During our second visit of 2019, we were able to operate on the other foot of Ely Jane, a teenager whose first foot was operated on for repositioning/arthrodesis in spring 2019. We had planned surgery on the second foot in the spring, but had to delay the procedure because of a skin lesion. The operation with Dr Vlaev at Tokuda hospital on 4 October went well. The child made good progress post-surgery and we were obviously very happy to see this young girl, who had begun losing the ability to walk before her first operation, start walking again and now have a functional future with excellent prospects. With the repositioning of her second foot, she will be able to continue to make progress with her walking rehabilitation.

This is another ‘textbook case’ of care for a neuro-orthopaedic deformity, requiring a combination of orthopaedic surgical skills and vital equipment in the post-operative phase after repositioning of the feet. The equipment was of course made at Dr Gurov’s practice with our dedicated partners.
 
This trip also enabled us to visit several children again with Dr Gurov and Dr Vlaev in both Sofia and Stara Zagora. We were lucky to share this trip with Vasil, a new partner who is taking over from Angel and developing skills in the equipment field. It was also a pleasure to share these consultations with a medical colleague of Dr Gurov. This young intern is training in orthopaedics in Sofia and has a definite interest in neuro-orthopaedics. We are looking forward to seeing him again during our next trip to Bulgaria.
 
The dates for our visits in 2020 are not yet fixed; we will definitely go to Sofia and Stara Zagora in March to see these children again, but no operations are planned as yet.

Our first visit of 2019 took place from 7 to 10 of March. During that time, Dr Fragnière had the opportunity to operate on Ely, a young person suffering from a progressive neurological disease with deformities of both feet that require surgical realignment. The plan had been to operate on both feet, but a skin injury on the left foot meant that it was not possible to operate on this side. The operation was performed at Tokuda Hospital.

Post-operative care is planned – the collaboration between Dr Vlaev, with whom Dr Fragnière operates, and Dr Gyurov, who produces the orthoses, is working perfectly. This approach combining surgical intervention and device fitting, which is essential for these neuro-orthopaedic conditions, is achieving success and the Foundation is naturally delighted.

Joint consultations with Dr Gyurov and Dr Vlaev took place in both Sofia and Stara Zagora during the visit. Our workshop in Stara Zagora is being well used. Arch supports and shoes are made in the workshop three days a week and Dr Gyurov offers consultations there one day a week. A small room is also available for a physiotherapist to take on neurological cases managed by Dr Gyurov.

Our Foundation’s mission in Bulgaria is continuing to develop with our local colleagues producing devices and the Foundation providing financial support as needed. Dr Fragnière supervises the work and remains in close contact with Dr Gyurov.

The next visit is planned for September/October 2019. The aim will be to operate on Ely’s other foot and to see other children in joint consultations.

Despite a very morose political climate in Bulgaria, the medical enthusiasm of our Swiss-Bulgarian team remains excellent, as proved by the consultation with four orthopaedic specialists, including myself, around the children on Friday morning. Our loyal local colleagues, Dr Gyurov and Dr Vlaev, were accompanied by Dr Fragnière and Dr Dontas. We were pleased to have the latter travel from neighbouring Greece to join us in Bulgaria for the second time to show us his interest in neuro-orthopaedics. Very interesting discussions and a strong medical presence clearly reassured the patients about our interest in them.

We identified 2 children that we will operate on with Dr Vlaev in early 2019. One has severe deformities of both feet, which must be surgically realigned then fitted with devices, and the other is young girl who has a marked difference in the length of her legs and must undergo surgery to equalise her lower limbs.

The team was also busy with consultations, in particular a half-day devoted entirely to children with lower limbs of unequal lengths. We looked at this in detail with Dr Vlaev by considering all theoretical aspects of the issue and could put it directly into practice.

Always seeking donors to secure the future of our volunteer work in Bulgaria, we held a small exhibition tennis tournament with Manuela at Stara Zagora. At this, many juniors from the local club and some adults were delighted to play with the former champion. This very friendly occasion made both young and old happy and enabled us to raise 2,000 leva (around CHF 1,200).

2018 review and outlook for the future

In line with the goals we set at the end of 2017, we reduced our trips to Bulgaria to two visits in 2018. This long-standing objective has finally been achieved, mainly because the local doctors and technicians we have trained over the past 10 years are now generally able to handle consultations and treat the children themselves. We are incredibly pleased with this result, which is the reward for all our hard work.

