Egészségügy | Traumatológia » Proposed Orthopedics and Traumatology Project, Lubumbashi

Source: http://www.doksinet 0 Proposed orthopedics and traumatology project Lubumbashi Project-Program Capacity building and strengthening framework of surgeons in Lubumbashi while improving the quality of health care of bones and joints. Yves NKULU-ILY Shabo 30/06/2015 Source: http://www.doksinet 1 Table of contents A. INTRODUCTION . 3 ABOUT BONES AND JOINTS . 3 INJURIES AND DISORDERS OF THE BONES AND JOINTS . 3 INJURIES AND COMMON DISORDERS OF THE MUSCULOSKELETAL SYSTEM: . 3 WHY DWELL ON ORTHOPEDICS AND TRAUMA? . 4 B. TARGET . 4 C. MOTIVATIONS . 4 D. OBJECTIVES . 5   GENERAL OBJECTIVE . 5 SPECIFIC OBJECTIVES. 5 E. PROJECT IMPLEMENTATION ACTIVITIES . 5 F. EXPECTED RESULTS . 6 G. MONITORING AND EVALUATION OF THE PROJECT . 7 H. OUR NEEDS . 7   I. A UNIT OF ORTHOPEDICS AND TRAUMATOLOGY WITH A RADIOLOGY SERVICE. 7 ORTHOPEDICS PRODUCTS: . 7 INTERVENTION STRATEGY . 7 THEORETICAL TRAINING PROGRAM. 8 PRACTICAL TRAINING PROGRAM . 8 RESEARCH WORK . 8

SERVICES OFFERED . 8 J. PARTNERS . 9 K. PROJECT RESOURCES . 9   L. HUMAN RESOURCES . 9 MATERIAL RESOURCES . 9 SCIENTIFIC ISSUES . 9   STATE OF THE ART AND BIBLIOGRAPHY . 9 SCIENTIFIC QUESTION(S) . 10 M. EXISTING STRATEGIES AND OTHER COOPERATION ACTIVITIES . 10 N. COMPLEMENTARITIES AND SYNERGIES . 11 O. GOVERNANCE OF THE PROJECT (ORGANIZATION CHART) . 11 P. CROSS-CUTTING PRIORITIES . 11 Q. DURABILITY. 12    INSTITUTIONAL SUSTAINABILITY . 12 FINANCIAL AND ECONOMIC SUSTAINABILITY . 12 SOCIO-CULTURAL APPROPRIATION. 12 R. TERMS OF REFERENCE . 12 S. ANNEXES . 13 CONTEXT . 13 ORGANIZATION CHART . 14 Source: http://www.doksinet 2 REFLEX INDICATIVE PLUG . 15 ANALYSIS AND MANAGEMENT RISKS . 16 INDICATIVE OPERATIONAL PLAN OF THE PROJECT . 17 ACTION PLAN OF THE PROJECT ACTIVITIES . 18 ESTIMATED BUDGET . 19 THE PROBLEM TREE. 20 THE LOGICAL FRAMEWORK . 21 FORMATS DESIRED FOR TRAINING . 22 CURRICULUM AT THE FACULTY OF MEDICINE (UNILU) . 24 THE IDENTIFIED

PARTNERS AND THEIR POTENTIAL CONTRIBUTIONS . 25 MEDICAL EQUIPMENT INDICATIVELY . 26 Source: http://www.doksinet 3 A. Introduction About bones and joints The health of bones and joints is essential to our well-being. Indeed, our bones have very important functions such as:      providing structure to the body; protecting internal organs; serving as an anchor to the muscles, ligaments, tendons and articulations that allow movement; storing calcium; they contain the bone marrow, which produces blood cells. The human skeleton consists of 206 bones of various sizes, which are supported and supplemented by ligaments, tendons, muscles and cartilage. The femur is the longest and heaviest bone while the stapes, located in the middle ear, is the smallest. Man skeleton has many differences compared to that of a woman. The basin is the region where this difference is most pronounced. Indeed, the pelvis of women is flatter, round and wide, allowing her to give birth. Other

differences would include the following:  in general, bones’ limbers and fingers are slightly more thick and long for males;  women generally have a narrower ribcage, finest cranial traits and humero-ulnar angle (elbow) more pronounced. Injuries and disorders of the bones and joints Our bones and joints are so essential to our everyday life that we are surprised how having a bone’s or joint’s injury or disorder may affect us. From one day to the next, we can no longer walk or drive or gradually a persistent pain may prevent us from getting up or holding our children in our arms; our life is transformed into a daily struggle, and this, even if the injury or disorder is temporary. In these cases, learning as much as possible on our State helps us to make decisions towards a treatment, and doing so makes us active participants in our own recovery. In addition, learning about the injuries and disorders of bones and joints before being hit personally helps us to prevent

them. Injuries and common disorders of the musculoskeletal system:   sprains and sprains; fractures of long bones;   diseases and bone tumors; assessment of injuries. Orthopedics is the surgical specialty that deals with the musculoskeletal system in the broad sense (i.e bones’ illnesses, articulations, muscles and tendons, ligaments and nerves). It, therefore, applies to all members and the skeleton, with the exception of skull and face’s bones. This field is subdivided into four subparts:   disorders of the upper limb; disorders of the lower limb;   diseases of the column; bone tumors. Trauma deals with fractures, sprains, contusions skeleton and the traumatic pathology of soft tissue like tendon rupture, tear and muscle strain, deep wound, cut finger etc. Treatment includes the use of plaster, Source: http://www.doksinet 4 orthotic bandage but also surgical repair (plate, nail, prosthesis, suture etc.) Trauma is often associated with

