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Francel Alexis, MD, (left) speaks with Kaye E. Wilkins, MD, in front of the Médecins Sans Frontières hospital, Port Au Prince, Haiti.
Courtesy of Richard M. Schwend, MD

AAOS Now

Published 3/1/2016
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Richard M. Schwend MD

Pediatric Orthopaedics Goes Global

POSNA COUR program helps visiting scholars take knowledge to developing countries
The Pediatric Orthopaedic Society of North America (POSNA) Committee on Children's Orthopaedics in Underserved Regions (COUR) Scholars Program was created in 2007 to provide educational opportunities for pediatric orthopaedic surgeons working in resource-challenged environments worldwide. Based upon the principle of building relationships between POSNA members and the international community, the program provides access to a major pediatric orthopaedic meeting for those who otherwise may not be able to attend, and fosters long-lasting relationships and ongoing educational opportunities for the visiting scholar. Financial support is available each year for four to six orthopaedic surgeons to attend either the POSNA Annual Meeting or the International Pediatric Orthopaedic Symposium (IPOS). Scholars are also encouraged to visit selected centers for observerships during their trip to the United States.

Nearly 50 percent of the population in the developing world is under 15 years of age. Unfortunately, most of those children lack access to adequate treatment of musculoskeletal conditions. Developing sustainable pediatric orthopedic care in such resource-challenged regions is difficult.

A door to Haiti
During the summer of 2009, Kaye E. Wilkins, MD, was on one of his many visits to Haiti, teaching at the medical school and government hospital in Port au Prince. A senior orthopaedic resident, Francel Alexis, MD, had helped to organize the trip and the teaching session. Dr. Wilkins recognized this young Haitian resident as a standout, exceptional in his knowledge, enthusiasm, and interest in the pediatric orthopaedic cases. As this nation of 10 million people lacked even a single pediatric orthopaedic surgeon, Dr. Wilkins arranged for Dr. Alexis to spend a month with him observing pediatric orthopaedic practice at the Christus Santa Rosa Hospital in San Antonio, Texas.

On Jan. 12, 2010, a 7.0 magnitude earthquake struck Haiti, destroying many of the classrooms, clinics, and much of the hospital where Dr. Alexis had been training.

Scott C. Nelson, MD, was working at the time in the Dominican Republic, and he traveled to Hôpital Adventiste in Carrefour, just west of Port au Prince, to provide urgently needed disaster relief, where he was soon joined by Dr. Wilkins. After several months of non-stop relief work, Dr. Nelson was determined to stay and develop a pediatric orthopaedic service at the Adventist Hospital. In March 2010, Dr. Wilkins sought out Dr. Alexis at the Médecins Sans Frontières hospital in Port au Prince and encouraged him to train in pediatric orthopaedics, with his fellowship expenses graciously supported by CURE International. A second surgeon, Eldine Jacques, MD, soon followed, undertaking a fellowship in pediatrics at the Adventist Hospital in Port au Prince.

During his fellowship training in 2011, Dr. Alexis received a POSNA COUR scholarship to attend the POSNA annual meeting in Montreal. In 2012, he became Director of Orthopaedics at Hôpital Adventiste, and received a second COUR scholarship to attend the 2012 IPOS meeting in Orlando, Fla.

"The COUR scholarship did a lot for me," Dr. Alexis said. "It opened my eyes and showed me the beauty and diversity of pediatric orthopaedics. It is an honor and privilege to be the first trained pediatric orthopaedic surgeon in Haiti."

At the POSNA Annual Meeting in Indianapolis, April 2016, Dr. Alexis will become the first Haitian member of POSNA.

Iraq and Ecuador
Dr. Ali A. Ahmed Al-Iedan, MD, of Basrah, Iraq, was sponsored by Dr. Wilkins and David A. Spiegel, MD, to attend the 2009 POSNA annual meeting in Boston. Dr. Al-Iedan sought to become the first pediatric orthopaedic surgeon in Iraq. During his scholarship, Dr. Al-Iedan was hosted by James W. Roach, MD, at Shriners Hospital, Salt Lake City; John G. Birch, MD, of Texas Scottish Rite Hospital, Dallas; and Dr. Spiegel at Children's Hospital of Philadelphia.

"My presence in the different orthopaedic centers in the United States and the vast experience that I have gained after the COUR scholarship have added to my interest and to my career," Dr. Al-Iedan said. "I have since had a great deal of experience and serious interest in developmental dysplasia of the hip, club feet, and many pediatric anomalies. I am now a member of several international pediatric orthopaedic societies, including POSNA. We are planning to start a new department of pediatric orthopaedics in Basrah, with your kind help and support. So my great thanks to POSNA for giving me such a chance."

Dr. Al-Iedan continues to interact with POSNA members, and attended both the POSNA and IPOS meetings in 2015. He has hosted Dr. Spiegel and Dr. Scott Hoffinger in Iraq on four occasions each, and Dr. Kaye Wilkins and Dr. James Roach twice.