Our role has changed since 2018 and we will be focussing on the following three activities and objectives in future:

*   Supporting the Bulgarian teams with complex cases that require our intervention

*   Developing operating activity for special cases that require Dr Bruno Fragnière’s expertise

*   Providing financial support for the production of orthopaedic devices by teams trained locally rather than having devices produced by Swiss technicians

The first visit of 2018 was marked by fairly intense medical activity, both with regard to consultations and operations. We had the opportunity to visit Tokuda Hospital for the first time for consultations with Dr Vlaev on Thursday and Friday afternoon. On Friday morning, we operated on a child with the same doctor with whom we had already performed several procedures in the past. The medical and surgical activity performed in Sofia was therefore supported and continued in Stara Zagora on Saturday with many children who were examined by Dr Gyurov. These were rather complex cases and required a combined orthopaedic and surgical approach.

Several children seen again during this visit had been treated through the foundation, combining surgical procedures and treatment with devices. Their good progress was a very nice example of the importance of devices in paediatric orthopaedics, which are often essential for perpetuating the surgical corrections obtained. Thus, we are now able to adequately treat all these children with various orthopaedic or neuro-orthopaedic conditions, whether they require treatment exclusively with orthoses or combining surgery and devices.

Despite the foundation’s slightly irregular presence in Bulgaria, device production will continue throughout 2018 in a very steady fashion under its supervision and through Angel. For a good number of these children, the foundation covers the costs of making the orthoses when the parents’ financial means are insufficient. In such cases, the produced devices are routinely checked during the consultations that we usually make with Dr Gyurov and Dr Vlaev. It must be noted that the past 10 years in Bulgaria have fully paid off because, in the large majority of cases, treatment by our colleagues in Bulgaria has been hugely successful.

The foundation’s next visit is scheduled for after the summer. We will have the opportunity to see many children again with Dr Vlaev and Dr Gyurov. We will also have the opportunity to operate on children at Tokuda. These procedures have already been planned.

The foundation’s 50^th trip to Bulgaria, 10 years after our first trip to the Stara Zagora region with Manuela and Bruno. It was an extremely gratifying assessment as the goals that the foundation set itself 10 years ago have been fully achieved.

During this last trip of 2017, we saw many children again, particularly those whom the foundation had fitted with devices, as well as two children who were operated on by Dr Vlaev in Sofia in September 2017. The progress of these two children is very favourable: the surgical goal has been achieved. Thanks to the surgery, these children, currently undergoing rehabilitation, will certainly have a better future. This trip was also an opportunity to provide many devices for new children and to change some devices that had become too small for children who had already been treated; we did this with Angel, our partner in Bulgaria.

We also ‘said farewell’ to a few children who had been regularly called back by the foundation for check-ups to monitor their development. In fact, after 10 years of investment in Bulgaria, and given that the foundation’s goals have been fully achieved, we are going to direct our on-site commitment a little differently while continuing to help underprivileged children and parents in the field of neuro-orthopaedics. The goal in the future is no longer to provide them with clinical follow-up, given that the local doctors who work with the foundation are perfectly capable of doing so, but rather to provide support to Bulgarian orthopaedic surgeons, particularly Dr Gyurov and Dr Vlaev. Going forward, Dr Fragnière will offer them his medical expertise to discuss difficult cases, assist Dr Vlaev in certain operations and continue to supervise device fitting in our orthopaedic workshop in Stara Zagora, which the foundation will certainly continue to own. We hope to achieve this goal by slightly decreasing the frequency of our trips to Bulgaria to two or three visits per year and by maintaining constant contact with the local doctors to provide them with medical advice at any time.

We will get to work on this new ambitious goal in April 2018.

For the first time in the history of Bulgarian paediatric orthopaedics (or at least as far as Dr Fragnière and Dr Vlaev are aware), multi-site surgery on IMC children was carried out during the same operation. Together with Dr Vlaev, we operated on two children from the foundation, with a competent team of anaesthetists, nurses and operating room assistants, in excellent conditions at Tokuda Hospital on Friday 15.09.2017. The children made very good progress after their operations and we were pleased to see them again subsequently with Dr Vlaev. This collaboration is clearly very encouraging because it enables the foundation’s team to set new goals for guaranteeing excellent care of disabled children in Bulgaria, not only in terms of skills in orthopaedic techniques and device fitting, but now also more in the area of paediatric orthopaedic surgery.

Medical work goes from strength to strength at our Stara Zagora base. Dr Gyurov has installed machinery to produce orthopaedic shoes and inserts such as arch supports. This new activity, albeit independent of that the Swissclinical foundation’s direct work, is carried out on our premises according to the cooperation agreements clearly set out with our dear colleague Dr Gyurov (see previous newsletter).

Our next visit in November 2017, the 50th visit by the foundation’s team, will mark the 10th anniversary of the launch of our medical work in Bulgaria. It is therefore an opportunity to take stock, and the prospect is already highly encouraging after a decade of investment both financially and in terms of human resources.

This was a very routine visit for the foundation with the usual consultation activities and device fittings, and we once again have Angel to thank for making several perfect orthoses.

