Orthopaedic oncology in Egypt
Walid Ebeid, MD
Professor and chairman, orthopaedic surgery department,
Head of orthopaedic oncology unit,
Cairo university, Cairo, Egypt
History
Before 1995 bone and soft tissue tumours in Egypt were not managed by a multidisciplinary team. Most of the malignant tumours were treated by amputation or radiotherapy. Limb salvage was done sporadically by orthopaedic surgeons but not within the context of an orthopaedic oncology unit. In Mansoura university, Professor Samir Kotb started doing limb salvage since the late 1980s and later popularized using recycling with extracorporeal irradiation.
Most orthopaedic surgeons were not specialized. Since most of the orthopaedic surgeons worked in both public and private hospitals, they were afraid that subspecialization would decrease the number of patients that they were treating and hence decrease their income.
Orthopaedic oncology was one of the earliest subspecialties to be acknowledged in Egypt for a very simple reason; treating patients with malignant tumours was not appealing and required a lot of effort and time and hence was not financially rewarding. Thus, orthopaedic surgeons were eager to refer their patients to specialized orthopaedic oncology centers rather than treating them.
The first orthopaedic oncology center in Egypt was founded in 1995 in Cairo university hospital. Professor Helmi Elhadidi, chairman of the orthopaedic department established this unit that was managed by Professor Ahmed Rizk. The unit was run by two doctors who have just returned to Egypt after completing their fellowships abroad.
Dr Walid Ebeid completed an orthopaedic oncology fellowship at Massachusetts General hospital with Dr Henry Mankin, Dempsey Springfield and Mark Gebhardt whereas Dr Sherif Amin has already finished a microsurgery fellowship with Professor Alain Gilbert in Paris. Both surgeons joined forces to manage patients with malignant bone tumours using vascularized fibular grafts for reconstruction. The unit would not have been successful without the strong collaboration with the newly founded paediatric oncology department at the National Cancer Institute in Cairo university. From that year and over the following 30 years patients with bone and soft tissue tumours have been treated in Cairo university by a multidisciplinary team including orthopaedic oncologists, medical oncologists, specialized radiologists and pathologists.
Simultaneously and over the following years orthopaedic oncology centers were established all over the country:
- In Assuit university, Dr Tarek Elgammal and Amr Elsayed established a microsurgery unit and used free vasularized grafts for reconstruction following resection of bone tumours.
- In Ain Shams university, Dr Sameh Shalaby, Rafik sadek and Mohamed Abdelrahman established the unit and started using many reconstructive techniques.
- In Alexandria university, Dr Adel Refaat established a unit after returning from Japan and together with Dr Awad Elmalky popularized pasteurization as a method for reconstruction.
- In Menoufeya university, Dr Ahmed Shaheen founded the unit after ending his orthopaedic oncology fellowship in Canada in the late 1990s.
- In Azhar university, Dr Issa Ragheb and Mahmoud Seddik founded the unit.
This was followed by establishment of units in Tanta, Zagazig, Sohag and Ismailia. They were all established in universities however later on centers were established in public hospitals such as Nasser institute and Helal hospitals. In 2007 the Children Cancer Hospital (CCH) was established, and the orthopaedic oncology unit was founded by Dr Ahmed Elghoneimy.
Medical Education and training
% of students joins the university residency program whereas the remaining 90% have their residency in public hospitals of the ministry of health. The orthopaedic training program in a university is composed of 3 years basic training (residency) followed by a minimum of 3 years advanced training (assistant lecturer). The training ends with an MD exam in orthopaedics as well as a thesis in an orthopaedic speciality. Only those who pass the MD exam are allowed to open their private clinic. University staff members are not full timers. Their average monthly salary ranges from 300 to 400 USD. Accordingly, they work in the university as well as the private hospitals and clinics. An orthopaedic surgeon becomes specialized in orthopaedic oncology during his advanced training program by choosing a thesis in oncology which allows him to get more time and in-depth training in an orthopaedic oncology unit. He starts practicing after passing his MD exams. Some egyptian orthopaedic oncologists had their fellowship training abroad in specialized centers in USA, Europe and Japan whereas others had their training in egyptian universities.
Economics and the healthcare system
Patients with bone and soft tissue tumours could be treated in university hospitals and public hospitals for free as follows: All students in schools and university are covered by a national insurance system that covers all their expenses in university and public hospitals. Patients who are not insured are funded by the ministry of health after completing required paperwork. Treatment in private hospitals is fully paid by the patients or by private insurance companies. The price of a distal femoral endoprosthesis could vary from 4000 to 14000 USD depending on the company (the market includes Egyptian, Turkish and German endoprosthesis)
In a country with limited resources, orthopaedic oncologists rely more on biological reconstructions such as vascularized grafts and recycling techniques. There is an established tissue bank in Cairo university since 1995, yet the use of allografts has not gained popularity for two reasons; first, the culture of Egyptians is not comfortable with taking tissues from cadavers thus preventing the appearance of a strong law for tissue donation, second, taking tissues from living donors limits your resources and makes the tissues more expensive.
In the last five years, the use of 3D printed implants and patient specific instruments has been gaining popularity. Navigation systems for resection and implantation are not available in the country. Pelvic reconstructions are usually done by hip transposition or iliofemoral fusions and in very few cases an ice cream cone prosthesis would be used.
Egyptian orthopaedic oncology group
It was founded in 2000 as a subsidiary of the Egyptian Orthopaedic Association (EOA). Now it has 52 members. It holds at least three meetings per year in Cairo, Alexandria and Menoufia. There is an annual bone and soft tissue tumour course held yearly over two days that targets specialized as well as young orthopaedic trainees.
In December 2024, Cairo held its first international orthopaedic oncolgy symposium. Many ISOLS members participated in that meeting which was held over two days. The first day discussed reconstruction options whereas the second day included presentations about benign bone tumours. It was a great success, and we are planning to make it a regular biannual meeting.
