Total hip arthroplasty in Cambodia - Our experience of two hundred and fifty six consecutive total hip arthroplasties in a low-income country & the challenge of service delivery in this setting.

The Children's Surgical Centre has performed 256 THAs since 2007, We aim to assess the outcome of arthroplasty in a LMIC. Primary outcome: all cause of re-operation, Secondary outcome: any other complication. A retrospective review of all consecutive THA since 2007 was conducted. Electronic and physical case notes were reviewed. Statistical analysis was performed using MedCalc. 256 THA. Mean age: 43, gender M2:1F. Common pathologies include (1) AVN (44%), (2) OA (11%) and (3) DDH (11%). Revision rate 13%. Time to revision was 2.8 years (0-9). Common revision reasons: (1) stem fracture (5.8%), (2) aseptic loosening (4.8%) and (3) infection (2.7%). Complications were identified in 85 patients (33.2%). Common complications included (1) aseptic loosening (10.5%) (2) stem fracture (5.8%) and (3) dislocation (5.8%). Patients at CSC benefit from THA, the complication rates at CSC are declining suggesting the apex of the 'learning curve' has passed. Cheap poorly manufactured implants continue to cause catastrophic failure.

Implementation and results of a surgical training programme for chronic suppurative otitis media in Cambodia.

BACKGROUND: Chronic suppurative otitis media is a massive public health problem in numerous low- and middle-income countries. Unfortunately, few low- and middle-income countries can offer surgical therapy. METHODS: A six-month long programme in Cambodia focused on training local surgeons in type I tympanoplasty was instigated. Qualitative educational and quantitative surgical outcomes were evaluated in the 12 months following programme completion. A four-month long training programme in mastoidectomy and homograft ossiculoplasty was subsequently implemented, and the preliminary surgical and educational outcomes were reported. RESULTS: A total of 124 patients underwent tympanoplasty by the locally trained surgeons. Tympanic membrane closure at six weeks post-operation was 88.5 per cent. Pure tone audiometry at three months showed that 80.9 per cent of patients had improved hearing, with a mean gain of 17.1 dB. The trained surgeons reported high confidence in performing tympanoplasty. Early outcomes suggest the local surgeons can perform mastoidectomy and ossiculoplasty as safely as overseas-trained surgeons, with reported surgeon confidence reflecting these positive outcomes. CONCLUSION: The training programme has demonstrated success, as measured by surgeon confidence and operative outcomes. This approach can be emulated in other settings to help combat the global burden of chronic suppurative otitis media.

A case of massive porocarcinoma.

A 53-year-old Cambodian woman presented with nodular masses on the right arm suggestive of a sarcoma-type malignancy. The masses were excised and identified as multiple benign eccrine poromas. The patient re-presented after two years with large relapsed tumours and axillary lymph node involvement. A forequarter amputation was undertaken. Histology confirmed the diagnosis of a porocarcinoma, which was likely to be due to malignant transformation of the original poromas. The size and multiplicity of the tumours represents a highly unusual presentation of these rare eccrine neoplasms.

Chronic hip dislocations: a rarity. How should we treat them?

BACKGROUND: Chronically dislocated hips (>6 weeks) are usually the consequence of difficulties accessing appropriate healthcare in a timely fashion after dislocation; this explains why they are more common in developing countries. Due to a lack of research, there is currently no consensus on the best treatment available for patients presenting with this condition. Therefore, it is important to assess the treatments available so as to ensure that doctors adequately manage those presenting with this debilitating condition in the future. OBJECTIVE: To identify the best treatment strategy for chronic hip dislocations based on the treatment outcomes achieved by a free surgical clinic in Phnom Penh, Cambodia. PATIENTS AND METHOD: A retrospective analysis of the surgical centre's electronic records was conducted. Patients presenting with hips dislocated for >6 weeks were included whilst congenitally dislocated hips were excluded. Treatment outcomes, based on follow up notes, were then assessed. Data abstracted during chart review was analysed using descriptive and comparative statistics. RESULTS: 72 patients presented to the clinic with chronic hip dislocations. 42 patients received recorded treatment and 32 were followed up. Among patients with follow-up, 63% experienced 'good' outcomes after treatment. Open reductions, the most common treatment, were successful 65% of the time. The use of preoperative traction increased the success of open reductions by 13%, however, this result was not statistically significant (p = 0.64). CONCLUSION: Open reductions with pre-operative traction seem to be an acceptable treatment in this setting.

