Chronic Diseases or Illnesses

The self-reinforcing constellation of the chronic noncommunicable diseases and conditions – diabetes, obesity, hypertension, and respiratory and cardiac disease – that adversely affect the management of orthopedic conditions in high-resource countries present more varied and complex problems in the developing world. Besides occurring at a younger age and being poorly controlled, patients may not be aware of the extent of their medical problems, may fail to understand the need for long-term medication to control the pathology, or may not have the resources to buy necessary drugs. The expensive tests, therapies, and consulting expertise found in Western health systems to prepare patients for elective surgery are lacking in resource-poor settings. Managing trauma in the face of unaddressed and unmanaged comorbidities can transform already complicated situations into complex life-threatening ones [1, 2].

Western diet, a sedentary urban lifestyle, and increasing longevity due to improvements in public health contribute to the ongoing increase in cardiac disease. The greater availability of antibiotics, even when inappropriately used, has seen a decrease in rheumatic heart disease, but it still remains a relatively common medical problem in developing countries, especially among the young and young adult populations. Unrecognized diminution in cardiac reserve and the lack of drugs outside the basics can compromise anesthesia and recovery.

Seventy percent of the over 280 million people with diabetes live in low- and middle-income countries (LMICs). It is one of the fastest growing chronic diseases, both in incidence and prevalence. The majority is type II diabetes, often undiagnosed for years leading to the additional burden of diabetic retinopathy, renal disease, and neuropathy that compromise orthopedic outcomes [3].

The world’s burden of chronic respiratory disease falls disproportionately among the poor in developing countries. Households that depend on open fires for food preparation often have poor ventilation, or the fuel incompletely combusts, causing high levels of chronic indoor particulate and toxic chemical pollution. Growing levels of air pollution in urban areas – caused by an increase in motorized transport, traffic jams of idling cars, spewing fumes from poorly tuned vehicles, and using inadequately processed petrol – increase the amount of low-grade, unaddressed chronic pulmonary pathology that can increase postoperative complications [4].

Ophthalmologic disease is widespread in developing countries and is often unrecognized or untreated. Trachoma, a highly contagious Chlamydia infection scarring the eyelids, cornea, and conjunctiva, is endemic in many parts of the developing world and, like most infectious diseases, is associated with poor sanitation and hygiene and disproportionately affects the poor. With an increase in both life span and the incidence of diabetes, untreated cataracts are a common cause of blindness or poor vision. Many public health systems lack formal visual screening programs.

Many public health workers consider tobacco as the number one health problem in the developing world. Its association with the increased incidence of cardiac and respiratory diseases and diabetes makes it a particularly lethal problem. Few smokers in developing countries fully understand the deleterious health effects of tobacco. Governments have little money or incentives for education campaigns and “Big Tobacco” actively lobbies to limit anti-smoking legislation or proposed tax increases that could potentially curb tobacco use. The idea that smoking adversely affects a wide range of health issues, including fracture healing, is laughable to many smokers in developing countries [5].

Nutrition

Malnutrition is difficult to assess clinically. Even in families with apparently well-nourished or frankly obese individuals, some members, especially women and children, may have unrecognized severe malnutrition. The deficiencies can be in calories, protein, vitamins, micronutrients, or any combination. Few developing country laboratories are equipped to sort out the specific deficiencies, while supplements may be beyond the means of the system and the individuals. Economic development, particularly in middle-income countries, is leading to a fairly new form of malnutrition: overnutrition. The prevalence of obesity is rapidly increasing in both sexes and in all age groups [6]. Adverse effects on health in general and orthopedic conditions in particular are well known.

Eating is highly cultural with certain food combinations prohibited or prescribed for the sick and ill that may not conform with a Western-trained physician’s idea of proper nutrition. High-protein meals are recommended for trauma and burn patients and those with catabolic complications. Multiple trauma patients can require up to 6000 cal/day. Families should be encouraged to provide supplemental proteins and calories in the form of eggs, milk products, meat, and legumes.

Deficiencies in vitamin D and calcium leading to osteoporosis and osteomalacia are common in women, including young women, living in societies that demand all parts of the body be covered. Osteoporosis is further compounded in the same populations by restrictions of physical activity. The lack of safe streets and areas for exercise further enforces a sedentary lifestyle among the growing middle class. Walking for exercise and enjoyment appears to many who have recently purchased a car to be a step backward in personal economic development. Supplemental calcium, vitamin D3, and vitamin C in sufficient and bioavailable doses may improve fracture healing and, if available, should be encouraged (Rickets is discussed in Chap. 12).

