World Orthopaedic Concern
Newsletter No 168
April ii 2015
Distributed from - laurence.woc@gmail.com
Websites www.worldortho.com & www.wocuk.org
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
“concerned” 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.
No one in the developed world can be unaware of the natural catastrophe that
struck the Himalayan valleys between Kathmandu and Pokhara, on Saturday
April 25th with a continuing series of huge after-shocks. The roll-call of death and
serious injury awaits assessment from areas which remain completely silent.!
Electricity, water and telecommunication services have been disrupted and
thousands dare not return to their dellings. Many of the hospital buildings including
the operation theatres were destroyed or damaged leading to patients being
treated in open fields.
There is an international appeal for help; the proximity of India is crucial. Speed is
of the essence, and distance = time. Within hours Indian helicopters were
airborne, but the “golden hours” of ATLS were slipping away.
There will be a long period during which inadequate facilities (mainly too few
experienced surgeons) will be hard pressed to provide basic treatment. Of course
it will seem that training will come too late. . .the need, for Trauma Surgery,
already understood before this catastrophe, is now emphasised. Immediately the
call, from our colleagues at the Nepalese Orthopaedic Association is for surgical
hands and equipment, necessary now and will be for many months to come.
The following are summary statistics, but they increase by the hour:35 districts, out of 75, are affected. 11 districts have priority for health
intervention, namely - Gorkha, Dhading, Raswa, Sindupalchowk, Kavre,
Nuwakot, Dolkha, Kathmandu, Lalitpur, Bhaktpur, Ramechhap. Already well
over 2000 bodies are accounted for; and twice as many are yet untraced.
“Our orthopedic colleagues in every hospital, are working flat out through day
and night, essentially saving life, with minimal resources. As much is done, so
more survivors are brought in, with open fractures, paralyses and abdominal
emergencies, All manner of specialist surgeons are turning from their specialties
to basic trauma.
“We are extremely thankful to all of you on behalf of Nepal Orthopaedic
Association for extending your personal concern and support to us at this extreme
time. The type of surgical equipment will change as the days go by, and
consumables are consumed; e.g. sutures, swabs, dressings, blood products,
plaster, K-wires, external fixatures, pins, screws, antibiotics and analgesics.
“Please be in touch with Dr Ramesh Prasad Singh (at 00977-9851042907 or
<rps2062@gmail.com> from Nepal Medical College and Teaching Hospital,
Attarkhel Jorpati, Kathmandu, Nepal.)
(on behalf of the Nepalese Orthopaedic Association).
-o0oEven before the events described above filled the airwaves, the World Health
Organisation had issued messages describing Surgery and Anesthesia as part
of Primary Health Care, integral to achieving Universal Health coverage.
They wrote:“Treatment of most surgical conditions does not require complex surgical
skills or equipment. Surgical care is increasingly recognized as a neglected
but efficacious and cost-effective addition to a basic package of health
services in LMICs. Communities living in severe poverty, rural and remote
geographic regions particularly, lack access to even the most basic surgical
care, which could be efficiently and cost-effectively delivered in such
settings.” (WHO, Geneva; April 2015)
Amongst the rural hospital establishments in south eastern Ethiopia, is the
Christian Mission in Soddo, in the rift valley.
-- “We usually have three Black Lion orthopaedic residents here every month.
They make an amazing contribution and work very hard. Of course, they get to
gain experience and expand their knowledge while here. They carry surgical
responsibilities commensurate with their skill levels and previous exposure. We
are busier than ever before, due partly to the fact that Black Lion has run out of
SIGN nails and their C-arm is down. So many of their hip and leg fractures are
coming our way!
“We are becoming increasingly a major trauma centre, making it difficult to fit in
the elective cases that are part of our duty. Crowded operating theatre conditions
make it hard for us to increase our productivity. We now operate on Saturdays
too - 6 working days a week. And of course there are emergencies on Sundays
too. The residents normally handle those themselves depending on their
experience.
From Dr Bob Greene.
-o0oContinuing our study of Zimbabwe, begun in the last Newsletter…
“Zimbabwe is quite unlike other subsaharan countries, in one respect. 40 or 50
years ago political turmoil overtook the country in several successive waves,
resulting sadly in mass emigration. This included the major part of the medical
profession. Many migrated south to South Africa. They left behind a set of small,
single storied hospitals - the present District hospitals - which continued almost
without surgical cover. It is like the ghost of a good health service.!
The result is that these hospitals remain exactly as they were the day the doctors
left, as if they had been "mothballed" 50 years ago. They have a brilliant nursing
staff, well educated, maintaining dedication and cleanliness, equal to the best on
the Continent; but largely empty.!! Theatre equipment is as a museum might be
in UK. Sets of old plates, pins, wires and K nails lie neatly in cloth packs, resterilized, every few months, but are almost never used. The usual complaint of
no equipment, does not apply - but it is not “modern”.!
