3rd world PCDS

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3rd world PCDS

  1. 1. 3 rd World Orthopaedics Lee S.Segal, MD Phoenix Children’s Hospital
  2. 2. “ 3 rd ” world Definitions based on stage of economic and social development <ul><li>WHO/UN classification </li></ul><ul><li>Least developed (48) </li></ul><ul><li>Developing (95) </li></ul><ul><li>Transitional economy (22) </li></ul><ul><li>Developed (26) </li></ul>
  3. 4. 2/3 world population “developing” (4 billion) Honduras – developing nation
  4. 5. Honduras <ul><li>One of the original “Banana Republics” </li></ul><ul><li>Poorest of the 5 Central American nations </li></ul><ul><li>90% of wealth possessed by 10% of population </li></ul><ul><li>Subject to natural disasters including hurricanes, mudslides and floods </li></ul>
  5. 6. Health Statistics <ul><li>Honduras United States </li></ul><ul><li>Fertility rate 4.4 2.1 </li></ul><ul><li>(3.4 - 8.7) </li></ul><ul><li>Infant mortality/ </li></ul><ul><li>1000 live births 31 6.8 </li></ul><ul><li>Life Expectancy 67.9y 76.9y </li></ul>
  6. 7. Honduras <ul><li>A typical rural town with one room shacks. </li></ul><ul><li>Tortillas and beans are diet staples and malnutrition is a common problem in rural areas </li></ul>
  7. 8. <ul><li>Is health care </li></ul><ul><li>a “right” or a “privilege”? </li></ul>
  8. 9. Health Care Delivery <ul><li>Government Hospitals </li></ul><ul><ul><li>“ Free” to all </li></ul></ul><ul><ul><li>Resources limited to the treatment of life threatening illness and trauma </li></ul></ul><ul><li>Private Hospitals </li></ul><ul><ul><li>Available only to the wealthy </li></ul></ul><ul><ul><li>Variable standards of care (~ 1980 US) </li></ul></ul><ul><li>Mexico and United States </li></ul><ul><ul><li>Available only to the very wealthy </li></ul></ul><ul><li>North American Medical “Brigades” </li></ul><ul><ul><li>The only resource for elective medical care for the poor </li></ul></ul>
  9. 10. “ waiting room”
  10. 21. <ul><li>“ The greatest republic of medicine knows and has known no national boundaries” Sir William Osler </li></ul>“ The greatest republic of medicine knows and has known no national boundaries” - Sir William Osler
  11. 23. Osteogenesis Imperfecta
  12. 24. OI <ul><li>“ Brittle bone disease” </li></ul><ul><li>Genetic disorder of connective tissue </li></ul><ul><li>90% affected individuals have identifiable defect in type I collagen </li></ul><ul><li>Type I collagen – major structural protein found in bone and skeletal connective tissue </li></ul>
  13. 25. 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:     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
  14. 31. Why should you care? <ul><li>Global economy </li></ul><ul><li>Isolationism no longer option </li></ul><ul><li>World is getting “smaller” </li></ul><ul><li>Global health burden </li></ul>
  15. 32. Swine flu
  16. 33. Global health burden <ul><li>“ 89% of the world’s population lives in developing countries that bear 93% of the world’s disease burden” </li></ul><ul><ul><li>- Satcher D: JAMA 1999 </li></ul></ul>
  17. 34. Global health burden <ul><li>1/2 world population lacks access to adequate primary health care </li></ul><ul><li>Life expectancy – 65% that of advanced nations (52years) </li></ul>
  18. 35. Global health burden <ul><li>Need for health care outstrips resources </li></ul><ul><li>Lack medical facilities </li></ul><ul><li>Lack trained medical personnel </li></ul><ul><li>Lack equipment </li></ul><ul><li>Lack transportation, access health care </li></ul>
  19. 36. Local / cultural issues <ul><li>Traditional medical system </li></ul><ul><li>Civil unrest / warfare </li></ul>
