April 2004 Bulletin

SIGN: Creating equality of fracture care worldwide

By Carolyn Rogers

If you sustain a severe leg fracture while living in the United States, you can expect a certain amount of pain and (temporary) inconvenience, but for the most part, your life should return to normal following treatment.

However, if you are one of the billion people living on less than $1 a day in the developing world, that fracture is likely to have a devastating effect on your life. Because you will not be able to afford proper fracture treatment, you'll be left permanently disabled or bed-ridden for life, no longer be able to work. If you're the breadwinner, your children will suffer as your family falls deeper into poverty and despair. You'll be left helpless and hopeless, all because you lack access to adequate orthopaedic care.

Vision: Equality of fracture care
Unfortunately, this disturbing scenario is played out every day in the developing world. Lack of adequate treatment, coupled with the fact that more than 80 percent of all severe fractures occur in developing countries, is responsible for a staggering number of disabled people in these nations.
Orthopaedic surgeon Lewis G. Zirkle Jr., MD, however, is dedicated to changing that bleak picture. Five years ago, Dr. Zirkle founded the Surgical Implant Generation Network (SIGN), a humanitarian organization dedicated to creating equality of fracture care throughout the world.

“Until recently, treatment with intramedullary (IM) nails—the state-of-the-art method for treating many serious fractures—has not been available to the poor in developing countries,” says Dr. Zirkle. “One of SIGN's goals is to make this the worldwide standard for fracture treatment.”

The results thus far are inspiring. In just five years, SIGN has established 80 projects in 36 countries throughout the world, including Vietnam, Indonesia, Thailand, India, Bangladesh, Nepal, Malawi, Nigeria, Honduras, Myanmar, El Salvador, Cambodia, Mexico, Guatemala, Nicaragua, Tanzania, South Africa, Uganda, Iran, Russia and the Philippines.

Training, instruments and a continuing supply of surgical implants are provided free to SIGN host surgeons, enabling them to provide quality fracture treatment for the poor. In the past five years, SIGN doctors have performed more than 8,700 surgeries.

“SIGN is taking off more and more,” Dr. Zirkle reports. “We did twice as many surgeries in 2003 as in 2002.”

Why such rapid growth?

“After doctors are trained in the system at one SIGN project, they're inspired to establish SIGN projects at their own hospitals,” Dr. Zirkle explains. “It keeps expanding from there.”

The inspiration for SIGN

Although SIGN was officially incorporated in 1999, its mission began back in 1968, when Dr. Zirkle was serving as an Army orthopaedic surgeon in Vietnam. The suffering he saw among the Vietnamese people prompted him to volunteer for extra duty as a civil actions officer. After a long shift of operating on soldiers, he ventured out into the countryside to care for people in rural villages.

At the end of his tour, Dr. Zirkle returned to the United States and started a practice. Several years later, he was still thinking about the troubles of people like those he'd met in rural Vietnam, whom he has described as “the gray people”—people ignored by others.

In the 1980s, his compassion for these people led him to Indonesia. At the time, the country had just one orthopaedic surgeon for its entire population of 80,000,000. Dr. Zirkle invested a great deal of time and effort in training surgeons in there. By the time he left, “We had trained 57 surgeons and had established four training centers,” he says.

In 1990, Dr. Zirkle decided to return to Vietnam to train surgeons and establish teaching centers there, much as he had in Indonesia.

In three weeks, Dr. Zirkle operated on 32 severely injured and deformed patients, gave daily lectures and conducted a seminar on surgical techniques. He found the Vietnamese doctors creative, dedicated and eager to learn new techniques.

By the end of his visit, even the previously wary government officials seemed to want him to stay. Dr. Zirkle has returned to Vietnam each year since.

“Teaching is not enough”

Thanks to Dr. Zirkle's efforts, developing countries such as Vietnam and Indonesia had many more trained surgeons by the mid 1990s. Therefore, “Reason dictated that the orthopaedic problems of these countries would be lessened,” Dr. Zirkle says.

However, a return trip to Indonesia in the late 1990s “proved our reasoning wrong,” he says.

While visiting a hospital on the Indonesian island of Sumatra, Dr. Zirkle and his Orthopaedics Overseas colleagues were shocked to find a man who had spent the past three years in traction—wasting away in a hospital room. The depressed and discouraged young man was just one of many patients they found in long-term traction.

“Speaking with this man was a sentinel event,” Dr. Zirkle says. “It inspired us to change our priorities.”

Although the doctors in Indonesia were skilled and eager to learn new techniques, they didn't have the implants necessary to fix the fractures. “We can teach, but if they do not have the materials to do the surgery, it's for naught,” Dr. Zirkle says.

It quickly became evident that ongoing education, communication and a reliable supply of implants and other surgical materials must be made available for improved fracture treatment to succeed, he says.

Creating SIGN
Working with like-minded physicians, surgeons and concerned citizens, Dr. Zirkle laid the groundwork for his vision of providing an all-encompassing system of training, hardware, follow-up and repeat visits to orthopaedic surgeons in developing countries. These would become the guiding principles by which all SIGN projects would be established.

