David A. Spiegel

Global surgery—defining a research agenda

In today’s Lancet, Thomas Weiser and colleagues report that there are 234 million major surgical procedures worldwide each year, one for every 25 people. This figure is more than twice the number of yearly births, and seven times the 33·2 million people infected with HIV. Because this estimate was based solely on major procedures, and did not include minor procedures or non-operative surgical care (eg, management of most blunt injuries), the actual surgical workload may be much higher. This massive volume of procedures, along with the attendant risks, clearly qualifies surgical diseases (any illness that Published Online June 25, 2008 DOI:10.1016/S01406736(08)60924-1

Surgical services in low-income and middle-income countries

Although substantial progress has been made in addressing the burden of communicable and vaccine-preventable diseases in low-income and middle-income countries the burden of diseases that are surgically treatable is increasing and has been neglected. Both morbidity and mortality from surgically preventable (eg elective hernia repair) or treatable (eg strangulated hernia) disorders can be greatly decreased through simple surgical interventions. Why should a child die from appendicitis or a mother and child succumb to obstructed labour when simple surgical procedures can save their lives? Why should patients suffer permanent disability because of congenital abnormalities fractures burns or the sequelae of acute infections such as septic arthritis or osteomyelitis? Many complications of HIV infection (eg abscesses fistulas Kaposi sarcoma) are also amenable to simple surgical interventions. Available epidemiological information and experiential evidence lend support to the conclusion that basic surgical and anaesthetic services should be integrated into primary health-care packages. (excerpt)

Improving Surgical Care in Low- and Middle-Income Countries: A Pivotal Role for the World Health Organization

In response to increasing evidence that surgical conditions are an important global public health problem, and data suggesting that essential surgical services can be delivered in a cost-effective manner in low- and middle-income countries, the World Health Organization (WHO) has expanded its interest in surgical care. In 2004, WHO established a Clinical Procedures Unit within the Department of Essential Health Technologies. This unit has developed the Emergency and Essential Surgical Project (EESC), which includes a basic surgical training program based on the “Integrated Management of Emergency and Essential Surgical Care” Toolkit and the textbook “Surgery at the District Hospital.” To promote the importance of emergency and essential surgical care, a Global Initiative for Emergency and Essential Care was launched in 2005. In what maybe the most important development, surgical care is included in WHO’s new comprehensive primary health care plan. Given these rapid developments, surgical care at WHO may be approaching a critical “tipping point.” Lobbying for a World Health Assembly resolution on emergency and essential surgical care, and developing “structured collaborations” between WHO and various stakeholders are potential ways to ensure that the global surgery agenda continues to move forward.

Open reduction for neglected traumatic hip dislocation in children and adolescents.

Neglected traumatic dislocation of the hip is extremely rare in children, and the preferred treatment remains unclear. This retrospective case series includes 8 children treated by open reduction. The mean age was 7.5 years (range, 2-16 years), and the mean follow-up was 7 years and 7 months (range, 4 month-16 years). Presenting complaints included pain (5/8) and gait disturbance (8/8). Traction failed to achieve a reduction in all cases. At follow-up, 6 hips remained reduced, and 2 achieved a nonconcentric reduction. All patients had evidence of avascular necrosis. Two patients, in whom a nonconcentric reduction was achieved, developed progressive flattening and joint space narrowing. Two patients had mild pain at follow-up, and 6 patients were able to squat. Range of motion was restricted both before and after open reduction, most notably in abduction and rotation. Postoperative improvement was seen in abduction (4 cases). Leg lengths were within 2 cm in 7 of 8 cases, and only 1 patient had a discrepancy greater than 2 cm. The results according to Garrett et al were good in 3, fair in 3, and poor in 2. The mean Harris hip score was 89. Patients with a concentric reduction had an adequate functional outcome despite evidence of avascular necrosis. The prognosis remains guarded, and we expect that a subset of patients will develop premature degenerative joint disease. However, we continue to offer patients an operative reduction, which we feel is preferable to other methods. A failed open reduction does not preclude options for salvage.

World Health Organization Global Initiative for Emergency and Essential Surgical Care: 2011 and Beyond

