Research & Publications

Abstract: Thumb hypoplasia is a congenital birth defect in which a child is born with an underdeveloped or missing thumb. It is a rare condition affecting approximately 1 in 100,000 live births and occurs equally in both males and females. Pollicization is a surgical procedure used to treat severe thumb hypoplasia by transferring another finger to the thumb position.

Twin girls aged two years and eight months, born to a 42-year-old para III mother, presented with bilateral thumb hypoplasia. There was no family history of similar complaints, and no consanguinity was identified between their parents. After excluding other associated anomalies, index finger pollicization was performed for all four hands of the children according to modified Buck-Gramcko techniques, with modifications from Ezaki et al.

Generally, index pollicization executed with careful preoperative, intraoperative, and postoperative planning will lead to aesthetically and functionally attractive thumbs for children with congenitally severe hypoplasia or absent thumbs.

Abstract: There is increasing interest in applying artificial intelligence chatbots like generative pretrained transformer 4 (GPT-4) in the medical field. This study aimed to explore the universality of GPT-4 responses to simulated clinical scenarios of developmental dysplasia of the hip (DDH) across diverse global settings.

Methods: Seventeen international experts with more than 15 years of experience in pediatric orthopaedics were selected for the evaluation panel. Eight simulated DDH clinical scenarios were created, covering 4 key areas: (1) initial evaluation and diagnosis, (2) initial examination and treatment, (3) nursing care and follow-up, and (4) prognosis and rehabilitation planning. Each scenario was completed independently in a new GPT-4 session. Interrater reliability was assessed using Fleiss kappa, and the quality, relevance, and applicability of GPT-4 responses were analyzed using median scores and interquartile ranges. Following scoring, experts met in ZOOM sessions to generate Regional Consensus Assessment Scores, which were intended to represent a consistent regional assessment of the use of the GPT-4 in pediatric orthopaedic care.

Results: GPT-4’s responses to the 8 clinical DDH scenarios received performance scores ranging from 44.3% to 98.9% of the 88-point maximum. The Fleiss kappa statistic of 0.113 (P = 0.001) indicated low agreement among experts in their ratings. When assessing the responses’ quality, relevance, and applicability, the median scores were 3, with interquartile ranges of 3 to 4, 3 to 4, and 2 to 3, respectively. Significant differences were noted in the prognosis and rehabilitation domain scores (P < 0.05 for all). Regional consensus scores were 75 for Africa, 74 for Asia, 73 for India, 80 for Europe, and 65 for North America, with the Kruskal-Wallis test highlighting significant disparities between these regions (P = 0.034).

Conclusions: This study demonstrates the promise of GPT-4 in pediatric orthopaedic care, particularly in supporting preliminary DDH assessments and guiding treatment strategies for specialist care. However, effective integration of GPT-4 into clinical practice will require adaptation to specific regional health care contexts, highlighting the importance of a nuanced approach to health technology adaptation.

Level of evidence: Level IV.

Abstract: Cleft lip and palate are among the most common congenital anomalies of the
head and neck region. Oral-facial clefts can be observed on the lips, jaw bones, and hard and
soft palates. This study aimed to assess the Pattern, clinical of children with cleft lip and/or palate who
visit CURE Children’s Hospital Ethiopia.

A retrospective chart review was conducted on patients who were operated from
January 1, 2016 to December 31, 2022, at the Cure Children’s Hospital in Ethiopia. The
Demographic and clinical data of cleft patients were collected using Smile Train Express (STX).
The collected data underwent analysis using descriptive statistics with SPSS version 26.

The study included 1379 surgeries done on patients with non-syndromic cleft palate or
lip. The average age at surgery was 21 months, with a male-to-female ratio of 1.78:1. The left
side was the most affected, and it was unilateral. The commonest surgery done was primary
unilateral lip-nose repair, with 694 (50.3%). The most common surgical technique used is Millard
rotation advancement 823 (59.7%). Regarding post-operative complications, palatal fistula
surgeries done for 73 (8.3%) patients and lip and nose revisions done for 38(2.75%).

The study reveals the common form of presentation was a left-sided, unilateral
cleft lip, which is treated with unilateral lip-nose repair. The high magnitude of the palatal fistula
is also reported, with the most common millard rotation advancement surgical treatment in the
study area. Therefore, policymakers and health planners should strengthen early treatment of
congenital anomalies in children and create awareness about the availability of treatment to
prevent long-term deformities related to cleft lip and palate.

Abstract: Treating clubfoot in walking-age children is debated, despite studies showing that using the Ponseti casting principles can correct the midfoot effectively. We aimed to explore techniques and approaches for the management of older children with clubfoot and identify consensus areas. A mixed-methods cross-sectional electronic survey on delayed-presenting clubfoot (DPC) was sent to 88 clubfoot practitioners (response rate 56.8%). We collected data on decision-making, casting, imaging, orthotics, surgery, recurrence, rehabilitation, multidisciplinary care, and contextual factors. The quantitative data were analysed using descriptive statistics. The qualitative data were analysed using conventional content analysis. Many respondents reported using the Pirani score and some used the PAVER score to aid deformity severity assessment and correctability. Respondents consistently applied the Ponseti casting principles with a stepwise approach. Respondents reported economic, social, and other contextual factors that influenced the timing of the treatment, the decision to treat a bilateral deformity simultaneously, and casting intervals. Differences were seen around orthotic usage and surgical approaches, such as the use of tibialis anterior tendon transfer following full correction. In summary, the survey identified consensus areas in the overall principles of management for older children with clubfoot and the implementation of the Ponseti principles. The results indicate these principles are well recognised as a multidisciplinary approach for older children with clubfoot and can be adapted well for different geographical and healthcare contexts.

Abstract: The development of a bone gap as a sequela of chronic osteomyelitis (COM) in childhood is uncommon. The factors that lead to such an occurrence are related to the type of infecting organism, toxins produced, and the stability of the segments. A critical factor for gap development in childhood is the type and extent of injury to the periosteum. The treatment of bone defects follows principles of enhancing the bone’s biological and mechanical environments whilst eliminating the infective process.

Many different techniques can be successfully employed to achieve the same primary goal of bony continuity, particularly in the management of smaller defects. Long-term outcome following restoration of bony continuity in chronic osteomyelitis bone gaps is mostly predicated on other factors of the disease process such as physeal and adjacent joint destruction.

Abstract: Superficial infections in the foot and ankle, such as those associated with ingrown toenails, are relatively common and easily diagnosed. A number of common and superficial foot infections do not require surgical intervention. However, deeper foot and ankle infections in children may present with non-specific symptoms, such as difficulty in weight-bearing, and little in the way of clinical signs. Foot infections should therefore always be considered in a limping child, especially when other causes are not found.

Calcaneal osteomyelitis is an uncommon cause for limp in childhood. The infection is different from other sites of osteomyelitis because of a paucity of systemic and local findings in the early stages combined with a high likelihood of normal parameters such as white blood cell count and C-reactive protein (CRP). The diagnosis is often delayed resulting in chronicity and sequelae. Imaging modalities may be needed to localise infection before commencing treatment. Broad spectrum and specific antibiotics, usually combined with trepanation, are the first line of treatment. Late cases may require drainage, debridement sequestrectomy and antibiotic-loaded beads. Calcanectomy and talectomy may be required for salvage.

Foot and ankle tuberculosis (TB) also usually presents with a limp and is rare. It forms a differential diagnosis in a child with subacute or chronic arthritis of the foot and ankle, a single or multiple radiological bony or joint lesions in the ankle and foot, associated with diffuse osteoporosis. A high index of suspicion should be entertained and confirmation obtained by biopsy and culture. Antituberculous drug therapy is the mainstay of treatment. Selective surgical intervention is indicated for neglected lesions, deformities, or joint and foot architecture collapse. The goal is disease control, and to achieve and maintain a stable painless foot.

Severe infections are not common in developed countries but in low- and middle-income countries, more advanced pathologies may be seen. This chapter will therefore aim to cover conditions from the mildest, including non-surgical conditions, through to more destructive pathologies, such as tuberculosis and Madura foot.

