During natural disasters such as earthquakes or tsunamis, most of the casualties are known to suffer from musculoskeletal injuries. This leads to an enormous need of orthopaedic (surgical) implants such as osteosynthesis plates, which are difficult to provide in developing countries that rely on imported ones. One of the alternatives is utilization of local resources, but only after they have been proven safe to use, and meet the international standards set. Through this paper we would like to urge the international community to include locally produced biomedical products, like osteosynthesis plates in their scientific evaluations and communications. When the quality of local products is proven, the reluctance to use local products also by surgeons from developing countries will disappear and larger scale production can be initiated. This in its turn solves many problems that come after natural disasters and stimulates the national economy in an efficient and effective way

Busscher, Henk J.

Dewo, Punto

Magetsari, Rahadyan

van Horn, Jim R.

Verkerke, Gijsbertus J.

English

Verkerke, Gijsbertus Jacob

NARCIS 

Treating natural disaster victims is dealing with shortages: An orthopaedics perspective.

During natural disasters such as earthquakes or tsunamis, most of the casualties are known to suffer from musculoskeletal injuries. This leads to an enormous need of orthopaedic (surgical) implants such as osteosynthesis plates, which are difficult to provide in developing countries that rely on imported ones. One of the alternatives is utilization of local resources, but only after they have been proven safe to use, and meet the international standards set. Through this paper we would like to urge the international community to include locally produced biomedical products, like osteosynthesis plates in their scientific evaluations and communications. When the quality of local products is proven, the reluctance to use local products also by surgeons from developing countries will disappear and larger scale production can be initiated. This in its turn solves many problems that come after natural disasters and stimulates the national economy in an efficient and effective way.</p

