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I can’t come to the United States without coming to the AAOS to say ‘thank you,’” said Daniel-John Lavaly, MD, of Sierra Leone. “It’s like a pilgrimage I have to make.”


Published 1/1/2012
Jennie McKee

African Orthopaedist on a Mission to Improve Care

AAOS international scholar focuses on trauma care

Daniel-John Lavaly, MD

When he visited Academy headquarters in Rosemont, Ill., in September 2011, Dr. Lavaly had recently attended the SIGN Flap Course in San Francisco as well as the Annual SIGN Conference in Richland, Wash. SIGN, the Surgical Implant Generation Network, is focused on providing training and instrumentation to surgeons in the developing world.

In 2009, noted Dr. Lavaly, he received an AAOS international scholarship to attend an AAOS/Orthopaedic Trauma Association orthopaedic extremity trauma course at the Orthopaedic Learning Center (OLC) and to participate in an observership with Bradley R. Merk, MD, at Northwestern Memorial Hospital in Chicago. According to Dr. Lavaly, that scholarship experience paved the way for him to participate in educational opportunities such as the SIGN events, thereby improving the orthopaedic care he and his fellow surgeons provide to patients.

Practicing orthopaedics in Sierra Leone
Dr. Lavaly is one of only a few orthopaedic surgeons in Sierra Leone, a country of almost 7 million people. He practices at Emergency Surgical Center, Goderich, a charity hospital on the outskirts of Freetown in Sierra Leone.

“The hospital is run by a nongovernmental organization,” said Dr. Lavaly. He noted that 60 percent to 70 percent of the hospital’s 99 beds are dedicated to trauma. “By default, we are the trauma center for the nation.”

Dr. Lavaly and his colleagues treat approximately 1,000 trauma cases per year, primarily tibia fractures due to motor vehicle and motorcycle accidents. Medical supplies and devices are in short supply, he reports, as is help from the international community. “We need volunteers and would welcome assistance from orthopaedic surgeons from the United States and other countries.”

The lack of training opportunities, he said, presents another hurdle.

“Training in the region is unaffordable, and scholarships are not available,” he said. “The main referral hospitals are not equipped to handle trauma and orthopaedics.

“Because we have a rising trauma burden,” he added, “we are constantly looking for ways to reduce length of stay so we can cope with the demand.”

Implementing improvements
Dr. Lavaly learned much during his 2009 scholarship experience, during both the orthopaedic extremity trauma course and the observership. He was impressed when he saw operating room teams at Northwestern Memorial Hospital conducting a “time-out” before surgery, an important step in the Universal Protocol, and has since implemented that valuable strategy at his hospital.

“We once had two patients with ankle problems who had the same name, were roughly the same age, and lived in the same area,” he recalled. “One needed a cast, and one needed open reduction and internal fixation. Because we did the time-out, we were able to sort them out.”

At the SIGN conferences, Dr. Lavaly has learned about using the SIGN intramedullary (IM) nail system, developed by Lewis G. Zirkle, Jr., MD, of SIGN Fracture Care International, to treat fractures of the tibia, femur, and humerus in under-resourced hospitals. In the past 2 years, Dr. Lavaly and colleagues have used the SIGN nail on approximately 170 adult patients with femoral shaft fractures. The procedure has replaced Perkins traction treatment, resulting in significantly shorter hospital stays.

“Patients achieve partial weight-bearing status almost immediately after surgery,” he said. “We try to get them discharged within 2 weeks.”

The SIGN nail also has lower infection rates than those associated with Perkins traction.

“The good thing about Perkins traction is patients have good knee function at the end of treatment,” said Dr. Lavaly, “but the bad thing is that two-thirds of them tend to have pin tract infections. Obese patients tend to have a fairly high nonunion rate with Perkins traction, and malunions are another problem.”

Working with IGOT and SIGN
According to Dr. Lavaly, his 2009 trip resulted in a connection to the Institute for Global Orthopaedics and Traumatology (IGOT), a nonprofit program created by the faculty and residents in the department of orthopaedic surgery at the University of California, San Francisco. IGOT works to address global healthcare needs of patients with musculoskeletal and traumatic injuries and disorders.

With IGOT’s help, Dr. Lavaly has been able to attend the SIGN flap courses to learn how to perform “free-flap” surgical procedures, as well as the SIGN conferences.

The events, said Dr. Lavaly, have been “very instructive and inspiring.”

“The most helpful thing I learned at the flap course was how to use the soleus muscle flap and the gastrocnemius flap to cover exposed bones,” he said. “At my hospital, we see many open fractures with exposed tibia, so being able to use calf muscle to cover exposed tibia is really thrilling. I haven’t seen a failed flap since I started doing them.”

Attending the 2011 SIGN Flap Course and the SIGN Conference inspired him to contribute more information to the SIGN surgical database. Although finding time to input information can be difficult due to the high volume of patients who require care, noted Dr. Lavaly, “the conferences really bring home the urgent need to put a premium on research.”

Passing on knowledge
Dr. Lavaly puts a strong emphasis on teaching other medical professionals in Sierra Leone the new skills he has learned and the knowledge he continues to gain.

“Hands-on teaching has been my means of passing on knowledge to the residents,” he said, noting that his hospital has held tutorial sessions on relevant topics.

“Last year, I shared a teaching video on applying an external fixator for open tibia fractures with one of the residents,” he said. “Within a week, he had to deal with an emergency call for an open tibia fracture and was able to correctly apply an external fixator.”

The AAOS scholarship, said Dr. Lavaly, brought him in contact with “world-class teachers in orthopaedic trauma.”

“It also set the stage for me to come in contact with people at SIGN Fracture Care International and IGOT, who are helping improve treatment of adult femur fractures at my hospital,” he said.

“Attending the OLC course during my scholarship visit was one of the best things that has happened to me in my orthopaedic career.”

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org