Orthopedic Surgery in the Developing World: Workforce and Operative Volumes in Ghana Compared to Those in the United States

Background

Musculoskeletal disease is a growing burden in low- and middle-income countries (LMICs), yet little research exists to describe the problem. The purposes of this study were to characterize orthopedic surgery in an LMIC and compare the findings to those from a developed country.

Methods

The study location was the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana. Orthopedic surgeon, resident, and postgraduate training program numbers were compared to analogous data from a developed nation, the United States. Annual surgical volumes were compared to those at a level I trauma center in the United States, the San Francisco General Hospital (SFGH).

Results

There were 24 surgeons in Ghana compared to 23,956 in the United States. There were 7 orthopedic residents and 1 residency program in Ghana versus 3,371 residents and 155 residencies in the United States. Annual case volume was 2,161 at KATH and 2,132 at SFGH. Trauma accounted for 95 % of operations at KATH compared to 65 % at SFGH. The proportion of surgeries devoted to severe fractures was 29 % at KATH compared to 12 % at SFGH. Infections comprised 15 % of procedures at KATH and 5 % at SFGH.

Conclusions

Annual case volume at a referral hospital in an LMIC is equivalent to that of a level I trauma center in an industrialized country. Total case volume is similar, but the LMIC institution manages a disproportionately large number of trauma cases, severe fractures, and infections. There is a large burden of orthopedic disease in the developing nation, and there are too few providers and training programs to address these conditions.     

Management of displaced radial neck fractures in children: percutaneous pinning vs. elastic stable intramedullary nailing

Background

The treatment of radial neck fractures in children varies according to the displacement, angulation, and skeletal maturity. There is a general agreement that displaced radial neck fractures with more than 30° angulations (Judet type III and IV fractures) should be surgically treated. There are several treatment possibilities for Judet type III and IV fractures including percutaneous pin reduction, elastic stable intramedullary nailing (ESIN), and open reduction with or without internal fixation. In this retrospective study we compared the clinical and radiographical outcomes, and complications following intramedullary versus percutaneous pinning in displaced radial neck fractures in children.

Materials and methods

Between 2000 and 2011, 20 patients were treated using closed reduction: in 12 cases we used percutaneous pinning, and in 8 cases we used ESIN. According to Judet classification the two groups were composed as follows: 10 (77 %) type III and 3 (23 %) type IV fractures in the percutaneous pinning group; 4 (57 %) type III, and 3 (43 %) type IV fractures in the ESIN group.

Results

After an average of 42 months, excellent results in Mayo elbow performance scores (MEPS) were obtained in 71 and 69 % of ESIN and percutaneous pinning groups respectively, with good results in the remaining cases apart from one fair case (8 %) in the percutaneous pinning group. After a radiological evaluation, all fractures healed in excellent or good alignment. When comparing the two groups, the subjects treated with the ESIN technique had higher range of motion (ROM) in flexion, extension and pronation. No patients developed complications, except three cases of asymptomatic enlargements of the radial head, reported only in the percutaneous pinning group.

Conclusion

In this research the clinical outcome, assessed with the MEPS, and the radiological alignment, were comparable between the subjects that were treated with percutaneous pinning and those with ESIN techniques; whereas the ESIN technique demonstrated higher ROM in flexion, extension and pronation. The ESIN technique seems to be the ideal approach both for the higher ROM values and for the absence of complications.     

Elastic stable intramedullary nailing (ESIN) in the adolescent patient—perils,pearls, and pitfalls

Purpose

Elastic stable intramedullary nailing (ESIN) has become the treatment of choice for diaphyseal long-bone fractures in children. This paper reviews the complications and limitations of this method which can occur when applying this osteosynthesis to patients within the adolescent age group.

Methods

Each topographic site where ESIN is used was analyzed individually and systematically. Technical errors, indicational problems, and mistakes during the rehabilitation process are pointed out and recommendations are given on how to avoid failure.

Results

ESIN can be safe and efficacious within certain limits also in the adolescent age group. Whenever errors and mistakes occur in combination, e.g., applying ESIN to a patient with a multi-fragmented fracture and a high body mass index (BMI), the adolescent age group is less forgiving to indicational “stretching” than the pediatric age group.

Conclusions

The best prophylaxis for failure of ESIN is a stable and symmetric construct with correctly sized implants. This holds even more true for the adolescent patient. Using ESIN in difficult situations such as longitudinally unstable fractures, patients with a body weight >50 kg, or away from the diaphysis should be considered and followed up carefully. If possible, these patients should be treated in specialized pediatric trauma centers.     

