Epidemiology of paediatric and adolescent fractures admitted to a South African provincial hospital

BACKGROUND : There are limited studies available that examine the epidemiology of children and adolescents admitted with orthopaedic injuries in developing countries. Several unique factors in South Africa, such as a large socio-economic divide and a public health sector with limited resources, are suggested to influence injury patterns and fracture management. The data emanating from this study may play a role in identifying potential preventative measures. The aims of the study were to determine the age, sex, duration of admission, aetiology and management regimen of paediatric and adolescent patients admitted with fractures in a South African provincial hospital. PATIENTS AND METHODS : We did a cross-sectional review of medical records for the period 1 January 2016 to 31 December 2017 at a South African provincial hospital. Convenience sampling was done, and demographic and clinical data was collected from patient records. All patients younger than 18 years at the time of injury who were admitted with fractures of the limbs, pelvis or spine were included. Patients with incomplete clinical records were excluded. RESULTS : A total of 731 patients were admitted during this period. After excluding patients with incomplete records, 526 (72%) were included in the study. From these records we found a higher percentage of males admitted (73%) and the average age was 7.72 years. The average duration of admission was 8.59 days. A fall on ground level was the most common mechanism of injury (70.0%), followed by pedestrian vehicle accidents (12.2%). The most frequently fractured regions were the forearm (36.4%), humerus (26.5%) and femur (18.9%). Multiple fractures were sustained by 2.4% and additional non-skeletal injuries were sustained by 2.9%. There was one fatality: a patient who presented with gunshot trauma. CONCLUSION : Despite fall-related injuries being the most common cause for admission, pedestrian vehicle accident prevention can have the greatest effect on admissions. They require significantly longer hospitalisation and present more frequently with additional injuries. By implementing safety strategies and improving road infrastructure, we can theoretically decrease the number of serious paediatric admissions. LEVEL OF EVIDENCE : Level 4.http://journal.saoa.org.zaam2021Orthopaedic Surger

Comparing outcomes between enhanced recovery after surgery and traditional protocols in total knee arthroplasty : a retrospective cohort study

BACKGROUND : Knee replacement surgery was traditionally associated with prolonged recovery and rehabilitation programmes in hospital. Enhanced recovery after surgery (ERAS) protocols have been shown to be cost effective while not compromising patient safety or functional outcome. Despite this proven efficacy, ERAS has not been widely adopted in South African orthopaedic practices. The aim of this study is to determine if it is possible to practise these guidelines in South Africa so as to decrease the length of stay (LOS) without an increase in complication rate or compromise in functional outcome. METHODS : Included in the study were 119 patients undergoing elective total knee arthroplasty between 2013 and 2017. They were divided into two cohorts. The first group was treated with a traditional protocol and included 59 patients. The second group was treated with ERAS and included 60 patients, following implementation of the ERAS protocol in 2015. The functional outcome was assessed using the Oxford Knee Score (OKS). The 30-day readmission rate was used to assess safety of early discharge. LOS and patient demographics were also collected to compare the cohorts. RESULTS : There was no clinically significant difference between the cohorts with regards to OKS or readmission rate. Two sample t-tests were used to compare these parameters. The mean OKS for the traditional group was 59.1 (SD 2.4), and for the ERAS group, 58.7 (SD 5.0) (p = 0.73). The readmission rate was 8.5% in the traditional group and 10% in the ERAS group (p = 1.00). The LOS was significantly decreased in the ERAS group, with a mean of 2.3 days (SD 1.8) compared to 5.0 (SD 2.2) in the traditional group (p < 0.001). CONCLUSION : ERAS protocols used in the South African context in elective total knee arthroplasty significantly decrease the LOS without compromising patient safety or functional outcome.http://journal.saoa.org.zadm2022Orthopaedic Surger

Topics, Skills, and Cases for an Undergraduate Musculoskeletal Curriculum in Southern Africa

Background: Most patients with orthopaedic pathology in low to middle-income countries are treated by nonspecialists. A curriculum to prepare undergraduate medical students for this duty should reflect the local pathology and skills that are required to manage patients in a resource-restricted environment. The aim of this study was to establish and prioritize a list of core orthopaedic-related knowledge topics, clinical cases, and skills that are relevant to medical students in southern Africa and areas with a similar clinical context. Methods: A modified Delphi consensus study was conducted with 3 interactive iterative rounds of communication and prioritization of items by experts from Africa, Europe, and North America. Preferred priorities were selected but were limited to 50% of all of the possible items. Percent agreement of ≥75% was defined as consensus on each of these items. Results: Most of the 43 experts who participated were orthopaedic surgeons from 7 different countries in southern Africa, but 28% were general practitioners or doctors working in primary or secondary-level facilities. Experts prioritized cases such as patients with multiple injuries, a limping child, and orthopaedic emergencies. Prioritized skills were manipulation and immobilization of dislocations and fractures. The most important knowledge topics included orthopaedic infections, the treatment of common fractures and dislocations, any red flags alerting to specialist referral, and back pain. Surgical skills for the treatment of urgent care conditions were included by some experts who saw a specific need in their clinical practice, but these were ranked lower. Conclusions: A wide geographic, academic, and expertise-specific footprint of experts informed this international consensus through their various clinical and academic circumstances. Knowledge topics, skills, and cases concerning orthopaedic trauma and infection were prioritized by the highest percent agreement. Acute primary care for fractures and dislocations ranked high. Furthermore, the diagnosis and the treatment of conditions not requiring specialist referral were prioritized. This study can inform national curricula in southern Africa and assist in the allocation of student clinical rotations