Experience of collaboration between a Dutch surgical team in a Ghanaian Orthopaedic Teaching Hospital.

BACKGROUND: Surgery is an indivisible, indispensable part of healthcare. In Africa, surgery may be thought of as the neglected stepchild of global public health. We describe our experience over a 3-year period of intensive collaboration between specialized teams from a Dutch hospital and local teams of an orthopaedic hospital in Effiduase-Koforidua, Ghana. INTERVENTION: During 2010-2012, medical teams from our hospital were deployed to St. Joseph's Hospital. These teams were completely self-supporting. They were encouraged to work together with the local-staff. Apart from clinical work, effort was also spent on education/ teaching operation techniques/ regional anaesthesia techniques/ scrubbing techniques/ and principles around sterility. RESULTS: Knowledge and quality of care has improved. Nevertheless, the overall level of quality of care still lags behind compared to what we see in the Western world. This is mainly due to financial constraints; restricting the capacity to purchase good equipment, maintaining it, and providing regular education. CONCLUSION: The relief provided by institutions like Care-to-Move is very valuable and essential to improve the level of healthcare. The hospital has evolved to such a high level that general European teams have become redundant. Focused and dedicated teams should be the next step of support within the nearby future.

A systematic review on dynamic versus static distal tibiofibular fixation.

BLACKGROUND: In the last couple of years dynamic fixation for syndesmosis injuries, using a suture-button technique, raised more interest due to its advantages over the static fixation. In the current systematic review suture-button fixation is compared to the traditionally applied static fixation in unstable ankle fractures accompanied with distal tibiofibular syndesmosis injury, including the functional outcome, post-operative complications, reoperation rate, recurrent diastasis and financial aspects. METHODS: A computerized literature search using PubMed/MEDLINE and EMBASE was conducted in search of suitable articles between January 2006 and February 2016. A total of 4 suture-button studies, 5 suture-button vs. static fixation studies and 1 study discussing the financial aspects were identified. RESULTS: The AOFAS of 104 patients treated with the suture-button device was 91.08 points with an average study-follow up of 24.85 months. The AOFAS of 106 patients treated with a static fixation device was 87.95 with an average follow-up of 24.78 months. Removal of the suture-button device was reported in 10.5% of 229 patients and removal of the screws in 38.5%. CONCLUSIONS: Dynamic fixation demonstrated to be a viable alternative to the static fixation device, with lower reoperation rates and less complications. They can accurately stabilize the ruptured syndesmosis without device breakage or loss of reduction. LEVEL OF EVIDENCE: 1A economic/decision.

[Management of blunt renal trauma in paediatric patients]. / Behandeling van stomp nierletsel bij kinderen.

- In 90% of children, blunt abdominal trauma is the cause of renal, splenic or hepatic injury or an injury affecting a combination of these organs.- Because children's kidneys are anatomically less protected than those of adults, potential renal injury following direct trauma affecting the child's flank, for example by a handlebar or knee should be considered.- Symptoms of renal trauma include excoriations or haematoma on the flank, a 'seatbelt-sign', macroscopic haematuria and fractures of the ribs and vertebra.- As haematuria does not correlate with the severity of renal injury, all children with persistent haematuria should undergo renal imaging.- Children without abnormalities on Doppler ultrasound examination and without macroscopic haematuria can be discharged from the emergency room.- Conservative management of blunt renal trauma is indicated for all haemodynamically stable children. However, haemodynamically unstable children need to undergo an urgent laparotomy. The routine use of bed rest is only indicated for grade V renal injuries.- A DMSA scan is recommended 6-12 weeks after trauma for grade IV-V renal injury.

Evaluation of admissions to the Major Incident Hospital based on a standardized protocol.

INTRODUCTION: The Major Incident Hospital (MIH) is a unique facility strictly reserved to provide immediate large-scale emergency care for victims of disasters and major incidents. We evaluated the implemented organization to identify strengths and weaknesses, and provide knowledge essential for further improvement of preparedness. METHOD: According to the Protocol for Reports from Major accidents and Disasters (PRMD) and along with our five scenarios for activation, we analyzed all the data from evaluation reports of all our deployments since the MIH was founded in 1991. RESULTS: The MIH was able to provide group-wise emergency care to military (29 admissions) as well as civilian victims of major incidents and disasters, both national (260) and international (226). Group-wise treatment was advantageous for quarantine, logistics, registration, emotional support and (pre)arrangements for family, media and security. Strong points are preparedness and availability of a dedicated facility, including ICU, X-ray and OR facilities, irrespective of MRSA status and prearranged cooperation, e.g., with a trauma centre, poison centre and the military. Evaluation, research and training resulted in a barcode registration system and continuous adaptations to improve preparedness. Shortage of resources did not occur; use of the MIH's available resources for national incidents though, could be further optimized. CONCLUSIONS: Recommendations for the future are: improvement of imbedding in regional and national procedures, continued dedicated time and staff for training, research and development, improvement of nuclear/biological/chemical decontamination facilities and preparedness, implementation of standardized scoring systems and expansion of registration systems to the prehospital setting. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s00068-010-0067-0) contains supplementary material, which is available to authorized users.