Pre-packing of cost effective antibiotic cement beads for the treatment of traumatic osteomyelitis in the developing world - an in-vitro study based in Cambodia.

The developing world often lacks the resources to effectively treat the most serious injuries including osteomyelitis following open fractures or surgical fracture treatment. Antibiotic cement beads are a widely accepted method of delivering antibiotics locally to the infected area following trauma. This study is based in Cambodia, a low income country struggling to recover from a recent genocide. The study aims to test the effectiveness of locally made antibiotic beads and analyse their effectiveness after being gas sterilised, packaged and kept in storage Different antibiotic beads were manufactured locally using bone cement and tested against MRSA bacteria grown from a case of osteomyelitis. Each antibiotic was tested before and after a process of gas sterilisation as well as later being tested after storage in packaging up to 42 days. The gentamicin, vancomycin, amikacin and ceftriaxone beads all inhibited growth of the MRSA on the TSB and agar plates, both before and after gas sterilisation. All four antibiotics continued to show similar zones of inhibition after 42 days of storage. The results show significant promise to produce beads with locally obtainable ingredients in an austere environment and improve cost effectiveness by storing them in a sterilised condition.

Frontoethmoidal meningoencephalocoele repair in Cambodia: outcomes and cost comparisons.

In Cambodia, spina bifida is rare, but frontoethmoidal meningoencephalocoeles (MECs) are common. Mean life expectancy for patients with congenital MECs may be <20 years, but the complex treatment required has not been available in the country until recently. During visits by combined neurosurgical/craniofacial teams from both Germany and France, a method of repair has been developed that is suitable for the local conditions, affordable and has allowed Cambodian surgeons to learn how to successfully treat MECs. The surgical technique and initial results with 30 patients have been described in a previous publication. This paper presents the outcomes of 128 cases and illustrates that it is cost-effective for these patients to be treated in Cambodia.

Immunological detection of cardiac glycosides in plants.

Australian native and introduced plants were examined, using digoxin immunoassays, to detect the presence of cross-reacting cardiac glycosides. These compounds were found in 27 species from 20 genera. The assay technique can also be used on serum samples to confirm cardiac glycoside ingestion.

Fine structure of three different anti-fluorescein combining sites: induced circular dichroism of hapten bound to autologous and heterologous recombinants.

We have previously reported the sequential appearance in hyperimmunized rabbits of three distinct types of antifluorescein-combining sites that can be distinguished by the characteristic induced circular dichroism (CD) of the bound hapten, fluorescein. Such induced CD depends on the configuration of the surrounding residues, and, in the case of anti-fluorescein, can be localized to the configuration of the sub-site which binds the hydroxyxanthenone moiety of fluorescein. In the present investigation, we have studied the fine structure of both autologous and heterologous recombinant sites and of the free chains by measuring the induced CD of bound hapten. Heavy chain dimers at pH 5.4 bound fluorescein that displayed a weak negative CD band which is different from that observed in any of the native antibodies. No induced CD was observed with light chains. Thus, the hydroxyxanthenone subsite does not exist intact in any of the isolated chains. Fluorescein bound to purified autologous recombinants, when studied at pH 7.5, exhibited CD spectra very similar to those observed for the original antibodies. Most significantly, fluorescein bound to purified heterologous recombinants, prepared in all possible combinations, showed CD spectra most similar to those exhibited by sites from which the heavy chain was derived. Thus, the microenvironment of the subsite appears to be due primarily to the heavy chain.

Traumatic arteriovenous fistulae.

Twenty-two cases of arteriovenous fistulae are reviewed retrospectively, with particular emphasis on their clinical presentation, physical signs, investigations and management. This review allows us to make certain conclusions for the future diagnosis and management of this condition.