Risk Factors for Infection after 46,113 Intramedullary Nail Operations in Low- and Middle-income Countries

Background

The fields of surgery and trauma care have largely been neglected in the global health discussion. As a result the idea that surgery is not safe or cost effective in resource-limited settings has gone unchallenged. The SIGN Online Surgical Database (SOSD) is now one of the largest databases on trauma surgery in low- and middle-income countries (LMIC). We wished to examine infection rates and risk factors for infection after IM nail operations in LMIC using this data.

Methods

The SOSD contained 46,722 IM nail surgeries in 58 different LMIC; 46,113 IM nail operations were included for analysis.

Results

The overall follow-up rate was 23.1 %. The overall infection rate was 1.0 %, 0.7 % for humerus, 0.8 % for femur, and 1.5 % for tibia fractures. If only nails with registered follow-up (n = 10,684) were included in analyses, infection rates were 2.9 % for humerus, 3.2 % for femur, and 6.9 % for tibia fractures. Prophylactic antibiotics reduced the risk of infection by 29 %. Operations for non-union had a doubled risk of infection. Risk of infection was reduced with increasing income level of the country.

Conclusions

The overall infection rates were low, and well within acceptable levels, suggesting that it is safe to do IM nailing in low-income countries. The fact that operations for non-union have twice the risk of infection compared to primary fracture surgery further supports the use of IM nailing as the primary treatment for femur fractures in LMIC.     

Operative versus nonoperative treatment for displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials

Introduction

There is insufficient evidence to indicate whether operative or nonoperative treatment is better for treating displaced midshaft clavicular fractures. We undertook a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the effects of the two treatments.

Methods

We searched the PubMed, EMBASE and Cochrane Library databases, and identified RCTs to compare the Constant score, DASH score, nonunion, malunion, and adverse events between operative and nonoperative groups of patients with displaced midshaft clavicular fractures.

Results

A total of 507 patients from 6 RCTs were subjected to meta-analysis. Operative treatment has an effect on improving function, which is demonstrated by significantly higher Constant scores (P = 0.0003) and lower DASH scores (P = 0.03). The rate of nonunion and the rate of malunion were significantly lower in operative group compared with that in nonoperative group (both P < 0.0001). However, the rate of adverse events was significantly higher in operative group compared with that in nonoperative group (P = 0.003).

Conclusions

Operative treatment provided a significantly better functional outcome, a lower rate of nonunion and malunion, but was accompanied with a higher rate of adverse events. However, the results should be interpreted with caution and further large-scale, well-designed RCTs on this topic are still needed.     

The change in energy absorbed post removal of metalwork in a simulated paediatric long bone fracture

Purpose

The surgical treatment of paediatric fractures is increasing. Open reduction and internal fixation (ORIF) with plates and screws is long established, whilst the use of elastic stable intramedullary nailing (ESIN) has become increasingly popular. This study quantifies, in terms of the energy required to produce a fracture, the biomechanical sequelae of both techniques post removal of metalwork, to provide clinicians with evidence to guide post-operative advice.

Methods

An immature bovine model was adopted to ascertain whether these techniques exposed the bone to a greater re-fracture risk following removal of the device. Bones were prepared to reflect ORIF or ESIN techniques, or prepared intact for the acquisition of control data. Each bone was tested to failure at 90 °/s, with the absorbed energy then being calculated to determine the relative difference between each technique and versus control data. Data describing peak shear stress and torque were recorded.

Results

Absorbed energy was reduced by 47 % in the ORIF group compared to both the control (p = 0.011) and ESIN (p = 0.018) groups. The peak shear stress and torque were also significantly different. All ORIF bones failed through drill holes, suggesting stress localisation around the defects.

Conclusion

This study suggests that there is a significantly higher re-fracture risk following the removal of ORIF plates when compared to both ESIN and the control environment. Whilst this may reflect the intuitive view of many clinicians, this study provides a quantitative value of the reduction in strength and should help clinicians to appropriately caution patients and parents prior to surgery.     

The assessment of bone mineral content and density of the lumbar spine and proximal femur in US submariners

Summary

The submarine environment is unique in that there is limited space and no sunlight, which may negatively affect skeletal health and lead to accelerated bone loss, osteoporosis, and fractures.

Introduction

The primary purpose of this study was to determine whether there was an association with submarine service, specifically time spent at sea, and bone mineral content (BMC) and bone mineral density (BMD) of the lumbar spine and dual proximal femur (total hip and femoral neck) measured by DXA.