physiotherapy. There is also orthopedic traumatology, which deals with fractures and injuries. Orthopedics deals with diseases of the musculoskeletal system, other than those immediately associated with trauma. Why dwell on orthopedics and trauma? Some musculoskeletal disorders affect particularly children and, where appropriate, fall within orthopedic surgeons specializing in Pediatrics. The later have received specific training on the assessment and treatment of bones, joints and muscles disorders among growing children. Conditions such as clubfoot, congenital dislocation of the hip (or developmental hip dysplasia) and infections of bones and joints (such as osteomyelitis) are common to children. Because they are growing, their problems are not the same as those of adults. Children react any other way than adults to trauma, infections or abnormalities. In fact, more bone and joint conditions affect only children Trauma surgery, by definition, takes place in an emergency context,

always more difficult to deal with for the surgeon as well as for the patient. The patient is not psychologically prepared to be operated and hospitalization increases the fall or trauma-related stress. For surgical treatment of certain fractures, it is very important to work with methods for which facilities can be developed locally (production of an external fixator low cost that can be produced in Africa). Orthopedic surgery requires extensive skills. It is impossible to describe all of the interventions, and the characteristic of a good doctor is to know its limits of competence. Because you cannot specialize in any type of surgery, and because nothing is well done than what is often done, our surgeons will only focus on the surgery of their expertise and will address to specialist colleagues, with whom they will work with confidence, patients requiring intervention outside of their fields of competence. Treatment requires knowledge of orthopedics and traumatology by medical

staffs. It is, therefore, imperative to undertake a capacity building inasmuch as orthopedic training would be too long and costly. The multidisciplinary nature of the specialty requires advanced training in various fields. Such a transfer of skills, therefore, requires a certain level of excellence in terms of theoretical, clinical, and operative training. Does the Congolese environment meet these requirements? Alternatively, will it meet the requirements anytime soon? To ensure the quality of care to caring for the sick and respond to the training needs of caregivers, training plans should be put in place. B. Target This project aims to train at least 20 young surgeons, clinicians and biomedical staff in Lubumbashi. The size of this project also aims to reach over a period of five years at least 500 direct patients and nearly 5,000 indirect patients from health problems of bones and joints. C. Motivations Several reasons argue for a project of this kind. The absence, in Katanga, in

the Democratic Republic of Congo of such structures able to welcome patients’ problems of healthy bones and joints cannot remain indifferent. In Lubumbashi, as in all the cities of the Democratic Republic of Congo, there are no orthopedic products; this makes it impossible to better support healthy bones and joints cases. Source: http://www.doksinet 5 NB: We express the wish to see this action challenged enough Congolese society and its decision-makers, so traditionally priority health situations do not evade the existence of other health problems. D. Objectives General objective Advancing the health of bones and joints in the Democratic Republic of Congo, city of Lubumbashi. Specific objectives This initiative will seek to:  Capacity building of surgeons in Lubumbashi while improving the quality of health care of the bones and joints. Assisted by foreign specialists, this program will be eventually able to provide much more complex training abroad. We will, therefore: a)

Create a dynamic training very specific for all staff involved in the management of patients; b) Institutionalize a training time in the form of a workshop involving all services.  Train the staff of relay: a) A training for all nurses in orthopedics and traumatology just for their knowledge; b) A comprehensive training; c) A targeted training in orthopedics and trauma. NB. It is essential that nurses be able to transmit information to the patients  Collect accurate data on the frequency, the predisposing factors, the geographical distribution and the evolution in time of the different types of health of bones and joints;  Support patients (Administer specialized care: medical treatment, surgical);  Reduce the rate of cases due to the health of bones and joints;  Facilitate the financial access to care to all patients; this will help reduce transfers abroad where the care is very expensive. E. Project implementation Activities    Orthopaedics and traumatology;

Congenital malformations (feet bots, dislocated hips etc.); Static disorder of the spine (scoliosis, kyphosis); At each activity will be affected an assistant in training. The wizards will be able to change activities every four months; they will have the opportunity to familiarize themselves with all aspects of the specialty during the past years of their training. The same goes for many students who are in contact with the service They too will have the opportunity to perform a rotation within this system, but only for one or two weeks by activity. Their training will, therefore, be optimized, especially as they will be truly faced the various activities of the service: interventions in the operating block, consultations, activities in the halls of plaster and work within the units of hospitalization. This in-depth transfer of skills will allow not only to be consistent among the pioneers of the medical community in Lubumbashi but also to gain experience in rare disorders. With a

good communication in the activities, problematic cases which fall within several areas of expertise can be discussed and resolved by the various teams experts. This initiative is therefore in seven phases as follows:  Training of young surgeons, clinicians, and biomedical staff: Training of Congolese colleagues will be a vital part of all the work. Training in the form of short courses with the involvement of our foreign partners. Young surgeons from Lubumbashi will be trained to improve care and to ensure the next generation of surgeons. Source: http://www.doksinet 6  Relay agents identification and recruitment of trainers and a coordinator and his Deputy: 18 agents relay and six trainers will be selected. There will be two agents by relay center For the implementation of the project, a coordinator will be recruited. He will be the referee of the project and will be responsible for the coordination of various activities. For the identification of the relays, the health

workers practicing in the targeted province of the project will be prioritized. As for the trainers and to the coordinator, they will be selected at the provincial or national level from a call to candidacy.       Training relay agents and staff the socio-medical techniques of taking care of patients: This training will be given by four men of health/experienced consultants in orthopedics and traumatology. The duration of training is of a week per center It will take place in two parts: theoretical and practical. This activity will be carried out in connection with the health authorities of different cities of the targeted province. The capacity of the system/reference evacuation of various centers will be also strengthened. The economic means must be available for the evacuation of patients identified in order that the pilot unit of orthopedics and traumatology of Lubumbashi to a load of their treatment. Awareness of the people of the cities of the province of

