Introduction

Musculoskeletal (MSK) disorders are common in populations all over the world and they are a leading cause of disability and time off work. A wide variety of conditions are included within the spectrum of MSK disorders. They may involve a number of different anatomical structures such as bone, the structures within joints and the periarticular structures which includes muscles, tendons, ligaments or bursae. They may have an acute onset as seen with hip fracture in an elderly osteoporotic patient or multiple bone trauma associated with road traffic injuries, or chronic knee pain associated with osteoarthritis or chronic neck pain associated with cervical spondylosis. The pain may be localised to a single joint area or patients may have chronic widespread pain (CWP). The source of the MSK disorder may be mild and minor as occurs with abnormal posture or overuse, or it may be severe and demand immediate intervention as in patients with suspected septic arthritis or neurological complications after spinal injury.

Measures such as the World Health Organisation (WHO) International Classification of Functioning, Disability and Health (ICF) can be used to determine the impact of a particular problem regardless of the cause. The ICF includes assessment of the body structure and function, activity limitation and any restriction to participation in life situations. The development of any impairment may also be influenced by contextual factors which also include personal and environmental factors.

The burden and impact of MSK disorders

A detailed discussion on the burden of MSK disorders is beyond the scope of this chapter and some of the disorders are discussed in detail in other chapters in this issue. Some of the more common conditions will be discussed briefly. The risk factors and some of the strategies to prevent or limit the consequences of these disorders are also discussed.

• A)
  

  MSK pain

MSK pain is one of the leading reasons for primary care consultations in industrialised countries. Community-based studies such as the community-oriented program for the control of rheumatic diseases (COPCORD) studies in developing countries were reviewed by Chopra and Nasser and they noted that the prevalence of painful MSK disorders in urban populations vary from 12% in Vietnam to 47% in Peru and from 12% in China to 55% among Australian aborigines in rural surveys . These studies have shown that although the spectrum of the rheumatic diseases was similar to industrialised countries, the burden of the disease was much higher.

Generalised MSK pain syndromes include CWP and the fibromyalgia syndrome (FMS). From an epidemiological perspective, it is important to determine the burden of MSK pain and its associated disability rather than the specific designation of the syndrome. The new American College of Rheumatology (ACR) criteria for fibromyalgia shows that there has been a change in the conceptualisation of chronic MSK pain syndromes as a continuum rather than a specifically defined category .

CWP occurs frequently all over the world and is estimated to range from 4.2% to 13.3% and contributors to this variation include genetic and environmental factors . In developing countries, the prevalence of CWP in not known. The prevalence of fibromyalgia varies from 0.8% in Finland to 3.7% in Italians . In Brazil, the prevalence of FMS was 2.5% and 3.2% in Bangladesh . The risk factors associated with the occurrence and persistence of CWP/FMS include female gender, increasing age, family history, obesity and poor mental or physical status.

• B)
  

  Low back pain

Low back pain is a common public health problem and is considered to be one of the leading causes of absence from work and limitation of activity all over the world . The incidence of the first episode of low back pain ranges from 6.3% to 15.4% over a 1-year period and many patients experience recurrent episodes. Among injured workers, about one-third has recurrence within 1 year . The low back pain may arise from different anatomical structures, and in the majority of patients the specific cause of the low back pain is not clearly identified. However, in only a minority of patients, the low back pain is due to infection, neoplasm or an osteoporotic fracture and these patients can usually be identified by careful history and examination.

The incidence of low back pain is highest in the third decade. The prevalence increases with age until 60–65 years and then declines . There is an increased prevalence of low back pain in association with a lower educational status and lower social status. Factors in the workplace which contribute to persistence of low back pain include low job satisfaction and low workplace support . In Japan, Matsui et al. found a point prevalence of low back pain of 39% in manual workers and 18.3% in male sedentary workers . Activities that involve lifting heavy weights, frequent bending and twisting are associated with lumbar disc disease. In low- and middle-income countries (LMICs), activities such as carrying loads on their head and agricultural activities are also common causes of low back pain . A number of psychosocial factors such as stress, depression and anxiety are associated with low back pain but it is not always clear whether they are causal or result from limitation of activity due to low back pain.

