Trauma Training for Nonorthopaedic Doctors in Low- and Middle-income Countries

Increasingly, nonspecialist Ghanaian doctors in district hospitals are called upon to perform a variety of surgical procedures for which they have little or no training. They are also required to provide initial stabilization for the injured and, in some cases, provide definitive management where referral is not possible. Elsewhere continuing medical education courses in trauma have improved the delivery of trauma care. Development of such courses must meet the realities of a low-income country. The Department of Surgery, Kwame Nkrumah University of Science and Technology developed a week-long trauma continuing medical education course for doctors in rural districts. The course was introduced in 1997, and has been run annually since. The trauma course specifically addresses the critical issues of trauma care in Ghana. It has improved the knowledge base of doctors, as well as their self-reported process of trauma care. Through the process we have learned lessons that could help in the efforts to improve trauma training and trauma care in other low-income countries. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.     

Cost-effectiveness of Surgery in Low- and Middle-income Countries: A Systematic Review

Background

There is increasing interest in provision of essential surgical care as part of public health policy in low- and middle-income countries (LMIC). Relatively simple interventions have been shown to prevent death and disability. We reviewed the published literature to examine the cost-effectiveness of simple surgical interventions which could be made available at any district hospital, and compared these to standard public health interventions.

Methods

PubMed and EMBASE were searched using single and combinations of the search terms “disability adjusted life year” (DALY), “quality adjusted life year,” “cost-effectiveness,” and “surgery.” Articles were included if they detailed the cost-effectiveness of a surgical intervention of relevance to a LMIC, which could be made available at any district hospital. Suitable articles with both cost and effectiveness data were identified and, where possible, data were extrapolated to enable comparison across studies.

Results

Twenty-seven articles met our inclusion criteria, representing 64 LMIC over 16 years of study. Interventions that were found to be cost-effective included cataract surgery (cost/DALY averted range US$5.06–$106.00), elective inguinal hernia repair (cost/DALY averted range US$12.88–$78.18), male circumcision (cost/DALY averted range US$7.38–$319.29), emergency cesarean section (cost/DALY averted range US$18–$3,462.00), and cleft lip and palate repair (cost/DALY averted range US$15.44–$96.04). A small district hospital with basic surgical services was also found to be highly cost-effective (cost/DALY averted 1 US$0.93), as were larger hospitals offering emergency and trauma surgery (cost/DALY averted US$32.78–$223.00). This compares favorably with other standard public health interventions, such as oral rehydration therapy (US$1,062.00), vitamin A supplementation (US$6.00–$12.00), breast feeding promotion (US$930.00), and highly active anti-retroviral therapy for HIV (US$922.00).

Conclusions

Simple surgical interventions that are life-saving and disability-preventing should be considered as part of public health policy in LMIC. We recommend an investment in surgical care and its integration with other public health measures at the district hospital level, rather than investment in single disease strategies.     

髋臼骨折术后下肢深静脉血栓形成的多因素分析

目的 分析影响髋臼骨折术后下肢深静脉血栓形成(DVT)的危险因素.方法 对102髋臼骨折术后DVT发生情况进行分析.术前及术后7～10d均用彩色多普勒检查双下肢深静脉血流通畅情况及DVT的发生,并对11项临床因素与人工关节置换术后DVT形成的相关性进行分析.结果 髋臼骨折术后发生DVT有18例,DVT发生率为17.65%(18/102).经Logistic多因素回归分析,与DVT相关的因素有6个,其中年龄、肥胖、静脉曲张及手术方式使术后发生DVT的风险分别增加到4.075、7.803、46.176和4.251倍(P＜0.05);硬膜外麻醉和踝泵练习使术后发生DVT的风险减少到0.121和0.114倍(P＜0.01).结论 年龄和肥胖是人工关节术后发生DVT的危险因素,而硬膜外麻醉和踝泵练习则是术后发生DVT的保护因素.髋臼骨折术后无症状DVT的大量存在,提示术后最好常规行双下肢彩色多普勒检查,一旦有DVT发生,及时治疗,防止发生致命性肺栓塞.     

交锁髓内针治疗股骨干骨不连短肢畸形

目的：分析股骨干骨不连肢体短缩的原因，探讨交锁髓内针植骨固定治疗股骨干骨不连短肢畸形的优缺点。方法；采用交锁髓内针固定，自体髂骨充填骨缺损区的术式治疗股骨干骨不连短肢畸形12例，所有病例随访1年以上。结果：12例全部一次愈合，平均愈合时间22个月。肢体延长平均3．2cm。无主钉、锁钉弯曲、折断等内固定失败。结论：(1)股骨干骨不连短肢的主要原因是骨折固定不牢靠造成骨吸收所致；(2)交锁髓内针植骨固定合理可靠，是治疗股骨干骨不连短肢畸形的较理想方法，但骨愈合缓慢；(3)植骨应避免遗留骨缺损，负重时间应向后推迟。     

Insufficient Bone Regenerate after Intramedullary Femoral Lengthening: Risk Factors and Classification System

Background  

Control of distraction rate with an intramedullary skeletal kinetic distractor (ISKD) may be problematic and a high distraction rate may result in insufficient bone regenerate.     