Abstract: The purpose of this study was to evaluate the effects of Velopharyngeal Insufficiency (VPI) on quality of life of adults with repaired cleft palate. Cleft palate is one of the most prevalent birth defects around the world. The study evaluated the effect of VPI on the quality of life among adults with repaired cleft palate in order to; to establish the effect of VPI on functional ability. The study targeted adults, both males and females with repaired cleft palate at Kenyatta Hospital, Nairobi City County. The study adopted a case study research design. 22 adults with repaired cleft palate, 2 maxillofacial surgeons and 1 speech and language therapist were purposively sampled for the study. The researcher used stratified random sampling to avoid gender bias.

The pilot study was carried out at Kijabe Hospital to ensure that different subjects are involved other than those in the actual study. The data was collected using questionnaires, and review of patients’ clinical notes in the maxillofacial clinic at Kenyatta National Hospital. The data was analyzed with the use of Statistical Package for Social Sciences version 21 for quantitative data. Categorical data was summarized using frequency tables and proportions. The findings showed that in assessing VPI severity and functional ability, there was a statistically significant association between VPI severity and air coming out of the nose when the respondents talk. There was also a significant association between VPI severity and perception of own speech being different from others, there was significant association between VPI severity and trouble to understand others when they cannot see their face.

The results show that most of the persons with VPI after cleft palate repair had challenges of air coming out of the nose and speech difficulties. The level of accessibility of speech therapists is still very low. The study recommends that improving personal belief and self-identify among persons with VPI after cleft palate repair would be essential in improving on how they perceive many things such as functional ability. Also, ensuring that speech therapy services are available for all patients is important in improving functional ability among persons with VPI after cleft palate repair.

Abstract: Lower limb deformities include conditions such as leg length discrepancy, lower limb deficiency and associated angular and rotational deformities of the hips, knees, ankles and feet. Children with lower limb deformities often have physical limitations due to gait irregularities and pain. The differences in the appearance and function of their lower limbs can discourage participation in social, recreational and leisure activities, which may result in behavioural, emotional, psychological and social adjustment problems. The health-related quality of life (HRQL) of these children is often impacted due to the factors discussed above, as well as by the complex surgical procedures. Surgical treatment options for limb deformities in children vary from limb lengthening and reconstruction to amputation. The lack of evidence demonstrating superiority of either treatment options and their effect on HRQL limits the ability of healthcare providers to counsel families on the best evidence-based treatment option for them.

Abstract: Cleft lip with or without cleft palate (CL/P)—a condition associated with speech, hearing, feeding, and dental problems, as well as anomalies of the bone and soft tissue around the mouth—is a common birth defect around the globe. The prevalence of this condition varies widely across different countries and regions, and is apparently highest among Asians and lowest among Africans.

A review of literature reveals that there exists a dearth of information on experiences of parents of children with CL/P and stigma communication, as well as cultural beliefs associated with CL/P in Africa. To fill this gap, we conducted a descriptive qualitative study examining the experiences of parents of children with CL/P, stigma communication, and cultural beliefs associated with CL/P in Kenya. Twenty four in-depth interviews were done involving purposefully sampled parents of children born with CL/P at AIC CURE International Hospital in Nairobi, Kenya.

Five overarching themes emerged under the lived experiences of parents of children with CL/P: Emotional experiences; relational experiences; burden of care and concerns; reaction by the public and friends; and source of social support. The stigma messages and beliefs associated with CL/P further exacerbated the stigma. The study revealed that stigma communication associated with CL/P remains a significant source of social and psychological anguish to parents and guardians of children with CL/P. These findings have critical implications for the management of stigma communication associated with CL/P. They point to the need for public awareness campaigns on CL/P to demystify the condition, its causes and treatment. The study shows that raising public awareness of CL/P would go a long way towards addressing the stigma associated with the condition. It underscores the need for open communication and engagement with all stakeholders to manage stigma communication associated with CL/P through culturally appropriate anti-stigma campaigns.

Abstract: To describe the clinical presentation, surgical management and outcome of labio-palatal clefts (LBF) in Niger.

This was a cross-sectional descriptive retrospective study that was carried out from January 1, 2011, to January 31, 2013. Patients were recruited in the odonto-stomatology department of the Niamey National Hospital and in the pediatric ward of the Niamey Children’s Cure Hospital. Our study parameters were as follows: gender, age, clinical features, management and outcome.

Out of 2333 patients who consulted during the study period, 285 (0.12%) with cleft lip and palate were recruited. There were 160 male (56.10%) and 125 female (43.85%). Their mean age was 8.13 years (range: 6 – 47 years). The age group of 6 to 10 years was the most represented with 136 patients (47.70%). There were complete forms 166 patients (58.24%). Sucking and phonation disorders were the main complaints associated with the malformation. Surgery was the sole treatment option, using cheiloplasty and palatoplasty. For 112 patients (41.20%), we used the surgical technique of Millard. The immediate and late aftermath of surgery was simple.

Labio-palatal clefts are more common in boys than in girls. The mean age at consultation is 8 years. Sucking and phonation disorders are the main complaints associated with the malformation. Despite the late definitive management, the aftermath of surgery is simple and the overall prognosis is good.

Abstract:

Background: Neglected traumatic hip dislocation in children is uncommon and there is no consensus on appropriate management. Previous studies report varied operative management with high rates of avascular necrosis and postoperative subluxation/dislocation. We report a series of 7 consecutive cases who underwent operative reduction after neglected hip dislocation and describe our technique for treatment.

Methods: All 7 children sustained posterior dislocations and had no treatment before presentation at our institution. An associated marginal acetabular fracture was present in 2 cases. One additional patient was excluded from the study due to complete loss of articular cartilage that precluded open reduction. The mean time before surgical intervention was 13.1 months (4 to 36 mo) with a mean age of 7 years (5.3 to 10.8 y). All children underwent preoperative skeletal traction for 10 to 14 days. A postero-lateral approach was used in all cases. The acetabulum was cleared of scar tissue and a femoral shortening performed as required (5 cases). Minor erosion of the articular cartilage of the posterior aspect of the femoral head was noted in 3/6 cases. After reduction, a posterior capsulorrhaphy was performed and the patient immobilized in a hip spica for 6 to 12 weeks.

Results: The mean follow-up was 44 months (33 to 56 mo). The majority of children (86%) could walk and run without a limp, could squat, and had no pain. One child had mild pain and a limp. Mean Harris Hip Score was 98.9. No hip subluxed or dislocated postoperatively. The radiographs at latest follow-up showed no evidence of growth disturbance in 29% of cases, coxa magna in 57%, and partial femoral head collapse in 1 case (14%). Of note, those patients managed within 8 months of injury had none or minimal evidence of growth disturbance.

Conclusions: At medium-term follow-up, open reduction with a postero-lateral approach, posterior capsulorrhaphy, and femoral shortening (as required) produces a satisfactory outcome with a stable, congruent reduction. Good clinical function can be expected with a low incidence of avascular necrosis.

Abstract

Background: WHO estimates that more than a billion people live with some form of disability and most of them live in the developing countries. The American Community Survey states that 5.6% of children between the ages of 5-17 live with disability. The situation in Ethiopia is not studied and most of the data on disability comes from the population census conducted every ten years. In this study we report on the impact of musculoskeletal (MSI) on the lives of school age children in Ethiopia.

Methods: This was a prospective mixed qualitative and quantitative research. The study was conducted at CURE Ethiopia Children’s hospital which is a specialized pediatric orthopedic hospital that provides free orthopedic care for children. The research was approved by the CURE IRB and a written consent was obtained from the participants. Children between 5 and 14 with acquired or congenital musculoskeletal impairment were interviewed using pretested questionnaires. We also conducted two focus group discussions conducted at a rural as well as an urban setting which were all recorded and translated to English.

Results: A total of 55 children with MSI were interviewed and 37 parents, 3 teachers and a physiotherapist were involved in the focus group discussions. These families spend a significant amount of their income for transport to the hospital and 68.3% reported getting that money was difficult. A third of these children do not go to school or have dropped out but the number goes to 69.2% when it comes to children with mobility problems. Over 80% of these children also reported abuse from peers. The three most important challenges that stood out during the focus group discussion were indignity and exclusion, financial struggles, and challenges in schools.

