Total joint replacement in sub-Saharan Africa:a systematic review

Outcomes of arthroplasty in sub-Saharan Africa are not widely reported. To our knowledge, this systematic review is the first to explore this topic. Scopus, EMBASE, Medline and PubMed databases were searched, utilising MeSH headings and Boolean search strategies. All papers from South Africa were excluded. Twelve papers reporting 606 total hip replacements (THRs) and 763 total knee replacements (TKRs) were included. Avascular necrosis was the most common indication for THR, whereas osteoarthritis was the main indication for TKR. HIV prevalence of up to 33% was seen. Improvements were seen in patient-reported outcome measures in both THR and TKR. The dislocation rate in THR was 1.6%. The deep infection rate was 1.6% for TKRs and 0.5% for THRs. Positive results were reported, with comparable complications to high-income countries. However, there is likely to be significant reporting bias and the introduction of mandatory registries would enable more accurate monitoring across the region

The burden of gunshot injuries on orthopaedic healthcare resources in South Africa

Background. Injuries inflicted by gunshot wounds (GSWs) are an immense burden on the South African (SA) healthcare system. In 2005, Allard and Burch estimated SA state hospitals treated approximately 127 000 firearm victims annually and concluded that the cost of treating an abdominal GSW was approximately USD1 467 per patient. While the annual number of GSW injuries has decreased over the past decade, an estimated 54 870 firearm-related injuries occurred in SA in 2012. No study has estimated the burden of these GSWs from an orthopaedic perspective.Objective. To estimate the burden and average cost of treating GSW victims requiring orthopaedic interventions in an SA tertiary level hospital.Methods. This retrospective study surveyed more than 1 500 orthopaedic admissions over a 12-month period (2012) at Groote Schuur Hospital, Cape Town, SA. Chart review subsequently yielded data that allowed analysis of cost, theatre time, number and type of implants, duration of admission, diagnostic imaging studies performed, blood products used, laboratory studies ordered and medications administered.Results. A total of 111 patients with an average age of 28 years (range 13 - 74) were identified. Each patient was hit by an average of 1.69 bullets (range 1 - 7). These patients sustained a total of 147 fractures, the majority in the lower extremities. Ninety-five patients received surgical treatment for a total of 135 procedures, with a cumulative surgical theatre time of >306 hours. Theatre costs, excluding implants, were in excess of USD94 490. Eighty of the patients received a total of 99 implants during surgery, which raised theatre costs an additional USD53 381 cumulatively, or USD667 per patient. Patients remained hospitalised for an average of 9.75 days, and total ward costs exceeded USD130 400. Individual patient costs averaged about USD2 940 (ZAR24 945) per patient.Conclusion. This study assessed the burden of orthopaedic firearm injuries in SA. It was estimated that on average, treating an orthopaedic GSW patient cost USD2 940, used just over 3 hours of theatre time per operation, and necessitated a hospital bed for an average period of 9.75 days. Improved understanding of the high incidence of orthopaedic GSWs treated in an SA tertiary care trauma centre and the costs incurred will help the state healthcare system better prioritise orthopaedic trauma funding and training opportunities, while also supporting cost-saving measures, including redirection of financial resources to primary prevention initiatives

The firearm pandemic: time to act and flatten the curve

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Civilian gunshot injuries in orthopaedics : a narrative review of ballistics, current concepts, and the South African experience

The incidence of civilian gunshot injuries is on the rise worldwide.Unfortunately, there is a lack of high-level evidence guiding management. The treatment of orthopaedic injuries from gunshots is complex and requires consideration of multiple aspects, including energy transfer to the tissue, severity of the wound, possible contamination, presence of fractures and associated injuries. With this narrative review we aim to discuss some of the relevant ballistics, current concepts, and controversies in the general management of civilian gunshot-related orthopaedic injuries based on the available evidence and personal experience. Important points which will be highlighted are the initial management in the emergency room, the assessment and management of soft tissue injuries, associated injuries, use of antibiotics, indication and techniques for fracture fixation, and gunshot injuries to joints.https://link.springer.com/journal/5902022-03-24hj2022Orthopaedic Surger

Fracture healing in patients with human immunodeficiency virus in South Africa

Background: Human immunodeficiency virus (HIV) reduces bone mineral density, mineralisation and turnover, and may impair fracture healing. Setting: This prospective cohort study in South Africa investigated whether HIV infection was associated with impaired fracture healing following trauma. Methods: All adults with acute tibia and femur fractures who underwent intermedullary nailing (IM) for fracture fixation between September 2017 and December 2018, at two tertiary hospitals, were followed for a minimum of 12 months post-operatively. The primary outcome was delayed bone union at 6 months (defined by the radiological union scoring system for the tibia [RUST] score <9), and the secondary outcome was non-union (defined as RUST score <9) at 9 months. Multivariable logistic regression models were constructed to investigate associations between HIV status and impaired fracture healing. Results: In total, 358 participants, who underwent 395 IM nailings, were enrolled in the study and followed up for 12 months. Seventy-one participants (71/358, 19·8%) were HIV positive (83 IM nailings [83/395], 21.0%). HIV was not associated with delayed fracture healing after IM nailing of the tibia or femur (multivariable odds ratio [OR]: 1·06; 95% confidence interval [CI]: 0·50–2·22). Participants with HIV had a statistically significant lower odds of non-union compared to HIV-negative participants (multivariable OR: 0·17; 95% CI: 0·01–0·92). Conclusions: Fractures sustained in HIV-positive individuals can undergo surgical fixation as effectively as those in individuals who are HIV negative, with no increased risk of delayed union or non-union

Is human immunodeficiency virus a risk factor for the development of nonunion?—a case–control study

