Orthopedic surgeon Robert E. Booth knew the conditions in the Nicaraguan hospital would not be equal to those of the pristine medical facilities he was used to in the United States.

So he bit his tongue when he saw the bare wires that ringed the small stucco building, the flies that came and went through the open-louvered windows, the dirt floor of the operating room.

But an exasperated Booth drew a line when, as he worked to surgically replace a patient’s knee, he saw a small black cat prowling the edges of the OR.

“Can we at least get the cat out?” he recalled asking the Nicaraguan nurse at his side.

“If the cat goes," she replied, “the snake comes back.”

Booth paused.

“I can live with the cat,” he said.

Fifteen years ago, Booth — the medical director of 3B Orthopaedics at Jefferson Health — and a small medical team volunteered their time to replace joints for patients living in Panama and Central America. They were invited to join a mission being organized by Operation Walk, a Los Angeles-based organization whose aim is to restore physical mobility to patients hobbled by disabled joints. Founded in 1996 by Dr. Lawrence D. Dorr, Operation Walk today includes more than 20 teams in the U.S., Canada, Ireland, and Thailand whose members have operated on 17,000 patients in 25 countries.

In 2009, Booth and a larger team of area surgeons, physician assistants, nurses, physical therapists, and anesthesiologists formed Operation Walk Philadelphia, a separate foundation that either travels on its own or partners with a Denver-based Operation Walk group. It’s funded by generous individual donors as well as by area hospitals, including Jefferson Health.

Planning for a mission commences eight months to a year in advance, said Liz Sees, a perioperative nurse coordinator for 3B Orthopaedics.

Organizers solicit artificial-joint manufacturers for donations (which usually consist of devices that are one generation old and would no longer be used in the U.S. market). They round up medications, instruments, and dressings. They complete reams of paperwork to ensure everything will make it through the host country’s customs processes.

Robert E. Booth, Jr., M.D., the medical director of 3B Orthopaedics at Jefferson Health, shown here with a model of a knee replacement in his Center City office in Philadelphia, December 04, 2019.
JESSICA GRIFFIN / Staff Photographer
Robert E. Booth, Jr., M.D., the medical director of 3B Orthopaedics at Jefferson Health, shown here with a model of a knee replacement in his Center City office in Philadelphia, December 04, 2019.

Crates containing most of the needed supplies are then shipped to the host country months in advance. The rest is hand-carried in massive duffel bags through airport security by the 60 or so team members.

Also in advance of the trip, the team receives and reviews about 150 X-rays belonging to potential joint-replacement patients. About one-third of the patients are found not to be good candidates for the procedure. Once the team arrives at the location, they physically examine the remaining patients, usually finding that another 25 are not healthy enough to undergo surgery.

“It’s heartbreaking to send them back home with no joint,” said Booth, who has replaced more than 35,000 knees in his career.

During the next four or five days, the surgeons operate on 60 to 70 patients. Most of the surgeries are for new knees and a handful are for new hips, said Booth. Some patients have conditions that are generally no longer seen in the United States, such as severe rheumatoid arthritis, which is now treated and controlled with medication.

X-ray of a Panama patient needing a knee replacement. Some patients have conditions not often seen in the U.S. such as severe rheumatoid arthritis, which is now controlled with drugs.
Courtesy of Robert Booth
X-ray of a Panama patient needing a knee replacement. Some patients have conditions not often seen in the U.S. such as severe rheumatoid arthritis, which is now controlled with drugs.

One Panamanian patient, for example, had arthritis so severe she hadn’t walked in years. Her joints were frozen at 90 degrees and her ligaments were not in great shape, Booth said.

The day after her double knee-replacement surgery, she was up and walking.

“It says more about her courage than my skills,” said Booth. “The changes you can make in people’s lives, even after all these years, it astounds me."

To his knowledge, said Booth, his team’s patients have have never experienced post-op infection.

“Why? I don’t know,” he said. But he speculates that the patients’ natural immune systems are more tolerant of organisms than the systems of patients in the United States, for example, where antibiotics are over-prescribed and hand sanitizer is everywhere.

Most of the team’s trips have been to Panama, where they often treat patients who once worked at a now-closed U.S. military base.

“When we left, these people had no jobs,” said Booth. They also lost access to regular medical care.

When it comes to tolerating pain, Booth has noticed a marked difference between Latin American and American patients. Overseas, patients who undergo double-knee replacements are able to walk 100 yards to the bathroom the next day without having taken any pain medication.

Part of the reason may be cultural: In the host countries, strong narcotics are often prescribed only to people who are terminally ill. Another part may have to do with limited access to pain medication in general: The pain drugs that the teams bring with them for use by orthopedic patients are instead dispensed by the local staff to cancer patients or those who are dying, Booth said.

The team’s missions include a major educational component. Surgeons teach local medical students and residents how to implant the artificial joints; physical therapists demonstrate how to manage the necessary range of motion exercises; and nurses discuss how to prepare a patient for surgery, pain management and wound care.

“Our job is to teach them how to take care of patients when we leave,” said Michelle Anderson, a physician assistant with 3B Orthopaedics who is also a medical coordinator for the trips.

And the education goes both ways, said Booth.

“We have learned that when a fly lands on a wound, you turn the [operating room] light away and it will take off,” he said. If that happened in a Philadelphia hospital, people would “be apoplectic."

Even with the 12-hour days, no air-conditioning and sometimes dangerous living conditions, the medical team comes home rejuvenated, Booth said.

“Everyone feel like they’re back doing what they imagined then went into medicine for."