Conclusions: This study highlights the most important challenges of children with musculoskeletal impairments are indignity and exclusion, financial struggles at home and challenges in school. Ethiopia is one of the countries that have legally committed themselves to delivering comprehensive rehabilitation services for people living with disabilities. The issues identified in our study can be considered as part of the comprehensive rehabilitation services and they need to be addressed properly with the concerned parties in order to improve the life and future of children with musculoskeletal impairments and their families.

Abstract: Low- and middle-income countries (LMICs) have continued to lag behind high-income countries in all measurable outcomes of health care. As concluded by the World Health Organization during the 2013 Global Forum on Human Resources for Health, an adequate healthcare workforce is mandatory to provide universal health coverage. Despite efforts to increase the numbers of healthcare workers, an extreme deficit in highly trained surgeons remains.

Several options exist to provide training for surgeons in LMICs, including local training by local surgeons, sending local surgeons abroad for training, or local training by short-term or long-term visiting surgeons from high-income countries. This article further discusses the benefits and challenges of each option and reviews the 10-year outcomes of the Orthopaedic Surgery Residency Program at the CURE Kenya Hospital in Kijabe, Kenya. The program has graduated nine orthopaedic surgeons who are all practicing in Africa, five of which are full-time attending consultants in residency training programs. An additional eight residents are currently in the program. Sustainable orthopaedic training can be accomplished in LMICs as demonstrated by the ongoing success of the CURE Kenya Orthopaedic Surgery Residency Program. Additional efforts to expand and replicate this model may assist in providing improved access to high-quality universal healthcare in LMICs.

Abstract:

Background: There are currently no published data directly comparing postoperative seizure incidence following endoscopic third ventriculostomy (ETV),with/without choroid plexus cauterization (CPC), to that for ventriculoperitoneal shunt (VPS) placement. OBJECTIVE: To compare postoperative epilepsy incidence for ETV/CPC and VPS in Ugandan infants treated for postinfectious hydrocephalus (PIH).

Methods: We performed an exploratory post hoc analysis of a randomized trial comparing VPS and ETV/CPC in 100 infants (<6 mo old) presenting with PIH. Minimum follow-up was 2 yr. Variables associated with and the incidence of postoperative epilepsy were compared (intention-to-treat) using a bivariate analysis. Time to first seizure was compared using the Kaplan–Meier method, and the relative risk for the 2 treatments was determined using Mantel-Haenszel hazard ratios.

Results: Seizure incidence was not related to age (P = .075), weight (P = .768), sex (P=.151), head circumference(P=.281),time from illness to hydrocephalus onset (P=.973), or hydrocephalus onset to treatment (P = .074). Irritability (P = .027) and vision deficit (P = .04) were preoperative symptoms associated with postoperative seizures. Ten (10%) patients died, and 20 (20%) developed seizures over the follow-up period. Overall seizure incidence was 9.4 per 100 person-years (9.4 and 9.5 for ETV/CPC and VPS, respectively; P =.483), with no significant difference in seizure risk between groups (hazard ratio, 1.02; 95%CI:0.42,2.45; P=.966).Meantimetoseizureonsetwas8.5moforETV/CPCand11.2mo for VPS (P=.464).As-treated, per-protocol, and attributable-intervention analyses yielded similar results.

Conclusion: Postoperative seizure incidence following treatment of PIH was 20% within 2 yr, regardless of treatment modality.

Abstract: Hydrocephalus in children has been inadequately recognized as an important cause of death and disability in developing countries. In addition to the expected congenital causes, for which high birth rates increase prevalence, neonatal infection and neural tube defects are especially important, and potentially preventable, causes. Research and public health policy have the potential to diminish the burden for both of these etiologies through prevention. The inadequate number of centers trained and equipped to treat hydrocephalus is a ubiquitous barrier to care for these children throughout the developing world. Relative to the treatment of other conditions, hydrocephalus treatment is very cost-effective; yet, poverty and insufficient health system support remain as significant obstacles to treatment. The lack of access to emergency neurosurgical care also renders shunt dependence more dangerous in these contexts. This provides a compelling argument for promoting primary endoscopic treatment whenever possible. In some regions, infants with hydrocephalus are not recognized as having a treatable medical condition, which can delay or prevent referral for neurosurgical treatment. A number of organized efforts in recent decades have made progress by providing treatment, training, research, and public education. But there is far more to be done.

Abstract:

Background: Congenital pseudarthrosis of the tibia (CPT) is a rare condition. The natural history of CPT includes persistent instability and progressive deformity. Several CPT treatment methods have been practiced, however, in Africa where there is scarce information on the modalities of treatment available and their outcomes.

Methods: A retrospective cross-sectional study which was conducted among patients with CPT at Beit Cure International Hospital (BCIH), Malawi. Forty-four patients were recruited in this study and their treatment modalities and outcomes were analyzed.

Results: Out of 44 patients recruited in this study, majority (63.6%) were male. The majority of cases were stage 4 congenital tibia pseudarthrosis by Crawford classification. Most patients were treated by more than one surgical modality; however, surgical excision and intramedullary rodding was commonly used (54.7%). The outcomes of treatment were good in 5%, fair in 30%, with amputation in 45% and poor outcomes in 20% of the patients. Complications developed in 60% of patients, predominated by limb length discrepancy. The foot and ankle status were rated by Oxford Foot and Ankle scoring system (OxFAQ).

Conclusions: Congenital pseudarthrosis of the tibia is a complex congenital disorder with multiple modalities of treatment. Majority of the patients were treated by more than one operation. Some patients ended up with amputation or poor outcome. Limb length discrepancy, deep infection and pin tract infection are among the common complications.

Abstract: The aim of the study was to develop a simple and reliable clinical scoring system for delayed presenting clubfeet and assess how this score predicts the response to Ponseti casting. We measured all elements of the Diméglio and the Pirani scoring systems. To determine which aspects were useful in assessing children with delayed presenting clubfeet, 4 assessors examined 42 feet (28 patients) between the ages of 2-10 years. Selected variables demonstrating good agreement were combined to make a novel score and were assessed prospectively on a separate consecutive cohort of children with clubfeet aged 2-10, comprising 100 clubfeet (64 patients).

Inter-observer and intra-observer agreement was found to be greatest using the following clinically measured angles of the deformities. These were plantaris, adductus, varus, equinus of the ankle and rotation around the talar head in the frontal plane (PAVER). Measured angles of 1-20, 21-45 and > 45 degrees scored 1, 2 and 3 points, respectively. The PAVER score was derived from both the sum of points derived from measured angles and a multiplier according to age. The sum of the points was multiplied with 1, 1.5 or 2 for ages 2-4, 5-7 and 8-10, respectively. This demonstrated a good association with the total number of casts to achieve a full correction (tau = 0.71). A score greater than 18 out of 30 indicated a cast-resistant clubfoot. The score could be used clinically for prognosis and treatment, and for research purposes to compare the severity of clubfoot deformities.

Abstract: There is inadequate pediatric neurosurgical training to meet the growing burden of disease in low- and middle-income countries (LMIC). Subspecialty expertise in the management of hydrocephalus and spina bifida—two of the most common pediatric neurosurgical conditions—offers a high-yield opportunity to mitigate morbidity and avoid unnecessary death. The CURE Hydrocephalus and Spina Bifida (CHSB) fellowship offers an intensive subspecialty training program designed to equip surgeons from LMIC with the state-of-the-art surgical skills and equipment to most effectively manage common neurosurgical conditions of childhood.

Prospective fellows and their home institution undergo a comprehensive evaluation before being accepted for the 8-week training period held at CURE Children’s Hospital of Uganda (CCHU) in Mbale, Uganda. The fellowship combines anatomy review, treatment paradigms, a flexible endoscopic simulation lab, daily ward and ICU rounds, radiology rounds, and clinic exposure. The cornerstone of the fellowship is the unique operative experience that includes a high volume of endoscopic third ventriculostomy with choroid plexus cauterization, myelomeningocele closure, and ventriculoperitoneal shunting, among many other procedures performed at CCHU. Upon completion, fellows return to their home institution to establish or rejuvenate a robust pediatric practice as part of a worldwide network of CHSB trainees committed to the care of underserved children. To date, the fellowship has graduated 33 surgeons from 20 different LMIC who are independently performing thousands of hydrocephalus and spina bifida operations each year.

