Limb reconstruction in a resource-limited environment.

Nando Ferreira,Jan Duedal Rölfing,Hemant Sharma,Mangal Parihar,David Ferguson,Vasudevan P Nandalan,Mauro Vivas,Gamal Ahmed Hosny,Ashok Johari,Sanjeev Sabharwal,Selvadurai Nayagam

doi:10.1051/sicotj/2021066

Abstract

Introduction: Limb salvage and reconstruction are often challenging and even more so in the limited resource setting. The purpose of this narrative review is to explore the strategies for addressing the unique obstacles and opportunities of limb reconstructive surgery in resource-limited environments globally. Methods: We review (1) the global burden and dimension of the problem, (2) the relevance of orthopedic forums and communication, (3) free and open-access software for deformity analysis and correction, (4) bidirectional learning opportunities, and the value of fellowships and mentoring between resource-rich and resource-limited countries, and (5) how societies like SICOT can help to tackle the problem. Finally, case examples are presented to demonstrate the choice of surgical implants, their availability in regions with limited resources, and how the universal principles of limb reconstruction can be applied, irrespective of resource availability. Results: Limb reconstruction can often be life-changing surgery with the goals of limb salvage, improved function, and ambulation. The contradiction of relatively few severe limb deformities in high-income countries (HICs) with abundant resources and the considerable burden of limb deformities in resource-limited countries is striking. Free, open access to education and software planning tools are of paramount importance to achieve this goal of limb reconstruction. Bidirectional learning, i.e., knowledge exchange between individual surgeons and societies with limited and abundant resources, can be reached via fellowships and mentoring. The presented cases highlight (1) fixator-assisted wound closure obliviating the need for plastic surgery, (2) open bone transport, and (3) hinged Ilizarov frames for correction of severe deformities. These cases underline that optimal clinical outcome can be achieved with low-cost and readily available implants when the principles of limb reconstruction are skillfully applied. Discussion: Limb lengthening and reconstruction are based on universally applicable principles. These have to be applied regardless of the planning tool or surgical implant availability to achieve the goals of limb salvage and improved quality of life.

Highlights

Limb lengthening and reconstruction surgery, including the management of congenital and acquired deformities, complex acute fractures, pseudarthrosis, and osteomyelitis, have advanced substantially in the last two decades [1, 2]
Surgeons have to find innovative ways of using available technology and consumables to circumvent the lack of resources that may be readily available in high-income countries (HICs) [1]
low- and middle-income countries (LMICs) surgeons point out their complex and high-volume caseload but often have limited published data on their clinical outcomes

Summary

Introduction

Limb lengthening and reconstruction surgery, including the management of congenital and acquired deformities, complex acute fractures, pseudarthrosis, and osteomyelitis, have advanced substantially in the last two decades [1, 2]. Leaps in technological advances have introduced computer-aided deformity correction software and hexapod external fixators, intramedullary lengthening and bone transport nails, patientspecific additive manufacturing solutions, and a whole host of biological options to the field of limb reconstruction [3,4,5,6,7] These technologies, are relatively expensive and not universally available, especially in resource-limited low- and middle-income countries (LMICs). With adequate planning and skillful execution, both open bone transport (Figure 4), as well as gradual correction of severe deformities (Figures 1 and 2), can be achieved at low-cost [53, 54] These clinical cases highlight that even with limited resources, the principles of limb reconstruction can be applied and that these techniques truly can save limbs and change lives. SICOT can contribute substantially in disseminating knowledge, skills, and resources on the globe and propagating specialized knowledge for limb reconstruction

Concluding remarks

Conflicts of interest

Ethical approval