World Orthopaedic Concern
Newsletter No 167
April
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.
Insofar as WOC expresses responsibility, it is towards improvements in
Orthopaedic care where facilities, including qualified doctors, are few.
Although a prominent cause of inequality is the simple one of poverty, it is
frequently stated that philanthropic Charity is not the solution. Taken alone, it
is only one of the lesser causative factors.
More difficult to organise is the different capabilities of would-be helpers. So
individual arrangements have to be made personally and essentially through
the hosts who, better than anyone, will know their own needs, and how the
skills of the prospective visitor will fit in with their own training program.
And finally there is the less predictable relationship, the basis of friendliness
and understanding, between all the persons involved.
It may be noticed that these Newsletters have placed an emphasis on
Conservative modes of managing the common conditions with which
hospitals, including those with a paucity of equipment, have to cope. This is
not an accident. The teaching and training of techniques has devolved to
those who manufacture the surgical tools and implants. This is not
inappropriate because no-one would wish that an implant be placed
incorrectly ! But by contrast the non-surgical techniques have been
neglected in the training programs of the western “Centres of Orthopaedic
Excellence!”
Relevant comment. -- From Fergus Paterson. to the editor. .
“A recurring theme in your Newsletters, seems to be the need for “general
orthopods” to visit developing countries rather than sub-specialists.
Few who have experience of othopaedics abroad would disagree with you,
but should we be asking the same question nearer to home?
“For the average District Hospital in the UK to provide reasonably
comprehensive cover for orthopaedic surgery, I estimate that a minimum of
seven consultants are required. One might therefore speculate as to how a
“foot and ankle” specialist could cope with an emergency upper limb fracture,
out of hours.
“ I was involved in a paediatric case recently where the consultant on call
was a “knee man “ and the only paediatric specialist was away on leave. The
“foot man” was clearly at a loss to know what to do; indeed I had my doubts
as to whether he had had any exposure to paediatric trauma throughout his
higher surgical training.!
“May I ask, have there been any similar rumblings of discontent among your
colleagues at the BOA? or worse still, any legal actions taken against Trusts?
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,
mainly rural economy, was an all-rounder who could turn his hand to all the
basic aspects of both general (in the broadest sense) and trauma surgery.
The Mission surgeon I worked with was just such a man, but all the young
African trainee doctors wanted to do was establish themselves in a private
practice in the city, and the sooner the better. “Modern” western-style
orthopaedic surgery has no place in such an environment.
“As for what is wrong with current orthopaedic sub-specialisation in the UK, -the article by Porteous and Wright in the latest issue of the journal, “Bone
and Joint, 360”, says it all.“
(Fergus Paterson).
This is an example of common comment in the Settings of Limited
Resources”. The problem runs very deep and the dangers are underrecognised.
-o0o-
Amongst the impediments to progress in hospital treatments, are all those
procedures which are dependant upon absolute sterility in the operating
room. Metallic joint replacement implants are an obvious example. But
excluding these, there are certain specific techniques, well tried in the West,
which carry little or no fear of infection.! These lend themselves to imperfect
theatre conditions.! Take for example the case for ARTHROSCOPY. Given
ordinary theatre discipline and plentiful sterile irrigation fluid, this is a safe
procedure. But that is not the only Danger.
Michael Mowbray trained through the decade during which the arthroscope
was perfected. His own experience of arthroscopy (in the UK) runs into
thousands, and he has yet to encounter a single case of theatre infection. He
has spoken at SICOT meetings about its safety even in settings of un-certain
sterility and has made himself available to conduct training sessions on site. .
But there is concern, arising from the “charitable” donation of highly
specialised equipment.
Arthroscopy and especially arthroscopic surgery, have a long learning curve
and require careful monitoring. Some doctors have a natural facility; to
orientate; others never will get it.
Paul Rompa (WACS) , stimulated by the coverage of Ziimbabwe in the last
Newsletter, writes from Ghana, describing his experience of arthroscopy in
Ziimbabwe, and in West Africa more recently.