Dr Gyurov’s studio in Stara Zagora is also progressing well. He now offers consultations to children from the Stara Zagora region every Friday and has installed several machines on our studio floor. He and his employees will use these primarily for the production of shoe inserts, such as arch supports or modifications to orthopaedic shoes. The devices will be made for both children and adults as Dr Gyurov is a high-profile figure in the country thanks to his company Ortoteh.

We also caught up with several children who would benefit from surgical treatment in addition to auxiliary aids. Our collaboration with Dr Vlaev from Sofia is taking shape: two children will be operated on jointly by Dr Fragnière and Dr Vlaev at Tokuda Hospital Sofia during our next visit in September 2017.

Spring has sprung and we enjoyed the sunshine throughout our last visit to Bulgaria, in which Angel carried out the usual consultations and device fittings exclusively at Stara Zagora.

In addition to the medical work, several other highlights from the trip are also worthy of note. First, we attended a special ceremony, during which we met members of the Stara Zagora authorities, and notably his excellency Mr Denis Knobel, the Swiss Ambassador to Bulgaria, who honoured us with his presence. This closing ceremony rounded off the three years of the Community Donation Fund Stara Zagora project made possible thanks to Daniella’s work in 2014 (see June 2014 newsletter). It was also the perfect opportunity to catch up with various people from the foundation team and representatives of the Bulgarian authorities. We are happy that the remaining funds from this project have been used to complete the renovation of the premises on the second floor of our building, where a school continued to rent space until summer 2016. The premises have now been refurbished, with a fully equipped classroom and several rooms where Dr Jovko Gyurov will install one or two machines to develop foot devices (arch supports and other shoe inserts).

The cooperation agreement signed by Manuella and Bruno on behalf of the foundation was another notable feature of this visit, formalising the relationship between Ortoteh Ltd., represented by Dr Gyurov, and the Swissclinical foundation. This agreement constitutes an essential step forward in the foundation’s occupation of the premises in Stara Zagora, and guarantees the long-term viability of the facility.

A further highlight was the arrival of Dr Stefan Tzerowski, a young orthopaedic surgeon in training at Gorna Bania hospital in Sofia, who has a clear interest in paediatric neuro-orthopaedics. Dr Fragnière had the pleasure of consulting with him in Sofia on Thursday afternoon and Sunday morning, and he will take part in consultations during our next visits. Dr Evgeni Vlaev, a new recruit, will also help us to establish best practices in paediatric neuro-orthopaedics and device fitting in Bulgaria over the long term.

Manuela and Bruno returned from the last visit of 2016 with a certain sense of ‘mission accomplished’. The foundation’s original aim was to develop an orthopaedic device fitting facility from almost nothing in a poor country where the state no longer supports this part of patients’ orthopaedic treatment. During the last week in Bulgaria, our Bulgarian colleagues worked without a Swiss technician, demonstrating clearly that they are now able to make these devices independently. They produced top-quality orthoses quickly, efficiently and economically, and even the children who are sometimes difficult to fit with devices encountered few problems.

After eight years’ work, we have also succeeded in developing a network of reliable contacts who can look after these patients across the country. In addition, we have identified several orthopaedic surgeons who will ensure that the children continue to be monitored. It was precisely this neuro-orthopaedic expertise, both in terms of maintenance and surgery, that we were seeking when we first embarked on our mission in Bulgaria. Now that we have found it, we can look at the long-term value of the foundation’s commitment in Bulgaria with a certain serenity.

During this visit, about 50 children were seen again, while 10 new patients received assessments and treatment proposals. Eight orthoses were also produced and many minor adjustments made to existing devices.

We received an added boost this time as Jérémie Mayerat, a young Swiss orthopaedic technician, joined the team alongside Kylian, Angel and Lucie. We produced many leg orthoses, and Jérémie did a magnificent job in redesigning Edice’s orthoprosthesis. Edice’s smile, which we first saw on our arrival in Bulgaria nine years ago, summed up just how happy he was when he left with his new prosthesis. Jérémie was planning to stay for two more weeks after we returned to Switzerland on 26 September. Angel, Lucie and Jérémie will take advantage of the studio in Stara Zagora to prepare prefabricated devices that we will be able to use in future to fit the children during their consultations. The trio will then return to the studio in Sofia, where they can learn from Jérémie and improve their production skills in certain devices.

In total this visit, we produced 11 leg orthoses, renewed Edice’s orthoprosthesis and fitted two children with prefabricated supports to correct their foot deformities. We also prepared arch support moulds for numerous children and therefore have a reserve of prefabricated supports.

In addition, we held many consultations during the week, mainly with children who we are reviewing as they develop. We saw only three new cases as the high volume of consultations means we are currently unable to take on new children.

Next visit 22 – 27 November 2016