Katanga of the project in relation to the case of the health of bones and joints: This activity will link in with radios and TVs stations of proximity in French and Swahili. There will be 80 broadcasts, either 10 emissions at least per city. The awareness message as well as, the outreach material for patients will be designed to link with the relay agents and the coordinator. Reliable and approved documents (patient awareness materials) by orthopedic surgeons will, therefore, help patients understand their situation while saving time. The consultations of patients; The supported patients: It is to the primary care physician that almost all patients would twiddle first in priority for information on their state of health. The general practitioners have more and more of patients concerned possibly by the problem of the bones and joints that they follow before, during and after their illness. Giving them the right information but also a better quality of life; such are the objectives

traces by this project. Even if the support for patients should be ensured by a specialized sector in orthopedics and traumatology, the treating physician of the patient should be involved more and more in the monitoring of the patients. He should ensure the continuity of care between the city and the hospital and the link with the orthopedist. The general practitioner should have the burden to accompany the patients. He/she should be in large part responsible for the "global support" of the patient who request, "A know-how" and "knowledge be ". He/she must improve the "quality of life of (its) patients", which, according to all the testimony, is very difficult to cross The monitoring of the impact of the training: A subsequent follow-up in the training is carried out as required in order to validate the maintenance of acquired, to identify potential new needs, to assess the satisfaction of persons trained and if not to revise some learning. F.

Expected results At the end of this project, the following results are expected:    Several young surgeons, clinicians, and biomedical staff have been trained (transfer of necessary skills); A small orthopedics and trauma emergencies service with a service of radiology in the event of falls, fractures, etc. is created; Creation of a unit of Orthopedics and Traumatology in Lubumbashi; Source: http://www.doksinet 7    The population of the province of Katanga has been sensitized with bones and joints’ problems health; Bones and joints’ problems health are identified and referred to the Committee of Orthopedics and Traumatology of Lubumbashi; Foreign partners have provided the support for medical treatment of patients. G. Monitoring and evaluation of the project Monitoring and evaluating activities of the project are essential to assess the progress made towards the objectives and the results. Daily monitoring: The project team will carry the monitoring out,

from the beginning of the activities until the end of the project. This team will be under the control of an executive office Tracking tools will be used and developed to measure the progress of the project’s activities. These tools will enable us to monitor the implementation of the project. They will also allow the executive office to prepare a quarterly report that will be sent to technical and financial partners. Mid-term evaluation: The Executive Board in connection with technical partners will make it. It will consist of performing an inspection to see more clearly the achievements of the project and its impact on the level and the living conditions of the beneficiaries. This evaluation-tracking tool will be used to highlight strengths, weaknesses or deficiencies observed. A mid-term evaluation report will be produced and submitted to the appreciation of various partners. Final evaluation: an independent consultant hired for this purpose will evaluate this. The purpose of this

evaluation is to judge objectively and so be informed of progress, achievements and the impact of the project on the living conditions of the beneficiaries. H. Our needs  A Unit of orthopedics and traumatology with a radiology service.  Orthopedics products: a. b. c. d. I. Orthotics ; Prostheses ; Orthotic insoles; Bandages ; e. Shoes; f. Wheelchairs and other facilities helping one to walk or assisting in walking. Intervention strategy We would like to reproduce the Genevan experience of gathering all the facets of specialty "orthopedic surgery" in the same unit; which would make also possible productive partnerships and therefore very strong synergies. A Certificate of Graduate Studies or Certificate of Special Studies could be delivered from the training, whose duration will depend on the prerequisite decided by common agreement with the partners. In order to better follow the action of the training and obtain the qualification to which it prepares, training

assistants with a prior clinical experience of more than 3 to 4 years in the areas of orthopedics and traumatology will not follow the course on the same length of time as those not having any. The delivery of this certificate may only be possible after completion of a dissertation focused on a number of clinical cases varied and followed for a period of compulsory time (ex.: Monitoring the patient on a minimum amount of time post-operative) and a presentation of a final examination. The subject of this dissertation must be different from the thesis or the Masters and/or Ph.Ds Source: http://www.doksinet 8 Victims of a severe trauma – such as some complicated fractures with open wounds - often suffer thoracicabdominal lesions and soft tissues; we propose therefore to develop a mini-ETC course as well (European Trauma course) that would cover the first aid for severe cases. This three days multidisciplinary course of advanced traumatology strategy would focus on a team approach and

non-technical involved skills in the elite of the trauma teams. This program will expose our training assistants to seven of the different spheres of Orthopedics namely orthopedic reconstruction, Pediatric orthopedics, musculoskeletal Oncology, surgery of the spine, upper limb surgery, surgery of the foot and ankle and trauma. Theoretical training program Theoretical training will be taught in different forms to be determined with the help of partners. We want it to be carried out based on conventional presentations coupled with bibliographical references and/or mimeographed documents and/or computer media (CD-ROM, Internet). We will primarily rely on the French version of the CD-Rom of PR. J - L LERAT (Lyon); this course is a free access copy. Practical training program The clinical work of our training assistants will consist of crisis consultations, consultations of the investigation, therapeutic consultations, and expertise and care interventions. Their practical training will be

based on clinical presentations to the supervisor, weekly summaries with the unit supervisor as well as the following supervisions:     supervision of clinical investigations by heads of the clinic (1 hour and a half per week on average the first year, 1 hour per week on average the second year); (Individual or group) supervision of the therapeutic work by executives of the service (up to 3½ hours per week). The second year, the training assistant can also benefit (individual) supervisory responsibilities; supervision of guard interventions by a referent surgeon; supervision of expertise by the unit head surgeon (as required). Research work Training assistants will be able to carry out a personal research work or integrate with the different lines of research available in particular, to prepare their postgraduate thesis, publications or presentations in congresses. They can enjoy at the end of the specific support of the staff of the research unit of the University, as