• C)
  

  Osteoarthritis

Osteoarthritis (OA) is the most common form of arthritis in both low-income countries and the rest of the world. In Asia, the prevalence of knee OA was 7.9% in a pooled sample of 41 884 patients from 11 COPCORD studies, which included younger patients . The prevalence was 16.7% among adults aged >45 years in the Johnston county study and 12.6% among adults in the National Health and Nutrition Examination Survey (NHANES) III study . The population of Asia is projected to rise to 4.3 billion in 2020 from the current 3.9 billion. It is estimated that 20% of the population will be over 60 years and that around 15% will have symptomatic OA. About one-third of these patients will have severe disability. Thus, in Asia alone, about 40 million of the 130 million people with OA will have severe disabling disease in 20 years time . The majority of patients in developing countries do not have access to joint replacement surgery and as a result they will have to endure severe disability for a significant part of their lives placing enormous strain on community resources.

The major risk factors for the development of knee OA are age, female gender, obesity, occupations that require squatting or kneeling for more than 2 h a day, climbing, lifting weights or prolonged standing and walking. Thus, prevention strategies, which include lifestyle measures to reduce obesity, and occupational-related strategies to avoid repetitive activities which predispose to OA, are of great importance.

• D)
  

  Rheumatoid arthritis

In Europe and North America, the prevalence of rheumatoid arthritis (RA) is estimated at 1% of the population, and a fall in the incidence of RA and an older age of onset has been recorded. In developing countries, the prevalence of RA has ranged from 0.1% to about 1% with most of the studies reporting a prevalence of between 0.2% and 0.5% . There also appears to be a rise in the prevalence of RA with a younger peak age of onset. Major advances have been made in our understanding of the pathogenesis and natural history of RA. Thus, achievement of remission or low-disease activity is now a realistic goal for most of the patients. In addition, the new 2010 American College of Rheumatology (ACR)/European league against rheumatism (EULAR) criteria enable a diagnosis of RA to be made earlier and facilitate the initiation of disease-modifying drug therapy before there is any joint destruction. The ‘treat to target’ approach has led to the development of treatment algorithms to achieve low disease activity or remission. The use of imaging techniques such as ultrasound and magnetic resonance imaging has further provided a challenge to try to achieve not only clinical remission but also remission based on imaging. However, cost and access to these imaging modalities will lead to clinical assessment and use of inflammatory markers as the mainstay of clinical practice in most parts of the world.

The availability of biological agents over the past decade has revolutionised the management of patients with refractory RA. The ability to develop targeted therapy has resulted in a number of different classes of biological agents being already available, and many newer agents are undergoing clinical trials at present. However, none of these agents is consistently associated with long-term remission and therefore more agents are needed. Unfortunately, the cost of these agents limits their use in the majority of the low-income countries. The risk of infections such as tuberculosis (TB) will further limit their use in countries which have a high background prevalence of TB. Newer treatment strategies to evaluate the response to short-term or intermittent use of these biological agents, and the availability of oral agents and bio-similar preparations, will hopefully result in lower prices and may increase the access to these newer agents.

Many patients in low-income countries do not receive the conventional disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate, chloroquine and salazopyrine at an early stage and only seek medical attention when there is joint destruction and severe disability. Thus, the most important challenge in the management of RA in these countries is early diagnosis and referral so that patients can have an adequate trial of conventional disease-modifying drugs, either singly or in combination. There is also an increased prevalence of TB in patients on steroids and conventional DMARDs . We also need to define the role of screening for latent TB or the use of INH prophylaxis in RA patients from high-risk communities who are on steroids and conventional DMARDs.

The factors contributing to a delay in diagnosis are many and include lack of education, cultural beliefs and inadequate access to appropriate care which includes physical infrastructure, human resources and the availability of medication. Although major strides have been made over the past two decades, strategies are needed to improve the education and skills of community health workers, primary health-care workers, medical students and medical practitioners.

The establishment of national or regional databases or registries is necessary to monitor local experiences with respect to safety and efficacy. These findings will help to guide clinical practice and also help to identify the most cost-effective models for the identification and management of large numbers of patients in resource-poor settings.

