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In this two-hour on-demand teaching session we will focus on hip arthroplasty in Africa. The session is a collaboration between Harvard Global Orthopedics Collaborative, Johns Hopkins Global Orthopedics Team, World Orthopedic Concern, and METAL, and was put together by a phenomenal team of medical professionals. In this session, Doctor David Evans will moderate keynote speakers, Doctor Samuel Hailu and Doctor Mufulira, as well as three presenters, Doctor Lupando, Doctor Nadaei, and Doctor Kennedy Yeboah. We will learn about the history of hip replacement surgery, available resources in Ethiopia, and the challenges and pathways available for hip arthroplasty in low and middle income countries. Join us on Saturday for this informative and inspiring session!
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The Harvard Global Orthopaedics Collaborative is hosting its first "Arthroplasty in Africa" virtual education conference, scheduled for 24 June 2023. The conference will focus on the hip -- hemiarthroplasty, primary total arthroplasty, and revisions.

Conference Goals:

  1. Showcase the complexity of cases in Africa and their surgical management in a resource-limited environment
  2. Improve knowledge, foster international discussion, and lasting relationships, and motivate the younger generation of orthopedic surgeons practicing in LMICs

Learning objectives

Learning Objectives: 1. Understand the global history related to hip arthroplasty. 2. Describe the challenges and complications of hip arthroplasty in low- and middle-income countries. 3. Recognize the importance of self-directed learning for improving knowledge and motivation in orthopedic surgery. 4. Become aware of the resources and support solutions available for hip arthroplasty in low- and middle-income countries. 5. Explore the opportunities for younger generation orthopedic surgeons to gain experience in arthroplasty.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

Good afternoon. Good morning, depending on which time zone you're in. Thank you so much for joining us today. Uh My name is Karen. Okay. Well, Harding, I'm the director of the Harvard Global Orthopedics Collaborative. And today we'll be doing um a short little conference just two hours long. Thank you so much for spending some time on a Saturday and joining us, this is Arthroplasty in Africa. This is hopefully the first session of many that we will do on this subject today, we'll be focusing on hip arthroplasty. Um So this uh this project is in this uh conference is in collaboration with several wonderful contributors. Uh Thank you so much to the Johns Hopkins Global orthopedics team, especially Doctor Julia Sony for contributing so kindly to this uh to this um project. Also world orthopedic concern. Very grateful to them for their collaboration and of course, Metal, which is a platform that we're all on today. Um And this uh this program was really um put together by a phenomenal group of people all of whom are listed here, Bianca Krishna. Yeah, Coryza Abdulai Sam and and Sohail were instrumentally to creating all of the lectures that you guys saw all the flyers that were sent out the emails, the coordination, uh collecting the cases for evaluation for selection for case presentation. So thank you so much of the team at Harvard Global Orthopedics Collaborative and also our nonprofit organizations. So, in a global um and today's session will be moderated by Doctor David Evans who just recently graduated from the Harvard Combined Orthopedic residency program. Uh And is about to start his Arthroplasty fellowship. So I'll actually hand it over to him to take over uh from this point forward. So, thank you so much, everybody for joining David. Go ahead, take it away. All right, I'll just pop over. All right, you can see that. Thank you. Good, good day, everyone. Uh Thank you for coming out. I'd like to just echo Kieran's words. Uh Thanks. We have a fantastic team here. Uh I'd like to especially thank Bianca do a, she's been instrumental uh in this whole process and all the administration and getting the videos together and everything. Um So, first of all, I'd just like to go over the course objectives. We'd like to obviously improve knowledge of primary and vision total hip. But really, we want to foster international discussion regarding arthropod arthroplasty delivery. And uh I want to look at the resources available and, and different support solutions and challenges that uh low and middle income countries face and also um support and motivate the younger generation orthopedic surgery surgeons in this country regarding the course structure as you you've seen throughout the week, we've had self directed learning with lectures online as well as articles associated with them. Um And then these will be available in the future moving forward. Uh If you weren't able to catch them all, we'd like to thank all of our recorded lecturers for their time and their um and their dedication to helping this be a success in terms of agenda. Today, we're gonna have to keynote speakers as well as uh each lecture will be 20 minutes in total 15 minutes of lecture. Uh and then five minutes following devoted to Q and A sessions here are featured lecturers. Today, we have Doctor Samuel Hailu as well as doctor um A Mufulira and then our three presenters, Doctor Lupando, Doctor Nada. See and Doctor Kennedy Yeboah. We also have some faculty here today to help us with discussion's. We have Doctor Barrett's, Doctor Brazoria, Doctor Morena, doctor only Doctor Wixted and Doctor Wooley. All right, I'll go ahead and now pass it on to doctor Same Hailu uh for his first keynote address. Hello, everyone. Thank you for having me and thank you for uh urine and all the team who worked hard to make this happen. I think it's, I hope this is one of the many more uh work that we're gonna do together. And I look forward to working with all of you together uh in the coming uh many more years. Can you see my screen? Ok. Not yet. Not yet, but thank you. I share your sentiment. Thanks for that intro. Can you see the knowledge? Mm. No, not yet. Yes, I see it on my end. Same. No, I can't see your screen yet. Oh, there it is. Yep. Now I can see it. Uh So, uh I think, uh Karen gave me, uh you know, uh an assignment to give a talk about, you know, mainly a little bit of uh what's going on in Ethiopia. Uh So I'll tell you a little bit of uh uh the story behind hip replacement in Ethiopia. And then uh I'll tell you, uh you know, my pathway to where I am now and now the challenges of what I faced and what people could learn from. Uh the thing is that I have come across. So I don't have anything to disclose. And that's me. I'm uh trauma and arthroplasty surgeon at Black Line Hospital, which is, I mean, teaching hospital in Addis Ababa under, under uh university and I did my orthopedic residency in Black Line Hospital. And then I did my uh trauma and Arthroplasty Fellowship at uh University of Toronto Sunnybrook, uh and Holland Center. And that was back in 2015. So it has been uh since 2016. I've been back in, uh I've been doing mainly, you know, pelvic hospitable and trauma and hip any uh knee replacements. And then I'm also the head of the trauma unit at Black Line Hospital and I chaired uh, fellowship program. So when it comes to a little bit of uh worldwide history, you know, the, uh, hip replacement has been, you know, documented in terms of uh surgery back in 18 eighties, uh, by, uh doctor, uh, blood work. And that was using ivory joints and then the, the successful hip replacement that we know in the 19 fifties by uh uh Charlie. And when we call, we only come to add this, uh you know, I've been looking for uh various uh available resources that I could find. And the documented one you know, I stand corrected. But so far, what I was able to find uh was uh we had a Cuban visiting surgeon who was in Ethiopia in Black Line from 22,004 to 2007. So 2004, I was basically, you know, a first year medical student in Black Line Hospital. So he was there. Uh basically, I was in the hospital when this was being good and I was not in the or, but I was in the hospital doing my uh medical uh study. So, so this, this is the, he wrote it in uh Spanish, didn't get, got yet published, but he posted it uh in one of their uh the French uh poster presentations and he did write uh eating detail and I was able to get in contact with him. He's, he's, he, you know, he now lives in Cuba's, but I was able to contact him and he sent me, you know, some uh x rays and things that he had with him. So this was the first case that was done in Ethiopia. So to their becomes that is available at the moment. So this might change when you have more evidence. Uh 55 year old, younger year old man who had a left femur neck fracture and he came those uh so you can make a uh uh I think I'm gonna getting comical. Can you hear me? OK. Can hear you. Yes, me. Okay. That's fine. So he gave eight months after uh sustaining left femoral neck fracture. So he's uh elementary uh school teacher and, you know, uh they had a little bit of uh donation that they got from Europe. So this is from uh deep you and it was all uh this was all they said that they had at the time. So you can see a manual, uh you know, in the interesting stuff to, to look back and, you know, ex explore. So this was their interrupt pictures that they had and this was doctor uh Rafael, uh showing uh residents back then doing his uh first hip replacement uh surgery. You can, you can see the eagerness of the people and the residents around him. So this was 2004 in October basically. And this is his, uh, post, uh, post op x rays that he shared with me. And, you know, you might, you might notice it is cemented, uh, hip replacement. But I didn't even know until, until the day before yesterday, uh, that, uh, you know, back in the days when they do, uh, cementing, uh, radio pick, you know, barium comes separate with from the same and the powder and then the antibiotics also. So 333 parts of the antibiotics and then the cement powder and then the radio pick uh stuff. So I think, I think that they didn't have the radio pick uh staff that the barium uh that's why we don't see his uh segment. But he, he said the Senate was also near uh expiration expiration date. So that could be the reason he uh sighted but you know, uh I don't know but for the, but this was the record first case that was done in Black Line Hospital. And he was also to able to send me a video of it actually. So two months after his left hip replacement, this was uh the patient uh working. Uh so, so this is a corridor in the bend in the ground floor of Black Line Hospital in the main building. Mhm. And then the next case that I was able to find was by doing Anderson. He's still a practice, well, retired orthopedic surgeon from the US. He has his own missionary hospital in southern part of Ethiopia called Christian Hospital. He, he has been practicing orthopedics in his hospital since 2004. And you know, he, he, he also got donation from uh biome it back then and he said he did his first hip replacement in it took uh 2066 and it's either 1000 late 2006, maybe early 2007. That's what he said. And this is one of his early x rays that he shirt with me in terms of publication. So this is the only publication that I was able to trace back. So it was published by uh Professor Brooke Lambie. So he's our department head now and uh Eric Toxin, he's a practicing surgeon in CVS at the moment. He was uh orthopedic surgeon back then. So, so they started doing hip replacements on uh in 2009. So this is the publication that they had in 2017 at Q and then we had a campaign. Uh I'll be again, it was a visiting uh surgeon from video campus in visiting surgeon from Nevada. Uh that was 2011. So they did uh this time I was actually a secondary uh orthopedics resident. So I was, I was, I participated uh this and you know, along my travel's, I, I had some uh no uh we about uh addressing the issues that we see in 80 OKA. And as a resident, I was able to travel in different places. And, you know, I realized back then I, I wanted to do trauma and then to address some of the complications, the late presentations that we see and I knew I had to do arthroplasty training as well. So I traveled to Toronto and did my fellowship and, uh I returned after a fellowship in December 2015 and it was until after a year. Uh, my return, I was not able to get any processes to do uh any hip replacement. But there was a visiting surgeon who came from Norway and, you know, after fellowship, this was our first uh hip replacement that we did together. And then no, Norway, uh pretty much the universal practice that they had is uh reverse uh hip uh reverse total hip. So they actually they do cementing of the acetabular side. So this was the first case uh that I did with him uh after my uh fellowship and then after a year of uh you know, doing this in private. So there was one center where there was availability of uh J and J product is so I did a few, few cases there. Uh But after a year, uh you know, we were able to get donations from Zimmer Parliament, Seattle. Uh by uh it was organized by Alexis Folic off. He's a spine surgeon practicing in uh Swedish hospital there in Seattle. So in 2017, we had uh you know, a campaign And in a week's time, we did about 2 20 totality replacement in uh being uh one bilateral uh replacement that we did with him. Uh This was a bilateral hip replacement case that we did. Uh we're using anterior approach and on a regular uh table. So this was exciting moment for me. So I did, I did the uh right side and he did the left side. So he showed me how to do the anterior approach on the left. And I did it on the right from the same uh very basically. And then, you know, uh 2018, he actually came back uh in the same month in November, he brought us a second state of hip replacement. And then uh until COVID came, we were able to get an you on replacement of uh joint, joint products from Zimmer Biomet donation basically. And the patient's get free of charge. The only thing they pay is for medications. And then uh some of the things that they might like drape, things like that. So, in the first campaign that we did, we did it using uh closed uh drip. But uh we had uh infection, uh one superficial infections that we're able to treat with uh oral anti politics. And then we had another deep infections that we have to do uh to stage revision. So after that, we uh stop using clothes and we started using uh you know, disposable drapes. Uh So those drapes the patient's by, along with some of the medications that they use. Otherwise we don't make them pay for any of the, uh, joint replacements or the surgery. And in black, like hospital. So we were able to do it until a couple of years back on a regular basis. But after COVID came, yeah, I think it's change it a little bit. So, this was one of the kids that came to us, you know, four years after he had acetabulum uh fracture, uh with uh you know, in stage posttraumatic uh Karen can, can you can ask uh some of the one of a couple of the faculties, what they would do uh if they had these kids? Sure, I don't see why not. Um any of the faculty. If they have the ability to um mute themselves, please go ahead. Yeah, I mean, obviously, uh this Doctor Julia is only by the way, um from