well as various service frameworks. Services offered • • • Documentation - information in orthopedics and traumatology a. Information measures; b. Monthly conferences-debates; c. Health campaigns Listening, counsel and guidance a. Accompaniment ; b. Internal and external resources Support and training a. Internet health information search Source: http://www.doksinet 9 J. Partners • • • • • • University of Lubumbashi (UNILU); Laval University (ULAVAL); Governorate; Ministry of health; Local businesses; IMEC; • The Canadian Orthopedic Association Global Surgery Committee (COAGS); • AO Alliance Foundation (AOAF)  University of the Witwatersrand (UW) K. Project resources We note that the Pediatric orthopedics was developed in France mainly for material, technical and pedagogical reasons. Human and material resources of this activity are therefore a very important guarantee of success. Orthopedics and Traumatology are very specific, highly technical

and require material and adequate equipment, and, more important than general surgery skills.  Human resources i. ii. iii.  2 doctors including a general surgeon (independent): Dr. Dédé NKULUBA TSHIBANGU et Dr Dieudonné Fassini KAFYEKE; 1 statistician computer scientist (Project Manager): lyshabo@hotmail.com; Faculty of Medicine: Pr. Dr Abdon MUKALAY, Pr Dr Julien ILUNGA and Pr Dr Claude MWAMBA Material resources i. Although the University of Lubumbashi does not have such a structure in its midst, it can provide the project with a furnished building. L. Scientific issues This project aims to correct deficiencies in surgery, in the Democratic Republic of Congo, in the domains of medical care as well as that of translational clinical research, also known as transfer , of health bones and joints’ cases. This deficiency results in a lack of leadership of the Congolese teams in these areas Scientific issues will, therefore, be based on: a. a more efficient organization of

research activities, promoting interactions between scientists and the emergence of new ideas; b. better control of records which will promote traceability and reproducibility of research’s results, and facilitate the delivery of training and knowledge; c. an improvement of the efficiency of the team in its research; d. provide reliable guarantees for partners in responding to the best international standards; e. saving time in scientific exploration by reproducing methods used  State of the art and bibliography We performed online searches of electronic databases i.e PUBMED, MEDLINE, and African Journals online that feature many African Journals not indexed by the ‘regular’ databases. The searches returned 55 articles and only a few of which were related to the DR. Congo and none was included in the review; search terms included orthopedics, musculoskeletal trauma, and surgery, Improved education in musculoskeletal conditions, training capacity and methods, technology, low

research capacity or the scope of practice, and outputs in Katanga, the DR. Congo So this state of the art has been prepared only from the reflection of the members of the project team as this issue has never been the subject of any study at the University of Lubumbashi. Source: http://www.doksinet 10 We also draw attention to the fact that this state of the art is perfectible; it opens the discussion and the space of possible projects. This state of the art simply wants to show that there is a great deal of invisibility - of ignorance - on what makes a difference or not for the different types of surgery in patients care. At the level of the Congolese society, this invisibility is because the relationship type of medical care specialist in charge of the health bones and joints’ case is not followed. This proposal was, therefore, unable to identify indicators required on exposure to risk and hardship; There is thus the lack of elements at the level of health for establishing

causal links due to poor care (or inappropriate) of health bones and joints’ cases. Invisibility is also reflected by the fact that certain surgery specialties have taken the place of other essential for adequate care: i.e health bones and joints ‘cases are supported by general surgery and at worst, general medicine. In general, donors, Congolese society, and its decision-makers are not aware of issues of the unsuitability of medical care; they are traditionally focused on priority health issues. Therefore, they do not measure how much improvement of adapted care conditions and their organization can contribute significantly to reducing deplorable situations (death, total or temporary disability, permanent disability and incapacities, shortfalls for Congolese companies and the Congolese state, etc.) Faculty of medicine organizes only 7 specializations including Pediatrics, internal medicine (Neurology, anesthesia and resuscitation), general surgery, gynecology obstetrics, basic

science (biomedical, laboratory, radiology,), public health (occupational medicine and environmental studies) and specialties (ophthalmology, dentistry, dermatology, ORL, physical medicine,).  Scientific question(s) No study in this area previously at the University of Lubumbashi. Acquisition and creation of a suitable expertise are conditions required for an effective recovery care and medical research. They are based in particular on the establishment of teams involving doctors and researchers and having the means to assess the relevance of innovative approaches that could eventually lead to clinical innovations. So we wonder, in the context of bones and joints’ health, how to effectively enhance the care and biomedical research? M. Existing strategies and other cooperation activities This project does not go along with any other activity both at the local and national levels or along with other activities of cooperation of the Academy for Research and Higher Education (ARES)

that are currently being implemented in relation to the issue. 2 well established regional groups and neighboring English-speaking countries foster postgraduate education in surgery and provide surgical training throughout the region of East and West, Central and Southern Africa. The College of Surgeons of East, Central and Southern Africa (COSECSA) is an independent body that delivers a common surgical training program with a common examination and qualification. COSECSA currently operates in 10 countries in the sub-Saharan region: Burundi, Ethiopia, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. The West African College Of Surgeons (WACS) is an independent body operating in the west African region. WACS accredited institutions for surgery are located in Nigeria. Source: http://www.doksinet 11 At the moment, the University of Pretoria is involved with training orthopedic surgeons in orthopedic trauma, in collaboration with the COSECSA. The trainees stay

with them for 6 to 12 months, depending on the requirements from their own countries. The good news is that the number of traumas and orthopedic (T&O) surgeons is rapidly increasing in Africa. However, while most T&O surgeons in English-speaking Africa (ESA) are now trained nationally or regionally, French-speaking Africa (FSA) is lagging behind, with surgeons only trained internationally, if at all. There is no reason why access to adequate T&O care education should remain difficult and rare for those who need it most. N. Complementarities and synergies There is no complementarity/synergy both at local and national levels. We will do our best to partner with established regional groups and neighboring English-speaking countries universities, at least in an advisory capacity or for internships. However, as said above, by reproducing the Genevan experience of gathering in one unit all facets of the orthopedic surgery specialty, this would make also possible productive