• E)
  

  Gout

Recent epidemiological studies have shown an increased prevalence of gout in Western populations as well as in developing countries in Asia . As a result, gout is now the most common cause of inflammatory arthritis. Patients with hyperuricaemia and gout have an increased risk of mortality which is due mainly to cardiovascular diseases . Men with gout have an increased mortality, independent of other risk factors when compared to men without gout . The risk factors for gout include non-modifiable risk factors such as age, sex and genetic variations in the transporter genes, and modifiable risk factors such as obesity, alcohol consumption, high purine intake and medications such as diuretics. In countries such as South Africa, Taiwan and Pakistan, the prevalence of gout has been reported to be higher in urban populations .

• F)
  

  Spondyloarthritis

The more common conditions within the spectrum of spondyloarthritis (SpA) are ankylosing spondylitis and psoriatic arthritis. The prevalence of ankylosing spondylitis varies depending on the background prevalence of human leucocyte antigen (HLA) B27 which ranges from less than 1% in Africa and the Australian aborigines to 50% in the Haida Indians in British Columbia . In Caucasians, the prevalence of ankylosing spondylitis ranges from 0.15% to 1.8% and the prevalence of psoriatic arthritis ranges from 0.02% to 2% . The Assessment of SpondyloArthritis International Society (ASAS) criteria have been developed for the assessment of axial SpA and peripheral SpA. . They include the use of magnetic resonance imaging for the detection of early sacroiliitis without having to wait for the development of radiographic grade 2 sacroiliitis bilaterally or grade 3 sacroiliitis unilaterally. Recent advances have also included the development of the Classification criteria for psoriatic arthritis (CASPAR) criteria for psoriatic arthritis and they are widely used in clinical and epidemiological studies . Biological agents are effective and used early for axial disease in patients with ankylosing spondylitis and psoriatic arthritis. Patients in developing countries are again at a major disadvantage as patients with axial involvement show a poorer response to salazopyrine when compared to biological agents.

• G)
  

  Occupation-related MSK disorders

Work-related MSK disorders are classified as upper extremity disorders, which include case definitions for 11 common conditions which have a strong association with work , and low back pain and lower extremity disorders . They are a common cause of pain, impaired work performance and disability, and result in absence from work in populations all over the world. They may result in localised problems which may be confined to the hand or shoulder, or the symptoms may be more widespread. In the USA, between 16% and 20% of compensation cases are related to back pain. The prevalence of upper limb disorders in the working population was 20% in the UK and between 20% and 30% in the USA. . In developing countries, poor working conditions, and the lack of stringent labour laws or their implementation, result in work-related MSK disorders being common. Some of the factors contributing to MSK symptoms in developing countries are activities such as carrying head loads, carrying loads on long poles on the shoulder and pulling rickshaws. A Bangladesh study of 100 men who carried head loads of 50–100 kg found that 40% had features of degenerative cervical spondylosis . The mean age of the patients was 35.7 years. Carrying head loads has also been associated with limitation of spinal flexion; back carrying contributes to kyphosis and shoulder carrying is associated with scoliosis . Carpet weaving is a common informal industry in many developing countries and upper limb, neck and back disorders are more common when compared to the general population in Iran .

• H)
  

  Road traffic injuries

The challenges of addressing the increasing number of fatalities associated with road traffic injuries (RTIs) in developing countries have been reviewed by Mohan . There are over 1.2 million deaths as a result of road traffic crashes annually. The morbidity and mortality associated with RTIs have been reduced significantly in high-income countries (HICs) over the past three decades. In LMICs, RTIs are among the second to sixth leading causes of death in the 5–60-year age group. The successes of many of the measures which have resulted in a decline in morbidity and mortality associated with RTIs in developed countries have focussed on motor cars and the occupants of motor cars. These include the wearing of helmets on bicycles and motorbikes and restriction on passenger numbers. The design of roads and intersections has also been directed mainly on the movement of cars, buses and trucks. In many of the LMICs, road users also include substantial numbers of bicycles, motor cycles, human-powered vehicles, pedestrians carrying loads and vehicles which have been designed locally. Thus, it is essential for additional innovative models to be developed to address the challenges in LMICs. It is heartening that the prevention of RTIs is regarded as a public health problem in many of the developing countries. It has also been identified as a strategic initiative of the WHO and hopefully there will be an even greater global effort to find solutions and reduce RTIs and their consequences.

