|ORIGINAL RESEARCH REPORT
|Year : 2016 | Volume
| Issue : 1 | Page : 34-39
Pattern of surgical procedures performed in the orthopaedic units of a tertiary hospital in South West Nigeria
Thomas O Adekoya-Cole1, Olasode Israel Akinmokun2, Sulaimon O Giwa1, George O Enweluzo1, Eyitayo O Alabi1, Omachoko Emmanuel Oguche3
1 Department of Surgery, College of Medicine, University of Lagos; Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
2 Department of Accident and Emergency, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
3 Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
|Date of Web Publication||2-Feb-2016|
Thomas O Adekoya-Cole
Department of Surgery, College of Medicine, University of Lagos, Idi-Araba, Lagos
Source of Support: None, Conflict of Interest: None
Background: Lagos University Teaching Hospital (LUTH) is one of the foremost teaching institutions in Nigeria. It is a recognized training institution for residency training in Nigeria. However, a thorough evaluation of the procedures being undertaken by the orthopaedic teams in this centre and the impact on the type of training being passed on to the resident doctors in training is the focus of this paper. Objectives: To determine the pattern of procedures performed by the orthopaedic units of the Department of Surgery, LUTH with a view to import the findings in re-organizing its structure based on service requirement, manpower allocation and to make recommendation. Methods: We retrospectively reviewed data including age, sex, procedures and leading surgeons retrieved from all our operating theatres over a period from 1st January 2010 to 31st December 2011. The data retrieved was analyzed. Results: A total 741 procedures were performed over the 2 year period. More male patients (58.5%) had procedures performed on them than the female patients. The mean age of patients treated was 37.2±15.5 years. Trauma related procedures accounted for 68.8% of the total procedures. Open reduction and internal fixation surgical operations were the most common trauma related procedure while ablative surgical operations following Diabetic Mellitus foot syndrome were the most common non-trauma related procedure performed. Conclusion: Trauma related surgery remains the most common procedures in our teaching hospital. Efforts should be made to increase the number of elective operations like Arthroplasties, Arthroscopic operations and Spinal axis correction operations being performed.
Keywords: Nigeria, orthopaedic procedure, orthopaedic training, pattern
|How to cite this article:|
Adekoya-Cole TO, Akinmokun OI, Giwa SO, Enweluzo GO, Alabi EO, Oguche OE. Pattern of surgical procedures performed in the orthopaedic units of a tertiary hospital in South West Nigeria. J Clin Sci 2016;13:34-9
|How to cite this URL:|
Adekoya-Cole TO, Akinmokun OI, Giwa SO, Enweluzo GO, Alabi EO, Oguche OE. Pattern of surgical procedures performed in the orthopaedic units of a tertiary hospital in South West Nigeria. J Clin Sci [serial online] 2016 [cited 2019 Dec 12];13:34-9. Available from: http://www.jcsjournal.org/text.asp?2016/13/1/34/175486
| Introduction|| |
The practice of the art of orthopaedics has evolved in great strides over the ages. Management of bony fractures and joint dislocations can be traced centuries back. The centuries-old dated Edwin Smith Papyrus contained how the ancient Egyptian surgeons reduced fractures and dislocations and immobilized them with splints. Evidences of splints made of wood or bamboo with linen padding were discovered in Egyptian mummies.,, Various treatments of fractures and dislocations have been documented and are still being practiced. Hippocrates' documentation on the method of reduction of shoulder dislocation is still being practiced today.,
However, it was Nicholas Andry who coined the word “orthopaedics” from the two Greek words “orthos” and “paidion,” meaning “straight” and “child,” respectively, in 1741. Professor Andry was quoted to have written “out of these two words I have compounded that of orthopedia, to express in one term the design I propose, which is to TEACH (emphasis) the different methods of preventing and correcting the deformities of children.” Teaching and training have been part of the focus of practice of orthopaedics from inception. The training, like in many surgical specialties, is usually in the form of master/apprentice relationship, a method that was further made popular by William Halstead with his model – see one, do one, teach one., Training of doctors in the art of orthopaedics is done in many hospitals; one such hospital is the Lagos University Teaching Hospital (LUTH), a foremost teaching institution in Nigeria. It is renowned for training specialists in various fields.
