Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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19 184 Surgery and Healing in the Developing World Technique A Technique B Figure 6. Bypass grafting for an unstable tibia following destruction by osteomyelitis. (Redrawn from: Fisher R. Selected Conditions in the Developing World. ICL 49, American Academy of Orthopaedic Surgeons, 2000.) the surrounding involucrum is essential to the skeletal stability of the limb. The sequestrum should not be removed until the involucrum has developed sufficiently to stabilize the extremity. If involucrum formation is prevented by severe infection or by early aggressive surgery, skeletal integrity will be lost. The limb will lose its normal length and contour and weight-bearing may not be possible. Although the infection will not be obliterated completely until the sequestrum has been removed, it can be controlled by debridement of the abscess cavity and antibiotic therapy. The process of involucrum formation may take up to two years. Patients often present after initial treatment with recurrent drainage caused by a retained sequestrum. The infection may have been quiescent for many years without signs or symptoms. Debridement of the sinus tract and removal of the sequestrum often will control the present symptoms. However, the infection might again remain quiescent for years, only to redrain in the future. Treatment with antibiotics in this population usually is reserved for coverage during and for a short time after surgical debridement. Long-term antibiotics use in chronic osteomyelitis probably does not have a place in the treatment regimen. Once large portions of the diaphyseal bone are lost because of either insufficient involucrum formation or aggressive surgical removal of an immature involucrum, reconstructive surgery with bone grafting is necessary to restore skeletal support of the limb. If the tibia is involved, the fibula usually hypertrophies to compensate. Fibula-to-tibia bone grafting above and below the tibial defect allows weight transfer through the fibula bypassing the tibial defect, (Fig. 6) To repair femoral defects, bone graft must be placed through the infected and avascular soft tissues. This is much more difficult and less successful than bypass grafting described for tibial defects.
Orthopedic Surgery 185 Suggested Reading 1. Brown P. Wound closure—or not? Techniques Orthop 1995; 10:155-157. 2. Cook J, Sankaran B, Wasunna AEO. Surgery at the district hospital: Obstetrics, Gynaecology, Orthopaedics, and Traumatology. Geneva world health organization 1991. 3. Dehne E, Torp R. Treatment of joint injuries by immediate mobilization. Clin Orthop 1971; 77:218-232. 4. Dye C, Scheele S, Dolin P et al. Global burden of tuberculosis. JAMA 1999; 282:677-686. 5. Fowels JV, Lehoux J, Zlitni M et al. Tibial defect due to acute haematogenous osteomyelitis. J Bone Joint Surg 1979; 61-B:77-81. 6. Fisher R. Selected conditions common in the developing world. In Instructional Course Lectures. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2000:49. 7. Gates DJ, Alms M, Cruz MM. Hinged cast and roller traction for fractured femur. J Bone Joint Surg 1985; 67-B. 8. Huckstep RL. Poliomyelitis: A guide for developing countries, including appliances and rehabilitation. Edinburgh Churchill Livingstone, 1975. 9. King M. Primary surgery—volume two—trauma. Oxford: Oxford University Press, 1987. 10. Krol J. Rehabilitation surgery for deformities due to poliomyelitis: Techniques for the district hospital. Geneva: World Health Organization, 1993. 11. Mock CN, Adzotor KE, Conklin E et al. Trauma outcomes in the rural developing world: Comparison with an urban level I trauma center. J Trauma 1993; 35:518-523. 12. Rush LV. Manual of rush pin techniques. Meridan: Rush/Berivon, 1988. 13. Sarmiento A. Functional bracing of tibial and femoral fractures. Clin Orthop 1972; 82:2-13. 14. Srinivasan H, Palande DD. Essential surgery in leprosy (Techniques for District Hospitals) Geneva: World Health Organization 1993. 15. Tuli SM. The art and science of orthopaedics in developing countries. J Bone Joint Surg 1985; 67-B:840-842. 19
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Surgery and Healing in the Developi
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Contents Foreword .................
