3rd World Orthopaedics

Lee S.Segal, MDPhoenix Children’s Hospital

““33rdrd” world” worldDefinitions based on stage of economic Definitions based on stage of economic

and social developmentand social development

WHO/UN classificationWHO/UN classification• Least developed (48)Least developed (48)• Developing (95)Developing (95)• Transitional economy (22)Transitional economy (22)• Developed (26)Developed (26)

2/3 world population “developing” (4

billion)

Honduras – developing nation

HondurasHonduras• One of the original “Banana One of the original “Banana

Republics”Republics”• Poorest of the 5 Central American Poorest of the 5 Central American

nationsnations• 90% of wealth possessed by 10% of 90% of wealth possessed by 10% of

populationpopulation• Subject to natural disasters including Subject to natural disasters including

hurricanes, mudslides and floodshurricanes, mudslides and floods

Health StatisticsHealth StatisticsHondurasHonduras United United

StatesStates

Fertility rateFertility rate 4.44.4 2.1 2.1 (3.4 - 8.7)(3.4 - 8.7)

Infant mortality/Infant mortality/1000 live births1000 live births 3131 6.8 6.8

Life ExpectancyLife Expectancy 67.9y 67.9y 76.9y76.9y

HondurasHonduras• A typical rural A typical rural

town with one town with one room shacks.room shacks.

• Tortillas and Tortillas and beans are diet beans are diet staples and staples and malnutrition is a malnutrition is a common problem common problem in rural areasin rural areas

Is health care Is health care a “right” or a a “right” or a “privilege”?“privilege”?

Health Care DeliveryHealth Care Delivery• Government HospitalsGovernment Hospitals

– ““Free” to allFree” to all– Resources limited to the treatment of life Resources limited to the treatment of life

threatening illness and traumathreatening illness and trauma• Private HospitalsPrivate Hospitals

– Available only to the wealthyAvailable only to the wealthy– Variable standards of care (~ 1980 US)Variable standards of care (~ 1980 US)

• Mexico and United StatesMexico and United States– Available only to the very wealthyAvailable only to the very wealthy

• North American Medical “Brigades”North American Medical “Brigades”– The only resource for elective medical care for The only resource for elective medical care for

the poorthe poor

“waiting room”

• ““The greatest The greatest republic of republic of medicine medicine knows and has knows and has known no known no national national boundaries” boundaries” Sir William OslerSir William Osler

““The greatest The greatest republic of republic of medicine medicine knows and knows and has known no has known no national national boundaries” boundaries” -Sir William Osler

Osteogenesis Imperfecta

OIOI•“Brittle bone disease” • Genetic disorder of connective tissue• 90% affected individuals have identifiable defect in type I collagen• Type I collagen – major structural protein found in bone and skeletal connective tissue

1994 - Tarah Lynne Schaeffer joins the cast. Wheelchair-bound Tarah proves over and over again that all kids like to play, laugh, learn, and have fun! Her spunky presence has helped children learn about the needs (and strengths!) of children with disabilities

A 2000 Sesame Workshop newsletter mentioned Tarah's inclusion in the cast as one of the top ten significant ways Sesame

Street has encouraged diversity:   

Why should you care?Why should you care?•Global economyGlobal economy•Isolationism no longer Isolationism no longer

optionoption•World is getting “smaller”World is getting “smaller”•Global health burdenGlobal health burden

Swine fluSwine flu

Global health burdenGlobal health burden• ““89% of the world’s population 89% of the world’s population

lives in developing countries that lives in developing countries that bear 93% of the world’s disease bear 93% of the world’s disease burden”burden”

- Satcher D: JAMA 1999- Satcher D: JAMA 1999

Global health burdenGlobal health burden• 1/21/2 world population lacks access world population lacks access

to adequate primary health careto adequate primary health care• Life expectancy – 65% that of Life expectancy – 65% that of

advanced nations (52years)advanced nations (52years)

Global health burdenGlobal health burden• Need for health care Need for health care

outstrips resourcesoutstrips resources• Lack medical Lack medical

facilitiesfacilities• Lack trained medical Lack trained medical

personnelpersonnel• Lack equipmentLack equipment• Lack transportation, Lack transportation,

access health careaccess health care

Local / cultural issuesLocal / cultural issues•Traditional Traditional

medical medical system system

•Civil unrest Civil unrest / warfare/ warfare

Musculoskeletal diseaseMusculoskeletal disease• Different in developing countries, Different in developing countries,

children significant % - chronic children significant % - chronic disability; malnutritiondisability; malnutrition

