Newsletter No.91 - October 2003
106 Harley Street
London W1G 7JE
Telephone Number: 020 7486 3131
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These Newsletters usually end with an invitation to readers to send in reports, descriptions or accounts of their experiences in the course of Orthopaedic Concern for the World. This time I shall begin with it because our readers, and even more those who only occasionally see a copy of this letter, require to know the extent of activity conducted in the name of Orthopaedics. Therefore I seek, with some sense of urgency, news of those who have not to date communicated with us. We would welcome material of a surgical anecdotal type - the sort which academic journals (e.g. JBJS) always reject - rather than a travelogue. This invitation goes out beyond those who subscribe to WOC or OO, but who engage in the work.
Perhaps the expression “the work” requires a definition. It includes all those who retain a fascination with Orthopaedic Surgery and who engage in clinical orthopaedic work for the benefit of developing countries. Again the expression clinical orthopaedic work requires definition. Much is practical, active surgery, through which the principles and standards of modern orthopaedics are displayed and, by example of surgery done together, taught. But it also includes those who no longer operate but whose retention of memory and marbles are invaluable tools of tuition.
WOC and OO are essentially enabling bodies and this Newsletter is the means by which information is spread. Neither is an essentially charitable body to which substantial sums are attracted and collected but they work closely with those who are, such as IMPACT, THET, WHO, The Lee Foundation and a dozen religious and humanitarian bodies. Not least amongst the doners are the WOC workers themselves. At this point it must be said that the main sources of finance are the WOC workers themselves who often pay their own travelling expenses and subsistence, and freely contribute their time accommodated by the host hospital or other institution. This means that WOC and OO are largely autonomous, without power and perhaps the better for that.
Amongst the Regional Reports we have not had one from Malcolm Swann who has worked for some years as a freelance, itinerant pair or surgical hands. Sadly he is not currently a subscribing member of WOC and I fear there may be dozens, even hundreds like him, equally engaged in “the work” but not sponsored by WOC or OO, or a major charitable body. He refers to “SOC” - Swann’s Orthopaedic Concern! One reason suggested is that for a 73 year old, stuffy rules insist that a charitable body cannot accept responsibility with those no longer in continuing surgical practice, which by custom is assumed to be 70 years of age. Such rules do not even apply to the National Health Service, for whom need overrules all. But the NHS does have a customary date of retirement, 65 years, with all sorts of pension implications. These restrictive dates have their function, but were never established in order to penalise those who have been critically evaluated as doing priceless surgical work and whose dedication would lead them to a love of “the work”. So Swann receives no corporate funding. Readers who have similar stories please let us have them. And because this Newsletter has but a limited circulation, please pass on this copy.
REPORTS AND CORRESPONDENCE FROM THE REGIONS
From Mr Dan Williams (Trainee from the Bristol Orthopaedic Rotation, UK). Dan Williams writes about his visit between February and July 2003 to the Unit of Trauma & Orthopaedics in the Transkei, South Africa. He describes Umtata as a vibrant, bustling African town (pop. 200,000) with a surrounding rural population approaching 4 million. The general hospital and the Bedford Orthopaedic Centre, is 7 kilometres outside the town and is a place of secondary referral from some 20 or 30 rural hospitals and clinics throughout the Transkei.
Professor Chris McConnachie , Chairman of the Orthopaedic Charity, African Mission Hospital, issues a regular invitation to young orthopaedic surgeons. He moved to Umtata in 1981 setting up the charity organisation for the Transkei. A series of new operating theatres was recently opened by Nelson Mandela with a dedicated outpatient and x-ray department, intensive care and doctors’ accommodation. Special facilities include a 30 bed unit for spinal disease, 60 beds dedicated to children and 80 more for general orthopaedics and trauma. Twin operating theatres run continuously every week day. According to available anaesthetic cover, as many as three tables can be running simultaneously. Chris McConnachie has equipped the unit to a high standard including an Image Intensifier so that all manner of complex orthopaedic cases are managed, including the trans-thoracic approach to the front of the dorsal spine for cases of tuberculosis. The most frequent cause interrupting the constant flow of surgical work is the occasional failure of water supply.
Professor McConnachie is the only certified orthopaedic surgeon in the region and his staff include one Indian colleague, two Cuban surgeons and four Medical Officers (from Cuba, Italy and South Africa). They manage a 1 in 5 rota with Dan Williams as the visitor. Each day commences with a clinical meeting at 8.00 am to discuss the admissions from the previous day, their diagnosis and the surgical procedures completed. Patients arriving from outlying clinics, mostly selected for their complexity, may number over 100 in a busy day.