partnerships and thus very strong synergies. O. Governance of the project (organization chart) Its overall governance structure (strategic, intelligence, operational, administrative, etc.) should be part of that of the medical faculty of the University of Lubumbashi. This initiative will have to develop a strategy that fits into that of the University of Lubumbashi and helps increase the momentum of its research environment, training, and development, including the relationships and partnerships that it will forge internally as externally and develop the involvement in regional projects. Partners will help us with:    training of medical and paramedical staff through international internships in their hospitals; technical support or an expertise in these disciplines; collaboration particularly in the context of the training and the design of a Department of Orthopedics and traumatology. P. Cross-cutting priorities Gender is crucial for the balanced development of the health

sector and the Congolese Constitution guarantees the equitable participation of women and men in all sectors and at all levels of the country. From the commitments made by the Congolese people, in its Constitution, REFLEX INDICATIVE PLUG will be contextualized to local needs and will speak first to local partners and the topics covered and the various resources listed will exemplify for many actors that would mean apply a transversal approach to gender equality. Indeed, gender equality, empowerment and the strengthening of the capacities of women (empowerment) is one of the keys of vault of the reduction of poverty and inequality, sustainable and equitable growth, as well as the achievement of all development Millennium goals. Promoting equality between men and women is a way to have a lasting impact on the conditions of life of men, women and children. The intervention will, therefore, ensure to meet the specific needs of women and men trying to reduce existing inequalities between

women and men especially in the recruitment of training assistants, in the care of patients, in the awareness of populations to bring patients and the management of the project. Source: http://www.doksinet 12 Q. Durability  Institutional sustainability The Department of surgery within the Faculty of medicine at the University of Lubumbashi will be the focal point of the project and will be assisted by foreign partners in this initiative. The initiative will focus on the methods for which facilities can be developed locally. The creation of a unit of Orthopedics and Traumatology, lined manufacturing locally of orthopedic products and facilities of trauma, will allow therefore the continuation of the activities (research and/or training as well as taking in charge patients) at the end of the project.  Financial and economic sustainability The project will undoubtedly carry benefits on behalf of the Congolese society (challenge-based research) and will have a ripple effect on

operative management of patients, research, and higher education at the University of Lubumbashi while fully integrating into its overall strategy. Conditions of reproducing this initiative have therefore been built: a. the unit of orthopedics and traumatology of Lubumbashi has acquired the ability to produce locally orthopedic and traumatology products; b. to set prices (orthopedic and traumatology facilities, consultations, medical care, monitoring, and training); c. covering its expenses and treatment of its staff ensuring, in short, it can be managed with economic profitability, even a modest one.  Socio-cultural appropriation We will expand the communication at the level of the stakeholders, and no one will be excluded, on the procedure to be followed in the field of orthopedics and traumatology. In addition, following a logic of pedagogy to clarify and explain the objectives, aims, and challenges to their scope. Finally, we will strengthen the capacity of our surgeons,

medical and paramedical staff in orthopedics and traumatology and we will use them as possible as we should. R. Terms of reference       Train actors in relation to evolution of scientific knowledge; Strengthen the capacity of actors in this activity; Strengthen the capacity of actual and potential beneficiaries; Create a unit of Orthopedics and Traumatology; Ensure the monitoring and evaluation; Develop the final report. Source: http://www.doksinet 13 S. Annexes Context Country overview The Democratic Republic of the Congo (DRC) is a country with vast resources. Its surface area of 23 million square kilometers spans the equivalent of two-thirds of the European Union. Fewer than 40% of the nearly 70 million inhabitants live in urban areas, according to the latest NSI (National Statistics Institute) estimates. With 80 million hectares of arable land and over 1,100 minerals and precious metals, the DRC has the potential to be one of the richest countries on the

African continent and a driver of African growth. Political context Since 2001, the country has been recovering from a series of conflicts that broke out in the 1990s and the effects of a protracted economic and social slump. In 1999, after the Lusaka Peace accords were signed, a transitional government was established pending the presidential elections in 2006 that were held peacefully. New institutions such as the Parliament, the Senate, and provincial assemblies, are now operational. Joseph Kabila and his party won the presidential and legislative elections held in November 2011, however, these elections raised concerns about the transparency of the electoral process. The next presidential elections are slated for 2016. The DRC remains a fragile country with tremendous needs in terms of reconstruction, economic growth, and governance. The security situation is improving but remains tense, particularly in the eastern provinces Peacebuilding and economic recovery efforts are being

carried out in a challenging social context. Economic overview After an economic slump in 2009 that brought the growth rate down to 2.8% due to the global financial crisis, the DRC posted an annual average economic growth rate of 7.4% during the 2010-2013 period, and of 87% in 2014, both of which are well above the average in Sub-Saharan Africa. This performance is driven by the robust extractive industries and by favorable trends in commodity prices. Public investments have also helped spur growth. Inflation, which posted a staggering 53% in 2009, has stood at 1% since 2013 as a result of the implementation of prudent fiscal and monetary policies. Social context Despite an impressive economic growth rate and a reduction in the poverty rate from 71% in 2005 to 63% in 2012, the poverty rate remains high in the DRC. The country ranks second to last on the Human Development Index (186 out of 187 countries), and its per capita income, which stood at $220 in 2012, is among the lowest in the

world. The United Nations estimates that there are some 23 million displaced persons and refugees in the country and 323,000 DRC nationals living in refugee camps outside the country. A humanitarian emergency persists in the more unstable parts of the DRC and sexual violence rates remain high. Source: http://www.doksinet 14 Organization chart Department of surgery General Surgery Deputy Coordinator Research teams:  Trauma ;  Orthopedics. Orthopedic surgery and Traumatology Coordinator Support functions:  Function of international relations and partnerships ;  Computer and information systems function;  Function of Statistics, documentation and research archives. Digestive surgery Secretary Budget functions, internal communication and support to piloting Source: http://www.doksinet 15 Reflex indicative plug Who has access? Women Training Care Heath Research Leadership Total: Practical needs genus: Strategic needs genus: Opportunities to address gender:

Who has a part to the project? Men Women Men Source: http://www.doksinet 16 Analysis and management risks Risks Lack of time to finalize the project Action plan Job planning Responsible for monitoring Project team Lack of relevant information on the subject Meetings with stakeholders Project team Unavailability of stakeholders Rendezvous programming with stakeholders Project team Lack of necessary equipment for the project Project’s list of important materials and equipment Project team Poor understanding of the problem Evolution reviews between training assistants Project team Exodus of Congolese doctors Assessment of the commonly advanced reasons to Project team identify possible solutions to doctors’ exodus Non-achievement of goals set Project review with its Coordinator The Executive Board in connection with technical partners Source: http://www.doksinet 17 Indicative operational plan of the project Intermediate outcome - Activities Training of young

surgeons, clinicians, and biomedical staff Identification of relay agents Relay agents’ training Populations’ awareness Consultation of patients Medical care of patients Monitoring of the training impact Formatting and production of the final report of the project Year 1 J F M A J A S J F M A J A S J F M A J A S J F M A J A S J F M A J A S J F M A J A S J F M A J A S J F M A J A S Year 2 J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S NB. The table above provides a full chronogram while the following gives a more detailed action plan M J M J M J M J M J M J M J M J Year 3 M J J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S J

F M A O N D J A S M J M J M J M J M J M J M J Year 4 M J J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S J F M A O N D J A S M J M J M J M J M J M J M J M J O N D M J O N D M J O N D M J O N D M J O N D M J O N D M J O N D M J O N D Source: http://www.doksinet 18 Action plan of the project activities OBJECTIVES ACTIVITIES Capacity building of surgeons in Lubumbashi while improving the quality of health care of the bones and joints. Training in orthopedics and traumatology Train the staff of relay. Identification Monitoring of the training impact Training Specifically collect data on the frequency, predisposing factors, geographical distribution and the evolution in time of the different types of bones and joints’ health. Populations’ awareness Take charge of the patients (administer specialized care:

medical, surgical treatment) Medical care of patients Facilitate financial access to care for all patients; this will reduce transfers abroad where medical care is very expensive. Consultations at low cost Reduce the rate of cases due to the bones and joints’ health. Final report of the project TARGET At least two dozen young surgeons, clinicians, and biomedical staff OFFICIALS Foreign specialists CHRONOGRAM* T1 T2 T3 X X X Coordination of the project Relay Agents and sociomedical staff Coordination of the project Populations of Katanga Coordination of the project At least two dozen young surgeons, clinicians, and biomedical staff Foreign specialists Populations of Katanga Coordination of the project Medical care at low cost Partners’ satisfaction vis-à-vis cooperation; X X Populations access time to services; X X X X Populations percentage reached by the actions. X Participations rate of stakeholders and the population in activities related to

the project. X Rates of use by the population of Services and actions. Training assistants Coordination of the project * Indicators, interim evaluation, selected meet the SMART criteria (specific, measurable, acceptable, realistic and temporally defined). * The first year timetable. The capacity of the partnership to help achieve the project objectives. Availability of new services and activities offered X X X Populations of Katanga T4 X Training assistants Consultations of patients INDICATORS* X X X Stakeholder satisfaction vis-à-vis the project. Source: http://www.doksinet 19 Estimated budget YEAR 1 (€) A. Investment costs (max 25% of the total budget) A.1 Buildings (often rehabilitation) A.2Equipement A.3Vehicles A.4 Office furniture A.5 Other (B). Operational costs B.1 Preparation fee (max €2500 at the beginning of the project) B.2 Equipment maintenance B.3 Consumer goods B.4Communication B.5 Representation costs (maximum €500(/ year) B.6 Travel expenses

in the partner countries and local B.7 Congress registrations B.8 Local per diem (€20 /d) B.9 International travel costs B.10 International living expenses B.11 Shipping costs B.12 Other C. Staff costs (max 25% of the total budget) C.1Service contracts C.2 Topping-up (max 40% of salary) C.3 Employment contracts D. Fellowships/ scholarships D.1 Allocations of short-term scholarships in the partner country D.2 Scholarships in the partner country (ie Masters) D.3 Doctoral Scholarships in the partner country D.4 Local Study Scholarships (ie Masters) D.5 Local doctoral Scholarships BE-TOTAL A - D (€) E. Coordination costs E.1 In the partner countries (5% of the budget package A to D) E.2 DR Congo (5% of the budget package A to D) TOTAL (€) YEAR 2 (€) 369842,69 369842,69 YEAR 3 (€) YEAR 4 (€) TOTAL (€) - - - - 2500 - - - 369842,69 369842,69 327070.39 2500 12500 1250 500 12500 1250 500 12500 1250 500 12500 1250 500 50000 5000 2000 92460,67 23115,16 92460,67

23115,16 92460,67 23115,16 92460,67 23115,16 369842,68 92460,64 69345,51 103153,86 25788,47 4671Z24 30946,15 69345,51 103153,86 25788,47 4671Z24 30946,15 69345,51 103153,86 25788,47 4671Z24 30946,15 69345,51 103153,86 25788,47 4671Z24 30946,15 277382,04 412615,44 103153,88 185676,96 123784,6 36984,28 18492,14 18492,14 36984,28 18492,14 18492,14 36984,28 18492,14 18492,14 36984,28 18492,14 18492,14 1479371,2 147937,12 73968,56 73968,56 1627308,32 Source: http://www.doksinet 20 The problem tree Secondary effect 1: Difficult, if not impossible, reintegration into society due to the loss of performance or disability. Result 1: Non-specialized surgeons in orthopedics and traumatology for patients’ medical care. Result 2: Medical care under inappropriate conditions with inadequate materials/equipment. Consequence 3: High medical care costs abroad. CENTRAL PROBLEM: Poor management of cases of bones and joints health in Katanga. Direct cause 2: Lack, in Katanga, of