Methods

This is a cross-sectional study of 462 submariners 20–91 years old. Variables included in the analysis were age, height, race, alcohol intake, tobacco use, fracture history, conditions, and medications known to cause bone loss and osteoporosis and submarine service.

Results

Of the submarine service predictors, only serving onboard a diesel submarine was determined to be independently associated with a reduction in BMD of the total hip and femur neck, while no submarine service predictor increased the odds of having low BMD. In submariners 50+ years old, the age-adjusted prevalence of osteopenia was 15.7 % (lumbar spine) and 40.4 % (femur neck), while the prevalence of osteoporosis was 4.8 % (lumbar spine) and 4.2 % (femur neck), rates that did not differ from NHANES 2005–2008. In submariners <50 years old, 3.1 % was below the expected range for age. The proportion of submariners 50+ years old that met the FRAX criteria for pharmacological treatment was 12 %.

Conclusions

Intermittent periods of submergence that can range from a few days to 3+ months do not appear to compromise skeletal health differently than the general population.     

The effect of inferomedial screw on postoperative shoulder function and mechanical alignment in proximal humerus fractures

Aim

The aim of the study was to evaluate the clinical and radiologic results of locking plate fixation with or without inferomedial screw (IMS) in surgically treated proximal humerus fractures.

Patients and methods

Thirty-six patients with displaced proximal humerus fractures from two centers were operated using locking plate. All of the fractures were classified according to the Neer classification. In 18 of the cases, an additional IMS running through the medial curvature of the surgical neck was used. There was no significant difference among both groups in terms of height, gender, weight, and mechanism of injury. The fractures were evaluated according to the radiographic and functional findings during follow-up period of 14 months in average (range 8–32 months). At the end of first year, shoulder radiographs were received and shoulder examinations were performed using ASES scores. Humeral head-shaft angles were measured by true AP projections. Head-shaft angle measurements were categorized as varus if <125, normal if between 125 and 145, and valgus if >145.

Results

Mean time for fracture healing was 18 weeks. Complete union was achieved in 35 patients by the end of 6 months. In one of the 18 displaced proximal humerus fractures of IMS (+) group, the head-shaft angle was measured to be <125, whereas six patients had varus deviation in IMS (?) group at follow-up (p < 0.05). Mean ASES scores of IMS (+) group and IMS (?) group were 58.21 ± 5.82 and 38.61 ± 3.44, respectively (p < 0.001).

Conclusion

Use of inferomedial screw running through the medial curvature of surgical neck prevents varus deformity and improves functional outcome after surgical treatment for proximal humerus fractures.     

Die elastisch stabile intramedulläre Osteosynthese der diaphysären Klavikulafraktur

Background

The aim of this study was to compare the outcome of open reduction versus closed reduction of midclavicular fractures using elastic stable intramedullary nailing (ESIN) in both groups.

Methods

Titanium elastic nails were used to treat 40 patients undergoing minimally invasive ESIN between December 2006 and July 2009. A total of 19 patients were treated with a closed reduction and 21 patients required open reduction.

Results

The Constant Score revealed no significant differences between the two groups (closed 87.4±9.0; open 85.3±7.1) nor did the DASH Score (closed: 5.0±6.5; open 5.8±7.3). The strength measurement of shoulder abduction was consistent in each group: 75.7±22.0 N in the closed reduction group and 74.2±26.0 N in the group with open treatment.

Conclusion

There was no difference comparing right- and left-sided injuries and the outcomes were consistent irrespective of the treatment method. When appropriately indicated open and closed intramedullary nailing are very successful modalities of treatment. There were no significant differences in shoulder function after either procedure.     

Feasibility study on the potential of a spiral blade in osteoporotic distal femur fracture fixation

Introduction

Osteoporotic fractures of the distal femur (primary as well as periprosthetic) are a growing problem in today’s trauma and orthopaedic surgery. Therefore, this feasibility study should identify the biomechanical potential of a (commercially available) spiral blade in the distal femur as compared to a single screw without any additional plate fixation. Additionally, the influence of cement augmentation was investigated.

Materials and methods

An artificial low density bone model was either instrumented with a perforated spiral blade or a 5 mm locking screw only. Additionally, the influence of 1 ml cement augmentation was investigated. All specimens were tested with static pull-out and cyclic loading (50 to 250 N with an increment of 0.1 N/cycle).

