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UNIVERSITATEA DE MEDICIN I FARMACIE IULIU HAIEGANU CLUJ-NAPOCA

Dan Ionu COSMA

LOCUL TRATAMENTULUI CONSERVATIV ORTOPEDIC N PICIORUL STRMB CONGENITAL VARUS-EQUINUS IDIOPATIC Tez pentru obinerea titlului de Doctor n Medicin - rezumat-

CONDUCTOR TIINIFIC: Prof. univ. dr. Ioan PRIAN

2007

INTRODUCERE

Piciorul strmb congenital varus equinus idiopatic este o malformaie congenital osteoarticular care continu s preocupe comunitatea restrns a ortopezilor pediatri, ncepnd de pe vremea lui Hippocrates. Ignacio Ponseti, profesor la Iowa University, afirm c nu exist malformaie osteoarticular major mai uor de diagnosticat i de tratat dect piciorul strmb congenital varus equinus idiopatic. Cu toate acestea, este o adevrat provocare pentru ortopedul pediatru alegerea conduitei terapeutice astfel nct, la maturitatea osoas, s se obin un picior cu o morfologie i funcie acceptabil. n prezent, majoritatea ortopezilor sunt de acord c, la debut, tratamentul piciorului strmb congenital varus equinus idiopatic (PSCVEI) trebuie s fie conservativ, nonchirurgical. Din acest motiv, n lucrarea de fa, am ncercat s stabilesc locul pe care acest tip de tratament l ocup n managementul PSCVEI pentru c, cu ct ne ndeprtm de vrsta propice tratamentului, acesta devine mai agresiv pentru dezvoltarea piciorului, iar rezultatele morfologice i funcionale devin net inferioare celor din perioada anterioar. Structura tezei de doctorat cuprinde dou pri: partea general i partea special.
PARTEA GENERAL

n partea general este prezentat stadiul actual al cunoaterii n domeniul studiat: delimitri conceptuale, inciden, etiopatogenie, arhitectura normal a piciorului, modificrile anatomo-patologice din piciorul strmb congenital varus equinus idiopatic i principiile de tratament conservativ n PSCVEI, accentul fiind pus pe modificrile anatomo-patologice. Cunoaterea arhitecturii normale a piciorului i a modificrilor patologice faciliteaz nelegerea principiilor de tratament conservativ. Capitolul dedicat elementelor conceptuale realizeaz o delimitare a formelor de picior strmb congenital varus equinus idiopatic (PSCVEI) existente: forma postural i forma veritabil. Aceast delimitare este n concordan cu principiile International Clubfoot Study Group (ICFSG). Conform recomandrilor ICFSG, studiile tiinifice asupra PSCVEI trebuie s exclud din loturile studiate formele posturale. Acestea sunt forme benigne, complet reductibile la natere i care se vindec n absena oricrui tip de tratament. Aceast precizare este important pentru a stabili cadrul metodologic n care s-a desfurat studiul de fa, fiind incluse n acesta doar formele veritabile i fiind excluse formele posturale care ar fi putut vicia rezultatele obinute. Urmtoarele dou capitole (Inciden i Etiopatogenie) trateaz problema frecvenei cu care apare aceast malformaie osteoarticular i cauzele care o determin. Analiza literaturii internaionale de specialitate arat c incidena PSCVEI este variabil, n funcie de zonele geografice i de populaia studiat. O inciden mai crescut este raportat n Africa Central i n rndul populaiei din Hawaii. n etiopatogenia acestei malformaii sunt incriminate dou categorii de factori: factori extrinseci (teoria mecanic, toxine, temperatur, medicamente, radiaii electromagnetice) i factori intrinseci (genetici). n prezent, studiile de transmitere genetic sunt acceptate pe plan internaional, accentul cznd pe transmiterea poligenic a bolii. Modelul multifactorial este considerat de majoritatea autorilor ca fiind cea mai plauzibil explicaie pentru observaiile din studiile de epidemiologie genetic n PSCVEI. Studiile viitoare au datoria s exploreze mecanismele moleculare ale geneticii, pentru a identifica genele responsabile de apariia piciorului strmb congenital varus equinus idiopatic.

n continuare, accentul este pus pe aspectele care privesc arhitectura normal a piciorului i modificrile anatomo-patologice din PSCVEI. Arhitectura piciorului este complex i este adaptat funciei polivalente pe care acesta o ndeplinete. Conceptele biomecanice sunt prezentate detaliat, integrnd factorii musculari i osoi care contribuie la forma i funcia normal a piciorului. Partea dedicat anatomiei patologice din PSCVEI realizeaz o grupare a modificrilor n funcie de structurile afectate: tegumentare, articulare, musculare, vasculare i neurologice. Prezentarea modificrilor articulare respect un tipic unitar, fiind descrise, grupat, modificrile osoase (suprafeele articulare) i cele ale mijloacelor de unire (capsul i ligamente). Prin iconografia inclus n text, sunt ilustrate toate elementele patologice care determin poziia vicioas din piciorul strmb congenital varus equinus idiopatic. n finalul prii generale, sunt prezentate principiile de tratament conservativ n PSCVEI. n prezent, pe plan internaional, sunt acceptate dou metode de tratament conservativ: metoda Ponseti i metoda francez (sau metoda Bensahel). Principiul pe care se bazeaz ambele metode const n producerea unei deformri plastice (permanente) asupra ligamentelor i tendoanelor scurtate, implicate n apariia deformrii. Manipulrile succesive, urmate de imobilizri gipsate, se bazeaz pe capacitatea vscoelastic a esutului conjunctiv de a produce o deformare plastic prin procesul cunoscut sub numele de relaxare de stress. Deformarea este corectat ct mai mult posibil prin manipulare blnd, care plaseaz esuturile retractate sub tensiune. Pe msur ce piciorul este meninut n poziia de maxim corecie, tensiunea asupra esuturilor retractate se reduce n timp. Cnd tensiunea se reduce semnificativ, corecia progresiv se obine prin repetarea procesului.
PARTEA SPECIAL

Partea special cuprinde, sub forma a apte studii tiinifice, contribuiile personale la tema studiat. Fiecare dintre acestea este prezentat folosind structura clasic: introducere, material i metod, rezultate, discuii i concluzii.
STUDIUL SISTEMELOR DE CLASIFICARE N PICIORUL STRMB CONGENITAL VARUS EQUINUS IDIOPATIC

n prezent, n literatura de specialitate, sunt descrise dou sisteme de clasificare (Dimeglio i Pirani), care sunt suficient de comprehensive, dar n acelai timp simplu de nvat i de aplicat n practic. Scopul acestui studiu este de a determina dac ntrun centru independent se poate aplica cu succes unul sau cele dou sisteme de clasificare, de o manier practic i reproductibil. Material i metod ncepnd cu anul 1998 am iniiat un studiu retrospectiv i, apoi, prospectiv asupra sistemelor de clasificare i metodelor de tratament n PSCVEI. n acest studiu au fost analizate cazurile noi de PSCVEI, n perioada 1998-2005. Pn n anul 2004, n Departamentul de Ortopedie Pediatric a Spitalului Clinic de Recuperare Cluj-Napoca a fost folosit metoda francez modificat de tratament conservativ a PSCVEI i sistemul de clasificare a lui Dimeglio. ncepnd cu anul 2004, am aplicat metoda lui Ponseti i, concomitent, am folosit sistemele de clasificare a lui Pirani i Dimeglio. Din acest motiv, pentru a aprecia aplicabilitatea celor dou sisteme de clasificare, am mprit lotul iniial de studiu n 2 loturi: lotul A (copii tratai n perioada 19982004) i lotul B (copii tratai n perioada 2004-2005). Lotul A a fost format din 52 de 2

copii (30 biei i 22 fete). Lotul B a fost format din 21 de copii (8 biei i 13 fete). Pentru evaluarea acestui lot am folosit ambele sisteme de clasificare: Dimeglio i Pirani. Lotul A a fost analizat statistic retrospectiv, iar lotul B a fost analizat prospectiv. Am analizat gradul de corelaie ntre scorul Pirani i scorul Dimeglio cu intenia de a depista o dependen ntre cele dou variabile analizate. Rezultate Majoritatea picioarelor analizate din lotul A au fost moderate ca severitate. Scorul pentru ntregul lot a variat ntre 4 i 19 puncte (din 20 puncte) n clasificarea Dimeglio. Scorul mediu acordat de examinatori a fost de 10,3 i, respectiv, 10,6 puncte pentru cele 74 de picioare, fr a exista o diferen semnificativ statistic ntre aceste medii (p>0,05). Coeficientul de corelaie Pearson a fost de 0,95 (p<0,05). Clasificarea medie n grade de severitate pentru ambii examinatori a fost 2,5, cu un coeficient de corelaie de 0,77. n lotul B, scorul Dimeglio a variat ntre 3 i 18 puncte, iar scorul Pirani ntre 0,5 i 6 puncte. Scorul Dimeglio mediu a fost de 10,7 puncte, iar scorul Pirani mediu a fost de 4,9 puncte. ntre cele dou valori medii a variabilelor analizate nu exist diferene semnificativ statistic (p>0,05) i coeficientul de corelaie a fost 0,82. Clasificarea Dimeglio medie n grade de severitate a fost 2,7, care se coreleaz (coeficient de corelaie 0,79) cu scorul Pirani mediu de 4,9 puncte. Concluzii Dei cele dou sisteme de clasificare, Dimeglio i Pirani, au principii de notare a deformrii diferite (reductibilitatea pentru Dimeglio i aspectul morfologic pentru Pirani), coeficientul de corelaie ridicat indic faptul c gravitatea mare dat de clasificarea Dimeglio se coreleaz cu cea a lui Pirani i invers. Aplicnd sistemele de clasificare ale lui Dimeglio i Pirani ntr-un centru independent, am constatat c aceste sisteme sunt adecvate i uor de aplicat n practic, mai ales dup faza iniial de nvare. Studiul ntreprins a demonstrat c variaia interobservator este relativ mic pentru sistemul lui Dimeglio, iar coeficientul de corelaie bun ntre sistemele lui Dimeglio i Pirani recomand folosirea lor simultan n examinarea PSCVEI, avnd n vedere c aspectele examinate (reductibilitatea i aspectul morfologic al piciorului) sunt diferite i complementare.
STUDIUL RETROSPECTIV AL TRATAMENTULUI PICIORULUI STRMB CONGENITAL VARUS EQUINUS IDIOPATIC PRIN METODA FRANCEZ MODIFICAT

