Report of the Instructional Course on Amputation Surgery and Related Prosthetics; Compound Fractures; Neuropathic Foot
The first instructional course in the developing world following the ISPO conference on amputation surgery was arranged in Moshi, Tanzania and included also treatment of compound fractures and the insensitive foot. The venue was selected because of TATCOT's (Tanzanian Training Centre for Orthopaedic Technologists) importance as an institution in East-Africa with an ISPO recognised programme for the education of orthopaedic technologists recruited from the whole area. TATCOT was established in 1981 by GTZ (the German Technical Cooperation Agency) in KCMC (the Kilimanjaro Christian Medical Centre). About 14 orthopaedic technologists graduate from the centre each year, approximately half of them being from outside Tanzania. The facilities were most suitable and the back-up from the TATCOT staff greatly appreciated. Practical problems arising from electric supply interruptions and other minor incidents were competently dealt with by the local staff. It was considered important to arrange the event in close collaboration with a locally established system under the supervision of ISPO officers to control the content of the programme and its economical operation. This, together with the appropriate mix of lecturers with solid local knowledge and experienced teachers from the Western world is a prerequisite to the successful completion of the programme. However, the latter group must be adaptable to the local requirements of the participants. Established and proved methods must be in focus, but obviously also more advanced contemporary techniques touched upon as long as they are in accordance with approved ISPO principles and, in particular, balanced with local possibilities.
The course was well-attended with 35 participants from the English-speaking African countries (ie Kenya, Zambia, Malawi, Mozambique, Gambia and Uganda - ranked according to numbers attending) and Tanzania, with 9 participants from the country at large and a further 32 from the Kilimanjaro Christian Medical Centre and TATCOT in Moshi. Funding for a large proportion of the participants was provided from DANIDA (the Danish Overseas Aid Agency), DSE (the German Foundation for International Development), the UK National Member Society and Otto Bock GmbH, who also contributed to the catering provision.
The course was organised by the Honorary Treasurer, J. Steen Jensen, who was responsible for the programme and the Honorary Secretary, Norman A. Jacobs, who was responsible for other aspects. Local arrangements were made by Harold Shangali and Wilfred Raab. Through collaboration with the Tanzanian Health Authorities, World Orthopaedic Concern (WOC) and the International Committee of the Red Cross (ICRC), it was possible to flavour the programme with teachers who had a long experience of practice in Africa.
Course participants and instructors
The first day started with N. A. Jacobs reviewing the essentials in the education of the clinical team. It continued with the treatment of compound fractures by J. Jellis from Lusaka, who gave a comprehensive review of the type of trauma in the African continent and the basic principles for treatment, in particular, addressing the importance of assesssing the soft tissue injury and avoiding primary wound closure.
K. Rankin, who has worked in Bulawayo for many years and has recently written a PhD thesis on external fixation, offered an outstanding didactic session on the principles and practical application of such devices using available materials. U. Grob of Muhimbili Hospital in Tanzania spoke mostly about A. O. internal fixation, which applies more to highly experienced centres in the industrialised world than in the developing world. K. Rankin presented ways of achieving effective fracture bracing and emphasised the use of a brim in the management of femoral shaft fractures as an alternative to prolonged skeletal traction. J. Jellis reviewed the treatment of the infection of bone and joints in relation to trauma, emphasising the need for extensive debridement. This was followed by a thorough discussion about the removal of dead and infected bone and soft tissue as prerequisites for success. The day was closed with a useful and highly appropriate lecture about physiotherapy, and the psycho-social need for different aids for the amputees. This was given by the local physiotherapy instructor, B. Mworia.