An audit of the previous year, 2002, revealed 300 fractured femora, 230 supracondylar fractures and over 200 gunshot wounds. Motor vehicle accidents, domestic violence and tribal troubles (80% of total) lead to a large number of open compound fractures, many of which have failed the treatment by traditional “village doctors”. In addition 150 cases per year have advanced tuberculosis of bone, mainly of the spine. Acute and chronic osteomyelitis, cerebral palsy and the usual array of congenital conditions, particularly club foot, make up the bulk of the remainder. Rarer pathological conditions included the following: Tumoral Calcinosis, Fibrodysplasia and Myositis Ossificans Progressiva.
Dan Williams gained immense experience from this four month visit and has had a paper accepted by the South African Journal of Orthopaedics. Dan took part in over 180 theatre procedures of which over 120 he managed personally. Although fractures of the femur were common, the neck of the femur was affected in only six cases! Cases requiring ORIF included 15 supracondylar fractures, 10 femoral shaft fractures, 6 forearm bones and 3 ankles.
As a volunteer visitor, Dan was accommodated most comfortably in a house adjacent to the old Missionary Church with one other volunteer. He soon got used to the church bells and Sunday singing which on Easter Day was still in full swing at 2.00 am. A car was available and he was able to visit the spectacular “ Wild Coast” where endless sunbathed beaches were in striking contrast to his homeland in Wales. He ends his excited report with warm gratitude to Chris and Jenny McConnachie for their never ending hospitality and their acceptance of him as part of the ANM family. He received some support for his venture from WOC and also through them from Orthodynamics and 3M Healthcare. It is clear to your editor that Dan Williams has enormously enhanced his confidence and ability as an orthopaedic surgeon during his four months in Umtata. (Contact address: Professor McConnachie, Bradford Orthopaedic Centre, Umtata, Eastern Cape Province, Republic of South Africa.)
From Dr Temitope Alonge
The Senior Lecturer and Consultant Orthopaedic & Trauma Surgeon from Ibadan sends the following message. He is very interested in the prospect of establishing a proposed sub-speciality entitled “Third World Orthopaedics”. He makes a very sensitive suggestion that it be re-titled “Orthopaedics in the Third World” because the former title presupposes that modern orthopaedic practices are alien to the Third World. (This editor might emphasise that the epidemic of loose prostheses and the multiple revision procedures, which load the operating lists in western hospitals, are indeed mercifully alien to the developing world and might be considered alien to real orthopaedics.) Dr Alonge comments that bone and joint infection and delayed management of open fractures constitute a major part of the developing casemix and yet some of the principles derived and developed from living tissues are becoming neglected when the complications of inanimate implants dominate the field of surgical pathology. Dr Alonge says that some of the lessons of chronic osteomyelitis require to be relearned in the West.
Dr Alonge looks forward to the forthcoming 26 th Annual General Meeting of the Nigerian Orthopaedic Association combined with the 5 th Congress of the African Society of Trauma & Orthopaedics, which is scheduled to be held between the 2 nd and 6 th December 2003 at the Premier Hotels, Ibadan, Nigeria. The theme of the conference is bone and joint disease in Haemoglobinopathy, with a sub-theme of degenerative diseases. Dr Alonge issues a warm invitation to all the readers of this Newsletter to attend and contribute to this important meeting.
BLANTYRE , MALAWI
Professor Chris Lavy sends us his Newsletter No 8, across the top of which there is a fine photograph of the new two-storey Orthopaedic Hospital, for which he recognises the munificence of the Beit Trust ( Woking, UK) and the American based Christian charity, Cure International. They are proud to have welcomed during the last year David Whitney, Skip Gilber, Hilary Green, Dave Gaw, Bill Johnson, Bill McDade, Shafiq Pirani, Malcolm Swann, Steven Wood, Simon Smith, Joe Serra, Mick and Maggie Johnson, and most recently, Hugh and Trish Phillips.
Chris Lavy describes his pattern of work as being centred on Blantyre where the new Orthopaedic Hospital is, but with frequent visits to outlying clinics and district hospitals where minor surgery may be done. Major cases are brought back to Blantyre. Each distant visit is essentially one of triage - a recent clinic at Nkhotakota was typical, where 112 patients were seen and assessed. The day’s work ends when the last patient has been seen, not before. Each list at Blantyre contains two or three untreated club feet together with a bizarre assortment of skeletal deformities from untreated trauma or contracture.