扩张自锁髓内钉与交锁髓内钉治疗胫骨干闭合骨折的临床比较研究

目的对比髓内扩张自锁髓内钉固定术(self-locking expandable intramedullary nail)与交锁髓内钉内固定术(interlocking in-tramedullary nail)治疗胫骨干闭合骨折的临床结果,并探讨髓内扩张自锁髓内钉技术要点。方法治疗胫骨骨折31例,其中自锁髓内钉组15例,交锁髓内钉组16例。记录手术时间、术中出血量、术中X线机透视次数、术中术后并发症、下地时间,骨折愈合时间、术后1年膝关节KSS评分结果。结果随访15～21个月。自锁髓内钉组、交锁髓内钉组手术时间分别为[(32±17)min,(58±21)min,P0.05]、术中出血量[(71±25)ml,(145±31)ml,P0.05)]、术中X线透视次数[(6±2)次,(14±6)次,P0.05)],术中术后并发症发生率、下地时间、骨折愈合时间、术后1年膝关节KSS评分无显著性差异。结论胫骨干闭合骨折是髓内扩张自锁髓内钉固定术的适应证,该术较交锁髓内钉术更微创,手术时间短,治疗效果与交锁髓内钉术大致相当,但其远期效果需要进一步临床研究。     

Risk Factors for Penile Prosthetic Infection

Purpose

We determined the risk factors for penile prosthesis infections.

Materials and Methods

The records of 156 men undergoing 167 procedures for insertion of a penile prosthesis were reviewed. The device was implanted during a primary uncomplicated procedure in 114 cases. Simultaneous penile reconstruction was performed in 23 cases. A malfunctioning penile prosthesis was replaced or repaired immediately following removal in 30 cases. Minimum followup was 1 year.

Results

The infection rate was 1.8 percent after insertion of a penile prosthesis in 114 men without previous penile surgery compared to 21.7 percent for procedures requiring reconstruction of the corpora, which was significantly different (p less than 0.01). The infection rate after revision of a penile previous penile surgery compared to 21.7 percent for procedures requiring reconstruction of the corpora, which was significantly different (p less than 0.01). The infection rate after revision of a penile prosthesis was 13.3 percent, which was significantly greater than that following primary uncomplicated implantation (p less than 0.05) but not different from that for patients requiring reconstruction (p = 0.5). There was no difference in patient age, etiology of impotence or associated medical disorders among the 3 groups. Operative time was significantly longer for patients requiring penile reconstruction than for the other 2 groups (p less than 0.01).

Conclusions

The risk of infection is significantly greater when penile reconstruction is required, and appears to be related to increased duration of surgery. The increased risk of infection associated with revision of a penile prosthesis cannot be explained by patient characteristics or operative time.     

交锁髓内钉的临床应用体会

作者报道１０２例（１０５侧）交锁髓内钉的应用体会。男８２例，女２０例，年龄１７～７５岁。股骨４５例（４６侧），包括髁上骨折４例，股骨干加粗隆部骨折４例。胫骨５２例（５４侧）。肱骨５例。手术采用不扩髓３１例（肱２，胫２２，股７），扩髓７１例（肱３，胫３０，股３８）。采用静力交锁为主，静力交锁改动力交锁６例。病理性骨折２例，其中肱骨和股骨各１例。人工股骨头置换术后骨折１例。出现髓内钉偏长１例，偏短３例。对侧皮质断裂３例。螺钉不在交锁孔内３例。感染１例。本文讨论了适应证、手术注意点和并发症的预防。并讨论了扩髓与不扩髓，静力与动力交锁问题。作者认为长骨骨折应用交锁髓内钉是极好的指征，且其范围越来越扩大，值得普遍推广     

股骨重建钉治疗股骨干合并同侧髋部骨折适应证探讨

目的探讨股骨重建钉治疗股骨干合并同侧髋部骨折的手术适应证。方法根据入选标准和排除标准,回顾2001年1月至2011年1月收治的股骨干合并同侧髋部骨折病例15例,其中男14例,女1例;年龄21~64岁,平均35.5岁。通过比较术前、术后即刻、术后1、3、6和12个月的临床和影像学随访结果,评估骨折愈合情况和并发症,分析股骨重建钉治疗股骨干合并同侧髋部骨折的最佳适应证。结果全部病例获得随访,随访时间14~48个月,平均27.8个月。13例股骨干骨折一期获得骨性愈合,愈合时间(6.2±4.1)个月,14例股骨颈骨折一期获得骨性愈合,愈合时间(5.4±2.9)个月。合并症:1例股骨远端骨折由于狭部限制,重建钉过细,局部旋转不稳定,并发肥大性骨不连;1例股骨中段骨折延迟愈合;2例股骨干旋转畸形愈合;1例股骨颈头下型骨折不愈合。末次随访时进行Friedman-Wyman评定,优12例,良2例,差1例,优良率93.3%。结论股骨重建钉适用于绝大部分股骨干骨折合并髋部骨折,尤其是股骨颈基底部骨折合并股骨干近端或狭部骨折。但对于股骨颈头下型、难复位的股骨颈骨折合并股骨干远端骨折,股骨重建钉并非最佳的治疗方案。     