The second day's programme was opened by a well balanced presentation by J. Jellis and K. Rankin about general patient management and the basic techniques of amputation surgery, emphasising anchorage of the muscles to the bone and gentle treatment of the skin. Also an interesting and precise talk about the treatment of snakebites was given by J. Jellis, both with regard to prevention of amputation through fasciotomies but also in performing a needed amputation in accordance with approved principles. The general discussion about level selection was flavoured by a presentation about amputation patterns by K. Katabe, Zambia. Further basic principles of biomechanics were presented by N. A. Jacobs in an easily digestible fashion with simple and understandable force diagrams. The day was closed by J. Gehrels, who presented experiences from the ICRC prosthetic workshops in war inflicted areas, in particular, with respect to locally produced components based on available materials. A long debate about appropriate technology developed and came to the conclusion of the importance of applying, approved biomechanical and functional principles to local manufacturing based on available, inexpensive materials, although sometimes requiring imports from neighbouring countries. In particular, the manufacturing of prosthetic components and feet from polypropylene attracted great interest.
The programme for the third day opened with N. A. Jacobs reviewing the biomechanics of the trans-femoral amputation, with particular emphasis of muscle force requirements, socket shape and the benefits of the longest possible stump. N. Govan described the configurations and basic differences between quadrilateral and the narrow ML (ischial containment) sockets as well as outlining the steps of impression casting of the stump. Against the background of the prosthetic possibilities, J. Steen Jensen advised about surgical techniques of the classic trans-femoral amputation with myodesis and the recently described method with adductor transposition to the lateral aspect of the femoral bone, said to increase muscle strength and stump length. The new programme layout was well accepted and resulted in good discussion about the importance of teamwork leading to the surgeons' understanding of prosthetic possibilities and what is consequently required from the surgery. Finally, J. Gehrels described manufacturing of knee units and feet based on simplified technology and use of local materials. The day ended with a tour of TATCOT.
Panel Discussion: Joop Gherels, Uma Grob, John Jellis, J. Steen Jensen, Ken Rankin and John Bowker.
On the fourth day, J. Steen Jensen talked on knee-disarticulation and supracondylar procedures, emphasising the benefits of omitting bone resection and of obtaining an end-bearing and pressure tolerant stump by amputation through the joint space. N. A. Jacobs described the biomechanical advantages and N. Govan the prosthetics, emphasising the ease of suspension and socket manufacture. H. Shangali and J. Gehrels described materials and components and again inexpensive solutions were highlighted by J. Gehrels applying a uniaxial knee joint placed on the posterior aspect of the socket to avoid protrusion of the knee mechanism. Trans-tibial amputations were didactically presented by K. Rankin, followed by a review of the biomechanics by N. A. Jacobs and lectures on suspension variants by N. Govan and again appropriate technology and materials by J. Gehrels.
The last day started with ankle and foot amputations with J. Bowker especially emphasising the Syme's amputation technique. Following this, N. A. Jacobs presented the biomechanics and J. Gehrels gave an extensive review of prosthetics and an attractive simplified method of making a prosthetic foot, in accordance with the approved biomechanical principles. Finally, the programme, closed with a comprehensive review by J. Bowker on the insensitive foot and its care, both surgically and conservatively with weight-relieving casts and footwear. The discussions left the impression that this problem was well taken care of in East-Africa through leprosy dispensaries acting in accordance with Brand's principles and that the same basic principles of foot insoles could be applied to sandals by modifying them with rubber pads. During the day a tour of the facilities at KCMC was arranged.
It was our impression that the amputation part of the programme was well received, both by the doctors and the orthopeadic technologists and that such instruction programmes were greatly needed in order to improve contact and understanding between these two groups.
The success of the course was achieved through the harmonious composition of experts appointed and financed by WOC with experience from surgery in the developing world, ICRC with extensive experience of local manufacturing and ISPO with high demands in setting standards and recommendations for appropriate procedures. The collaboration between these three organisations will hopefully continue and establish a solid foundation for future programmes in the developing world. ISPO is currently planning similar courses for China, Southeast Asia, Eastern Europe and Central America for the coming few years and the costs to the Society seem well justified.
J. Steen Jensen and Norman A. Jacobs