Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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182 Surgery and Healing in the Developing World
on one end and a point on the other. Because they are somewhat flexible, they
provide alignment but not necessarily rigid fixation. They can be inserted percutaneously
for treatment of most long bone fractures but are most useful for fractures
of the lateral malleolus, radius, ulna and humerus.
Infection
Musculoskeletal infections are endemic throughout the developing world. Polio,
leprosy, tuberculosis and pyogenic osteomyelitis are major causes of disability in all
such cultures. Polio and leprosy primarily involve the neurologic system, and surgery
is directed at the secondary musculoskeletal deformities. Tuberculosis and pyogenic
infections directly invade bones, joints and the spinal column and thus damage
both mobility and structural integrity of the skeletal system.
Polio has been greatly reduced worldwide and current efforts are aimed at complete
vaccine prevention of new polio cases in the near future. When the acute
disease is completely erradicated, there will be residual deformities to be dealt with
for many years to come. Corrective surgery is usually done electively and in concert
with a rehabilitation program which includes bracing, walking aids, and other mobility
aids such as special wheelchairs. Simple percutaneous tendon releases or
muscle-tendon lengthening followed by locally adapted splints will yield significant
functional improvement for most patients. More complex surgery involving arthrodesis
and tendon transfers should be attempted only if the local resources permit.
Musculoskeletal deformities in the leprosy patient are secondary to the loss of
motor function and sensation principally in the terminal portions of the extremities.
It is estimated that there are about 1.6 million people worldwide afflicted by
leprosy although the disease is now treatable by combination antibiotic therapy.
Like polio, the musculosketetal deformities are treated electively and involve arthrodesis
and tendon transfers. Most leprosy surgery is done in designated centers where
resources and expertise can be concentrated and focused on this population.
It has been estimated that the world prevalence of tuberculosis has reached 32%
or about 1.8 billion people. In the developing countries, perhaps one-third of the
population with tuberculosis will have involvement of the musculoskeletal system,
principally the spine and lower extremities. Tuberculous infection of major joints is
treated similar to management of pyogenic infections with open drainage of the
abscess, antimicrobial therapy and restoration of function when the infection is controlled.
Often, because of the indolent nature of this infection, much joint destruction
has already occurred by the time the diagnosis is made. In such cases arthrodesis
following the initial debridement will provide satisfactory function in major weight
bearing joints.
Spinal tuberculosis usually begins in the vertebral body causing significant bone
destruction and kyphotic deformity. Notoriously, the cartilage of the disc spaces is
preserved until late and with extension of the infection, paraplegia occurs commonly
from either bony deformity or direct extension of the abscess into the epidural space.
Numerous protocols have evolved for dealing with the tuberculous spine surgically
and include abscess drainage through either a costotransversectomy approach or a
transthoracic approach. In the latter, anterior bone grafting using a rib or fibula is the
common procedure. The anterior aspect of the spinal canal can be decompressed
through either of these incisions if spinal cord involvement has occurred. In areas
where such surgery is not possible, medical treatment alone is used along with brac-