BJJ News
Bridging the gap
The Malawi National Joint Registry
ackground Joint replacement registries play an impor tant role in monitoring and improving outcomes around the world. However, out of forty members of the International Society of Arthroplasty Registries (ISAR) there are only three national joint registries in lowincome countries, including our registry. [1] The number of total joint arthroplasties (TJAs) performed in a low-income setting, such as Sub-Saharan Africa, is increasing. There are various reasons for this, including the wider availability of surgical expertise and resources. There is also an increase in the use of arthroplasty surgery to provide a social businesses platform in the healthcare setting. A social business is a non-loss, not-for-profit, non-dividend company that is financially self-sustainable; the profits realised by the company are reinvested in the company. In other words, the hospitals provide a private elective surgical service that funds free healthcare for those most in need. An example of this model is Beit CURE International Hospital (BCIH) (fig.1)in Blantyre, Malawi – ‘Adults pay a fee, so that children can walk free’. Little is known about the long-term results of TJA in low-income countries, and how they compare with results from highincome countries. The age of the patients and the indications for joint replacement differ considerably from those in the developed world, and include a larger proportion of HIV-positive patients. Patients are commonly younger and continue to work in physicallyactive jobs after their operation. Furthermore, facilities, resources and the training of operating surgeons are substantially different to those of a high-income country.
S. Graham N. Lubega W. J. Harrison
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Fig. 1 Beit CURE International Hospital The Malawi Nat ional Joint Registr y The BCIH was built in 2002 and included a dedicated arthroplasty service. Before this, only a small number of TJRs had been performed in Malawi and on an infrequent basis. The Malawi National Joint Registry (MNJR) registry was started in 2005 in order to ensure that patients who had undergone a TJR in Malawi were followed up and the surgical and functional outcome of their procedures were accurately recorded for purposes of both clinical governance and research. Over the last 10 years it has evolved to include other centres in the country: it is now the only national joint registry (NJR) in SubSaharan Africa, and one of the only registries in the world in a low-income country. In partnership with the MNJR, some units in Malawi now offer annual TJR ‘camps’, where visiting surgeons provide a free arthroplasty service for a select number of patients. All of these patients are then followed up and the outcomes are recorded on the MNJR. To date, 265 total hip arthroplasties (THAs) and 163 total knee arthroplasties (TKAs) have been entered into the registry: 22% of THRs
(58) and 2 % (4) of the TKRs are in HIV-positive patients.[2] The reason for the difference in these numbers is due to the high incidence of osteonecrosis of the femoral head as a result of HIV and its treatment (highly active anti-retroviral therapy – HAART). The primary indications for THA and TKA in our registry are respectively osteonecrosis of the femoral head and osteoarthritis. The mean age of the patients who have undergone TKA is 65 years (24 – 84) and that of patients who have undergone THA, 55 years (15 – 88). Fully trained arthroplasty surgeons perform all the TJRs. All patients are assessed pre-operatively and consented for inclusion in the registry. After counselling and consent they are tested for HIV: a determination of the CD4 level in those who test positive and the use of HAART treatment are recorded. Routine preoperative tests include a full blood count and a blood slide for malarial parasites. Patient recorded outcome measures (PROMS) are recorded, including EQ-5D-5L scores, Harris Hip Score (HHS) and Oxford Hip Score (OHS) for patients undergoing THR, and an Oxford Knee Score (OKS) for patients undergoing
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