Scopul acestui studiu este de a evalua i prezenta rezultatele tratamentului conservativ al PSCVEI prin metoda francez modificat n intervalul 1998-2003, prin prisma necesitii interveniei chirurgicale eliberare postero-medial (EPM) la vrsta de 18 luni. Material i metod Lotul de studiu a fost format din 52 de copii (74 de picioare) cu vrst mai mic sau egal de 9 luni. Pentru toi pacienii din lotul de studiu am evaluat urmtoarele variabile: vrsta la prima prezentare n serviciul nostru, tipul anterior de tratament, numrul de imobilizri gipsate necesar coreciei complete, tenotomia ahilian n antecedente, amplitudinea dorsiflexiei nainte i dup tratament i compliana la folosirea ortezelor. Rezultate Vrsta medie la prima prezentare a fost de 31,85 luni (cu limitele de 1 lun i 9 luni). Dintre aceti pacieni, 38 (73%) au avut vrsta sub 6 luni, iar restul, adic 14 3

(27%) au avut vrsta cuprins ntre 6 i 9 luni. n momentul prezentrii n serviciul nostru, aceti pacieni prezentau una sau mai multe deformri clinice ale PSCVEI necorectate, iar indicaia de prezentare n serviciul nostru a fost n 80% din cazuri intervenia chirurgical (eliberare postero-medial). Pentru corecia deformrii piciorului prin metoda francez modificat la copii din lotul de studiu au fost necesare 52 imobilizri gipsate succesive, ntinse pe parcursul a 156 sptmni. Nici unui copil din acest lot de studiu nu i s-a practicat tenotomia de alungire ahilian. La sfritul perioadei de urmrire (125,62 luni), adic la vrsta de 18 luni, 13 picioare din 74 (17,56%) au necesitat eliberare postero-medial (EPM) pentru corecia complet a deformrilor reziduale post tratament conservativ. Concluzii Utilizarea metodei franceze modificate n tratamentul conservativ al piciorului strmb congenital varus equinus idiopatic permite obinerea rezultatelor favorabile n mai mult de 80% din cazuri. n cazul n care este necesar intervenia chirurgical, ea se limiteaz doar la structurile posterioare i mai puin la cele mediale. Modificarea tehnicii originale prin creterea perioadei de imobilizare i reducerea perioadei de manipulare permite obinerea acelorai rezultate, dar cu eliminarea dificultilor legate de tratamentul zilnic al copilului, care n unele cazuri determin necompliana prinilor la tratament.
STUDIUL PROSPECTIV AL TRATAMENTULUI PICIORULUI STRMB CONGENITAL VARUS EQUINUS IDIOPATIC PRIN METODA PONSETI

Scopul acestui studiu este prezentarea rezultatelor tratamentului conservativ n piciorul strmb congenital varus equinus utiliznd metoda Ponseti. Material i metod ncepnd cu anul 2003 am iniiat un studiu prospectiv, n care au fost inclui toi copiii cu PSCVEI, tratai dup metoda Ponseti n Departamentul de Ortopedie Pediatric al Spitalului Clinic de Recuperare Cluj-Napoca, n perioada 2003-2005. Lotul de studiu a fost format din 51 de copii (74 de picioare). Pacienii au nceput tratamentul ct mai precoce dup natere. Tratamentul a vizat succesiunea de manipulri i imobilizri gipsate, descris de Ponseti. Dup fiecare edin de manipulare, a fost aplicat imobilizarea gipsat cruro-podal, care a fost schimbat la 5-7 zile. Pentru toi pacienii din lotul de studiu am evaluat urmtoarele variabile: vrsta la prima prezentare n serviciul nostru, tipul anterior de tratament, tenotomia ahilian n antecedente, numrul de imobilizri gipsate necesar coreciei complete, necesitatea tenotomiei ahiliene, amplitudinea dorsiflexiei nainte i dup tratament. Rezultate Vrsta medie la debutul tratamentului a fost de 20,96 luni (cu limitele 2 sptmni i 14 luni). Dintre aceti pacieni, 46 (90,2%) au avut vrsta sub 6 luni, iar 5 pacieni (9,8%) vrsta peste 6 luni. Marea majoritate a pacienilor (37 pacieni) nu au urmat nici un fel de tratament anterior. Corecia utiliznd metoda Ponseti a necesitat 1 pn la 7 imobilizri gipsate (mediana = 5). 90% din pacieni (46 copii) au necesitat pentru corecie un numr mai mic sau egal de 5 imobilizri gipsate. Perioada necesar coreciei de la aplicarea primei imobilizri pn la ultima a variat de la 1 pn la 6 sptmni (valoarea medie 51 sptmni). Tenotomia percutan a tendonului Ahile a fost necesar la 68 de picioare. 4

Dintre cei 37 de pacieni care nu au beneficiat anterior de tratament conservativ, 2 pacieni 4 picioare (5%) au necesitat completarea coreciei prin eliberare posteromedial la vrsta de 18 luni. Concluzii Metoda Ponseti a fost adoptat n prezent de numeroase centre din ntreaga lume i doar de Departamentul de Ortopedie Pediatric al Spitalului Clinic de Recuperare Cluj-Napoca n Romnia. Metoda Ponseti este sigur, reprezint o cale eficient de tratament conservativ n PSCVEI i scade efectiv numrul interveniilor chirurgicale pentru corecia acestei deformri. n plus, ea poate fi aplicat cu succes copiilor n vrst de pn la 2 ani, care nu au fost supui interveniei chirurgicale n antecedente.
STUDIUL COMPARATIV AL METODELOR DE TRATAMENT CONSERVATIV N PICIORUL STRMB CONGENITAL VARUS EQUINUS IDIOPATIC: METODA FRANCEZ MODIFICAT VS. METODA PONSETI

ncepnd cu anul 2003, n Departamentul de Ortopedie Pediatric al Spitalului Clinic de Recuperare Cluj-Napoca am aplicat, n premier naional, metoda Ponseti. Deoarece rezultatele metodei Ponseti nu au mai fost analizate pn n prezent n Romnia, am iniiat un studiu prospectiv cu scopul de a compara rezultatele acestei metode cu cele ale metodei franceze modificate, utilizat pn n 2003 n serviciul nostru i n alte servicii de ortopedie pediatric din ar. Material i metod Lotul de studiu a fost format din 103 copii suferind de PSCVEI (148 picioare) tratai n serviciul nostru n perioada 1998-2005. n perioada 1998-2003, protocolul de tratament conservativ s-a bazat pe metoda francez modificat. ncepnd cu anul 2003, am aplicat metoda Ponseti. Pentru a evalua rezultatele celor dou metode de tratament am mprit lotul iniial de studiu n dou subloturi: A i B. Sublotul A a cuprins copii suferind de PSCVEI tratai n serviciul nostru, n perioada 1998-2003 dup metoda francez modificat. Acest lot de studiu a fost format din 52 de copii (30 biei i 22 de fete). Sublotul B a inclus copiii tratai dup metoda Ponseti n perioada 2003-2005. 51 de copii au satisfcut criteriile de includere n acest lot. Valorile variabilelor studiate n cele dou loturi de studiu au fost analizate n raport cu necesitatea tratamentului chirurgical (eliberare postero-medial) la vrsta de 18 luni. Rezultate Comparativ, ntre cele dou loturi de studiu am putut consemna o diferen semnificativ statistic ntre vrsta la debutul tratamentului: 31,85 luni sublotul A i 20,96 luni sublotul B (p<0,05). De asemenea, numrul de imobilizri gipsate necesar coreciei deformrii n lotul A (52) nu a fost semnificativ diferit fa de lotul B (42), p>0,05, n schimb perioada imobilizrii necesar coreciei a fost semnificativ redus (p<0,05) n lotul B fa de lotul A (52 sptmni pentru lotul B fa de 156 sptmni pentru lotul A). Criteriul principal de evaluare a eficienei celor dou metode de tratament conservativ n PSCVEI (numrul de picioare la care este necesar tratamentul chirurgical eliberare postero-medial la vrsta de 18 luni) este net n favoarea metodei Ponseti: 4 picioare (5%) au necesitat EPM la pacienii din lotul B de studiu fa de 13 picioare (18%) la pacienii din lotul B (p=0,0093). 5

Concluzii Tratamentul conservativ al PSCVEI prin metoda Ponseti duce la corecia complet a tuturor deformrilor ntr-o perioad mai scurt de timp dect metodele tradiionale. Metoda Ponseti, la fel ca i metoda francez modificat, necesit aproximativ acelai numr de imobilizri gipsate. Dar metodele tradiionale de tratament conduc mai frecvent la necesitatea eliberrii postero-mediale, care determin creterea costurilor datorit spitalizrii, anesteziei generale i manoperei chirurgicale. Metoda Ponseti necesit doar o intervenie chirurgical minor, practicat n condiii de ambulatoriu i n anestezie local.
IMPORTANA UTILIZRII ORTEZELOR DE ABDUCIE A PICIORULUI DUP TRATAMENTUL PSCVEI PRIN METODA PONSETI