Jim Harrison , has made for himself a speciality with the Ilizarov circular frame equipment, used in many corrective procedures. Incidentally Chris Lavy says that experts in the use of this equipment would be particularly valuable visitors. The recent visit of Hugh & Trish Phillips made a demonstration of hip replacement. Such surgery is not commonly required in Malawi but occasional cases occur for which no other treatment can be effective. The occasion of this visit attracted visiting surgeons from Zimbabwe, Zambia, Tanzania and Uganda. Around them an international meeting developed. J & J, UK were the generous sponsors of this high-tech demonstration.
On the subject of high technology, comprehensive AO equipment is now available in Blantyre and yet most fractures are still managed conservatively. Restricted indications mean that internal fixation is employed only when the indications are absolute, not relative. For all this machinery, a C arm image intensifier is becoming increasingly necessary.
At the end of a very full and exciting letter of orthopaedic activity, Professor Lavy acknowledges his debt to the Christian Blind Mission for their constant funding from their base at Winship Road, Milton, Cambridge CB4 6BQ, United Kingdom.
Professor N K Aggarwal writes from Ludhiana, Punjab. He describes the orthopaedic developments at the Christian Medical College, Ludhiana, setting up an Institute of Orthopaedics & Trauma. He hopes to develop sub-specialities including joint replacement surgery, spinal surgery, trauma and arthroscopic surgery in relation to sporting injuries. He sends an urgent invitation for visiting specialists within these areas to work at the Centre to set the ball rolling, for periods varying between a few weeks and a few months. All residential costs would be met by the Institute for visiting volunteers. Anyone wishing to know more about this urgent need should contact Professor Aggarwal through the following e-mail address:
Dr Berbudi writes a charming letter from Makassar, Indonesia. He wrote a few days before he was to receive the Eyre Brook medal, presented by WOC for special service, in this case the setting up of hospitals dedicated to the management of leprosy. “I will be 72 years of age on the 23 rd April, which means on my birthday I will receive the prize for my work all these years. In fact it is not the habit of Indonesian people to mark birthdays with presents, although it is beginning amongst the younger generations. Occasionally foreign nurses used to surprise me with birthday wishes when I was at Tangerang, between 1970 and 1983 and after that in Makassar. I have a great feeling of pride at this recognition of Surgery, which is the only corrective technique to help those with established deformities. I must pass on my gratitude to the Netherlands Leprosy Relief Association who have given much to support my work and enabled me to train surgeons to follow in this speciality. Our country of 200 million people is widely separated amongst 3000 islands, most of which are remote from surgical care.”
MEETINGS IN PROSPECT
Dr Rajaskaran (The President-Elect of WOC International) writes to tell us about the Indian Orthopaedic Association meeting between 16 th and 20 th December 2003, during which there will be a General Meeting of WOC ( India). He also repeats his invitation for applications by a trainee registrar from Europe or America to spend two months at Ciombatore [
Dr Bhasker Banerji writes to inform us of the 10 th Annual Congress of the Paediatric Orthopaedic Society of India to be held in Allahabad in February 2004. The official website for the meeting is www.posi2004.com.
From Geoffrey Walker (
). Geoffrey wrote on the 15 th September 2003 referring to the fundamental organisation of WOC International as an offspring of SICOT with a major contribution at SICOT’s Triennial Meetings. Between these triennial occasions there are smaller annual meetings of SICOT, of which the most recent was held in September 2003 in Cairo. Geoffrey reminds us that the next annual occasion will be in Havana, Cuba, in September 2004. Movements are already afoot to arrange accommodation for WOC delegates. This is a venue with obvious attractions to many people who have not had the opportunity to visit a country emerging into international tourism. There will obviously be opportunities for fascinating visits to the distant parts of Cuba and other Caribbean countries. It is not too early for members of WOC to begin to put together possible papers for presentation in Havana. Abstracts, of about 50 words, might be sent to the current head office of WOC International, c/o British Orthopaedic Association, Royal College of Surgeons, 35-43 Lincoln’s Inn Fields, London WC2A 3PN, UK. Or to the Honorary Secretary of WOC International, Dr Ger Olyhoek,
The next major meeting after that will be the triennial SICOT event in Istanbul, September 2005. The registration fee for WOC members to attend the SICOT meeting is presently under discussion and will be announced in the next Newsletter.
FROM THE FELLOWSHIPS AND FOUNDATIONS
The IMPACT Annual Review 2003, describes the continuing vigorous activity of IMPACT (India)’s Lifeline Express, The Hospital Train, for which Indian Railways have pledged a new coach to double the operating capacity.