Historic overview of treatment techniques for rib fractures and flail chest.

INTRODUCTION: From the beginning of the twentieth century till the current time, an overview is presented of the surgical treatment for rib fractures and flail chest. METHODS: Many techniques have been used to stabilize the thorax wall. There has been no follow-up for the most described techniques and the evidence provided is at its best at L3-4. This, together with the noninvasiveness of mechanical ventilation, has made the latter the golden standard. CONCLUSION: However, the recent introduction of better and fully dedicated materials provides the possibility of exploring the surgical treatment of chest injuries. The authors make a case for operative treatment of rib fractures and flail chest.

[Lower leg amputation due to critical limb ischaemia: morbidity, mortality and rehabilitation potential]. / Onderbeenamputatie wegens kritieke ischemie: morbiditeit, sterfte en mogelijkheden tot revalidatie.

A total of 3 patients, a female aged 66 years, a male aged 67 years and a female aged 82 years, presented with rest pain or gangrene of their lower extremities as a result of critical limb ischemia (CLI). Radiographic studies showed non-reconstructable arterial obstructive disease in the 66-year-old female patient, who underwent an uncomplicated primary amputation and subsequent rehabilitation. Bypass surgery was initially performed in the male patient. However, failed reconstruction and progression of ischaemia necessitated transfemoral amputations to be performed, which was followed by impaired rehabilitation. In the 82-year-old female patient gangrene was the indication for primary amputation. She died due to progressive sepsis following surgery. In about 40% of patients with CLI, major lower extremity amputation is the ultimate solution. The morbidity, mortality and rehabilitation potential in CLI and the factors that influence these outcomes are discussed. The most clinically relevant determinants of morbidity, mortality and rehabilitation following major lower extremity amputation are comorbidity, age, preoperative mobility and amputation level.

Long-term results of percutaneous transluminal angioplasty for symptomatic iliac in-stent stenosis.

OBJECTIVE: This study describes the long-term results of endoluminal therapy for iliac in-stent obstructions. DESIGN: This is a retrospective study. MATERIALS AND METHODS: From 1992 to 2005, 68 patients (22 women), with a mean age of 61+/- 13 years and 16 bi-iliac in-stent obstructions, underwent 84 endovascular interventions for focal iliac in-stent stenoses (n = 61) or occlusions (n = 23). Primarily, only uncovered stents were placed. All patients were symptomatic: 70% had disabling intermittent claudication, 23% had resting pain, and 7% had trophic changes. All had in-stent diameter reduction exceeding 50% that was confirmed by duplex scanning and angiography. Procedures were performed under local anesthesia via the femoral route. RESULTS: All interventions were initially technically successful, with a minor complication of pneumonia in one patient (2%). Initial clinical success was achieved in 86% of patients. PTA alone was used to treat 72 (86%) in-stent obstructions, the other 12 (14%) had PTA and renewed stent placement. The 30-day mortality rate was 0%. Mean follow-up was 35 months (range, 3 months to 10 years) and included duplex scanning. Primary clinical patency was 88% at 1 year, 62% at 3 years, and 38% at 5 years follow-up. During follow-up, 28 (33%) of 84 extremities required secondary reinterventions because of symptomatic renewed in-stent stenosis, and 11 were treated successfully with repeated endovascular interventions. Secondary patency at 1 year was 94%, 78% at 3 years, and 63% at 5 years. Surgical intervention was eventually needed in 17 (20%) of the 84 extremities. CONCLUSIONS: Endoluminal therapy for iliac focal in-stent obstructive disease seems to be a safe technique with acceptable long-term outcome and therefore a true alternative to primary surgical reconstruction.

Bilateral extracranial aneurysm of the internal carotid artery--a case report.

The authors report a case study of a 78-year-old man with a bilateral extracranial atherosclerotic aneurysm of the internal carotid artery. The patient was treated surgically with resection of the aneurysm and restoration of the flow with a polytetrafluoroethylene (PTFE) graft. The postoperative period was uneventful. Histologic tests demonstrated almost complete destruction of the elastin fibers. The potential hazards of an aneurysm of the internal carotid artery indicate that surgical treatment is warranted.