Scopul acestui studiu a fost de a evalua importana utilizrii ortezelor de abducie a piciorului dup corecia deformrii prin metoda Ponseti i importana gradului de educaie al familiilor copiilor tratai dup aceast metod pentru a determina posibilii factori predictivi pentru recidiv. Recunoaterea factorilor de risc asociai frecvent cu posibilitatea de recidiv ne permit analizarea mai atent a pacienilor cu scopul mbuntirii msurilor care trebuie luate pentru succesul tratamentului. Material i metod n perioada 2003-2005, n Departamentul de Ortopedie Pediatric al Spitalului Clinic de Recuperare Cluj-Napoca au fost tratai dup metoda Ponseti 51 de copii (74 de picioare) suferind de picior strmb congenital varus equinus idiopatic. Dintre acetia, 5 pacieni au avut vrsta peste 6 luni i au fost exclui din lotul de studiu. Vrsta medie a pacienilor rmai n lotul de studiu (46 de pacieni) a fost de 12 sptmni, cu limitele 2-24 sptmni. Din cei 46 de pacieni, 8 nu s-au mai prezentat la control dup vrsta de 18 luni, iar la 2 copii s-a practicat eliberarea postero-medial la vrsta de 18 luni, rmnnd n lotul de studiu 36 de pacieni. Ortezele de abducie a piciorului au fost prescrise pentru utilizarea continu (23 de ore/zi) n primele 3 luni dup suprimarea imobilizrii gipsate i n timpul somnului diurn i nocturn (8 ore/zi) pn la vrsta de 3 ani. Am definit compliana la folosirea ortezelor utilizarea lor pentru cel puin 23 de ore/zi n primele 3 luni i cel puin 8 ore/zi pn la vrsta de 3 ani. Necompliana a fost definit ca incapacitatea de a respecta criteriile de mai sus pn la vrsta de 18 luni. Rezultate Din cei 36 de pacieni, 25 (69%) de pacieni (35 de picioare) au fost compliani i 11 (31%) pacieni (15 picioare) au fost necompliani la utilizarea ortezelor de abducie a piciorului. La vrsta de 18 luni s-a constatat c n grupul necompliant scorul Pirani a crescut semnificativ fa de grupul compliant, ceea ce semnific o degradare a rezultatului iniial. De asemenea, s-a constatat c n grupul compliant la utilizarea ortezelor de abducie a piciorului, scorul Pirani s-a meninut sau s-a mbuntit semnificativ (p<0.05), pe cnd n grupul necompliant evoluia a fost spre deteriorarea rezultatelor iniiale obinute prin imobilizare gipsat (p<0.05). Concluzii Analiznd factorii de risc pentru apariia recidivei, constatm c gradul de complian la utilizarea ortezelor de abducie a piciorului este puternic asociat cu apariia recidivelor. Copilul unei familii care nu respect protocolul de ortezare are un risc relativ de 33 de ori mai mare pentru recidiv dect copilul unei familii care 6

utilizeaz ortezele de abducie a piciorului conform recomandrilor. De asemenea, constatm c tipul ortezelor utilizate nu este corelat cu riscul de apariie al recidivelor. Gradul de educaie al familiilor copiilor suferind de PSCVEI nu influeneaz decisiv compliana la folosirea ortezelor, dei se poate constata o tendin la complian crescut n rndul familiilor cu studii de nivel cel puin universitar. Din acest motiv consider esenial utilizarea corect a ortezelor de abducie a piciorului n tratamentul conservativ al piciorului strmb congenital varus equinus idiopatic dup metoda Ponseti, n ciuda obstacolelor pe care le ntmpinm uneori din partea prinilor.
REDUCEREA NUMRULUI DE INTERVENII CHIRURGICALE PENTRU TRATAMENTUL PSCVEI DUP IMPLEMENTAREA METODEI PONSETI

Experiena acumulat ca prim centru de ortopedie pediatric din Romnia care a adoptat i utilizat metoda Ponseti n tratamentul conservativ al piciorului strmb congenital varus equinus idiopatic, m-a determinat s studiez modul n care tratamentul conservativ precoce influeneaz necesitatea ulterioar de tratament chirurgical n serviciul nostru. n acest scop, am realizat un studiu retrospectiv care analizeaz numrul de eliberri postero-mediale pentru PSCVEI n raport cu numrul total de intervenii chirurgicale din serviciul nostru n intervalul de timp n care tratamentul conservativ al PSCVEI a fost realizat prin cele dou metode diferite de tratament conservativ. Material i metod Prima etap a constat n analiza rezultatelor tratamentului conservativ n piciorul strmb congenital varus equinus idiopatic n perioada 1998-2005. Datorit faptului c n aceast perioad au fost utilizate dou metode diferite de tratament conservativ, am mprit aceast perioad n dou intervale de timp distincte: primul interval 19982003 cuprinde copiii tratai dup metoda francez modificat i al doilea interval 2003-2005 conine copiii tratai dup metoda Ponseti. Pentru fiecare interval studiat, am analizat numrul copiilor tratai, respectiv al picioarelor, i procentul rezultatelor favorabile (numrul picioarelor care la vrsta de 18 luni nu au necesitat tratament chirurgical eliberare postero-medial raportat la numrul total de picioare tratate). A doua etap a constat n analiza retrospectiv a interveniilor chirurgicale efectuate n Departamentul de Ortopedie Pediatric al Spitalului Clinic de Recuperare ClujNapoca n perioada 1998-2005. n aceast perioad au fost practicate un numr total de 1882 intervenii chirurgicale. Dintre acestea, pentru tratamentul chirurgical al PSCVEI, au fost practicate 127 eliberri postero-mediale limitate sau extinse, dup tehnica McKay prin abord Cincinatti. Rezultate n perioada 1998-2005 au fost tratai conservativ n serviciul nostru 103 copii (148 de picioare) suferind de picior strmb congenital varus equinus idiopatic. 52 de copii (74 de picioare) au fost tratai ntre 1998-2002, utiliznd metoda francez modificat i 51 de copii (74 de picioare) au fost tratai n intervalul 2003-2005 utiliznd metoda Ponseti. Numrul eliberrilor postero-mediale pentru tratamentul chirurgical al piciorului strmb congenital varus equinus idiopatic n perioada studiat a fost de 127, cu o valoare medie de 15.866.46 EPM pe an (limite 8-26). Tendina cresctoare din perioada 1998-2002 este reprezentat grafic (coeficientul de corelaie Pearson=0.94, p=0.015), iar coeficientul de corelaie Pearson ntre 7

numrul de eliberri postero-mediale sub 18 luni i numrul total de eliberri posteromediale n perioada 2003-2005 este 0.92 n intervalul de ncredere de 95%. Concluzii Studiul nostru s-a ntins pe o perioad de 8 ani. n acest interval tratamentul PSCVEI a fost efectuat dup dou metode diferite: metoda francez modificat i metoda Ponseti. Analiznd numrul eliberrilor postero-mediale efectuate n serviciul nostru n cele dou perioade corespunztoare celor dou tipuri de tratament conservativ, am constatat c acesta a sczut semnificativ n perioada corespunztoare tratamentului conservativ prin metoda Ponseti. Pe baza rezultatelor noastre, putem afirma c utilizarea metodei Ponseti este un factor decisiv n reducerea numrului eliberrilor postero-mediale, fr a impieta rezultatele favorabile ale tratamentului PSCVEI, care au cunoscut o tendin cresctoare. Aceste rezultate au fost obinute n condiiile n care adresabilitatea spre serviciul nostru a crescut n perioada menionat. Un factor care poate fi responsabil de aceast cretere a adresabilitii este utilizarea n premier naional n Romnia a metodei Ponseti pentru tratamentul conservativ al PSCVEI.
CREAREA I IMPLEMENTAREA SISTEMULUI INFORMAIONAL INTEGRAT PENTRU PICIORUL STRMB CONGENITAL VARUS EQUINUS IDIOPATIC

n sprijinul nevoii de cunoatere a dimensiunii pe care PSCVEI o are n ara noastr, am proiectat, creat i implementat un sistem informaional integrat pentru piciorul strmb congenital varus equinus. Pe baza informaiilor cuprinse n acest sistem, prinii vor avea la dispoziie o resurs informaional care s le permit luarea unei decizii cu privire la modul de tratament al bolii copilului lor. Material i metod Sistemul informaional integrat pentru piciorul strmb congenital varus equinus idiopatic cuprinde dou componente: componenta medical adresat personalului medical i componenta de informare destinat prinilor i copiilor suferind de PSCVEI. Componenta medical deriv din necesitatea de analiz riguroas a acestei patologii, de cunoatere exact a incidenei acestei afeciuni n Romnia i de cunoatere exact a tipului de tratament practicat n Romnia. n acest scop am conceput o aplicaie, realizat n Microsoft Access 2003, care cuprinde baza de date propriu-zis, formularul de introducere a datelor i formularul de raport. Componenta de informare se adreseaz prinilor copiilor diagnosticai cu picior strmb congenital varus equinus idiopatic. n acest scop a fost elaborat un material multimedia care combin i integreaz diferite tipuri de media: imagini, scheme i text, cu scopul de a completa informaiile despre piciorul strmb congenital varus equinus idiopatic existente n momentul de fa, n limba romn, pe Internet. Acest material a fost realizat n limbajul hipertext HTML cu ajutorul aplicaiei AceHTML i a fost publicat pe Internet la adresa http://piciorstramb.bravehost.com. Rezultate Se constat faptul c majoritatea informaiilor disponibile pe Internet despre PSCVEI provin de la forumurile de discuii i de la societile comerciale cu activitate n domeniul medical, n timp ce instituiile academice sunt responsabile doar n mic msur de difuzarea informaiilor autorizate. Analiznd coninutul tuturor paginilor, am constatat c nici un site nu conine informaii cu privire la etiologia, manifestrile clinice i tratamentul PSCVEI. Acest 8

aspect, coroborat cu faptul c majoritatea informaiilor disponibile provin din surse neautorizate medical, ne-au condus la concluzia c resursele informaionale disponibile pe Internet despre PSCVEI sunt extrem de reduse, practic inexistente. Concluzii Componenta medical a sistemului pe care l-am implementat n serviciul nostru, reprezentat de aplicaia Microsoft Access de colectarea i analizare a datelor, s-a dovedit extrem de util. Modul uniform de colectare a datelor permite a analiz riguroas a acestei afeciuni congenitale, eliminnd n mare parte erorile de tip culegere a datelor. Apreciem c aceast aplicaie poate fi implementat n orice centru de ortopedie pediatric din ar, resursele materiale necesare fiind minime, practic disponibile oriunde. Site-ul de informare a prinilor despre PSCVEI pune la dispoziia lor o resurs informaional, care s le permit luarea unei decizii cu privire la modul de tratament al bolii copilului lor. Numrul mare de accesri (133 n 2 luni) demonstreaz c aceast resurs era ateptat de mult timp, n contextul n care informaiile avizate medical despre PSCVEI sunt extrem de puine.
CONCLUZII GENERALE

