Monday, 05 December 2022 | Dr Gaurav Sanjay & Dr BKS Sanjay
GUEST COLUMN
The United Nation General Assembly had proclaimed December 3 in 1992 as the International Day of Persons with Disability (IDPD). As done annually, it was observed recently to promote an understanding of disability issues and to mobilise support for the dignity, rights and wellbeing of persons with disabilities.
Disability is an umbrella term which covers an impairment in body function or structure. Such people face difficulty in executing certain tasks and have difficulty as an individual to deal with day to day activities. Being orthopaedic surgeons, we will confine our discussion to orthopaedic disabilities related with locomotion. According to a 2011 census, 20 per cent of all the disabilities are of orthopaedic nature. We believe that the health of the limbs is as important as the health of the heart. Whatever mankind has achieved by now, is mainly due to locomotion, be it in war or in peace.
The main causes of orthopaedic disabilities are club foot (CTEV), cerebral palsy (CP), congenital dislocation of hip (CDH), scoliosis, myopathies, myelo-meningocele and rickets. In certain myopathies there is genetic transmission. The patients suffering with these diseases should get counseling preferably pre-conception. In the last 30 years, a lot of work has been done by governments, non-governmental organisations and communities all over the world. This has been made possible by their social commitment and improvements in techniques and medical advancement. In our experience, 40 years ago the patients of myelomeningocoele rarely survived after birth and even if they survived, the infection and septicemia usually led to their death sooner or later. But nowadays, many of these new born are not only surviving but after medical or surgical intervention they are leading a reasonably good life. The incidence of infection in children has been reduced due to judicious use of antibiotics and surgical intervention. The deformities related to infection have been significantly reduced in the last 40 years. However the deformities and disabilities have increased proportionately after traumatic injuries especially after road traffic accidents particularly the open joint injuries.
Polio had been the main cause of deformities and disabilities in the past. However India has become polio free since March 2014. There are no new cases of polio, but millions of patients suffering from polio in the past continue to suffer from post polio residual deformities and still lead a hard life. These patients require braces and multiple surgical correction and reconstruction to make them lead a reasonably well life.
In spite of the improvement in medical and technical fields, the incidence of deformities and disabilities due to congenital anomalies are not decreasing proportionately but rather increasing because of increased birth rate and decreased infant mortality rate (IMR). IMR has improved significantly since the independence of our country. According to a Government of India report, incidence of IMR was 145 per thousand live births in 1947 but as of now the IMR has reduced to 27 per thousand live births by 2022. Management of deformities and disabilities have significantly improved after early detection, early treatment including surgical intervention and better follow up of the patient. Recent social, economic, medical and technical developments have spread awareness about the diseases in general. Hence, the scenario of management of congenital deformities including club foot has changed.
The senior author remembers in his early days of orthopaedic training, the multiple visits of club foot patients in club foot clinic with a prolonged waiting list for club foot surgery being the common scenario. The incidence of only serial plaster application in club foot as a modality of treatment has reduced and also changed though the incidence of club foot surgeries has increased significantly in the past two decades. Hundreds of patients of club foot surgeries have been operated by us with significantly improved results. In certain properly selected cases, quality surgery and a regular follow up of these patients have given such good results that after 5-10 years of surgery it has become difficult to say if these particular children ever had any deformity in the past.
Posterior medial soft tissue release (PMSTR) was a common surgical technique performed about 40 years ago which has been replaced by Ponseti technique with tenotomy lately. In the authors’ experience, reconstructive surgery with soft tissue release, Ilizarov fixator and tendon transfer give excellent results in properly selected, cooperative patients particularly those who understand the problem of deformity and disability and value of the surgery.
The results of treatment in CTEV have improved significantly but the scenario is not the same in Congenital Dislocation of Hip (CDH) and in scoliosis surgery. The principle of surgery in CDH and scoliosis are the same as in club foot. Sooner the correction better are the results. Myopathies do not need surgical intervention though scoliosis usually needs surgical correction particularly for aesthetic reasons when the curve is large. Scoliosis is an abnormal sideways bending deformity of the spine which is usually seen near puberty but can also be detected earlier by observant friends and parents. Scoliosis patients mostly lead a normal life and can do almost all activities. Scoliotic patients develop early degenerative changes in the spine in comparison to the normal population.
Road traffic accidents are causing havoc and producing significant disabilities in the society. Road traffic accidents have taken over the deformities caused by other reasons. Nowadays these road traffic accidents are high energy injuries which are fatal and usually involve multiple bones. In such a condition, it is very difficult in general, to give pre-injury functional outcomes in these injuries in spite of the best possible treatment available in the country. The growth and development of an individual depends on locomotion, which is important in every stage of life. Locomotion depends upon strength of bone, joints and muscles which are controlled by various neuro-vasuclar structures. Injury to any of these structures can give rise to deformity and disability. Deformity and disability caused due to any reason affects the individual, family, community and the nation. Therefore, the goal is to enable the individual with a disability to live a life with the least impediment. The correction of deformities and disabilities requires a multi disciplinary approach. The needs of people with disabilities are the same as those of a non-disabled person. Deformity and disability due to any reason should be rectified as soon as possible, because “plants can be straightened easily, not the trees”.
(Padma Shri recipient Dr BKS Sanjay and Dr Gaurav Sanjay are orthopaedic surgeons based in Dehradun. Views expressed are personal)