childcare for the patients of problems of healthy bones and joints. Direct cause 3: Health’s proble;s evaded by the traditionally priority health situations. Effect of the direct cause 3: Populations not aware of the problem of bones and joints in Katanga Effect of the direct cause 1: Relay agents uninitiated to orthopedics and traumatology. Effect of the direct cause 1: No specialization in orthopedics and traumatology at local universities. Direct cause 1: Surgeons are not trained in orthopedics and traumatology in Katanga. Effect of the direct cause 3: The province lacks sufficient financial means. SPECIFIC OBJECTIVE A C T I V I T I E S Side effect 3: This is a considerable loss of profits for the Congolese State. Side effect 3: Accidents at work are increasingly affect the budgets of local businesses. Effect of the direct cause 2: Difficult, if not impossible, physical rehabilitation. R E S U L T S Secondary effect 1: More cases of disability, total or temporary

disability and permanent incapacity. Effect of the direct cause 2: Orthopedic products not found on the local market (no Orthotics or prosthetics members). E X P E C T E D Source: http://www.doksinet 21 The logical framework   By 2019, at least, two dozen young surgeons, clinicians and biomedical staff are trained in Lubumbashi;  By 2019, the creation of a unit of Orthopedics and Traumatology in Lubumbashi. Capacity building of surgeons in Lubumbashi while improving the quality of health care of the bones and joints;  By 2019, patients are treated at the unit of Orthopedics and Traumatology Lubumbashi; Collect accurate data on the frequency, the predisposing factors, the geographical distribution and the evolution in time of the different types of the health of bones and joints.  By 2019, availability of health data from bones and joints in Lubumbashi;  By 2019, the creation of a unit of Orthopedics and Traumatology in Lubumbashi.  Theoretical

training program;  Practical training program; By 2019, creation of a training Centre in Orthopedics and Traumatology to Lubumbashi.  Research work;  Services offered.   Advancing the health of bones and joints in the Democratic Republic of Congo, city of Lubumbashi. Summary of objectives/activities 1.1 training in orthopedics and Traumatology OVI ( Objectively Verifiable Indicators) Key resources (physical according to budget lines: and non-physical) Faculties of Medicine of the universities below: UNILU, ULAVAL Faculty of Medicine of:   UNILU ULAVAL Faculties of Medicine of the universities below: UNILU, ULAVAL Means/sources of verification Costs main: A. Investment costs (€) 1.2 identification of relay agents A. Investment costs (€) B. Operational costs (€) 2.2 consultations of patients 2.3 Medical care of patients Trained specialists continue to work in Lubumbashi;  Populations’ awareness to bring patients is ensured.

Training plans’ implementation. Assumptions Orthopedic products for the treatment of the cases of health bones and joints are available in sufficient quantity. B. Operational costs (€) 1.3 training relay agents 2.1 Populations awareness  C. Staff costs (€) C. Staff costs (€) D. Fellowships/ scholarships (€) D. Fellowships/ scholarships (€) TOTAL: (€) 2.4 follow-up of training impact Such training requires a certain level of excellence in terms of theoretical and clinical training. The Congolese environment does not meet these requirements or is not able to meet them soon. Source: http://www.doksinet 22 Formats desired for training This project proposal is not definitive but rather evolutionary taking into account all possible parameters. Qualification in pediatric surgery is obtained in France by validation of a DESC (complementary diploma of specialized studies) in infant surgery. This validation is a follow-up to the DES (diploma of specialized studies) in

general surgery In France and Belgium, the certificate of advanced studies is issued to doctors who performed a training of 3rd cycle, 3 to 4 years depending on the specialties, after completion of a dissertation. This training takes 5 weeks of teaching in orthopedics and traumatology for those already with practical experience of 3 to 4 years (it takes 3 or 4 years for those not having any). Our wish is that training takes place at home but for some specialized training requiring a high-performance equipment, those who are already advanced have the opportunity to participate in international internships. This training will also rely on services of foreign volunteers’ orthopedists for medical care and, by ricochet, transfer of practical skills. As a first step, we need four of our teachers (general surgeons and other fulfilling the conditions of five weeks of training) and four of their assistants to be trained abroad and they will support training of other locally (10). We will,

therefore, rely on them, at first, for the continuity of training while some are preparing their specialties and /or doctoral theses. The others, who will undoubtedly need 3 or 4 years to complete their training, will follow it locally - if possible! We will also need two people trained in Health Information Technologies to compensate for the deficiencies raised by us in the State of the art and bibliography; they can, therefore, help our researchers through their interventions in health informatics, health analysis, medical information and electronic medical record. Two persons may also benefit from training in medical imaging (Interventional Musculoskeletal Spine - Members and belts Radiology), two in the orthopedic laboratory and four for the manufacturing of orthopedic and traumatology facilities (Orthotics and Prosthetics). For pediatric orthopedic surgery, we will need two training assistants (preferably pediatricians). For them it will be necessary that they have previously

completed further training – non-organized home - whose pedagogical purpose of education will ensure quality training in pediatric surgery, thus placing them at a level comparable to that of other training assistants. Following a specialist training in orthopedic surgery, two certified individuals will add a period of over-specialization in musculoskeletal oncology to complete their training. This Certificate will be awarded, depending on the case, after five weeks of training, either after 3 or 4 years of training and after fulfilling the following conditions:    theoretical course (200 hours), practical courses (6-8 semesters of boarding school) sanctioned by a faculty review; Monitoring of 380 hours of internship (with 180h mandatory) specializing in Orthopedic Clinics preferably locally (with the support of foreign volunteers orthopedic) or in Europe and North America; Completion of a dissertation focused on a number of varied and monitored clinical cases during imposed