  20. 37. Musculoskeletal disease <ul><li>Different in developing countries, children significant % - chronic disability; malnutrition </li></ul><ul><li>Late presentation of traumatic injuries </li></ul><ul><li>Neglected congenital deformities </li></ul><ul><li>Sequelae infectious diseases </li></ul>
  21. 38. Supracondylar fracture/gunstock deformity
  22. 39. Global trends <ul><li>Rural  Urban </li></ul><ul><li>Aging population </li></ul><ul><li>Increased trauma-related injuries </li></ul><ul><li>Increased degenerative diseases </li></ul><ul><li>Communicable diseases - paradox </li></ul>
  23. 40. VDRR
  24. 41. VDRR <ul><li>Rickets - from old English word wrick , which means &quot;to twist.&quot; </li></ul><ul><li>Numerous etiologies – nutritional (Vit. D) </li></ul><ul><li>Those refractory to Vit. D supplementation – commonly low serum phosphate </li></ul><ul><li>Familial, x-linked </li></ul><ul><li>VDRR – familial hypophosphatemic rickets </li></ul>
  25. 42. VDRR <ul><li>Pathogenesis – phosphate wasting at the proximal tubule </li></ul><ul><li>Defective regulation of the Na + - PO 4 co-transporter at cell border </li></ul><ul><li>Low levels of inorganic PO 4 impair function of ossification </li></ul><ul><li>Mutant PHEX gene on X chromosome </li></ul>
  26. 43. VDRR <ul><li>Delayed motor milestones </li></ul><ul><li>Short stature </li></ul><ul><li>Flaring at ends of bones with most rapid growth (wrists, knees, ribs) </li></ul><ul><li>Bowing of WB long bones </li></ul><ul><li>Widened physis </li></ul><ul><li>Delay dentition </li></ul>After treatment 
  27. 47. The post-op ward
  28. 50. Chronic osteomyelitis <ul><li>AHO – untreated </li></ul><ul><li>(developing countries) </li></ul><ul><li>Trauma / open fractures </li></ul><ul><li>Complications after surgery </li></ul>
  29. 51. Weston PM: Care of the injured in the third world-What can we learn? Injury 18:297-303, 1987 <ul><li>Chronic osteomyelitis </li></ul><ul><li>Extremely common in developing countries </li></ul><ul><li>Huge global burden </li></ul>
  30. 52. Uganda Children’s Orthopaedic Rehabilitation Project 1996-2002 <ul><li>5163 children evaluated & treated </li></ul><ul><li>874 orthopaedic operations </li></ul>2001 Statistics
  31. 53. 874 Surgical Procedures / 2001 <ul><li>Osteomyelitis / Septic Arthritis 20% 180 </li></ul><ul><li>Clubfeet 20% 180 </li></ul><ul><li>Trauma / Burns 18% 159 </li></ul><ul><li>Congenital & Angulatory 10% 92 </li></ul><ul><li>Polio 8% 58 </li></ul><ul><li>TB Spine 4% 31 </li></ul><ul><li>CP 2% 20 </li></ul><ul><li>Post-injection paralysis 2% 19 </li></ul><ul><li>Miscellaneous 16% 135 </li></ul>
  32. 54. Why treat chronic osteomyelitis? <ul><li>May make the biggest impact of anything we surgeons can do in poor countries </li></ul><ul><li>Reduces burden of disability </li></ul><ul><li>Improves quality of life </li></ul>Norgrove Penny in Uganda
  33. 55. Why is chronic osteomyelitis such a major problem? <ul><li>Late presentation/neglect </li></ul><ul><li>Malnutrition/poverty </li></ul><ul><li>Limited resources </li></ul><ul><li>Antibiotics/sensitivities </li></ul><ul><li>$$$ to pay – food vs. medicine </li></ul><ul><li>Access to health care / follow-up </li></ul><ul><li>Imaging studies </li></ul><ul><li>Coexistent disease: SCD/TB/HIV </li></ul>
  34. 56. Clinical presentation <ul><li>Fever </li></ul><ul><li>Pain </li></ul><ul><li>Malaise </li></ul><ul><li>Soft tissue swelling </li></ul><ul><li>Bone tenderness </li></ul><ul><li>Sinus with persistent discharge </li></ul>
  35. 57. <ul><li>Pathogenesis </li></ul><ul><li>Metaphysis </li></ul><ul><li>Subperiosteal abcess </li></ul>