John Hopkins. Um happy to be here. Um on that right side, obviously, this uh significant deformity of that as a tablet. Um And in this particular case, I'll probably just use a jumbo cup. But um but uh and the main issue is gonna be obviously on the acetabular side, the femoral side seems relatively um normal um with regards to the mythology. So uh you can either use a large cup or in, in the case where you don't have that, then you probably just want to um I'm guessing in the relatively lower resource setting, I probably could use part of the head and tuck it right into the top of the cup and, and set the cup relatively low using the head as essentially like a bone graft. Um Obviously, if I was in um uh if I had all the resources available to me, then I may use a trabecular metal augment up there. So that would be the option. Yeah. Thank you anybody with a different idea. Uh This is uh Mike Barretts. Uh excuse my setting. I'm, I'm on a vacation, but I really wanted to join you guys today and I'm honored to be here and thanks for the invitation. Uh I actually agree with doctor only. I think that uh in this particular case, if you have every resource available to you and this is a young patient, you're trying to keep the center of rotation of the hip, really an atomic. You probably want to keep a low hip center and use some sort of augmentation superior early. Uh when you have all the resources, some sort of a metal augment. But if you don't, you could either use a high hip center, uh which I think you still have plenty of coverage, you get fixation or you could use the femoral head as a superior buttress with some screws to, to sort of help buttress the cup superior early. But uh I think any of those options would be good options for this patient. And I agree the femoral side would be pretty standard. Just out of curiosity, guys. Do you think cement alone would be sufficient for an augment up there or no? Uh Probably, you know, initially, yes, I think that um so I think the goal of an augment would be obviously fixation if you can get in growth anywhere really immediately or in fear, li uh then the cement would be a good initial fixation. Uh But long term, I would suspect failure because of how brittle the cement would become. Uh I would say um cement will probably put things at risk of failure just because of the sheer stress is um that, that cement cemented cup is probably gonna experience but um I'll rather try to get some in growth here. And um and obviously, if I have no other choice, I had no femoral head to tuck um superior early. Then um then you do what you have to do. Kabah Pierre Marie and Victor from the perspective of working and living in a low income setting. Uh Yeah, go ahead, go ahead. Uh So good to see you all. Thank you for your invitations. Um And you to see Doctor Hailu. Um Well, who should we share two different countries in Haiti? And, and uh yeah, but we have the same, pretty much the same experience uh in terms of our training. Um Yeah, I completely agree with Dr Oh no, I would um, and are limited settings and I had two applications like that. You cut the head, try to fix it as best you can. That superior aspect of it and then just see if you can put a really high, high neck on it. But um, you wouldn't be able to have those really big cups or anything like that. So that's, that would be my, my go to for sure. Yeah, thank you ready for uh Yeah, go ahead. Oh, yeah, sure, thanks. Uh That's a, that's a, that's a pretty, that case is typical from our side of the world here. Sometimes we are forced to get maybe more imaging, maybe a CT scan. Uh We're starting to have a lot of cities cans available in, even in uh in smaller centers, uh level five hospitals here in Kenya now, at least to study that head and, and, and, and, and then the, and the, and the acetabulum more um police, you cut the head and you use it in terms of recreating, recreating the world before you remained and you put your prostheses, I think. Uh that's that and of course, a jumbo cap as doctor only has mentioned. Uh That's, that's for us. Yeah, thank you, Victor. So basically, you know, whenever possible winter we try to avoid, you know, center. So everybody's trying to uh guide us into putting uh cup where it belongs. And you know, these are the options uh that, that that are cited. But, you know, unless it is, you know, unless we are out of option, we don't want to put, uh, you know, the cup in a high center. Uh, so these are the options that are available, you know, in general. But, uh, so in our settings, you know, the largest couple have is 50 sometimes, you know, we, that might not be, is, uh, the largest size we have is 60. So it might not be uh you know, pick enough to get to uh where it needs to be. And augment is something that we don't have at this In Black Line Hospital. And we don't want to uh do a high hip center. And hence, you know, we used uh the head and uh did uh you know what you call a shelf graft with flying buttress flat on the top and then, uh you know, the undersized his well rimmed and uh you know, he hit it quite uh well, uh this is uh what uh we did but, you know, things didn't go uh smooth all the way. And after uh COVID heat and then the war, you know, uh that we have in our northern part of the region. Uh Zimmer Biomet was not willing to give us uh donations, uh you know, until uh the war was settled, but, but now the war is settled and uh we're still in contact with them. Hopefully we'll be able to get a replacement uh product Ear's. Uh but in black line as well find uh two years we were not able to continue because we don't have a donation. Uh You know, so, so the challenge is, you know, uh continued, you know, uh in private side, you know, I've been exploring uh the options since, you know, 2000 15 and it's, it's expensive stuff and there's no distributor, uh and organized distributor in our setting. You know, you know, even I don't have to go further, even in Kenya Victor can tell us, you know, they, they have plenty of uh process distributors and they don't have to buy uh set. So in our setting, you know, you have to buy the set and then you have to buy inventory and that, that's the, the only way we can, you know, provide these uh services and, you know, to get sustained supply. I think this is quite a challenge and uh foreign, foreign exchange, you know, getting us roller is also quite a big challenge in our setup. Uh So, you know, after doing a few cases in the private setup that I told you earlier when I uh started doing this, you know, there was no more option of sizes and, you know, I had to look for my own option. And then, you know, I bought my first set of uh in planters and, you know, I have to keep, you know, a bunch of uh inventory in my store to start doing this in private. So this was one of the first cases that I did using uh my own uh supply purchase supplies basically. And, you know, uh things got better in private setting afterwards. Uh And there are some peculiar things that we noted in, in our settings and probably the same in majority of African settings, uh even was, you know, 40% of all the patient's that I did totally uh in private setting were later to a vascular necrosis. And majority of those patient is actually need a bilateral hip replacement. And these are in a young, young group of patient's. And uh so then my inventory basically, you know, shifted to uh ceramic in private setting. And then I, I wanted to have, you know, more experience with the direct anterior approach. So I traveled again, you know, to build them to have a better exposure in direct anterior approach. And I came back uh in Belgium. So the first case that I did with bilateral hip was in 2018 and this was my first ever like, you know, uh anterior approach to do after getting appropriate direct anterior training and all the approach that we did in uh Toronto was lateral. Uh So, so this was another, you know, experience for me. So, you know, I I, when, when I came back from Belgium, I came with these issues, meeting vision is issued drips and you know, I uh started being anterior approach with. Uh this was my first ever, you know, bilateral hip replacement after uh my uh father training. And then, you know, this basically became the routine, you know, whenever you have a bilaterality, uh even young patient is, you know, good hemodynamic status, you know, otherwise, okay. So I do, I do uh bilateral hips and uh the other things that is more uh useful, uh you know, it became handy until the anterior approach also became handy. Uh Even earlier cases where we have, you know, stage two, even on the contralateral side, I am able to do once I have total hip in the other side, you know, core decompression with uh bone marrow uh installation. So, you know, anterior approach has really changed the way I practice it replacement uh in Ethiopia. However, you know, the challenges continued. So again, you know, uh we had a distributor which, which was, you know, basically helping us and getting supplies, you know, they basically sell us the whole uh inventory. Uh but you know, it became expensive because, you know, the profit margin increases twice because the supplies and then the hospital, you know, has to have a profit margin in the distributor. So, you know, that that became quite expensive for patient's, even in private settings. And then the foreign exchange, you know, even for the profit that we pay for the distributorship that we had locally, we have to pay in Forex, which is uh quite uh the constraint. So for me, the way forward was to establish my own company. So I establish my own importing company called at this auto. Just to make sure that we have, you know, available uh you know, uh sustained supply with which which can provide an affordable products. And then, you know, I grew up my inventory with various options. So now I have like three different companies uh to supply, to supplying me uh to provide for patient. So most of the patient's do not have four necessarily for another bigger companies that we know of. So, and now I have, you know, a good quality uh you know, uh low post uh supply of product ear's and we're doing uh that. So this is one of the kids that I did uh with a good supply, a good product supply that I was really happy with with much more affordable uh for uh patient's. Uh So these are my mentors that I would like to thank. So uh Marco Louisianan and uh Richards Jenkinson from University of Toronto. Professor Corton Christopher Curtain is from Belgium. He's the one that taught me how to do anterior approach on a regular table without having to do you know uh extent extension of the hip or extension of the table or, you know, using traction table or anything. So, I'm, I'm, I'm, I'm indebted. Uh And I'm grateful for their uh you know, uh, teaching and, and then I would like also to time, you know, uh Alexis folic off who has been, you know, keen to in supplying our uh, supplies for hip replacement is in Black Line Hospital. And I'd like to thank also, uh, Doctor Rafael, who was, uh, the pioneer, you know, are setting to start this, uh, service in Ethiopia. And, uh, you know, uh, one of, uh, the supplies from Alexis comes through, uh result, it tells in Seattle and we'd like to thank all. So the Ministry Affairs, it can fully drug administration in our home uh university hospital who have been supportive in providing this. And uh you know, through the organization that are established, the hope is that would like to have a foundation alongside of it. And you know, those patients who are happy with the service as they got our willing to donate for patients who cannot afford. And we like also to collect some uh fenders and, you know, expand the service for patient's that cannot uh afford uh these expensive procedures. You know, we are willing to volunteer. It's really mainly the sustained supper of things that are lacking. So these are some of the things that, you know, uh my Armamentarium and we are trying to address the issues that we have in black like hospital. Thank you everybody for listening back to you. Okay. All right. Thank you doctor. Hey Lou. That was wonderful. Uh for me, it was inspirational. See how you took your experiences from Toronto and then realized the supply chain issue and create your own company. Um Just like to remind everyone you can put all your questions in the chat if you have any um for now for the interest of time or doctor via Le Mans Ania looking at uh complicated primary th A are you there? Violet? Yes. Uh See my my presentation. Not yet. Not yet. So uh Violet, I'm happy to share your slides for you for you. Excuse me? Can you see my presentation? No, we can't see your slides. Hello, Violet. Can you hear us? Can you hear us? Yes, I can. Can you see my presentation? We cannot see, you cannot take your presentation. I'm happy to share your slides for you. If you like if you like please, I'll be happy. Okay. I can't see it in a full screen. It's just uh did we lose Violet? Looks like we might have lost Violet. Let's uh let's perhaps move on to one of the other presenters while um uh Doctor Lupando works on her tech stuff. Um Henry, are you available? I am here. Uh Okay, great. Let me share your slides. So. Okay. Thank you. Hi, everyone. I'm having to see um an orthopedic and general surgeon from Cameroon. Uh And I may just begin by first. Thanking Kieran and uh all the others for having me have this platform to talk about it. And I'm happy again to see peer and, uh, same who've been involved a lot in sign another project. So it's quite a small world. So, um, as part of my intro, actually, I trained as a general surgeon with the Pan African Academy of Christian Surgeons, which is a general surgery residency program we see in many Ruhr away mission hospitals around Africa and the partnership with the Cosecha which awards a fellowship. So it's a, an extensive residency program in general surgery made for oral communities. And so we're training, doing all forms of surgery, anything surgical. So my train involves skills of general surgery, ent gain and all of that. And so I finished, you're not surgery now, did oughta pedic with Theo Kenya where we did orthopedics from a pediatric orthopedics, plastic anything. So at the moment I do anything surgical. So, um it's masturah of or treat, but I'm in a job of orchard and master of none. So I must say I'm not an actual plus the surgeon. I just do what I can under the circumstances where I find myself. So I can, I'm not an expert in any of it. Um, to present one of the cases I did recently, which is a 54 year old mechanic whom I had done. Uh, those are one of my first hip replacements I did also three years ago, which was a Samantha trope last for adverse planet cause it's just like what same also experiences. And two years later, he came complaining of some bit of pain and they in hips. We are always worried about losing in or infection. It did not have any sign of infection threats, affected losing. And in fact, unfortunately, could not get the last X rays. He was actually having some loosening of or wearing of the cup or sorry losing of the cement of the cemented cup. And so I told him to come back for a revision cop and he never showed up. He showed up one year later with most significant erosion of the acetabulum as you see in the next slide. Yeah, the next slide. Um So this is what he now