Reconstructive considerations in low and middle-income countries

Inexpensive Materials for Microsurgery in Middle- and Low-Income Countries

With the continuous incorporation of new technologies and advancements in surgical technique, microsurgical procedures around the world have generated a higher success rate and innovative procedures are now possible. In this setting, limitations regarding accessibility and acquisition of medical resources and equipment for these types of operations may be difficult in developing countries. We believe the dexterities of surgeons go beyond the surgical technique, meaning that we are able to use everyday materials to re-create affordable solutions that can be used during surgery in a safe way. This manuscript presents our experience with different surgical instruments and gadgets, developed out of necessity, to improve microsurgical interventions in developing countries.

No implant, no solution, lost cases to surgery: orthopedic trauma triage for surgery in an NGO hospital in Sierra Leone

INTRODUCTION

In low-income countries (LIC), international surgeons face the fact that there are patients they cannot treat. The goal of this study was to identify and analyze patients lost to treatment.

MATERIAL AND METHODS

We analyzed retrospectively the data of 282 trauma victims from a non-governmental organizational (NGO) hospital in Sierra Leone, Africa. During a 3-month period (10.10.2015-08.01.2016), these patients had 367 injuries and underwent 263 orthopedic surgeries. Despite a clear indication, some patients did not receive surgical treatment. We identified these injuries and the reason why they could not be operated. The anatomic region of the injury was evaluated and if they had a bone or soft tissue defect or were infected.

RESULTS

We identified 95 (25.89%) injuries in 70 patients (47 males; 23 females) that were not be operated. The reasons were lack of specific implants (no implant group; N = 33), no treatment strategy for the injury (no solution group; N = 29), and patients that were lost (lost patient group; N = 33), almost equally distributed by 1/3. In the no implant group were mainly closed fractures and fractures of the pelvis and the proximal femur. The implants needed were locking plates (N = 19), proximal femoral nails (N = 8), and implants for pelvic surgery (N = 6). In the no solution group were nearly all bone (P < 0.0000), soft tissue defects (P < 0.00001) and infections (P = 0.00003) compared to the rest and more open fractures (P < 0.00001). In the lost patients group, most fractures were closed (24 out of 33, P = 0.033). These fractures were mostly not urgent and were postponed repeatedly.

CONCLUSION

One quarter of the patients did not receive the surgical treatment needed. Besides acquisition of implants, surgical skills and expertise could be a solution for this issue. Nevertheless, these skills must be passed to local surgeons.

Subclavicular flap: A valid reconstructive option among anterior chest flaps in oral cancer patients

BACKGROUND

The subclavicular pedicled flap is based on the thoracic branch of the supraclavicular artery, and it represents a versatile reconstructive option for low-middle third face defects. Since its use in head and neck surgical oncology has not been popularized yet, we propose its application for oral cavity reconstruction after cancer resection by showing favorable results.

METHODS

Eighteen subclavicular pedicled flaps were used to treat intraoral defects after oral squamous-cell cancer resection between June 2015 and December 2018. Tumor dissection type, complications, donor and reconstructed area results, and functional and aesthetic outcomes were assessed.

RESULTS

No major complications were observed and all of the flaps survived. Adjuvant therapy was administered without delay when needed, and all of the patients had normal functional outcomes and good aesthetic results.

CONCLUSIONS

The subclavicular flap is an excellent choice for the reconstruction of oral cavity defects. Selection of patients should exclude positive lower-third neck node and include appropriate informed consent for women due to the possibility of deformity of the breast. In our opinion, this flap has the potential for common application given its consistent anatomy and donor site advantages, including long pedicle, high pivot point, and relatively unlimited flap width.