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Rule of thumb in Orthopaedics
Background
Orthopaedics in Sub-Saharan Africa is a critical field due to the high burden of trauma, infectious diseases affecting bones (such as osteomyelitis and tuberculosis), congenital deformities, metabolic bone diseases, degenerative joint diseases and conditions like neglected fractures and bone deformities. Due to limited resources, poor healthcare infrastructure, and a shortage of specialists, it is important to adopt practical approaches and follow essential rules of thumb and guidelines to optimize orthopaedic care in this region.
Rules of thumb
1. Trauma and Fracture Management
Trauma is a leading cause of morbidity and mortality globally and more so
in sub-Saharan Africa, particularly due to road traffic accidents, falls, and occupational injuries. Managing fractures efficiently is a core part of orthopaedic practice in this region.
Rules of Thumb
Early Stabilization of Fractures:
Stabilize fractures as soon as possible to reduce pain, prevent further damage to soft tissues, and avoid complications like fat embolism syndrome. For long bone fractures, external fixation or traction is often used initially when resources are limited.
Non-Operative Treatment for some selected fractures simple fractures:
In settings with limited surgical capacity, conservative treatment (such as casting or bracing) should be prioritized for non-displaced or stable fractures. Avoid unnecessary surgical interventions.
Prompt Treatment for Open Fractures:
Open fractures are emergencies that need immediate wound cleaning, debridement, and stabilization. Administering antibiotics early helps prevent infection, and surgical fixation should follow once the patient is stabilized.
Functional Rehabilitation:
Emphasize early rehabilitation and physiotherapy to promote recovery and prevent long-term disabilities, especially in settings where follow-up may be limited.
Guidelines
AO Trauma Guidelines: Recommend early debridement, external or internal fixation for open fractures, and administration of antibiotics to prevent infection. Rehabilitation protocols should be implemented early to restore function.
WHO Guidelines for Trauma Care: Stress the importance of establishing trauma care systems, including basic fracture management, in low-resource settings. Immediate stabilization and pain control are emphasized, even in the absence of advanced equipment.
2. Infectious Bone Diseases (Osteomyelitis and Bone TB)
Osteomyelitis and bone tuberculosis (TB) are significant challenges in sub-Saharan Africa due to poor sanitation from ubiquitous native or traditional bone setters (non-orthodox medical practitioners) as the major first contact, delayed diagnosis, and inadequate treatment.
Rules of Thumb
Early Diagnosis and Long-Term Antibiotics for Osteomyelitis:
In chronic osteomyelitis, early diagnosis and prolonged antibiotic therapy (6 to 12 weeks) are critical. Surgical debridement of infected bone tissue may be necessary to prevent further progression.
Bone TB Requires Multi-drug Therapy:
For bone tuberculosis, follow the same multidrug therapy regimen as pulmonary TB, usually consisting of isoniazid, rifampin, pyrazinamide, and ethambutol. Surgery may be necessary to stabilize the spine or other affected areas in advanced cases.
Close Monitoring for Recurrence:
Both osteomyelitis and bone TB have high recurrence rates, so follow-up and monitoring are crucial. Implementing long-term antibiotic treatment and ensuring adherence is key to reducing relapses.
Guidelines
WHO Tuberculosis Guidelines: Recommend the use of standard TB drug regimens for bone and joint TB, along with appropriate surgical interventions for spinal and joint involvement.
Osteomyelitis Treatment Guidelines: Suggest prolonged antibiotic therapy and, when necessary, surgical debridement for chronic cases. Treatment adherence and monitoring are critical in preventing relapses.
3. Congenital Deformities (Clubfoot and Developmental Dysplasia of the Hip)
Congenital deformities such as clubfoot and developmental dysplasia of the hip (DDH) are common in sub-Saharan Africa, and early intervention can prevent long-term disability.
Rules of Thumb
Ponseti Method for Clubfoot:
The Ponseti method, which involves serial casting and bracing, is the gold standard for treating clubfoot. Start treatment as early as possible (ideally in the first few weeks of life) to achieve the best outcomes.