1.1.Late presentation of traumatic Late presentation of traumatic injuriesinjuries

2.2.Neglected congenital deformitiesNeglected congenital deformities3.3.Sequelae infectious diseasesSequelae infectious diseases

Supracondylar Supracondylar fracture/gunstock deformityfracture/gunstock deformity

Global trendsGlobal trends• Rural Rural Urban Urban• Aging populationAging population• Increased trauma-related injuriesIncreased trauma-related injuries• Increased degenerative diseasesIncreased degenerative diseases• Communicable diseases - paradoxCommunicable diseases - paradox

VDRR

VDRRVDRR• Rickets - from old English word Rickets - from old English word wrickwrick, which means "to twist." , which means "to twist."

• Numerous etiologies – Numerous etiologies – nutritional (Vit. D)nutritional (Vit. D)

• Those refractory to Vit. D Those refractory to Vit. D supplementation – commonly supplementation – commonly low serum phosphate low serum phosphate

• Familial, x-linkedFamilial, x-linked• VDRR – familial VDRR – familial

hypophosphatemic ricketshypophosphatemic rickets

VDRRVDRR• Pathogenesis – phosphate Pathogenesis – phosphate

wasting at the proximal wasting at the proximal tubuletubule

• Defective regulation of the Defective regulation of the NaNa++- PO- PO44 co-transporter at co-transporter at cell bordercell border

• Low levels of inorganic POLow levels of inorganic PO44 impair function of impair function of ossificationossification

• Mutant PHEX gene on X Mutant PHEX gene on X chromosomechromosome

VDRRVDRR• Delayed motor Delayed motor

milestonesmilestones• Short statureShort stature• Flaring at ends of Flaring at ends of

bones with most rapid bones with most rapid growth (wrists, knees, growth (wrists, knees, ribs)ribs)

• Bowing of WB long Bowing of WB long bonesbones

• Widened physisWidened physis• Delay dentitionDelay dentition After treatment

The post-op wardThe post-op ward

Chronic Chronic osteomyelitisosteomyelitis

• AHO – untreatedAHO – untreated(developing countries)(developing countries)

• Trauma / open Trauma / open fracturesfractures

• Complications after Complications after surgerysurgery

Weston PM: Care of the injured in the third world-Weston PM: Care of the injured in the third world-What can we learn? Injury 18:297-303, 1987What can we learn? Injury 18:297-303, 1987

Chronic osteomyelitisChronic osteomyelitis• Extremely common Extremely common

in developing in developing countriescountries

• Huge global burdenHuge global burden

Uganda Children’s Orthopaedic Uganda Children’s Orthopaedic Rehabilitation ProjectRehabilitation Project

1996-20021996-2002

• 5163 children evaluated & 5163 children evaluated & treatedtreated

• 874 orthopaedic operations874 orthopaedic operations

2001 Statistics2001 Statistics

874 Surgical Procedures / 2001

Osteomyelitis / Septic ArthritisOsteomyelitis / Septic Arthritis 20%20% 180180ClubfeetClubfeet 20% 20% 180180Trauma / BurnsTrauma / Burns 18% 18% 159159Congenital & AngulatoryCongenital & Angulatory 10% 10% 92 92PolioPolio 8% 8% 58 58TB SpineTB Spine 4% 4% 31 31CPCP 2% 2% 20 20Post-injection paralysisPost-injection paralysis 2% 2% 19 19MiscellaneousMiscellaneous 16% 16% 135135

Why treat chronic osteomyelitis?Why treat chronic osteomyelitis?

• May make the biggest impact of anything we surgeons can do in poor countries

• Reduces burden of disability

• Improves quality of lifeNorgrove Penny in

Uganda

Why is chronic osteomyelitis Why is chronic osteomyelitis such a major problem?such a major problem?

• Late presentation/neglectLate presentation/neglect• Malnutrition/povertyMalnutrition/poverty• Limited resourcesLimited resources• Antibiotics/sensitivitiesAntibiotics/sensitivities• $$$ to pay – food vs. medicine$$$ to pay – food vs. medicine• Access to health care / follow-upAccess to health care / follow-up• Imaging studiesImaging studies• Coexistent disease: SCD/TB/HIVCoexistent disease: SCD/TB/HIV

Clinical presentationClinical presentation• FeverFever• PainPain• MalaiseMalaise• Soft tissue swellingSoft tissue swelling• Bone tendernessBone tenderness• Sinus with persistent dischargeSinus with persistent discharge