The worlds burden of surgical diseases is large and increasing. Unfortunately, <5 % of all surgical procedures are performed in countries ranked within the lowest one-third in terms of per-capita health expenditures [1]. The unmet need for surgical care results in unacceptable morbidity/mortality rates associated with a host of conditions (trauma, pregnancy-related complications, other emergencies). This is especially true for rural and marginalized populations in low- and middle-income countries (LMICs). Recognizing that variations in the spectrum of surgical diseases are observed among and within countries, “essential” surgery and anesthesia may be viewed as a core group of services that can be delivered within the context of universal access. These high-priority interventions are those for which: (1) there is a large public health burden; (2) the treatment is highly successful; (3) the treatment is cost-effective [2]. To date, essential surgery and anesthesia have received minimal financial and political support as public health strategies because of the perception that the services are costly, are resource-intensive, require highly specialized training, and benefit only a fraction of the population relative to competing health interests. Evidence is amassing to refute these claims. The World Health Organization (WHO) Global Initiative for Emergency and Essential Surgical Care (GIEESC) was launched in 2005. It is a global forum whose goal is to promote collaboration among a diverse group of stake-holders (individuals, institutions, societies, universities, ministries of health, other nongovernmental organizations) to strengthen the delivery of surgical services at the primary referral level in LMICs (http://www.who.int.surgery) [3–6]. The inaugural meeting was at WHO headquarters in Geneva, Switzerland in November 2005 [7], and subsequent biennial meetings were hosted by ministries of health in Dar es Salaam, Tanzania in September 2007) [8] and Ulaanbaatar, Mongolia in June 2009) [9]. There are currently more than 624 GIEESC members from 93 countries representing all six WHO regions. In all, 45 % of members are from LMICs. The LMICs with ≥10 GIEESC members are India, Nigeria, Ethiopia, Ghana, and Uganda. The WHO GIEESC members have contributed to a number of activities aimed at strengthening the delivery of essential surgical services in LMICs. One component involved the implementation, local adaptation, and translation of training tools that were developed by the WHOs Emergency and Essential Surgical Care (EESC) project, which was initiated in the Clinical Procedures Unit of the Department of Essential Health Technologies in 2004 [3–6]. These training tools include the WHO Integrated Management of Emergency and Essential Surgical Care (IMSCStoolkit [10] and the Manual of Surgical Care at the District Hospital [11]. These materials have been introduced in 39 countries through collaborations with the respective Ministry of Health (MoH) and WHO country offices. The materials have been translated into Mongolian, Spanish, Chinese, Vietnamese, Korean, Dari, and Farsi. A WHO situational analysis tool to assess the availability of EESC at the level of individual health facilities was developed in 2007. It was based on infrastructure, human resources, procedures, equipment, and supplies [12]. This questionnaire has now been utilized in more than 35 countries, and the data collected and entered in the WHO EESC Global Database has been published to highlight gross deficiencies in the availability of EESC [13–22]. The WHO EESC Global Database was created to facilitate data entry from different countries. The situational analysis tool has been integrated into the WHOs Service Availability Mapping (SAM) technology [23] with the goal of facilitating monitoring the availability of surgical services at the facilities level. This technology was introduced in Mongolia in 2009. Plans have been made to continue with a surgical module in the WHOs recent adaptation of facilities-based monitoring, Service Availability and Readiness Assessment (SARA). A planning tool was developed to assist policymakers integrate EESC into their national health plans.An online Global MedNet serves as a platform for online discussions and for posting announcements and materials related to GIEESC (http://www.who.int/ surgery/globalinitiative/en/).

What's New in Orthopaedic Rehabilitation.

Orthopaedic rehabilitation is a subspecialty that involves the care of patients who have complex musculoskeletal problems that are often global in nature and stretch beyond the function of one joint. Rehabilitation combines biomechanics and biology in a unique manner that focuses on improving the patient’s functional outcome and overall well-being. As a result, the principles espoused by this field are relevant to every orthopaedic surgeon’s practice. This specialty update highlights presentations and advances in several areas of orthopaedic rehabilitation discussed at meetings of the Orthopaedic Rehabilitation Association, the American Academy of Orthopaedic Surgeons (AAOS), and other specialty organizations over the past year. Notable studies and abstract presentations are also summarized.

Generation of political priority for global surgery: a qualitative policy analysis

BACKGROUND Despite the high burden of surgical conditions, the provision of surgical services has been a low global health priority. We examined factors that have shaped priority for global surgical care. METHODS We undertook semi-structured interviews by telephone with members of global surgical networks and ministries of health to explore the challenges and opportunities surgeons, anaesthesiologists, and other proponents face in increasing global priority for surgery. We did a literature review and collected information from reports from organisations involved in surgery. We used a policy framework consisting of four categories-actor power, ideas, political contexts, and characteristics of the issue itself-to analyse factors that have shaped global political priority for surgery. We did a thematic analysis on the collected information. FINDINGS Several factors hinder the acquisition of attention and resources for global surgery. With respect to actor power, the global surgery community is fragmented, does not have unifying leadership, and is missing guiding institutions. Regarding ideas, community members disagree on how to address and publicly position the problem. With respect to political contexts, the community has made insufficient efforts to capitalise on political opportunities such as the Millennium Development Goals. Regarding issue characteristics, data on the burden of surgical diseases are limited and public misperceptions surrounding the cost and complexity of surgery are widespread. However, the community has several strengths that portend well for the acquisition of political support. These include the existence of networks deeply committed to the cause, the potential to link with global health priorities, and emerging research on the cost-effectiveness of some procedures. INTERPRETATION To improve global priority for surgery, proponents will need to create an effective governance structure that facilitates achievement of collective goals, generate consensus on solutions, and find an effective public positioning of the issue that attracts political support. FUNDING None.

Chronic Osteomyelitis in Children

Chronic osteomyelitis leads to considerable morbidity, and complex treatments are often required for eradication of infection and treating complications such as bone loss, angular deformities, and leg length discrepancy.