Screening for Developmental Dysplasia of the Hip (DDH):
Early screening for DDH is essential, especially in high-risk populations. Ultrasound screening, where available, or clinical assessment using the Ortolani and Barlow manoeuvres can detect DDH early.
Non-Surgical Treatment First:
For most congenital deformities, non-surgical methods should be the first line of treatment. Surgery is reserved for severe cases or when conservative treatment fails.
Guidelines
Global Clubfoot Initiative Guidelines: Recommend the Ponseti method for managing clubfoot. Training healthcare providers in this method is crucial for expanding access to treatment in resource-limited areas.
AAP Guidelines for DDH: Suggest screening for DDH in newborns and infants, with ultrasound or clinical evaluation. Early treatment with bracing (Pavlik harness) is preferred for non-surgical management.
4. Neglected Trauma and Malunited Fractures
Neglected trauma, delayed fracture treatment, and malunited fractures are common due to the scarcity of orthopaedic services in many parts of sub-Saharan Africa.
Rules of Thumb
Corrective Osteotomy for Malunited Fractures:
For malunited fractures causing functional impairment, corrective osteotomy (surgical cutting and realignment of the bone) is often required to restore normal function. Pre-operative planning with x-rays is critical for success.
Non-Operative Management of Stable Malunions:
If a malunion does not affect function significantly or surgery is not feasible, non-operative management with physiotherapy can help patients adapt to residual deformities.
Functional Rehabilitation for Chronic Cases:
For neglected injuries, focus on rehabilitation and strengthening to maximize function, even if corrective surgery is not possible.
Guidelines
AO Principles of Fracture Management: Suggest osteotomy for malunited fractures when necessary. The guidelines also emphasize the importance of timely intervention to prevent malunion, particularly in children.
5. Bone Tumours
Primary bone tumours, including osteosarcoma and Ewing's sarcoma, and metastatic bone tumours require prompt diagnosis and management in resource-limited settings.
Rules of Thumb
Early Biopsy for Suspicious Lesions:
Any suspicious bone lesion or swelling, particularly in children and young adults, should be biopsied early to rule out malignancy. Timely referral to specialized centers for treatment is crucial.
Limb-Sparing Surgery Where Possible:
Limb-sparing surgery, combined with chemotherapy, should be the goal for treating malignant bone tumours. However, in settings where this is not feasible, amputation may still be necessary to save the patient’s life.
Limb-Sparing Surgery Where Possible:
Palliative Care for Advanced Cases: In cases where curative treatment is not possible, palliative care focusing on pain management and improving quality of life is essential.
Guidelines
NCCN Guidelines: Recommend early diagnosis and a multidisciplinary approach for managing bone tumours. Limb-sparing surgery is emphasized in treatable cases, while palliative care is critical for advanced malignancies.
Orthopaedic Oncology Guidelines: Suggest using biopsy to confirm diagnoses and early intervention with chemotherapy and surgery in osteosarcoma and other aggressive bone cancers.
6. Spinal Injuries and Deformities
Spinal injuries, particularly from trauma and tuberculosis, and congenital deformities such as scoliosis (majority of scoliosis are however idiopathic) are significant orthopaedic challenges in sub-Saharan Africa.
Rules of Thumb
Immediate Immobilization in Spinal Injuries:
Early immobilization of spinal injuries using cervical collars, backboards, or external supports is critical to prevent further neurological damage. Avoid unnecessary movement of the patient until the spine is stabilized.
Surgical Stabilization for Unstable Spinal Injuries:
Surgical stabilization using rods and screws should be considered for unstable spinal injuries. In resource-limited settings, external bracing or traction may be used when surgery is not feasible.
TB Spine (Pott’s Disease) Management:
Treat TB spine with anti-TB medication, and consider surgical decompression, instrumentation and deformity correction as case may be for advanced cases with neurological deficits or spinal instability.
Guidelines
WHO Spinal Cord Injury Guidelines: Recommend early immobilization, surgical stabilization when necessary, and rehabilitation to prevent long-term complications from spinal cord injuries.