University of Twente Research Information

Technology and Health Care 16 (2008) 255–259 255IOS PressTreating natural disaster victims is dealingwith shortages: An orthopaedics perspectivePunto Dewoa,b,∗, Rahadyan Magetsaria, Henk J. Busscherb, Jim R. van Hornb andGijsbertus J. Verkerkeb,caDepartment of Orthopaedics and Traumatology, Sardjito General Hospital, School of MedicineUniversity of Gadjah Mada, Jogjakarta, IndonesiabDepartment of Biomedical Engineering, University Medical Center Groningen, University ofGroningen, The NetherlandscDepartment of Biomechanical Engineering, University of Twente, The NetherlandsReceived 28 February 2008Revised /Accepted 22 March 2008Abstract. During natural disasters such as earthquakes or tsunamis, most of the casualties are known to suffer from muscu-loskeletal injuries. This leads to an enormous need of orthopaedic (surgical) implants such as osteosynthesis plates, which aredifficult to provide in developing countries that rely on imported ones. One of the alternatives is utilization of local resources,but only after they have been proven safe to use, and meet the international standards set. Through this paper we would like tourge the international community to include locally produced biomedical products, like osteosynthesis plates in their scientificevaluations and communications. When the quality of local products is proven, the reluctance to use local products also bysurgeons from developing countries will disappear and larger scale production can be initiated. This in its turn solves manyproblems that come after natural disasters and stimulates the national economy in an efficient and effective way.Keywords: Natural disaster, orthopaedic, osteosynthesis plate, local resources1. IntroductionA heavy earthquake, with a magnitude of 6.3 on the Richter scale, struck the Indonesian island Java on27 May 2006 at 05:54 local time, around 25 km south-southeast of the city of Jogjakarta. The earthquakecaused 5,782 deaths, while 36,299 people were injured, 135,000 houses damaged, and an estimated 1.5million people were left homeless. The Tsunami of 26 December 2004 [3] caused world-wide 186,983deaths, 125.000 injured and 42,883 missing persons.Earthquake and Tsunami casualties are known to suffer mainly from musculoskeletal injuries, espe-cially fractures due to collapsed walls and other building structures. After the Jogjakarta earthquake,almost 60% of all injured people were casualties with fractures requiring orthopaedic surgery (Fig. 1).∗Address for correspondence: Punto Dewo, Department of Orthopaedics and Traumatology, Sardjito General Hospital, Schoolof Medicine, University of Gadjah Mada, Jalan Kesehatan No. 1, Jogjakarta 55281, Indonesia. E-mail: orthougm@indo.net.id;dewo777@yahoo.com.0928-7329/08/$17.00 2008 – IOS Press and the authors. All rights reserved256 P. Dewo et al. / Treating natural disaster victims is dealing with shortages                Fig. 1. Earthquake and tsunami victims.This constituted an impossible task for the seven orthopaedic surgeons practicing in the city of Jog-jakarta. In addition, many paramedics happened to live in the Bantul district, which suffered most fromthe earthquake. The board of directors of the Indonesian Orthopaedic Association (PABOI) and theNational Coordination Board for Disaster (BAKORNAS) responded fast to this disaster and directedorthopaedic surgeons and surgery teams from almost all over Indonesia to Jogjakarta to assist in treatingthe casualties. These and foreign relieve teams had to reach Jogjakarta by car or via the nearby airport ofSolo, since the Jogjakarta airport and railway station were closed due to heavy damage. During the firstdays after the earthquake, surgical teams worked around the clock, mostly doing debridement of woundsand provisional stabilisation of fractures.In Sardjito General Hospital, the referral hospital in Jogjakarta, 15 surgery teams worked simultane-ously, and within 3× 24 hours the acute phase for all casualties was considered over (Tables 1–4). Thatwas only the beginning, however, of the overall work to be done, because now patients either neededdefinitive surgery for their fractures, or a second operation for infected wounds (Table 5). Infectionswere rampant since antibiotics, mandatory in the treatment of open fractures, were not available for suchlarge numbers of casualties. Moreover, often the definitive fixation of fractures was impossible due tolack of osteosynthesis plates, screws, nails and external fixators, which all have to be imported fromWestern countries (Fig. 2).The lack of bone plates has three causes. First, imported bone plates are very expensive. Althoughnot officially stated, the Indonesian ministry of health initially said that their budget could only providesurgical implants for one thousand patients, which is only a fraction of the number of patients in needof a plate. Moreover, most people in Indonesia have no health care insurance. When they suffer fromillnesses, like fractures due to the frequently occurring traffic accidents, and need surgery, they usuallycannot afford the high costs of an operation and imported osteosynthesisplates. An orthopaedic operationusing such an implant in Indonesia costs about USD 700 or more. Considering that the Gross DomesticProduct (GDP) in Indonesia is USD 3,390, while only USD 110 is spent on health care per capita perannum [2], it becomes clear that adequate treatment for the earthquake victims according to WesternP. Dewo et al. / Treating natural disaster victims is dealing with shortages 257Table 1Number of casualties treated in dr. Sardjito hospitalby age and gender after the May 2006 earthquake onthe Indonesian island JavaAge (y.o.) Gender Total DeathFemale Male0–10 24 21 4511–20 48 36 8421–30 253 111 364 2131–40 265 176 441 1341–50 167 86 253 1151–60 122 96 218 1861–70 55 36 91 3171–80 29 24 53 24> 81 15 13 28 11Total 978 599 1.577 129 (8.2%)Table 2Number of casualties treated in dr Sardjito Hospital by ageand region after the May 2006 earthquake on the Indonesianisland JavaAge (y.o.) Region TOTALLower Upper Upperextremity extremity and lower0–10 24 