Some areas have a high incidence of iodine-deficiency goiter, though most such individuals are euthyroid. In severe cases, hypothyroidism may develop and complicate orthopedic treatment.

Anemia and Hemoglobinopathies

Chronic anemia is a widespread problem in developing countries, especially in women following multiple pregnancies and in children after repeated bouts of malaria. A hemoglobin (Hb) level below 6 g compromises the body’s ability to heal acute injuries, infections, and chronic conditions. Such patients require blood transfusions before even minor surgery, such as skin graft. Some surgeons will not do skin grafting if the Hb is below 10 g [7], but more important than the Hb value is the quality of the granulation tissue, itself dependent on good tissue oxygenation. We would not hesitate to skin graft on a good granulation bed with an Hb of 8 g. Organized blood banks may not be present or reliable, making family members a common source of transfused blood, often with only rudimentary cross matching. Local doctors are usually adept at “conjunctiva grams” – correlating the color of the conjunctiva of the lower eyelid with an Hb estimate or observing the color of the tongue or palm – but a finger-stick Hb is more reliable.

Though hardly a disease, pregnancy as a “comorbidity” needs to be assessed in young women. The attendant anemia, potential hypertension, and cultural restrictions may complicate orthopedic treatments. It is wise to assume that all women of childbearing age are pregnant and ask a colleague how best to verify this.

Hereditary coagulopathies, such as hemophilia A or B, are severe diseases and not commonly seen in low-income countries, because of the short life expectancy. In middle-income countries, the diagnostic and therapeutic resources may be available for treatment, and one might see a child or adolescent with a musculoskeletal complication, such as a chronic arthropathy, with stiffness or ankylosis. Any procedure, including closed manipulation, is at high risk for complications and should be considered only if hematology expertise is present and replacement factors are available in adequate supply. Milder forms of coagulopathies are often undiagnosed and may present as significant postoperative bleeding [8].

Hereditary hemoglobinopathies such as sickle cell disease or thalassemia are common in LMICs. They are recessive diseases. The heterozygotes are healthy carriers of the trait, which is said to be protective against certain diseases such as malaria. The many forms of thalassemia are seen in Asia, the Middle East, and some parts of Africa. They are relevant to orthopedic care only because they are associated with chronic anemia. Sickle cell disease on the other hand has significant, sometimes dramatic musculoskeletal manifestations. It is common in West Africa and to a lesser degree around the Mediterranean basin. It should be part of the routine differential diagnosis for musculoskeletal pain and/or infection.

Sickle cell crisis manifests with acute abdominal and/or long bone pain, which can be multifocal and severe. Both proximal humerus and femur and vertebrae are common sites, leading to avascular necrosis with degenerative joint disease or acute and subsequent chronic osteomyelitis, usually with a visible sequestrum on x-ray. The differential diagnosis between a sickle crisis and acute osteomyelitis is not easy, especially in children. In general, acute osteomyelitis will give a slightly higher fever and a more elevated white count. Older patients who have had crises before can usually say if their symptoms are the same or different compared to previous episodes.

The cornerstones of treatment are transfusion for anemia and aggressive PO or IV hydration. If there is no significant improvement at 24 h, empirical use of antibiotics should be considered. X-ray changes are late findings, and the decision to decompress a suspected infection should be based on other factors (see Chap. 29).

Sequestrectomy, after correction of the anemia, is the treatment of choice for chronic osteomyelitis in association with sickle cell disease. We have found no evidence in the literature to support the idea that use of a tourniquet will precipitate a crisis [9]. We have undoubtedly and unknowingly performed many procedures on sicklers using a tourniquet without obvious deleterious effects. The benefits of a clear and dry field outweigh the risks, if any, in our opinion (see Chap 31).

Infectious and Parasitic Diseases

High incidences of hepatitis A, B, and C are found in many developing countries leading to acute and chronic liver disease that may impinge on healing orthopedic injuries and infections. Poor sanitation and lack of controls regarding food processing lead to hepatitis A. A history of widespread, poorly controlled past public health policies that allowed programs to reuse unsterilized needles for vaccinations and injections has spread hepatitis B and C.

The patterns of incidence for HIV/AIDs (see Chap. 15), the hepatitises, and TB (see Chap. 33) vary among countries and even within the regions of a country. One’s local colleagues should be able to give an idea of prevalence and specific signs and symptoms to help make these diagnoses.

