The healthcare system costs of hip fracture care in South Africa.

Despite rapidly ageing populations, data on healthcare costs associated with hip fracture in Sub-Saharan Africa are limited. We estimated high direct medical costs for managing hip fracture within the public healthcare system in SA. These findings should support policy decisions on budgeting and planning of hip fracture services. PURPOSE: We estimated direct healthcare costs of hip fracture (HF) management in the South African (SA) public healthcare system. METHODS: We conducted a micro-costing study to estimate costs per patient treated for HF in five regional public sector hospitals in KwaZulu-Natal (KZN), SA. Two hundred consecutive, consenting patients presenting with a fragility HF were prospectively enrolled. Resources used including staff time, consumables, laboratory investigations, radiographs, operating theatre time, surgical implants, medicines, and inpatient days were collected from presentation to discharge. Counts of resources used were multiplied by unit costs, estimated from the KZN Department of Health hospital fees manual 2019/2020, in local currency (South African Rand, ZAR), and converted to 2020 US$ prices. Generalized linear models estimated total covariate-adjusted costs and cost predictors. RESULTS: The mean unadjusted cost for HF management was US$6935 (95% CI; US$6401-7620) [ZAR114,179 (95% CI; ZAR105,468-125,335)]. The major cost driver was orthopaedics/surgical ward costs US$5904 (95% CI; 5408-6535), contributing to 85% of total cost. The covariate-adjusted cost for HF management was US$6922 (95% CI; US$6743-7118) [ZAR113,976 (95% CI; ZAR111,031-117,197)]. After covariate adjustment, total costs were higher in patients operated under general anaesthesia [US$7251 (95% CI; US$6506-7901)] compared to surgery under spinal anaesthesia US$6880 (95% CI; US$6685-7092) and no surgery US$7032 (95% CI; US$6454-7651). CONCLUSION: Healthcare costs following a HF are high relative to the gross domestic product per capita and per capita spending on health in SA. As the population ages, this significant economic burden to the health system will increase.

Ethnic and gender-specific incidence rates for hip fractures in South Africa: A multi-centre study.

BACKGROUND: Limited data exist on the incidence of hip fractures in South Africa (SA). We report gender and ethnic specific incidence rates of hip fractures in SA. METHODS: In a multicentre prospective study, conducted in geographically defined municipalities of three provinces in SA, a structured questionnaire was administered to all subjects aged 40 years and over, presenting with a new atraumatic hip fracture, from 1 April 2017 to 31 March 2018. Gender and ethnic specific incidence rates (IR) of hip fractures were calculated using population statistics from Statistics SA. FINDINGS: Of the 2767 subjects enrolled, 1914 (69·2%) were women and 853 (30·8%) were men. The majority of subjects were from the White population (40·9%) followed by those from the African (26·4%), Coloured (18·7%) and Indian (13·9%) populations. Men with hip fractures were significantly younger than women in the total group (69 [IQR 59-79] versus 77 years [IQR 68-84], p < 0·001) and in each ethnic group. White subjects were significantly older (p < 0·0001) and Africans significantly younger (p < 0·0001) than the other ethnic groups. In women, the highest IR was noted in the White population (176·0 per 100,000), followed by that in the Indian (147·7 per 100,000), Coloured (73·2 per 100,000) and African populations (43·6 per 100,000). A similar pattern was seen in men albeit at lower rates, with the highest rate in White men at 76·5 per 100,000. In the total study population and the African population, the IR was higher in men compared to women in subjects under 60 years. In the White population, the IR was higher in men compared to women in the 40-44 years age group. While in the Coloured and Indian populations the IR was higher in men compared to women in the 40-49 years and 45-54 years age groups, respectively. There was an increase in the relative risk ratios with age in the total study population, and in all ethnic groups in both women and men. INTERPRETATION: Hip fractures occur in all ethnic groups in South Africa with higher IRs in the White and Indian populations compared to the Coloured and African populations. Consistent with the published literature, the overall hip fracture IR was higher in women than in men, except in the younger age groups, and increased with age. FUNDING: South African Medical Research Council and the University of KwaZulu-Natal Competitive Research Grant.

The effect of lockdown regulations on SARS-CoV-2 infectivity in Gauteng Province, South Africa.