Telmo I. Tapia, MD, the only pediatric orthopaedic surgeon in Cuenca, Ecuador, was selected to be a POSNA COUR scholar in 2012 and attended the IPOS annual meeting, sponsored by V. Elaine Joughin, MD. After the meeting, he spent time with me at Children's Mercy Hospital in Kansas City.

"Although it has been several years since I received a COUR scholarship, I continue to speak about the experience to my colleagues and am living it through friends, programs, and initiatives I have started since," Dr. Tapia said. "It changed my practice and defined strategies. In my hospital we established a Ponseti clinic, got the courage to continue with developmental dislocation (dysplasia) of the hip (DDH) screening, pushed through a program to concentrate pediatric fracture care, and we hope to host a POSNA conference in our beautiful city."

Eye to the future
Through 2016, 50 international scholars will have participated in the COUR program. Of those, 24 participants from 17 countries recently took part in an online survey to assess the program's impact and improve the experience for future scholars. Overall, 71 percent cited a lack of specialized training programs as their biggest challenge, and 92 percent said they have remained in contact with POSNA members via consultations, visitations, and collaborations.

All of the survey respondents said that attending the meeting led to changes in their clinical practice, and 92 percent reported sharing knowledge gained through the program with other healthcare providers in their home countries. Many commented that the pairing of a meeting with an observership enhanced the experience. All expressed interest in organizing a national or regional course in collaboration with POSNA on a variety of pediatric orthopaedic topics.

Challenges have arisen during the early years of the program. The requirement for scholars to have a POSNA sponsor can be difficult if the applicant does not already have a relationship with a POSNA member. In response, the COUR committee has a list of willing sponsors who can be paired with an applicant if needed. Early on, funding was uncertain, but generous support of some of POSNA's partners has provided stability and growth.

Further research is needed to assess the long term impact of the program on access and quality of pediatric orthopaedic care in regions served by the scholars. Future directions may include the collection and analysis of prospective survey data, providing micro-grants for the scholars to participate in research and encouragement of scholars to establish local pediatric orthopaedic societies and training programs.

One of the major benefits of having international scholars participate in POSNA annual meetings or IPOS has been the development of pediatric orthopaedic treatment programs in many countries with limited resources. Scholars from India, Sri Lanka, Bangladesh, Iraq, Mexico, Honduras, Argentina, Vietnam, and more have been inspired to organize local and national pediatric orthopaedic societies. Thus, the COUR program has been instrumental in expanding pediatric orthopaedic resources and expertise on a global level.

Richard M. Schwend, MD, is vice president of POSNA and a former chair of the COUR program.

COUR International Visiting Scholars
2008
Luis Fernando Caicedo (Columbia)
Jhonny Ivan Melgar Celleri (Ecuador)
Batsukh Jargalsaikhan (Mongolia)
Joseph Theuri Macharia (Kenya)

2009
Ali Al-Iedan (Iraq)
Elijah Muteti (Kenya)
Kongkham Sounthavong (Lao PDR)
Vann Thy (Cambodia)

2010
Vuthy Chhoeurn (Cambodia)
Thanh Van Do (Vietnam)

2011
Nariman Abol Oyoun (Egypt)
Olayinka Adegbehingbe (Nigeria)
Serdyk Alexandrovna (Ukraine)
Francel Alexis (Haiti)
Hai Li (China)
Hitesh Shah (India)

2012
Olayinka Oladiran Adegbehingbe (Nigeria)
Binod Bijukachhe (Nepal)
Jose Pablo Munoz (Costa Rica)
Ngiep Oucheng (Cambodia)
Telmo Ivan Tapia (Cuenca, Ecuador)
Gabriel Ramos Zelaya (Nicaragua)

2013
Sergey Khmyzov (Ukraine)
Francisco Nyiiro (Uganda)
Sandeep Arvind Patwardhan (India)
Chasanal Rathod (India)
Mario Sequeira Somoza (Nicaragua)
Hongwen Xu (China)
Tewodros Tilahun Zerfu (Ethiopia)

2014
Ara Aivazyan (Armenia)
Rajiv Suresh Negandhi (India)
Jairo Javier Rios Roque (Nicaragua)
Raed Abbas Saadoon (Iraq)
Songkiat Thanacharoenpanich (Thailand)
Sunil Ranjith Wijayasinghe (Sri Lanka)

2015
Leonardo Cury Abrahao (Brazil)
Alarie Aroojis (India)
Ayana Birhanu (Ethiopia)
Eldine Jacques (Haiti)
Sarwar Ibne Salam (Bangladesh)
Matthias Schmauch (Mozambique)

2016
Mandar Vikes Agashe (India)
Garcia Cielo Estrera Balce (Philippines)
Erika Iliana Arana Hernandez (Mexico)
Aaradhana Jivendra Jha (Nepal)
Mesfin Etsub Kassahun (Ethiopia)
Juan Carlos Navas Solares (Guatemala)