International Orthopaedics
the rewards are well worth the challenges

Dennis Jeanes
Manager, Communications & Advocacy
Canadian Orthopaedic Association

"The first purchase that people in the developing world make, after they've moved to the city and found a job, is a motorcycle that then becomes the family vehicle," says Dr. Lew Zirkle, noted American orthopaedist and inventor of the SIGN IM nail system. Anyone who has stepped into the maelstrom that passes for traffic flow in major urban centres such as Rio de Janeiro, New Delhi and Djakarta, or who has travelled the back-country dirt roads in places like Vietnam, Tanzania and Afghanistan, knows whereof Dr. Zirkle speaks. 

"The traffic in Kampala was mostly scooters, but it's the big trucks that I remember. Most of them were in very bad shape, and you really wondered whether their brakes were going to work," says Dr. Peter O'Brien, COA President and head of UBC's orthopaedic trauma division, recalling his time in 2007 in Uganda. "At the time, people were moving into the city from rural areas, filling the roads and city streets. There was no infrastructure, no sidewalks, just traffic." Accidents waiting to happen.

And they do happen - a lot. According to the WHO, road accidents injure annually up to 50 million people globally, almost 90% of whom live in the developing world. Half those injuries involve vulnerable road users such as pedestrians, cyclists and motorcyclists. "It's an emerging epidemic. Even in war zones, like Afghanistan and Iraq, we see lots of road accidents," says Zirkle. "Trauma kills more people between the ages of five and 44 than AIDS, TB and malaria combined. Everybody in the developing world wants to buy a motorcycle or a car, so the number of deaths and injuries isn't going to go down." And for those who are injured in the motor mayhem (or by such common misadventures as falls or farm accidents) the consequences are often calamitous.

Complex trauma cases involving open fractures receive only the most rudimentary of care in the developing world, since the vast majority of people are too poor to pay for proper treatment. The prognosis for many, many patients is grim: grossly malformed, weakened limbs or possibly amputation, and lifelong disability. "In a family, if the father gets into trouble, who is going to work? The mother has no choice but to start supporting the family, and the kids get sent off to work early," says paediatric orthopaedic surgeon Dr. Marc Moreau, who is also a founding member of a non-profit Edmonton-based orthopaedic team that travels every year to Quito, Ecuador. "If it's the mother who becomes disabled, then who looks after the kids?"

As Zirkle has seen in many parts of the world, most recently in Tanzania, family members are often forced to stop visiting their loved one because they can't afford the dollar or so a day to take the bus. Soon after, the disabled patient "disappears" into the clinic's landscape, shunted out of the way to the ward's periphery or out onto a porch, sometimes with no more than a mattress if beds are in short supply. It's a life of unadulterated misery.

"I'm humbled to know that our surgeons around the world become advocates for these 'invisible' patients. They want to help them, and I think it is incumbent upon us to take care of these injured people before they are disabled or lose a limb," says Zirkle, summing up both the motive and the mission behind his brainchild, the Surgical Implant Generation Network (SIGN). This global network of 144 programmes in 49 countries now boasts a roster of some 3000 surgeons trained in the SIGN technique, using implants and instruments designed by Zirkle: "Usually, there is no C-arm to help you do the interlocks. You have to develop your tactile senses. I can tell you, having worked with and without a C-arm, that doing SIGN surgery is far more fun, because you feel where the end of your hand reamer is. You feel where the end of your drill bit is, and you develop those tactile senses until it's almost second nature."

Based in Redland, Washington, SIGN supplies its various sites around the world with initial training by volunteer surgeons, its signature IM nail and ongoing resource support. All surgeries - on average, 100 per site per year - are entered into SIGN's database to monitor the nail's effectiveness. Over time, the database has evolved into a forum, where surgeons abroad can report suggestions for alternative indications of the SIGN nail and discuss results with other surgeons. "These surgeons are fantastically skilled," says Zirkle. "They have innovated and learned new things. I teach them what I know, but I also learn from them."

For all of its global reach and impact, SIGN remains a small organization, with a staff of about 20 and Zirkle its only full-time orthopaedic surgeon. Financing depends on an array of corporate partners - notably Acumed - who provide SIGN with ongoing financial, technical and in-kind donations, and on the generosity of the local community: "The average donation is $100, and mostly from central Washington State." However, the key to success is recruiting volunteer trauma surgeons (usually from the US and Canada) who, after learning SIGN's tactile surgical technique, either visit an existing site to lend a hand or help establish a new site. Either way, the idea is to teach, learn and develop lasting friendships with the host surgeons, to re-distribute the trauma expertise concentrated in the West throughout the developing world. And make no mistake: to get involved is to transform lives and to become transformed in the process.