presented with. Over a year later, the cement had eroded in 2000 dabble in significantly. And I also saw some wearing of this stem as well. And so we've been communicating about this all along and I told him to come. I never expected what I saw, what was I to do? My greatest suspicion was that he not only had maybe a fracture, but he also had an infection because at this time, he was on morphine on trauma door and he told me he couldn't sleep. He was in non religion thing. And so um when he came and said he was ready enough, but it said it after reading some money and now told him he definitely had an infection. Now, if it didn't have an infection. It means I had to revise the cough. I didn't have such a dremel head to give her a specific problem. He already had surgery. So there was no place for using the femoral head at a graft. So, uh I had one of the implants that could be a femoral cemented, spent I had to, uh, try to get the largest cup from the noncemented company, which we're using, which was the 70 millimeter they didn't have an augment in their system. And so I told him, I suspect there is an infection and my surgical plan was after doing the work up, I had a normal CBC. He had a normal ESR of six millimeters. I could not see any infection obviously by my limited investigation, but I definitely so losing, I turned out doing the kid he treated with me that if it's just to take out the implant for him to have some relief of faith, he'll be better off. And so my surgical plan was to do as such next month. So in terms of my planning, I knew I was going to pick out the implant because it definitely had infection. But if in case there was no infection uh had stand by the largest cup that the company had reached a 17 millimeters. I also had a revision stem which was cemented because there was no way to use a noncemented extent from my understanding from what we had of the female, everything was essentially eroded and there was likely a fracture. So when I got in, I went through the startup grocery, a poet did not want to get adequate access and lo and behold intraoperatively. It was just clear joint flu and fragments of cement. We aspirated a treat and immediately sent for a cell count which was we didn't normal, I think was less than 10 or 15,000. So I took the risk that he had no reception based on our preliminary findings. I learned I would like to be educated more that I depleted all the cement er was possible and the choke can Terek area was essentially lose because he had a pathologic fracture. It had just a thin layer of cortical bone left. So what we did was we got an India craze bone graft after the breathing the tab alone. And we're able to wage the uh to the uh in that case, bone graft superior early. But if you look at the X ray, if we could back out it, uh we could go back to the fifth flight. So uh if you look, there was a superior subluxation of that cement of that cemented cup. So I thought if a problem was a bit that we had an inferior space, which was an advantage for me to be able to really more in serially and with the grass up, I was able to get a tight feet using a more inferior winning. We can go back to our seven slide now. And with that, I was able to get a price feet which was really stable and we're able to put two screws in next slide. Our digital mission was bad Postal. But this is what I finally got when I, so this time I decided to fix the stem with uh uh 4.5 fleet. I didn't have any other standard plate that we could use and I bent the superior part. No. But after I did that, after the reaming, there was no way to put the stem because of these cruise and there was little uncle because the cement, the cottage was very three. So um I first please, the proximal and the most distant screw sideways should have my sent in and I traded the whole which I was going to put my school. Then I loaded it with the name and quickly put the same. Then I put in my schools to inter digitate in the cement. In that way, I could have a good physician of the lateral wall. So I hope it can last for many years because those cruise are embedded in the subsequent. And the cement had enough with the screws in place at the same time. And he was able to have quite a stable situation next leg. And so the patient came to see me six weeks later, he was pain free. In fact, he told me he had stopped all his pain medications. The next flight we showed you sleep walking. I don't know why it's rotated, right. So that's in walking. I don't know why he has that external rotation. Maybe somebody will explain something was wrong with my technique and this is six week follow up X ray and he is pain free. So my fears next slide is, um, I am very aware about the amount of precision I got at the stroke, a testicle area. I don't know how long this cement with all. Definitely, I know Britain, he's too young. He's about 50 for uh I'm worried when the pain goes away, you forget, don't have any bone. So that just in case there was infection it six week out. I'm not seeing anything. I hope there was no uh low grade infection which I need X slide. So the conclusion, actually, in the midst of limited technical skills and resources, I'm pleased that we still are able to uh do a surgery like this hybrid because this was uh the implant, the hard way from two companies. And just like what, how do, how you also mentioned, I had to buy these implants myself. I have to uh set of implants from two different companies. Uh I just have that as a backup and that was able to save us from having uh this patient. And so I really want to thank Karen and have a global for learn from quite a good number of your in similar circumstances like myself and a friend of mine and also a friend of Karen Linda and Jonathan her. And I would, I would project who supported, I mean, getting this implants as well as my hospitals team, my other colleagues, surgeons, whom we all thought through this case is over and over and we actually gave up. But I was happy that I told the patient I would definitely not make it worse. Uh I would definitely only make him better or make the situation a bit uh better without much pain. And so that's what, that's what I could do for him. And that is what I want to present you this afternoon. Uh I'll be very happy to see your comments, your criticisms about what we did in this case. Thank you. Thank you, Henry. Tough case. We go ahead, take a look to you. Thank you, Doctor dot See that that is a tough case. Uh We, we like this case because it was a difficult decision point when you weren't sure if they were infected or not, but they had uh relatively reassuring inflammatory markers. And you went ahead with the revision. Uh My question for you to start off was what would you have done in this scenario where it was perhaps a more concerning picture with more definite signs of infection? Would you have gone ahead with the space replacement? You probably would have been, you know, more reticent to put in bone graft in that scenario. Um But just curious on your thoughts, uh If you were more concerning for infection. First of all, yes, if I thought infection, I had two options, I had the optimal processes which I had stand by. My plan was to put cement around it and then implant it, then deposit a lot of cement beats around it and see if that would do something. And the worst case scenario was just two packs cement in it and keep him with something like a good stone and then hope to come much later or have someone better than myself handle his case in the future. But my plan was to make sure I have the mainstay to with Vanco and uh in a meeting in the cement. Yeah. Sorry, I have one question. Hello. Uh Thank you, Doctor Henry for a very wonderful case. But what I was looking at, I think the proximal part of the fema, those significant bone loss. And I was wondering how did you manage to put back the professors and then put a plate and fix the the fracture. Didn't have a lot bone stock, so to speak. So to me, I was wondering like maybe one could do with the absence of infection. One could do a proximal femoral resection and use uh approximal replacement stand. Hello. Hello, here you. Yes, we hear you Henry. Were you able to hear that question? You're muted? Henry. So I didn't hear it. The question Henry from uh Doctor Lupando was whether you would consider doing a proximal femoral replacement because of the massive bond lows. I feel like there is unless I'm not seeing carefully the X ray Karen while we're sorting this out. Can I ask a question of the faculty, the, the joint faculty? Yeah, sure. I have sort of, this is a curious case in that the, the poly clearly showed, you know, very significant where and I'm assuming that if the cultures came back negative and it wasn't infected that what we're looking at here is um you know, an inflammatory reaction potentially secondary to the poly wear. And I'm wondering, is this a case of, of bad polyethylene or is this a case of the cement getting loose and then the poly wearing irregularly? Um you know, I'm just sort of looking at the etiology of this massive bone license and it, you know, in the presence of that very significant poly wear. I'm just wondering if the fundamental underlying problem here isn't bad poly. And is that, is that a problem that you see, you know, particularly given that you're using lower cost implants? Is this a quality control issue on the supply of the poly or what do you think the underlying etiology of the, of this massive inflammatory reaction? Um So, Doctor Wooley from Haiti, uh thank you for the question. I think that's a really good question. I have had a similar experience less than two year out with really bad polyethylene. Um So I think that you, you touched based on, I think, same also touched based on that. Um some of the implants companies who are advertising uh in many parts of the world or low cost and often times you would have that, that issue, um because of um the use of uh low cost implants. So that's a really good point that you touch base, especially that we've had that experience here in Haiti. Um So that's, that's really critical to, to kind of know which employees you're using. I don't know, I don't know what implant that company was specifically was, but, but it's definitely can be one of the ideologies of, of the issue that's at hand. That's an interesting concept. I mean, this amount of wear is, is kind of when I first looked at this X ray, I was obviously just like Doctor and Dawsey, very concerned for infection, but that's an interesting comment. Uh Pierre Marie and Jack that this may have something to do with the polyethylene. Uh You look at that, you know, that X ray, you have very eccentric poly wear and you know, that amount of poly loss can certainly, you know, contribute to, you know, you know, massive inflammatory reaction secondary to polly particles. You know, they used to call this, you know, cement disease as well. You don't typically see it at two years and I, you know, I would wonder, I just don't know, I don't do enough arthroplasty to know whether or not, if the cement gets loose, will the poly wear irregularly or is it the poly wearing it regularly that leads to the cement loss? I just don't, I mean, this, uh, there's also this, like, license around the cement border, right? I mean, do you think that? Hey. Yeah. Hello? Hi. Can you hear me? Yes, we can hear you okay. Actually, the poly was not worn out. There was no wearing out of the poly. It is this, the cement was very much untapped on the poly. So it's the cement that came out of the acetabulum and I'm sure as he was walking around, he was wearing out his bone. Well, the interesting thing um Doctor Endosy on your films, I mean, this is a great case. You did a beautiful job on reconstructing that thing. But when you look at that original film, you can see that the head is a lot closer to your metal ring. I'm presuming that's the metal ring inside the poly, which you know that, that, that polly wear can be on a, on a millimeter or a micro millimeter level and you can get significant volumetric ali loss and it makes grossly look okay. And you know, I just, when you look at that X ray, it's hard to imagine that head being as e centric in that metal ring, you know, as it is and not have significant polyp where I just, again, I'm not an arthroplasty. I don't do this regularly and I'd like to hear from some of the arthroplasty guys, you know what they think. But it looks to me, Henry, like you've got significant, um, you know, quite significant e centric, you know, where, relative to that metal ring that they provide you in the poly. So, just to give some perspective as well, I mean, I've had to sort of similar like you're on mute. Unfortunately, uh doctor uh you're on mute, doctor. I'm thinking doctor Marina, your mute. Oh, we can't get through to him. Oh, man, that's okay. I'll send him a message. Can you hear us? You're, you're on mute. We couldn't hear what you said. Sorry. I thought I thought I was audible. Um Yeah, I was just saying, I've seen two similar cases that I had and I don't know if Henry had asked specifically, the patient's both presented with very early loosening of the cup. And it was further questioning where they mentioned some trauma where they've fallen. And I think there was loosening of the cement and then you get where from that and further loosening and when you open them up, they had a lot of linear wear in the poly as well, which may have either been because of the trauma, but also because the change in position and where they were point loading on the poly, I think that that does sometimes cause it as well. I've had two of those. So in this case, it's the poly getting loose or the cement getting loose leading to the poly wear, not the other way around then. Yeah, that's interesting. Very interesting. Uh Julius, do you have experience with large amounts of cement like that? Is that contribute to it? Like in the last case, we were suggesting using cement for filling microphone but has a bit of a delay. It seems. Yeah, thanks for that question. I twisted. Um So I uh I see your point. Certainly, obviously you're looking at that X ray and oh, by the way, the endosy excellent work, you know, um much profiteer for make, making, making uh you know, beautiful tasting lemonade out of those lemons. Um But um but, but um to, to your question, Jack, I think um I think, I think obviously when you look at that X ray, you think in the infection from the start, but, you know, uh it seems like from the work up, there was no infection and to everybody's point from earlier, um that could have been just massive osceola isis certainly. Who knows what came before? What, you know, it was it the where that came before the loosening of the loosening and essentially the vertical orientation of the cup that accelerated the where, you know, that it's um it's easy to play Monday morning quarterback but I mean, it's certainly difficult to determine um what came before what. But um if we truly don't think this is a little great infection or uh that infection was absolutely ruled out, then, um, that could also just be osteolysis that, I mean, that the scalloping that you see in the proximal femur certainly um was consistent with um some of the worst osteolytic cases that I've seen. Um and certainly the fact that the, that osteolysis, uh bone loss essentially led to