Summary Background Risk of mortality following surgery in patients across Africa is twice as high as the global average. Most of these deaths occur on hospital wards after the surgery itself. We aimed to assess whether enhanced postoperative surveillance of adult surgical patients at high risk of postoperative morbidity or mortality in Africa could reduce 30-day in-hospital mortality. Methods We did a two-arm, open-label, cluster-randomised trial of hospitals (clusters) across Africa. Hospitals were eligible if they provided surgery with an overnight postoperative admission. Hospitals were randomly assigned through minimisation in recruitment blocks (1:1) to provide patients with either a package of enhanced postoperative surveillance interventions (admitting the patient to higher care ward, increasing the frequency of postoperative nursing observations, assigning the patient to a bed in view of the nursing station, allowing family members to stay in the ward, and placing a postoperative surveillance guide at the bedside) for those at high risk (ie, with African Surgical Outcomes Study Surgical Risk Calculator scores ≥10) and usual care for those at low risk (intervention group), or for all patients to receive usual postoperative care (control group). Health-care providers and participants were not masked, but data assessors were. The primary outcome was 30-day in-hospital mortality of patients at low and high risk, measured at the participant level. All analyses were done as allocated (by cluster) in all patients with available data. This trial is registered with ClinicalTrials.gov , NCT03853824 . Findings Between May 3, 2019, and July 27, 2020, 594 eligible hospitals indicated a desire to participate across 33 African countries; 332 (56%) were able to recruit participants and were included in analyses. We allocated 160 hospitals (13 275 patients) to provide enhanced postoperative surveillance and 172 hospitals (15 617 patients) to provide standard care. The mean age of participants was 37·1 years (SD 15·5) and 20 039 (69·4%) of 28 892 patients were women. 30-day in-hospital mortality occurred in 169 (1·3%) of 12 970 patients with mortality data in the intervention group and in 193 (1·3%) of 15 242 patients with mortality data in the control group (relative risk 0·96, 95% CI 0·69–1·33; p=0·79). 45 (0·2%) of 22 031 patients at low risk and 309 (5·6%) of 5500 patients at high risk died. No harms associated with either intervention were reported. Interpretation This intervention package did not decrease 30-day in-hospital mortality among surgical patients in Africa at high risk of postoperative morbidity or mortality. Further research is needed to develop interventions that prevent death from surgical complications in resource-limited hospitals across Africa. Funding Bill & Melinda Gates Foundation and the World Federati...
Small bowel perforation following a capsule endoscopy (CE) is a rare but dreadful complication. We report a CE induced small bowel perforation in a patient with Crohn's disease where preoperative investigations failed to reveal any strictures. 2011; 93: e69-e70 Ann R Coll Surg Engl
Tendon ruptures associated with ankle fractures and dislocations or subtalar dislocations are very rare entities with only a few reports of these in the literature. We report a case of an open subtalar dislocation and associated isolated proximal rupture of the flexor digitorum longus tendon at the musculotendinous junction, following a relatively low energy trauma. The finding of the avulsed flexor digitorum longus tendon was intraoperative, and management involved thorough washout of the joint and a primary side-to-side tenodesis with the flexor hallucis longus tendon. The patient has made a good functional recovery from his injuries. This case is reported because of the rarity of this combination of injuries and the associated management dilemma with which it presented us. KEYWORDSFlexor digitorum longus rupture -Subtalar dislocation -Flexor digitorum longus repair -Foot and ankle trauma Subtalar dislocation is a fairly rare injury accounting for only 15% of all talar injuries and no more than 1% of traumatic dislocations.1 These usually result from high energy trauma such as falls from height, athletic injuries and motor vehicle accidents. Subtalar dislocations are classified into four types: medial (accounting for 80% of the total), lateral (17%) and two rarer types (anterior and posterior). Tendon ruptures around the distal tibia and ankle are very rare entities. 4 Injury to the tibialis posterior tendon associated with subtalar dislocations has been described previously. However, to our knowledge, no previous cases of isolated rupture of the flexor digitorum longus (FDL) associated with traumatic open subtalar dislocation have been described. Case HistoryA 24-year-old muscular patient was seen in the emergency department following a fall in his bathroom. He described slipping on the wet floor with plantar flexion and eversion of his right foot. There was no history of previous ankle sprains or ligament laxity. His foot was pink but a posterior tibial pulse was not palpable. He had no other distal neurovascular deficit of his right foot. There was a 4cm laceration beginning anteroinferiorly to the medial malleolus and extending posteriorly (Fig 1). An osteochondral defect was noted on the lateral aspect of the distal subtalar articular surface. Ankle radiography showed a lateral subtalar dislocation with no obvious fracture. The subtalar dislocation was reduced under sedation in the emergency department, and intravenous antibiotics and tetanus vaccination were administered promptly. The wound was dressed with saline soaked gauze and the patient's leg was placed in a below-knee plaster of Paris cast. Following reduction, computed tomography (CT) of the ankle showed congruent reduction, with some intraarticular debris but no overt fractures (Fig 2).The patient was admitted to theatre the next morning on a planned trauma list. The exploration of his ankle wound revealed communication with the ankle joint. The flexor retinaculum was ruptured, and there was complete rupture of the superficial and deep p...
The outcomes seen support the use of the Ligamentotaxor in the management of middle phalanx intra-articular fractures. It is simple to apply, potentially avoids the secondary complications of open reduction and gives reproducible results. However judicious patient selection is advised.
In order to synthesise the existing evidence of Traditional Bone Setters' (TBS) treatment and its associated complications in Low and Middle Income Countries (LMICs), we conducted a literature search following PRISMA guidelines. The keywords “traditional bone setter”, “traditional bone healer”, “traditional bone setting”, “fracture”, “complication”, “low income country”,” low to middle income country”, “poor outcome” and “death” were searched in PubMed. Articles included in the review demonstrated complications associated with treatment by TBS for Musculoskeletal injury in LMICs. Out of 878 papers screened, twelve studies were finally included for review. Seven were prospective, and five retrospective studies. All were observational studies with all but one hospital based, the remaining being community based, and investigated the outcomes of treatment of fractures by traditional bonesetters published between 1999 and 2020 in LMICs. In total, this review covers 833 participants with 691 complications of TBS treatment. We identify a significant number of limb and life-threatening complications including mortality associated with the treatment by TBS. However, recent studies have shown that TBS are willing and keen to engage with local orthodox services and training courses. As shown in many countries, this can lead to a reduction in complications including mortality and can form a favourable environment where TBS and orthodox services can work side by side.
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