First operating list

I was picked up by Dr Ogedad this morning to take me and my suitcase ( weighing 35 plus kgs) full of donated orthopaedic equipment to the hospital here. I am very grateful to Dunedin Hospital for this donated equipment which was very much welcomed by all the orthopaedic registrars. I went over the equipment with them and they looked very happy.

Tuesday is theatre list day. I was curious whether anything had changed in the operating theatre since my last visit! Well the only difference I noticed is that they replaced the doors. Otherwise everything was the same. They had 2 image intensifiers at one stage but they have broken down and nobody can fix them here. This is a real problem with high tech equipment in countries like Haiti. No technical support. The registrars told me that one day when they were using it they saw smoke coming out from the back of the tower and that was the end! So unfortunately all orthopaedic cases have to be done without intra operative imaging which makes things rather difficult.

The first case was a lady in her 60’s with a displaced neck of femur fracture. She had been put on Warfarin for DVT prophylaxis which I was told about just before the induction of the anaesthetic. I was reassured that it had been stopped 24hrs ago and when I enquired about her INR they told me that this blood test was not being done at the hospital. I had a chat to Steve Benford, anaesthetist, who told me that the anaesthetic registrar was about to give a spinal which is normally contra indicated if the patient is on Warfarin because of the risk of intraspinal bleeding. Anyway surgery went ahead uneventfully from a bleeding and anaesthetic point of view but due to the limited sizes of hip implants available the insertion of the stem required some ‘hearty’ reaming. However in the end it all looked good.

The second case was a middle aged man who presented with longstanding stiffness of his lower limbs and as a result could only walk with 2 axillary crutches . The history was unclear but it looked like he had a tibial shaft fracture on the left which resulted in a malunion ( healed in a bent position) and a proximal tibia and tibial plateau fracture and discontinuity of the extensor mechanism as his knee was almost ankylosed ( stiff) and the patella retracted proximally. His main problem was an ankylosis of both ankles in equinus ( both feet pointing downwards)which forced him to walk on the tip of his toes. As both ankles were completely stiff any soft tissue surgery , for example a tendo Achilles lengthening ,wouldn’t have achieved any correction so we decided that the only way to help this man would be to correct his ankle deformities by carrying out an osteotomy through the ankle joint to bring his feet to a plantigrade ( foot at 90 degrees to the leg) position. We did the right side first and obtained a good correction. The fixation was done with pins as there were no appropriate screws available followed by a plaster.

The last case was cancelled as by that stage it was 4.00pm.

So there you go: 2 operations in one day! You have to have the’ glass half full rather than half empty‘ attitude here to keep your spirits up!!!