significant uh weakening of the proximal femoral bone and subsequently lead into fracture. Um kind of goes along the line of the thinking of osteolysis. So, um I think increase in credible work was done. I'm I'm just like doctor and uh he said I am still worried about that stem because obviously, it seemed like the only the proximal part of the stem was cemented. So, and, and the distal part of the stem is still um uncemented even though it's designed to be cemented. So, um but I mean, in credible work was done and I certainly hope that that patient continues to enjoy it for a long, long time. So speaking of uh I'm sorry, just uh just for a second, same, I there was a question that Violet asked earlier that I didn't want to ignore just because there was some technical issues that we had. And it does also speak to what Julius just mentioned about the osteoporosis and Sandy maybe you can also answer this from your perspective. She brought up the concept of the proximal femoral replacement. Now, I think, um you know, Henry wasn't able to answer the question, but I'm sure he would probably say that the access to a proximal femoral replacement in his set up is very challenging. But I know that Doctor Lupando does a lot of oncological reconstruction. So perhaps she has a mechanism for having access to those devices. I'm just curious if that was something that our colleagues working in a high income setting would have thought of in this kind of set in this kind of case. And our colleagues working in low income settings. Um Is this something that you ever are able to consider or factor into your, your practice? Well, no, not, not, at least not for me. I think even even if I had the option, I would still try to upward using it anyways. Uh But one of the things that I wanted to raise is uh from my African colleagues or uh do you, do you guys use uh non crosslink uh cemented cups? Could, could this be, you know, I mean, and then the link it and low cost half a cup? Sorry, we can hear you, we can hear you. No, I didn't hear the question because my mic was muted, just opened it up. No, I was wondering, you know, I'm not use that. Uh mhm They're high crosslink two cups. Yeah, I'm here for a *** from others. Others. Yeah. Same. Yeah. Yeah. Grass Linked. But then again, I think 11 thing to consider is where it comes from. I mean, you don't want to, um, you, you have to be sure of what, what, what is on the back. It put it that way. You know, a lot of unscrupulous people out there will sell you something and tell you it's ultra Highmark away, highly puzzling when it's not. And it just depends where you get it from. I think that's always the question for most of us is how do you trust the implants? You know, he will tell you we have a very good copy, so to speak of so implant and does the same, but we don't have the long term results. So it depends where you get it from. I think as well. One thing I would add is, um, and I think I had that conversation with Dr Hyalu a couple of years ago. Um, not only where it comes from, but kind of see if they have in that in there setting literature and support evidence that those implants actually work. Um If you're, you know, I think that's, that's true everywhere, whether it's a low income country or high income country, the company is going to sell you whatever he wants to sell you because I think it's the best implant. But in our setting, it is very critical to do academic research on the implants. And if we had that conversation with one of the companies that was quote unquote one of the best and actually turned out not to be. So, I think that's very critical for any low income setting to identify the company that has a, at least some sort of mid to long term outcome um of, of those infants before um going into venturing into um, hip replacements or hip replacements or even uh most revision. Uh Well, I would suspect that these, these very batch to batch, you know, part of the reason that uh implants that we get our, you know, so consistent is a, is a huge quality control process to make sure that each batch of them is consistent. And I wonder if there's, you know, batch to batch variation in, in other suppliers. Again, I, I don't know. I'm just curious. Yeah, let me, let me uh Doctor Victor here from China. Yes. Uh interesting case there. I mean, and, and, and you, you put in a lot of work. Uh this case to me brings a lot of issues here that uh along the lines of quality, we're having a lot of implants coming in, low quality implants coming in and a lot of a tra plus D surgery is being done even into most corners of the country. So what that means in our center such as ours, where is uh where there's a fully functioning Metropoulos unity of getting a lot of revisions to do. And a lot of them present like this infection, looking at this case that presented there, there's a high likelihood that infection has a role in all the nuisance, see and the kind of a picture that you're having there often, you can, you can go in and do a big debridement, take samples out for culture and they come out negative for the uh uh maybe challenges within the laboratory or because of the prolonged uh antibiotic used by the patient before they came to our center. So there's issues of quality is there and their ability of the lab to isolate uh bacteria that could very often give you such a picture again, implants. Uh As one of our colleagues as mentioned there, you can have a box saying this is uh you know, the best polyethylene, you can get cross linked top of the range. But if you're subjected to quality checks, uh about 100% of them will when, when uh would would meet uh what is written on the box. I had a similar issue a few weeks ago when I came across a box with a QR code which I scanned and it opened for me some uh this is just a box I ran into, you know, and it, it opened for me a link from, I don't know where, you know, uh that shows that there's a lot of quality concerns, especially you know, part of the world. And uh this has made me in the center that I work now where we've established uh droplets unit to uh follow up whatever comes and try and collect whatever information regarding that implant that was clear in order to uh uh find and evaluate in the future, how um we're quality issues regarding the implants, of course, the issue, other issues such as uh technique and all that would would come as as well. So it is an interesting case. When I look at this case, I see a lot of uh opportunity for us, especially in this part of the world uh to look at our systems. Yes. Great points. Victor, thank you. Um There are a few questions from the uh audience here. Um David, do you mind just reading them? Cause I think I have a bit of an echo coming from me. Uh One was asking the use of a long femoral stem as a substitute for a proximal femoral replacement. Given the significant mental isis people's thoughts on that. Uh And the other question was on the use of bone graft in the setting of the implants. Uh Does the nature of the implant affect the potential risks associated with the use of bone graft? I guess we could start with the question of does a long femoral stem here? Uh Substitute for a PFR if you have that option available to you, I guess the question is for Dr and Nancy. Correct anyone I think, could, could probably answer these, I mean, uh, the person who I asked the question about the bone graft, right? Is that first question? Yes. Okay. Um, I mean, I'm not really sure about, um, I mean, in this particular case where I'm very highly suspicious of infection despite the, uh, results of those, um, studies that were done. Absolutely by Doctor and Dassey. Um, I certainly don't think that you want to take any, you know, um, a lung graft to, to, to and add that to the, to the mix. Obviously, some um autographed, you know, either, I mean, really a crest to potentially an option, but um what, what it did on the, on the cup side was pretty, pretty, pretty awesome. Um So I certainly don't think that, um, you can't fault that at all. Um, on femoral side that remains the big concern that is, you know, I'll do you, um, um, maintain the, the fixation on that femoral site and I think that the endosy rightly identified that as a potential failure point in the near future. Um And I think just watching that patient over time is what's going to help with that with the long femoral stem based stop substitute of proximal femoral replacement to doctor Liu Condos questioner. Yeah, I actually wanted to comment that in this particular case, you want to try to preserve the trochanter as much as possible, you know, just like the quad is the, is the key to the knee, the abductors, I'll have the keys to the is the key to the hip. And as much as possible, you want to try to preserve that bony um um the bony construct with the abductors. Anytime you have to, to, to use a proximal femoral replacement, you are going to a second option because obviously not attach the abductors to an implant. So you're attaching uh soft tissue to, to metal and that's not ideal. So in whatever way you can do it, you want to try to preserve the actual counter and try to do whatever you can to, to um create some fixation that still maintains the fidelity of the abduct. So, um uh yes, long femoral stem in high resource settings, we would have used the cement lis stand with great fixation in the, in the, in the his mus meaning in the distal or the diagnosis of the femur. Um But obviously that's, that's an issue here. So to, to get those types of influence and the great work was still done. Thanks. Thanks doctor only. Thanks, doctor, anyone claiming that one. We'll go ahead and we'll go ahead and move. Uh Doctor LaVonda. Are you available to, to share your presentation? Now, I can share uh Doctor Liu Condo if you just want to start your condo if you just want to. Um uh Thank you very much um for having this opportunity to be in this uh great forum hear to learn about total hip replacement. Uh My case today is about primary total hip afro plus. In setting of infection, we all know that uh there's increasing number of total joint replacement worldwide and uh we have an estimate of uh 500 million total replacement be done by year 2030. Uh This is because of aging population, but also because of uh vascular necrosis. Uh and in our setting, it can be either due to post trauma, but in many other cases where you see bilateral osteonecrosis is often times associated with HIV. So uh with the treatment uh that uh uh it's given to this patient together with HIV itself. Uh You find that this patient uh tend to have uh osteonecrosis that actually warrant a total replacement. And uh this by itself causes a, a challenge because of the immunocompromised though we do them when they are immuno competent and many of the things has to be taken as far as joint replacement is concerned. Uh My name is Violence. Know Pond as you have well mentioned and I worked with him, Billy Orthopedic Institute. I also had that I had the Department of orthopedics Arthrology and the reconstructive surgery. I'm also a general lecture of my Bill Universe College of Health Sciences. Uh As one has very well mentioned, I, I'm interested in joint replacement and musculoskeletal oncology, but we're not doing those fancy resection and replacement uh because of the constraints that we have in terms of first knowledge. But again, because of the implant that we don't have uh that are required for such big resection of tumor's and then replacing the joint depending on where you did the resection. So I'm located in Jerusalem. So the main objective of this case presentation is uh to highlight that HIV infection and the drug that I used uh predisposed patient to have osteonecrosis. First, they have osteoporosis which predispose them to have fracture. But at the end of the day, they also have osteonecrosis and this make things much worse unless you capture this patient very early. But the next objective is to to foresee the possibility of having intra operative paraprosthetic fracture. Uh huh because of the osteoporosis that this patient have. But then the indication for fixation of the structure and the choice of implant that you need for paraprosthetic fracture in a setting of poor quality born next slide. So this slide is here just to highlight on how, how, how, how much joint replacement have we done this? We analyzed this that time from the beginning where we started, we started hip replacement in 2004. And this where my senior who mentored me to 2017 where we analyze this data. And uh we, as far as hip replacement is concerned, you can see we had about 9 52 cases and of this majority are due to degenerative disease of the joint. But this chunk of people here, these are due to a vascular necrosis and they're equally divided between post traumatic osteonecrosis and uh A VN. So this is uh the burden of uh osteonecrosis that we have. So, I'm going to share with you a case of 61 years old men who presented to us like uh three months ago with uh with a history of three years of pain on the on both groin that was progressive and it was limping and that was limiting his activity of daily living. And uh by the time we saw this patient, he was using a walking aid. He had no low back pain and had no history of trauma, neither diabetes. And now he's sort of smoking or, and he's sort of using steroid. Uh This is a patient who has been on recto on who has been diagnosed as HIV patient for 16 years and he's a very good compliant patient. He started on ever era era of a since then to date next slide, please. So on clinical examination, he had obvious tenderness on both hip and he had atrophy of the gluteal muscle as well as quadriceps muscles. And uh the range of motion was restricted in both hit because of pain. And uh he had no flexion contractures. The thomas test was negative. He had no tenderness on the spine and the power of both lower mama. I mean lower limbs were normal and he had a positive passive straight leg raising tests as well as the role leg test was positive. Next slide. So because of that history straight, one would think of a possible a vascular necrosis because it was a straight history patient was really open about it. Uh So we thought of a vascular necrosis uh on both hip with probably an osteoarthritis. And that would probably make this as a steady for osteonecrosis. Uh next slide. So, uh this is uh this is uh x ray the first when it came, we did this hip and this was like 2.5 month ago. This hip was much worse than what you're seeing on the, on the right side. Uh He had uh collapsed femoral head with osteo with osteoarthritis. You can see from this other part, there's thinning of the cortices, there's widening of the intramedullary canal, but also there's lack of the trabecula and that indicates severe osteo penia with the collapse form of go ahead and slightly osteophyte. I can see an osteophyte, they're probably with coexisting or so arthritis. So we did this hip, it was very uneventful surgery. We normally go. Uh We use a lateral harding approach. Uh Some of us put the patient supine, some of us, they do it in uh lateral position. But basically, we all do the direct lateral heading approach. So the issue here is the risk a point here is when you're trying to when you have done your capsulectomy and you're trying to dis look at the hip. This is the time when you're likely to have