As the Chief Resource Person, Govt. of Karnataka's Corrective Surgery Scheme for Locomotor Disabilities (http://www.disabilityactindia.org/), I was asked by the Commissionerate for Persons with Disabilities to conduct a 6-hour workshop on "Appropriate Corrective Surgery for Locomotor Disabilities", "Management of Cerbral Palsy" and "Locomotor Disability Certification Procedure" for all the state government cadre orthopaedic surgeons from Karnataka. The workshops were conducted on January 21, 2003; February 25, 2003; and May 20, 2003.
The striking feature that emerged from the workshop was that though many Orthopaedic Surgeons expressed an eagerness to conduct such operations, very few of them had the required training and supporting facilities at their district hospitals. Only 3 Orthopaedic Surgeons had access to C-arm, while 10 had a physiotherapist equipped to deal with postoperative rehabilitation after corrective surgery. Only 2 had a trained orthotist who could fabricate various types of orthoses and repair them. 20 Orthopaedic Surgeons expressed a willingness conduct corrective surgeries at their present hospital under guidance of experts in a tertiary center via Telemedicine (video satellite link).
Almost all the Orthopaedic Surgeons admitted that their postgraduate training (MS or D. Ortho) was woefully inadequate in equipping them in the technical skills required in the assessment and performance of appropriate corrective surgery and wanted the health department to first conduct practical training programs or apprenticeships at regional centers like Bangalore Children's Hospital before being asked to conduct corrective surgeries independently.
Locomotor Disability is defined as "a person's inability to execute distinctive activities associated with moving both himself and objects from place to place and such inability resulting from affliction of the musculo-skeletal and/or nervous system." In India, a Person with Disability is defined as a person suffering from not less than 40% of any disability as certified by a medical authority. The meeting emphasized that for those persons whose disability is temporary (most locomotor disabilities would fall in this category), the disability certificate would be valid for a period of 5 years. In fact, the doctors were urged not to issue any "Permanent" disability certificate to children below the age of 5 years, because many ill-advised parents in the lower socio-economic groups tend to prefer keeping their child disabled and refuse corrective surgery fearing loss of govt. grant of Rs. 125 a month.
With the Pulse Polio program-implemented by the Govt. of India and supported by Rotary International- a big success, new cases of Polio are rare in Karnataka. But unofficial estimates say we still have almost 4 million victims of Post Polio Residual Paralysis and an equal number of Cerebral Palsy patients in India. Somewhere between 1 to 3 % of Karnataka's population has moderate to severe disabilities; 76% of them live in the rural areas. The ones that present for surgery now-a-days are usually adolescents/adults with complex bony deformities. Each of these patients has at least 2 or 3 bony deformities and joint problems at different levels, which need to be tackled. This makes at least 7 to 8 million surgeries that need to be performed!
Suitable cases for corrective surgery include Polio (one leg or arm; both legs with normal trunk and arms), Cerebral palsy (diplegia and hemiplegia), limb deformity (e.g., bone infection, club foot, bent/twisted leg), and post burns contracture.
It is well known that persons with locomotor disabilities, when made upright and walking with support following appropriate corrective surgery, are accepted by the community, educated by parents, and become employable when they reach maturity.
The tragedy is that very few such surgeries are carried out in Karnataka due to various reasons like…
- Lack of resources: poverty, distance, problems in transporting a child with disability, time off work
- Lack of Orthopaedic Surgeons trained in assessment, surgery and rehabilitation
- Lack of appropriate medical facilities, e.g., instruments, Operation Theatres, physiotherapy, orthotics
- Most hospitals and Orthopaedic Surgeons consider corrective surgery for locomotor disabilities as unglamorous, uninteresting, unsatisfying (unreal patient expectations, poor follow-up) and financially unrewarding
- Attitudes and ignorance: myths about disability, beliefs in traditional "healers", lack of concern for the child with disability
- (Misguided) advice by some doctors, physiotherapists and CBR workers that it is better to suffer disability rather than the complications of failed surgery
The unfortunate result is that interest in tackling the existing cases is taking a backseat and the majority of reconstructable cases are condemned to crawling on the ground, resulting in severe deformities and contractures, which preclude caliper or splint fitting. The ones that do undergo surgery (either "free" or "Camp Surgery") have a significant failure rate because of inappropriate selection of cases, inappropriate operations, inadequate postoperative rehabilitation and post-operative complications.
According to the W.H.O., a trained Orthopaedic Surgeon at the District level should do selected soft-tissue operations for polio. The majority of cases requires a tertiary care setup with specialized facilities and highly trained Orthopaedic Surgeons. The overriding principles of Corrective Surgery is "quality is of paramount importance and takes priority over quantity." No corrective surgery is justified in situations where reasonably sufficient pre-operative/intra-operative/post-operative care cannot be provided.
Aims of corrective surgery: To improve the function of the affected limb by:
1. Overcoming the effects of muscle paralysis, e.g., tendon transfers
2. Correcting deformities
3. Restoring joint mobility
4. Stabilizing flail and unstable joints
5. Relieving pain
6. Restoring limb length discrepancy
Pitfalls of corrective surgery:
• Many patients fear that they will become worse after surgery. This fear is well grounded because many unthinking and untrained surgeons make many mistakes of indication as well as performance in surgery which does indeed do more harm to these patients
• A failed operation is a financial disaster to the person with disability
• Most failed operations cannot be salvaged: one has to hit bull's eye the first time!
Recommendations of the meeting: What corrective surgery deserves
- Tertiary level hospitals: ideally one in every state-specially catering to the needs of patients with locomotor disabilities, with selected cases being done at the district level by trained surgeons
- Multi-disciplinary team approach: Pediatric Orthopaedic Surgeon, Developmental Pediatrician, Neurologist, Clinical Psychologist, Physiotherapist, Occupational Therapist, Orthotist, etc.
- Spot-on assessment & documentation: X-rays and video recording (of walking patterns-before and after surgery) stored carefully and digitized for computer storage & retrieval
- Planned surgery: Fully equipped, clean Operation Theatres; C-Arm Image Intensifier units for accurate surgery; Powered instruments, drills, etc. where required
- Expert Postoperative Care: Specialized nursing facilities; Pain relief and humane treatment-regardless of economic and social status; Exercises and gait training must be supervised by Physiotherapist; Orthoses and Calipers must be individually prescribed, measured and modified when need arises