BACKGROUND: On 26 March 2020, the South African (SA) government initiated a 21-day national level 5 lockdown which was subsequently eased off and downgraded to level 4 on 1 May and to level 3 on 1 June. The effect of lockdown measures on SARS-CoV-2 infectivity is currently uncertain. In this article, we analyse the effects of the lockdown measures on the SARS-CoV-2 epidemic in one of the epicentres in SA. OBJECTIVES: To measure the effects of lockdown measures introduced in SA on SARS-CoV-2 attack rates (ARs, the percentage of individuals who tested positive in a specified time period) in Gauteng Province during a 4-month period (March - June 2020). METHODS: In this retrospective cohort study, we used a comprehensive database from an independent pathology laboratory in Gauteng. We analysed trends of positivity rates of reverse transcription polymerase chain reaction tests done during the 4-month period. The ARs are reported over time (unweighted and age-weighted 14-day moving averages) by age groups, gender, and different regions/districts in Gauteng. RESULTS: A total of 162 528 tests were performed at a private laboratory between 5 March and 30 June 2020, of which 20 574 were positive (overall AR 12.7%). These positive tests constituted 44.8% of all positive cases in the province (20 574/45 944). Sixty-two percent of all tests were done in June during lockdown level 3. There was an exponential increase in the AR in June (18.3%) when lockdown was eased to level 3, in comparison with 4.2% (March), 2.2% (April) and 3.3% (May). The increase in June was seen in all the age groups, although it was more pronounced in the 21 - 60 years age groups than the younger (0 - 20 years) and older (>60 years) age groups. The AR was significantly higher in males (13.2%) compared with females (12.1%) (χ2 test, p<0.0001). CONCLUSIONS: The findings of this study testify to the rapid increase in ARs resulting from easing of the lockdown regulations, especially to level 3 in June. Of concern is the upward trend in the AR across all age groups, especially <20 years (15.9%), which was not reported in other parts of the world. Population age dynamics should therefore be considered when taking future decisions about lockdown regulations.

The posterior-only surgical approach in the treatment of tuberculosis of the spine: outcomes using cortical bone allografts.

Aims: The surgical treatment of tuberculosis (TB) of the spine consists of debridement and reconstruction of the anterior column. Loss of correction is the most significant challenge. Our aim was to report the outcome of single-stage posterior surgery using bone allografts in the management of this condition. Patients and Methods: The study involved 24 patients with thoracolumbar TB who underwent single-stage posterior spinal surgery with a cortical bone allograft for anterior column reconstruction and posterior instrumentation between 2008 and 2015. A unilateral approach was used for 21 patients with active TB, and a bilateral approach with decompression and closing-opening wedge osteotomy was used for three patients with healed TB. Results: A median of 1.25 vertebrae were removed (interquartile range (IQR) 1 to 1.75) and the median number of levels that were instrumented was five (IQR 3 to 6). The median operating time was 280 minutes (IQR 230 to 315) and the median blood loss was 700 ml (IQR 350 to 900). The median postoperative kyphosis was 8.5° (IQR 0° to 15°) with a mean correction of the kyphosis of 71.6%. Good neurological recovery occurred, with only two patients (8%) requiring assistance to walk at a mean follow-up of 24 months (9 to 50), at which time there was a mean improvement in disability, as assessed by the Oswestry Disability Index, of 83% (90% to 72%). Conclusion: The posterior-only approach using cortical allografts for anterior column reconstruction achieved good clinical and radiological outcomes. Differentiation should be made between flexible (active) and rigid (healed) TB spine. Cite this article: Bone Joint J 2018;100-B:1208-13.

Osteosarcoma patient outcomes at a South African tertiary hospital.

BACKGROUND: Osteosarcoma is the most common primary malignant bone tumour. There is a high incidence of late presentation in the developing world, posing additional challenges in the treatment of this aggressive disease. OBJECTIVE: To evaluate clinical outcomes of patients with osteosarcoma at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), a tertiary hospital in South Africa, and compare these with similar studies in the developing world. METHODS: This was a retrospective study of 61 patients treated at CMJAH between 2007 and 2011, with a minimum follow-up of 1.3 years (range 1.3 - 6.3). RESULTS: An average of 4.5 months elapsed before patients were first seen at the CMJAH tumour unit. Fifty-eight patients (95.1%) initially sought conventional medical care. Three patients (4.9%) presented with pathological fractures. All the patients underwent biopsy, performed an average of 3 weeks after arrival at the tumour unit. In most cases the delay was due to limited access to magnetic resonance imaging. Most patients (n=41, 67.2%) were at Enneking stage 2B, 4 (6.6%) were at stage 2A and 16 (26.2%) were at stage 3. Of the patients, 13 (21.3%) underwent limb salvage procedures, 33 (54.1%) had amputations, 4 (6.6%) refused further treatment and 11 (18.0%) received palliative care only; 55 patients (90.2%) received chemotherapy. Two patients developed local recurrence, one of whom had an amputation and the other further wide excision. Two patients received palliative radiotherapy. Of the patients, 82.0% were HIV-negative, 4.9% HIV-positive and the rest of unknown status. At the time of the study, all but two patients, who came from other countries, were traceable or known to have died. Our overall 1-year and 5-year survival rates were 62.7% (95% confidence interval (CI) 49.1 - 73.9) and 38.1% (95% CI 24.6 - 51.4), respectively. Male patients and those with a higher Enneking stage had a poorer prognosis. CONCLUSION: Although most patients sought conventional medical care, unacceptable delays worsened survival. However, our survival rates are better than those in other developing countries. We advocate that professional, public and political awareness of osteosarcoma be improved as a matter of urgency, to facilitate rapid tertiary referral and expedite management.

