Clinician-driven strategies to sustain health justice in the public health sector

One objective of the South African National Health Act No. 61 of 2003 is the provision of best possible healthcare services to all within the limits of available resources. Cost consciousness and prevention of wasteful expenditure is required to sustain the provision of a high standard and affordable medical care to all. When available resources are threatened and diminishing, as is the case in our nation in these recent months and likely to persist for the foreseeable future, elective surgeries are at imminent risk of being postponed indefinitely. The tendency to delay or postpone elective surgery emanates from the natural need to prioritise patients with acute life-threatening conditions or traumatic injuries which compete with elective pathologies for resources. Postponement of elective surgeries prolongs patient suffering and poor quality of life, and does not support the mandate of health justice.

Universal healthcare coverage: we might not need to throw the baby out with the bathwater

UHC can be achieved with any of the models except the uninsured model. Many countries using the other models have shown that you can achieve UHC while still leaving a role for private insurance and private healthcare facilities. At this stage, it appears the South African policymakers have elected to go with an NHI model. The question that then comes to mind is, what exactly does the term National Health Insurance mean? Well, the answer is more complicated than I imagined. Cuadrado et al. investigated this and found that the most common characteristics are that it ensures universal coverage, is state-regulated with some degree of societal representation, has a public revenue source that goes into a single fund that functions as a single payer, and the service is provided by a mixture of public and private providers in a mixture of proportions. And to me it seems that it is this last aspect that is creating a lot of uncertainty in the medical community at the moment. What will this mixture of public and private service provision look like in the future in South African healthcare?

Intimate partner violence: an orthopaedic agenda

In 2019, South Africa made global headlines as thousands marched to parliament following the murder and rape of a 19-yearold university student. The population was taking a stand against gender-based violence (GBV). Femicide in South Africa is five times higher than the global average, with intimate partner violence (IPV) being the primary contributor. One in three women globally have experienced IPV in their lifetime, with the brunt borne by low-to-middle-income countries (LMICs). Despite this, the IPV challenge remains largely neglected in the LMIC setting, with a lack of meaningful interventions. Action needs to be taken.

Improving quality of care in total knee arthroplasty using risk prediction: a narrative review of predictive models and factors associated with their implementation in clinical practice.

From patient selection to discharge planning, the shared decisionmaking process between patient and surgeon can benefit from clinically informed multivariable prognostic models. A prognostic model is a statistical formula that takes patient characteristics and predicts an outcome, such as the Risk Assessment and Prediction Tool (RAPT), which predicts discharge destination following total knee arthroplasty (TKA) and total hip arthroplasty (THA). A powerful model predicts the outcome accurately, according to a range of metrics each measuring a specific aspect of predictive performance. Statistical predictive models can outperform clinicians’ predictive capability. This is potentially due to predictive models being less prone to clinicians’ biases, such as characteristics considered risk factors based on prior personal clinical experience alone. Predictive models are also able to process a greater amount of complex data and generate a prediction where clinicians would be unable to process the sheer volume and complexity of information.

Thirty-day unplanned reoperation following spinal surgery: how does the South African private sector measure up?

Spine surgery has seen rapid advancement due to novel technological innovations, safety improvements, and increased understanding of the pathophysiology of spinal conditions.In 2017, the number of spine surgery procedures performed worldwide totalled approximately 5.2 million, with procedure numbers forecast to grow at 7.9%, approaching 7.6 million cases annually by 2022.2 As the number of surgeries continues to grow, surveillance and continuous improvement in the quality and safety of spine surgeries constitute important precautions, promoting both patient wellbeing and cost-effective care.

A radiological assessment of tibia shaft fractures stabilised with intramedullary nails by trainee surgeons

Tibial fractures are among the most common long bone fractures, and frequently occur in young, healthy patients who are of working age. There are no published epidemiological data specific to South Africa (SA), but international studies show tibial shaft fractures to be the second most frequent long bone fracture after humeral fractures and the most common long bone fracture in young adults. Additionally, SA has a high burden of trauma, particularly interpersonal violence and motorised vehicle accidents, which disproportionately affect young, working age men.