In May of 1999, Dr. Zirkle traveled to Southeast Asia to initiate four SIGN “pilot projects” in public hospitals—one each in Thailand and Indonesia, and two in Vietnam. He assisted in numerous surgeries to train the partnering physicians in the SIGN techniques. These four pilot projects laid the foundation for additional, ongoing partnerships in other parts of the world. 
Today, just five years later, what began as little more than a handful of donated surgical items and borrowed office space now includes a staff of 12 full-time employees and a state-of-the-art manufacturing facility for producing the SIGN IM nails, screws, jigs, and other hardware necessary for fracture care treatment in developing countries.

Surgical database
As SIGN grows and the number of its projects increases, data collection is becoming more important. For that reason, the organization recently developed a new data collection system for its project surgeons, released in August 2003.

SIGN surgeons have always been expected to provide feedback on instruments, implants, techniques and results to assist in the development of new SIGN tools and techniques. With the new surgical database, they can now submit their reports and comments quickly and easily through the SIGN Web site (www.sign-post.org). Dr. Zirkle personally reviews all of the surgery reports submitted to the database—now at least 10 entries per day.
The password-protected database serves as a repository for patient data as well as pre- and post operative X-rays.

“We now have a very large fracture series and are pleased to make the information gathered available to project managers,” Dr. Zirkle adds. A demo is available on the SIGN Web site.

“Walking again” thanks to volunteers, donors
“Every day, SIGN is able to help fracture victims walk again because of the generosity of our donors and volunteers, and the commitment of our staff,” Dr. Zirkle says.

SIGN's activities are currently financed by Dr. Zirkle and other contributors. The organization continues to seek financial support from individual donors and corporations.

Technical support from the Oregon-based surgical instrument company, Acumed, and its founders has been invaluable, he says. “They've really been angels to us.”

Acumed made the first instrument and implant sets that SIGN used to start its four pilot projects, he explains. “They've given advice, counsel and financial help to SIGN since its inception.”

To date, 10 U.S. orthopaedic surgeon volunteers have traveled overseas to teach and establish SIGN projects throughout the world, Dr. Zirkle says. “I see more and more orthopaedists showing an interest in this.”

In addition to Dr. Zirkle, orthopaedists who have volunteered on behalf of SIGN include John T. Giesen, MD; David H. Moehring, MD; David S. Whitney, MD; John W. Staeheli, MD; Robert S. Schultz, MD; Carla Smith, MD; Larry D. Hull, MD; Wendelin W. Schaefer, MD; Narendra G. Gurbani, MD; and Robert A. Yancey, MD. “I'd like to see more participants from the United States,” Dr. Zirkle says. “I'd love to set up a lot of reciprocal visits, as well.”

“They are my brothers”
In The Sign Post, Dr. Zirkle recently shared the story of his October 2003 visit to South East Asia. He was traveling with a local surgeon on an overcrowded highway in Bangladesh where no ‘rules of the road' seemed to apply. Cars veered within inches of each other and drivers were blasting their horns as they maneuvered into any empty space, no matter how small. Despite the near chaos, the doctor at the wheel seemed completely unperturbed.

Curious, Dr. Zirkle asked his opinion of the other drivers. The man responded, “They are my brothers.”

This answer touched Dr. Zirkle, who believed it epitomized the overall feeling of the trip, which also had included stops in Cambodia, Vietnam and Myanmar as well. Most of the SIGN programs they'd visited were well established, so the term ‘brotherhood'—applying both to men and women—“described both the friendship and actions experienced on the trip,” he wrote.

An adage that Dr. Zirkle has used to describe the dedication of the Vietnamese doctors he's come to know can be applied to his life, as well: “Real joy comes not from riches or from the praise of men, but from doing something worthwhile.” To learn more about SIGN's mission, visit its Web site at www.sign-post.org. Dr. Zirkle can be contacted at (509) 371-1107, or via e-mail at signcom@sign-post.org .

In Honduras, SIGN founder Lewis G. Zirkle Jr., MD, (right) sits beside 15-year-old Elver. The boy — who is the breadwinner for his entire family — severely fractured his femur weeks before, but could not afford proper care. Dr. Zirkle was able to repair Elver’s leg using a SIGN implant.

X-rays of Elver’s badly fractured femur.

AAOS donates $80,000 in books to SIGN

In January 2004, the Academy donated $80,000 of orthopaedic reference books and CD-ROMs to the Surgical Implant Generation Network (SIGN), a nonprofit corporation dedicated to creating equality of fracture care throughout the world.

“These books are invaluable because SIGN project physicians often do not have access to current medical literature,” says Lewis G. Zirkle Jr., MD, SIGN founder and president. “I cannot thank the AAOS enough for this contribution.”

The donation includes 50 copies each of Orthopaedic Knowledge Update, Instructional Course Lectures (Volumes 43-46) and Essentials of Musculoskeletal Care; 100 Orthopaedic Basic Science slide sets, and more.

To date, SIGN has sent a full set of materials to eight projects in Vietnam, three in the Philippines, three in Bangladesh, one in Pakistan, four in Myanmar and one in the Dominican Republic.

“The hospital libraries that we teach in have very few any books,” Dr. Zirkle says. “This donation will advance medical knowledge and improve orthopaedic care throughout the world.”

Colleagues at Danang Hospital in Danang, Vietnam, gather around a recent shipment of donated SIGN equipment and AAOS educational materials.

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