Abstract:

Background: To describe the extent of renal disease in Ugandan children surviving at least ten years after spina bifida repair and to investigate risk factors for renal deterioration in this cohort.

Patients and Method: Children who had undergone spina bifida repair at CURE Children’s Hospital of Uganda between 2000 and 2004 were invited to attend interview, physical examination, renal tract ultrasound, and a blood test (creatinine). Medical records were retrospectively reviewed. The following were considered evidence of renal damage: elevated creatinine, hypertension, and ultrasound findings of hydronephrosis, scarring, and discrepancy in renal size >1cm. Female sex, previous UTI, neurological level, mobility, detrusor leak point pressure, and adherence with clean intermittent catheterisation (CIC) were investigated for association with evidence of renal damage.

Results: 65 of 68 children aged 10–14 completed the assessment. The majority (83%) reported incontinence. 17 children (26%) were performing CIC. One child had elevated creatinine. 25 children (38%) were hypertensive. There was a high prevalence of ultrasound abnormalities: hydronephrosis in 10 children (15%), scarring in 42 (64%), and >1cm size discrepancy in 28 (43%). No children with lesions at S1 or below had hydronephrosis (p = 0.025), but this group had comparable prevalence of renal size discrepancy, scarring, and hypertension to those children with higher lesions.

Conclusions: Incontinence, ultrasound abnormalities, and hypertension are highly prevalent in a cohort of Ugandan children with spina bifida, including those with low neurological lesions. These findings support the early and universal initiation of CIC with anticholinergic therapy in a low-income setting.

Abstract:

Objective: Hydrocephalus is a medical condition in which there is an abnormal accumulation of cerebrospinal fluid (CSF) in the brain. Segmentation of brain imagery into brain tissue and CSF [before and after surgery, i.e., preoperative (pre-op) versus postoperative (post-op)] plays a crucial role in evaluating surgical treatment. Segmentation of pre-op images is often a relatively straightforward problem and has been well researched. However, segmenting post-op computational tomographic (CT) scans becomes more challenging due to distorted anatomy and subdural hematoma collections pressing on the brain. Most intensity- and feature-based segmentation methods fail to separate subdurals from brain and CSF as subdural geometry varies greatly across different patients and their intensity varies with time. We combat this problem by a learning approach that treats segmentation as supervised classification at the pixel level, i.e., a training set of CT scans with labeled pixel identities is employed.

Methods: Our contributions include: 1) a dictionary learning framework that learns class (segment) specific dictionaries that can efficiently represent test samples from the same class while poorly represent corresponding samples from other classes; 2) quantification of associated computation and memory footprint; and 3) a customized training and test procedure for segmenting post-op hydrocephalic CT images.

Results: Experiments performed on infant CT brain images acquired from the CURE Children’s Hospital of Uganda reveal the success of our method against the state-of-the-art alternatives. We also demonstrate that the proposed algorithm is computationally less burdensome and exhibits a graceful degradation against a number of training samples, enhancing its deployment potential.

Abstract: In the last 10 years, considerable work has been done to promote and improve neurosurgical care in East Africa with the development of national training programs, expansion of hospitals and creation of new institutions, and the foundation of epidemiologic and cost-effectiveness research. Many of the results have been accomplished through collaboration with partners from abroad. This article is the third in a series of articles that seek to provide readers with an understanding of the development of neurosurgery in East Africa (Foundations), the challenges that arise in providing neurosurgical care in developing countries (Challenges), and an overview of traditional and novel approaches to overcoming these challenges to improve healthcare in the region (Innovations). In this article, we describe the ongoing programs active in East Africa and their current priorities, and we outline lessons learned and what is required to create self-sustained neurosurgical service.

Abstract:

Background: Total hip replacement (THR) surgery has evolved over years to the point that it has been considered as “the operation of the century”. For developed countries, arthroplasty is well established for the management of various joint disorders and has completely revolutionised the treatment of the arthritic hip. The story is different in developing nations. Expensive implant costs and lack of trained orthopaedic surgeons are the main constraints; poverty has caused African countries to remain behind from enjoying the benefits of this medical breakthrough. In this study, we report our first and largest series of 50 such surgeries performed at the CURE Hospital in Addis Ababa. We believe that this is the first consecutive case series from Ethiopia and wanted to share our experience.

Methods: Prospectively, all consecutive patients that underwent THR at CURE Hospital from October 2009 to October 2013 were followed for over 3 years using clinical assessments and hip scores. The hip implant used was a Stryker Omnifit Uncemented HA-coated prosthesis. The Visual Analog Scale (VAS) for pain and the Modified Oxford Hip Score were used to assess outcomes. Variables recorded for each patient included sociodemographic information, diagnosis, comorbidity, surgical approach, duration of surgery, estimated blood loss, implant sizes for Ethiopian hips, complications, sequelae, hip scores, and final patient satisfaction. These were analysed using SPSS version 16. Patterns and learning points were observed.

Results: Of the 50 consecutive THR patients, 26 were male. Mean age was 48 years (range 14-85). In 30 hips, the right side was operated on, and 2 were bilaterally treated. Primary osteoarthritis (OA) and avascular necrosis (AVN) were the leading diagnoses requiring THR. Previous partial hip replacement (PHR, hemiarthroplasty) was converted to THR in 6 patients. The commonest comorbidities were diabetes mellitus and hypertension. There were 4 hips that dislocated after THR and 1 needed revision surgery. There was 1 persistent infection, 1 case of deep vein thrombosis (DVT), and 1 death. Mean EBL was approximately 1 L and only 5 patients needed transfusion. The most common sizes for Ethiopian hips were a 28 mm+0 head, 52 mm acetabular shell, and 140 mm #8 stem. The VAS and Modified Oxford Hip scores both improved significantly, and the results were comparable with international standards.

Conclusions: THR is a viable, safe, and effective option in Ethiopia. Appropriate staff training, careful patient selection, continuous supply chain of implants, and establishing a dedicated joint replacement centre will reliably sustain THR surgery.

Abstract:

Abstract:

Background: Postinfectious hydrocephalus in infants is a major health problem in sub-Saharan Africa. The conventional treatment is ventriculoperitoneal shunting, but surgeons are usually not immediately available to revise shunts when they fail. Endoscopic third ventriculostomy with choroid plexus cauterization (ETV–CPC) is an alternative treatment that is less subject to late failure but is also less likely than shunting to result in a reduction in ventricular size that might facilitate better brain growth and cognitive outcomes.

Methods: We conducted a randomized trial to evaluate cognitive outcomes after ETV–CPC versus ventriculoperitoneal shunting in Ugandan infants with postinfectious hydrocephalus. The primary outcome was the Bayley Scales of Infant Development, Third Edition (BSID-3), cognitive scaled score 12 months after surgery (scores range from 1 to 19, with higher scores indicating better performance). The secondary outcomes were BSID-3 motor and language scores, treatment failure (defined as treatment-related death or the need for repeat surgery), and brain volume measured on computed tomography.

Results: A total of 100 infants were enrolled; 51 were randomly assigned to undergo ETV–CPC, and 49 were assigned to undergo ventriculoperitoneal shunting. The median BSID-3 cognitive scores at 12 months did not differ significantly between the treatment groups (a score of 4 for ETV–CPC and 2 for ventriculoperitoneal shunting; Hodges–Lehmann estimated difference, 0; 95% confidence interval [CI], −2 to 0; P=0.35). There was no significant difference between the ETV–CPC group and the ventriculoperitoneal-shunt group in BSID-3 motor or language scores, rates of treatment failure (35% and 24%, respectively; hazard ratio, 0.7; 95% CI, 0.3 to 1.5; P=0.24), or brain volume (z score, −2.4 and −2.1, respectively; estimated difference, 0.3; 95% CI, −0.3 to 1.0; P=0.12).

