The morning flight booked with Air New Zealand to Tonga was rescheduled to Monday evening June 5. I commenced an Outpatient clinic on Tuesday at 8.20 am followed by a ward round in the afternoon discussing the inpatient cases. The clinic was busy and for me to see as many patients as possible, all the transcribing was done by the Doctors assisting me with the clinic.

It was pleasing to see the results of patients at the Outpatient clinic who had been operated on during my March visit, particularly the case of a SUFE teenage patient who had been unable to walk properly for six months, prior to surgery. At two months post fixation he was walking pain free with only a slight limp.  

It was encouraging to arrange chemotherapy treatment for a 17-year-old Tongan lad with an aggressive form of Osteosarcoma in India. He had had an above knee amputation with full clearance but required chemotherapy to improve his life expectancy from 10% five-year survival to 80 % with chemotherapy. The referral was possible with the network available through Dr Basappa, of Bangalore, India an Orthopaedic Surgical colleague. The reason for arranging treatment in India was because it was substantially less than if it was undertaken in either New Zealand or Australia. During my visit the formal approval was given to proceed with the Chemotherapy over a six-month period at Sri Shankar Cancer hospital in Bangalore. The hope is that treatment will commence as soon as possible as it will be potentially lifesaving.

A set of plates and locking screws arrived from India that will be used for distal femoral fractures as well as large fragment plates. This adds to the substantial lot of equipment already in place to deal with most fractures. There is, however, a shortage of the 16- and 18-mm small fragment cortical screws because of their frequent usage. The plan will be to purchase a couple hundred of these screws and 20 mm screws as well.

The operative cases that I did from Wednesday to Friday are listed below were excellent learning cases for the resident surgeons. As I am teaching the surgeons the operative time is slower than if I was to perform the surgery myself. The teaching I see as being an important part of the visit to give the surgeons as much confidence to undertake these procedures without my supervision.

We were able to use the trauma table for two cases, one a fracture neck of femur and the other a slipped femoral epiphysis. Without this surgical table these cases could not be operated on, hence the value of the table. 

The surgical kits were reviewed. This will make it easier for the surgeons to use particularly for fracture neck of femurs. The hope is that the resident surgeons will be more confident to undertake these operations in the future.

On Friday afternoon a zoom meeting was held with Dr Basappa (Orthopaedic Surgeon – Bangalore, India) and Dr Tangi (Head General Surgeon - Vaiola hospital) and me to discuss the theatre surgical upgrade, which is planned for 2024 pending fundraising. A Power point presentation was given by the contracting company detailing the ventilation, cladding, and flooring of the operating theatres. There was discussion about an onsite meeting with the contractor sometime next month when I will be in Tonga. We were also able to meet with Mr Ssawan later in the zoom meeting. He has been instrumental in procuring the equipment from India. To date NZD35,000 has been purchased.  

On Saturday morning I was able to meet with the Nuku’alofa Rotary club at a breakfast meeting. It was a fruitful meeting. I gave an overview of the Orthopaedic Surgical project and the new project to upgrade two operating theatres. The hope is that as the host club they will be able to play an integral part in the project to upgrade the operating theatres in Vaiola hospital. On my return to Tonga next month for the Tongan medical association meeting I will attend the Saturday Rotary club meeting to update them on the project progress.

Later this month three of the operating nurses will be attending an AO fracture course in Auckland to upskill in the use of trauma fixation techniques. This has been funded through the Pacific Medical association who have the contract from the Ministry of Foreign Affairs and Trade New Zealand to support the South Pacific nations in Medical/ Surgical aid.

I have been asked to speak at the 75^th Tongan medical conference in July, which will allow me to present the current work and projects being undertaken. During that time in Tonga, I am hoping to meet some of the New Zealand consulate staff of the High Commissioner office to discuss the work being done in Tonga.   

OPD cases seen Tuesday 6 June 2023

TF M 12 Greenstick fracture mid shaft right radius Rx Cast

CFF18 Subperiosteal haematoma. Rx Conservatively

MF F 80 Soft tissue mass Left anterior thigh and met lung. Malignant Fibro histiocytoma Rx Conservatively.

*KH M 11 Chronic Osteomyelitis right proximal Humerus Rx Multiple Debridement and washouts. Small wound distal end of scar. Rx Cotrimoxazole and Rifampicin

TH M 57 Lumbar spondylosis. Rx NSAID’s

FH M27 Mild post traumatic OA right shoulder. Rx NSAID’s

SK M 17 Broken K wire end right elbow. Rx Surgical removal August Australian Ortho team.