Over half a billion of the world’s people are infected with malaria. The plasmodium species account for between one and two million deaths per year, primarily in children under 5 years. The stress of trauma and/or surgery may set off a recurrence of the chronic illness. Patients who have had previous episodes will often self-diagnose their condition. Malaria should be considered in the differential for any fever in endemic areas, but it is mandatory that postoperative wound infection be ruled out as a cause of fever even while treating the parasite. As with TB, the diagnosis of malaria requires some human and laboratory resources that are not always available. The tests yield a fair number of false negatives, and it is common for local providers to start malaria treatment without a confirmed diagnosis. A rapid clinical improvement is a reliable sign that the diagnosis is correct.

Parasitic helminths are widespread and highly correlated with poverty, poor community sanitation, and ignorance of hygiene. 1.3 billion people worldwide have ascaris infestation [10]. Even moderate infections in children can lead to undernutrition. Over 20,000 people per annum, primarily children, die of such infestations, usually due to bowel or biliary obstruction. The prevalence of hookworm stands at one billion and is a common cause of anemia due to chronic blood loss from the intestine [9]. These and other roundworm infestations are treated with a short course of albendazole or mebendazole. In highly endemic areas, routine treatment on admission may be warranted.

The blood fluke causing schistosomiasis is endemic in the bodies of still freshwater of many tropical and subtropical developing countries. Two hundred million people worldwide are infected with over 20 million having chronic illness due to persistent infection or irreversible damage to the GI and GU systems [9]. A large proportion of those infected are aged 14 and under. It is rated the second most important socioeconomic/public health problem after malaria and can compromise orthopedic treatment.

Other Comorbidities

Alcohol and mind-altering drugs are a growing problem in LMICs, because of an increase in disposable income. Alcohol is known to interfere with fracture healing, and cocaine is well known to cause anesthetic complications. The local substance of preference may be one that is unfamiliar to a visiting surgeon, producing a confusing constellation of signs and behaviors, especially in the face of shock and trauma. The local emergency room or outpatient department personnel will usually have experience with specific local products and are the best source of information. Substance abuse is highly associated with both non-intentional injuries, such as road traffic injuries, and intentional injuries caused by violence. It is estimated that worldwide around 15% of the burden of trauma is alcohol related, even higher in certain areas [11]. Complications of chronic alcoholism, such as clotting disorders or withdrawals, should be kept in mind when preparing for surgery.

In some populations, gout is a significant problem leading to severe disability. Tophi in unusual areas and inflammation masquerading as soft tissue infection or osteomyelitis can make diagnosis difficult, especially during a perioperative flare-up.

Though diabetes is rapidly becoming the world’s leading cause of peripheral neuropathy, in tropical and subtropical areas where leprosy is common, it is still a significant source of hand and foot deformity due to motor loss and imbalance and sensory loss (see Chap. 11).

Some populations are predisposed to dental caries due to the mineral composition of their teeth or the limitations of diet, which when combined with poor oral hygiene can lead to severe periodontal infections which may seed operative or injury sites. Loss of teeth or loose teeth interferes with adequate nutrition. Although outside the realm of orthopedics, tooth abscess may lead to maxillary or mandible osteomyelitis. Basic knowledge of tooth extraction and drainage of facial bone infections can come in handy in areas where resources are limited.

Populations in developing countries are not immune to depression. According to the World Health Organization, major unipolar depression is a significant contributor to the global burden of ill-health. Dealing with a limb- or life-threatening orthopedic disease or injury is stressful even though patients may not display depression in ways Western surgeons are used to. Local health staff can identify such patients and help provide culturally sensitive care and counseling. Victims of conflict present a very wide spectrum of orthopedic injuries and conditions but share in common a high prevalence of psychological scarring, such as post-traumatic stress disorder (PTSD) [12]. This aspect of patient management cannot be overlooked and may have a significant negative effect on the overall outcome (see Chap. 44).

Many patients will not be aware of having comorbidities that can complicate their orthopedic management or know that past illnesses have left residual health problems. Besides the chronic systemic impairments common in high-resource medical practice, many of the comorbidities are tropical diseases for which most volunteers will have little experience. Many of these conditions have characteristic clinical presentations, making it especially important to complete a thorough exam, including a diligent dermatological inspection. Diseases such as leishmaniasis, Chagas disease, hydatid disease, typhoid fever, and amebiasis may be common in limited areas. Ask the local doctors what coexisting morbidities they typically encounter, the clinical presentations, and how they are best treated.