Professor Samuel Olusegun Ogunlade is a medical doctor and consultant orthopedic and trauma surgeon who graduated from the University of Ibadan, and had specialised training in University College Hospital, Ibadan as a general surgeon. He was in Europe for higher surgical training, spending one and a half years in Ireland in orthopedics. He was also in the United Kingdom to continue the training, which he finished in December 1995. On his return to Nigeria that same month, he began working as a consultant orthopedic surgeon until he was promoted to Professor of Surgery in the University of Ibadan in 2010. Just retiring from the University College Hospital UCH, Ibadan, Prof. Ogunlade, in this interview with Oluwatoyin Malik, speaks on cases resulting in trauma, causes and management of arthritis which affects many patients, and how the federal government can help in the reduction of treatment cost by subsidising consumables and other needed materials for patients. Excerpts:
Sir, we will like you to tell us about orthopedics and trauma which you majored in in your profession and the experiences you’ve had with patients?
The first thing you will notice is that because we have a lot of vehicles on our roads, the accident rate is much, compared with those of industrialized nations. Ours is even more because of the poor regulations, and then the pervasive use of alcohol, which are now in sachets. And with the advent of motorcycles now, the accident rate in the town has been horrendous. Most of the injuries you now see in the town are the injuries we used to see in those days on motorways because of high motorcycle use. It’s usually a direct hit, either on the ground or by a vehicle. And there are incidents of open fractures. Open fracture means the bone is exposed, and it is quite a very challenging issue. And to compound the problem is that most of these motorcycle riders have little or nothing to protect them. And, of course, they don’t have enough money for treatment. And then, most of the passengers that they carry, called the pillions, I doubt if they have money. They use motorcycle as a means of transportation because of their low level of income. So, that is expected most of the time, and a major challenge.
The trauma load is very much. But we need to have more control in the towns, and the use of sachet alcohol is a major problem, because they can now have it in their pockets and take it even when they are riding. And when some of them come, they smell of alcohol or even a bit tipsy. And we believe that’s a major challenge. But the burden of motorcycle injuries is high, and we have documented in most of our publications the burden of these injuries, which is very high.
There is the issue of arthritis being experienced by both gender, including osteoarthritis, osteoporosis and rheumatoid arthritis. What are the causes and how can they be managed?
Coming to the other part, which is orthopedics, the major problem is joint arthritis. Arthritis is of the major joints. In a layman’s language, it is the wear and tear of the joint. If you break the thigh of a chicken before, you will see that the cover of the head of the thigh is shiny, and the hollow too is shiny. That’s the way our joints, everybody’s joints are. But over the years, this shiny thing starts to change, the cartilage starts to break down, they become rough, and later the bone underneath is exposed. That’s what you call osteoarthritis. We call it degenerative changes. But in layman’s terms, it is called wear and tear in the joint.
What are the causes?
I will tell you that we don’t know the cause of the majority that occurs. That’s why you see some people, they are slim, they have it; some people are fat, they don’t have it. But we know that this kind of arthritis sometimes runs, kind of maybe familial. We’re not saying it’s hereditary, but maybe familial.
Now, those ones, we don’t know what causes it. But we know some are caused by certain things. Now, one of them is rheumatoid, which is inflammation of the joints. It’s as if the body joints are attacking each other.
How does that come about?
It’s an immunological process, in which case the body produces something that attacks the joints. The joint gets inflamed and starts destroying the cartilage. It is not very common here. It is more common in Western world. But we see it also here. It’s the joints of the hands that are commonly affected, followed by the knees, the hip, the elbow, the neck. Even, the neck bones sometimes shift over each other, all of that causing massive damage. So, one will end up with arthritis of the joint. We have some in which some crystals are deposited in the joint. We call those ones gout. If it’s not treated, it will also destroy and produce Osteoarthritis.
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Also, in the trauma mentioned before, when someone falls off a motorcycle or is involved in a road traffic accident, the knee gets damaged, the hip gets damaged. Eventually, osteoarthritis develops in those joints. Also common here are infections, that is, the infection of the joint, especially in the younger age group. If it’s not well treated, you get the joint destroyed.
What causes such infections?
Most of the time, in children, you really don’t know, but you know children fall down often. So, abrasion here, abrasion there, organisms get into the bloodstream, then from the bloodstream now to the bone or to the joint.
Some people also experience slipped disc, cervical and lumbar spondylosis.