Conclusions: This single-center study involving Ugandan infants with postinfectious hydrocephalus showed no significant difference between endoscopic ETV–CPC and ventriculoperitoneal shunting with regard to cognitive outcomes at 12 months.

Abstract:

Background: The EQ-5D is a standardised instrument that measures health-related quality-of-life and explores cost-effectiveness of treatments. Malawi is a low-resource country that would benefit from assessment of quality-of-life among individuals living with chronic conditions. Chichewa is the official native language of Malawi. The Chichewa version of the EQ-5D-3L developed by EuroQoL group has not been validated with Chichewa speakers. The purpose of this study was to evaluate the clinimetric properties of the Chichewa EQ-5D-3L.

Methods: Patients with orthopaedic conditions were recruited in the outpatient orthopaedic clinics and wards at Queen Elizabeth Central Hospital, Blantyre, Malawi. Fifty-three patients with various musculoskeletal problems were administered the Chichewa EQ-5D-3L and World Health Organization quality of life (WHO-QOL) questionnaires. To assess repeatability, a separate test–retest population of 20 patients were also selected from orthopaedic clinics and wards to fill out the questionnaire twice.

Results: Convergence validity was determined, with each of the WHO-QOL domains and the EQ-5D descriptive index and visual analogue scale (VAS) having good to moderate correlation (r = 0.3–0.7). Internal consistency was measured for the descriptive index, and the Cronbach’s alpha was 0.7. The ceiling effect for the descriptive index and the VAS were 9.4% and 0%, respectively. No respondents reached floor effect for the descriptive index or the VAS. The test retest intraclass correlation coefficient reliability at 14 days was 0.984 for the VAS and 1 for the descriptive index, with all 20 respondents providing the same responses.

Conclusions: The EuroQoL translated version of the Chichewa EQ-5D-3L was found to demonstrate adequate validity, internal consistency, floor/ ceiling effects, and reliability.

Abstract: Injuries are a global public health concern because most are preventable yet they continue to be a major cause of death and disability, especially among children, adolescents, and young adults. This enormous loss of human potential has numerous negative social and economic consequences. Malawi has no formal system of prehospital trauma care, and there is limited access to hospital-based trauma care, orthopaedic surgery, and rehabilitation. While some hospitals and research teams have established local trauma registries and quantified the burden of injuries in parts of Malawi, there is no national injury surveillance database compiling the data needed in order to develop and implement evidence-based prevention initiatives and guidelines to improve the quality of clinical care. Studies in other low- and middle-income countries (LMICs) have demonstrated cost-effective methods for enhancing prehospital, in-hospital, and postdischarge care of trauma patients. We encourage health sectors leaders from across Malawi to take action to improve trauma care and reduce the burden from injury in this country.

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Abstract: Neurosurgery in Uganda was virtually non-existent up until late 1960s. This changed when Dr. Jovan Kiryabwire spearheaded development of a neurosurgical unit at Mulago Hospital in Kampala. His work ethic and vision set the stage for rapid expansion of neurosurgical care in Uganda.

Abstract: Trauma disproportionately affects low- and middle-income countries, many of which do not have the surveillance systems required to design effective prevention and treatment strategies. This study aimed to establish such a system at a district hospital in Malawi in order to decrease the number of preventable injuries in the country. The most common cause was falls (53.2%), and 94.8% of patients were treated and sent home. Study recommends for preventative interventions specifically targeting this group of the population

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Background: Chronic Suppurative Otitis Media (CSOM) is a common cause of hearing loss and many complications such as meningitis. Many approaches to treatment of CSOM have been unsatisfactory because CSOM microbiological isolates as well as their sensitivity patterns vary from place to place.

Objectives: To determine the pattern of microbiological isolates of CSOM and the demographic characteristics of patients with CSOM at the University Teaching Hospital, (UTH) and Beit Cure Hospital (BCH) in Lusaka, Zambia.

Study design: The study was a hospital-based Cross sectional descriptive study.

Study Setting: The study was conducted at the ENT outpatient clinics of UTH and BCH in Lusaka, Zambia.

Methodology: 100 CSOM patients were included in the study. Quantitative data on the participants’ demographic details and clinical features were obtained using structured questionnaires. The middle ear discharge was aseptically collected using a sterile cotton swab. In the laboratory, samples were inoculated on agar media to isolate microorganisms and antibiotic susceptibility testing was done using Kirby Bauer method as per CLSI guidelines.

Results: Out of the 100 CSOM patients studied, 33(33%) were children below 18yrs and 67(67%) were adults. 59(59%) of the patients had unilateral CSOM while 41 had bilateral CSOM which gave a total of 141 ears that were analyzed. 119(84.4%) had pure cultures, 20(14.2%) had mixed cultures and 2(1.4%) had no growth. Of the 169 microbiological isolates, the most frequent isolates were Proteus mirabilis 49(29.0%), Pseudomonas aeruginosa, 32(18.9%), coagulase negative Staphylococcus 18(10.7%) and klebsiella pneumonie 17(10.1%). High sensitivity rates were revealed to Gentamycin (64-100%), meropenem (68-100%), ceftazidime (85-100%), ceftriaxone (64-80%), and ciprofloxacin (66- 88%). High resistance rates were recorded to Amoxicillin-clavulanate (as high as 100%), ampicillin (as high as 100%), tetracycline (as high as 91.2%) and cotrimoxazole (as high as 100%) and penicillin (as high as 100%).

Conclusion: Proteus mirabilis was the most dominant microbiological isolate followed by Pseudomonas aureginosa. The isolated microorganisms had high susceptibility rates to gentamycin, meropenem, ceftazidime, ceftriaxone and ciprofloxacin. There were high resistance rates to amoxicillin-clavulanate, ampicillin, tetracycline, cotrimoxazole and penicillin.

Abstract:

Objective: The study was carried out to determine the tribal and geographical distribution of patients with osteogenesis imperfecta in Kenya.

Design: This was a 14 year retrospective review study.

Setting: Cure Hospital, Kenya.

Materials and Methods: The medical charts of all patients admitted with  Osteogenesis Imperfecta (OI) over a period of 14 years [2000 to 2014] were reviewed.

Results: A total of 80 patients with osteogenesis imperfecta were seen. Fifty seven point five percent of the patients with OI were males and 42.5% were females. Thirty seven point five percent were of Kamba origin while 28.8% were from the Kikuyu tribe. Majority of these patients came from Eastern region of Kenya with 26.25% coming from Machakos and 30 out of the total of 80 patients were from Kamba tribe.

Conclusions: Most of these patients come from Eastern region of Kenya. Majority of patients with OI were of Kamba origin followed by the Kikuyu tribe. A larger epidemiological study needs to be carried out to more conclusively determine the relative prevalence and genetic patterns of osteogenesis imperfecta in Kenya.

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Abstract: The incidence of spina bifida (SB) is known to differ among regions. Very little has been reported about the relationship between the incidence of SB and ethnic patterns of origin in Zambia except for the general impression that it is prevalent. The aim of the study was to establish the ethnic pattern of origin of children with SB in Zambia. It was a retrospective cross sectional study. Using a checklist, data was collected from clinical files of children with SB from the University Teaching Hospital (UTH) and Beit Cure Hospital (BCH) from 2001-2010. Descriptive statistical analysis was done in SPSS version 17. A total of 253 children with SB were identified of whom 88 (35%) of them originally came from the Southern Province of the country while the lowest province was the North-Western Province with 7 (3%). Further, a total of 77 (30%) children were referred from the Southern Province of the country and the lowest province that was represented was the North-Western Province with 5 (2%). Observed is the evidence that SB is very prevalent in the Southern Province of the country. With the presence of Uranium in the Southern Province of Zambia, a serious study ought to be done to investigate the possible link of the pollutant with the prevalence of SB in the region. It is essential that the government looks seriously at Uranium Mines being operated in the Province.

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Abstract: Billions of people worldwide do not have access to even the simplest surgical procedures. But a new global initiative has launched that hopes to change the situation. Bridget Huber reports. Joshua Bukenya was barely a week old when he started having convulsions in March, 2014. His worried parents took him to be prayed over at a church near their home in eastern Uganda’s Buyende district. At first, it seemed to work, said his mother, Mera. But, with time, it became clear that the child’s head was growing abnormally large. In November, his mother brought him to the CURE Children’s Hospital in the city of Mbale for treatment. There, doctors explained that he had infant hydrocephalus, a life-threatening accumulation of fluid in the brain, in his case likely caused by the infection that was also responsible for his seizures.

