Education and training in orthopaedic oncology in Ethiopia; CURE & Black Lion COSECSA course

Max Gibbons (Co Authors: Duncan Whitwell, David Wood, Flora Gibbons, Biruk Wamisho, Gelataw Tessema and Richard Gardner)

Max Gibbons trained in Oxford and London and is a Consultant Orthopaedic Surgeon and Specialist in Orthopaedic Oncology and Hip and Knee Surgery at the Nuffield Orthopaedic Centre in Oxford. He was awarded a Hunterian Professorship in 2016 by the Royal College of Surgeons of England for research on the surgical treatment of sarcoma. He is involved in surgical training in Africa through the COSECSA Oxford Orthopaedic Link programme.

In 2012 the College of Surgeons of East Central and Southern Africa (COSECSA) with Oxford University established the first Paediatric Trauma and Orthopaedic Surgery Course. The Programme was proposed to improve trauma management in sub-Saharan Africa through education, training and research.

The link is supported by United Kingdom Department for International Development and is based on British Orthopaedic Association (BOA) and Royal College of Surgeons (FRCS) surgical training programmes. The success of the initial course was expanded to provide training courses in paediatric orthopaedics, deformity and in hip and knee arthroplasty with practical sessions.

Orthopaedic surgical training in Ethiopia is developing to meet the increasing demand and surgical needs of young population of 100+m (19yr = median) in paediatric trauma, late bone infection, deformity as well as primary bone tumours.

However, with an oncology service now established in Addis Ababa, there is a desire to establish an integrated orthopaedic tumour service and a need to train the next generation of surgeons in treating bone tumours. The surgical management of malignant primary bone tumours in Ethiopia is primarily amputation due to advanced disease at initial presentation, as well as the need for specialist expertise and equipment needed for limb salvage.

In response to a request from local surgeons at Tikur Anbessa Specialised Hospital and CURE Ethiopia Children’s Hospital for a training course for resident surgeons in bone tumours, flaps and surgical techniques in limb sparing surgery, a practical course in orthopaedic oncology was proposed.

Faculty and delegates

The Faculty at Addis Ababa University Hospital and CURE Ethiopia surgeons with visiting orthopaedic and plastic surgeons from the University of Oxford and Perth Australia.

Delegates are limited to 35-40 final year residents in training and orthopaedic surgeons. All participants complete a pre and post-course MCQ comprising of 20 questions based on the course content and surgical anatomy.

The course is based on the FRCS Orthopaedic Examination Teaching Programme and is open to resident surgeons, recently appointed consultants and those with an interest in orthopaedic oncology and reconstructive surgery.

Programme

All trainees sit a pre and post-course MCQ comprising 20 questions. Pre-course MCQ scores range between 30-75% and post scores range 65-95%. Certificates are awarded on successful completion of the module.

Lectures are undertaken in the morning sessions, followed by afternoon cadaver surgical anatomy; providing a comprehensive three-day overview in the diagnostic principles and management of bone and soft tissue tumours and the current surgical treatment of sarcoma and related conditions. An example of one of the course days is shown in Figure 2.

Figure 2: Course Programme for day-two of the 2017 training course.

The importance of the multidisciplinary team in the diagnosis, management and treatment of primary bone tumours is emphasised with illustrated lectures on the pathology, MSK imaging and surgical and medical treatment in orthopaedic oncology.

The interactive sessions include demonstrations of different surgical approaches and techniques, case reviews discussions (Figure 3), and the key concepts, tips and tricks in orthopaedic surgical oncology.

Figure 3: Primary bone tumour case discussion.

Delegates present FRCS examination cases, and host surgeons presented patients for discussion on local surgical management of these conditions in Ethiopia.

Cadaveric surgery

The practical sessions are supervised and demonstrated by the faculty with dissection and surgical approaches undertaken by delegates on prepared cadavers in the Department of Anatomy at the Tikur Anbessa Specialised Hospital (Figure 4). This allows unique experience in surgical exposures and human anatomy in the Hunterian tradition.