肝移植术后早期肺部细菌感染的危险因素分析

目的 分析原位肝移植术后早期肺部细菌感染的发生情况及其危险因素。方法 回顾性分析笔者所在医院2010年1月至2012年6月期间行下腔静脉逆灌注法原位肝移植术的96例终末期肝病患者的临床资料。采用多因素非条件logistic回归分析探索肝移植术后早期肺部细菌感染的危险因素。结果 96例患者中有29例于肝移植术后早期发生肺部细菌感染,感染率为30.21%,其中感染G-需氧菌19例（65.52%）,感染G＋需氧菌10例（34.48%）。患者的术前终末期肝病模型评分（OR=2.165,P=0.001）、术中输血量（OR=1.952,P=0.003）、术后3 d血肌酐平均值（OR=1.913,P=0.001）、术后3 d液体负平衡时间（OR=0.196,P=0.023）及术后住院时间（OR=1.923,P=0.003）均与术后早期肺部细菌感染有关。结论 原位肝移植术后早期易发生肺部细菌感染。术前改善患者基础状况、术中控制输血量、术后控制输液量和住院时间及术后改善肾功能均可减少术后早期肺部细菌感染的发生。     

长管骨髓内钉远端交锁技术改进

目的：介绍一种借助C臂透视锁远端交锁钉的方法。方法：129例带锁髓内钉应用这种方法锁远端锁钉。结果：共锁远端锁钉204枚，平均透视次数为4．7次、平均锁钉时间为11min。结论：本方法简便易行，无需特殊设备，大大减少透视次数、锁孔时间及术中出血。     

Sanatmetal前臂髓内钉微创治疗尺桡骨骨干骨折

目的探讨应用Sanatmetal前臂髓内钉治疗尺桡骨骨干骨折的手术疗效。方法2005年7月~2007年3月,应用Sanatmetal前臂髓内钉治疗尺桡骨骨干骨折32例;其中男18例,女14例;年龄26~71岁,平均42岁。前臂尺、桡骨双骨折17例,尺骨骨折7例,桡骨骨折8例。32例中多段骨折7例,陈旧性骨折骨不连2例。结果术后随访3~21个月,平均7个月。术后无一例发生伤口感染及髓内钉断裂或松动。32例均完全骨性愈合,愈合时间平均为4个月。按Anderson评分标准评定:优28例,良4例。肘关节伸屈活动功能丧失5~30°,平均17.5°,前臂旋前功能丧失10~35°,平均21.6°,旋后功能丧失10~40°,平均27.5°。结论应用Sanatmetal前臂髓内钉治疗尺桡骨骨干骨折,具有手术损伤小,固定牢固等优点,是治疗前臂骨折较理想的手术方法。     

两种手术方式治疗股骨干骨折带锁髓内钉固定术后骨不连

目的通过对比性研究评价两种手术方式治疗股骨干骨折带锁髓内钉固定术后骨不连的疗效。方法回顾分析2009年1月至2010年7月针对41例股骨干骨折带锁髓内钉固定术后骨不连患者采用手术治疗的临床效果,20例行髓内钉取出加滑槽植骨锁定加压钢板固定(A组),21例行断端周围植骨加锁定钢板辅助固定(B组),评估手术时间、手术出血量、植骨愈合率等情况。结果两组患者经8～13个月随访,平均11个月。两组手术时间分别为(130±25)min、(90±17)min,两组间比较差异有统计学意义(P<0.05);手术出血量分别为(436±60)mL、(304±37)mL,两组间比较差异有统计学意义(P<0.05);两组植骨融合率分别为90%、95.2%,两组间比较差异无统计学意义(P>0.05)。结论两种手术方法治疗股骨干骨折带锁髓内钉固定术后骨不连均可得到满意的疗效。骨折断端周围植骨加钢板辅助固定治疗的手术方法具有操作相对简单、手术时间短、创伤小、手术并发症少等优点。     

带锁髓内钉治疗股骨复杂多段粉碎骨折

目的：探讨带锁髓内钉治疗股骨复杂多段粉碎骨折的临床疗效和优点。方法：应用带锁髓内钉治疗股骨复杂骨折21例。结果：随访9-28个月，术后骨折全部愈合，并发症少。患肢关节功能优良。结论：股骨带锁髓内钉是治疗股骨复杂骨折的首选内固定方法。