Global Spine Care Initiative: Provides recommendations for managing spinal trauma and deformities, focusing on non-operative care in resource-constrained settings
7. Amputation and Prosthetics
Amputation is sometimes the only viable option for managing severe trauma, infections, or tumours. Providing proper post-amputation care and access to prosthetics is essential for improving patient outcomes.
Rules of Thumb
Ensure Proper Stump Care:
After an amputation, stump care and rehabilitation are essential for preventing complications and preparing the patient for prosthetics. Focus on maintaining a functional limb and preventing contractures.
Provide Access to Prosthetics:
In collaboration with local or international NGOs, prosthetic services should be made available. Even basic prosthetics can significantly improve mobility and quality of life.
Rehabilitation and Reintegration:
Rehabilitation after amputation is crucial for the patient's physical and psychological recovery. Counselling and vocational training can help patients reintegrate into society.
Guidelines
WHO Guidelines on Prosthetics and Rehabilitation: Emphasize the importance of early rehabilitation, stump care, and the provision of prosthetics to improve function and independence for amputees.
ISPO Guidelines: R.ecommend ensuring access to affordable prosthetics and ongoing rehabilitation services, especially in low-resource settings where amputations are common
8. Postoperative Care and Rehabilitation
Effective postoperative care and rehabilitation are critical components of orthopaedic surgery, particularly in sub-Saharan Africa where long-term follow-up is often challenging.
Rules of Thumb
Early Mobilization:
Encouraging early mobilization after surgery helps prevent complications such as deep vein thrombosis (DVT) and pressure ulcers. Even simple bed exercises can help improve outcomes in resource-limited settings.
Infection Prevention and Wound Care:
Proper wound care and infection prevention strategies, such as regular dressing changes and early identification of infections, are essential. Use prophylactic antibiotics as recommended to reduce the risk of surgical site infections.
Physical Therapy:
Prioritize physiotherapy to enhance recovery, improve function, and prevent complications. This is especially important for post-fracture management and after joint surgeries like hip replacements.
Guidelines
WHO Guidelines on Rehabilitation: Emphasize early mobilization, physical therapy, and rehabilitation as key components of postoperative care. Focus on community-based rehabilitation for patients in remote areas.
AAOS Postoperative Care Guidelines: Recommend infection prevention protocols, including sterile techniques during wound care and appropriate use of antibiotics. Early mobilization and patient education are also essential.
9. Joint Replacement Surgery
Joint replacement, particularly hip and knee arthroplasty are done in sub-Saharan Africa, but due to cost and resource constraints it is not widely available. It remains a valuable option for patients with severe osteoarthritis or joint damage.
Rules of Thumb
Patient Selection:
Joint replacement should be reserved for patients with severe joint damage or arthritis who have not responded to conservative treatments. Select patients who are likely to benefit from the procedure and have access to postoperative care.
Proper Prosthesis Selection:
Use affordable and durable prostheses suited for the local population, particularly in younger patients who require long-lasting solutions. Cemented prostheses are more commonly used in sub-Saharan Africa due to cost and ease of use.
Postoperative Care and Follow-Up:
Ensure that patients have access to follow-up care and physical therapy after joint replacement to maximize outcomes and reduce the risk of complications like joint dislocation or infection.
Guidelines
Global Arthroplasty Guidelines: Stress the importance of patient selection and proper prosthesis choice in low-resource settings. The guidelines also emphasize postoperative care, particularly physical therapy, to ensure functional recovery.
AAOS Guidelines for Joint Replacement: Provide protocols for selecting appropriate candidates, using the correct prostheses, and ensuring effective follow-up care.
10. Management of Orthopaedic Infections
Infections related to trauma, surgery, or systemic diseases (such as septic arthritis) are significant causes of morbidity in orthopaedics in sub-Saharan Africa.
Rules of Thumb
Early Detection and Treatment:
Early diagnosis of orthopaedic infections is crucial. Empiric antibiotic therapy should begin as soon as infection is suspected, followed by culture-directed therapy.
Debridement and Drainage:
In cases of septic arthritis or osteomyelitis, early and aggressive surgical debridement and drainage are essential to control the infection and prevent further damage.