*OK F 52 Non-Union fracture left femur. Rx ORIF March. Rx Mobilise with crutches protected weightbearing for one month.

S L M38 Rupture ligamentum patella. Six weeks post repair. Rx Continue in splint in extension. Commence quads strengthening.

LL M 31 Right tibial shaft Fracture. Rx BK cast. CT confirmation of healing lateral aspect.

*EL M 65 OA right hip joint. Rx Right hip replacement 2025/26 (Ideal case)

*MM M 13 SUFE Rx ORIF Mar 2023. Mobilizing well.

SM M 6 Fracture left Tibia Fibula RxAK cast.

*OM M64 Bimalleolar Fracture right ankle joint. For ORIF.

VO M43 Medial tibial plateau Fracture Rx with cast for a further month.

KP F 56 Retrocalcaneal bursitis Rx NSAID’s

SP M20 Achilles tendonitis. Rx NSAID’s

MP F 40 Lumbar spondylosis, PMHx Ca Breast. Review Nov

*AP M 44 Non-Union of segmental proximal fracture Rx Double plating March 23. Mobilizing well. PWB for a further month.

*SS F 44 Lateral meniscal tear. Rx Cortisone injection/ NSAID’s Scope in future.

OT M 17 Osteosarcoma right proximal leg. Rx AK amputation. Refer to India for Chemotherapy.

LT M 33 Gd open left distal Tibial fracture. Rx BK cast and Abs.

*MT F 39 Old dislocated lunate associated with carpal tunnel syndrome. Right CTR March 23. Effective in relieving the CTS. Rx wrist conservatively and in future consider wrist fusion or a proximal row carpectomy.

*KT M 4 Pathological fracture right Tibia with significant angulation. Rx with Corrective osteotomy to both the Tibial and fibular with an AK cast.

AT M3 Tibial fracture Rx AK cast for three weeks.

VS M23 Mild angulated metacarpal neck fracture Rx Cast and buddy strapping.

ZS 34 M Fracture right medial malleolus Rx BK cast for two more weeks.

OT 13 M Salter Harris Type 4 fracture right knee joint. CAT scan confirmed displacement Rx Knee Brace

*TK 68 M AO Type B fracture, Rx ORIF

GV 36 F Chronic osteomyelitis left mid foot, ? Charcot Rx Cotrimoxazole and Rifampicin

SN 64 M Lower back pain CAT scan Discitis L4/5 level Hb 4, WBC 20 ? TB discitis. Admit.

SF 43 F Broken plate with non union proximal left ulnar fracture. Rx ORIF

PF 55 M Lower back pain due to lumbar spondylosis Rx NDSAID’s.

SA Fracture distal end of Fibula Rx Impact boot

SL 13 M Salter 3 fracture right ankle joint. Rx BK cast for further two weeks.

EL 44 M Osteomyelitis Rx Cotrimoxazole and Rifampicin.

VF 18 M Partial rupture of lig patella Rx Aspiration 60 mls of haemarthrosis Assess further USd.

SL 22 F Medial meniscal tear For arthroscopy.

Operative cases

Wednesday 7 June

KT 4 M Corrective osteotomy right Tibial and Fibula, Application AK Cast. Surgeons: Drs A Aholelei and J van Dalen

TK 68 F ORIF of bimalleolar fracture right ankle joint. Surgeons: Drs S Akaudaand J van Dalen

SS 29 M Incision drainage of Psoas abscess right hip. Surgeons: Drs A Aholelie and J van Dalen

Thursday 8 June

GM 64 M ORIF of fracture left NOF and MUA of distal left radial fracture (Fractures one month old). Surgeons: Drs A Aholelie and J van Dalen

SF 43 F Removal of broken plate and ORIF of fracture left proximal ulnar with bone grafting. Surgeons: Drs Aholelie and J van Dalen

ET 46 F ORIF of bimalleolar fractures right ankle joint. (Fractures two weeks old). Surgeons: Drs A Aholelei, S Akauda and J van Dalen.

Friday 9 June

PM 12 M SUFE left hip ORIF ( Using trauma table ) Drs A Aholelie and J van Dalen.

OM 64 M ORIF fracture ankle joint. Drs A Aholelie and J van Dalen.

PM 18 M ORIF of 5^th Metacarpal fracture Drs S Akauda and J van Dalen

John van Dalen FRACS

Orthopaedic Surgeon

10 June 2023