Primary hip and knee arthroplasty at district level is safe and may reduce the burden on tertiary care in a low-income setting.

BACKGROUND: Arthroplasty procedures in low-income countries are mostly performed at tertiary centers, with waiting lists exceeding 12 to 24 months. Recently, this is further exacerbated by the impact of the Covid Pandemic on elective surgeries. Providing arthroplasty services at other levels of healthcare aims to offset this burden, however there is a marked paucity of literature regarding surgical outcomes. This study aims to provide evidence on the safety of arthroplasty at district level. METHODS: Retrospective review of consecutive hip and knee primary arthroplasty cases performed at a District Hospital (DH), and a Tertiary Academic Hospital (TH) in Cape Town, South Africa between 1st January 2015 and 31st December 2018. Patient demographics, hospital length of stay, surgery related readmissions, reoperations, post-operative complications, and mortality rates were compared between cohorts. RESULTS: Seven hundred and ninety-five primary arthroplasty surgeries were performed at TH level and 228 at DH level. The average hospital stay was 5.2 ± 2.0 days at DH level and 7.6 ± 7.1 days for TH (p < 0.05). Readmissions within 3 months post-surgery of 1.75% (4 patients) for district and 4.40% (35) for tertiary level (p < 0.05). Reoperation rate of 1 in every 100 patients at the DH and 8.3 in every 100 patients at the TH (p < 0.05). Death rate was 0.4% vs 0.6% at district and tertiary hospitals respectively (p > 0.05). Periprosthetic joint infection (PJI) rate was 0.43% at DH and 2.26% at TH. The percentage of hip dislocation requiring revision was 0% at district and 0.37% at tertiary level. During the study period, 228 patients received their arthroplasty surgery at the DH; these patients would otherwise have remained on the TH waiting list. CONCLUSIONS: Hip and Knee Arthroplasty at District health care level is safe and; for the reason that the DH feeds into the TH; providing arthroplasty at district level may help ease the pressure on arthroplasty services at tertiary care facilities in a Southern African context. Adequately trained surgeons should be encouraged to perform these procedures in district hospitals provided there is appropriate patient selection and adherence to strict theatre operating procedures. LEVEL OF EVIDENCE: Level III Retrospective cohort study.

The management of acute knee dislocations: A global survey of orthopaedic surgeons' strategies.

PURPOSE: Great variety and controversies surround the management strategies of acute multiligament knee injuries (aMKLIs) and no established guidelines exist for resource-limited practices. The aim of this study was to compare the management approach of acute knee dislocations (AKDs) by orthopedic surgeons from nations with different economic status. METHODS: This descriptive cross-sectional scenario-based survey compares different management strategies for aMLKIs of surgeons in developed economic nations (DEN) and emerging markets and developing nations (EMDN). The main areas of focus were operative versus non-operative management, timing and staging of surgery, graft choice and vascular assessment strategies. The members of the Societe Internationale de Chirurgie Orthopedique et de Traumatologie (SICOT) were approached to participate and information was collected regarding their demographics, experience, hospital setting and management strategies of aMLKIs. These were analyzed after categorizing participants into DEN and EMDN based on the gross domestic product (GDP) per capita. RESULTS: One-hundred and thirty-eight orthopedic surgeons from 47 countries participated in this study, 67 from DEN and 71 (51.4%) from EMDN. DEN surgeons had more years of experience and were older (p < 0.05). Surgeons from EMDN mostly worked in public sector hospitals, were general orthopedic surgeons and treated patients from a low-income background. They preferred conservative management and delayed reconstruction with autograft (p < 0.05) if surgery was necessary. Surgeons from DEN favored early, single stage arthroscopic ligament reconstruction. Selective Computerized Tomography Angiography (CTA) was the most preferred choice of arterial examination for both groups. Significantly more EMDN surgeons preferred clinical examination (p < 0.05) and duplex doppler scanning (p < 0.05) compared to DEN surgeons. More surgeons from EMDN did not have access to a physiotherapist for their patients. CONCLUSIONS: Treatment of aMLKIs vary significantly based on the economic status of the country. Surgeons from DEN prefer early, single stage arthroscopic ligament reconstruction, while conservative management is favored in EMDN. Ligament surgery in EMDN is often delayed and staged. EMDN respondents utilize duplex doppler scanning and clinical examination more readily in their vascular assessment of aMLKIs. These findings highlight very distinct approaches to MLKIs in low-resource settings which are often neglected when guidelines are generated.