  36. 58. pathogenesis Sequestrum : avascular, harbor micro-organisms Involucrum : host response
  37. 59. Goals of treatment <ul><li>Eradicate infection </li></ul><ul><li>Obtain osseous union </li></ul><ul><li>Correct angular deformity </li></ul><ul><li>Address LLD </li></ul>
  38. 60. Weston PM: Care of the injured in the third world-What can we learn? Injury 18:297-303, 1987 <ul><li>apply basic surgical principles </li></ul><ul><li>choose simple rather than complex techniques </li></ul><ul><li>treat most surgical conditions satisfactorily in absence of expensive or sophisticated facilities </li></ul>
  39. 62. Weston PM: Care of the injured in the third world-What can we learn? Injury 18:297-303, 1987 <ul><li>adapt some of the newer surgical techniques for use in unusual situations </li></ul>
  40. 63. Ilizarov /distraction osteogenesis <ul><li>Not require microvascular surgeons </li></ul><ul><li>bone regenerate correct size for anatomic site </li></ul><ul><li>Not require ready access of donor bone </li></ul><ul><li>wound margins approximated </li></ul><ul><li>Transfusions and ancillary procedures few </li></ul><ul><li>Ilizarov not require antibiotics in treatment of chronic osteomyelitis </li></ul>
  41. 68. Clubfeet <ul><li>Incidence 1/1000 </li></ul><ul><li>distribution ♂=♀ </li></ul><ul><li>Bilateral 50% </li></ul><ul><li>Etiology unknown (genetic /environment) </li></ul><ul><li>Natural history </li></ul>
  42. 72. MF CAVUS HF VARUS MTA HF EQUINUS 4 components
  43. 75. 1 2 3 4 5 SR 9 days old
  44. 76. Ponseti technique worldwide Avoid extensive surgery, untreated sequelae + galosh sign
  45. 77. EA 1 week old
  46. 78. Ponseti technique <ul><li>After pTAL, LLC x 3 weeks </li></ul><ul><li>Then wear Ponseti AFO’s and Denis-Browne bar full-time x 3 months </li></ul><ul><li>Then N/N for 3-4 years </li></ul>
  47. 79. EA at last follow-up
  48. 80. Orthopaedics = “straight child”
  49. 82. 72 o 51 o
  50. 87. Benefits volunteering 3 rd world mission <ul><li>Educational </li></ul><ul><li>Understand diagnosis, natural history, consequences of delay in treatment of diseases </li></ul><ul><li>Treat in a broader cultural context </li></ul><ul><li>“ systems” based approach to medicine </li></ul><ul><li>Share knowledge and skills </li></ul>
  51. 88. Share knowledge and skills
  52. 89. benefits <ul><li>Personal </li></ul><ul><li>Get more out of experience than you give </li></ul><ul><li>“ Make a living by what you get, make a life by what you give” </li></ul><ul><li>Understand ones limitations in a stressful environment </li></ul><ul><li>Become better physician </li></ul><ul><li>Gain broader perspective </li></ul>
  53. 90. 3 rd world healthcare volunteering <ul><li>Appropriate </li></ul><ul><li>Acceptable </li></ul><ul><li>Sustainable </li></ul>
  54. 91. Appropriate, acceptable, sustainable <ul><li>Provide assistance only when invited and welcomed </li></ul><ul><li>Medical needs often too great to provide service assistance only </li></ul><ul><li>Education is the most effective method of providing sustainable solution </li></ul><ul><li>When possible, preferable to train people in their own country </li></ul><ul><li>Transfer of medical care should not be based on OUR cultural biases </li></ul>
  55. 92. &quot;Give a man a fish and he will eat for a day. Teach a man to fish and he will eat for the rest of his life.&quot;
  56. 94. references <ul><li>Mountains beyond Mountains - Kidder </li></ul><ul><li>Awakening Hippocrates – O’Neil </li></ul><ul><li>www.global-help.org </li></ul>
  57. 95. Muchas Gracias!

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