ABSTRACT
BACKGROUND: Djibouti has no paediatric orthopaedics department and three options are available for difficult cases: transfer of the patient to another country; overseas mission transfer to Djibouti by a specialised surgical team; and management by a local orthopaedic surgeon receiving guidance from an expert. The extreme poverty of part of the population of Djibouti often precludes the first two options. Telemedecine can allow the local orthopaedic surgeon to receive expert advice. HYPOTHESES AND STUDY DESIGN: We prospectively recorded all the paediatric orthopaedics teleconsultations that occurred between November 2009 and November 2011. Our objective was to assess the performance of the teleconsultations. We hypothetized that this option was influential in decision making. MATERIALS AND METHODS: We assessed the influence of the teleconsultation on patient management (i.e., change in the surgical indication and/or procedure). We then used the electronic patient records to compare the actual management to that recommended retrospectively by two independent orthopaedic surgeon consultants who had experience working overseas. Finally, we assessed the clinical outcomes in the patients. RESULTS: Of 48 teleconsultations for 39 patients, 13 dealt with diagnostic problems and 35 with therapeutic problems. The teleconsultation resolved the diagnostic uncertainties in 90% of cases. Advice from the expert modified the management in 37 (77%) teleconsultations; the change was related to the surgical indication in 18 cases, the surgical technique in 13 cases, and both in six cases. Agreement between the advice from the independent consultants and the treatment delivered by the local surgeon was 2.2/3. Clinical outcomes were good or very good in 31 (81%) of the 38 treated patients. CONCLUSIONS: This study establishes the feasibility and usefulness of paediatric orthopaedics teleconsultations in Djibouti. The introduction of telemedicine has changed our approach to challenges raised by patients in remote locations or precarious situations. Input from experts considerably benefits patient management. LEVEL OF EVIDENCE: III, prospective comparative study.
Subject(s)
Developing Countries , Orthopedic Procedures , Pediatrics , Remote Consultation , Adolescent , Child , Child, Preschool , Djibouti , Feasibility Studies , Female , Humans , Infant , Male , Outcome Assessment, Health Care , Program Evaluation , Prospective StudiesABSTRACT
BACKGROUND: The best surgical strategy for extra-capsular proximal femoral fractures (PFFs) is controversial in the elderly. Poor bone quality and neck screw instability can adversely affect the results with currently available fixation devices, which predominantly consist in dynamic hip screw-plates and proximal reconstruction nails. HYPOTHESIS: The helical blade of the proximal femoral nail antirotation (PFN-A™) achieves better cancellous bone compaction in the femoral neck, thereby decreasing the risk of secondary displacement. MATERIALS AND METHODS: We retrospectively reviewed consecutive cases of PFN-A™ fixation performed between 2006 and 2008 in 102 patients (75 females and 27 males) with a mean age of 84.9 ± 9.5 years (range, 70-100 years). Functional outcomes were assessed using the Parker Mobility Score. RESULTS: Mean follow-up in the 102 patients was 21.3 ± 17.5 months (4-51 months). Fracture distribution in the AO classification scheme was A1, n=45; A2, n=41; and A3, n=16. At last follow-up, Parker Mobility Score values in the 65 survivors were 0-3, n=35; 4-6, n=11; and 7-9, n=19. Fracture union was consistently achieved, after a mean of 10.3 ± 3 weeks. Blade back-out allowed by the device design occurred in 16 (15.7%) patients but caused pain due to screw impingement on the fascia lata in only five patients (of whom two underwent reoperation). Cephalic blade cut-out was noted in three (2.9%) patients, of whom one required reoperation because of acetabular penetration. Two hardware-related fractures were recorded. DISCUSSION: The new PFN-A™ device ensures reliable fixation with low mechanical complication rates. Although our data do not constitute proof that a helical blade is superior over a neck screw, they suggest a decreased rate of construct failure and may serve as a basis for a comparative study.
Subject(s)
Bone Nails , Femoral Neck Fractures/surgery , Fracture Fixation, Internal/methods , Hip Joint/surgery , Aged , Aged, 80 and over , Bone Screws , Female , Femoral Neck Fractures/mortality , Femoral Neck Fractures/physiopathology , France/epidemiology , Hip Joint/diagnostic imaging , Hip Joint/physiopathology , Humans , Male , Prosthesis Design , Prosthesis Failure , Radiography , Range of Motion, Articular , Rotation , Survival Rate/trends , Treatment OutcomeABSTRACT
OBJECTIVE: Our objective was to assess the influence of teleconsultations on patient management and clinical outcomes in a developing country. MATERIALS AND METHODS: All the surgical teleconsultations by a single surgeon (orthopedist) between November 2009 and November 2011 were recorded. RESULTS: Neurosurgery and pediatric orthopedics were the two most important specialities most often concerned, accounting for 67% of the 157 teleconsultations for 138 patients. The teleconsultations resolved the diagnostic uncertainties in 29 of 37 cases (78%). Advice from the expert modified management in 69% cases. Clinical outcomes were good or very good in 86% of the treated patients. CONCLUSIONS: This study establishes the feasibility and usefulness of surgical teleconsultations in Djibouti.
Subject(s)
Remote Consultation , Surgical Procedures, Operative , Adolescent , Adult , Aged , Child , Child, Preschool , Developing Countries , Djibouti , Feasibility Studies , Humans , Infant , Middle Aged , Prospective Studies , Time Factors , Young AdultABSTRACT
We report a case of hematogenous streptococcus pneumoniae infection of a total knee arthroplasty observed in an 82-year-old woman who initially presented a lung infection. The therapeutic approach was largely dictated by the patient's precarious general status. Arthroscopic washings were associated with adapted antibiotics followed by removal of the prosthesis and replacement with a spacer. The patient declined further intervention so the prosthesis was not reimplanted. Hematogenous infections of joint prostheses are rarely caused by such streptococcal species. Since this is a well known germ, it would be logical to apply the usual rules for treatment of infected prostheses caused by sensitive germs. However, the analysis of the present case and a review of the literature shows that various therapeutic approaches have been used. These infections appear to be more common in seriously ill patients which could explain this variability. Mortality is high. The number of reported cases is too small to propose a specific treatment.