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25. Dentistry .....................
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Editor Contributors Harold P. Adolp
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Foreword Surgery and Healing in the
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“poor, but modern”, as for exam
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There may be at least one considera
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It is that higher accountability th
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1 2 Surgery and Healing in the Deve
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CHAPTER 2 Surgery in Developing Cou
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2 10 Surgery and Healing in the Dev
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CHAPTER 4 International Surgical Ed
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CHAPTER 9 Lab-in-a-Suitcase: Saving
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10 72 Surgery and Healing in the De
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CHAPTER 12 Communication in the Thi
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CHAPTER 13 Anesthesia in the Third
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13 100 Surgery and Healing in the D
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CHAPTER 15 Basic Obstetrics and Obs
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CHAPTER 1 CHAPTER 26 Reconstructive
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Reconstructive Surgery in the Tropi
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CHAPTER 1 CHAPTER 27 Factors Influe
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Distribution and Incidence of Tropi
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CHAPTER 1 CHAPTER 28 Population Dyn
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Population Dynamics Of Surgical Tro
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Metabolic Maladaptation 289 Introdu
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Metabolic Maladaptation 291 some of
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Metabolic Maladaptation 293 In this
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Metabolic Maladaptation Table 1. Si
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Metabolic Maladaptation Table 4. Go
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Metabolic Maladaptation 299 the rev
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Metabolic Maladaptation Table 5. As
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Metabolic Maladaptation Table 6. Co
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Metabolic Maladaptation 305 the ris
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Metabolic Maladaptation Table 8. Go
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Metabolic Maladaptation Table 10. G
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Metabolic Maladaptation Table 12. C
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Metabolic Maladaptation 313 cell an
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Metabolic Maladaptation 315 Biologi
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Metabolic Maladaptation 317 from io
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Metabolic Maladaptation 319 25. Lon
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CHAPTER 1 CHAPTER 30 Nutrition and
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Nutrition and Development in Africa
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CHAPTER 1 CHAPTER 31 Uterine Ruptur
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Uterine Ruptures in Rural Zaire Tab
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Uterine Ruptures in Rural Zaire 329
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CHAPTER 1 CHAPTER 32 Vesicovaginal
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Vesicovaginal Fistula in Democratic
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CHAPTER 1 CHAPTER 33 Ophthalmology
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Ophthalmology Figure 2. Refractive
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Ophthalmology Figure 4. A tonometer
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Ophthalmology 341 ml of 40 mg/ml IV
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Ophthalmology Figure 6. Axis determ
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Ophthalmology 345 thalmic set prepa
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Ophthalmology 347 Procedures Region
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Accommodating Deficits in Material
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Abscesses and Other Infections Trea
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CHAPTER 1 CHAPTER 36 Surgical Train
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Surgical Training of Nurses for Rur
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Training of Medical Assitants in Mo
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CHAPTER 1 CHAPTER 38 Training Surge
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Training Surgeons in the Developing
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Mobile Surgery Figure 1. 405 of tec
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Mobile Surgery Figure 3. 407 Childr
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Mobile Surgery 409 We have realized
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CHAPTER 1 CHAPTER 40 Public Health
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Public Health Problems on Burma Fro
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Medical Adventures in the Nigerian
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CHAPTER 1 CHAPTER 42 Wanted Glenn G
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Wanted 431 Studies Center (//www.am
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Wanted 433 MacArthur (The John D. a
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Wanted 435 most pathologic presenta
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Wanted 437 “outliers” in the he
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World Health 439 challenge: name fo
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CHAPTER 1 CHAPTER 44 Treating Other
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Treating Others: Human Sciences in
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Treating Others: Human Sciences in
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CHAPTER 1 CHAPTER 45 The Impact of
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The Impact of a Volunteer Medical M
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CHAPTER 1 CHAPTER 46 Field Notes on
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Field Notes on a Typical Day in a H
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