Salvage Options in the Cerebral Palsy Hip: A Systematic Review.

Background: No preferred procedure exists for the chronically painful, unreconstructable subluxated or dislocated hip in cerebral palsy. The purpose of this study was to compare pain relief and complication rates of salvage procedures in cerebral palsy for ambulatory and nonambulatory populations. Methods: We searched Medline, Embase, and Cochrane databases using the search terms “cerebral palsy” and “hip dislocation.” Inclusion and exclusion criteria were established to maintain data quality for analysis. A systematic review yielded 28 studies. Relevant information for postoperative pain and complications were extracted from each study and described. Our initial search identified 721 articles. Two hundred twenty duplications were excluded. Five hundred one were screened by title and abstract. One hundred articles underwent further full text and reference evaluation, yielding 25 studies. An additional 3 studies were then identified from the list of 25, yielding a total of 28 studies, which met our inclusion criteria. Results: Among nonambulators, femoral head resection (FHR), valgus osteotomy (VO), and total hip arthroplasty (THA) were found to relieve pain better than arthrodesis [odds ratio (OR) 7.3, 95% confidence interval (CI), 2.2-24.8; OR 5.9, 95% CI, 1.6-22.8; OR 11.7, 95% CI, 1.1-297.5, respectively]. Arthrodesis had a significantly higher complication rate than FHR, VO, THA, and shoulder prosthetic interposition. No significant differences in complication rate were found between FHR and VO. Pain relief rates among nonambulators for FHR, VO, THA, shoulder prosthetic interposition, and arthrodesis were 90.4%, 88.4%, 93.8%, 90.9%, and 56.3%, respectively. Complication rates among nonambulators were 24.0%, 33.3%, 35.3%, 28.6%, and 106.3%, respectively. Comparison of pain relief and complication rates among ambulatory cerebral palsy patients in all procedures except THA was not possible because the populations could not be separated from nonambulators in numbers sufficient to perform statistical analysis. Data were available for 32 confirmed cases of THA in ambulators and was associated with a 93.3% pain relief rate and a 38.2% complication rate. Conclusions: Among nonambulators, the available literature suggests that FHR, VO, and THA may be superior at relieving pain than arthrodesis. FHR had the lowest absolute percentage of complications; however, no significant differences in complication rate or pain relief were found in nonambulators undergoing FHR or VO. Most of the complications for VO were implant related, and potentially amenable to hardware removal versus complications in FHR, which were related to the procedure itself such as proximal migration and heterotopic bone formation. THA in nonambulators was associated with complications such as dislocation and revision. Arthrodesis in nonambulators was associated with >100% complication rate and inferior pain relief compared with other procedures. Ambulatory patients had excellent pain relief with THA; however, the complication rate is higher than can be expected with non-neurological populations. Insufficient data exist to support use of other salvage procedures in ambulators. These conclusions should be interpreted with caution as all studies involved level IV evidence. Level of Evidence: IV (systematic review of level IV studies).

Community-acquired Methicillin-resistant Staphylococcus aureus Musculoskeletal Infections: Emerging Trends Over the Past Decade.

Background: The emergence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has altered the management of pediatric musculoskeletal infections. Yet, institution-to-institution differences in MRSA virulence may exist, suggesting a need to carefully examine local epidemiological characteristics. The purpose of this study was to compare MRSA and methicillin-sensitive S. aureus (MSSA) musculoskeletal infections with respect to prevalence and complexity of clinical care over the past decade at a single children’s hospital. Methods: We retrospectively reviewed a series of patients presenting to The Children’s Hospital of Philadelphia with a diagnosis of osteomyelitis, septic arthritis, or both over a 10-year period. Inclusion criteria were S. aureus (SA) infections proven by positive culture of blood, bone, or joint aspirate. Exclusion criteria were non-SA infectious etiologies. Hospital-acquired infections were also not included to exclusively evaluate acute, community-acquired cases. Data related to hospital course, laboratory values, and number of surgical interventions were collected and compared between MRSA and MSSA cohorts. Results: In our series of pediatric patients, we identified 148 cases of acute, community-acquired musculoskeletal SA infections (MRSA, n=37 and MSSA, n=111). The prevalence of MRSA musculoskeletal infections increased from 11.8% in 2001 to 2002 to 34.8% in 2009 to 2010. Compared with MSSA, MRSA infections resulted in higher presenting C-reactive protein levels (10.4 vs. 7.8 mg/L, P=0.04), longer inpatient stays (10 vs. 5 d, P<0.01), multiple surgical procedures (n>1) (38% vs. 14%, P<0.01), increased sequelae (27% vs. 6%, P<0.01), and more frequent admissions to the intensive care unit (16% vs. 3%, P<0.01). Conclusions: At our institution over the past decade, we found an approximate 3-fold rise in community-acquired pediatric MRSA musculoskeletal infections accompanied by an elevated risk for complications during inpatient management. Awareness of the epidemiological trends of MRSA within the local community may guide parental counseling and facilitate timely and accurate clinical diagnosis and treatment. Level of Evidence: Level II—prognostic retrospective study.