a fracture. And uh when you're doing the reaming of the femoral uh of the fema uh to get the size of the processes that you're going to implant. This is again another risk point where you can have a fracture. So this is a time when you should be very careful. And uh when you do the trials and reduce, this is another point where actually you can have a fracture. So these are the point that you need to be careful so that you do avoid uh to have a para prophetic fracture, especially with this patient who is prone to have this uh problem. Um So this patient went home without this other hip and he was very happy and uh we did allow weight bearing immediately on this uh on this hip hip. And uh he came uh five weeks later, he had no infection of so whatsoever. And uh he came for another hip in another 4 to 5 weeks where we had a normal routine at the pre operative uh without and uh reviewed by Anesthesias uh protocol. And this patient was fit for surgery with normal viral, I mean, with a suppressed viral lord and the CD four were high. And this remember this is a very compliant patient. And uh we did this uh right hip and unfortunately, we had uh para prophetic fracture on the greater trochanter, which was undisplaced. And this was during rasping of the femoral, uh femoral of the fema. So we managed to come out without displacing the fracture. And again, the same standard of uh we, we did uh I mean, we did lateral hiding, supine position. Nothing has changed as it was in the first surgery. So we restricted this patient from weight bearing because we didn't want to overload the abductors that would cause an a version of the greater trochanter. And uh he's currently uh doing a soul touch and full weight bearing on the on the left hip. Next slide. Yeah. So I've talked about this. He was discharged after a week, no weight bearing. And uh he's ambulance with full weight bearing on the other side. He has no surgical site infection and there's no limb length discrepancy. So no complications on the left hip. But we had this interpretive very prophetic faction, the greater trochanter, which was not fixed because it was undisplaced. So, uh we, we, we, we have already said that the number of afro plaques is going to be increased because the proportion of patient with avascular necrosis uh is also high and because of the treatment, uh they uh prone to have uh totally replacement in their lifetime and oftentimes bilateral Austrian a process. Uh um and this is uh I osteoporosis, we know because this is the over expression of ranking cytokine, which mediated classic activity that caused osteoporosis. But also the air of is uh which has uh protests inhibitor, uh lead it to osteonecrosis. So, this patient are prone to have osteonecrosis as well as osteoporosis and risk of a fracture. So, what you have to do in this patient, you also have to rule out other risk factors that can accentuate the presence of uh osteoporosis and osteonecrosis. And these are the things like uh diabetes, uh patient who are smoking and any patient who is using steroid. So it's good to foresee all those other factors, but we can modify so that to reduce the risk of fun, having severe form of uh disease. A pre operative planning is very crucial because these are the risk patient with who can have infection can have uh deep vein thrombosis, but also they can have paraprosthetic fracture from their Detrol, can't even distant to the, to the, to the, to the, to the fema. So these are the patient that you really need to be careful so that you do not have this complication, which can actually make things even worse in the setting, whereby we don't have most of the implant of revision that can cutter for any fracture that can occur in this case. So be careful when you are, you're, you're, you're, you're rasping the fema when you're reaming and when you're impacting the stem so that you can avoid all this complication in these uh such compressions. So as I said, the initial dislocation is a point whereby you can have this complication. It depends on how you, you release the soft tissue around and how you get the, you, you do your dislocation because at that particular point, you are likely to have problems. So you need to be careful and even when you're reducing the hip, yeah, during trial, but even during the final implant, implantation of the professors, you need to be very careful. So that to avoid uh those complications that can arise from this uh kind of patient, you need to do a proper templating. So as to uh to to, to have a proper sizing, that reduces the problem of uh paraprosthetic fracture and other related uh complications. Next slide. So the goal of fixing pere prophetic fracture is to have good alignment, stable professors, achieve union before the implant failure and achieve retain function of this patient. The challenges uh limitation of fixation because often times you have a professors in C two and therefore you have a lot of struggle on how you can, you know, driving your screws and especially in the law, income country where you don't have the special school that can in plate, actually, that can can assist you to, to fix such a such a very prophetic fracture and especially uh in the setting of a poor bone quality, be careful on the vascularity because this is already compromised situation. And therefore, if you don't observe the biology, you're likely to end up with a lot of problems including infection. As I said, already, the moderna re access is obscured and therefore you have to be very careful. Uh patient factor, you need to have a good baseline of the patient, uh pre operative uh factors. It means you really have to work uh to work out this patient, very careful so that you reduce the complications that may arise uh from this uh from this uh kind of patient next slide. So this is just a Vancouver classification of paraprosthetic fractures. Ours was uh Vancouver A at the greater trochanter. As I said, it was undisplaced fracture. And uh there's a bit of controversy is that if it is undisplaced, then you can actually leave it. But if it is displaced, then you need to to fix this uh fraction, either bicycle ege or cable wires or, or the alka uh plate, I mean talk until uh plate so that you can actually maintain the function of the abductors which is very vital after totally replacement the next slide. So um so the clinical principal fixation uh is uh always the rest between healing before the hardware fails. And therefore, again, uh talk about, I mean respect the soft tissue, watch the bone metabolism and look for other court existing uh problem that could uh accentuate the existing problem in these kind of patient's uh you load if it is stable. Remember I told the first left hip we allow this patient to Lord, but much depends on how the coating of the stem is because some of the implant, a special that comes to our in Africa will say they're coating is not very good. So that should be um should be looked at so that uh you, you decide on whether you're going to do full weight bearing in this case or you're going to avoid weight bearing, depending on the quality, as you have mentioned earlier, the quality of the professors that we have. Um Yeah. Next, next uh slide. So this is just a modified Vancouver that includes the defect. I mean the paraprosthetic fracture in there. See tabla next slide, please. Yeah. So management of uh oh yeah, so post open Ege Mint uh if uh this is just a repetition again, if it is a stable fracture, uh how do you decide to fully weight bearing? So there are other factors. But if you believe you have a good step, the fixation was press fit, then you should actually allow uh fully weight bearing. And if it's not, then you, you, you, you, you, you probably do know weight bearing or or with, with the working aid. Otherwise you also do some isometric exercise to strengthen the muscle, especially the quadriceps, muscle, the gluteal muscles. So it's to improve function of this patient. So total replacement is on the rise uh and the cause is not only degenerative disease of hip, which uh which causes this but also in young patient who own treatment for other problems that are more vulnerable and uh more um they are likely to have more complications as the patient with degenerative disease. So one should be aware of this problem. So as you take this patient with a bit of precautions, so that you avoid some of the complications that can come. Uh I mean that can arise from this patient. They are prone to uh infection, pere prophetic fracture, loosening and uh and many other uh complications that can occur. So you need a routine screening, identify some of the risk factors so that you avoid all these complications, you need to have a good surgical technique uh in order to, to halt all this possible complications that can occur. Thank you very much. Thank you. Uh Thank you doctor. Uh We enjoyed this case because it showed how every cases you need even within the same patient going from one side to the other. Um I had one question. There are a few questions and chats as well. You discussed fixing peri prosthetic fractures. I was curious in Tanzania, what options were available to you if, if say that stroke had displaced greater. Uh you know, if you, if you have cables readily available or if you had played it or or what your options are there. Uh Usually we, we, we are very, we, we don't have the full range of uh fixing the para prophetic fracture. What we can use is just K wires and set Cleage. We don't have cables, we don't have proper paraprosthetic plates. We just use normal DCP plate. Uh And this is often times a problem because these are the patient that come with failures. So this is a problem that we face. Doctor Liu Condo. There's doctor uh in the chat um from Mustafa Maasai. Staying great case, Doctor Opondo, what is your cut off point for the CD? Four count progressed to the total hip. Doctor Lupando just remembered on mute when you speak. I don't think we can hear you. So power. Uh any, any the viral lord should be less than, I mean, it should be less than 200 and the CD four should be above that. I don't know if you have a different guidelines. Absolutely. Uh huh Any clients from the other faculty on that point about total hip replacement in HIV. Yeah, this is uh Doctor Karimun Mafioso. I'm from Malawi. Uh Malawi is unique in the region in that we actually have been maintaining a national Joint Registry and uh we have published some results on uh total hip replacement in HIV. Positive patient's. There's a paper by Simond Grandmom which was published in 2014. Of course, it's a small cohort. We had about 29 patient's uh in which 43 thr s we're done. Of course, this was in a cohort of HIV, positive patient's who had no haemophilia or drug use. What's notable is Malawi has an HIV treatment policy where at the time had a policy where, um, if you are HIV, positive CD four count less than 200 you have started on antiretroviral therapy. Uh, in terms of the patient's pre operatively, the cut off was that patient, if there were less than their, the CD four count of less than 200 surgery was postponed and they were started on A RVS until the CD four count was over. Uh 200. Uh Of note is patient's also routinely get co-trimoxazole prophylaxis as part of the HIV, prophylaxis otherwise standard. Uh thr uh you know, uh management was done. Uh So our results were generally good. Uh Most of our patient's were followed up up to three years. There were no revision procedures or early or late uh infections uh that we noticed in this group, there were no incidences of a septic loosening or prosthetic functions. So at least from this study, I know it's uh not a long term follow up and it's a rather small cohort. We seem to have positive results in uh HIV, infected individuals. Thanks. Comi that's very insightful. Another question from the audience for, for you and also for Doctor Lupando is uh it's directed to erect. Uh Do you think there's any, there's any programs Arabia among people living with HIV, I didn't get that the question is, do you need for a screening program for a VN among people living with HIV? Yes. Uh This is something that we have been brainstorming at the institute. Uh after observing that we're having a lot of patient with uh bilateral avian and whenever you screen them and some of them actually don't tell you anything. So we have this routine of screening those patient who come for total replacement. So when you have a bilateral avian, definitely it normally come positive for HIV. And we thought probably it would be ideal to go to the uh the clinic. I mean to, to collaborate with our physician who are handling this patient and probably screen and find out if we can have those early stage. Uh I mean, you have those patient with early stage avian like stage one and stage two where you can probably do something. And I was wondering whether the uh the by force for night have a role in this. I don't have any data uh that uh is strong enough to substantiate use of life force fernet in this patient. And therefore, if you, you capture this uh stage one and two patient, then you might actually reduce the rate of joint replacement in this patient and you're left with those who have advanced disease. So I think it, it is high time that we, we, we do that. I agree with Dr Jimmy. I think you asked the question that we should do that. We had one more question earlier in the chat. Actually, I think is pertinent for now and it was the use of cord decompression, uh probably in earlier stages of ABN. Uh if you could just share your thoughts if that's something you're doing. Yeah. Uh recently we have, uh we have, uh most of us are picking, picking some of the patient with early Avian and uh we do code the compression though. We still don't have the right uh basic tool to do that. But we try so that we don't end and especially for young patient, we don't want them to, to, to have their joint replaced at early age. So we try and do it called the compression. And uh some of our doctor using platelet reached uh to, to, to enhance Australian icis so that we can, I mean, save their, their head for, for, for, I mean, in order to uh to avoid the possibility of other in joint replacement. So we do that. And I think the number increasing, I think, well, uh if you talk to doctors from my, I think that we have a quite good number of patient. I don't know the follow up, but this is the step that we have taken so that we, we avoid joint replacement at early age. Thank you. I just, I want to just do more comments uh for this case and then we'll move on just for the sake of time. Uh Same you had presented in your presentation about doing core decompression. I thought maybe you might have a comment and then maybe one more comment from what the other faculty and then we'll move. Yeah. So yeah, thank you. Uh It is, it is my go to uh preservation intervention for early stage, even if you know, the uh there is an identified cause for the heavy in and if that of course can be stopped and you know, if it is not an an an ongoing issue, I will, I will, I will look all the compression and you know, I have seen good results with it and there there is some good publication showing, you know, you can minimize the risk of conversion up to, you know, 60 70% with uh concentrated uh bone marrow aspirates uh infiltrations. So there is there is, you