Osteosarcoma patient outcomes at a South African tertiary hospital

Background. Osteosarcoma is the most common primary malignant bone tumour. There is a high incidence of late presentation in the developing world, posing additional challenges in the treatment of this aggressive disease. Objective. To evaluate clinical outcomes of patients with osteosarcoma at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), a tertiary hospital in South Africa, and compare these with similar studies in the developing world.Methods. This was a retrospective study of 61 patients treated at CMJAH between 2007 and 2011, with a minimum follow-up of 1.3 years (range 1.3 - 6.3).Results. An average of 4.5 months elapsed before patients were first seen at the CMJAH tumour unit. Fifty-eight patients (95.1%) initially sought conventional medical care. Three patients (4.9%) presented with pathological fractures. All the patients underwent biopsy, performed an average of 3 weeks after arrival at the tumour unit. In most cases the delay was due to limited access to magnetic resonance imaging. Most patients (n=41, 67.2%) were at Enneking stage 2B, 4 (6.6%) were at stage 2A and 16 (26.2%) were at stage 3. Of the patients, 13 (21.3%) underwent limb salvage procedures, 33 (54.1%) had amputations, 4 (6.6%) refused further treatment and 11 (18.0%) received palliative care only; 55 patients (90.2%) received chemotherapy. Two patients developed local recurrence, one of whom had an amputation and the other further wide excision. Two patients received palliative radiotherapy. Of the patients, 82.0% were HIV-negative, 4.9% HIV-positive and the rest of unknown status. At the time of the study, all but two patients, who came from other countries, were traceable or known to have died. Our overall 1-year and 5-year survival rates were 62.7% (95% confidence interval (CI) 49.1 - 73.9) and 38.1% (95% CI 24.6 - 51.4), respectively. Male patients and those with a higher Enneking stage had a poorer prognosis.Conclusion. Although most patients sought conventional medical care, unacceptable delays worsened survival. However, our survival rates are better than those in other developing countries. We advocate that professional, public and political awareness of osteosarcoma be improved as a matter of urgency, to facilitate rapid tertiary referral and expedite management

Development of a lower limb arthroplasty service in a developing country : Lessons learned after the first 100 cases (joints).

There is emerging evidence that total hip arthroplasty (THR) can be safely practiced in developing countries but scant evidence of safety of total knee replacement (TKR). The purpose of this study is to evaluate the outcomes of these procedures focusing on procedure related complications. This is a retrospective study of the first 100 arthroplasties (92 patients) consisting of 58 TKR and 42 THR with a minimum follow-up of 26 months (range of 26 to 47 months). Major complications included deep infection in one TKR and dislocation of one THR and one TKR. Two patients died in the second post-operative week from cardiac events following TKR. Blood transfusion rate for hips and knees was 13.7% and 5.6% respectively. THR can be safely performed in less than ideal circumstances in developing countries in carefully selected patients. More importantly this study demonstrates that TKR can be safely practiced under the same circum-stances.

The safety of osteoporosis medication.

Osteoporosis is a common, costly and serious disease, which is still too often regarded as an inevitable part of the normal ageing process and therefore sub-optimally treated, especially in the elderly--in fact, only two out of every 10 patients who sustain a hip fracture receive any form of assessment or prophylactic therapy for osteoporosis. One out of five patients die within 1 year after a hip fracture, and < 50% are capable of leading an independent life. Yet very effective anti-fracture therapy, capable of reducing fracture risk by 35 - 60%, is available. A number of publications have recently questioned the safety of drugs routinely used to treat patients with osteoporosis. This paper attempts to put the situation into perspective and expresses the National Osteoporosis Foundation of South Africa's view on the safety of these drugs. Their efficacy in preventing skeletal fractures and their cost-effectiveness are not addressed in any detail. The paper emphasises the fact that all osteoporosis medications have side-effects, some of which are potentially life-threatening.

Impact of HIV on bone and joint surgery.