Spondylosis is a form of arthritis of the joints. But the joints are not synovial joints per se, like they’re not the joints that move as much as the knee or hip. So, what then happens again with that one is that in between the vertebra, the vertebra bone is like a small cube of bone on top of each other. In between the cubes, there’s something we refer to as shock absorber. They are like thick gel that God put in between them. And then surrounded with tough fibers. So, that’s why we can bend, that’s why when we climb and jump down, it doesn’t hurt us. It absorbs the shock. Mm. But over the years, as one gets older, by the time one gets to the age of 35, that disc, that gel starts getting drier. The fluid gets less. And after some time, the fiber that surrounds it breaks, and then that thick gel pops out. When it pops out, next to it is a nerve that controls the leg, upper and lower limbs. When it then presses on that nerve, pain starts. The pain goes to the leg, the limb that is above, and also at the level of the joint. And it irritates the nerve. When anything presses the nerve, it starts sending signals, like electric shock sometimes. And that’s what happens. That’s what we call slipped disc. Because the structure is no longer there, there’s now more abnormal movement between the bones. That abnormal movement now causes pain at the level of the back. But pressure on the nerve will cause pain down the legs. So, that can occur from the neck down to the lower back. And it depends now on individuals. For some, it’s the neck part. For others, it’s the lumbar or the thoracic one that is more.
The one in the chest, at the back of the chest, is the one that is more. So, it depends on which one is more. If it’s the neck, we call it cervical spondylosis; if it’s the the middle one, the one at the level of the chest, we call it thoracic spondylosis; if it is the lower back, we call it lumbar spondylosis. But lower back pain is now the commonest symptoms of back pain in Nigeria. Common in people who do sedentary work. Common in those who have to lift heavy weights. Common in those who have to sit down for so long.
What of farmers that have to bend while tilling the ground?
Yes, they do have, because they have to bend most of the time.
We also hear of women. Does child labor and tasks done by women contribute to joint pains?
We don’t think they contribute to that of the back, but we think they contribute to the knee. Knee arthritis is so common in women that before you see a man coming with it, you have seen six or seven women. And I can tell you most of the knee replacement we do are almost always in female.
Does arthritis result in paralysis or immobility of the legs and hands?
Arthritis does not cause paralysis. It is nerve injury, or spinal cord injury, or brain injury that can cause paralysis. But arthritis makes the joints very stiff and painful. And because of that, patients may not be able to move quite satisfactorily. It rarely causes complete immobility, but it can make mobility quite difficult, painful, and slow. So, it does not cause paralysis, but it does reduce mobility of patients.
How can arthritis be prevented?
Well, for now, the majority of the arthritis, we do not know what causes them. That is, we call them idiopathic, of unknown etiology. That is the commonest mode of arthritis. But there are certain things that we know cause arthritis:
Repetitive injury to the joints, especially the knees, the back, the hips in athletes, in footballers. Or road traffic accidents to the joints — hip fracture, fracture around the knee, fracture around the ankles. If those fractures are not accurately treated and reduced, they usually lead to arthritis.
Also, some crystals. Some people who have what you call gout, they have deposits of uric acid from their blood into the joints. This also can cause arthritis.
Also, in patients with sickle cell disease, the blood flow to some parts of the bone —especially the head of the femur and some other joints — get blocked, and of course, the bone then dies. We call that avascular necrosis. Then, that part, especially the hip, will collapse, and once there is incongruity in the joint, then osteoarthritis develops.
Also, excessive weight can also induce osteoarthritis. Bleeding in the joints of patients with hemophilia can develop into osteoarthritis. And then, patients with rheumatoid arthritis, though not as common as in the Western world, the end result of severe rheumatoid arthritis is usually osteoarthritis developing in such joints.
Is arthritis curable? If not, how can it be managed?
For now, it is still not curable. There’s a lot of research going on on how to replace the cartilage that has been damaged. But for now, they are still mainly at an experimental stage, not available globally for treatment.
What we do for arthritis is to treat. If we can find the cause, we remove it. We treat and manage, and also to prevent rapid progression.
For those with arthritis of the knees and the hips, we advise them to walk, but they must avoid all those aerobic exercises like jumping, jogging, or running. Brisk walking is much better. But the best for arthritis in the lower limbs is swimming. Swimming is one of the very good areas, a very good therapy for arthritis, but usually, we encourage people not to swim in very cold waters, because that can cause muscle spasm and pain. Also, the water should be warm to make it therapeutic.
Now, the treatment when the arthritis becomes very severe is surgery. And there are various forms of surgeries that are done: some to correct the deformities, some to change the joint itself (the articular surfaces), and then some to change maybe half of a joint. But surgery is quite very effective, especially in the hips, knees, ankles, and elbow. Total joint replacement can give a very, very long-lasting, pain-free, good range of movement in those joints.
Can the use of traditional medicine be applied to arthritis management?