know, reasonable evidence, not maybe that great, but in the absence of uh you know, uh ongoing uh causative agent, I think it's a good thing to consider. But in cases where, you know, the course is identified and it is, you know, an ongoing process like, you know, Arab HIV patient is uh on certain medications that are known to be risk factors uh on patient is that are on steroids that cannot be, you know, uh stopped in cases where like, you know, uh chronic renal failure patient is uh in this, in this scenarios, I don't think, you know, according cooperation is something that I would consider uh just because, you know, the underlying factor cannot be halted in an ongoing issue. So in those scenarios, maybe, you know, if it's possible, it's something that I would potentially consider. Uh and, you know, until uh you know, it really uh until I, I make sure that, you know, uh causative agent, you know, is, can be stopped, you know, if it is uh identified, I don't consider core decompression. Basically. Thanks. Any, any uh 11 more comment from the faculty before we move on or should we just go ahead uh Dominic or you? Oh, yeah, please go ahead. Call me. Yeah, I certainly think uh what we're seeing from our National Joint Registry is that the leading indication for total hip replacement, at least in Malawi is actually a VN and uh 44% of those with AVIAN are actually HIV positive. Um And what's interesting about our cohort and what's different from uh you know, uh the results on the international scene is that our cohort of patient's are HIV positive and non drug users and IV drug users. So I think this is an important area of study. Uh We certainly should look at the outcomes so that we can generate our own evidence based on how to manage these patient's best. It's encouraging to see that at Moy uh Doctor Lapindo and her team are doing quite a few um hip replacements. I'd be interested to see what their long term outcomes and their outcomes in their HIV positive patient's uh are going to be in the long term. Your skin. Uh Hello. Yeah. Uh It's very, unfortunately that we are, we are, we are very poor in uh database. That is a major problem that we have and uh analyzing our data. So I think this is the area where we can actually collaborate so that we have a solid e data bet that we can actually uh analyze and have the all those outcome published. So that's the main other problem that we have in most of the low income country. Yeah. So we cannot really figure out how, how, what are the outcome of this patient. But at least we are doing fine on a uh on a on a general term. We are, we are fine but uh I cannot substantiate it until you have data and analyze the data. So we need the basic uh I mean a database for that. Thanks, Doctor Window. Let's uh let's move on to the next presentation by Doctor Kennedy Yeboah from Ghana. Um Doctor Yeboah. Are you ready to present? Yes, ma'am. All right. Let me share my screen and then you can, you can go ahead. Okay. Thank you for the opportunity. My name is Dominic Nadia Bwa and uh I have taken Atro Plastic Fellowships in Apollo Hospital, India Bustle in Switzerland and Charlotte. Doctor Carolina in the US. A work in Ghana currently where we have a high incidence of high energy hey fractures. And I would like to present our experience is the management of one of state cases net uh conversion to the hip Atripla city that is undertaken in a resource limited environment like Ghana. And to also outline the challenges of hip arthroplasty in our part of the world and to demonstrate outcomes that follow hip arthroplasty in the low middle income country. Next, I present a 40 year old man who got involved in a road traffic crash as a driver of a vehicle resulting in severe pain in the left hip and inability to walk. There were no other complaints or injuries. This patient was referred to a center 14 days after injury, on account of a left ashtabula fracture, he was a high demand patient. There was no history of chronic diseases such as diabetes or hypertension. He does not smoke and takes alcohol occasionally. Next on physical exam, the patient look well, generally hemodynamically stable and was a lit. The left lower limb was shortened at the time of presentation by about four centimeters and externally more rooty tid. There was standard in Suva. They left groin, the greater to counter and the proximal left eye, there was lots of movement of the left hip joint. Next, we took a plain X ray and a CT scan. A plain X ray issued an interior column left acetabular fracture. As you can see a loop actinium disruption, there was some Strattera displaced neck of femur fracture. As you can see a CT scan with three D reconstruction equal issued a fracture of the base of the neck of the left fema with an interior column ashtabula fracture. Next. So we prepared this patient and uh we undertake open reduction, internal fixation of both the anterior column acetabular fracture and the fracture of the neck of the femur. So for the acetabulum fracture, we use the modified stopper approach, we reduced and fix the fracture of the 3.5 millimeter reconstruction plate and the neck of female was fixed with Kanye later screws. After the surgery, the patient had persistent left hip in and a limp which we assisted to six months and we took x rays at six months and we saw various collapse. As you can see of the femoral neck. We also saw vascular necrosis of the head of the femur. And uh as you can see the femoral neck was grossly certain. Next. So you prepare this patient for conversion to to hip Atripla tree, which was performed as six months um from injury. So this um surgery was done using the posterior approach to the hip, ceramic and ceramic bearing surfaces, used a cement lis cap for the stable um and the cement list term for the female and the hypothesis that was used was be brown uh made in Germany. Next two years after surgery, patient still complains of pain in the left groin and the pain also in the left eye, the pain is aggravated by fiscal ization. Um On physical examination, the patient has a limp and bullies with a stick as you can see very three cm shortening of the left low alim uh for which three centimeter suri's has been provided on the left side next. So at two years, actually of the purpose of this patient shows losing on the femoral stem with subsidence of this term, resulting in impingement of the proximal fema, the greater trochanter on the Valium and the femoral head appear e centric on the X ray with undertaking Esr and Syria too protein test. They don't show elevation. So currently we have entertaining the diagnosis of the septic loosening of the stem and the planning to undertake joint aspiration for liquid side count culture and sensitivity testing. The treatment plan for this patient going forward is to undertake a revision of the stem um to a long and larger one. Next, there have been a number of um authors who have reported that in the management of femoral neck fractures, especially when they are displaced. The initial reduction and taxation, the quality of the reduction itself and how early reduction is achieved are predictors of the avascular necrosis of the femoral head. So, in the patient of our report, the patient had a significantly displaced neck a fema fracture which was reduced and fixed at 16 days after injury. Equally, a number of protests have also shown that the incidents of re operation after internal fixation or displaced femoral neck fractures range is between 2036%. And some others have advised that um based on the high incidence of re operation, initial prostatic replacement may be undertaken to avoid re operation. So for this patient of our report, he has a field hip fracture fixation which was savaged by conversion total hip arthroplasty. Again, it is widely reported that um conversion, total hip arthroplasty often presents with poorer functional outcomes. And the success rates are equivalent of dues of uh revision. Uh total hip arthroplasty. Our patient at two years after surgery after total hip arthroplasty. So, complaints of hip ing and X ray has soon losing and subsidence of the stem. Next. So, um in conclusion from this case report, we have concluded that if you have a displaced neck of femur fracture with structural interior column acetabular fracture, where not fixed early and delayed too. As long as 16 days after surgery, you run a significant risk of getting the vascular necrosis of the femoral head virus collapse. And also authorities of the hey conversion, total hip arthroplasty should be anticipated in such cases of late fixation of human in fractures have an issue. And we are seeing that meticulous surgical planning and attention to detail are necessary to maximize outcomes in terms of uh conversion total hip Atro plastys. Next. Thank you for your kind attention. Thank you, Doctor Bennet. Oh, boy. It was a very interesting case. Very tough case. You have a fixation, a primary of conversion and then a revision. Now, um my question for, for you here is it, was there any thought when you're so delayed to the fixation of just going straight to a total hip if you had an inter capsular femoral neck fracture may be higher than a basicervical. But would you consider, you know, immediately or would you always attempt the fixation that far out? Yeah. Thank you for your question. Yes, this came to our mind. The main hindrance was availability of the prosthesis, you know, part of the world, they are not covered by insurance and uh we ordered them uh demand as and when is required. So this the fixation of the neck fracture was to buy as time to arrange for prosthetic replacement. That's very interesting. How, how long does it take? You typically get uh the replacement replacement in Ghana? It takes between two weeks to three weeks to get uh a prosthetic joint delivered to you. If you place an order, just a general question from me. Yeah, I was wondering and this could be answered by anybody. At what point in time when you have somebody with acetabular fracture, you'll decide to do acute total replacement. What should you have to decide? Know this patient? I'm not going to reconstruct the Ceta blah. I'm going straight to do a totally uh perhaps uh Jack, are you there, Jack, like said, do you have any comments on that one or same? I know that you're also a pelvic gas tabula surgeon? Okay. Yeah. So, uh you know, in our settings in general, you know, try to avoid uh actual totality replacements just because, you know, the process uh is not really available. Uh and it's not mostly affordable communications uh either. So, uh but, you know, if there are patient is that afford it and it's uh available, there are certain cases that I would consider, you know, act you're totally replacement is uh but, you know, bear in mind that acute totally replacements in certain is it tablet fractures is not going to be straight for uh hip replacement. You might need to reconstruct that problem at times you might also need a revision or at least, you know, attend cup multi whole uh shell. So, so you could, you know, at least bypass the fractures, uh you know, with sort of internal fixation of uh the plate, you know, acting as an internal fixation from within the acetabulum basically. So the cases that I would consider uh could be, you know, uh certain cases that come to you, uh you know, delayed uh say, you know, typically three weeks might be something that, you know, you see in the Western literature. But depending on the age, you know, even a late construction for us that just could be a achieved. But in general, no community possible fractures, you know, with marginal impaction uh femoral head injuries. And you know, those uh those those that are, you know, past 50 years, you know, those are the uh one of the scenarios that I would consider, you know, uh to totally replacement, you know, committed anterior and medial will fractures in the elderly. You know, you could also consider, you know, acute to have a replacement in general. Uh But, you know, late cases, late presenting cases where uh you know, there is a reasonable congruence uh in a younger age group, you know, you could consider, you know, leaving them alone, delay them because they might do reasonably well, even without, you know, any interrogation, you know, and you know, leave them alone and let them create, you know, uh consolidated acetabular. And then later on, you could do uh simpler hip replacement and say, you know, down after like six months or uh more period of time, they would have been a well healed acetabulum, which uh might might need a little bit bigger size of the acetabulum size than you would normally use. But, you know, it could be something that could be achieved with the primary hip replacement. So in general, I'll try to relay acuity replacement in a Stalin fracture. Sitting is one other possible. Thanks, same. That's great. Um Just for the interest of time we're running a bit behind schedule here. Um, I was wondering if we could move on to the Emmy's presentation. Um, and then we can open up for discussion a little bit at the end. Um, just for, uh, you know, for everybody's, uh, you know, schedule. Uh, how many are you free to share your slides and give a presentation? Remember? You're still muted as well. Hello? You don't? Hello? Yeah, I mean, we can hear you. Hello, Colombia. We can hear you. I don't know if you can hear me? No, I couldn't hear. Can you see my screen? We can see your screen. Yes, we can. All right. Uh Good morning or good afternoon, depending on where you are. So I'm gonna give a talk about hit arthroplasty in low income nations and the role of national Joint registries. Um Sort of gonna give a case study for Malawi. I am uh Doctor um Mafioso. I'm a consultant orthopedic and trauma surgeon. Um I work for the cameras. University of Health Sciences. I'm based in Blantyre Malawi and I practice at Queen Elizabeth Central Hospital, which is the largest referral hospital in uh in Malawi. Now, I have no relevant disclosures to make. Now, the objectives of my talk are I hope by the end of it, you appreciate the practice and the results of hip opera plasty in resource constrained environments. Appreciate the role and results of national Joint registries in resource constrained environments and hopefully appreciate the confidence of an effective and successful National Joint Registry. Now, just a bit about Malawi Malawi is in the southern eastern part of Africa are neighbors are Zambia, Zimbabwe, Mozambique and Tanzania. Uh It's a relatively small country. Um It has three main cities in Zuzu Lilongwe, Blantyre. Uh um I work out of Blantyre which is in the southernmost part of the country now. Uh by most measures, it's what you'd consider low income countries. 