted to the orthopaedic ward of a Zambian tertiary care hospital were invited to take part in-depth face-to-face interviews. Interviews were continued until thematic saturation was achieved. Interviews were recorded and transcribed. Analysis was done using an inductive grounded theory approach.

Of 13 patients approached, 12 consented to take part. Analysis of the themes from the transcripts led to the emergence of four core categories of quality care which are important to the patient: i) restoring the patient to normality (category: ‘restoring normality’), ii) establishing trust between patients and providers (‘trusting the provider’), iii) respecting the patient and allowing them to maintain autonomy (‘autonomy and respect’) iv) finding ways for patients to enjoy their time in the hospital (‘enjoying life’). From these results, a patient perspective theory of quality care emerged. This theory posits the idea that high-quality care in this context needs to fulfil these four core categories. Additionally, these core categories were ranked on significance and priority.

The hierarchy of core categories could help to identify areas to improve care quality in this setting. Not only has this study helped to determine local priorities for achieving high-quality care but can encourage others to test injured patient perceptions of care quality in comparable settings.