Deformity Correction in Haiti with the Taylor Spatial Frame




The Taylor Spatial Frame (TSF) is an external-fixator that corrects deformities in 6 axes, and can successfully manage disorders involving multiplanar deformities. In the developing-world, orthopaedic surgeons are often faced with deformities from neglected trauma and birth defects more severe than those typically seen in developed-countries. This article evaluates the applicability of TSF in the challenging medical environment of Haiti. At Haiti Adventist Hospital, the authors treated 80 cases using the TSF with a minimum follow-up of 1-year. Good results were observed in 99% of the cases (79 out of 80), approaching similar outcomes than those described in literature.


Key points








  • There is a high prevalence of congenital, posttraumatic, and postinfectious limb deformities in Haiti.



  • Haiti has a substantial need for external fixation, which can be used to treat complex deformities in a precise and efficient manner.



  • Gradual correction with the use of distraction osteogenesis creates a new realm of opportunity for the treatment of severe deformities, bone deficits, and length discrepancies that are frequently seen in Haiti.



  • The Taylor Spatial Frame has been shown to be an appropriate technology for the treatment of many patients in Haiti.






Introduction: nature of the problem


The reasons for the high prevalence of congenital, posttraumatic, and postinfectious limb deformities in resource-limited countries such as Haiti includes the following: lack of environmental regulation (teratogenic pollutants in the air, soil, and water), lack of education, urbanization, transportation-related injuries, natural disaster, lack of prenatal care, and limited access to health care. This high prevalence of limb deformities, many of which are severe, presents some unique challenges in the limited-resource environment and creates the need for improvisation and innovation. Ideally this must not be allowed to compromise results. Indications and surgical techniques may vary based on the type and severity of limb deformities being treated, but surgical principles should remain the same, independent of geographic location.


The basic principle of deformity correction involves normalizing the alignment of the mechanical axis of the affected limb. Essentially, the center of the knee falls on a straight line linking the femoral head to the center of the ankle. Lower extremity deformity correction requires precision to obtain good short-term and long-term results. Preoperative radiographic analysis of the hip or ankle deformity will reveal secondary/compensatory deformities. It is important to also include an analysis of sagittal plane alignment. The location of the apex (or apices), also called the CORA (center of rotation of angulation) must be determined. This location is found by first analyzing joint orientation angles, determining which bone is involved, and then defining the point where the proximal and distal axes intersect. These concepts have been elucidated elsewhere in great detail.


Globalization, communication, and technology have increased our ability to improve orthopedic care around the world. The Taylor Spatial Frame (TSF), with its Internet-based Total Residual Program (TRP), has made deformity correction easier and more accurate than the first-generation Ilizarov ring fixator technology. The widespread availability of the Internet has put the TSF technology within reach in austere environments, provided that reliable follow-up of patients is possible.


Economic challenges are a significant factor in developing nations such as Haiti. More than 90% of the population has no health care insurance, and most patients are only able to pay a small amount, if anything, for surgical operations. The cost of orthopedic hardware is prohibitive in many situations. The use of an expensive device such as the TSF may seem unrealistic in the developing world. Medicolegal considerations in North America have limited the reuse of external fixation components and thus have created a source for high-quality “pre-owned” external fixator equipment for the developing world. These “gently used” TSF parts are donated by volunteer surgical mission groups hospital, and constitute a viable and reliable supply chain.


The implications of reusing external fixators in resource-limited environments are different from those in North America, owing to perceptions and medicolegal issues. Is it safe to reprocess external fixators for multiple use? In most of Europe (where resources are not severely limited) and in developing countries, external fixators are reused on a regular basis, despite their being labeled “single use only.” With an eye toward cost containment and social responsibility, some hospitals in North America have sought pathways to reprocess single-use devices (SUDs). The Food and Drug Administration (FDA) has classified SUDs into 3 categories: noncritical risk (level 1), semicritical risk (level 2), and critical risk (level 3). The reuse of fixator clamps and bars that do not penetrate the skin are considered level 1 SUDs by the FDA. These SUDs have approved device reprocessing protocols, including cleaning to remove all biological material, dismantling the device, inspection of components for defects or fatigue cracks, and resterilization. In Haiti, the authors use similar methods of checking the components for defects, discarding damaged parts, lubricating struts, and cleaning and resterilizing all components in organized instrument trays.