Joshua was luckier than most African children with hydrocephalus. His family lives close enough to a charity hospital that has pioneered a new treatment for the condition and provides the neurosurgery regardless of a family’s ability to pay. But in sub-Saharan Africa, most children in need of such surgery for hydrocephalus-an estimated 250 000 each year—don’t get it, and their prospects are dim. About half will die, in pain, by 2 years of age and most of those who survive will be severely disabled.

Even people who need a simple operation often go without; globally, about 5 billion people have no access to surgical care, according to the Commission on Global Surgery published on April 27. That means conditions that could be treated surgically, like obstructed labour or appendicitis, can become a death sentence. And something as simple as a broken bone can disable a person for life. Scaling up basic surgical services in low-income and middle-income countries could save an estimated 1·5 million lives per year in these countries, according to the most recent edition of Disease Control Priorities.

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Background: This study was conducted to assess analgesia and side effects of neostgmine administered with
caudal bupivacaine for pediatric lower extremity orthopedic surgeries in routine clinical practice.

Methods: In this blinded effectiveness trial, we studied 86 children aged 1-12 years undergoing lower extremity orthopedic surgeries. After induction of general anesthesia, 43 children in Group-B received 1 ml/kg of 0.25% bupivacaine and the other 43 in Group-BN received 1 ml/kg of 0.25% bupivacaine with 2.5 mic/kg neostgmine caudally. Demographic data, hemodynamic data before and after caudal, ASA status, duration of general anesthesia, duration of surgery, episode of post-operative nausea and vomiting (PONV), frequency of rescue analgesics per 24 hour, pain score and sedation score were recorded. Analgesic duration was defined as time from caudal injection to first rescue analgesic administration. Mann-Whitney test to compare median values and chi-square test for nominal data were used. A value “P<0.05” was considered as statistically significant.

Result: The median analgesic duration in Group-B was 5.8 ± 2.3 hr and 8.7 ± 5.3 hrs in Group-BN (p=0.003). Number of patients who required rescue analgesic drug doses within 24 hr twice, four times and more than four times were significantly different among the groups (p<0.05). There was no difference among the groups regarding pain and sedation scores. The PONV incidence was observed in Group-B (4.6%) and Group-BN (13.9%) which is not statistically significant (p>0.05) across the groups.

Conclusion: In routine clinical practice, addition of neostgmine to caudally administered bupivacaine prolongs analgesic duration without significant difference in PONV. It also decreases rescue analgesic consumption within 24 hours.

Abstract: Clubfoot is one of the most common congenital deformities, with an incidence of one in 1000 live births worldwide. In Kenya, approximately 1200 infants are born with clubfoot every year. Left untreated, clubfoot leads to painful, disabling deformity and social stigmatization. Bracing is an integral part of the internationally accepted standard of care, and the Ponseti method of clubfoot management with compliance with bracing is considered to be the key to a successful outcome (1). This has brought the type of brace under scrutiny, with newer ‘child-friendly’ braces recommended over the traditional Dennis Brown brace (Figure 1), which has been associated with high rates of noncompliance. However, these child-friendly braces are expensive (USD$300) and out of reach for most families of affected children in Kenya and other developing countries. The Steenbeek foot abduction brace (SFAB) is made locally in Kenya at a cost of <USD$10 (Figure 2). The SFAB has been in use since the inception of the Clubfoot Care for Kenya (CCK) program in 2005. Therefore, we performed a study investigating SFAB acceptance, tolerability, compliance, complications and outcomes in the CCK program.

Abstract: The dancing procession in Echternach, a small town in Luxembourg, is a centuries-old religious procession to the shrine of St. Willibrord that has taken various forms over time. At one point in history, the celebrants took three steps forward and two steps backward, thus taking five steps to make one step of progress. This , I think, provides a good analogy for the last 100 years of progress in our understanding and treatment of hydrocephalus.

I joined this procession when my family and I moved to Uganda in 2000 to work with CURE International, a non-profit Christian organization, in founding a pediatric neurosurgery hospital for the region. When the hospital was opened, it quickly became apparent that infant hydrocephalus was the most overwhelming problem, and we subsequently found that the majority (60%) of these cases were secondary to neonatal ventriculitis. We has subsequently reported the enormous burden of infant hydrocephalus in sub-Saharan Africa and the long-term outcome for these postinfectious hydrocephalus cases. We were soon treating >500 new infants for hydrocephalus at the CURE Children’s Hospital of Uganda each year.

Creating shunt dependence was more problematic in sub-Saharan Africa than in developed countries and begged the question as to what the best treatment for hydrocephalus would be in that particular context. However, I suggest that we do not yet know the correct answer to that question for this or any other context because we have an incomplete understanding of both cerebrospinal fluid (CSF), physiology, and hydrocephalus. The problem is compounded by often not recognizing our unfounded assumptions.

Abstract: We report the short-term follow-up, functional outcome and incidence of early and late infection after total hip replacement (THR) in a group of HIV-positive patients who do not suffer from haemophilia or have a history of intravenous drug use. A total of 29 patients underwent 43 THRs, with a mean follow-up of three years and six months (five months to eight years and two months). There were ten women and 19 men, with a mean age of 47 years and seven months (21 years to 59 years and five months). No early (< 6 weeks) or late (> 6 weeks) complications occurred following their THR. The mean pre-operative Harris hip score (HHS) was 27 (6 to 56) and the mean post-operative HHS was 86 (73 to 91), giving a mean improvement of 59 points (p = < 0.05, Student’s t-test). No revision procedures had been undertaken in any of the patients, and none had any symptoms consistent with aseptic loosening. This study demonstrates that it is safe to perform THR in HIV-positive patients, with good short-term functional outcomes and no apparent increase in the risk of early infection.

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Object: Antibiotic-impregnated shunts have yet to find widespread use in the developing world, largely due to cost. Given potential differences in the microbial spectrum, their effectiveness in preventing shunt infection for populations in low-income countries may differ and has not been demonstrated. This study is the first to compare the efficacy of a Bactiseal shunt system with a non–antibiotic-impregnated system in a developing country.

Abstract:

Objective: The study was done to determine outcome of treatment of chronic musculoskeletal infections involving bone after use of local antibiotic impregnated cement and report the microbiological patterns of these infections in our hospital.

Setting: A.I.C. Kijabe Hospital, Kenya.

Patients and Methods: The medical charts of all patients treated with antibiotic cement were reviewed over the period of one year [September 2012 to September 2013]. The cohort consisted of 80% males and 20% females. The patterns of cultures for infections were reviewed and the procedure of antibiotic impregnated cement placement described.

Results: Twenty patients charts were reviewed, 4 (20%) were females and 16 (80%) males with ages ranging between 4 years and 62 years. Of these 40% had infected non unions of tibiae and femur, 25% open fractures, 25% chronic osteomyelitis. Culture results revealed 25% mixed infections, 20% staphylococcus aureus. All patients had initial debridement and antibiotic impregnated bone cement. Infection was cleared in 95% of the patients with 75% having radiological evidence of healing. Forty percent had bone transport of between 4 and 6 cm. A 100% of the patients had negative cultures at the time of antibiotic cement spacers removal.

Conclusions: Use of antibiotic impregnated bone cement could be used in treating chronic musculoskeletal infections.

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Abstract: 26 consecutive patients (37 hips) with avascular necrosis (AVN) of the femoral head treated surgically at our institution from 1999 to 2008 were reviewed . The aims of the study were to evaluate the risk factors associated with AVN in HIV positive and HIV negative individuals, and assess early response to total hip replacement (THR) surgery in HIV positive and negative patients. There were 15 male and 11 female  patients in total. The mean age for all patients was 47.1± 8.0 years  (range, 33 to 66 years). 12 patients were HIV positive, 11 patients were HIV negative and 3 patients had unknown HIV status. Excessive alcohol intake was the most common risk factor for developing AVN .15 patients (58%) had more than one risk factor for AVN and only 2/12 (17%) HIV positive patients had no other risk factor apart from HIV infection. There were no early postoperative complications in 34 arthroplasties in both HIV positive and negative patients. The aetiology of AVN seems often to be multifactorial, even in the presence of HIV infection. Early response to arthroplasty surgery in AVN of the femoral head is equally good irrespective of the HIV serostatus of the patients.

