Surgery and Healing in the Developing World - Dartmouth-Hitchcock

CHAPTER 1
CHAPTER 19
Orthopedic Surgery
Richard C. Fisher
Introduction
Orthopedic surgery in the developing world is characterized by a unique set of
medical problems and a lack of standard diagnostic and therapeutic equipment with
which to work. There is a wide spectrum of available facilities from country to
country and within countries from urban to rural areas. The situation in each location
thus has a unique set of parameters. To work successfully in this environment
requires a thorough knowledge of basic medical principles and fundamental surgical
skills. For orthopedists, the necessary skills include a thorough understanding of the
anatomy and pathophysiology of musculoskeletal processes including fracture mechanism,
fracture healing, and infection. Skills in the closed treatment of common
fractures and the application of traction are essential. The surgical principles of tissue
handling, sterile technique, and wound management are necessary in an environment
with extremely scarce resources and high complication rates. The American
Orthopedic (AO) principles involving internal fixation of fractures are sound and
useful even if the essential equipment is not always available. The functional treatment
of injuries, as taught by Dana, Brown, and Sarmiento, is critical to the overall
success of patient care in developing nations.
X-ray equipment is pivotal to orthopedic care. Often older more basic X-ray
machines function best in this environment as they are more reliable and require
fewer repairs. The ability to perform certain operative procedures is often predicated
on whether X-ray equipment is available in the operating room.
There are many innovations possible. One hospital in Bhutan uses a portable
unit that can be disassembled and taken to all parts of the hospital and, in times of
crisis, to different parts of the country. X-ray film is extremely expensive and in
many areas it is cut into small pieces large enough only to include the area of injury.
Finger X-rays might be taken on a 5 x 8 centimeter piece of film greatly extending
the number of exams possible.
Many orthopedic procedures can be treated either operatively or nonoperatively
depending upon the facilities available. The concept of a “safe operating room” is
useful for such decision making. Important variables include trained operating room
personnel, trained surgeons, a sterile environment, safe anesthesia, sterile instruments,
proper implants, and functioning X-ray equipment. If the required resources
are not available, alternative methods of treatment should be sought.
It is necessary to understand the cultural norms of the area in which one is
working. Many societies require the squatting position for social functions. Hip
prosthesis or fusion may be less acceptable than an excised femoral head in these
areas. Amputations should be carefully considered as they create unacceptable social
Surgery and Healing in the Developing World, edited by Glenn Geelhoed.