In training specialists, especially in surgical units, theater sessions are of utmost importance. Various surgical skills and maneuvers are taught during theater sessions. This is to ensure that surgical residents learn the necessary skills. It is, therefore, necessary to evaluate the surgical operations that are being performed. This will determine the type of surgical skills and help appraise the quality of training being passed on to the residents.
This paper reviewed the pattern of procedures performed in the orthopaedic units of LUTH with a view to import the findings in reorganization, manpower development and allocation, and to make recommendations for improvement, both in the types of procedure being performed and for the scope of services being rendered to the public. It will also help to assess the exposure to surgeries and the quality of surgical skills being transferred to the residents in training with subsequent ways of improving the same. It is an audit of the surgical procedures performed within the period reviewed.
| Materials and Methods|| |
The study was a retrospective study conducted over a 2-year period. This study was from January 1, 2010 to December 31, 2011. The study included all patients who presented to the orthopaedic units of LUTH and had procedures performed on them, either at the main modular operating theater or the emergency room operating theater. This study, however, excluded patients who had only primary suturing of lacerations performed on them. Patients with incomplete data were also excluded from the analysis.
LUTH is a major referral center in Lagos State. It is one of the major training, teaching, and research centers in the country. The institution was established in 1962 and the orthopaedic units of the Department of Surgery were among the units created from the hospital's inception. LUTH is a 760-bedded hospital with various outpatient clinics and two emergency rooms, namely, the accident and emergency room and children emergency room (CHER).
Lagos State is a situated in the southwest region of Nigeria. It has a population of 9,113,605 (based on 2006 census). LUTH is located within the Surulere Local Government Area (LGA) and also borders Mushin LGA. Both LGAs have a combined population of 1,134,722 (based on the 2006 census).
The operation registers in both the main Modular Theater and the Emergency Room Theatre were analyzed. The operation registers contained lists of both the elective and emergency cases that were done. The total number of procedures done was obtained. The demographic data, diagnoses, and surgical procedure done were also obtained. Patients who had more than one theater session for different procedures were counted once but the procedures were counted separately.
Data were collated and analyzed using Microsoft Excel Starter 2010 (by Microsoft Corporation, Redmond, Washington, USA). Frequency distribution tables and diagrams were used for the variables. The mean, median, range, and standard deviation (SD) were calculated for qualitative variables. The F-test was used to compare the mean calculated and Chi-square test was used to examine the statistical significance between any two categories of variables. All statistical tests were two-tailed and carried out at 5% level of significance.
| Results|| |
Seven hundred and forty one procedures were performed on 581 patients in 638 theater sessions. Three hundred and forty male patients (58.5%) were operated on while 241 female patients (41.5%) also had surgical procedures done within the same period with a male: female ratio of 1.4:1 [Figure 1]. The age range was from 15 days to 89 years with a mean age of 37.2 ± 15.5 years (SD) and median age of 35 years. The mean age for the male patients was 36.1 ± 14.0 years while that for female patients was 38.9 ± 17.4 years (F-test = 0.087, Chi-square test = 20.044, two-tailed P = 0.2720). The majority of the patients (n = 234, 40.28%) were within the age range of long bones 20–39 years.
Trauma-related procedures were performed in 68.8% of the total procedures performed. Open reduction and internal fixation of fractures were the most common surgeries performed during this period. This was followed by wound debridement following trauma and diabetic foot syndrome [Figure 2]. Ablative surgeries such as limb amputations and partial foot amputations were also common surgical procedures.