70% of the population lives on less than $2 a day. Life expectancy is at a small 63 years old, but we have a relatively large population at 20 million population growth annual is 2.6%. Uh GDP is 12.63 billion per capita is 634.8 as of 2021 according to the World Bank. So we are firmly in what the World Bank would describe. A low income country. GDP is growing rather slowly. At 2.8%. We are an agricultural based economy predominantly for ex exchange. The green dollar comes from selling barely tobacco. I think we're the largest producer of barely tobacco in the world. So most of our foreign reserves actually come from our sale of tobacco. Of course, things have been changing as you can see from this graph from 2005 going downwards, this has been coming down low. This is rather relevant to the practice of arthroplasty in Malawi. But um as well, this uh matters for most sub Saharan Africa as same might have mentioned in his talk. One of the challenges he faces is Forex in trying to import prosthesis. As you can see, it's a headline from a newspaper article, what bank had cautioned us on forex shortages. So every once in a while we experienced forex shortages that make importing of uh proces is quite difficult in the country. In terms of our current health expenditure per capita as of 2020 we're spending about $32 per person. Um As you can see, this doesn't compare to favorably. Um This doesn't compare to favorably to what higher income uh countries spend on their uh citizens. They spend at least 6180. While middle income countries spend up to 289 the average for Sub Saharan Africa is $73. So, uh you know, we're far below what more Sub Saharan Africa spend. Now, communicable diseases take the lion's share of this funding. Uh Orthopedics is relatively considered low on the priority list. Uh In terms of physicians, we have a low number of physicians per uh 1000 popular 1000 people. There are 14 specialist orthopedic surgeons who are concentrated in the major cities are workload is predominantly trauma. We have the fourth highest annual old injury, maturity rate is little cutting time, forecourt case orthopedics. In terms of our healthcare, it's free in government hospitals and this is funded through taxation is currently no national health insurance in place. So there are plans to establish one private healthcare is available and this is through private health insurance or self payment. Now, in terms of afro plastic, it's mainly available privately. We have knee and hip and it's mostly primaries. The more complex revisions are usually sent for external referral in terms of the public sector. Uh Usually arthroplasty is provided in the form of camps. So we occasionally have experienced high volume arthroplasty surgeons who come down to Malawi and mentor uh locals into performing arthroplasty. There's a variable availability of him arthroplasty available in the public hospitals. As you can see, these pictures were taken from the one of the major hospitals in Malawi, the central hospitals. So you can see this is a visiting high volume arthroplasty surgeon with local surgeons from Malawi in clinic, seeing a patient reviewing him before the camp. And you can see one of the surgeons operating with one of the local surgeons there by ensuring that local surgeons are mentored and their skill transfer and patient's that they operate uh after they've left get proper care uh in terms of follow up for complications now are challenges. Same has mentioned, these are not so different from what they uh they face in Ethiopia. We have implant limitations and this has to do largely to do with cost but as well, inability to buy purchase implants because of Forex. We have low volumes as a result of the cost as well. And this affects training of our residents and as well in terms of uh you know, the practice of uh the local orthopedic surgeons. So they have low number of athol, a plastic cases under their adults outside of season, arthroplasty car camps, it's only available privately. So this limits training of our residents since our residents, they're mainly do their training through the public sector. Now, it's not a very attractive market for prosthesis manufacturers, Malawi because we're low volume uh center. So uh we do not have a supplier within the country. We have to actually order from neighboring countries, either South Africa or Kenya. So there's no local prosthesis uh supply. Now, Malawi circumstances are not unique. They can be extrapolated to most Sub Saharan African countries. They're relatively low orthopedic surgeon numbers relatively low arthroplasty volumes. The limited resource capacity for revision cases, inadequate health sector financing, patient demographics and implications are definitely different from higher income nations. And there's a very big need for arthroplasty services. Uh This is about Malawi but I might as well be talking about any country I could pick up on a map in Sub Saharan Africa. Now which brings me to uh this research paper that was done by Peter Davison uh looking at total joint replacement in Sub Saharan Africa. So this was a systematic review. They excluded South Africa. I think we'll all appreciate the economics of South Africa is rather uh different. Uh They are within Sub Saharan Africa, but they have first world resources. So there were 12 papers reporting a total of 606 total hip replacements. Uh vascular necrosis was the most common indication for total hip replacement. This is in contrast to what has been reported in western literature where the prevailing indication uh arthritis uh HIV prevalence was up to one third of the patient's what had total hip replacement and an HIV prevalence of uh were HIV positive. Now, improvements were definitely seen in patient reported outcomes. So, Harris Hip school and Oxford Hip school, the dislocation rate in thr was only 1.6% and a deep infection rate was 0.5% for total hip replacement. What was common in general is that none of the theaters uh that were used in the papers and laminar airflow of course, uh The importance of this in recent richer has been questioned, but this is an important factor to note as well. Uh DVT prophylaxis and pre operative antibiotics were standard and almost all patient's were fully web or weightbearing by J too. What this review generally showed we're good results with comparable complications to high income countries. Of course, what was disappointing to note from the papers reviewed is that data on HIV status was generally poor reported. Uh most of the studies had excluded results analysis of the results from HIV positive patient's. However, Graham at all, based on data from allowing national joint registry reported on a cohort of HIV patient's undergoing thr they had excellent results, no complications mean follow us 42 months in general inpatient mortality within Sub Saharan Africa. From this systematic review was 0.2%. And as I mentioned, the Harris hip school improved uh in most of the studies now, uh as far as I'm aware, and as far as it could be ascertained from this systematic review, Malawi's only country in Sub Saharan Africa to have a dedicated national joint registry. The majority of the data uh was for miracle prospective databases in as seen in the systematic review. Uh This presents a problem in that there's a possibility of a reporting biases. Uh as surgeons, we tend to only report our best results. If you go to a conference, you're not going to in general report. Your worst case is you report the best ones. So those that tend to publish tend to come from centers where the results are generally good as opposed to data that's obtained from the National Change Registry. You don't have the option of cherry picking your results. Now, Malawi has a national joint Registry, uh it's run by the Malawi Orthopedics Association. Now, registries allow epidemiological demographic status studies as well as comparison of outcomes across implants and institutions within the country. Now, they're definitely benefits to having a low plastic registries uh too low income countries. Um I like this quote uh from one of the authors in the systematic review that say the aims of an African hip registry are different from those of the Western registry implants and techniques are not the main issue. This is not what should be the focus. Now in general, follow income countries having a national joint registry will help highlight weaknesses in orthopedic training and practice. Uh Of course, offer valuable demographic information on patients' as I've already discussed that the demography that we're starting to see within Sub Saharan Africa is different from the West and this helps determine our current and future needs for the Sub Saharan African population. Uh There's a possibility as well of identifying and suitable implant designs and manufactures. So you're able to tell whether one manufacturer uh has an unreasonably high implant failure rate and whether they're causing potential harm, especially in a setting where we're always trying to get more bang for our buck and we're using traditional implant suppliers. Now, of course, as I said, uh problem is we don't have the data. We have small studies. Hopefully, if low income nations sub Saharan Africa, more specifically have National Joint Registry, there's a possibility of pulling our data and coming up with conclusions uh in regards to outcome far much earlier now. And as far as registries are concerned, the first registry was the Swedish and the registry in 1976 that was soon followed by a hip register in 1979. Since then, other countries in Europe can ID A and Australia have established registries. Now in Sweden, the estimate that uh the economic burden of revision surgery is significantly lower in countries with registries. Their own example is that for each percentage point reduction, uh in revision surgery, they're able to serve between $42.5 million 212.6 million dollars annually. Now, in general, people often agree that you have an effective joint registry, you need a joint registry that provides timely feedback to stakeholders. Stakeholders. In this case would be the surgeons and the manufacturers of different implants. And of course, any effective joint registry has to have uh provide complication surveillance and of course result in a reduction in patient mobility and an effective joint registry as well should be able to monitor new surgical techniques and implant technology and provide this information produced stakeholders. Now, in order to have a successful national joint interest, see, there's certain components that you need to have at least four important components that you need to have. One. You need good funding and organizational control. Uh You need participation on the part of stakeholders. So hospitals have to be willing to actively maintain registries. And of course, uh you need the participation on the part of the surgeons as well and you need to make sure you have good data management. So garbage in garbage out, monitor the quality of your data actively. It should be an active process. And of course, there's no use of having a National Joint Registry if there are no mechanisms for giving feedback to stakeholders. So this needs to be available. Now, Malawi uh recently published uh 10 year outcomes from the National Joint Registry. Uh in regards to total hip arthroplasty, uh there were about 83 total hip hop four passes performed in 70 patient's. The mean age was 52 years. And uh this cohort include at least 24 patient's who were HIV positive. As I mentioned, the main indication for surgery with uh A VN. 41% of the hips had a BN. There were no desperate uh perioperatively and no complications at six weeks. Now, 46 of the patient's, we're seeing a 10 years post operatively with good hires hip schools and mean Oxford hip schools. Uh five hips were revised due to loosening. Uh There were no infections or dislocations reported. Uh 14 patient's died. Of course, these uh died uh not secondary to the thr uh not secondary to the procedure itself. And what's reassuring to note again is that these uh HIV positive patient's had no complications and they're Harris hip scores were generally good as well. So a little bit on our joint registry, it was established in 2005. It's uh it's uh managed by the Malawi Orthopedic Association before it was rolled out, it had to get ethical approval uh from the local Ethics Board. Uh All patient's that who have had or about to undergo total hip replaced normal T car TKR in Malawi. Our approach to give consent in general. This is the data collected for the Malawi National Joint Registry Age Gender Surgical Indication, uh aesthetic grade type of implant, cementing techniques and HIV service status of the patient and Harris hips call pre and post operatively. As of 2013, 2014 also started uh collecting data about Oxford uh hips fall. Now there were no a laminar flow theaters. The surgeries were done in no uh theatres with no laminal throws in general. Patient's were reviewed at 636 months and then annually, they were assessed for pain and function and radiographs were evaluated for radio recency factors around the implant. So it change in position or heterotopic ossification assessments were done for infection. Uh In general procedures were performed by six surgeons in at least three institutions. Uh in general, uh all surgeries would use the uh cemented prosthesis uh with antibiotics, loaded cement. Um in terms of uh Harris hip schools at 10 years, uh there was a decline noted but these schools were comparable with those of other series at the same time from those in high income settings and they were generally above the thresholds parading they need for revision. Now, out of a joint registry, we've been able to publish a few papers. We've been able to publish uh works on total hip replacement in HIV, positive patient's and uh short term outcomes from total knee arthroplasty in low income countries, both have had good outcomes uh motivated by our National Joint Registry. I think Zambia has made some inroads towards establishing their own National Joint Registry and they published a paper uh reviewing uh they're registry as far as I'm aware. uh there isn't a country in Sub Saharan Africa who is currently managing a National Joint Registry. Now, in general, we can see from my talk that despite resource constraints where uh we have good results reported in the literature and Sub Saharan Africa. And of course, we have a slightly different demographic from high income nations. We need to analyze the long term outcome results. Um uh This cohort, uh there's obviously a role for national joint registries within the region in ensuring the delivery of equality, arthroplasty service. My hope is after this talk, we can seriously consider uh each within our own country is introducing our own national um joint registries and thereby as well standardizing the data that is controlled and thereby allowing us to pull um data from different countries and come up with uh long term outcome results uh for our patient's. Thank you. These are my sources. Thank you calling me excellent presentation. Very interesting. I think that it's very clear to me that uh even from the case presentations done today that there's a big need for uh joint registry that's Sub Saharan African Wide perhaps. So, uh it seemed like there was some interest among the presenters and the faculty. So we should continue this conversation would be something that we would at at Harvard, be very interested in trying to find a way to support uh if there's any way that we could do that. Um But I'll open it up to, you know, sorry, David, go ahead if you have any questions and for any of the fact, no, I thought that was wonderful doctor. Um uh I would just ask, what would you uh recommend are the first steps to starting a registry for those countries that might want to begin? I think, I think uh first of all their, their needs to be a concessions by the local orthopedic association that this is the direction