Submitted by Dr. Mohan on 26 December, 2011
The patient
A young man was referred to me by our orthopedic specialist just to see if anything was possible to be done for him; he had lost his shoulder in a war injury but his entire left upper limb was otherwise intact – only no shoulder joint. To this day I am glad that he thought of asking a plastic surgeon. All the previous ortho surgeons that the patient saw told him nothing was possible. Such correction was not described.
Darfur to Dubai
This man had had his shoulder blown off in the civil war in Darfur and was left to die in the field. He was then picked up after a few days, cleaned up and taken to kenya much later, There a surgeon tired to fix the arm bone [humerus ] to the residual scapula [shoulder blade bone] by a long steel plate and screws. This predictably failed, the screws worked loose, the plate got exposed and he went to three adjacent countries seeking treatment. Someone brought him to Dubai in this state. He went to the Irani hospital where he was told after several visits that it cannot be repaired. He saw one of the orthopedicians in our hospital as a last resort before going back.
The problem
The central issue seemed to be that there was no joint structure, no muscle, no bony shelf [called acrominon] so there was no way even a prosthetic steel bone could be fitted. So it was declared as a hopeless case. His hand and elbow were fully intact and he had a normal lower humerus. But as he had no shoulder he could not use this limb.
The Plan
I looked at it as a case for detailed planning of 1. What is lost and 2. How can we replace the lost parts. When the orthopedician raised his list of ‘objections’ to joint replacement, each objection was met with a possible solution in plastic surgery. I finally told him – give me your wish list and I can try and fill that list.. This is what we plastic surgeons do!
Finally after careful planning, this boy underwent a reconstruction of his shoulder with the following steps. Although two of these steps have been used by other surgeons in the past, no report exists of all these methods being used in combination to totally build a shoulder.
The Surgery
The missing bone segment and head of humerus was replaced by a steel implant [this was perfectly executed by our ortho doctor]. The capsule of the joint was made from a hernia mesh and a cardiac Dacron patch joined together as a bilayer construct. The missing bony shelf of acrominon was built from the outer part of collar bone. One of the muscles involved n the initial lift of the shoulder [supraspinatus]was actually present but had to be pulled out as an island flap and its length extended by fascia. Finally the entire construct was covered by functional LD muscle flap bearing skin as well. This muscle will enable him to raise this bio-synthetic shoulder joint at will.
After 4 weeks of healing and eager waiting, he did raise this shoulder and the shoulder did look and function like one. He of course required a lot of physiotherapy and re-training but his visa and money ran out and and he disappeared to followup.
Outcome
I managed to track him down again after 4 years and was told that he is working in a garage lifting objects and generally using his left arm satisfactorily!
This case was absolutely amazing. Nothing like this has ever been reported but the more important point here is that plastic surgical principles can be applied to most seemingly hopeless situations to find some sort of solution – the art of the possible! There is an imaginative streak in every plastic surgeon tempered by prudence and experience of course. There are no written solutions for every problem, there are only principles that have stood the test of time. As one pioneer in plastic surgery so ably stated: “the problem itself suggests the solution”