"We've been doing this for 10 years now, and we're hooked," says Marc Moreau, who as part of a growing brigada of professionals and lay people goes to Quito for about 20 days annually to provide orthopaedic care, mostly total hip replacements - hip dysplasia is highly prevalent in Ecuador's adult population - and a range of paediatric procedures.

"There are these identical twins. Both had club feet, which we fixed, and now they come back to the clinic every year to say hello to us," says Moreau, who clearly takes great delight in seeing their progress. And then there are memorable patients such as the tiny - "no more than four-foot-six" - 71-year-old woman, "with these long, long pigtails," who lived alone on a farm in the jungle. "She quickly became everybody's sweetheart, because she was so small and so independent," recalls Moreau. "She came in by bus, and all she wanted to do was to keep up her farm and tend her animals. So we replaced her hip, and off she went back to her farm."

After the first couple of visits to Quito, the nucleus of the original team (Moreau and his wife, Barb, anesthetist Dr. John Lilley, and orthopaedic surgeon Dr. Greg O'Connor) decided to formalize the group's endeavours for administrative and fund-raising purposes as a registered charity, the Canadian Association of Medical Teams Abroad (CAMTA). Since then the team has grown from 20 to 84, and the mission has doubled in length of time in South America. A typical team includes both paediatric and adult orthopaedic surgeons, anesthetists, family physicians, OR, recovery room and ward nurses, a physiotherapist, an anesthetic technician, orthopaedic residents, pre-med students, nursing students and lay people. Each member is responsible for raising the equivalent of his or her own expenses ($2300 this year). "A lot of people raise twice or three times that amount," says Moreau, "which is a good thing, because it means one or more patients can receive a hip replacement."

Experience has taught the CAMTA team to divide its efforts into two successive sessions of ten days each, so that if supplies run out or are forgotten, or special needs occur, the second team can bring down what's needed. "We carry everything in hockey bags," says Moreau. "The OR nurses, especially, work very hard at getting the equipment packed. Our implants are delivered in plastic shipping trollies just before we go."

Friendly relations with everyone from the security guard at the door of Quito's Fundacion Tierra Nueva hospital to the staff social workers to orthopaedic surgeon Dr. Manuel Ordoñez (who finds patients and does postoperative follow-up) help make things run as smoothly as possible. Says Moreau: "Dr. Ordoñez is a wonderful man. He knows how we do things and is very familiar with our postoperative routines. These days, if there's a problem, he can contact us by e-mail. He gives up a lot of his time, and he's not paid to do this; however he decided to make this programme part of his life and to give back to the community. We're very thankful."

But like many small-scale non-profit organizations, CAMTA needs to grapple with its own success. Moreau worries that "we're a well-organized machine when we get there, but I'm afraid we may be burning out the people who manage and administer our activities at home before the trip." The logistics of getting 84 people onto planes bound for Quito with all the right documentation, vaccinations and equipment, not to mention issuing the requisite cheques and tax receipts, is daunting to say the least. Accordingly, CAMTA's executive is looking at how it can further develop its infrastructure and provide some relief to a core group of volunteers who faithfully assume the burden year after year.

"There are many Canadian surgeons involved in delivering orthopaedic care throughout the world," notes Peter O'Brien. Indeed, UBC's orthopaedic department has "twinned" with Mulago Hospital at Makerere University in Kampala to provide training through surgeon exchanges and to deliver programmes such as the Uganda Sustainable Club Foot Care Project, which teaches the Ponseti Method. "At the COA, we receive many requests for information on international orthopaedics, often from residents who are looking for a different kind of experience." So in this year of his presidency, O'Brien has decided to give some exposure to the topic at the upcoming Annual Meeting in Whistler, BC, and perhaps indirectly act as matchmaker between interested parties. Lew Zirkle will be there as the Presidential Guest Speaker to talk about "Creating Equality of Fracture Care Throughout the World." And there will be two related symposia on international orthopaedics and war surgery.

"It's an important subject," says O'Brien. "Every Canadian orthopaedic surgeon does trauma, and in that respect they could be very helpful to the developing world, even if it's just to do clinical help to free up local surgeons. The challenges are great, but the rewards are well worth it. This year's meeting provides surgeons and residents who might be interested with an opportunity to sign up and become citizens of the world."