Review Article

Limb reconstruction in a resource-limited environment

¹ Limb Reconstruction, Division of Orthopaedic Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, 7600 Stellenbosch, Cape Town, South Africa
² University of California, San Francisco, Limb Lengthening & Reconstruction Center, UCSF Benioff Children’s Hospital Oakland, 747 52nd Street, OPC 1st Floor, Oakland, CA 94609, USA
³ Benha University Hospital, 13511, Benha, Egypt
⁴ Hull Limb Reconstruction and Bone Infection Unit, Hull University Teaching Hospitals, University of Hull, Hull HU3 2JZ, United Kingdom
⁵ Paediatric Orthopaedics, B. Nanavati Super Specialty Hospital, 400056 Mumbai, India
⁶ Thangam Institute of Orthopaedic Surgery, Trauma & Ilizarov, Thangam Hospital, Palakkad, 678004 Kerala, India
⁷ Bone reconstruction and lengthening sector, El Cruce High Complexity Hospital, 1888 Buenos Aires, Argentina
⁸ Center for Limb Lengthening & Reconstruction, Mangal Anand Hospital, 400071 Mumbai, India
⁹ Royal Liverpool University Hospitals and Royal Liverpool Children’s Hospital, L7 8XP Liverpool, United Kingdom
¹⁰ The James Cook University Hospital, TS4 3BW Middlesbrough, United Kingdom
¹¹ Children’s Orthopaedics and Reconstruction, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J801, 8200 Aarhus, Denmark

^* Corresponding author: jan.roelfing@clin.au.dk, jan.roelfing@rm.dk

Received: 23 November 2021
Accepted: 13 December 2021

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.