Abstract: Roughly one-third of the world’s nearly 7 billion people are covered by approximately 1/20 of its neurosurgeons. Neurosurgeons in the more developed countries have a moral obligation to increase access to neurosurgical care for the rest of the world. This can be achieved most effectively through neurosurgical education. Many neurosurgeons have already contributed greatly in this regard. Because of insufficient access to neurosurgical care, most children with hydrocephalus in Africa go untreated. Possibly as many as 2000 infants per neurosurgeon per year will develop hydrocephalus in sub-Saharan Africa. We have adopted a disease-specific strategy for training and equipping centers to provide evidence-based endoscopic treatment of hydrocephalus to save lives while avoiding the danger of shunt dependence, which is magnified in this context. In Uganda, we have successfully educated one to save a relative few. Our aim is to educate a few to save many. Such a disease-specific approach may provide a useful strategy for increasing access to care for other common, treatable neurosurgical conditions in resource-poor settings.

Abstract:

Object: Evidence from the CURE Children’s Hospital of Uganda (CCHU) suggests that treatment for hydrocephalus in infants can be effective and sustainable in a developing country. This model has not been broadly supported or implemented due in part to the absence of data on the economic burden of disease or any assessment of the cost and benefit of treatment. The authors used economic modeling to estimate the annual cost and benefit of treating hydrocephalus in infants at CCHU. These results were then extrapolated to the potential economic impact of treating all cases of hydrocephalus in infants in sub-Saharan Africa (SSA).

Methods: The authors conducted a retrospective review of all children initially treated for hydrocephalus at CCHU via endoscopic third ventriculostomy or shunt placement in 2005. A combination of data and explicit assumptions was used to determine the number of times each procedure was performed, the cost of performing each procedure, the number of disability-adjusted life years (DALYs) averted with neurosurgical intervention, and the economic benefit of the treatment. For CCHU and SSA, the cost per DALY averted and the benefit-cost ratio of 1 year’s treatment of hydrocephalus in infants were determined.

Results: In 2005, 297 patients (median age 4 months) were treated at CCHU. The total cost of neurosurgical intervention was $350,410, and the cost per DALY averted ranged from $59 to $126. The CCHU’s economic benefit to Uganda was estimated to be between $3.1 million and $5.2 million using a human capital approach and $4.6 million–$188 million using a value of a statistical life (VSL) approach. The total economic benefit of treating the conservatively estimated 82,000 annual cases of hydrocephalus in infants in SSA ranged from $930 million to $1.6 billion using a human capital approach and $1.4 billion–$56 billion using a VSL approach. The minimum benefit-cost ratio of treating hydrocephalus in infants was estimated to be 7:1.

Conclusions: Untreated hydrocephalus in infants exacts an enormous price from SSA. The results of this study suggest that neurosurgical intervention has a cost/DALY averted comparable to other surgical interventions that have been evaluated, as well as a favorable benefit-cost ratio. The prevention and treatment of hydrocephalus in SSA should be recognized as a major public health priority.

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Object: Infantile hydrocephalus in East Africa is predominantly postinfectious. The microbial origins remain elusive, since most patients present with hydrocephalus after antecedent neonatal sepsis (NS) has resolved.

Methods: To characterize this syndrome in Ugandan infants, the authors use polymerase chain reaction targeting bacterial16S ribosomal DNA from CSF to determine if bacterial residue from recent infections were detectable. Bacteria were identified based on the relationship of genetic sequences obtained with reference bacteria in public databases. The authors evaluated samples from patients presenting during dry and rainy seasons and performed environmental sampling in the villages of patients.

Results: Bacterial DNA was recovered from 94% of patients. Gram-negative bacteria in the phylum Protobacteria were the most commonly detected. Within the phylum, Gammaprotcobacteria dominated in patients presenting after infections during the rainy season, and Betaprotcobacteria was most common following infections during the dry season. Acinetobacter species were identified in the majority of patients admitted after rainy season infection.

Conclusions: Postinfectious hydrocephalus in Ugandan infants appears associated with predominantly enteric gram-negative bacteria. These findings highlight the need for linking these cases with antecedent NS to develop more effective treatment and prevention strategies.

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Abstract: The burden of infant hydrocephalus in East Africa is significant, with more than 6000 new cases estimated per year. The majority is caused by neonatal infection, and should thus be preventable. With about 1 neurosurgeon per 10,000,000 people in East Africa, initial treatment for hydrocephalus is often unavailable. This also renders shunt dependence more dangerous in East Africa than in the developed world. Endoscopic third ventriculostomy combined with choroid plexus cauterization (ETV/CPC) has proven effective in avoiding shunt dependence in the majority of infants. Unlike shunts, most failures of endoscopic treatment are evident in the early months after surgery, with later failures being rare. Easily accessible clinical parameters can be used to predict the likelihood of success in a given patient.

There appears to be no developmental advantage to shunt dependence compared to treatment by ETV/CPC. Cooperative efforts such as the East African Neurosurgical Research Collaboration are needed to broaden the scope of research and training needed to significantly reduce the morbidity and mortality of this disease.

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Background: The child presenting with quadriceps femoris/contracture that is resistant to serial manipulation and plaster casting and the older child with a fixed contracture of the quadriceps is treated surgically at the African Inland Church-Cure International Children’s Hospital. The surgery involves soft tissue release and lengthening of the quadriceps tendon. Open reduction of the knee and femoral osteotomy is done as indicated.

Objective: To analyze the outcome of surgical treatment of quadriceps femoris contracture in children. Setting: AIC-CURE International Children’s Hospital in Kijabe, Kenya.

Methodology: This is a review of files of children in our hospital treated surgically for quadriceps fibrosis over a period of three years (January 2005 to December 2007).

Results: There were fifty one cases of quadriceps fibrosis in thirty six patients treated surgically over the study period. Thirty one cases were excluded due to incomplete records or patients lost to follow-up. Consequently, the remaining twenty cases were analyzed. The pre-operative range of motion of the knee was grouped as follows: two cases had dislocated knees, three had hyperextension contractures, thirteen (0-30 degrees) and two (31-60 degrees). The final post-operative range of motion was grouped as follows: three (0-30 degrees), four (13-60 degrees), three (61-90 degrees), one (91-120 degrees) and nine (full range of flexion). Gain in flexion ranged from minus forty degrees to positive 140 degrees. The average gain in flexion was 94.7 degrees. Five patients underwent a second procedure to improve flexion. Soft tissue complications developed in four cases.

Conclusion: Quadriceps femoris/contracture responds well to surgical treatment with an expected gain in flexion of 94.7 degrees. The commonest complication is skin breakdown.

Abstract: Epilepsy prevalence in the developing world is many fold that found in developed countries. For individuals whose conditions failed to respond to pharmacotherapy, surgery is the only opportunity for cure. In Uganda, we developed a center for treatment of intractable temporal lobe epilepsy (iTLE) that functions within the technologic and expertise constraints of a severely low resource area. Our model relies on partnership with epilepsy professionals and training of local staff. Patients were prescreened at regional clinics for iTLE. Individuals meeting inclusion criteria were referred to the treating Ugandan hospital (CURE Children’s’ Hospital of Uganda, CCHU) for video-EEG (electroencephalography), computed tomography (CT) imaging, and neuropsychological evaluation. Data were transferred to epilepsy experts for analysis and treatment recommendations. Ten patients were diagnosed with iTLE and surgically treated at CCHU. Six (60%) were seizure free, and there was no neurologic morbidity or mortality. Our model for surgical treatment of pharmacoresistant TLE has functioned successfully in a true developing world low resource setting.

