Increasing Access to Surgical Services in Sub-Saharan Africa: Priorities for National and International Agencies Recommended by the Bellagio Essential Surgery Group

In this Policy Forum, the Bellagio Essential Surgery Group, which was formed to advocate for increased access to surgery in Africa, recommends four priority areas for national and international agencies to target in order to address the surgical burden of disease in sub-Saharan Africa

Salmonella septic arthritis of the shoulder in Zambian children.

Nineteen children under the age of two with salmonella septic arthritis (SSA) of the shoulder presented to Mukinge Hospital between 1st January 1992 and 31st March 1993. There were 13 boys and six girls. All patients were below the 50th centile for weight. The most common presentation was swelling, pyrexia and non-use of the arm. Pain was not always present. All patients were anaemic but in many cases had both WBC and ESR in the normal range. All patients were treated with drainage and antibiotics. All made a good recovery and were discharged pain free, apyrexial and using the affected arm. One patient was re-admitted because of recurrent infection. Nine patients reviewed after one month had continued good function with no clinical sign of infection. We conclude that where intestinal salmonella are endemic, low nutritional status is likely to be a factor in the development of a bacteraemia, and that the intra-articular extension of the proximal humeral metaphysis and repetitive minor trauma to the joint are predisposing factors to the development of shoulder infection

Salmonella septic arthritis in Zambian children.

Thirty-four children under the age of 3 years with septic arthritis presented to Mukinge Hospital between 1 January 1992 and 31 March 1993. Twenty-six of these cultured Salmonella spp. The salmonella group comprised 17 males and 9 females with an average age of 10 months. Most patients were anaemic and all were under 50th centile for weight. The commonest presentation was swelling, pyrexia and non-use of the limb. The mean white cell count (WBC) was 14,000/mm3 and the mean erythrocyte sedimentation rate (ESR) was 15.8 mm/h, but in many cases both the WBC and ESR were normal. All patients were treated with drainage and antibiotics. All made a good recovery and were discharged pain free, apyrexial and using the affected joint. One patient was readmitted because of recurrent infection. Nine patients reviewed after 1 month had continued good function. We consider that malnutrition and local trauma are predisposing factors to the development of salmonella septic arthritis in a population where salmonella is endemic

For how long should antibiotics be given in acute paediatric septic arthritis? A prospective audit of 96 cases.

Ninety-six cases of uncomplicated acute septic arthritis in children aged 12 years and under were treated by arthrotomy under general anaesthesia, saline washout and antibiotics for six weeks. They were prospectively studied for 24 weeks to assess clinical, haematological and radiological changes. Clinical improvement was most marked in the first two weeks and did not change significantly after six weeks. Haematological indices (haemoglobin concentration, serum white cell count and erythrocyte sedimentation rate) all improved from the start of treatment and continued to improve throughout the study, even after antibiotics were finished. Radiological changes in the bone adjacent to the infected joint were noted to be present in 21 cases by two weeks after presentation, and in a further 10 cases by six weeks after presentation, suggesting some continued infective activity in the bone adjacent to the septic joint even after two weeks of antibiotics. No new radiological changes were noted after six weeks. It is therefore suggested that antibiotics in septic arthritis should be continued for six weeks

Septic arthritis.

Don L Goldenberg1 in his helpful seminar on septic arthritis, does not mention septic arthritis in children from developing countries. Septic arthritis is rare in children from developed countries but is fairly common in sub-Saharan Africa.2, 3, 4 and 5During 15 months in 1981and#x2013;82, we prospectively studied 88 cases of septic arthritis seen in the paediatric department of the Queen Elizabeth Central Hospital (QECH) in Blantyre.2 Salmonella spp were the causative agents in 20 (23%) cases. Staphylococcus aureus, and#x3b2;-haemolytic streptococcus, and Haemophilus influenzae accounted for only nine (10%), ten (11%), and three (3%) cases, respectively. The salmonella arthritis occurred during the rainy season among children younger than 5 years who were often underweight and anaemic. The shoulder was the most frequently affected joint and we postulated that predeliction for this site may have been due to repeated minor trauma to the joint when a child was lifted by the upper arm on to his mother's back.In rural Zambia, during 14 months in 1992and#x2013;93, Lavy and Lavy5 found that 26 of 33 cases of septic arthritis in children aged under 3 years were due to Salmonella spp. They also reported that the shoulder joint was most commonly affected and the children were malnourished and anaemic. No child with sickle-cell disease was identified in either study. The study in Malawi was undertaken 3 years before the first case of HIV-1 was reported in the country. In the Zambian study, all ten children who were tested for HIV-1 antibodies were negative.In 1996and#x2013;97, salmonellae were isolated from 158 (45%) of 350 positive blood cultures taken in the paediatric department of the QECH, Blantyre. 62 joints were aspirated and 38% of the aspirates grew salmonellae on culture. 16 (73%) of 22 shoulder joints were infected with a salmonella of which 14 were S typhimurium. In our situation, salmonellae are sensitive to chloramphenicol and it is our first-choice antibiotic for septic arthritis. Cetriaxone, as advised by Goldenberg, would be effective but is too expensive and seldom available

Percutaneous fixation of scaphoid fractures. An anatomical study.

Percutaneous scaphoid fracture fixation has many advantages over the open method of fixation. We describe the anatomical basis for a safe percutaneous approach. Cannulated screws were inserted into 32 cadaveric scaphoids through 1 cm palmar incisions under fluoroscopic control. We then measured the distance between the entry point in the scaphoid and important local neurovascular structures. We also measured the angle of entry of the guide wire in two planes. The mean distance of the entry point from the main radial artery was 14 mm (range, 7-24 mm); from the radial nerve 19 mm (range, 7-35 mm); from the recurrent branch of the median nerve 29 mm (range, 14-45 mm); and from the superficial branch of the radial artery 5 mm (range, 0-8 mm) The mean radial angle of insertion was 34 degrees and the mean palmar angle of insertion was 58 degrees. Percutaneous fixation of scaphoid fractures puts the superficial palmar branch of the radial artery at risk. We recommend a 1 cm incision centred over the scaphotrapezial joint and dissection under direct vision to the entry point in the scaphoid rather than a completely percutaneous approach

Correlation of clinical and ultrasonographic findings after Achilles tenotomy in idiopathic club foot.

Achilles tenotomy is a recognised step in the Ponseti technique for the correction of idiopathic congenital talipes equinovarus in most percutaneous cases. Its use has been limited in part by concern that the subsequent natural history of the tendon is unknown. In a study of 11 tendons in eight infants, eight tendons were shown to be clinically intact and ten had ultrasonographic evidence of continuity three weeks after tenotomy. At six weeks after tenotomy all tendons had both clinical and ultrasonographic evidence of continuity