Pathogenesis• Metaphysis

• Subperiosteal abcess

pathogenesis

Sequestrum: avascular, harbor micro-organismsInvolucrum: host response

Goals of treatmentGoals of treatment•Eradicate infectionEradicate infection•Obtain osseous unionObtain osseous union•Correct angular Correct angular deformitydeformity

•Address LLDAddress LLD

Weston PM: Care of the injured in the third world-Weston PM: Care of the injured in the third world-What can we learn? Injury 18:297-303, 1987What can we learn? Injury 18:297-303, 1987

• apply basic surgical apply basic surgical principlesprinciples

• choose simple rather choose simple rather than complex than complex techniquestechniques

• treat most surgical treat most surgical conditions satisfactorily conditions satisfactorily in absence of in absence of expensive or expensive or sophisticated facilitiessophisticated facilities

Weston PM: Care of the injured in the third world-Weston PM: Care of the injured in the third world-What can we learn? Injury 18:297-303, 1987What can we learn? Injury 18:297-303, 1987

adapt some of the newer surgical techniques for adapt some of the newer surgical techniques for use in unusual situationsuse in unusual situations

Ilizarov /distraction Ilizarov /distraction osteogenesisosteogenesis

• Not require microvascular surgeonsNot require microvascular surgeons• bone regenerate correct size for anatomic bone regenerate correct size for anatomic

sitesite• Not require ready access of donor boneNot require ready access of donor bone• wound margins approximatedwound margins approximated• Transfusions and ancillary procedures fewTransfusions and ancillary procedures few• Ilizarov not require antibiotics in treatment Ilizarov not require antibiotics in treatment

of chronic osteomyelitisof chronic osteomyelitis

ClubfeetClubfeet• Incidence 1/1000Incidence 1/1000• distribution ♂=♀distribution ♂=♀• Bilateral 50%Bilateral 50%• Etiology unknown Etiology unknown

(genetic (genetic /environment)/environment)

• Natural historyNatural history

MF CAVUS

HF VARUS

MTA

HF EQUINUS

4 components

1 2 3 4 5SR 9 days old

Ponseti technique worldwideAvoid extensive surgery, untreated

sequelae

+ galosh sign

EA 1 week oldEA 1 week old

Ponseti Ponseti techniquetechnique

• After pTAL, LLC x After pTAL, LLC x 3 weeks3 weeks

• Then wear Ponseti Then wear Ponseti AFO’s and Denis-AFO’s and Denis-Browne bar full-Browne bar full-time x 3 monthstime x 3 months

• Then N/N for 3-4 Then N/N for 3-4 yearsyears

EA at last follow-upEA at last follow-up

Orthopaedics = “straight child”

72o

51o

BenefitsBenefitsvolunteering 3volunteering 3rdrd world mission world mission

EducationalEducational• Understand diagnosis, Understand diagnosis,

natural history, natural history, consequences of delay in consequences of delay in treatment of diseasestreatment of diseases

• Treat in a broader Treat in a broader cultural contextcultural context

• ““systems” based systems” based approach to medicineapproach to medicine

• Share knowledge and Share knowledge and skillsskills

Share knowledge and skillsShare knowledge and skills

benefitsbenefitsPersonalPersonal• Get more out of experience Get more out of experience

than you givethan you give• ““Make a living by what you Make a living by what you

get, make a life by what get, make a life by what you give”you give”

• Understand ones limitations Understand ones limitations in a stressful environmentin a stressful environment

• Become better physicianBecome better physician• Gain broader perspectiveGain broader perspective

33rdrd world healthcare world healthcare volunteeringvolunteering

•AppropriateAppropriate•AcceptableAcceptable•SustainableSustainable

Appropriate, acceptable, Appropriate, acceptable, sustainablesustainable

• Provide assistance only when invited and Provide assistance only when invited and welcomedwelcomed

• Medical needs often too great to provide Medical needs often too great to provide service assistance onlyservice assistance only

• Education is the most effective method of Education is the most effective method of providing sustainable solutionproviding sustainable solution

• When possible, preferable to train people When possible, preferable to train people in their own countryin their own country

• Transfer of medical care should not be Transfer of medical care should not be based on OUR cultural biasesbased on OUR cultural biases

"Give a man a fish and he will eat "Give a man a fish and he will eat for a day. Teach a man to fish and for a day. Teach a man to fish and he will eat for the rest of his life." he will eat for the rest of his life."

referencesreferences• Mountains beyond Mountains - Mountains beyond Mountains -

KidderKidder• Awakening Hippocrates – O’NeilAwakening Hippocrates – O’Neil• www.global-help.orgwww.global-help.org

Muchas Gracias!Muchas Gracias!