World Orthopaedic Concern

Newsletter No 165 February (ii) 2015

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This Newsletter is circulated through the internet, and through all WOC Regional Secretaries in the hope that they will be able to download and distribute it to those who may not be connected through the “Net.” It is addressed to all interested in orthopaedic surgery, particularly to areas of the world with great need but limited resources.

To add to this standard introduction, it is our sincere wish that copies of these Newsletters will be distributed to all who share our serious concern for those who manage some terrible injuries with limited equipment or guidance.

For anyone contemplating a benevolent teaching visit to one of the many parts of the world where surgical facilities are “limited”, we have tried to convey some of the problems, dangers and warnings. Of course these can never anticipate the unpredictable, but the visitor should to take an early opportunity to learn what isavailable in the way of surgical instruments(solving at least one “unknown”). There are bound to be instruments with which any visitor will be unfamiliar. Your job is to manage with the unfamiliar.

The vising surgeon’s priority is to pay close attention to communication with the patient. He may not understand the language, but should not hesitate to ask for a translation of everything said to the patent. The example to be set, is that orthopaedics is a very personal practice, not a surgical performance. Beware of the situation in which you feel that you are expected to demonstrate an operation. You may recognise this when your host asks you what operation would you like to do.!You much make it clear that your priority is to the diagnosis and thence to the proper treatment for each patient; and then to convey why you come to your decision.

For the experienced surgeon (surely the most useful type to the host hospital) he or she will chose to act as an observer to start with, constantly observing the style of work, the experience of the hospital staff and the standard of sterile technique.The surgical trainer is not asalesman.

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The community of orthopaedic surgeons may be divided into two groups:

1.those who strive to invent surgical procedures, to stretch the limits of reconstructive treatment; and

2. those who worry as to whether any benefit flows from the treatment.

In the scale of things, most of group 1.live and work in the wonderful world of affluent achievement; Those in group 2, who naturally follow the other, but they lack the sophisticated means by which innovations might be challenged. Evidence (experience) Based Medicine (EBM) in orthopaedic surgery depends upon a significant period of time and scrupulous review of patient outcomes It is as if the patient has become the experimental animal.

Consequently the visiting surgeon bears a great responsibility in acing as a filter with regard to imaginative treatments. On the other hand (as ever) standard, established, classical treatments are the ones which the neglected lands of diminished income, seriously need. Therefore the word “research” has a totally different meaning where facilities are few.

For this reason we owe gratitude to senior WOC fellow, James Waddell (Toronto) who has recently put together a critical study. There have been very few attempts to apply the principles of the Random Controlled Trial to what modern orthopaedics views as “Old Hat” and “History.” Such an attitude is an example of neglect for the major problems suffered by most of the world’s population. But it is worse than that; modern orthopaedics depends absolutely on the fundamentals of biological healing and it is with those that innovations must be compared.

Waddell has collected the statistics from a dozen peer-reviewed papers on common fractures, treated by open and by closed methods. Fractures near the wrist, elbow, shoulder and ankle are included and contrasts are by no means convincing. These are not (of course) double blinded, but matched in all other criteria. They provided evidence that indications for open surgery are not strong, and open to other persuasions.They do not include fractures around the knee or the hip for which surgery is usually preferred. Arguments are many and varied, but Waddell makes the telling remark in summary --- “Conservative treatment cannot be properly performed if the practitioner is unfamiliar with the principles of conservative treatment.” The lack of formal training in the fine points of non-operative management, is how it gets a bad reputation. Waddellagrees that surgical treatment may be the best option; but is by no means always so; and that applies everywhere in the world - not just in the developing world but also in the Centres of Orthopaedic Excellence. Just as technical training is essential for safe surgery, so also it is essential for non-operative treatment. A list of the references maybe obtained directly from <>

A great number a acknowledged experts have joined this debate.There was a time when men with bitter experience would say that there is no such thing as Internal fixation of fractures; only internal suturing. Modern biomechanics proves that to be out-of-date in the case of intramedullary nails and replacement hemi-arthroplasty. This then is not a discussion comparing closed vs open reduction. but a plea to look ahead, to foresee structural failure as a possibility in every case. This is most important when there is a real possibility of contaminating infection.

I am reminded of the anecdote attributed to Norman Roberts (Liverpool, many many years ago). He was contemplating a patient, with non-union and a weeping wound, admitted to hospital for his eleventh operation; “every one of which, (he said) “was necessary, except the first.”

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With all these thoughts in mind, a team from WOC is to examine the situation in a neglected area of Southern Africa, In this instance, Zimbabawe. It is not possible adequately to acknowledge our debt to the local hosts who have been outspoken in their enthusiasm for this visit. Arrangements have been made, in order of priority, to confer with the Ministry of Health, with the Medical University Colleges, with town Hospitals, and with every contributor to care in the distant rural communities and their serving Missionary Hospitals -- even perhaps with the unqualified community “healers”. There is clearly a profound understanding of the depth of their needs and the manner in which the shortage of qualified medical manpower might be enhanced.

In Summary, the following has been extracted form the formal program drawn up by Dr Ton Schosser, for the March 2015 project:-

Zimbabweis suffering in he area of access and quality of health services in general and in trauma and orthopedic care in particular. This is comparable with many other sub-Saharan countries, under the combination of limited resources (like financial constraints, lack of skilled professionals and health-care staff, infrastructure, equipment, materials, medicines etc.) and an increasing demand for appropriate care of a growing population and a strong increase in road casualties.