Objective: Human immunodeficiency virus (HIV) infection has been suggested to be associated with an increased risk of the development of nonunion after a fracture. This prospective matched case–control study in South Africa investigated common risk factors, including HIV status, that influence the development of a nonunion after a femur or tibia fracture. Methods: Adult participants (cases) with established nonunions of the femur or tibia shaft were recruited over a 16-month period, between December 2017 and April 2019. They were matched for (1) age; (2) sex; (3) fracture site; and (4) fracture management type, with “control” participants who progressed to fracture union within 6 months of injury. All participants were tested for HIV. Multivariable logistic regression models were constructed to investigate associations between known risk factors for the development of nonunion and impaired fracture healing. Results: A total of 57 cases were matched with 57 “control” participants (44/57 male, 77.2% vs. 13/57 female, 22.8%, median age 36 years). HIV status was not associated with the development of nonunion after the management of tibia and femur fractures, on both univariate (odds ratio, 0.40; confidence interval, 0.10–1.32; P = 0.151) or multivariable (odds ratio, 0.86; confidence interval, 0.18–3.73; P = 0.831) analysis. No other confounding factors were shown to have any statistically significant impact on the odds of developing nonunion in this study cohort. Conclusion: This study demonstrates that HIV does not seem to increase the risk of the development of nonunion and HIV-positive individuals who sustain a fracture can be managed in the same manner as those who are HIV negative

Anterior-posterior view by full-body digital X-ray to rule out severe spinal injuries in Polytraumatized patients

Background Spinal injuries are present in 16–31% of polytraumatized patients. Rapid identification of spinal injuries requiring immobilization or operative treatment is essential. The Lodox-Statscan (LS) has evolved into a promising time-saving diagnostic tool to diagnose life-threatening injuries with an anterior-posterior (AP)-full-body digital X-ray. Methods We aimed to analyze the diagnostic accuracy and the interrater reliability of AP-LS to detect spinal injuries in polytraumatized patients. Therefore, within 3 years, AP-LS of polytraumatized patients (ISS ≥ 16) were retrospectively analyzed by three independent observers. The sensitivity and specificity of correct diagnosis with AP-LS compared to CT scan were calculated. The diagnostic accuracy was evaluated by using the area under the ROC (receiver operating characteristic curve) for sensitivity and specificity. Interrater reliability between the three observers was calculated using Fleiss’ Kappa. The sensitivity of AP-LS was further analyzed by the severity of spinal injuries. Results The study group included 320 patients (48.5 years ±19.5, 89 women). On CT scan, 207 patients presented with a spinal injury (65%, total of 332 injuries). AP-LS had a low sensitivity of 9% (31 of 332, range 0–24%) and high specificity of 99% (range 98–100%). The sensitivity was highest for thoracic spinal injuries (14%). The interrater reliability was slight (κ = 0.02; 95% CI: 0.00, 0.03). Potentially unstable spinal injuries were more likely to be detected than stable injuries (sensitivity 18 and 6%, respectively). Conclusion This study demonstrated high specificity with low sensitivity of AP-LS in detecting spinal injuries compared to CT scan. In polytraumatized patients, AP-LS, implemented in the Advanced Trauma Life Support-algorithm, is a helpful tool to diagnose life-threatening injuries. However, if spinal injuries are suspected, performing a full-body CT scan is necessary for correct diagnosis

Tuberculosis of the foot and ankle in children

The purpose of our retrospective study is to critically assess the long-term outcome of tuberculosis of the foot and ankle in children and to define an initial classification system that would relate to prognosis

The burden of gunshot injuries on orthopaedic healthcare resources in South Africa

Background. Injuries inflicted by gunshot wounds (GSWs) are an immense burden on the South African (SA) healthcare system. In 2005, Allard and Burch estimated SA state hospitals treated approximately 127 000 firearm victims annually and concluded that the cost of treating an abdominal GSW was approximately USD1 467 per patient. While the annual number of GSW injuries has decreased over the past decade, an estimated 54 870 firearm-related injuries occurred in SA in 2012. No study has estimated the burden of these GSWs from an orthopaedic perspective. Objective. To estimate the burden and average cost of treating GSW victims requiring orthopaedic interventions in an SA tertiary level hospital. Methods. This retrospective study surveyed more than 1 500 orthopaedic admissions over a 12-month period (2012) at Groote Schuur Hospital, Cape Town, SA. Chart review subsequently yielded data that allowed analysis of cost, theatre time, number and type of implants, duration of admission, diagnostic imaging studies performed, blood products used, laboratory studies ordered and medications administered. Results. A total of 111 patients with an average age of 28 years (range 13 - 74) were identified. Each patient was hit by an average of 1.69 bullets (range 1 - 7). These patients sustained a total of 147 fractures, the majority in the lower extremities. Ninety-five patients received surgical treatment for a total of 135 procedures, with a cumulative surgical theatre time of >306 hours. Theatre costs, excluding implants, were in excess of USD94 490. Eighty of the patients received a total of 99 implants during surgery, which raised theatre costs an additional USD53 381 cumulatively, or USD667 per patient. Patients remained hospitalised for an average of 9.75 days, and total ward costs exceeded USD130 400. Individual patient costs averaged about USD2 940 (ZAR24 945) per patient. Conclusion. This study assessed the burden of orthopaedic firearm injuries in SA. It was estimated that on average, treating an orthopaedic GSW patient cost USD2 940, used just over 3 hours of theatre time per operation, and necessitated a hospital bed for an average period of 9.75 days. Improved understanding of the high incidence of orthopaedic GSWs treated in an SA tertiary care trauma centre and the costs incurred will help the state healthcare system better prioritise orthopaedic trauma funding and training opportunities, while also supporting cost-saving measures, including redirection of financial resources to primary prevention initiatives