• I)
  

  Osteporosis

The ageing of the population all over the world will lead to an increased burden of osteoporosis. In Europe, osteoporosis contributes significantly to total disability-adjusted life years (DALYs) . In the USA, 54% of postmenopausal white females are osteopaenic and 30% are osteoporotic, and at age 80 years, 27% have osteopaenia and 70% are osteoporotic . A high prevalence of osteoporosis has also been reported from Latin America, India and Iran . The 1-year mortality after a hip fracture is 20–25% and nearly half of the survivors fail to regain full independence . Osteoporosis is addressed in greater detail elsewhere in this issue.

• J)
  

  Impact of human immunodeficiency virus (HIV) infection

The impact of HIV infection on bone and joint surgery has been reviewed by Govender et al. In developing countries, the HIV epidemic places a great strain on the limited resources to cope with the management of patients who require orthopaedic surgery. Among patients who were admitted for orthopaedic surgical procedures, 16% were HIV positive in Zimbabwe, 24% in Zambia and 30% in the Johannesburg trauma unit in South Africa . In HIV positive patients requiring orthopaedic surgery, there is concern about the increased risk of wound infection as well as late infections around implants, wound healing and bone union. The risk of infection has been reduced to about 3.5% with the use of newer implants and improved surgical techniques . There is also a nearly 500-fold higher risk of developing TB infection of the spine, bone and peripheral joints . In addition, there is also a 45-times greater risk of osteonecrosis (avascular necrosis) in HIV-positive patients related to the use of protease inhibitors, hyperlipidaemia, use of corticosteroids and alcohol abuse .

According to the UNAIDS Global Report, at the end of 2009, there were 33.3 million adults and children with HIV, and of them 22.5 million were living in sub-Saharan Africa and a further 4.1 million in South and South East Asia . In 2009, there were 2.6 million new infections with HIV and 1.8 million AIDS-related deaths. At the end of 2009, there were a total of 5 254 000 people who were receiving anti-retroviral therapy, and of these, 971 556 were in South Africa. Although much more needs to be done to reduce the burden and impact of HIV infection, the increased use of highly active retroviral therapy (HAART) will hopefully contribute to a reduction in morbidity related to MSK disorders. A variety of MSK syndromes have been reported in association HAART and they include myopathy, rhabdomyolysis, osteonecrosis, hyperuricaemia, immune reconstitution inflammatory syndrome with the development or relapse of RA and systemic lupus erythematosus and a variety of soft-tissue rheumatic syndromes .

The management of patients with HIV infection and RA or HIV-associated arthritis also presents challenges and we need to develop validated effective guidelines for their management.

The burden and impact of MSK disorders

A detailed discussion on the burden of MSK disorders is beyond the scope of this chapter and some of the disorders are discussed in detail in other chapters in this issue. Some of the more common conditions will be discussed briefly. The risk factors and some of the strategies to prevent or limit the consequences of these disorders are also discussed.

• A)
  

  MSK pain

MSK pain is one of the leading reasons for primary care consultations in industrialised countries. Community-based studies such as the community-oriented program for the control of rheumatic diseases (COPCORD) studies in developing countries were reviewed by Chopra and Nasser and they noted that the prevalence of painful MSK disorders in urban populations vary from 12% in Vietnam to 47% in Peru and from 12% in China to 55% among Australian aborigines in rural surveys . These studies have shown that although the spectrum of the rheumatic diseases was similar to industrialised countries, the burden of the disease was much higher.

Generalised MSK pain syndromes include CWP and the fibromyalgia syndrome (FMS). From an epidemiological perspective, it is important to determine the burden of MSK pain and its associated disability rather than the specific designation of the syndrome. The new American College of Rheumatology (ACR) criteria for fibromyalgia shows that there has been a change in the conceptualisation of chronic MSK pain syndromes as a continuum rather than a specifically defined category .

CWP occurs frequently all over the world and is estimated to range from 4.2% to 13.3% and contributors to this variation include genetic and environmental factors . In developing countries, the prevalence of CWP in not known. The prevalence of fibromyalgia varies from 0.8% in Finland to 3.7% in Italians . In Brazil, the prevalence of FMS was 2.5% and 3.2% in Bangladesh . The risk factors associated with the occurrence and persistence of CWP/FMS include female gender, increasing age, family history, obesity and poor mental or physical status.