Abstract: Patients infected with HIV presenting with an open fracture of a long bone are difficult to manage. There is an unacceptably high rate of post-operative infection after internal fixation. There are no published data on the use of external fixation in such patients. We compared the rates of pin-track infection in HIV-positive and HIV-negative patients presenting with an open fracture. There were 47 patients with 50 external fixators, 13 of whom were HIV-positive (15 fixators).

There were significantly more pin-track infections requiring pharmaceutical or surgical intervention (Checketts grade 2 or greater) in the HIV-positive group (t-test, p = 0.001). The overall rate of severe pin-track infection in the HIV-positive patients requiring removal of the external-fixator pins was 7%. This contrasts with other published data which have shown higher rates of wound infection if open fractures are treated by internal fixation.

Abstract: Immune deficiency associated with pneumocystis carinii pneumonia and Kaposi’s sarcoma was first recognised in the United States in 1981. The causative virus, now known as the human immunodeficiency virus (HIV), was identified in 1983 by Barre-Sinoussi, Montagnier and colleagues at the Institut Pasteur, Paris.^1,2 The resulting disease has been known as acquired immune deficiency syndrome (AIDS).

In 1983 Bayley³ described aggressive cases of Kaposi’s sarcoma in Zambia. In the same hospital in Lusaka, Jellis⁴ highlighted the musculoskeletal manifestations of HIV-AIDS.

The author’s interest in the relation of HIV to the practice of orthopaedic and trauma surgery began during post-graduate training in Bulawayo, Zimbabwe in 1994, and has continued in Blantyre, Malawi since 1999.

HIV is a retrovirus which encodes its genome in RNA and transcribes genome copies in DNA using the enzyme reverse transcriptase. This occurs within host cells such as the human CD4 (T helper) lymphocyte. HIV is marked by a fall in the CD4 cell count with an associated decrease in immunity, particularly in humoral immunity.

Antiretroviral therapies such as nucleoside analogues and protease inhibitors reduce the viral load in the host serum and restore the numbers of host CD4 cells. The infected individual is not cured but their immunity is at least partially restored.

Abstract:

Object: The author investigated the 1-year outcomes for shunt treatment of hydrocephalic children in Uganda, comparing the results using the inexpensive Chhabra shunt ($35 US dollars), widely used in East Africa, with those using the Codman-Hakim Micro Precision Valve shunt ($650).

Methods: The results in 195 consecutive children (mostly infants) in whom shunts were placed were studied prospectively. In Group 1, 90 patients randomly received either the Chhabra or Codman shunt as primary treatment for hydrocephalus. In Group 2, 105 patients received the Chhabra shunt when endoscopic third ventriculostomy could not be performed or had failed. The end points of the study were shunt malfunction, shunt migration, wound complication, death, or no problem at 1 year. Of all patients, 9.7% were lost to follow up and 15.9% died before 1 year. The occurrence of complications in all patients were infection (9.7%), migration/disconnection (6.3%), wound complication (5.7%), valve malfunction (3.4%), ventricular catheter obstruction (2.8%), and peritoneal catheter obstruction (1.1%). There was no statistically significant difference in any outcome category for patients receiving the Codman or Chhabra shunt (p = 0.2463–1.0000).

Conclusions: Ventriculoperitoneal shunt insertion for treatment of hydrocephalus can be performed in a developing country with results similar to those reported in developed countries. No difference in outcome was noted between the two shunt types. No advantage was found in using a shunt system that, in this setting, is prohibitively expensive.

Abstract:

Object: The aim of this prospective study was to investigate the causes of hydrocephalus in Uganda, the efficacy of endoscopic third ventriculostomy (ETV) in this environment, and whether existing parameters could be used to guide patient selection.

Methods: Three hundred consecutive children, 81.3% of whom were younger than 1 year of age, underwent ventriculoscopy preceding ETV as an initial treatment for hydrocephalus. In 179 patients (60%) the hydrocephalus was caused by a cerebrospinal fluid infection; in 76% of patients the infection had occurred in the 1st month of life. In 229 patients (76.3%) ETV was performed; 2% of patients were lost to follow up after less than 1 month and the surgical mortality rate was 1.8%. The first ETV was successful in 115 patients (52%); the mean follow-up period was 15.2 months. The mean time to repeated operation following a failed ETV was 1.5 months. Sixty-five patients underwent a second endoscopy; 37 underwent a second ETV, of which 14 procedures (38%) were successful (mean follow-up period 12.25 months). The overall success rate for ETV was 59%. Among patients older than 1 year of age, the procedure was successful in 22 (81%) of 27 with postinfectious hydrocephalus (PIHC) and 18 (90%) of 20 with nonpostinfectious hydrocephalus (NPIHC). The success rate of ETV among those patients younger than 1 year of age was 59% (60 of 101) for patients suffering from PIHC and 40% (21 of 52) for those suffering from NPIHC. Age correlated with success for NPIHC (p = 0.0002) and PIHC (p = 0.0421). The success rate of the surgery for patients with myelomeningocele and hydrocephalus who were younger than 1 year of age was 40% (eight of 20). The success rate of the surgery for PIHC in infants younger than 1 year of age was 70% (44 of 63) among patients with aqueductal obstruction but 45% (14 of 31) among patients with aqueductal patency (p = 0.0254). Fourth ventricular size as demonstrated on cranial ultrasonography or computerized tomography scanning predicted whether the aqueduct was patent (p = 0.0001).

Conclusions: Infection is the most common cause of hydrocephalus in Uganda. In all children older than 1 year of age and in those younger than 1 year of age with PICH and aqueductal obstruction, which was reliably predicted by cranial ultrasonography, ETV was effective.

Abstract: More than 80% of the population of the world and a vast reservoir of orthopaedic pathology is located in developing countries. Our experience is mainly in central and sub-Saharan Africa, yet our conclusions hold for poor countries of all continents.

The need for both elective and emergency orthopaedic services in developing countries is great. Most of the degenerative musculoskeletal diseases seen in the West are prevalent, as well as conditions such as untreated club foot, gross genu varum and valgus, tuberculosis of the spine and severe chronic osteomyelitis. Road traffic accidents are becoming an epidemic. More than 80% of deaths in road traffic accidents and more than 90% of those involving children occur in developing countries.¹ In Malawi there are only four orthopaedic surgeons to care for a population of 12 million people. The need for postgraduate training in orthopaedic surgery in a developing country is undeniable, but whether this should be the only level of training depends on the general level of health services in the country. In Malawi, most of the 25 district hospitals have only one doctor of Senior House Officer level and no specialists. The majority of patients are managed by paramedical personnel known as clinical officers. Our main emphasis in training is to instruct these clinical officers in practical orthopaedics and the treatment of fractures. Each district hospital has one or more orthopaedic clinical officers (OCOs), who are able to treat most trauma safely and relatively conservatively. We have a visiting consultant support service which is patchy at present, but will improve as the number of trained specialists increases. Thus, in Malawi a two-tiered orthopaedic training programme has evolved, where we can train OCOs and postgraduate orthopaedic surgeons side-by-side. The majority of the OCOs work at the district level, while the orthopaedic surgeons are in central or teaching hospitals providing service for clinical referral and increasing the scope of training programmes. We believe this is to be a realistic, cost-effective, and achievable strategy. Other developing countries, where there are more doctors, may aim to have a postgraduate level surgeon at every district hospital (either an orthopaedic surgeon, or a generalist with orthopaedic experience).

Abstract: We followed prospectively 38 orthopaedic implants in 36 HIV-positive patients. X-rays and clinical examination were used to assess union, and observation was made for early and late wound sepsis for 12 months from the time of surgery. Two patients died of causes unrelated to the implantation, two patients had implants removed for reasons other than infection and eight cases were lost to follow-up. Of the 26 cases that were reviewed at 1 year, no late sepsis was identified. All of the fractures, non-unions, osteotomies and arthrodeses united. The literature indicates that late sepsis following arthroplasty occurs more frequently in haemophiliacs who are HIV positive than their HIV-negative counterparts. It is still not certain whether or not such a risk also applies to HIV-positive patients who are not haemophiliacs and have undergone internal fixation of fractures or non-unions. This study increases the confidence that fixation in immune-compromised patients with intact skin is safe, at least for the time period that the implant is required. Further studies are required to know whether or not fixation implants should be removed.