1. Piciorul strmb congenital varus equinus idiopatic (PSCVEI) este o deformare complex, multiplanar a piciorului. Formele veritabile de PSCVEI sunt acelea n care deformrile nu sunt reductibile la prima prezentare i nu apar n cadrul altor sindroame. 2. Factorii probabili implicai n etiologia piciorului strmb congenital varus equinus idiopatic pot fi clasificai n 2 categorii: factori intrauterini sau extrinseci, care influeneaz dezvoltarea fetal, i factori intrinseci, genetici. 3. Aplicnd sistemele de clasificare ale lui Dimeglio i Pirani ntr-un centru independent, am constatat c aceste sisteme sunt adecvate i uor de aplicat n practic, mai ales dup faza iniial de nvare. Studiul ntreprins a demonstrat c variaia inter-observator este relativ mic pentru sistemul lui Dimeglio, iar coeficientul de corelaie bun ntre sistemele lui Dimeglio i Pirani recomand folosirea lor simultan n examinarea PSCVEI, avnd n vedere c aspectele examinate (reductibilitatea i aspectul morfologic al piciorului) sunt diferite i complementare. 4. Utilizarea metodei franceze modificate n tratamentul conservativ al piciorului strmb congenital varus equinus idiopatic permite obinerea rezultatelor favorabile n mai mult de jumtate din cazuri. n cazul n care este necesar intervenia chirurgical, ea se limiteaz doar la structurile posterioare i mai puin la cele mediale. Modificarea tehnicii originale prin creterea perioadei de imobilizare i reducerea perioadei de manipulare permite obinerea acelorai rezultate, dar cu eliminarea dificultilor legate de tratamentul zilnic al copilului, care n unele cazuri determin necompliana prinilor la tratament. 5. Tratamentul conservativ al PSCVEI prin metoda Ponseti duce la corecia complet a tuturor deformrilor ntr-o perioad mai scurt de timp dect metodele tradiionale. Metoda Ponseti necesit doar o intervenie chirurgical minor, practicat n condiii de ambulatoriu i n anestezie local. n concluzie, metoda Ponseti este sigur i reprezint o cale eficient de tratament conservativ n PSCVEI. 6. Utilizarea ortezelor de abducie a piciorului reprezint o etap extrem de important n tratamentul conservativ al PSCVEI dup metoda Ponseti. Evoluia 9

pacienilor necompliani s-a deteriorat semnificativ pn la vrsta de 18 luni. n contrast, evoluia picioarelor pacienilor compliani a rmas constant sau s-a ameliorat. Din acest motiv consider esenial utilizarea corect a ortezelor de abducie a piciorului n tratamentul conservativ al piciorului strmb congenital varus equinus idiopatic dup metoda Ponseti, n ciuda obstacolelor pe care le ntmpinm uneori din partea prinilor. 7. Din punct de vedere al managementului sanitar, se poate afirma c metoda Ponseti este o metod sigur i eficient, care reduce numrul interveniilor chirurgicale de corecie a PSCVEI. Aceast metod poate fi folosit cu succes la toi copiii cu vrst mai mic de 2 ani, care prezint PSCVEI, chiar dac au urmat alt tip de tratament conservativ n antecedente. 8. Programele de educaie sanitar ndreptate spre medicii neonatologi, pediatri i de familie trebuie s ncurajeze adoptarea acesteia ca gold standard n tratamentul piciorului strmb congenital varus equinus idiopatic. 9. Implementarea unui sistem informaional integrat, avizat medical, reprezint o necesitate actual n domeniul medical din Romnia. Realizarea acestui sistem pentru o malformaie congenital de natur ortopedic (PSCVEI) s-a dovedit a fi un demers unic n Romnia, oferind o baz de cercetare a acestei patologii i, totodat, o resurs informaional de calitate, avizat din punct de vedere medical, disponibil copiilor i prinilor. Prinii utilizeaz acest site ca un ghid pentru entitatea patologic de care sufer copilul lor i ca o baz pentru consultaie. n viitor, integrarea acestor resurse informaionale ntr-un sistem naional unic de tip Registru Naional va spori calitatea informaiilor disponibile pentru orice cercettor din Romnia, iar rezultatele studiilor lor vor putea genera baza pentru elaborarea unor protocoale de tratament unice, disponibile n orice centru medical din Romnia, contribuind n acest fel la creterea calitii actului medical i la uniformizarea sa. 10. Studiul sistemului informaional pentru PSCVEI s-a bucurat de suportul financiar obinut prin Grantul CNCSIS TD nr. 470/2006 Studiul strategiei de tratament conservativ ortopedic n piciorul strmb congenital varus equinus idiopatic (director de grant: dr. Dan COSMA), confirmndu-se utilitatea cercetrii pentru domeniul medical ca tem inovativ. 11. Studiul ntreprins deschide noi direcii de cercetare, pe de-o parte prin punerea n practic a unei noi metode de tratament conservativ n PSCVEI, iar pe de alt parte prin identificarea unor cadre conceptuale noi. Pe parcursul cercetrii, majoritatea rezultatelor au fost publicate n reviste de prestigiu, internaionale (Journal of Pediatric Orthopedics B) i naionale (Journal of Pediatric Surgical Specialties, Clujul Medical, Applied Medical Informatics, Revista MedicoChirurgical). n faa unui domeniu att de vast i n continu schimbare, realizez c este aproape imposibil de a atinge i trata toat gama de concepte referitoare la aceast tem.

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CURRICULUM VITAE
INFORMAII PERSONALE
Numele i prenumele Adres Telefon Email Naionalitate Data naterii Numele prinilor COSMA DAN IONU Str. Observatorului nr. 9, ap. 3, 400500 Cluj-Napoca 0745493041 dcosma@umfcluj.ro Romn 07.01.1977 tefan i Maria

ACTIVITATE PROFESIONAL
Perioada Funcia Numele angajatorului Perioada Funcia Numele angajatorului Perioada Funcia Numele angajatorului 2006 prezent asistent universitar titular, medic rezident ortopedie pediatric Catedra de Chirurgie i Ortopedie Pediatric, Universitatea de Medicin i Farmacie Iuliu Haieganu Cluj-Napoca 2003 2005 preparator universitar titular, medic rezident ortopedie pediatric Catedra de Chirurgie i Ortopedie Pediatric, Universitatea de Medicin i Farmacie Iuliu Haieganu Cluj-Napoca 2002 2003 medic rezident ortopedie pediatric Spitalul Clinic de Urgen pentru Copii M.S. Curie Bucureti

EDUCAIE I FORMARE
Perioada Calitatea Specializarea Numele instituiei de nvmnt Perioada Calitatea Specializarea Numele instituiei de nvmnt Perioada Calitatea Specializarea Numele instituiei de nvmnt Perioada Calitatea Specializarea Numele instituiei de nvmnt Perioada Calitatea Numele instituiei de nvmnt 2003 prezent doctorand Ortopedie Pediatric (prof.dr Ioan Prian) Universitatea de Medicin i Farmacie Iuliu Haieganu Cluj-Napoca 2002 prezent medic rezident Ortopedie pediatric Universitatea de Medicin i Farmacie Iuliu Haieganu Cluj-Napoca 1995 2001 student Medicin general Facultatea de Medicin General Universitatea de Medicin i Farmacie Iuliu Haieganu Cluj-Napoca 1991-1995 elev Informatic Liceul de Informatic Tiberiu Popoviciu, Cluj-Napoca Absolvent cu Diploma de Merit 1987-1991 elev coala General Nr. 2 Cluj-Napoca

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APTITUDINI I PROFESIONALE

COMPETENE
Titlul tiinific Doctorand (titlul tezei: Locul tratamentului conservativ ortopedic n piciorul strmb congenital varus equinus idiopatic, prof. dr. Ioan Prian) Stagii practice de Ortopedie pediatric pentru studenii anului V MG 1 carte i 17 lucrri (conform cu anexa) Director de grant CNCSIS nr. 470/2006 cu titlul Studiul strategiei de tratament conservativ ortopedic n piciorul strmb congenital varus equinus idiopatic Membru n grantul CNCSIS nr. 1394/2006 cu titlul Studiul comparativ al instabilitii coxo-femurale neonatale n municipiile Cluj-Napoca i Zalu, director de grant: conf.dr. Dana Vasilescu Membru n grantul CEEX nr. PC-D01-PT11-261/2005 cu titlul Realizarea unei reele intercentrice pentru dezvoltarea i monitorizarea utilizrii tehnicilor medicale de chirurgie minim invaziv n ortopedie i traumatologie, responsabil local: conf.dr. Dana Vasilescu Membru n grantul CEEX nr. 12566/2006 cu titlul Promovarea cercetrii romneti la programele europene n domeniul utilizrii fixatoarelor externe n alungirea i reconstrucia osoas n hemicondrodiastazis, pseudartroz i maladia Lobstein, responsabil local: conf.dr. Dana Vasilescu

Activitatea didactic Lucrri publicate Granturi

Cursuri de formare i perfecionare

Current Concepts in Paediatric Trauma 22-23.01.2007, Cluj-Napoca, Romnia First EPOS-POSNA Course 25-27.01.2007, Bratislava, Slovacia Treatment of Pilon Fracture Workshop 18-20.05.2006, Cairo, Egypt Taylor Spatial Frame Workshop 18-20.05.2006, Cairo, Egypt Basic Ilizarov Application (I&II) Workshop 18-20.05.2006, Cairo, Egypt The Athletic Child 05.04.2006, Dresden, Germany The Second Scandinavian International Seminar on Fractures in Children 21-23.09.2005, Saro-Goteborg, Sweden Tehnici moderne de instrumentaie segmentar n chirurgia scoliozei 17-18.06.2005, Bucureti AIOD Course 13.10.2004, Bucureti Basic knee arthroplasty course 13-14.05.2004, Royal Bolton Hospitals, Marea Britanie

