Good morning from Kenya!! We are in the midst of our ‘summer’ here on the Rift. The sun is bright and strong at our 7,000+ feet of elevation. The grass has turned a crunchy brown. Tree limbs tend to sag during the day. The red dust travels everywhere, both inside and outside of buildings and people. I walked along the back yard, looking across the Rift this morning, enjoying the view. The far hills had a gauzy curtain of haze obscuring the fine details. The spiked top of Mt. Longonot emerged above this misty layer to reflect the early morning sun’s rays. Sunsets have been painted with brilliant reds and purples. The evening skies are a vast array of stars. The beauty of the Rift is a sight I recommend for all to see and enjoy. All over the world we can enjoy the striking drama of creation if we just take time to seek and relax. I loved to walk in the Michigan dunes in all seasons, stopping to see how the details have changed since my last visit. Amazing!
We had a wild week here in Kijabe. If we did not have a few ‘no shows,’ we would still be operating. Sometimes the schedule gets too much due to other commitments wresting away time. Anyway, as is always the case, we finished in good fashion, caring for all who needed our care.
Two weeks ago in Kisumu, I had the opportunity to see one of two siblings with an unusual problem. Recently, we admitted the other brother for his second operation. Both siblings have an impressive sounding disorder: Popliteal Pterygium Syndrome. Say that five times quickly and see if you stumble. The disorder is highlighted by a thick, fibrous band that extends from the buttock all the way down the limb toward the heel. Patients have a large web that crosses the knee and blocks the ability to extend the knee. The band appears deceptively thin, and for those unaware, the problem looks like a relatively simple operation: divide the band and let the knee loose. Wrong!
Bound tightly to the back of this band are the nerves and vessels to the lower extremity. So if you cut aggressively to release the ‘simple’ band you have simply divided the nerves and vessels to the leg! You have taken a bad problem and made it terrible. Surgery has not been written to be all that successful on these deformities. So what are we doing going there?
Last year one of the residents scheduled both siblings for admission. The older, Hillary, hopped with a stick and had trouble fitting his pants on. School was a very long journey for him. His web was not terrible, but I knew surgery on the deformity was like reaching blindly into a hole in the valley. You may get bitten by a snake!
The younger brother had both lower extremities involved. The knees were flexed beyond which walking was not possible; he crawled around. The optimistic resident thought we could just release the bands and maybe need a skin graft to restore the function. I first of all shook my head and allowed the resident later to present a talk on various causes of knee contractures and their treatment.
Interestingly, I had been contemplating options for this type of problem for some time. We took a couple days to discuss this deformity with Dad to make sure he understood if our plan fails, the only other reasonable option is to remove the leg or try to fit a wheelchair. Dad thought that the hope for walking was better than what the boys had and understood there were risks. I was hoping he would say no surgery.
We had a plan that sounded reasonable and should be possible. We would first do the older boy, and if that worked, plan to do the other child the following day. Taking a deep breath and saying a prayer of healing, we started. I had diagrammed out the various incisions planned. First, a gentle transverse incision is made crossing over the web across the back of the knee. The nerves and vessels were tightly bound. We released all the tissue front and back of these structures. As we attempted to straighten the knee the vessels and nerves were tightening and sitting in the open air. We actually anticipated this but, of course, hoped for a miraculous exception.
Phase two lead us to the thigh. We approached the femur thigh bone. We cut the bone and allowed the ends to overlap, relaxing the stresses on the nerves and vessels. We then measured the correct amount of bone to remove, and, using the fine orthopedic tool (a saw), shortened the femur. A plate and screws stabilized and aligned the bones.
The nerves and vessels still were airborne, since we took the minimum of bone we could and still gain extension. So, phase three. We then elevated a flap of skin, fat, and superficial fascia from the leg like a long tongue. The flap was then rotated across the back of the knee giving a nice thick covering for the nerves and vessels. The area where we stole the tissue was covered with skin grafted from the thigh.
The next morning Dad was excited for the other brother to go to theatre. I was less so, as we faced another major ordeal. The younger brother had dense webs and significant flexion contractures. We did a similar operation, and the knee came out as well!
Last week in Kisumu, the elder brother showed off his leg. He walks without problem using a small shoe lift. He can run and play ball! Another miracle I was thrilled to witness!
The younger brother came in to CURE Kijabe for the other knee, his left. The first one has normal motion. The left knee was done as a repeat operation of the one done on the right. Now both lower extremities look in better position. I look forward to the time when both brothers walk and run. I am also thrilled there are no more siblings at home with this disorder.
The week held many other challenges too numerous to list here. I think I may talk about a problem new to Kenya that has emerged as western influence crosses the globe. We had a four year old with an untreated congenital dislocation of his hip. When I arrived in Kenya in 1998, a long time missionary surgeon told me this problem did not exist in Kenya; I was thankful. But now… more about this later.
We are thankful for all the children coming to the hospital for our care. The CURE team is faced with challenges in all aspects of our care each week. Some problems appear straightforward but are not. Others, at first glance, appear very complicated but correct quite easily. Families come seeking hope for their child, hope we can offer to all because we do and will continue to work in His grip.