Europe has a large pool of health human resources, both in the private and public health system, which continues to expand. There are strong linkages between Zimbabwe and Europe from the time of the European migration to Africa and now with the reverse migration from Africa to Europe. The health professionals also share common ethics and solidarity and take pride in ensuring access to medical care to all parts of the population in need and in making sure there is a network of professional societies to improve practice and quality of care.

Project focus: Mpilo Central Hospital in Bulawayo and its referral area. (Bulawayo City, Matebeland North and South and the Central Province of the Midlands).

DrAad van Geldermalsen, public health advisor based in Harara and Dr Davies Dhlakama, retired Director of Health Ministry offered to assist in organising the necessary contacts with and briefing of officials and orthopaedic colleagues in the Capital.

Zimbabwe Orthopaedic Association

We will also discuss with the local stakeholders the wish to strengthen and support the existing Zimbabwe Orthopedic Association by linking them not only with COSECSA and other African Societies but also to our brother European societies. Such a professional association not only advocates, promotes and supports access, coverage and quality of care in the area of Trauma and Orthopedic care, but alsoserves to protect the interests of the professionals (in consultation with the government, insurance and the like).

Countrywide

Depending on the progress of this project in the target area, extension to other partsof the country will be second on the agenda.

We shall depend on the involvement and local leadership of YahayaMalango, Aad van Geldermalsen and Davis Dhlakama(with able assistance of DrShiva Murugasampillay). Toconstruct a Zimbabwe-Europe-Medical and Health Care Bridge, aiming at collaboration between every style of health worker with the hope this will also stimulate the establishment of institutional linkages between hospitals and professional organizations in Europe with professionals in Zimbabwe.

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Dr. YahayoMalango writes, describing his own program -- “My story, like most health professionals trying to improve services locally is the story of the woodcutter so busy cutting wood he never had time to sharpen his axe.....so the assistance you are rendering us comes as a refreshing encouragement to keep on fighting and trying with some view of a future. Any personal collaboration would go a long way in improving the physical, social and economic wellbeing of the disabled in this organization.Orthopaedic work previously done at Mpilo may be revived and I am 100% with you all. if a quarter of the concept note can come to fruition, we would have gone a million miles forwards. ”

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This office receives many requests that we train and teach the importance of non-operative modes of management for patients undergoing fracture care, not just in the low and middle income countries, but in highly developed countries where much surgery of questionable necessity is performed !!

-- a few selected quotations from “Correspondence” follow. . .

“In the present high pressure schools of medical education, the finer aspects of practice depend upon experienced trainers. And yet In those high pressure schools of medical education there are no longer any general orthopaedic surgeons. The demands of patients (in huge numbers) place logistical strains on the system. Consequentially the trainees are neglected, often having to perform service work unsupervised. It is a dilemma common to all expanding economies.

Economics rather than Politics pays for a Nation’s medical profession. It is no longer proper (nor practical) to rely upon the missionary zeal that still inspires numerous generous organisations. (Barry Fearn)

“It is not only in the underdeveloped countries where there is lack of ‘broad’ training. Things are not so dusty in the UK!Today’s Consultant may have been trained as a general orthopod, but specialisation followed and now dominates western practice. With the curtailment of proper training, due to the European Working Time Directive, people can only be brought up to standard by early specialisation. Remember, it took approximately 30,000 hours to train our generation.” (Frank Horan)

“I spent a year at a mission hospital in Kenya under the auspices of VSO. I came to the conclusion then that the most useful surgeon in a developing, predominantly rural economy, was an all-rounder who could turn his or her hand to all the basic aspects of both general (in the broadest sense) and trauma surgery. The missionary I worked with was just such a man.

“Has anything happened since then to change my views? Judging by your reports the answer has to be “no”. But where are the all-rounders to be found nowadays? As for what is wrong with current orthopaedic sub-specialisation in the UK, the article by Porteous and Wright in the latest “Bone and Joint 360” says it all.” (Fergus Patterson.)

“Very touching Newsletters, and sincerely grateful for our contribution to be featured.Couldn't help shedding a tear. Poverty creates many problems not just lack of resources.They are unique to each locality and complicate the delivery of Healthcare. We aremore thanhappy to share with you our experience.‬ (Y. Malango.)

“I hope your message is getting to ‘people in high places’ in the Western Orthopaedic circles.” (Malcolm Morrison.)

“What is important in fracture treatment is that trainees understand the natural healing process and the fundamentals of fracture treatment. This does not man that “Hi Tech” is to be suppressed, but be taught in the light of predictable outcomes. Fractures of the femoral shaft do usually unite when treated in Thomas’ splint or by K nail. Many bone setters are doing good work. In Putur near Chennai, there are bone setters with a tradition of many hundreds of years. Several Orthopaedic surgeons have visited them and been impressed by their work and their results.” (DevenTaneja)

CURE International. “In the past, we have posted opportunities with CURE International with WOC. I wanted to let you know that we are still seeking a Medical Director/Pediatric Orthopedic Surgeon for our hospital in the Philippines. We also seek orthopedic surgeons with opportunities in Niger, Dominican Republic and Malawi.All of these opportunities are posted on our website at Feel free to share this link with folk who might be interested in these opportunities. Or, if you want an actual posting (in PDF format), we can forward one of those for any and all of the above positions.”

(M.Laurence.)