• B)
  

  Low back pain

Low back pain is a common public health problem and is considered to be one of the leading causes of absence from work and limitation of activity all over the world . The incidence of the first episode of low back pain ranges from 6.3% to 15.4% over a 1-year period and many patients experience recurrent episodes. Among injured workers, about one-third has recurrence within 1 year . The low back pain may arise from different anatomical structures, and in the majority of patients the specific cause of the low back pain is not clearly identified. However, in only a minority of patients, the low back pain is due to infection, neoplasm or an osteoporotic fracture and these patients can usually be identified by careful history and examination.

The incidence of low back pain is highest in the third decade. The prevalence increases with age until 60–65 years and then declines . There is an increased prevalence of low back pain in association with a lower educational status and lower social status. Factors in the workplace which contribute to persistence of low back pain include low job satisfaction and low workplace support . In Japan, Matsui et al. found a point prevalence of low back pain of 39% in manual workers and 18.3% in male sedentary workers . Activities that involve lifting heavy weights, frequent bending and twisting are associated with lumbar disc disease. In low- and middle-income countries (LMICs), activities such as carrying loads on their head and agricultural activities are also common causes of low back pain . A number of psychosocial factors such as stress, depression and anxiety are associated with low back pain but it is not always clear whether they are causal or result from limitation of activity due to low back pain.

• C)
  

  Osteoarthritis

Osteoarthritis (OA) is the most common form of arthritis in both low-income countries and the rest of the world. In Asia, the prevalence of knee OA was 7.9% in a pooled sample of 41 884 patients from 11 COPCORD studies, which included younger patients . The prevalence was 16.7% among adults aged >45 years in the Johnston county study and 12.6% among adults in the National Health and Nutrition Examination Survey (NHANES) III study . The population of Asia is projected to rise to 4.3 billion in 2020 from the current 3.9 billion. It is estimated that 20% of the population will be over 60 years and that around 15% will have symptomatic OA. About one-third of these patients will have severe disability. Thus, in Asia alone, about 40 million of the 130 million people with OA will have severe disabling disease in 20 years time . The majority of patients in developing countries do not have access to joint replacement surgery and as a result they will have to endure severe disability for a significant part of their lives placing enormous strain on community resources.

The major risk factors for the development of knee OA are age, female gender, obesity, occupations that require squatting or kneeling for more than 2 h a day, climbing, lifting weights or prolonged standing and walking. Thus, prevention strategies, which include lifestyle measures to reduce obesity, and occupational-related strategies to avoid repetitive activities which predispose to OA, are of great importance.

• D)
  

  Rheumatoid arthritis

In Europe and North America, the prevalence of rheumatoid arthritis (RA) is estimated at 1% of the population, and a fall in the incidence of RA and an older age of onset has been recorded. In developing countries, the prevalence of RA has ranged from 0.1% to about 1% with most of the studies reporting a prevalence of between 0.2% and 0.5% . There also appears to be a rise in the prevalence of RA with a younger peak age of onset. Major advances have been made in our understanding of the pathogenesis and natural history of RA. Thus, achievement of remission or low-disease activity is now a realistic goal for most of the patients. In addition, the new 2010 American College of Rheumatology (ACR)/European league against rheumatism (EULAR) criteria enable a diagnosis of RA to be made earlier and facilitate the initiation of disease-modifying drug therapy before there is any joint destruction. The ‘treat to target’ approach has led to the development of treatment algorithms to achieve low disease activity or remission. The use of imaging techniques such as ultrasound and magnetic resonance imaging has further provided a challenge to try to achieve not only clinical remission but also remission based on imaging. However, cost and access to these imaging modalities will lead to clinical assessment and use of inflammatory markers as the mainstay of clinical practice in most parts of the world.