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Workplace module for health studies Semester 2 2003-2004, University of Central Lancashire, Marea Britanie The Postgraduate Health Informatics Residential Week-end 12-14.03.2004, The Oaks Hotel, Reedley Burnley, Marea Britanie The UCLAN seminar on the 2004 GMS contract 24.02.2004, The Harris Knowledge Park, Fulwood Preston, Marea Britanie Microcurs de artroscopie 01-02.06.2002, Iai Cursul intensiv internaional de imagistic osteoarticular 26.04.2002, Institutul Clinic Fundeni, Bucureti Curs de Prim Ajutor Medical Specializat 05-26.09.1999, Spitalul Clinic de Urgen Floreasca, Bucureti Premii i distincii obinute Premiul II pentru lucrarea Abordarea diagnostic a nodulilor tiroidieni la Al 5-lea Congres Internaional al Studenilor i Tinerilor Medici, Timioara, 4-6 Mai, 2001 Premiul III pentru lucrarea Aportul diagnostic al ecografiei n cazul depistrii scintigrafice de nodului reci tiroidieni la Sesiunea de Comunicri tiinifice Studeneti MEDICALIS, 30 Martie 1 Aprilie, 2001, Cluj-Napoca Premiul II la Olimpiada Naional de Fizic, 1995, Galai Meniune la Olimpiada Naional de Fizic, 1994, Timioara Premiul II la Olimpiada Naional de Fizic, 1993, Braov Meniune la Olimpiada Naional de Fizic, 1991, Brila Meniune la Olimpiada Naional de Fizic, 1990, Giurgiu Experiena acumulat n programe i proiecte Bursier ERASMUS/SOCRATES in perioada februarie-mai 2004 la University of Central Lancashire, Preston, Marea Britanie. Principalele rezultate obtinute: - deprinderea medodei Ponseti in tratamentul conservativ al PSCVEI; - organizarea si structurarea bazelor de date electronice; - realizarea materialelor informative pentru pacienti/parinti. Membru n comitetul de organizare al simpozionului Aspecte n tratamentul fracturilor la copil i al workshopului Osteosinteza stabil cu tije elastice centromedulare n fracturile copilului, 07.12.2005, ClujNapoca Membru n comitetul de organizare al simpozionului Actualiti n diagnosticul i tratamentul displaziei de old la sugar i copilul mic, 10.12.2004, Cluj-Napoca. Scientific Reporter la 25th EPOS Meeting, 05-08.04.2006, Dresden, Germania Membru n comitetul de organizare al cursului internaional Current Concepts in Paediatric Trauma, 22-23.01.2007, Cluj-Napoca, Romnia

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Raportor pentru Romnia la masa rotund Meeting of the East European Pediatric Orthopedic Surgeons. Exchange of ideas, discussions of further cooperation, 27.01.2007, Bratislava, Slovacia Participri la conferine i congrese Multidisciplinary approach of congenital malformations; 19-21 october 2006, Sinaia Le 16eme congres national SRCOP; 7-9 septembrie 2006; MamaiaConstana 2nd International Course of Skeletal Deformities Correction, Cairo, Egypt, May 18-20, 2006 25th EPOS Meeting, Dresda, Germania Boala Hirschprung Actualiti n diagnostic i tratament Symposium, 09.12.2005, Cluj-Napoca. Masa rotund Aspecte n n tratamentul fracturilor la copil, 07.12.2005, Cluj-Napoca. Workshop-ul Osteosinteza stabil cu tije elastice centromedulare n fracturile copilului, 07.12.2005, Cluj-Napoca. A III-a Conferin Naional de Consens SRCOP; 8-10 septembrie 2005; Costineti-Constana. Conferina Zilele Spitalului Clinic de Recuperare , 24-26.03.2005, Iai. Simpozionul omagial Profesor Dr. Alexandru Pesamosca, 12.03.2005, Bucureti. Simpozionul Actualiti terapeutice n practica medical, 23.02.2005, Zalu. Simpozionul Actualiti n diagnosticul i tratamentul displaziei de old la sugar i copilul mic, 10.12.2004, Cluj-Napoca. Zilele Universitii de Medicin i Farmacie Iuliu Haieganu ClujNapoca, 2004. 16th National Congress of Pediatric Surgery and Orthopaedy; 21-23 October 2004; Poiana Braov. SOROT National Conference; 14-15 october 2004; Bucureti. World Congress of Pediatric Surgery; 22-27 June, 2004; Zagreb; Croatia. A XXIII-a Conferin Naional Anual de Medicin Fizic i Recuperare, 15-18 octombrie 2003, Cluj-Napoca. Conferina Naional de Consens a Societii de Chirurgie i Ortopedie Pediatric din Romnia, 9-11 octombrie 2003, Timioara. 1st Balkanic Congress of Pediatric Surgery; 25-27th of September, 2002; Constana. Al 7-lea Congres Naional de Chirurgie i Ortopedie Pediatric; 29.05. 02.06.2002; Iai. Al 4-lea Congres Naional de Angiologie i Chirurgie Vascular; Mai 17-19, 2001; Cluj-Napoca. Al 5-lea Congres Internaional al Studenilor i Tinerilor Medici; Mai 46, 2001; Timioara. Sesiunea de Comunicri tiinifice Studeneti MEDICALIS; Martie 30 Aprilie 1, 2001 ; Cluj-Napoca. 1st International Medical Conference for Students and Young Doctors; October 26-28, 2000; Sibiu. 4th Balkan Congress of Medicine and Dentistry for Students and Young Doctors. October 2-4, 2000; Craiova. Al IV lea Congres Naional Al Studenilor i Tinerilor Medici; Aprilie 68, 2000; Constana. Sesiunea de Comunicri tiinifice Studeneti; Martie, 2000; ClujNapoca. edina de comunicri, Societatea Romn de Chirurgie, Filiala Cluj ; Noiembrie 25, 1999. Al 3-lea Congres Naional de Angiologie i Chirurgie Vascular ; Mai 27-29, 1999 ; Cluj-Napoca. Al III-lea Congres Naional al Studenilor n Medicin i al Tinerilor Medici; Martie 26-27, 1999; Sibiu. Zilele Universitii de Medicin i Farmacie Iuliu Haieganu ClujNapoca; Decembrie 3-4, 1998 ; Cluj-Napoca. Zilele Universitii de Medicin i Farmacie Iuliu Haieganu Cluj-

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Napoca; Decembrie 4-5, 1997 ; Cluj-Napoca. Membru al societilor profesionale Membru activ al Societii Romne de Chirurgie i Ortopedie Pediatric 2006 2008 secretar executiv al Societii Romne de Chirurgie i Ortopedie Pediatric - diplom de operator PC - diplom de analist-programator ajutor

Alte competene

APTITUDINI PERSONALE

COMPETENE
Limb matern Limbi strine romna englez Certificate in Applied Languages in English as a Foreign Language 1 with Merit University of Central Lancashire, Preston, UK foarte bine foarte bine foarte bine Francez bine bine bine Italian bine bine bine

Abilitatea de a citi Abilitatea de a scrie Abilitatea de a vorbi Limbi strine Abilitatea de a citi Abilitatea de a scrie Abilitatea de a vorbi Limbi strine Abilitatea de a citi Abilitatea de a scrie Abilitatea de a vorbi

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IULIU HAIEGANU UNIVERSITY OF MEDICINE AND PHARMACY CLUJ-NAPOCA

Dan Ionu COSMA

THE PLACE OF THE CONSERVATIVE ORTHOPEDIC TREATMENT IN CONGENITAL IDIOPATHIC CLUBFOOT PhD. Thesis - abstract-

SCIENTIFIC COORDINATOR: Prof. Ioan PRIAN,MD, Ph.D.

2007

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INTRODUCTION

The congenital idiopathic clubfoot is a congenital malformation of the bones and joints that has concerned the paediatric orthopaedists since Hippocrates. Ignacio Ponseti, professor of the Iowa University, states that no major bone-joint malformation is easier to diagnose and treat than the congenital idiopathic clubfoot. Despite the statement content, the selection of the therapeutic conduct is a real challenge for the paediatric orthopaedic surgeon aiming at reaching an acceptable morphology and function when the bone becomes mature. At present, the majority of the orthopaedists agree that the treatment of the clubfoot should be conservative and non-surgical at onset. This is the reason for which the author has made an effort to define the place of the conservative treatment in clubfoot management. Another reason is related to the fact that the further the age that is suitable for the treatment, the more aggressive the care becomes for the foot and the less efficient the morphological and functional outcomes of the procedure.
THE GENERAL PART

The general part begins with the presentation of the state-of-art in this field put under investigation: concepts, notions are defined, the incidence, etiopathogenesis, normal foot configuration, anatomic and pathological alterations found in the congenital idiopathic clubfoot and the principles of the conservative treatment of clubfoot are presented; a special stress is put on the anatomical and pathological alterations of the foot. An in-depth knowledge of the normal architecture of the foot and of the pathological modifications facilitates understanding the conservative treatment principles. The chapter dedicated to the theoretical background makes a distinction between the existing forms of clubfoot: the postural and the true form. This distinction agrees with the principles of the International Clubfoot Study Group (ICFSG). According to the ICFSG recommendations, any scientific research concerning congenital clubfoot should omit postural forms in the lots under study. These forms are benign, they can be reduced entirely at birth and can be cured with no specific treatment. This is worth mentioning when wishing to establish the methodological framework of the present study as we omitted postural forms that could affect our outcomes and we included only true clubfoot forms in our investigation. The following two chapters (Incidence and Etiopathogenesis) treat of the issue of the frequency of this malformation of the bone and joint as well as of its causes. The international reference literature studied shows that the incidence of the congenital clubfoot varies according to the geographical area and population under research. Central Africa and Hawaii present a higher incidence. In the ethiopathogenesis of the malformation two categories of factors are pointed out: extrinsic factors (the mechanical theory, toxins, temperature, medicines, electromagnetic radiation) and intrinsic factors (genetic). Today the studies referring to a genetic transmission of the malformation are internationally accepted and polygenetic factors are emphasized in this respect. The multi-factorial model is, in fact, the one most accepted by the majority of researchers in clubfoot genetic epidemiology. Further studies are to explore the molecular mechanisms of genetics in order to identify the genes responsible for the occurrence of clubfoot. The thesis goes on with aspects concerning the normal architecture of the foot and the anatomic and pathological modifications in clubfoot. The foot architecture is a 17

complex one, adapted to the multi-functional purposes it serves. The biomechanical concepts are presented here in detail, muscular and bone factors contributing to the normal function and form of the foot are detailed. The section dedicated to the pathological anatomy in clubfoot groups the modifications coming up function of the structures affected: skin, joint, muscle, vascular and neurological components. The description of the joint alterations is made in a well-defined pattern as bone (joint surfaces) alterations are followed by the joining means presentation (capsule and ligaments/sinews). The textual iconography helps illustrating all the pathological elements defining the defective position of the congenital idiopathic clubfoot. The end of the general part describes the main principles of the conservative treatment in clubfoot. At international level, nowadays, two main conservative treatment approaches are accepted: the Ponseti method and the French method (or the Bensahel method). The principle of the both methods named above consists in producing a plastic (permanent) deformation of the shortened ligaments and tendons, involved in the deformation. Successive manipulations and plaster cast immobilisations follow. They are based upon the visco-elastical capacity of the conjunctive tissue of producing a plastic deformation through the process known as stress relaxation. The deformity is corrected as much as possible by smooth manipulations, putting the retracted tissue under tension. The tension is released in time as long as the foot is maintained in the position of maximum correction. When the tension is reduced significantly the progressive correction is reached by repeating the procedure.
THE SPECIFIC PART