Several clinical studies have been published showing no loosening of components, no loss of fixation, no increase in pin-site infections, and no mechanical failures when reusing fixators. In the rare event of mechanical failure of an external fixator component, it can usually be repaired in the clinic with noninvasive, nonoperative means.


Haiti Adventist Hospital (HAH) treats many complex cases of malunion, acquired deformities, and neglected congenital conditions. Orthopedic surgeons face considerable challenges when treating these deformities in Haiti. Patients often are not able to access health care in a timely fashion, and there may be barriers to follow-up. Many severe and sometimes previously operated deformities present to the national referral center. Often these are sequelae of simple issues that have been poorly treated. Although the Haitian immune system is generally strong, the lack of sterile conditions in surrounding hospitals and the often delayed or neglected treatment of postoperative or posttraumatic infections add significant challenge to the treatment of deformities that involve chronic osteomyelitis. These infections are treated with a very proactive approach to surgical debridement followed by a course of intravenous and/or oral antibiotics. Prolonged empiric protocols of intravenous antibiotic treatment that are common in the United States are often not possible in Haiti. This situation requires clinicians to depend on meticulous surgical debridement followed by limited use of oral antibiotics and close clinical follow-up. The TSF has enabled the authors to address many of these complex deformities, sometimes complicated by osteomyelitis and resultant bone defects and shortening ( Figs. 1–6 ).




Fig. 1


Case 1. Bilateral Blount disease (tibia vara) in a 14-year-old boy. ( A ) Preoperative standing view demonstrates bow legs and internal tibial torsion. ( B ) Preoperative radiograph shows advanced Blount disease bilaterally. ( C ) Intraoperative view after bilateral TSF application, before correction. ( D ) Final follow-up after frame removal showing straight legs.



Fig. 2


Case 2. Valgus deformity and growth arrest of the left distal tibia fracture in a 17-year-old boy. The deformity was neglected for 14 years before treatment. ( A ) Preoperative appearance, anterior view. ( B ) Preoperative appearance, posterior view. ( C ) Preoperative anteroposterior ankle view showing severe valgus. ( D ) Immediate postoperative view of TSF. ( E ) Clinical view after correction. ( F ) After frame removal.



Fig. 3


Case 3. Severe genu valgum deformity in a 22-year-old man with familial hypophosphatemic rickets. ( A ) Immediate postoperative views of both legs showing monolateral fixators on femurs and TSF on tibias. ( B ) Clinical photo at the end of correction. ( C ) During rehabilitation. ( D ) Standing after external fixator removals.



Fig. 4


Case 4. A 14-year-old girl with hypophosphatemic rickets. This patient shows severe genu valgum and external tibial torsion malrotation. ( A ) Preoperative view. ( B ) After completion of treatment of the left side, and during treatment of the right side. ( C ) Shortly after right leg frame removal. ( D ) Follow-up visit, showing her preoperative photos.



Fig. 5


Case 5. Bilateral neglected clubfoot in a 14-year-old girl. ( A ) Preoperative view showing severe deformities in both feet. ( B ) Close-up view of both feet. ( C ) During treatment with miter frame TSF. ( D ) After TSF removal from the right foot.



Fig. 6


Case 6. Bilateral neglected Blount disease in a 27-year-old man. ( A ) Preoperative clinical photo showing bilateral genu varum, worse on the right. ( B ) Just before surgery. ( C ) Right-sided TSF after correction. ( D ) Left-sided TSF during surgery. ( E ) Standing clinical view at the end of correction on the second, left side.




Introduction: nature of the problem


The reasons for the high prevalence of congenital, posttraumatic, and postinfectious limb deformities in resource-limited countries such as Haiti includes the following: lack of environmental regulation (teratogenic pollutants in the air, soil, and water), lack of education, urbanization, transportation-related injuries, natural disaster, lack of prenatal care, and limited access to health care. This high prevalence of limb deformities, many of which are severe, presents some unique challenges in the limited-resource environment and creates the need for improvisation and innovation. Ideally this must not be allowed to compromise results. Indications and surgical techniques may vary based on the type and severity of limb deformities being treated, but surgical principles should remain the same, independent of geographic location.