Results

In the non-augmented groups, the mean pull-out force was significantly higher for the blade fixation (p < 0.001). In the augmented groups, the difference was statistically not significant (p = 0.217). Augmentation could increase pull-out force significantly by 72 % for the blade and 156 % for the screw, respectively (p = 0.001). The mean number of cycles to failure in the non-augmented groups was 12,433 (SD 465) for the blade and 2,949 (SD 215) for the screw, respectively (p < 0.001). In the augmented group, the blade reached 13,967 (SD 1,407) cycles until failure and the screw reached 4,413 (SD 1,598), respectively (p < 0.001).

Conclusion

The investigated spiral blade was mechanically superior, significantly, as compared to a screw in the distal femur. These results back up the further development of a distal femoral blade with spiral blade fixation for the treatment of osteoporotic distal femur fractures.     

Ergebnisse und Komplikationen der Behandlung periprothetischer Femurfrakturen mit einem winkelstabilen Plattensystem

Background

Locked plate devices offer advantages in the treatment of periprosthetic femur fractures associated with fixed total hip or total knee arthroplasty. The purpose of this study was to evaluate the early results and complications with a locked plate system (NCB-DF®).

Patients and methods

A total of 31 patients (mean age 76 years, 7 males, 24 females) with a femur fracture above a fixed total knee arthroplasty (TKA, n=12) or a total hip arthroplasty (THA, n=19) were treated with a locked plate.

Results

There were 11 complications necessitating revision: 6 implant failures, 2 in patients with a THA and 4 in patients with a TKA, 4 hematomas and 1 infection and 2 patients died. After 6 months all fractures had healed securely but a secondary correction was necessary in one patient.

Conclusion

Fixation of periprosthetic femur fractures with a locked plate system provided satisfactory results in patients with a THA, however, the relatively high implant failure rate in fractures above a stable TKA is a cause for concern.     

Treatment of isolated diaphyseal fractures of the radius with an intramedullary nail in adults

Background

The goal of the radius diaphysis fractures in surgical treatment is restoration of bone length, rotation correction and to secure fixation that allows early mobilization. The purpose of this study is evaluating the results of intramedullary (IM) radius nail for the treatment of isolated adult diaphyseal fractures of the radius.

Materials and methods

We retrospectively reviewed adults with isolated fractures of the radius, who were treated with closed or mini open reduction with a IM radius nail between May 2008 and November 2011 and who were followed for a least 1 year. Patients with a Galeazzi fracture, a pathological fracture, or patients with nonunion after previous surgeries were excluded. All patients were allowed full range of motion without any external support. Primary outcomes were Grace and Eversmann rating, Disabilities of the Arm, Shoulder and Hand (DASH) scores.

Results

Twenty-three enrolled patients (mean age 34 years; 17 men) had 23 isolated radius fractures. Mean time to fracture union was 12 weeks (range 10–13 weeks) for radius fractures. No patient had nonunion, deep infections, or radioulnar synostosis. Follow-up ranged from 12 to 42 months. Grace and Eversmann ratings of 21 patients were excellent or good, and 2 patients were medium. Mean DASH score was 4.2 points (range 0–13.3).

Conclusions

Our experience indicates that this new IM radius nail may be considered as an alternative to plate osteosynthesis for fractures of the radius diaphysis in adults. IM nailing of radius fractures provides reliable bony union and excellent postoperative clinical results in adults.     

Callus formation is related to the expression ratios of estrogen receptors-alpha and -beta in ovariectomy-induced osteoporotic fracture healing

Introduction

This study characterizes ovariectomized (OVX)-induced osteoporotic fracture healing with focus on estrogen receptors (ERs). Callus formation plays a critical role in fracture healing, and ERs are well-known mechanosensors in osteogenic pathways. It was hypothesized that callus formation was related to and partially determined by the difference in expression patterns of ERs in both normal and OVX-induced osteoporotic fractures.

Methods

Closed femoral fracture in SHAM and ovariectomized rats were used in this study. Weekly callus width (CW) and area (CA), endpoint mechanical properties, gene expressions of Col-1, BMP-2, ER-α, ER-β and ER-α:ER-β ratios (ER-ratios), and correlations were assessed at 2, 4 and 8 weeks post-fracture.