In Bangladesh the Jibon Tari Hospital Ship continues as the focus of the Delta waterways with seaplane links through Mission Aviation Fellowship. John Lourie has recently returned from a surgical visit there and presented his work to IMPACT’s Annual General Meeting in London.
Recent reconnaissance in Kenya, Tanzania and Sri Lanka is opening up areas in which IMPACT will make donations. These also include Zanzibar, Malawi and the Seychelles. In Tirana, Albania, the country’s only Orthopaedic Centre, has been given a number of pieces of surgical equipment.
The 4 th meeting of the Lee Foundation/Tan Sri Dr Runme Shaw Fellowship Selection Committee was held in July 2003. In an opening address Dr Kanda Pillay described the origins of the Fellowship and its philosophy to provide exposure for doctors who are from Asean countries, and from less developed nations from around the greater Asian region. Dr Pillay suggested that should there be other interested applicants from even less developed nations, other than Asia, they should also be considered. The order of priority was chosen to be:
1) Asean countries, for example, Indonesia, Myanmar
2) Asian regional countries, e.g. Nepal, Bangladesh
3) Other less developed nations, for example Central Africa
Dr Pillay went on to say that India had been considered, but there were now so many centres of excellence, with well trained surgeons in that country, that the facilities were already in place.
The curriculum vitae of ten applicants for orthopaedic surgical fellowship and five hand and reconstructive microsurgical applicants are considered and those chosen were informed. They included the following places of origin; Ethiopia, Nepal, Indonesia, The Philippines and India. The list of the 39 Fellows in the past relating back to 1976 is appended in the report. Apart from the above countries of origin, they included Korea, Thailand, Taiwan, Sri Lanka, Pakistan and Tanzania.
WOC International held a meeting on Thursday 11 th September 2003 concurrent with that of SICOT in Cairo. The President began by expressing WOC’s appreciation to SICOT for their continued support and for maintaining the link between the Scientific body and those involved in hands-on training. In his coverage of Regional activities, Mr Tuson used Bangladesh as an example of a country which had expanded from zero to 300 orthopaedic surgeons over a period of some 50 years. He confirmed the established contributions from WOC to the training programmes in Ethiopia, Malawi and Nepal. He welcomed developments in the Transkei, Kenya and Zambia and reported that WOC ( Netherlands) had opened units in Ghana and Indonesia. WOC Australia’s activities include Indonesia and Fiji. From the USA, Orthopaedics Overseas runs 12 projects in various widespread parts of the world.
Warm appreciation was expressed to Dr Dennis Gates and his secretary for the work they had done over the previous years as our President and most particularly for establishing the World Wide Web through which the Newsletter will be delivered. Representatives from East Africa emphasised that the Internet was not available to every Department and that the paper copy of the Newsletter was still an essential vehicle for communication.
The Sicot Diploma - Professor Leong reported that the examination had been held and there were ten successful candidates.
Under “Any Other Business” the matter of age in regard to participating volunteer surgeons was raised. The representatives of East and Central Africa saw no difficulty in welcoming surgeons over the age of 70 because they felt that wisdom and fitness were far more important criteria than the number of years since birth.
Dr Michael Hoogmartens from Leuven, Belgium, writes to appreciate the exchange of information we have through this Newsletter but from a technical point of view he asks a question. His experience is largely in East Africa where he operates on about 25 neglected club feet each time he visits the area over a period of 2-3 weeks. Over the years he has come to worry about the extent of initial surgery in the timescale imposed upon him. In particular he worries that when he leaves, 3 weeks later, he does so with a feeling of apprehension about aftercare.
Many have referred to the difficulties in developing countries where the level of education is barely up to the provision of trained nurses. To a much greater extent, the difficulty of communicating with and relying upon the mothers of these child patients with numerous competitive siblings. All who operate on CTEV are conscious of the propensity for the serious cases to recur, with the need therefore of constant supervision and manipulation when the child emerges from splintage. This reservation may occasionally lead to surgery of greater extent and complexity than might be necessary with well established aftercare facilities. Alternatives to wide radical release might be triple arthrodesis or even, in extreme cases, talectomy. What is really required is a well organised and trained parent to teach the others in a class, using whatever local language is current, and thus provide follow-up on a regular basis. Instructions are so often neglected, even in the most advanced centres. Herein lies an argument for this sort of surgery to be concentrated in dedicated units.
There is room for wide debate on all these issues. It is hoped that a communication can be made between those who have experienced the problems over the years. Upon these points comments are invited.
The editor reminds all of his e-mail address, with repeated requests for items of news well in advance of the next Newsletter, which will be transmitted in January 2004.