The availability of biological agents over the past decade has revolutionised the management of patients with refractory RA. The ability to develop targeted therapy has resulted in a number of different classes of biological agents being already available, and many newer agents are undergoing clinical trials at present. However, none of these agents is consistently associated with long-term remission and therefore more agents are needed. Unfortunately, the cost of these agents limits their use in the majority of the low-income countries. The risk of infections such as tuberculosis (TB) will further limit their use in countries which have a high background prevalence of TB. Newer treatment strategies to evaluate the response to short-term or intermittent use of these biological agents, and the availability of oral agents and bio-similar preparations, will hopefully result in lower prices and may increase the access to these newer agents.

Many patients in low-income countries do not receive the conventional disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate, chloroquine and salazopyrine at an early stage and only seek medical attention when there is joint destruction and severe disability. Thus, the most important challenge in the management of RA in these countries is early diagnosis and referral so that patients can have an adequate trial of conventional disease-modifying drugs, either singly or in combination. There is also an increased prevalence of TB in patients on steroids and conventional DMARDs . We also need to define the role of screening for latent TB or the use of INH prophylaxis in RA patients from high-risk communities who are on steroids and conventional DMARDs.

The factors contributing to a delay in diagnosis are many and include lack of education, cultural beliefs and inadequate access to appropriate care which includes physical infrastructure, human resources and the availability of medication. Although major strides have been made over the past two decades, strategies are needed to improve the education and skills of community health workers, primary health-care workers, medical students and medical practitioners.

The establishment of national or regional databases or registries is necessary to monitor local experiences with respect to safety and efficacy. These findings will help to guide clinical practice and also help to identify the most cost-effective models for the identification and management of large numbers of patients in resource-poor settings.

• E)
  

  Gout

Recent epidemiological studies have shown an increased prevalence of gout in Western populations as well as in developing countries in Asia . As a result, gout is now the most common cause of inflammatory arthritis. Patients with hyperuricaemia and gout have an increased risk of mortality which is due mainly to cardiovascular diseases . Men with gout have an increased mortality, independent of other risk factors when compared to men without gout . The risk factors for gout include non-modifiable risk factors such as age, sex and genetic variations in the transporter genes, and modifiable risk factors such as obesity, alcohol consumption, high purine intake and medications such as diuretics. In countries such as South Africa, Taiwan and Pakistan, the prevalence of gout has been reported to be higher in urban populations .

• F)
  

  Spondyloarthritis

The more common conditions within the spectrum of spondyloarthritis (SpA) are ankylosing spondylitis and psoriatic arthritis. The prevalence of ankylosing spondylitis varies depending on the background prevalence of human leucocyte antigen (HLA) B27 which ranges from less than 1% in Africa and the Australian aborigines to 50% in the Haida Indians in British Columbia . In Caucasians, the prevalence of ankylosing spondylitis ranges from 0.15% to 1.8% and the prevalence of psoriatic arthritis ranges from 0.02% to 2% . The Assessment of SpondyloArthritis International Society (ASAS) criteria have been developed for the assessment of axial SpA and peripheral SpA. . They include the use of magnetic resonance imaging for the detection of early sacroiliitis without having to wait for the development of radiographic grade 2 sacroiliitis bilaterally or grade 3 sacroiliitis unilaterally. Recent advances have also included the development of the Classification criteria for psoriatic arthritis (CASPAR) criteria for psoriatic arthritis and they are widely used in clinical and epidemiological studies . Biological agents are effective and used early for axial disease in patients with ankylosing spondylitis and psoriatic arthritis. Patients in developing countries are again at a major disadvantage as patients with axial involvement show a poorer response to salazopyrine when compared to biological agents.

• G)
  

  Occupation-related MSK disorders

Work-related MSK disorders are classified as upper extremity disorders, which include case definitions for 11 common conditions which have a strong association with work , and low back pain and lower extremity disorders . They are a common cause of pain, impaired work performance and disability, and result in absence from work in populations all over the world. They may result in localised problems which may be confined to the hand or shoulder, or the symptoms may be more widespread. In the USA, between 16% and 20% of compensation cases are related to back pain. The prevalence of upper limb disorders in the working population was 20% in the UK and between 20% and 30% in the USA. . In developing countries, poor working conditions, and the lack of stringent labour laws or their implementation, result in work-related MSK disorders being common. Some of the factors contributing to MSK symptoms in developing countries are activities such as carrying head loads, carrying loads on long poles on the shoulder and pulling rickshaws. A Bangladesh study of 100 men who carried head loads of 50–100 kg found that 40% had features of degenerative cervical spondylosis . The mean age of the patients was 35.7 years. Carrying head loads has also been associated with limitation of spinal flexion; back carrying contributes to kyphosis and shoulder carrying is associated with scoliosis . Carpet weaving is a common informal industry in many developing countries and upper limb, neck and back disorders are more common when compared to the general population in Iran .