There were 638 theater sessions with the consultant surgeons as the leading surgeons in 411 sessions (64.4%) while the residents were leading surgeons or were assisted by the consultant orthopaedic surgeon in 227 theater sessions (35.6%) with a ratio of 1.81:1 [Figure 3].
|Figure 3: The ratio of the status of the leading surgeon who performed the procedures|
Click here to view
| Discussion|| |
This review is a form of audit of the surgical procedures that were performed in the orthopaedic units of LUTH. The vast variability of the types of surgeries performed is noted. These procedures included Bony procedures [Table 1], Soft tissue procedures [Table 2], procedures involving repair of Neurovascular structures [Table 3], Procedures involving the joints [Table 4], Spine procedures [Table 5] and procedures involving the Tendons [Table 6]. It should be stated that some of the surgeries were done in conjunction with surgeons from other units in the Department of Surgery. The plastic unit and the cardiothoracic unit were the most involved units. However, the orthopaedic surgeons and orthopaedic resident doctors were involved in all these procedures. Collaboration is encouraged in clinical practice. The patients benefit maximally when teams collaborate in their management. The resident doctors in training also benefit from such collaborations. They are exposed to surgical skills that are not available within the primary unit.
We are aware that some of the procedures recorded in this review are not in the exclusive purview of orthopaedic surgeons. Procedures such as skin grafting, wedge excision of ingrown toe nails, and even ablative surgeries such as amputations of limbs are not exclusively performed by orthopaedic surgeons. These procedures can also be performed by the general surgeons, family physicians, and general practitioners. However, the orthopaedic units continue to perform these procedures to ensure that trainees (both orthopaedic and other rotating residents) are well-tutored in the act of performance of these procedures. The resident doctors in general surgery and family physicians do rotate through the orthopaedic units and are therefore, offered the opportunity of being exposed to these skills and learning the appropriate techniques for these procedures.
An orthopaedic resident in training is required to acquire various skills while in training. Residency program is a period of advanced medical training and education that normally follows graduation from medical school and licensing to practice medicine and that consists of supervised practice of a specialty in a hospital and in its outpatient department. It is a structured training program with the objective of producing highly skilled specialists and professionals. Surgical training requires the acquisition of technical and nontechnical skills. Acquisition of technical skills is important in performing surgical procedures. Acquiring these procedural skills is critically important in surgical residency training program. These procedural skills in training are learnt and acquired during live surgical operations  where these skills and surgical maneuvers are taught and demonstrated by the trainer. The surgical skills acquired improve with practice. Proficiency in surgical technical skills and techniques is a product of hours spent with the masters  and the volume of such procedures assisted and performed under supervision. Orthopaedic surgical procedures require a high degree of surgical operating skills that can only be acquired during a training program. The frequency of some of the procedures recorded in this review is low, especially procedures such as arthroplasty, arthroscopy, and spinal surgeries [Table 7]. Efforts are being made to improve the frequency of these procedures through sensitization of the public on the availability of these services in our institution. Increasing the frequency of these procedures will provide a more robust training of the residents and also improve the proficiency of the surgeons themselves. It will improve the learning curves of some of these procedures.,,
|Table 7: The ratio of trauma related procedures against non-trauma related procedures|
Click here to view
Most surgeries in this review were performed by the consultants. This is expected in a teaching hospital where most of the patients are referred due to the availability of specialists. The residents in training are also allowed to perform certain procedures, either by themselves or under supervision of the consultants depending on the type of surgery and the skill level required to perform such surgery. Surgical skill training can be augmented with the use of surgical skill simulations and surgical skill laboratory. The surgical skill simulations and surgical skill laboratory help the orthopaedic trainees to achieve confidence and competence in procedures prior to live surgeries. Simulation in medicine can be broadly defined as “any technology or process that recreates a contextual background in a way that allows a learner to experience mistakes and receive feedback in a safe environment.” Surgical simulation training provides the opportunity for the trainees to develop surgical skills in a controlled environment with minimal risks to patient safety. Surgical simulation can be used for arthroscopic surgeries. Cadaveric simulations can be used for joints procedures, fractures fixations, and soft tissue repairs such as vascular repairs, tendon repairs, and nerve repairs. This avenue is being considered already.