In 2007, approximately 33 million people were living with human immunodeficiency virus (HIV) infection worldwide. Sub-Saharan Africa has been hardest hit by the HIV pandemic. In this chapter the impact of HIV infection on bone and joint surgery is reviewed. The management of orthopaedic trauma and diseases specific to HIV infection (such as osteonecrosis, bone tumours, and bone and joint infection) in patients with HIV infection are discussed. The importance of universal protection during surgical procedures is emphasized. The guidelines developed by the Centers for Disease Control for HIV-positive health workers and their involvement in the treatment of these are discussed.

The cost and benefit of prophylaxis against deep vein thrombosis in elective hip replacement. DVT/PE Prophylaxis Consensus Forum.

UNLABELLED: A consensus forum was convened to evaluate the economic considerations associated with prophylaxis against thrombo-embolic disease in patients undergoing hip replacement therapy in South Africa. This forum consists of orthopaedic surgeons, vascular surgeons and a statistician. METHODS: The forum was instructed to evaluate the economic costs of the commonly used forms of prophylaxis of thrombo-embolism in patients undergoing hip replacement surgery in South Africa, looking at short-term events only. The methods used for the prophylaxis of thrombo-embolism in South Africa were determined by a postal survey. A decision tree was constructed to determine the events that will occur after a clinical decision to use no prophylaxis. The probabilities of these events were then determined. Protocols for and costs of prophylaxis and treatment were established. With the decision tree and these costs, the cost of the various modalities of prophylaxis was then determined. RESULTS: The probability, determined by the forum, of developing a deep-vein thrombosis (DVT) when no prophylaxis is used was 0.5, with a mortality rate of 2.1%. The cost of this decision was R875. No prophylaxis given, but a venogram performed on day 7, reduced the mortality rate to 0.7%; however, this cost R3 017. The cost of low-molecular-weight heparin was R1 223 (probability 0.26, mortality rate 1.1%), while unfractionated heparin with a graduated compression stocking (GCS) cost R1 351 (probability 0.24, mortality rate 1%). Aspirin with a GCS cost R777 (probability 0.35, mortality rate 1.5%).

Atlanto-axial rotatory fixation.

OBJECTIVES: To analyse the causes of atlanto-axial rotatory fixation (AARF) and discuss the diagnosis and treatment. DESIGN: Retrospective case studies. SETTING: Medical University of Southern Africa-Ga-Rankuwa referral hospital. PATIENTS: A total of 10 patients admitted to and treated in the Department of Orthopaedics, Ga-Rankuwa Hospital, between July 1989 and June 1993. OUTCOME MEASURE: Dynamic computed tomography (CT) scan. RESULTS: Upper respiratory tract infection and trauma were the commonest causes of AARF. There was a delay in diagnosis ranging between 4 weeks and 2 years 6 months. Clinical and radiological reduction was obtained by gradual skeletal traction in 6 patients. Two patients had improvement of the torticollis but still had subluxation on the CT scan. In 1 patient no reduction was obtained on occipitocervical fusion and transoral decompression was necessary. In 1 case the parents refused any form of treatment. There was no recurrence in the 7 patients followed up (minimum 6 months). CONCLUSION: This study shows that AARF is often diagnosed late. The patients diagnosed early responded well to skeletal traction followed by external support. In patients diagnosed late the AARF could not be reduced completely and needed surgical fusion. If untreated, condition can be complicated by tetraparesis.

Tuberculosis of the cervical spine.

Tuberculosis of the cervical spine is rare, comprising 3-5% of cases of tuberculosis of the spine. Eight patients with tuberculosis of the cervical spine seen during 1989-1992 were reviewed. They all presented with neck pain. The 4 children presented with a kyphotic deformity. In all the children the disease was extensive, with a large prevertebral abscess formation, while in the adults it was localised to one or two motion segments. Cord compression was present in 4 of the 8 patients. All the patients were treated with antituberculosis drugs and 6 underwent surgery. There was full neurological recovery in all patients. The kyphosis was improved though not fully corrected. There was a problem in stabilisation of severe involvement of the body and dens of C2. Surgery seems to play a major role in the treatment of tuberculosis of the cervical spine.

Fractures of the vertebral lamina associated with unifacet and bifacet cervical spine dislocations.

Unifacet and bifacet dislocations of the lower cervical spine are very common injuries. Occasionally these injuries may be associated with fractures of the lamina which, in the absence of computed tomography, are often discovered in theatre. The presence of a fracture of the lamina makes the standard posterior wiring and fusion biomechanically unstable even when the vertebra above is included. A retrospective study to assess the incidence of these fractures and their final outcome was undertaken. Forty-three patients operated on for cervical spine dislocations during the period June 1989 to December 1990 were analysed. Twelve were found to have associated lamina fractures. At final discharge 5 of the 12 patients had kyphosis due to translation, despite good peri-operative reduction. One patient had neurological deterioration, which improved after an anterior plating and fusion.