Chronic Infections Need Long-Term Therapy:
Chronic infections like osteomyelitis often require extended antibiotic treatment (6 to 12 weeks) repeated debridement and other surgical interventions like arthrodesis which is also a treatment for joint infection in some selected cases. Monitor patients for recurrence and ensure follow-up.
Guidelines
Infectious Diseases Society of America (IDSA) Guidelines for Osteomyelitis: Recommend long-term antibiotic therapy and surgical intervention for osteomyelitis. Early diagnosis and treatment are critical to prevent chronicity.
AAOS Guidelines for the Prevention of Surgical Site Infections: Suggest appropriate use of prophylactic antibiotics, sterile surgical techniques, and timely wound care to prevent infections following orthopaedic procedures.
11. Bone and Joint TB
Bone tuberculosis, particularly spinal TB (Pott’s disease), is prevalent in sub-Saharan Africa due to the high incidence of tuberculosis.
Rules of Thumb
Early Anti-TB Therapy:
Initiate anti-tuberculosis treatment as soon as bone or joint TB is diagnosed. Treatment typically includes a 6- to 12-month course of standard anti-TB drugs (isoniazid, rifampin, pyrazinamide, and ethambutol).
Surgical Intervention for Advanced Cases:
For advanced cases of spinal TB with neurological deficits or spinal instability, surgical decompression and stabilization, ddeformity correction may be necessary.
Follow-Up and Monitoring:
Ensure long-term follow-up to monitor treatment response and prevent relapse, particularly in cases with spine involvement.
Guidelines
WHO Tuberculosis Guidelines: Recommend the use of standard anti-TB regimens for bone and joint TB, with surgical intervention when necessary for spinal involvement. The guidelines also stress the importance of monitoring and follow-up.
International Spine Care Initiative: Provides recommendations for managing spinal TB, focusing on conservative treatment with anti-TB medications and surgery only when required.
12. Bone Health and Prevention of Osteoporosis
Although osteoporosis is less common in younger populations in sub-Saharan Africa, it remains a concern in elderly populations, particularly postmenopausal women.
Rules of Thumb
Screen High-Risk Populations:
Screen elderly patients, postmenopausal women, and individuals with chronic conditions such as HIV/AIDS or malnutrition for signs of osteoporosis. In low-resource settings, clinical risk factors (such as fractures after minimal trauma) may be used to diagnose osteoporosis in the absence of advanced imaging.
Calcium and Vitamin D Supplementation:
Ensure adequate calcium and vitamin D intake in at-risk populations, particularly in older adults. Nutritional counselling can help prevent bone loss.
Encourage Weight-Bearing Exercises:
Promote regular weight-bearing exercises to strengthen bones and reduce the risk of fractures in elderly populations.
Guidelines
WHO Guidelines on Osteoporosis: Recommend calcium and vitamin D supplementation, along with weight-bearing exercises, as key strategies for preventing osteoporosis. Screening high-risk populations and educating patients are essential for managing bone health.
International Osteoporosis Foundation Guidelines: Suggest using clinical risk factors to diagnose osteoporosis in low-resource settings and emphasize prevention through nutrition and physical activity.
Conclusion
Orthopaedic care in sub-Saharan Africa faces unique challenges due to limited resources, a high burden of trauma, infectious diseases, and congenital deformities. By following practical rules of thumb, such as early stabilization of fractures, early diagnosis and treatment of infections, and prioritizing non-operative treatments when appropriate, healthcare providers can optimize patient outcomes in this context.
Guidelines provided by international organizations such as the WHO, AAOS, and AO Trauma offer valuable frameworks for managing orthopaedic conditions, emphasizing prevention, early intervention, and appropriate rehabilitation. Training local healthcare workers, improving access to orthopaedic services, and fostering partnerships with global health organizations are critical steps in addressing the orthopaedic healthcare needs of sub-Saharan Africa, ultimately leading to improved patient outcomes and quality of life.