“In the 70-ties we had a very good NGO and General hospital in Zimbabwe.
At the General Hosp. orthopedic surgeons did the hard parts of the
traumatology and general surgeons the chest and abdomen.
In my first year I worked at the Umtali (now Mutare) hospital in the Eastern
Highlands, to adapt my previous experience of arthroscopy. I needed to get
used to the inflexible periarticular tissue of the manual farm workers, and
their tougher skin and tighter muscles. I noticed that performing an
arthroscopy on the knee is a much more difficult procedure than I was used
to; not only is skin tight but also the internal structures, and the joint space is
narrower.
The anterior horn of the medial meniscus runs higher up, and access to the
lateral side of the joint is more difficult All this affects the performance of
arthroscopic surgery, making the use of “posts” and lateral tensioning on the
knee, very important.
These comments are relevant because in modern times, arthroscopes are
sometimes available with very little guidance as to their use, prior to surgery.
Even the diagnostic use of the arthroscope requires a lengthy learning curve,
apart from decisions on the indications for its use. It may not be appreciated
that forceful use of the instrument will damage both the instrument and the
knee joint.! Powered tools, shavers and so forth, have a potential to “take
over” the operation from the surgeon’s control and “plough” the articular
cartilage; which we have frequently observed. There are very few indications
for arthroscopy in osteoarthritis. A loose body is one, but not every damaged
meniscus calls for its removal. The instrument itself is delicate, constructed
with precision, and is expensive. It requires careful maintenance, but given
an adequate supply and flow of sterile saline, it is safe. However difficulties
arise from unfamiliar anatomical variations.
In short, complex specialisms require total dedication to the subject, to the
exclusion of other parts of orthopaedics. These points are essential for the
“learning curve”. We have a binding duty to pass them on. Although much
may be learned by mistakes, there is no extra value in repetition of error.
These points emphasise the need for lengthy periods of guided instruction,
which should precede academic tests.
(Aphorism:- There are contrasts and comparisons between a salesman and
a teacher. The former shows how easy and straightforward is a piece of
equipment; the latter is eager to reveal the difficulties and dangers, while
showing how they can be overcome. The latter holds the patient in his mind,
while the formerr takes little account of him.)
-
-o0o-
The LANCET’s Commission on Global Surgery is to launch its
analysis of the worldwide availability of “Essential Surgical Treatment”, on
April 27th and 28th.at the Royal Society of Medicine. This conference has
been postponed from earlier this year and the program has only just been
announced. With the announcement (on the Web), we are told that it is “fully
booked”, which is a pity because it had become a very popular annual fixture
at the larger venue, at the Royal College of Surgeons. (There is a waiting list
in case of any cancellations.) The subject is of such vital importance to our
Theme and Concern
The final session (at about 1500 hrs on Tuesday 28th) will be
chaired by Professor Chris Lavy; and the concluding speech,
summarising the present and the future plans, will be given by the
President of the Royal College, Ms Clare Marx. Clearly there will be
an Orthopaedic emphasis.
Quoting from the College Announcement,…-- the Conference will
address the following matters:-“What is the role of the UK and other high income countries in delivering
safe, affordable, and equitable surgical care to all those who need it,
through multidisciplinary teams? The Conference aims to challenge the
audience of practitioners, students, retirees, and educators to
reconsider how one can and should engage in global surgery.
“Over the last year, the Lancet Commission on Global Surgery has
examined the state of surgery within the global health agenda,
identifying the role of essential surgery in low and middle-income
countries, (defining) priority actions to overcome barriers to safe and
affordable surgical care, and (apportioning) the roles of governments
and institutions in the attainment of these goals. This meeting will
present and debate the results of these discussions in four essential
areas; health systems, workforce, data management, and finance.”
In the next WOC Newsletter, we shall report on these deliberations, so that
our members and readers, already engaged in the work, shall be aware of
Institutional involvement in this huge subject.
[M. Laurence]