Trauma-related surgeries constituted the majority of the procedures performed (68.8%) [Table 7]. Injuries from trauma remain a burden in Africa and indeed, Nigeria.,, This is in contrast to studies from centers outside our shores. A report prepared in 2007 by Canizares et al. on orthopaedic surgery in Ontario, Canada stated that trauma surgeries accounted for 33% of the cases. Garrett et al. in a paper on the practice of the orthopaedic surgeon in USA listed in order of frequency the most common procedures performed by orthopaedic surgeons in the country. Knee arthroscopy and meniscectomy was the most common. This was followed by shoulder arthroscopy and decompression. This is in contrast to our findings where open reduction and internal fixation of fractures were the most common procedures performed. This was followed by wound debridement mostly following traumatic injuries. Concerted efforts should be galvanized to reduced traumatic injuries in our environment. Most of the traumatic events are preventable through adequate precautionary measures and by instituting preventive measures. The most common nontrauma procedure is ablative surgical operations in the form of limb amputations, partial foot amputations, or ray amputations from diabetic foot syndrome and rarely from peripheral vascular diseases. Efforts should be made to educate the populace on the danger posed by diabetic mellitus syndrome through television and radio programs and the print media.
| Conclusion|| |
Trauma-related surgery remains the most common procedure performed by orthopaedic surgeons in the teaching hospital. The number of elective operations such as arthroplasties, arthroscopic operations, and spinal axis correction operations remains low. Public education on the treatment available for orthopaedic problems should be done by professional bodies and the government should support this.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Badoe EA. A brief history of surgery. In: Badoe EA, Archampong EQ, da Rocha-Afodu JT, editors. Principles and Practice of Surgery Including Pathology in the Tropics. 3rd
ed. Accra: Ghana Publishing Corporation; 2000. p. 1-10.
Colton C. The history of fracture treatment. Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C, editors. Skeletal Trauma. 3rd
ed. Philadelphia: Saunders; 2003. p. 3-27.
Kakria HL. Evolution in fracture management. Armed Forces Med J India 2005;61:311-2.
Muminagic SN. History of bone fracture: Treatment and immobilization. Mater Sociomed 2011;23:111-6.
Cole A, Pavlou P, Warwick D. Injuries of the shoulder, upper arm and elbow. In: Solomon L, Warwick DJ, Nayagam S. editors. Apley's System of Orthopaedics and Fractures. 9th
ed. London: Hodder Arnold, An Hachette UK Company; 2010. p. 733-66.
Ponseti IV. History of orthopaedic surgery. Iowa Orthop J 1991;11:59-64.
Powell AC, Nelson JS, Massarweh NN, Brewster LP, Santry HP. The modern surgical lifestyle. Bull Am Coll Surg 2009;94:31-7.
Gottlieb D. How can I improve my surgical skills? Available from: www.medscape.com/viewarticle/552730. [Last accessed on 2014 Dec 16].
Karam MD, Westerlind B, Anderson DD, Marsh JL; UI Orthopaedic Surgical Skills Training Committee Corresponding. Development of an Orthopaedic surgical skills curriculum for post-graduate year one resident learners-The University of Iowa experience. Iowa Orthop J 2013;33:178-84.
Hopper AN, Jamison MH, Lewis WG. Learning curves in surgical practice. Postgrad Med J 2007;83:777-9.
Bianco FJ, Cronin AM, Klein EA, Pontes JE, Scardino PT, Vickers AJ. Fellowship training as a modifier of the surgical learning curve. Acad Med 2010;85:863-8.
Subramonian K, Muir G. The 'learning curve' in surgery: What is it, how do we measure it and can we influence it? BJU Int 2004;93:1173-4.
Gaba DM. The future vision of simulation in health care. Qual Saf Health Care 2004;13(Suppl 1):i2-10.
Nordberg E. Injuries as a public health problem in sub Saharan Africa: Epidemiology and prospects for control. East Afr Med J 2000;77(Suppl):S1-43.
Nordberg E. Injuries in Africa: A review. East Afr Med J 1994;71:339-45.
Nantulya VM, Reich MR. The neglected epidemic: Road traffic injuries in the developing Countries. BMJ 2002; 324:1139-41.
Canizares M, Badley E, Davis A, MacKay C, Mahomed N. (2007). Orthopaedic Surgery in Ontario in the Era of the Wait Time. Available from: . [Last accessed on 2013 Feb17].
Garrett WE Jr, Swiontkowski MF, Weinstein JN, Callaghan J, Rosier RN, Berry DJ, et al
. American board of orthopaedic surgery practice of the orthopaedic surgeon: Part-II, certification examination case mix. J Bone Joint Surg Am 2006;88:660-7.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]