The specific part contains the personal contribution to this topic presented as seven scientific research studies. Each study is presented in the classical form, i.e. it has an introduction, material, method, results, discussion and conclusions.
STUDY OF THE CLASSIFICATION SYSTEMS IN CLUBFOOT

Nowadays, the specialist references describe two quite comprehensive systems of classification (Dimeglio and Pirani), easy to learn and apply practically. The purpose of this study is that of determining whether in an independent centre one can apply successfully, practically and reproducibly one or both systems of classification. Material and method Beginning with 1998 we have started a case-control/retrospective, respectively a cohort/prospective study regarding the classification systems and the treatment methods in clubfoot. The new clubfoot cases from 1998 to 2005 have been presented. Until 2004, in The Department of Paediatric Orthopaedics of the Clinical Rehabilitation Hospital of ClujNapoca the modified French method of conservative treatment was used for clubfoot and Dimeglios classification system. Since 2004, the Ponseti method has been applied and concomitantly, Pirani and Dimeglio classification systems have been used. To be able to assess the applicability of the two systems of classification we have divided the initial series in two lots: lot A (children treated during 1998-2004) and lot B (children treated during 2004-2005). Lot A included 52 children (30 boys and22 girls). Lot B was made up of 21 children (8 boys and 13 girls). Both systems of classification have been used for the assessment of this lot: Dimeglio and Pirani. Lot A was analysed retrospectively from a statistical point of view, while lot B prospectively. 18

We made an analysis of the Pirani and Dimeglio scores to look for dependence between the two variables under investigation. Results The majority of the feet in lot A exhibited a moderate severity. The score for the entire lot varied between 4 and 19 points (out of 20 points) in the Dimeglio classification. The average score was 10,3 and, respectively, 10,6 points for the 74 feet, with no statistically significant correlation between these two averages (p>0,05). The Pearson correlation coefficient was 0,95 (p<0,05). The average severity level for the two examiners was 2,5, with the correlation coefficient 0,77. In lot B, the Dimeglio score varied between 3 and 18 points, and the Pirani score between 0,5 and 6 points. The average Dimeglio score was 10,7 points, the average Pirani score was 4,9 points. No statistically significant difference was found between these two average values of the variables (p>0,05) and the correlation coefficient was 0,82. The average Dimeglio classification related to the degree of severity was 2,7, correlated with the average Pirani score (the correlation coefficient 0,79) of 4,9 points. Conclusions Though the two classification systems, Dimeglio and Pirani, mark in different ways the deformity (reducibility for Dimeglio and the morphological aspect for Pirani), the high correlation coefficient indicates that the higher severity given by Dimeglio classification correlates with Piranis and vice-versa. The application of the two systems of classification, Dimeglio and Pirani, in an independent centre led us to the conclusion that the two systems are suitable, easy to apply practically once learnt. The study carried out has demonstrated that the interobserver variation is relatively small for the Dimeglio scoring, and the good correlation coefficient between the Dimeglio and Pirani recommends their simultaneous use in the assessment of clubfoot, as the aspects under investigation (foot reducibility and morphological aspect) are different and complement each other.
THE RETROSPECTIVE STUDY OF THE CLUBFOOT TREATMENT USING THE MODIFIED FRENCH METHOD

The purpose of this study consists in evaluating and presenting the results of the conservative treatment of clubfoot by means of the modified French method, between 1998 and 2003, seen from the viewpoint of the need for surgery posterior-medial release (PMR) before the age of 18 months. Material and method The lot of study was made up of 52 children (74 feet) younger than or equal to the age of 9 months. The following variables have been investigated with all the patients in the lot: age of the first presentation in our department, the previous treatment type, number of plaster cast immobilisations needed for the complete correction, previous Achilles tenotomy, amplitude of dorsiflexion before and after the treatment and compliance to orthoses. Results The average first presentation age was 31,85 months (ranging between 1 month and 9 months). Of all these patients, 38 (73%) were under 6 months of age, the rest, i.e. 14 (27%) having the age between 6 and 9 months. When coming to our department, the patients exhibited one or more clinical deformities related to uncorrected clubfoot, and the indication for coming to our service was in 80% of the cases for surgical intervention (posterior-medial release). 19

In order to induce correction through the modified French method in the children in the lot, 52 successive plaster casts were necessary, for a duration of 156 weeks. No child in this lot was subjected to Achilles tenotomy procedure. At the end of the follow-up period (125,62 months), i.e. at the age of 18 months, 13 feet of 74 (17,56%) required posterior-medial release (PMR) for the full correction of the residual deformities after conservative treatment. Conclusions The use of the modified French method in the conservative treatment of the clubfoot leads to favourable results in more than 80% of the cases. When the need for surgery is still present, it is reduced to the posterior rather than medial part. The modification of the original part by increasing the immobilisation length and reducing the manipulation time enables the same results. However the difficulties related to the daily care of the child are removed and this is an advantage considering that because of these difficulties made sometimes parents not comply with the treatment requirements.
THE PROSPECTIVE STUDY OF THE TREATMENT BY PONSETI METHOD IDIOPATHIC CLUBFOOT

The aim of this research was to show what the results are when the Ponseti method is used in the treatment of the congenital clubfoot. Material and method Beginning with the year 2003, we have initiated a prospective study, in which all the children presenting clubfoot, treated according to the Ponseti method in the Department of Paediatric Orthopaedics of the Clinical Rehabilitation Hospital ClujNapoca, between 2003-2005 were included. The lot of study comprised 51 children (74 feet). The patients started their treatment as early as possible after birth. The treatment consisted in successive plaster cast immobilisations as described Ponseti. After each session of manipulations the long-leg casts were put on and changed every 5-7 days. The following variables have been assessed with all the patients in the research lot: age of the first presentation in our department, the previous treatment type, number of plaster cast immobilisations needed for the complete correction, previous Achilles tenotomy, the need for Achilles tenotomy, amplitude of dorsiflexion before and after the treatment. Results The average age at which treatment started was 20,96 months (ranging between 2 weeks and 14 months). Out of this group, 46 (90,2%) were under 6 months of age, 5 patients (9,8%) were older than 6 months. The majority of the patients (37 patients) did not follow any treatment before this one. The correction with the Ponseti method required from 1 to 7 plaster casts (average = 5). 90% of the patients (46 children) required less than 5 plaster casts. The period of time needed for correction since the first immobilisation up to the last immobilisation varied from 1 to 6 weeks (average 51 weeks). The percutaneous tenotomy of Achilles tendon was necessary in 68 feet. Of the 37 patients not subjected previously to conservative treatment, 2 patients 4 feet (5%) needed the completion of the correction by posterior-medial release at the age of 18 months.

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Conclusions The Ponseti method has been adopted by many hospitals and centres in the world, but only by our department in Romania. The Ponseti method is safe and efficient in the conservative treatment of clubfoot and decreases the number of surgical interventions needed for the correction. Another advantage is that it can be successfully applied to children having the age up to 2 years who had not been subjected to surgery previously.
THE COMPARATIVE STUDY OF THE CONSERVATIVE METHODS OF TREATMENT IN CONGENITAL IDIOPATHIC CLUBFOOT: THE MODIFIED FRENCH METHOD VS. THE PONSETI METHOD

The Ponseti method began to be applied in the Department of Paediatric Orthopaedics of Clinical Rehabilitation Hospital Cluj-Napoca in the year 2003 for the first time in our country. As results related to the Ponseti method have not been investigated before in Romania, we began a prospective study in order to compare the results of this method vs. those of the modified French method used until 2003 in our department and in other departments of paediatric surgery in our country. Material and method The lot of study was made up of 103 children suffering of clubfoot (148 feet) treated in our department between 1998-2005. In the 1998-2003 period, the conservative treatment protocol was based on the modified French method. After 2003, we used the Ponseti method. In order to make an evaluation of the results of the two methods of conservative treatment we divided the initial lot in two sublots: A and B. Sublot A included clubfoot-suffering children, treated in our service in the period from 1998 to 2003 based on the modified French method. This lot was made up of 52 children (30 boys and 22 de girls). Sublot B included children treated according to the Ponseti approach in the interval 2003-2005. The criteria of inclusion in this lot allowed the entering of 51 children. The values of the variables studied in the two lots were analysed in relation to the need for surgical intervention (posterior-medial release) at the age of 18 months. Results Comparatively, a statistically significant difference between the two lots could be found concerning the age of beginning the treatment: 31,85 months for sublot A and 20,96 months for sublot B (p<0,05). The number of plaster casts needed for the correction of the deformity in lot A (52) was not significantly different compared to lot B (42), p>0,05, but the time needed for immobilisation was much reduced (p<0,05) in lot B vs. lot A (52 weeks for lot B compared to 156 weeks for lot A). The main criterion of assessing the efficiency of the two conservative treatment methods in PSCVEI (number of feet requiring surgical interventions posteriormedial release at the age of 18 months) is evidently in favour of the Ponseti approach: 4 feet (5%) needed PMR in the case of the patients in lot B as compared to 13 feet(18%) in the lot B patients (p=0,0093). Conclusions The conservative treatment of clubfoot through the Ponseti method leads to the full correction of all deformities in a shorter period of time than the traditional methods. The Ponseti approach similar to the modified French method requires approximately the same number of plaster casts. However, the classical methods more often need to 21

be followed by posterior-medial release and this increases the costs related to hospitalisation, general anaesthesia and surgical manoeuvre. The Ponseti approach requires only a minor intervention, practiced ambulatory and in local anaesthesia.
IMPORTANCE OF FOOT ABDUCTION BRACE AFTER THE PONSETI TREATMENT OF CLUBFOOT