Results

CW and CA results confirmed that OVX-induced osteoporotic fracture was delayed at 2–4 weeks with impaired endpoint mechanical properties. Gene expressions of ER-α and ER-β were higher in the SHAM group at week 2 (p < 0.05) and later lowered at week 8; whereas the OVX group showed an opposing trend. Moderate correlation existed between ER-α and BMP-2 (0.545, p = 0.003), and ER-ratio and BMP-2 (0.601, p = 0.001), and BMP-2 to CW and CA (r = 0.709, p = 0.000 and r = 0.588, p = 0.001, respectively). ER-α and ER-β proteins expressions were confirmed by immunohistochemistry at the fracture callus in reparative progenitor cells, osteoblasts- and osteoclasts-like cells.

Conclusion

We conclude that the delayed healing rate and impaired callus quality in OVX-induced osteoporotic fracture is related to the delayed expression of ERs. A high ER-α:ER-β ratio favors callus formation.     

Assessing leg length discrepancy following elastic stable intramedullary nailing for paediatric femoral diaphyseal fractures

Introduction

Femoral overgrowth is a recognised phenomenon following fractures of the femoral diaphysis in children. This study was designed to assess leg length discrepancy (LLD) following elastic stable intramedullary nailing (ESIN) and its clinical significance.

Materials and methods

A retrospective review of children who underwent ESIN with DePuy ACE^® Nancy nails between 1997 and 2001 for diaphyseal femoral fractures. Evaluation was by questionnaire, clinical examination and radiological measurement.

Results

17/26 (65%) patients were followed up for a mean time of 48 months (21–77). Average age at surgery was 9 years. Mean operative time was 78 min with a mean hospital stay of 7.8 days. Mean time to union was 10 weeks. A statistically significant LLD of +3.2 mm is demonstrated in children aged 4–8 years (P = 0.05). LLD is not statistically significant in children over 8 years.

Conclusion

ESIN is a successful treatment for paediatric diaphyseal femoral fractures and allows early mobilisation and discharge. A statistically significant LLD is observed in children aged 4–8 years although clinically only one patient in the entire series was aware of a leg length discrepancy. In addition clinical methods of leg length measurement are sensitive for LLD and we conclude that routine radiographic follow up is not necessary unless clinically indicated.

     

Theatre within 36 h for patients with fracture of the proximal femur: can we deliver?

Background

Proximal femur fractures carry significant levels of morbidity and mortality. Surgical delay is one factor that adversely affects outcome in these patients. In 2010, hospital-income from patients with proximal femur fractures was linked to the surgery being undertaken within 36 h of admission. Can we deliver this target?

Materials and methods

Data from the 2009 National Hip Fracture Database was interrogated and appropriate patients were identified. Patient records were reviewed to identify the reasons for surgical delay. Mortality rates were compared within 36 h and after.

Results

Five-hundred and thirty-two patients were admitted in 2009, 118 (22 %) of them were delayed more than 36 h. Surgery was delayed for a variety of identified reasons. Median time to surgery was 24 h (1–273). Ninety-day mortality for patients treated within 36 h was 12.4 %, but 25 % (P = 0.047) in patients delayed for medical problems.

Conclusions

Not all patients with a fracture of the proximal femur can have surgery within 36 h of their injury. However, we have identified and describe four specific areas that could increase the number of patients who meet this target.     

The olecranon osteotomy provides better outcome than the triceps-lifting approach for the treatment of distal humerus fractures

Introduction

Intra-articular distal humeral fractures can be approached in a variety of ways. The purpose of this study is to evaluate and compare the functional outcomes of two approaches: approach with olecranon osteotomy and triceps-lifting approach for the treatment of intra-articular distal humeral fractures.

Methods

This study shows a consecutive series of 54 intra-articular distal humeral fractures of 54 patients who were treated with open reduction and internal fixation with anatomic plating. Lateral plating was performed in 10 (45.5 %) patients, and medial and lateral parallel plating was performed in 12 (54.5 %) patients in olecranon osteotomy group, while lateral plating was performed in 8 (25 %) patients, and medial and lateral parallel plating was performed in 24 (75 %) patients in triceps-lifting group.

Results

Mean follow-up was 38.3 months for olecranon osteotomy group and 41.4 months for triceps-lifting group. Functional outcomes according to MAYO elbow score and extension-flexion motion arc values were significantly better in olecranon osteotomy group (p < 0.05).

Conclusion

Approach with olecranon osteotomy provided better functional outcomes than triceps-lifting approach. Additionally, intra-articular distal humerus fractures can be safely treated with olecranon osteotomy which provides more control over the elbow joint and better visualisation and allows early postoperative rehabilitation.

Level of evidence

IV.