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Our own BFIRST committee member, Sarah Tucker, has a longstanding connection with Nepal, after being asked to help with lower limb trauma for earthquake victims. This is an important area for work in a country like Nepal, as osteomyelitis is a common outcome of an open fractures, where there is no social care for the disabled, and an amputation can mean the difference between being able to work or not. Four Nepalese plastic surgeons (Kiran, Surendra, Krishna & Sunil) visited the UK in October 2016, to learn specifically about microsurgery for lower limb injuries. This involved intense training with cadaveric dissection and microsurgical workshops. In March 2017, Sarah, along with Mr Bob Handley (Consultant Orthopaedic Surgeon), visited Kirtipur and Bir Hospitals in Nepal, as a follow-up visit. The latter is the oldest and largest government hospital in Kathmandu. It was a real delight to see the local surgeons taking on cases that they wouldn’t have been able to do before. Their Head of department, said he saw a paradigm shift in the type of cases they were able to do on their return from the UK.

Our team were shown cases and discussed management with the local surgeons, the emphasis being on teaching and supporting them to reach their own conclusions. The highlight of the first week was that Sarah and Bob were invited to give a presentation to the orthopaedic and plastic surgeons at Bir Hospital, where trauma cases are generally taken. They spoke about collaboration and demonstrated it by giving a combined presentation on orthoplastic surgery. It was well received and there was a very positive response to the concept of orthopaedics and plastics working together on acute open, fractures as well as osteomyelitis cases. Two cases were planned for the following week.

Case History 1

The debridement took place as a joint case at Bir. Placement of pins for a circular frame were discussed and modified to allow for the microsurgery to take place and it was very encouraging that the two teams listened to one another and worked together well. The next day a latissimus dorsi flap was raised and transferred to cover the bone ends at Kirtipur Hospital.

This was an extremely technically demanding case, working with vessels affected by chronic inflammation and through a circular frame but they showed themselves to be more than equal to the task.

Case History 2

The frame on this case was unlikely to need adjusting so the plan was to do the whole procedure of debridement and free tissue transfer in one sitting at Bir Hospital. The microsurgical instruments were taken down from Kirtipur along with 2 sets of X4 loupes as there was no microscope available there.

Given the restrictions of not having a microscope, vessel anastamosis was done end to end once it had been confirmed that the foot was well supplied by the dorsalis pedis artery.  This was another extremely demanding case, but considering that the patient went on the table at 11.30am, the team did well to finish at 8pm.

Both flaps were diligently monitored and have been successful so far. It is very clear that this group of surgeons are very talented and are providing advanced plastic surgery in a resource poor setting. They do not turn anyone away or offer different surgical solutions depending on ability to pay, but rely on charitable donations to be able to offer a high quality service to all-comers.