The hospitals demonstrate the single shortage of Surgeons. In some hospitals
the level of skilled care is exemplary, done mostly by general surgeons,
uncontaminated by "orthopaedic" publication or advertisement. All the principles
of 50 years ago obtain, and we saw them skillfully used. It is my impression that
the district hospitals urgently need training visitors who know how to use those
old tools and retain the necessary skills the which were taught to the general
surgeons of 50 years ago. They are to be found in the text books of even longer
ago. Perhaps one should not be surprised that some of the best work done in the
Zimbabwe District hospitals, is done by general surgeons, rather than by trainees
already bound on a career in the specialty of Orthopaedics, and already tempted
into “open” management of Injury. If that were to be agreed in the “host
profession” (in Zimbabwe), we should be directing our teaching and
traumatological training towards the young general surgeons; and if that were to
be successful, many might change from general surgery to orthopaedics, which
historically was the origin of our specialty. (This is largely my own analysis. ML)
There is a limited number of retired folk who can recall those old days, but that is
where most of the district hospitals of Zimbabwe are now. Fergus Paterson’s
comment in the 167th Newsletter, is pertinent. The old apprenticeship system is
the required pattern. I am not moved by the appeals for arthroscopes, CT
scanners, joint replacements, where they do not have plaster, suturing material
nor even crutches.!
-o0oFrom these and previous messages, it is clear that the need, in support of the
surgical profession, is experienced trainers for the young apprentices to be with
the trainees in their work and to contribute to their technical expertise. Any
“donated” equipment must be accompanied in use and guided through the
possible complications. Essential ingenuity cannot develop through published
Text Books or Journals, but in the course of Performance.
However there have been several works written specifically for the situation
which obtains in the LMICs (or SLRs - Settings of Limited Resource). The classic
of these remains the priceless work of John Charnley “The Closed Treatment of
Common Fractures”. This has been reprinted regularly; and has been updated to
include new non-operative methods. The best of this group includes that of
Augusto Sarmiento and Loren Latta, with the title “The Nonsurgical Treatment
of Fractures”. This lavishly illustrated work addresses every skeletal injury and
covers those unstable fractures which do undoubtedly benefit from surgery. The
authors have included the biology of fracture healing, in the first 37 pages,
thereby making logical the process by which all treatments aim to assist. It is very
available directly through the publisher, (at www<Jaypeebrothers.com> New
Delhi, London, St Louis, & Kolkata).
Another up-to-date work -- “Global Orthopedics: Caring for Musculoskeletal
Conditions and Injuries in Austere Settings”, edited by Drs. Richard A. Gosselin,
David A. Spiegel, and Michelle Foltz. (Publisher: Springer), contains a wealth
of personal hints and tricks by which the principles of conservative treatment are
achieved in the absence of modern equipment – in other words, with emphasis
on fundamental principles, rather than particular pieces of manufacture.
Previously the most valuable books were those of 70 years ago, such as
Charnley’s “Closed Treatment” or Crawford Adams’ “Outline of Fractures”. But
the new tomes have been brought the work up-to-date in regard to fundamental
techniques, without being based upon unobtainable implants or scanners. They
are essential steps on the way towards the future developments in traumatology.
Another Classic work, emanating from actual African experience, developed form
the dedicated early work in Uganda, by Ron Huckstep, lately the Professor of
Orthopaedic at Sydney NSW, who died at the North Shore Hospital, on April 10th
2015.
In Memoriam
Ron Huckstep was one of the pioneers who met at Oriel College, Oxford, in
1978. The idea was born which identified the need for the training of Orthopaedic
surgeons who work in those parts of the world where facilities for surgery were
and still are, limited or lacking.
Philosophically Ron came from a background of medical missionaries. Studying
at the Middlesex Hospital, London, he embarked on a career in surgery and sat
the Fellowship Examination just before enlisting for National Service. Fate took a
sharp turn when he was posted to Singapore, which was promptly over-run.! He
became a Prisoner-of-War, and did not learn whether he had passed or failed his
Fellowship until he was released. Ron was never one to waste time; careful
records of his experiences in the camp “sick bay” lead to writings on such diverse
conditions as typhoid and polio.
He resumed at the Middlesex Hospital, pursuing his broad medical interests. The
influence of Arthur Eyre-Brooke lead him to join the new movement of support for
the undeveloped world. He took part in the Inaugural meeting at Oriel College,
Oxford (1978). He was, with Kanda Pillay and Allan McKelvie, the leaders of
what was to become WOC. He joined the Department of Surgery at Makerere,
Uganda, with Professor MacAdam, who took a very broad view of surgery as
required, not to specialise.
Geoffrey Walker spent a month or so with him in Uganda and writes about
Ron’s energy directed towards to provision of splints and shoes, and correction
of deforming contracture. Later he developed/designed tools for the management
of fractures including the locked intramedullary nail for long bones. In 2008 he
was awarded the Arthur Eyre-Brooke Medal for work in Orthopaedics in underresourced lands.
Throughout his life Ron maintained consuming interest in the appropriate training
for orthopaedic practice in circumstances of impoverished hospital practice. This
is best demonstrated in his published writings which are still available at minimal
cost, in paperback.
Orthopaedic problems in the newer world: Report on a Commonwealth
Foundation lecture tour March-September, 1970... by R. L Huckstep (1971)
Poliomyelitis: A Guide for Developing Countries Including Appliances and
Rehabilitation for the Disabled (Medicine... by R.L. Huckstep, Nov 1975)
Picture Tests Orthopaedics/Trauma (Colour Guide) by Ronald L. Huckstep, R.
L. Huckstep and Eugene Sherry (Jan 1994)
Simple Guide to Trauma by Ronald L. Huckstep, (Jan 1995)
The message from his published work is unchanged over the decades, and still is
under-taught.
(M. Laurence)