I usually tell people, when you talk of traditional medicine, if you are talking of herbs and roots, very little effect, because most of what are in the herbs may be in some of the tablets that are produced. But otherwise, because, as I’ve told you before, the cause is poorly understood, so anything that is done in a traditional way is just a dart in the dark. Rarely does it make any difference in osteoarthritis.
What advice do you have for those with arthritis?
The first thing is, once it starts to develop, you should see your doctor. Let them evaluate you and find out if they can find a cause for your arthritis. If a cause can be found, then the cause is treated. But if a cause cannot be found, then you’ll be given advice on various forms of exercise therapies that are beneficial, and to avoid those ones that may be damaging the joint.
And also, the patient will be taught also on judicious use of analgesics to reduce the arthritis. When we treat patients with osteoarthritis or arthritis, as generally said, you don’t tell them to take drugs as if they are taking drugs for blood pressure or diabetes mellitus. Once the acute phase of the pain is settled, the patient is asked to stop taking those analgesics so that they can have enough time to be free from those drugs. And then if patients do that – because when arthritis is starting, it comes, after some time it goes, then it recurs, and when it recurs, it’s treated, and then it subsides.
It’s only when they now have to be permanently on analgesic, and the analgesic itself is not even giving enough relief of symptoms, that we then consider doing surgery for such patients.
How can we compare health statistics and management in Nigeria with the Western world?
In the Western world, each country has its philosophy. When I talk about the Western world now, I’m going to limit myself to Europe. Europe, typically United Kingdom, the principle is that at the point of need in healthcare, you do not pay. So, they run the system, but they make sure that people now pay more taxes, those who are working, companies, they are they tax companies more, they tax individual more. But in Nigeria earlier, when our population was lower, I remember then as a young doctor, children don’t pay. Anybody with tuberculosis does not pay. Anybody with cancer does not pay. And those who are declared as poor don’t pay. But over the years, there have been complexities, which I don’t want to enter into, in our health financing.
So, comparing health management in Nigeria to elsewhere, as we all know, those in trauma, such as the motorcycle riders, don’t have money to do operations or to attend to themselves in hospitals.
But I have always advocated that what government now needs to do in our hospitals is that they should now include what I call targeted healthcare system, which I think they are starting now, and I will give you an example. Knee and hip replacement cost a huge amount of money. And I believe the best way is that, for example, University College Hospital, should aim to do 50 knee replacement surgery this year. Let the government know the cost, and then they can negotiate the cost with the hospital. And this money will then be made available to the hospital for a knee replacement.
Now, you remember now they have also done the issue of dialysis. There is heavily subsidized dialysis now, which is good for the government, which I’m happy with. But in surgical areas, they should also get funding for surgeries such as hip and knee replacement. This is a major source of concern for our patients, because most of those with such health challenges are relatively poor. They can’t afford the care, and some of them, it takes them about two, three years to raise the fund to be able to do this surgery. So, it would be good if the government could be magnanimous enough to start what I call targeted care. Also for the cases of trauma. However, the government is doing quite a lot, we should note that.
In which areas?
They have what they call mono-hospitals for trauma. One is in Igbobi in Lagos, one in Kano, one in Enugu. Those were the big three in those days in Nigeria. I think there are more now all over the country. I think they should be between 10 and 12.
But I still think the government needs to find a way of subsidizing some of the materials – the metals, the implants used for the patients, and also making available for us, uh what you call some specialized equipment like image intensifiers, in addition to reducing tax. In UCH, the hospital has been gracious to get one, but we need one in the emergency theatre in the Accident and Emergency Clinic. There’s one already in theatre. We also need in other theatres such orthopedic and neurosurgery. But we have had to share the one for both, and we cannot take it out of the main theatre to our A&E theatre. We were doing so before, it got damaged.
So, now, the government should get us one or two more, so that it will also facilitate most of what we do, and reduce the cost of the care. The other thing I believe that the hospital can also do with regard to surgery is well, I’m not going to make suggestions to them, but they need to get certain things available for the hospitals.
In certain countries, they do that. Things like gauze, cannulas, spinal needles, some of the hospital consumables in the theatre, some countries buy them nationally or regions, large amounts, and they then send them to these hospitals. Those are some of the things we have to buy at very high cost here. But if a government can negotiate with companies, just like they do in the UK with the NHS. Whatever NHS buy in UK, they are lower in price than in the market because they buy quite a large amount of such materials. So, things like gauze, surgical gloves, methylated spirit, povidone-iodine, cannulas, infusions, if government can get them in a large amount and give them to all these hospitals, it will reduce drastically these surgical fees being paid and all other things.
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