Maputo, Mozambique is one of the newest SIGN programs started by Yinka Oloruntoba, M.D. from Bedford Hospital. Dr. Oloruntoba has now started SIGN programs in Lesotho, Swaziland, Mozambique, South Africa and plans to start two in Rwanda.

At this writing Maputo surgeons have done 19 SIGN surgeries with excellent reporting. The standard treatment in the United States is to remove all dead tissue and contamination from the fracture areas where the skin and muscle have been damaged and penetrated either by the force that caused the fracture or by the bones breaking, damaging these tissues from within. The fracture fixation is placed when the wound is cleaned and the skin can be sewn up. This protocol is not followed in Maputo or Bedford Hospital due to lack of operating room time at night when most open fractures present themselves. The operating room schedule has a back log of at least one week so these open fractures do not get cleaned as quickly as they would in the United States. This means that the soft tissue wounds take longer to heal and can drain for many days and weeks. Placement of metal in the presence of a draining wound is contraindicated and adds to the risk of bone infection.

Each day we had to balance the risk of infection against fracture fixation. Fracture fixation is necessary also for fracture healing. Decisions were to delay surgery until the wound was healed which necessitated longer periods of hospitalization and perhaps even infection or amputation. Studies have shown that the bacteria present in a wound are usually caused by contamination from the hospital. The surgeon's technique is excellent. Their results are good as noted on the database even though they face problems and decisions that we do not have to face here in the United States.

Bedford Hospital is located in Umtata, South Africa. Umtata is the former Transkei part of South Africa. Bedford Hospital is an orthopaedic referral hospital for 4.5 million people. Dr. Yinka Oloruntoba is an integral part of the orthopaedic staff. He revitalized the SIGN program at Bedford Hospital when he moved there from Lesotho. Dr. Alexander Mojela is the current SIGN program manager in Lesotho. He took the 6 hour drive to visit and do surgery with us at Bedford Hospital.

Dr. Mojela is a musically talented and giving person. He was popular with the patients because he took the time each day to visit each ward and sing to the patients. He enjoyed the moment and did what he could at the time to assist his fellow humans.

The dynamics of treating open fractures described in Maputo are the same at Bedford except that there are very few beds at Bedford hospital. Almost all of the beds are filled with patients fracture patients so the orthopaedic surgeon on call must find a bed for patients with open fractures in the province hospital until time can be found in the operating room. Many patients travel 3 or more hours with wounds that have not healed well enough to proceed with surgery. This adds a social service element to the work of the orthopaedic surgeon.

We learned about other factors that play a role in the results of treating fractures in the poor of Southern Africa. Our vision of "Creating Equality of Fracture Care throughout the World" involves primarily the donations of SIGN implants and instruments. We are now expanding our role of education of surgeons. The 6th annual SIGN conference to be held in Richland Washington from September 21 to 23 will include a broad range of trauma related topics presented for the benefit of the visiting overseas surgeons. Click here to view the complete program.

As we flew away from Africa I was reminded of a quote in Mr. Mandela's biography: "I have discovered the secret that after climbing a great hill, one only finds that there are many more hills to climb". Nelson Mandela's quote well represents the future of SIGN in Africa.