Orthopedic Education in

Ethiopia, a ten year perspective

Duane Anderson, MD
Soddo Christian Hospital
Soddo Ethiopia
Aerial view Soddo Christian Hospital
 Great progress in orthopedic
education in ET in the last 10 years
• From 1 to 3 training programs in ET!
• From very few implants available 10 years ago
to many now
• Quality of the graduating residents is
improving each year
Soddo Christian Hospital
• I came initially in the fall
of 2004 to look at the
hospital
• I Brought a Sign Nail set
• I came permanently in
the fall of 2005 to do
surgery and teach
residents
 1st time to Pharmid in 2005 or 6
• They had 6.5 and 4.5 screws without drills, or
instrument sets, very few plates
• No 3.5 screws, or small fragment plates, I had
to import them from Synthes in Switzerland
• They had fixed angle blade plates for the hip
and no DHS!
• Very few instruments for orthopedic surgery
 Teaching residents for 10+ years
• 2005-2010 I taught GS residents orthopedic
surgery in Soddo
• GS residents did nailings, ex fix, even hip
replacement surgery!
• They told residents in Addis what they were
doing…
• Graduates went usually to gov’t district hospitals
and did not have adequate orthopedic supplies to
do the surgeries they were trained to do
• They also became busy with GS activities and lost
interest and expertise in orthopedics
Teaching Black Lion Orthopedic
residents since 2010
Teaching Black Lion Orthopedic
residents since 2010
 Working technology is important to
orthopedic education
Using C arm, wrist, shoulder, hip
, etc using CT scanner for a biopsy
 Learning new Surgeries
Dr. Milkias with SCH’s first
Bipolar patient
Pelvic Surgery
 Acetabular and Pelvic Surgery
• Stepwise process in • In Ethiopia C-arms not
learning always available
• Start with simple • Need to develop ways
• Start by learning the of doing complex
approaches, first watch surgery with out the C-
then do arm
• Then simple reductions
and plating
• Progress to more
difficult surgeries
Complex Pelvic Fracture Treatment without a C-arm
2011

Duane Anderson, MD
Segni Bekele, MD
Mogus Mulu, MD
Abebe Chala PT
Soddo Christian Hospital
Soddo Wolaitta Ethiopia
Ilio-inquinal approach: 1st window

head
Anterior approach to
the SI joint

foot

Stab wound for screw placement

 See and palpate
top of S1 vertebrae
Edge of pelvic brim corresponds to lower edge
safe area of S1
Correct AP placement

You can see the SI joint

You can feel this

edge with your
finger
 Good Results Possible Safely
Name Age Fracture Approach; Followup Total Complication
Sex Fixation (months) score
1.
D 28M Ischial ramus, Anterior; 3.5 mo 63 % none
Left sacral , and SI screw, anterior
SI dislocation ex-fix
Unrecognized
TY 30M Left SI joint Anterior; 11 mo 91% extraperitoneal
2 dislocation, symphysis plate bladder rupture,
symphisis pubic and SI joint screw Infected surgical
diastases wound involving
the anterior ORIF,
transient L5 nerve
root injury

3 FA 39F Right sacro iliac Anterior; 11 mo 91 % none

joint dislocation, plate pubis and
symphysis pubis symphysis, SI
diastases, left joint screw
superior ramus

4 ZS 24M Iliac wing fx, Anterior; 18 mo 94 % none

left SI joint Anterior ex fix,
dislocation plate of SI joint

5 25M SI and Anterior; anterior 2 mo

symphyseal ex fix, open SI
disruption, pubic screw
rami fx
6 55M Bilateral SI, Iliac Anterior; 9 mo 66% Nonunion R SI
wing and pubic ORIF wing, open
rami fx SI screw, anterior
ex fix

7 13F SI and Anterior; 5 mo 78% none

symphyseal plate pubis and
disruption, pubic symphysis, open
and rami fx’s SI screw, anterior
ex fix
 Complex Pelvic Surgery
• Possible in Ethiopia
• Stepwise learning process
• Asking God for help
• Not doing more that I am capable of right now
• Willing to learn from others and my own
mistakes
AO pelvis course
• My son Lucas and Sami
have gone to this course
• Lucas taught me how to
do percutaneous SI
screws at SCH
• This course is in the US,
Europe, should also
have it here in ET!
 My journey on Pelvic and Acetabular
Surgery
• Learned in my residency
• Did simple acetabular surgery in private practice in the
US
• Came here 11 years ago and was pushed to do more
• Learned from doing difficult cases here
• Textbook learning, operating with a GS at the
beginning on anterior approaches
• Sending cases to experts in the USA for advice
• Going to courses in the USA
• Going to the U of Utah and observing difficult cases
• Doing more and more surgery
 Surgical Cases at SCH, 4 residents
• 2856 orthopedic cases • Adequate cases per
at SCH in 2015 resident is important for
• 500 Sign nails since one education
year ago • Adequate breadth of
experience in the
diversity of orthopedics
is also important
 Surgical education principles
• Adequate cases/ resident
• Instruction by senior staff is ideal
• The number of residents has to be limited to
give each resident the number of cases
needed to make them excellent, you can’t
learn surgery just by watching!
 Surgical education/implants
• Having the implants available to be able to do all
of orthopedic surgery is important for the
advancement of the specialty
• This is made difficult by the Ethiopian Birr, money
exchange international policy, adequate capital
• Implant manufacturers need to be encouraged to
have representatives in this country
• Ethiopia should make their own starting with the
simple
 Maintenance of C-arms, Digital x-ray
and CT scanners
• Without this technology being regularly
maintained we don’t have reliable patient care
and education
• There needs to be a partnership of gov’t
institutions and private maintenance companies,
a C-arm is something that needs love and
attention
• ET is training biomedical technicians, this training
is VERY important and needs to be excellent in
every way
 Training and private Hospitals
• Cure and SCH are
partners with Black Lion
in the fullest sense of
the word
• Every opportunity
needs to be maximized
for educational
purposes
 Goals for Orthopedic Education
• Increase the number of training centers in the country
• Provide all the technology and implants for each
training center to become a center of excellence in its
own right
• Allow outside educators to come into Ethiopia without
so much difficulty in licensing, part time instructors
have to be able to operate
• Make it possible to have full time instructors in
government institutions
• Subspecialty training is the next step in excellence