Figure 4: Anatomy and approaches.

The afternoon sessions were divided over three days into upper limb and lower limb approaches, joint replacement surgery, pelvis and amputation surgery. Common extensile and classic exposures are demonstrated and then hip knee and shoulder arthroplasty and anatomical dissections by trainees.

The final practical session is on raising common flaps, with all trainees expected to perform a clean medial Gastrocnemius Flap technique scored by the examiners (Figure 5). Feedback confirmed the value of the practical sessions where flap techniques were demonstrated. These techniques were later successfully used by delegates to treat a patient with upper limb bone/soft tissue loss from a crocodile bite, as well as a patient needing a hindquarter amputation for pelvic osteosarcoma.

Figure 5: Medial Gastrocnemius Flap.

In addition, the cadaveric practical sessions allowed trainee and experienced surgeons to practice difficult amputations including forequarter, through hip and hind-quarter.

The current surgical management of malignant bone tumours in Africa, as it was historically in the UK, is primarily amputation with limited ability to offer limb sparing surgery and the use of endoprosthetic replacement for sarcoma. These courses are aimed to highlight alternative biological and orthoplastic techniques, as well as developing the delegates ability to manage challenging cases.

The established course has by request of COSECSA, been expanded to other affiliated training centres and in 2019 at the Cancer Diseases Hospital Lusaka.

The sarcoma surgical experience in Ethiopia was presented by Dr Ermias, showing the application and development of new reconstructive techniques (Figure 6) in limb salvage and thus avoiding amputation and the extended use of flaps soft tissue reconstruction of soft tissue tumour, burns and trauma surgery (Figure 7).

Figure 6: A case from Tikur Anbessa Specialised Hospital: Sarcoma resection and reconstruction, avoiding amputation.

Figure 7: Biological fibula graft used for shoulder reconstruction.

Delegate Feedback is key in improvement of course and content and also to address local surgical developments in managing bone tumours in Ethiopia (Figure 8).

Updates and presentations on surgical pathology and medical oncology at Tikur Anbessa Specialised Hospital emphasised the development of integrated and dedicated

Figure 8: Course feedback.

MDT and application of new techniques of biological reconstruction (fibula graft) and the use of PMMA in segmental defects and joint reconstruction.

In addition to surgical approaches, regional anaesthesia techniques with practical cadaver demonstrations are performed by delegates and Faculty. The first endoprosthetic replacement in an 18-year-old male with an advanced giant cell tumour (Figures 9 & 10) affecting the distal femur was undertaken at CURE Ethiopia Children’s Hospital after cadaveric demonstration in the 2016 Course.

Figure 9a: Giant cell tumour of bone and endoprosthetic replacement in an 18-year-old male.

Figure 10: Endoprosthetic distal femoral replacement in an 18-year-old male with GCTB at CURE Ethiopia.

This has led to a Global Surgery Initiative with Perth Australia, Oxford and Industry (Stanmore/Stryker and Signature Orthopaedics) to design and provide an affordable implant system available in Africa for bone tumour and arthroplasty surgery.

A RCS National Diploma in Orthopaedic Oncology was approved in June 2020 and will be available to surgeons in training through the COSECSA Oxford University Link.

Conclusion

The collaboration of Oxford University, Tikur Anbessa Specialised Hospital and Cure International UK continues to bear fruit. We look forward to further developing this partnership in training and service provision in the management of sarcoma for years to come.

Further reading and resources

• WHO Classification of Tumours of Soft tissue and Bone 4th Edition 2013.

• Extensile Exposure AK Henry Churchill Livingstone 1957.

• Clinical Anatomy Harold Ellis Wiley Blackwell 1992.

• CURE Ethiopia Children’s Hospital: https://cure.org/hospitals/ethiopia.

• CURE International UK: https://uk.cure.org/.

• COSECSA Oxford Orthopaedic Link COOL: www.ndorms.ox.ac.uk/research/researchgroups/global-surgery/projects/cooltraining-in-trauma.