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Introduction and objectives
Orthopedic conditions, those concerned with conditions involving the musculo-skeletal system, vary in their presenta-tion, disability, and required treatments. They include both musculoskeletal trauma, degenerative diseases as well as congenital disorders, and management of orthopedic conditions can range from simple traction for a femur fracture, the Ponseti method for clubfoot to recon-structive surgery for severe scoliosis. Given the numerous conditions and their complexity, similarly the epidemi-ology of orthopedic conditions can be difficult to characterize. In countries with significant barriers which limit access to health care, the incidence, prevalence and disability associated with orthopedic conditions is especially difficult to estimate. Though easier to obtain, hospital data will not give fully accurate estimates as the cost, limited transport and lack of availability of surgeons skilled in orthopedic proce-dures will often dissuade patients from seeking timely care at health facilities. Another way to obtain data on disease prevalence is to perform national sur-veys. Via a cluster sampling approach random individuals can be evaluated in a systematic way to obtain information on the conditions of interest. These sur-veys are often done in settings with lim-ited centralized health data under the name of Demographic Health Surveys (DHS). However, the standardized DHS mostly elicit information on infectious diseases and reproductive health rather than on conditions in need of surgical evaluation and treatment. Therefore the Surgeons OverSeas Assessment of Sur-gical need (SOSAS) was developed. This article is an overview of the epidemiol-ogy of orthopedic conditions determined from the SOSAS surveys done previ-ously in Sierra Leone and Rwanda.
Methods
SOSAS is elsewhere described in detail[1] and an evaluation by the enumerators from Sierra Leone can be found in a prior edition of this journal. [2] In brief, SOSAS is a two-stage cluster-based household assessment of surgical need. The study starts by interviewing the head of the household on household demographics and any deaths in the previous 12 months. Following is a structured verbal ‘head-to-toe-examina-tion’ of two randomly assigned house-hold members. They are asked if they ever had a condition, which should have been surgically evaluated. Responses can include: wound, burn, mass, or deformity and many other symptoms understandable to the layman. Timing and mechanism in case of an injury are also recorded. This article will look at data that relates to trauma and ortho-pedic conditions from several SOSAS subanalyses previously published. [3-5]
Results
Data from Sierra Leone, from 2012, revealed that at least 24% of the re-spondents (873 individuals) had at least 1 lifetime traumatic injury, meaning any time during their life which they recalled. Of those 873, 12% (452 indi-viduals) had this injury in the last year. Each respondent could report more than one injury, therefore a total of 1,316 injuries were noted. Females were less likely to report an injury than males with an OR of 0.69 (95% CI 0.57-0.83). From the Rwanda study, the overall data was similar; with 27% (870 individu-als) reporting an injury related surgical condition in their lifetime, however only 7% (228 individuals) stated that this was in the last year.
In both Rwanda and Sierra Leone, falls were the most common cause of injury (45% and 43% respectively). In Rwanda this was followed by animal related inju-ries (16%) and weapons (11%), whereas in Sierra Leone stab/slash/cut injuries (29%) and burns (12%) followed. In Si-erra Leone 69% of the injuries related to the extremities and in Rwanda this was 49%, followed in both countries by in-juries to the face, head, neck. Although most injuries were related to falls, most fatal injuries were road traffic related (32% of the total deadly injury incidents) followed by falls (29%).
The Sierra Leone data was further analysed for non-traumatic musculo-skeletal problems and a total of 256 (7%) had a non-traumatic problem related to orthopedics in their lifetime, with 236 (6%) in the past year and 209 (6%) had this as an active problem at the time of the survey. Adults and elderly were more likely to have these types of problems than children (OR respectively 2.65 and 9.38). Females were equally likely to have a non-traumatic musculoskeletal problem. Rural as opposed to urban residency was associated with greater likelihood of having a non-traumatic musculoskeletal problem (OR 1.44). In children these non-traumatic injuries were attributable to congenital deformi-ties in 36%, and mass or growth in 28%. Acquired deformity was significantly less common in children (22%) than in adults (46%) or the elderly (73%), where the latter’s most affected body part was the back (49%). Non-traumatic foot problems were prevalent in children (28%) as opposed to 19% in adults and 14% in the elderly. A total of 14 respon-dents (5.1% of the non-traumatic mus-culoskeletal problems) noted recurrent drainage from a specific site as a proxy for possible osteomyelitis.
Discussion
As noted from other work, traumatic injuries account for a large propor-tion of the global burden of disease. [6] The proportion of global deaths from injuries was estimated at 9.6% in 2010 with a 46% rise in proportion of deaths due to road traffic injuries as well as to falls. [7] Secondary to the barriers to ac-cess to health care, 91% of global injury related deaths occur in Low- and Middle-Income Countries. [8] The SOSAS results from Sierra Leone and Rwanda high-light that injuries as well as non-injury related musculoskeletal conditions are significant burdens to the population. It is also likely that similar prevalence of orthopedic conditions exist in other Low- or Middle-Income Countries. Community-based surveys from Ghana on injuries had similar findings; it also stated that falls are associated with a high burden of disability. [9] Road traffic injuries have been further evaluated in Tanzania, with about 33 / 1000 person years, or 3.3% of the population in Dar es Salaam annually involved in a road traffic incident and in need of surgical (orthopedic) evaluation. [10]
Population data on specific orthopedic conditions in Low- and Middle-Income Countries is limited. Some hospital and surgical camp related data is available for osteomyelitis; for example from a random assessment of an orthopedic clinic in Uganda which found that 10% of their evaluations were related to osteomyelitis. [11] A hospital extrapolation of the incidence of clubfoot estimated clubfoot to be present in 1.2 per 1000 live births. [12] Knowing the prevalence of these specific conditions in a hospital assists the hospital manager in logistics and focus but might not give the correct reflection of what is happening in the population.
As shown in this article, community surveys can elicit information on surgi-cal and orthopedic need. However, these surveys are not perfect by any means. The SOSAS study, recently validated in Nepal [13], relies on self-reporting by re-spondents which is subjective to recall, interviewer’s bias and misinterpretation. Furthermore specific diagnoses are not collected which might frustrate the clinician who is ready for action with a scalpel during a short-term surgical camp. However, it does starts one to think about how to strengthen health systems in a sustainable way for injured and disabled patients. Resources must be provided for prevention, therapeutics and rehabilitation. Action is needed in traffic safety campaigns, pre-hospital management as well as capacity and know-how in the medical setting. Obvi-ously, this asks for commitment from governments and global health agencies, and for those organizations the uncov-ering of the burden for the population via epidemiological data might make a difference.
References
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