um you want to go because that's the most important part you have to have uh it taken by the local surgeons. Now there's no use establishing a National Joint Registry when two thirds of your surgeons are not willing to report their outcomes. I think once you have a buy in from the local tha pedic Association, everything else becomes uh easier because I think they're going to be the stewards of the National Joint Registry. It helps in Malawi that this concessions was easily reached because we have a small number of surgeons. Uh generally agree. But when you have 100 surgeons, it makes it even more challenging. Same. Um And maybe Victor from Kenya and Violet from Tanzania. Has there been any thought into creating um these source of registries in your settings? Yeah. Yeah. I've done Victor here from Kenya. Uh Yes. Um excellent presentation from Malawi. And it's really inspiring to, to, to, to, to know that Malawi has managed to do this despite, of course, it's uh economic uh situation and also the uh population. And the challenge of course, it is facing with the infectious disease, competing with orthopedics and and all the other uh necessary medical special specialties available. Now for us in Kenya, there's been talk, uh we've had a lot of uh situations where we've talked about the need for a joint registry. And uh most of us in arthroplasty, understand that it's important. Uh We however, having succeeded and uh this, this has led to us thinking like in our center, thinking of setting up hospital best kind of registry which will eventually uh be up scaled to become a regional and hopefully national. Uh of course, it uh from Malawi, I think it was easier because uh maybe it was they had fewer number of surgeries. So it's not difficult to get by. But of course, installation such as ours where the number of uh sergeants doing arthroplasty is is high, then it's more challenging. And uh but still it has to be done one question, where do you get your funding? How did you get your funding for your project for your arthroplasty problem? And secondly, how do you um how do you compile the data that you receive? Do you do it centrally through your orthopedic National Orthopaedic Association or you do it remotely and then you uh push the data forward to a central location. How do, how do you go about it? So I miss that. Um So we're lucky enough to um get some funding from several organization. One was the John Channel E Trust um A oh Foundation and uh British Orthopaedic Association. So that has really helped in terms of running this registry. It's run centrally through a central office and then data is sent to uh an officer who is in charge of uh of the registry. Um So really the importance is also on the surgeon to ensure when they have done a joint registry to inform this officer uh of this uh replacement. And from there, the officer actively follows up but it's done centrally. Oh yeah. Lastly, then maybe, perhaps, maybe you can share your email with me and then maybe we can pick up this discussion on the later on. And uh we see where, how we can collaborate and and make this uh this side of the. Uh definitely I'll share that with you. So from our side, we had maybe a couple of hospital based registries but the nationwide, you know, uh we, we had some discussion during our orthopedic society meeting, but uh we were not able to get funding to take it further. Uh But definitely we have uh that asset, uh questionnaires and everything. Uh, but defending is really our, the limiting factor for Ethiopia at the moment, I think it would be very helpful for us on our side if we could find a way of trying to support this effort. I mean, the idea of a Sub Saharan African wide, um you know, hip Fracture Hip Arthroplasty Registry would be just phenomenal for so many reasons. Um You know, identifying good producers of implants, identifying best practices, um risk factors for complications. I mean, the list goes on and on. Um I guess we'll continue this conversation offline about what would be the like, how much funding would be necessary? What, what would it go towards that sort of thing, be very useful? Um There, there's one question just to bring it back to a more clinical um point of view uh from the audience. Um uh Johannes Negussie do had the question, what is the place in total hip replacement of young patient's after septic arthritis as post septic hip is common in Africa. But I mean, I know that in, in the Fracture Registry and certainly the project that's being done uh by the Norwegians in Malawi, you guys do have a lot of post septic hip patient's that end up being put on that list with a very long waiting list. So I'm just curious if you and some of the others would like to comment, uh an answer to Johannes question. Uh, total hip replacement and septic arthritis. Do you guys do that? What are your thoughts? Yes. Uh I think from one of the articles we, uh we've actually reported uh total hip replacement one in a TB patient um with generally good outcomes um as for actually analyzing this subset septic arthritis because mostly we see that. But uh you know, the end stage of it all, you know, they've probably had a history of septic arthritis as a child that was missed and then they have an arthritic joint. Uh but as for somebody who have a definitive diagnosis and uh an acute uh definitive diagnosis, no, we don't have that data available but generally, you know, you know, have had good reason. Yeah, doctor like, you know, did you have a comment any other comments about that? I think that the question was for um you know, post you know, septic arthritis happened as a kid. They have obviously arthritis and then doing those cases, I think it's a common indication. Um The other, the other question. Sorry, same. Did you, do you want to say? Yeah. So my take on it is I don't, I don't advise people to undergo hip replacement, let alone in septic or in any other scenarios unless there is, you know, uh signific can't be in affecting their bail you living. You know, I don't recommend them at all. I strongly advise them against this. You know, patient's with everyone of them, come to us with, you know, Angulos Jeep without pain, uh post safety. Keep they come uh asking for hip replacement with shortening, uh complain things like that. So my, my take on it is, you know, it's not an easy thing, you know, hip following uh TV is straightforward physical, you know, you know, you need to deal with TV and represent a reactivation and things like that. But for safety keeps a different ballgame. Now, the uh femoral side back and you know, even I don't think the canal is not that easy to deal with. So I think it should be in a strongly reconsider before indulging into converting a septic keep into a replacement unless there is, you know, good enough strong evidence in even even in those scenarios should make sure you have all the backups possible to consider converting them into it. Totally. Thanks. Same one more good question. A couple more good questions from the chat here. Uh Same, your whole presentation was actually about this one. So what solutions do you implement to overcome the logistical challenges related to prosthetic acquisition, distribution and patient follow up in these settings. This is from Alexis Gonzales. You had a very nice presentation talking about your system. Maybe you just want to give three quick points about you're muted. Same, sorry, same. You're, you're muted. We can't hear you. Oh, so that was, uh, Alexis, if I, if I may ask you can't, right where you're, you're, where you are from, uh, you know, you know, depending on the rules and regulations that we have in our settings. You know, we might have, uh, different ways of addressing, uh, this, this issue basically. Right. You know, in Ethiopia one, there is no in Ethiopia, Kenya, in some of the, uh, most of the African countries, there is no, uh, oh, dear, same. I think your connection is cutting I/O a little bit. I'm, I'm afraid. Can't really hear you. Um, yeah, there you are going to hear me now. Yeah, we can hear, you know, uh, so basically, you know, uh, the main, the main issue that we have at the moment is, you know, the supply is quite limited. Uh, I'm trying to get funding and donations is, you know, always very challenging and limiting. Uh, you know, in terms of the top type of supplies, you know, the inventory get is quite limited. So I think the way forward is, you know, to find a reliable, uh, people to address this by importing it or if you can get into it, you know, you can actually solve most of the issues including, you know, the cost and things like that. I think the way, the way for our, if your country's rule is not against you, uh you know, importing it that, that might be uh the way forward. But, you know, again, you have to think twice, you know, and no, the uh your demography to get, you know, uh Thanks, same. And I think the takeaway that I took from your presentation is you created this own, your own importation company. You have wonderful relationships would be uh Ministry of Health and the FDA. In order to get these devices into the country, it requires building that network and being creativelive to find solutions, which I thought was really inspiring from your talk. Um The last question I have here before we'll wrap things up is from Samson Tool. Uh How do you adjust limb length in a very deformed acetabulum and shorten limb? What is the place of using C arm when you want to put the cup where it should be? Maybe I'll pose this one too. Uh Doctor Kennedy Yeboah Dominic. Do you have a comment on that one? And perhaps also Cable Marina, if you would like to comment on that to be great to hear from you? Yeah, thank you, Karen. Um The, the shortening, uh it will depend on what is causing the shortening if it is uh due to subsidence of the stem, like the case we presented from Ghana. In that case, you have to address it specifically. But if it's due to a dysplastic cast Obel, um then you need to uh set your cup at a level that will restore the center of rotation of the hip. And uh using uh cm or inter operative imaging could be very helpful in making sure that you don't have a high set center of rotation. Thanks, Dominique. Um Keppra. Are you there? Do you have any comments on that one? I mean, if he with with any surgery areas proper planning prior and I think if you can template well early on. So again, it does dependent supply. I mean, supply our use. Uh we're able to get templates from them as well. So the difficulty then is getting the proper X rays. But if you get the proper x rays, you ensure that you do your pre op templating, then it gives you a better idea of where you want to place both the components established and the femoral component before you start and then interpreted li if you find any big variants on what you're expecting, then that's when you start to have to think on your feet and see what you can do to change it. Um But yeah, it's, it's not easy. I mean, even having a C arm for those who do have a C arm introducing uh again, if you don't have a C arm cover, that's introducing something that's not sterile into your field and a lot of things that will prevent you from doing that. So I think it's, it's, it can be challenging. And also the other, I think in the end, the question is you meant this notice to talk about a lot of shortening, you have to be realistic as to how much shortening you can correct. And I think you just have to have a discussion with the patient's beforehand. Uh You know, you have a patient with a five centimeter shortening, which is often we do see sometimes uh you just say to the, you know, they have to, you have to be realistic that you can't correct all the shortening. You know, I've had one or two patient's with some sciatic stretch and pain afterwards from trying a little bit too much to try and reconstruct the length. Uh And sometimes you just have to accept that it's uh that you're not going to get it all the way. Great comments. Thank you. Um As I get the last set of slides up and running for our conclusion, are there any more comments, Karen Economic one suggestion? Yes, I I think that just as you suggested, we need to merge our data across Africa because of low volumes. The African market is unattractive to um manufacturers and distributors of uh tra plastic components. So when we emerge data, it could increase the strength of the market and probably attract these manufacturers to, to improve the supply of um revision, especially revision components are to improve actual plasty in Sub Saharan Africa. Thank you. I agree. With you Dominic. Absolutely. I think if, if there was evidence that there was a market in Sub Saharan Africa, that would certainly attract large companies to turn their attention to the continent. And it would also give an opportunity for smaller companies from say India or China that are already playing a role in distributing devices to Africa to let's say, improve the quality and improve their penetration into the African market so that they can um you know, showcase actual high quality implants that there are those to be to be seen, you know, um giving feedback on the quality from these sorts of studies I think would be very useful in many different ways. Great, great uh presentations from everybody. And uh I guess I'll just say a few words here in conclusion. Thank you so much to all of our presenters in our faculty. Uh All of the folks who helped us organize the conference, everybody who contribute a lecture to the pre recorded materials helped us evaluate the, the articles that went out as well with pre pre uh three course materials. And of course, all of our case presenters are um featured lecturers, same and co any. Uh and of course, all of our faculty who contributed to the discussion today, both from the United States and from overseas. Thank you so much for your help. Um So for those of you who are asking in the chat and just to summarize here, uh there is a certificate of participation for anybody who attended today's conference. You attend the live conference and you complete the course evaluation pre imposed conference. You'll get a certificate of participation. Thank you so much for joining us today on behalf of the Harvard Global orthopedics Collaborative and our nonprofit organizations. So on a global, we're really grateful for the opportunity to showcase the Incredibles talent, the challenges as well as the solutions to um to building hip arthroplasty in Africa. It's really our pleasure to do this. Thank you so much of the global orthopedics that John Hopkins Group, world orthopedic concern and of course to medal for uh for allowing us to use their platform today. Any comments or questions, please send us an email. Um We're always happy to communicate and please do fill out our survey so we can continue a these conferences better. This is our first attempt at doing hip arthroplasty arthroplasty in general. Um We really want to focus on trying to improve access to this essential surgery uh for the poor and the vulnerable, you know, the the average person, uh the people who cannot afford it. Um you know, in private setting, that's our goal to make these sorts of essential surgeries available to all. Um And if these educational um opportunities are helpful in that way, please do let us know how we can make them even better. So, thanks so much