Further readings
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- Michael Baumgaertner, Simon Lambert, Markku T Nousiainen. Adult Trauma. Adult trauma (aofoundation.org) Accessed 13th September 2024
- Jha Y, Chaudhary K. Diagnosis and Treatment Modalities for Osteomyelitis. Cureus. 2022 Oct 26;14(10):e30713. doi: 10.7759/cureus.30713. PMID: 36439590; PMCID: PMC9695195.
- WHO consolidated guidelines on tuberculosis: Module 4: treatment – drug-resistant tuberculosis treatment, 2022 update [Internet]. Geneva: World Health Organization; 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK588564/
- Besselaar AT, Sakkers RJ, Schuppers HA, Witbreuk MM, Zeegers EV, Visser JD, Boekestijn RA, Margés SD, Van der Steen MC, Burger KN. Guideline on the diagnosis and treatment of primary idiopathic clubfoot. Acta orthopaedica. 2017 May 4;88(3):305-9.
- Ansar A, Rahman AE, Romero L, Haider MR, Rahman MM, Moinuddin M, Siddique MA, Al Mamun M, Mazumder T, Pirani SP, Mathias RG. Systematic review and meta-analysis of global birth prevalence of clubfoot: a study protocol. BMJ open. 2018 Mar 1;8(3):e019246.
- Archer JE, Chauhan GS, Osman K, Thomson C, Dewan V, Nandra R, Stevenson J. The British Orthopaedic Oncology Management audit protocol. Journal of Surgical Protocols and Research Methodologies. 2021 Sep;2021(1):snab005.
- Shaw BA, Segal LS, Otsuka NY, Schwend RM, Ganley TJ, Herman MJ, Hyman JE, Smith BG. Evaluation and referral for developmental dysplasia of the hip in infants. Pediatrics. 2016 Dec 1;138(6). Evaluation and Referral for Developmental Dysplasia of the Hip in Infants | Pediatrics | American Academy of Pediatrics (aap.org) Accessed 13th September 2024
- Biermann JS, Chow W, Reed DR, Lucas D, Adkins DR, Agulnik M, Benjamin RS, Brigman B, Budd GT, Curry WT, Didwania A, Fabbri N, Hornicek FJ, Kuechle JB, Lindskog D, Mayerson J, McGarry SV, Million L, Morris CD, Movva S, O’Donnell RJ, Randall RL, Rose P, Santana VM, Satcher RL, Schwartz H, Siegel HJ, Thornton K, Villalobos V, Bergman MA, Scavone JL. NCCN Guidelines Insights: Bone Cancer, Version 2.2017. J Natl Compr Canc Netw. 2017 Feb;15(2):155-167. doi: 10.6004/jnccn.2017.0017. PMID: 28188186.
- World Health Organization. WHO. Spinal cord injury. 16 April 2024. Spinal cord injury (who.int) Accessed 13th September 2024
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- ISPO. Prosthetics, Orthotics, and Assistive Technology. Prosthetics, Orthotics, and Assistive Technology – ISPO (ispoint.org) Accessed 13th September 2024
- World Health Organization WHO standard for prosthetics and orthotics. 1 February 2017. WHO standards for prosthetics and orthotics Accessed 13th September 2024
- World Health Organization. WHO. Rehabilitation. 22 April 2024. Rehabilitation (who.int) Accessed 13th September 2024
- AAOS Clinical Practice Guidelines. Clinical Practice Guidelines (aaos.org) Accessed 13th September 2024
- Waddell J, Johnson K, Hein W, Raabe J, FitzGerald G, Turibio F. Orthopaedic practice in total hip arthroplasty and total knee arthroplasty: results from the Global Orthopaedic Registry (GLORY). Foot/ankle. 2010 Sep 10;2(2):3. 039090005s.pdf (mdedge.com)
- AAOS Updates Clinical Practice Guideline for Surgical Management of Osteoarthritis of the Knee. 1st October 2023. AAOS Updates Clinical Practice Guideline for Surgical Management of Osteoarthritis of the Knee Accessed 13th September 2024
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- IDSA 2015 Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clinical Infectious Diseases, Volume 61, Issue 6, 15 September 2015, Pages e26–e46, https://doi.org/10.1093/cid/civ482 Accessed 13th September 2024
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