This part of the research aimed at finding out the role and importance played by the foot abduction brace applied after the foot was subjected to the Ponseti conservative treatment as well as the significance of the education level in the family of the children treated according to this method in order to see if there could exist predictive factors for recurrence. The recognition of the risk factors associated frequently to recurrence enable a more attentive scrutiny of the patients and better measures in view of successful care. Material and method In the interval 2003-2005, in the Department of Paediatric Orthopaedics of the Clinical Rehabilitation Hospital Cluj-Napoca 51 children (74 feet), suffering of idiopathic clubfoot, were treated according to the Ponseti method. In this group, 5 patients were over 6 months old and were excluded from the lot under study. The average age of the children who remained in our study lot (46 patients) was of 12 weeks, ranging between 2 and 24 weeks. Out of the 46 children, 8 did not come back for check-up after the age of 18 months, with 2 children the posterior-medial release was made at the age of 18 months, so that the number of patients finally included in the lot was 36. The foot abduction brace prescribed required permanent wear (23 hours/day) in the first three months after the plaster cast was taken out and during the day and night sleep (8 hours/day) up to the age of 3 years. Compliance with orthoses was defined in the terms below: 23 hours/day in the first three months after the plaster cast was taken out and minimum 8 hours/day up to the age of 3 years. Non-compliance was defined as the incapacity of observing the criterion mentioned above up to the age of 18 months. Results Out of the 36 patients, 25 (69%) patients (35 feet) complied with the requirement and 11 (31%) patients (15 feet) did not comply with the foot abduction orthoses. At the age of 18 months, it was found out that in the non-complying group the Pirani score increased significantly as compared to the complying group which means a deterioration of the initial result. Another finding with reference to the abduction orthoses complying group is that the Pirani score was maintained or improved significantly (p<0.05), while with the non-complying group the initial results obtained by plaster casts were damaged due to lack of use of orthoses (p<0.05). Conclusions The analysis of the risk factors for recurrence leads to the conclusion that the compliance to the use of abduction orthoses is strongly associated to recurrence occurrence. The child not observing the orthoses protocol presents a 33 times higher risk of occurrence as compared to a child using foot abduction orthoses according to doctor recommendations. The type of the orthoses was found not in correlation with the risk of recurrence occurrence. The level of education of the families of the children suffering of clubfoot does not decisively affect the compliance to the use of the orthoses, though we noticed a higher 22

tendency to comply with the requirement in the case of families with more education, at least tertiary education level. It is for this reason that we consider the correct use of the foot abduction brace is essential for the conservative treatment of the congenital idiopathic clubfoot according to the Ponseti method, in spite of the obstacles sometimes put by parents.
REDUCTION OF THE NUMBER OF SURGICAL INTERVENTIONS IN THE CLUBFOOT TREATMENT FOLLOWING THE PONSETI METHOD IMPLEMENTATION

The experience acquired as the first centre of paediatric Orthopaedics in Romania to ever use the Ponseti method in the conservative treatment of the congenital idiopathic clubfoot made me study the way in which the early conservative treatment influences the later need for surgery, in the case of the patients of our department. A retrospective study was carried out in this respect, to compare the number of posterior-medial releases for clubfoot versus the overall number of surgical interventions made in our service in the time interval in which the conservative treatment was made based upon the two approaches mentioned earlier. Material and method The first stage dealt with the analysis of the conservative treatment results in congenital clubfoot in the period 1998-2005. Due to the fact that in the period in discussion two different methods of treatment were used we divided the period in two distinct intervals: the first interval 1998-2003 including children treated according to the modified French method and the second interval 2003-2005 including the children treated in the Ponseti manner. For each of the intervals studied, we made analyses of the number of children in care, respectively of the clubfeet treated and the percentage of positive results (number of feet that did not require surgical treatment at the age of 18 months posteriormedial release relative to the total number of treated feet). The second stage consisted in the retrospective analysis of the surgical interventions made in the Department of Pediatric Orthopaedics of the Clinical Rehabilitation Hospital Cluj-Napoca in the period 1998-2005. In the time interval mentioned, a total number of 1882 surgical operations were made. In the case of clubfoot, 127 limited or extended posterior-medial releases, with the McKay procedure and the Cincinatti approach. Results In the period 1998-2005, 103 (148 feet) suffering of congenital clubfoot were treated conservatively in our department. 52 children (74 feet) were in our care in 1998-2002, and we used the modified French method for them while in the interval 2003-2005, 51 children (74 feet) were treated with the Ponseti approach. The number of posterior-medial releases for the surgical treatment of the congenital clubfoot in the period in question was of 127, with an yearly average of 15.866.46 PMR (between the limits 8-26). The increasing tendency in the period 1998-2002 is graphically represented (the Pearson correlation coefficient=0.94, p=0.015), the Pearson correlation coefficient between the number of posterior-medial releases under the age of 18 months and the total number of posterior-medial releases in the period 2003-2005 is 0.92 in the confidence interval 95%.

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Conclusions Our study covers 8 years. In this interval, the treatment of clubfoot was made according to two different methods: the modified French method and the Ponseti method. The number of posterior-medial releases in our service in the two periods of time for the two conservative methods applied shows a significant decrease in the time interval when the Ponseti method was used for treatment. Based on our results, we can assert that the Ponseti method is a decisive factor for decreasing the number of posterior-medial releases, improving the favourable results obtained in the improving clubfoot treatment. These results were obtained in a time when the addressability to our department has increased too. A factor of importance for increased addressability could be the use of the Ponseti method in the conservative treatment of clubfoot for the first time in our country.
CREATING AND IMPLEMENTING THE INTEGRATED INFORMATION SYSTEM FOR THE CONGENITAL IDIOPATHIC CLUBFOOT

In view of finding out the size of and demand created by clubfoot in our country, we have designed, created and implemented an integrated information system for the congenital idiopathic clubfoot. On the basis of the information and data in this system, the parents have an information resource at their disposal that enables them reach a decision concerning the way in which the deformity of their child could be treated. Material and method The integrated information system for the congenital clubfoot has two components: the medical component dedicated to the medical staff and the informative component dedicated to the parents and children suffering of clubfoot. The medical component derives from the need to have a rigorous analysis of this pathology and of exactly knowing the incidence of the deformity in Romania, as well as of the types of treatment carried out in our country. For this purpose, we have designed an application in the Microsoft Access 2003 approach, containing the database itself, the form for data introduction and the report form. The informative component is addressed to the parents of the children diagnosed with congenital talipes equinovarus idiopathic clubfoot. For this side, we have developed a multimedia material which combines and integrates various types of media: images, diagrams and text, to give as many details on congenital clubfoot as possible, to enlarge the information on this topic in Romanian on the Internet. This material was created in hypertext HTML with the help of AceHTML and was published on the Internet at the address http://piciorstramb.bravehost.com. Results It was found out that the majority of the information on clubfoot found on the Internet originate from discussion forums and medical commercial companies, the academic institutions being responsible for the dissemination of authorized data to a small extent. After reading all the pages on this topic, we found out that no site contained data on the etiology, clinical manifestations and treatment of clubfoot. This aspect as well as the fact that the majority of the available information originate not in authorised medical sources led us to the conclusion that the informative resources available on the Internet on PSCVEI are extremely reduced, not to say practically not existing.

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Conclusions The medical component of the system implemented in our service represented by the Microsoft Access application of data collection and analysis showed to be extremely useful. The uniform manner of collecting data permits a rigorous analysis of this congenital disease and removes many of the errors usually met in data collection, We think that this application can be implemented in any centre of paediatric orthopaedics in our country, as the resources needed are minimal and practically they are available anywhere. The site informing the families on clubfoot gives them data and information in a structured manner, helps them make a decision on the treatment to be followed in the case of the disease of their child The large number of calls (133 in 2 months) demonstrates that the resources has been expected for a long time as the information on clubfoot is extremely scarce.
FINAL CONCLUSIONS

1. The congenital idiopathic clubfoot is a complex, multi-planar foot deformity. The true forms of clubfoot are those in which the deformity cannot be diminished in the first presentation to the doctor and do not occur in other syndromes. 2. The potential factors involved in the congenital clubfoot etiology can be grouped in two groups: intrauterine or extrinsic factors, influencing foetal development and intrinsic, genetic factors. 3. Using the Dimeglio and Pirani systems of classification in an independent centre we have found that these systems are proper to and easy to apply, mainly after the stage of learning the systems is overcome. The study carried out has demonstrated that the inter-observer variation is relatively small for the Dimeglio system, and that there is a good correlation coefficient between the Dimeglio and Pirani systems, which recommends the simultaneous use of them in the clubfoot evaluation, as the aspects investigated (reducibility and the morphological aspect of the foot) are different and complementary. 4. The use of the modified French method in the conservative treatment of the congenital clubfoot leads to positive results in more than half of the cases. When the surgical intervention is it has to be made with posterior rather than medial structures. The modification of the original procedure by increasing the period of immobilisation and reducing the manipulation period leads to the same results, but the difficulties with daily care of the child are removed. It is known that these difficulties sometimes make parents not comply with the treatment and this is removed. 5. The conservative treatment of clubfoot by Ponseti method leads to a complete correction of all deformities in a shorter period of time than with classical methods. The Ponseti method needs only a minor surgery practiced ambulatory and in local anaesthesia. In conclusion, the Ponseti method is safe and represents an efficient conservative treatment manner in clubfoot. 6. The use of the orthoses for the foot abduction is a very important stage in the conservative treatment of clubfoot according to the Ponseti method. The patients who did not comply had a negative evolution as their state has deteriorated significantly up to the age of 18 months. In contrast, the feet of the complying patients remained constant or improved. It is for this reason that we 25

consider as essential the correct use of the foot abduction orthoses in the conservative treatment of the congenital clubfoot according to the Ponseti method, in spite of the barriers sometimes raised by parents. 7. As for the medical management, one can affirm that the Ponseti method is sure and efficient, reduces the number of surgical interventions for correcting clubfoot. The method can be successfully used for all the children under 2 years old even if they had been previously subjected to other forms of conservative care. 8. Health education programs for the neonathologists, paediatricians and family doctors must encourage its adoption as a gold standard for the treatment of the clubfoot. 9. The implementation of an integrated, medically authorised, information system represents a need for the medicine in Romania today. The achievement of this system for an orthopaedic malformation (clubfoot) has shown to be a unique effort in Romania, that supplies a base for research and a high quality information base, medically approved and also available to large groups of patients and families. Parents use this site as a guide for the pathological entity their child suffers and a base for consultation too. The integration of such informative resources in a national unique system in Romania, of the type National Register, will improve the quality of the data available for the researcher in Romania and the results of the research will generate unique treatment protocols so that, finally, the quality of the medical act and its standardisation will develop.