The basic principle of deformity correction involves normalizing the alignment of the mechanical axis of the affected limb. Essentially, the center of the knee falls on a straight line linking the femoral head to the center of the ankle. Lower extremity deformity correction requires precision to obtain good short-term and long-term results. Preoperative radiographic analysis of the hip or ankle deformity will reveal secondary/compensatory deformities. It is important to also include an analysis of sagittal plane alignment. The location of the apex (or apices), also called the CORA (center of rotation of angulation) must be determined. This location is found by first analyzing joint orientation angles, determining which bone is involved, and then defining the point where the proximal and distal axes intersect. These concepts have been elucidated elsewhere in great detail.


Globalization, communication, and technology have increased our ability to improve orthopedic care around the world. The Taylor Spatial Frame (TSF), with its Internet-based Total Residual Program (TRP), has made deformity correction easier and more accurate than the first-generation Ilizarov ring fixator technology. The widespread availability of the Internet has put the TSF technology within reach in austere environments, provided that reliable follow-up of patients is possible.


Economic challenges are a significant factor in developing nations such as Haiti. More than 90% of the population has no health care insurance, and most patients are only able to pay a small amount, if anything, for surgical operations. The cost of orthopedic hardware is prohibitive in many situations. The use of an expensive device such as the TSF may seem unrealistic in the developing world. Medicolegal considerations in North America have limited the reuse of external fixation components and thus have created a source for high-quality “pre-owned” external fixator equipment for the developing world. These “gently used” TSF parts are donated by volunteer surgical mission groups hospital, and constitute a viable and reliable supply chain.


The implications of reusing external fixators in resource-limited environments are different from those in North America, owing to perceptions and medicolegal issues. Is it safe to reprocess external fixators for multiple use? In most of Europe (where resources are not severely limited) and in developing countries, external fixators are reused on a regular basis, despite their being labeled “single use only.” With an eye toward cost containment and social responsibility, some hospitals in North America have sought pathways to reprocess single-use devices (SUDs). The Food and Drug Administration (FDA) has classified SUDs into 3 categories: noncritical risk (level 1), semicritical risk (level 2), and critical risk (level 3). The reuse of fixator clamps and bars that do not penetrate the skin are considered level 1 SUDs by the FDA. These SUDs have approved device reprocessing protocols, including cleaning to remove all biological material, dismantling the device, inspection of components for defects or fatigue cracks, and resterilization. In Haiti, the authors use similar methods of checking the components for defects, discarding damaged parts, lubricating struts, and cleaning and resterilizing all components in organized instrument trays.


Several clinical studies have been published showing no loosening of components, no loss of fixation, no increase in pin-site infections, and no mechanical failures when reusing fixators. In the rare event of mechanical failure of an external fixator component, it can usually be repaired in the clinic with noninvasive, nonoperative means.


Haiti Adventist Hospital (HAH) treats many complex cases of malunion, acquired deformities, and neglected congenital conditions. Orthopedic surgeons face considerable challenges when treating these deformities in Haiti. Patients often are not able to access health care in a timely fashion, and there may be barriers to follow-up. Many severe and sometimes previously operated deformities present to the national referral center. Often these are sequelae of simple issues that have been poorly treated. Although the Haitian immune system is generally strong, the lack of sterile conditions in surrounding hospitals and the often delayed or neglected treatment of postoperative or posttraumatic infections add significant challenge to the treatment of deformities that involve chronic osteomyelitis. These infections are treated with a very proactive approach to surgical debridement followed by a course of intravenous and/or oral antibiotics. Prolonged empiric protocols of intravenous antibiotic treatment that are common in the United States are often not possible in Haiti. This situation requires clinicians to depend on meticulous surgical debridement followed by limited use of oral antibiotics and close clinical follow-up. The TSF has enabled the authors to address many of these complex deformities, sometimes complicated by osteomyelitis and resultant bone defects and shortening ( Figs. 1–6 ).


Oct 6, 2017 | Posted by in ORTHOPEDIC | Comments Off on Deformity Correction in Haiti with the Taylor Spatial Frame
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