Measurement of functional acetabular column sizes using a 3D CT model, for guiding percutaneous screw fixation of acetabular fractures using fluoroscopy

Percutaneous screw fixation of acetabular fractures was described in 19981 and has since gained popularity due its minimally invasive nature and good outcomes. Unfortunately, this technique is not without potential complications, most of which are caused by cortical breaching that damages surrounding neurovascular and other vital structures. This led to the development of intraoperative computer tomography (CT) guidance with O-arms to improve the accuracy of screw placement and improve outcomes when compared to traditional fluoroscopic screening. These advanced imaging systems are not readily available in developing countries, such as South Africa,  which may explain why this surgical technique does not share the same popularity as in America and Eurasia. Comparisons of American and Chinese populations vary widely with regard to screw size, with additional significant differences between male and female populations. Complicating the process are the varying recommendations that have been made Page 38 Strydom S et al. SA Orthop J 2024;23(1) regarding the safe diameter of screws to be used in the fixation. Dedicated instrumentation is not currently available in South Africa and logistics and costs involved in pre-ordering and obtaining the correct screws from abroad leaves little room for error. Incorrect sizing can potentially lead to cortical breach when traversing the osseous columns, which can then lead to catastrophic vascular damage. Therefore, the correct selection of a screw with a safe diameter is vital for patient safety. Adequate intraoperative radiological guidance is also necessary to ensure correct screw trajectory.

Narrative review of the valgus knee in primary total joint arthroplasty

Total knee arthroplasty (TKA) is one of the most successful orthopaedic surgery procedures performed with reported survivability of 82% over 25 years using available pooled registry data. TKA is performed with the aim of providing long-term relief of pain and restoration of function. The technical goals of the total knee replacement include restoring the joint line, correcting limb alignment, ensuring stability of the joint, maintaining adequate range of motion, and ensuring correct patellofemoral tracking while utilising adequate fixation techniques for the inserted implants. Valgus deformity in the knee is defined as an angle of more than 10° between the anatomical axis of the tibia and femur in the coronal plane. Achieving the aforementioned goals in a knee with a valgus deformity continues to be a challenge.4,5 Knees with excessive preoperative valgus > 11° not corrected to neutral alignment (< 2.5° of valgus or > 7.4° of valgus) have a higher failure rate compared to knees with excessive valgus that are corrected to neutral alignment (3.3% compared to 1.9%). Furthermore, TKA in preoperative valgus malalignment is associated with twice the risk of failure of TKA in varus malalignment. Inflammatory arthritis, post-traumatic arthritis, primary osteoarthritis, metabolic bone disease or over-correction with high tibial osteotomy are known to be associated with a valgus knee deformity. Osteoarthritis remains the most common cause of a valgus knee deformity. There are both osseous contributions, from the distal femur and proximal tibia, as well as soft tissue contributions to the valgus deformity. When addressing the valgus knee deformity, the orthopaedic surgeon needs to be cognisant of the various pathoanatomic features of the deformity that need to be addressed and taken into consideration during the planning and execution of Page 44 Almeida RP et al. SA Orthop J 2024;23(1) the TKA. These include the surgical exposure, bone cuts, level of implant constraint, gap balancing, preserving the peroneal nerve, balancing the patellofemoral joint and the soft tissue closure.

3D printing in osteosarcoma of the scapula: a unique case

Osteosarcoma is a rare malignant bone tumour, accounting for less than 1% of all cancers. Around 70 000 new cases of invasive cancer are identified annually among 15- to 39-year-old adolescents and young adults (AYAs). It most commonly affects the long bones of the arms and legs, but can also arise in the flat bones of the body, such as the scapula. Chondrosarcomas constitute the most prevalent primary malignancy of the scapula in adults, whereas Ewing sarcoma is the commonest malignancy of the scapula in children.2 We present the case of a 14-year-old boy who reported with a dorsal surface osteosarcoma inhibiting his shoulder movement along with night pain. We explained the approach to the patient and obtained written consent from his parents and his assent for publication of the case report and accompanying images.

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South African Orthopaedic Journal - March 2024 Vol 23 No 1