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CURRICULUM VITAE
PERSONAL INFORMATION
Name and surname Address Phone Email Nationality Date of birth Parents name COSMA DAN IONU Str. Observatorului nr. 9, ap. 3, 400500 Cluj-Napoca 0745493041 dcosma@umfcluj.ro Romanian 07.01.1977 tefan and Maria

PROFESSIONAL ACTIVITY
Period Job title Workplace Period Job title Workplace Period Job title Workplace 2006 present Assistant lecturer, Resident doctor in Pediatric Orthopedics Department of Pediatric Surgery and Orthopedics, University of Medicine and Pharmacy Cluj-Napoca 2003 2005 Teaching assistant, Resident doctor in Pediatric Orthopedics Department of Pediatric Surgery and Orthopedics, University of Medicine and Pharmacy Cluj-Napoca 2002 2003 Resident doctor in Pediatric Orthopedics Emergency Hospital for Children M.S. Curie Bucureti

EDUCATION
Period Position Specialization Educational institute Period Position Specialization Educational institute Period Position Specialization Educational institute Period Position Specialization Educational institute 2003 present PhD student Pediatric Orthopedics (prof.dr Ioan Prian) University of Medicine and Pharmacy Cluj-Napoca 2002 present Resident doctor Pediatric Orthopedics University of Medicine and Pharmacy Cluj-Napoca 1995 2001 student Medicine Faculty of Medicine University of Medicine and Pharmacy Cluj-Napoca 1991-1995 High school student Computer science Computer Science High School Tiberiu Popoviciu, Cluj-Napoca Graduated with Honor Diploma

PROFESSIONAL COMPETENCIES
Scientific title PhD student (thesis title: The place of the conservative orthopedic treatment in congenital idiopathic clubfoot, Scientific coordinator: prof. dr. Ioan Prian) Practical sessions of Pediatric Orthopedics for 5th year students 1 book and 17 papers

Teaching activities Papers

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Grants

Director of CNCSIS grant no. 470/2006 with title Studiul strategiei de tratament conservativ ortopedic n piciorul strmb congenital varus equinus idiopatic Member of CNCSIS grant no. 1394/2006 with title Studiul comparativ al instabilitii coxo-femurale neonatale n municipiile Cluj-Napoca i Zalu, director: conf.dr. Dana Vasilescu Member of CEEX grant no. PC-D01-PT11-261/2005 with title Realizarea unei reele intercentrice pentru dezvoltarea i monitorizarea utilizrii tehnicilor medicale de chirurgie minim invaziv n ortopedie i traumatologie, director: conf.dr. Dana Vasilescu Member of CEEX grant no. 12566/2006 with title Promovarea cercetrii romneti la programele europene n domeniul utilizrii fixatoarelor externe n alungirea i reconstrucia osoas n hemicondrodiastazis, pseudartroz i maladia Lobstein, director: conf.dr. Dana Vasilescu

Courses

Current Concepts in Paediatric Trauma 22-23.01.2007, Cluj-Napoca, Romnia First EPOS-POSNA Course 25-27.01.2007, Bratislava, Slovacia Treatment of Pilon Fracture Workshop 18-20.05.2006, Cairo, Egypt Taylor Spatial Frame Workshop 18-20.05.2006, Cairo, Egypt Basic Ilizarov Application (I&II) Workshop 18-20.05.2006, Cairo, Egypt The Athletic Child 05.04.2006, Dresden, Germany The Second Scandinavian International Seminar on Fractures in Children 21-23.09.2005, Saro-Goteborg, Sweden Tehnici moderne de instrumentaie segmentar n chirurgia scoliozei 17-18.06.2005, Bucureti AIOD Course 13.10.2004, Bucureti Basic knee arthroplasty course 13-14.05.2004, Royal Bolton Hospitals, Marea Britanie Workplace module for health studies Semester 2 2003-2004, University of Central Lancashire, Marea Britanie The Postgraduate Health Informatics Residential Week-end 12-14.03.2004, The Oaks Hotel, Reedley Burnley, Marea Britanie The UCLAN seminar on the 2004 GMS contract 24.02.2004, The Harris Knowledge Park, Fulwood Preston, Marea Britanie Microcurs de artroscopie 01-02.06.2002, Iai

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Cursul intensiv internaional de imagistic osteoarticular 26.04.2002, Institutul Clinic Fundeni, Bucureti Curs de Prim Ajutor Medical Specializat 05-26.09.1999, Spitalul Clinic de Urgen Floreasca, Bucureti Prizes 2nd Prize for paper Abordarea diagnostic a nodulilor tiroidieni at Al 5-lea Congres Internaional al Studenilor i Tinerilor Medici, Timioara, 4-6 Mai, 2001 3rd prize for paper Aportul diagnostic al ecografiei n cazul depistrii scintigrafice de nodului reci tiroidieni at Sesiunea de Comunicri tiinifice Studeneti MEDICALIS, 30 Martie 1 Aprilie, 2001, ClujNapoca Experience in projects and programs ERASMUS/SOCRATES scholarship in the period february-may 2004 at University of Central Lancashire, Preston, UK. Results: - Ponseti method in clubfoot treatment; - management of electronic databases; - informative materials for parents and children. Member of organizing committee for Aspecte n tratamentul fracturilor la copil symposia and Osteosinteza stabil cu tije elastice centromedulare n fracturile copilului workshop, 07.12.2005, ClujNapoca Member of organizing committee for Actualiti n diagnosticul i tratamentul displaziei de old la sugar i copilul mic symposia, 10.12.2004, Cluj-Napoca. Scientific Reporter at 25th EPOS Meeting, 05-08.04.2006, Dresden, Germania Member of organizing committee for Current Concepts in Paediatric Trauma international course, 22-23.01.2007, Cluj-Napoca, Romnia Representative for Romania at Meeting of the East European Pediatric Orthopedic Surgeons. Exchange of ideas, discussions of further cooperation round table, 27.01.2007, Bratislava, Slovacia Congresses and conferences Multidisciplinary approach of congenital malformations; 19-21 october 2006, Sinaia Le 16eme congres national SRCOP; 7-9 septembrie 2006; MamaiaConstana 2nd International Course of Skeletal Deformities Correction, Cairo, Egypt, May 18-20, 2006 25th EPOS Meeting, Dresda, Germania Boala Hirschprung Actualiti n diagnostic i tratament Symposium, 09.12.2005, Cluj-Napoca. Masa rotund Aspecte n n tratamentul fracturilor la copil, 07.12.2005, Cluj-Napoca. Workshop-ul Osteosinteza stabil cu tije elastice centromedulare n fracturile copilului, 07.12.2005, Cluj-Napoca. A III-a Conferin Naional de Consens SRCOP; 8-10 septembrie 2005; Costineti-Constana. Conferina Zilele Spitalului Clinic de Recuperare , 24-26.03.2005, Iai. Simpozionul omagial Profesor Dr. Alexandru Pesamosca, 12.03.2005, Bucureti. Simpozionul Actualiti terapeutice n practica medical, 23.02.2005, Zalu. Simpozionul Actualiti n diagnosticul i tratamentul displaziei de old la sugar i copilul mic, 10.12.2004, Cluj-Napoca.

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Zilele Universitii de Medicin i Farmacie Iuliu Haieganu ClujNapoca, 2004. 16th National Congress of Pediatric Surgery and Orthopaedy; 21-23 October 2004; Poiana Braov. SOROT National Conference; 14-15 october 2004; Bucureti. World Congress of Pediatric Surgery; 22-27 June, 2004; Zagreb; Croatia. A XXIII-a Conferin Naional Anual de Medicin Fizic i Recuperare, 15-18 octombrie 2003, Cluj-Napoca. Conferina Naional de Consens a Societii de Chirurgie i Ortopedie Pediatric din Romnia, 9-11 octombrie 2003, Timioara. 1st Balkanic Congress of Pediatric Surgery; 25-27th of September, 2002; Constana. Al 7-lea Congres Naional de Chirurgie i Ortopedie Pediatric; 29.05. 02.06.2002; Iai. Al 4-lea Congres Naional de Angiologie i Chirurgie Vascular; Mai 17-19, 2001; Cluj-Napoca. Al 5-lea Congres Internaional al Studenilor i Tinerilor Medici; Mai 46, 2001; Timioara. Sesiunea de Comunicri tiinifice Studeneti MEDICALIS; Martie 30 Aprilie 1, 2001 ; Cluj-Napoca. 1st International Medical Conference for Students and Young Doctors; October 26-28, 2000; Sibiu. 4th Balkan Congress of Medicine and Dentistry for Students and Young Doctors. October 2-4, 2000; Craiova. Al IV lea Congres Naional Al Studenilor i Tinerilor Medici; Aprilie 68, 2000; Constana. Sesiunea de Comunicri tiinifice Studeneti; Martie, 2000; ClujNapoca. edina de comunicri, Societatea Romn de Chirurgie, Filiala Cluj ; Noiembrie 25, 1999. Al 3-lea Congres Naional de Angiologie i Chirurgie Vascular ; Mai 27-29, 1999 ; Cluj-Napoca. Al III-lea Congres Naional al Studenilor n Medicin i al Tinerilor Medici; Martie 26-27, 1999; Sibiu. Zilele Universitii de Medicin i Farmacie Iuliu Haieganu ClujNapoca; Decembrie 3-4, 1998 ; Cluj-Napoca. Zilele Universitii de Medicin i Farmacie Iuliu Haieganu ClujNapoca; Decembrie 4-5, 1997 ; Cluj-Napoca. Member of scientific societies Other competencies Member of Romanian Society of Pediatric Surgery and Orthopedics 2006 2008 executive secretary of RSPSO - PC operator - assistant programmer

FOREIGN LANGUAGES
Foreign language English Certificate in Applied Languages in English as a Foreign Language 1 with Merit University of Central Lancashire, Preston, UK Very good Very good Very good French Good Good Good

Reading Writing Speaking Foreign language Reading Writing Speaking

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Foreign language Reading Writing Speaking

Italian Good Good Good

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