21 − 4511–20 44 34 6 8421–30 196 76 12 28431–40 244 117 8 36941–50 182 36 5 22351–60 86 56 4 14661–70 53 22 − 7571–80 18 14 11 43> 81 5 4 3 12TOTAL 852 380 49 1.281Table 3Number of multiple injured casualties treated in dr Sardjito Hospital after the May2006 earthquake on the Indonesian island JavaLesion site (Primary) Head Chest Abdominal Pelvic Spine TOTALUpper extremity 23 6 3 − − 32Lower extremity 31 29 − 13 17 90Head 25 − − − − 25Chest 17 46 − − − 63Abdominal − − 40 − − 40Pelvic 14 − − 32 − 46Spine 33 − − 14 75 122TOTAL 143 81 43 59 92 418standards is impossible. Secondly, importing plates from Europe is done by Synthes Indonesia, thelocal representative of the European bone plate manufacturer (Synthes Representative Office Indonesia,through PT Merapi Utama Farma). Synthes Indonesia does not have that many implants in stock andeven collecting plates and screws from nearby countries did not yield a sufficient number of plates totreat all victims. Thirdly, donated surgical instruments and implants from overseas were delayed after258 P. Dewo et al. / Treating natural disaster victims is dealing with shortagesTable 4Number of casualties with open fractures treated in dr Sardjito hospital after the May 2006 earthquakeon the Indonesian island JavaGustilo Upper Lower Number of Intervention treatmentClassification Extremity Extremity patients ORIF External Fixation Plaster castType I 17 31 48 12 − 36Type II 13 34 47 24 8 15Type III:A 31 114 145 − 145 −B 37 116 153 − 153 −C 1 11 12 − − −Total 99 306 405 36 306 51Fig. 2. Fracture fixation using osteosynthesis plate.arrival due to custom procedures and destroyed transport connections [6].In order to overcome the shortage of surgical implants, implants can be re-used after appropriatecleaning to remove any potential pyrogenic or bacterial endotoxic substances as well as adhering mi-croorganism [5], but this is only done reluctantly by accepting higher risks of infection and fracture ofthe used plate. Moreover, the availability of used bone plates is decreasing. The second alternativeis utilization of local resources. Locally produced osteosynthesis plates are much cheaper and can beobtained faster than from abroad. In Indonesia there are at least four local manufacturers producingthese plates. Until recently, only a few Indonesian orthopaedic surgeons were willing to use locallyproduced plates because there is no scientific evidence available of their quality. Locally producedplates have to be proven safe to use and have to meet the international standards with regard to surfaceproperties like roughness and wettability in relation to biomaterial-centered infection, and with regard tomechanical properties like strength and resistance to fatigue, in order to convince orthopaedic surgeonsto use them. Lack of knowledge on testing procedures and lack of testing equipment in Indonesia andother developing countries prevents rigorous studies on the quality of bone plates produced locally inthe developing countries. Simultaneously, unawareness, lack of scientific challenge and associated poorchances of acceptance of scientific manuscripts dealing with evaluations of biomedical products madein developing countries, have demotivated scientists in the Western world to undertake such necessarystudies. Incidentally it is noted, that other major disasters, like the south Asian Tsunami in the Indianocean, and Katrina Hurricane in New Orleans experienced similar problems [4,7]. Long-term recoveryand rehabilitation in the presence of the above described shortages are poorly understood, which con-stitutes a continuous threat to the victims, even many years after the disaster. Because the internationalP. Dewo et al. / Treating natural disaster victims is dealing with shortages 259Table 5Estimated number of complications at one month after treatment of casualties causedby the May 2006 earthquake on the Indonesian island JavaComplications Open Fractures Closed Fractures TOTALType II Type IIIInfection 21/405 96/405 65/439 182(5.2%) (23.7%) (14.8 %) (14.8%)Loss of fixation − 33/405 23/439 56(8.2%) (5.2%) (6.6%)Inadequate fixation − 47/405 (11.6%) 51/439 98(11.6%) (11.6%)Unacceptable position 36/405 39/439 75(8.9%) (8.9%) (8.9%)attention is fading rapidly within days after a disaster [1], international support for long-term recoveryand rehabilitation programs is only limited.Through this paper we would like to urge the international community to include locally producedbiomedical products, like osteosynthesis plates in their scientific evaluations and communications. In-ternational research on these products should be stimulated and considered in peer-reviewed journals.When the quality of local products is proven, the reluctance to use local products also by surgeonsfrom developing countries, will disappear and larger scale production can be initiated. This in its turn,solves many transport problems after natural disasters. As an extra advantage, local economies will bestimulated in an efficient and effective way.References[1] R.J. Brennan and R.J. Waldman, The South Asian Earthquake Six Months Later – An Ongoing Crisis,N Engl J Med 354(2006), 1769–1771.[2] http://www.who.int/countries.[3] T. Lay, H. Kanamori, C. Ammon, M. Nettles, S. Ward, R. Aster, S. Bck, S. Bilek, M. Brudzinski, R. Butler, H. DeShon, G.Ekstrom, K. Satake and S. Sipkin, The Great Sumatra-Andaman Earthquake of December 26, 2004,Science 308 (2005),1127–1133.[4] S. Loewenberg, Louisiana Looks Back on a Week of Disaster,Lancet 366 (2005), 881–882.[5] R. Magetsari, E.B. van der Houwen, M.T.J. Bakker, H.C. van der Mei, G.J. Verkerke, G. Rakhorst, C.R. Hilmy, J.R. vanHorn and H.J. Busscher, Biomechanical and surface physico-chemical analyses of used osteosynthesis plates and screws– Potential for reuse in developing countries?J Biomed Mater Res B: Appl Biomater 70 (2006), 453–460.[6] S. Pincock, Indonesia struggles to resurrect health services,Lancet 365(9456) (2005), 281.[7] M.S. Sever, R. Vanholder and N. Lameire, Management of Crush-Related Injuries after Disasters,N Engl J Med 354(2006), 1052–1063.

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