• H)
  

  Road traffic injuries

The challenges of addressing the increasing number of fatalities associated with road traffic injuries (RTIs) in developing countries have been reviewed by Mohan . There are over 1.2 million deaths as a result of road traffic crashes annually. The morbidity and mortality associated with RTIs have been reduced significantly in high-income countries (HICs) over the past three decades. In LMICs, RTIs are among the second to sixth leading causes of death in the 5–60-year age group. The successes of many of the measures which have resulted in a decline in morbidity and mortality associated with RTIs in developed countries have focussed on motor cars and the occupants of motor cars. These include the wearing of helmets on bicycles and motorbikes and restriction on passenger numbers. The design of roads and intersections has also been directed mainly on the movement of cars, buses and trucks. In many of the LMICs, road users also include substantial numbers of bicycles, motor cycles, human-powered vehicles, pedestrians carrying loads and vehicles which have been designed locally. Thus, it is essential for additional innovative models to be developed to address the challenges in LMICs. It is heartening that the prevention of RTIs is regarded as a public health problem in many of the developing countries. It has also been identified as a strategic initiative of the WHO and hopefully there will be an even greater global effort to find solutions and reduce RTIs and their consequences.

• I)
  

  Osteporosis

The ageing of the population all over the world will lead to an increased burden of osteoporosis. In Europe, osteoporosis contributes significantly to total disability-adjusted life years (DALYs) . In the USA, 54% of postmenopausal white females are osteopaenic and 30% are osteoporotic, and at age 80 years, 27% have osteopaenia and 70% are osteoporotic . A high prevalence of osteoporosis has also been reported from Latin America, India and Iran . The 1-year mortality after a hip fracture is 20–25% and nearly half of the survivors fail to regain full independence . Osteoporosis is addressed in greater detail elsewhere in this issue.

• J)
  

  Impact of human immunodeficiency virus (HIV) infection

The impact of HIV infection on bone and joint surgery has been reviewed by Govender et al. In developing countries, the HIV epidemic places a great strain on the limited resources to cope with the management of patients who require orthopaedic surgery. Among patients who were admitted for orthopaedic surgical procedures, 16% were HIV positive in Zimbabwe, 24% in Zambia and 30% in the Johannesburg trauma unit in South Africa . In HIV positive patients requiring orthopaedic surgery, there is concern about the increased risk of wound infection as well as late infections around implants, wound healing and bone union. The risk of infection has been reduced to about 3.5% with the use of newer implants and improved surgical techniques . There is also a nearly 500-fold higher risk of developing TB infection of the spine, bone and peripheral joints . In addition, there is also a 45-times greater risk of osteonecrosis (avascular necrosis) in HIV-positive patients related to the use of protease inhibitors, hyperlipidaemia, use of corticosteroids and alcohol abuse .

According to the UNAIDS Global Report, at the end of 2009, there were 33.3 million adults and children with HIV, and of them 22.5 million were living in sub-Saharan Africa and a further 4.1 million in South and South East Asia . In 2009, there were 2.6 million new infections with HIV and 1.8 million AIDS-related deaths. At the end of 2009, there were a total of 5 254 000 people who were receiving anti-retroviral therapy, and of these, 971 556 were in South Africa. Although much more needs to be done to reduce the burden and impact of HIV infection, the increased use of highly active retroviral therapy (HAART) will hopefully contribute to a reduction in morbidity related to MSK disorders. A variety of MSK syndromes have been reported in association HAART and they include myopathy, rhabdomyolysis, osteonecrosis, hyperuricaemia, immune reconstitution inflammatory syndrome with the development or relapse of RA and systemic lupus erythematosus and a variety of soft-tissue rheumatic syndromes .

The management of patients with HIV infection and RA or HIV-associated arthritis also presents challenges and we need to develop validated effective guidelines for their management.