postoperative period and submission of a final exam. Our partners could offer training courses in various fields of orthopedics or trauma, joint reconstruction, pediatric orthopedics, spinal surgery. As for now, most of their internships last 12 weeks The involvement of interns in clinical care would depend on each candidate’s skills. It would be possible to organize rotations over shorter periods, but their Source: http://www.doksinet 23 experience shows that too short internships fail to assimilate all the essentials. To maximize the exposure of each candidate, it would be better to have a maximum of two interns per internship (rotation). For example, the 8 candidates could be divided into four teams based on four rotations of 8 weeks in the four fields of the specialty of orthopedics. Educational objectives: Provide extensive training in orthopedic surgery and traumatology. At the end of the training, the surgeon should be able to:     know the various ailments,

their approach, and their treatment; diagnose and treat correctly osteoarticular diseases; explain to the patient the different diagnostic and therapeutic elements eventually, refer complex cases to treat to whomever they should refer to. Source: http://www.doksinet 24 Curriculum at the Faculty of Medicine (UNILU) So far, training is organized according to the three cycles described in the table below. Cycle 1ER 2e 3e Grade Graduated (3 years): General courses and study of normal human (Anatomy and Physiology) Doctor of General Medicine (4 years): Study of the sick man (study of the pathology and surgical techniques) * DES/DEA/ (2 years academic) * Specialization (3 to 4 years) Deepening on skills and the practice of surgery and surgical pathologies * PhD thesis (PhD) * Aggregation (PhD) Option Biomedical Sciences Training of general practitioners: medical doctor * Specialization in 7 departments * Occupational medicine and environmental studies (beginning in 2014-2015). In 7

departments *DEA: Diploma of advanced studies Since the reform of the so-called work of Congolese universities Round Table (TRUC), graduate in medicine (medical doctor) is four years. Postgraduate program includes the diploma of advanced studies and Masters for two years. It includes courses and seminars (including a module for university teaching leading to Ph.D), as well as the submission of a dissertation Success in this program entitles the candidate to present a doctoral thesis. The specialist diploma (3 to 4 years program) is required to undertake research with a view to the presentation of a thesis of a doctorate or an aggregation of higher education in medicine. NB. Current capacities of musculoskeletal injuries (implants, imaging, etc) treatment available at UNILU are nonexistent and in imaging, we (within the entire Katanga province) rely on only one trained radiologist from a private company. The University of Lubumbashi is a contact institution managed by a Rector, the

professor Gilbert Kishiba Fitula (gkishiba@gmail.com & secretariatrectorat@uniluaccd) The Secretary General Academic is professor Boniface Kizobo Obweng (kizobo.obweng@uniluaccd) The dean of the medical school at the University of Lubumbashi is professor Dr. Abdon MUKALAY (muk ab@yahoofr & mukalay.mukalay@uniluaccd), the deputy dean in charge of Education is professor Dr Willy Arung (willyarung@hotmail.com) and professor Dr Claude Mwamba is the deputy dean in charge of university clinics (clomwamba@yahoo.fr & mulumbamwamba@uniluaccd) The surgical department head is professor Dr Francois Tshilombo KATOMBE. Professor Dr Julien is the pathologist doctor of the University of Lubumbashi (nijulien2011@yahoo.com & ilunganikulu@uniluaccd) Source: http://www.doksinet 25 The identified partners and their potential contributions PARTNERS/ANALYSIS ELEMENTS 1. HEALTH SERVICE  Hospitals and clinics Health personnel  Doctors and other 2. DONORS  USAID  DFATD 

EDF  ARES  VLIR The university of Laval (Prof. Dr Jean Lamontagne: jlamontagne67@yahoo.ca & jean.lamontagne@fmedulavalca) 3. 4. MEDIAS  Radio, TV and printing press 5. COMMUNITIES Orthopedic groups/NGOs that have worked in DR. Congo:  Johns Hopkins Group 6. LEADERS Decision makers    Traditional leaders Political and Administrative Authorities Social Leaders 7.    8. ORTHO INDUSTRY Shakti Orthopedic Sales (P) Ltd: info@shaktiortho.com RODIN4D: mariondivier@rodin4d.com IMEC: Dr. Sue Crawford - scrawford@imecamericaorg ADVISORY CAPACITY Regional infrastructure     Consultations Medical care   Resource mobilization Advocacy   Technical support (training and internship) Advice and monitoring  Extension messages on health cases of bone and joint CONTRIBUTIONS          Activities implementation Proximity of the population Resource mobilization Communities’ mobilization Advocacy

Volunteer work Engagement Research          Social mobilization Resource mobilization Social Supervision Informed Strategic Choice Good governance Justice administration Human rights promotion Implants, instruments and medical equipment supply   The University of the Witwatersrand (Prof MT Ramokgopa: mmampapatla.ramokgopa@witsacza /drmtr@mwebcoza) International infrastructure  CONTRIBUTIONS  The Canadian Orthopedic Association Global Surgery Committee (COAGS): Dr. Paul Moroz, PMoroz@cheoonca AO Alliance Foundation (AOAF): Dr. Claude Martin Jr, cmartin@ao-alliance.org  WORKING WORLD      Advice on our efforts Advocacy Volunteer work Contacts in various Governmental and non-Governmental organizations Source: http://www.doksinet 26 Medical equipment indicatively Full physio Cabinet      Table of fixed height: €574,56 Stool on castors height 39.5/48 cm: €2736, including VAT Stainless steel step 2

steps: €181,44, including VAT Surgeon leather stool: €154,44 Manual blood pressure monitor adult Holtex for GP: €51.28, including VAT Subtotal: 1235.32 €, including VAT Accessory surgery for ultrasonic dissector and handpiece             Sonoca 300: €578,39-foot pedal 3 m supply cable: €8,80, including VAT Cable jack ground 5 m: €239.98, including VAT Support for irrigation Pocket rod: €239.98 Hose for vacuum pump and jar greenhouses: €61.46, including VAT Suction jar 2000 Ml: €6.02, including VAT Collection 2000 Ml disposable Pocket: €10.14, including VAT Cable for straight handpiece: €522,72 Angled handpiece cable: €504,52 Box of sterilization without irrigation: €843,48 Box of sterilization with installation of irrigation: €1746,36 Spare hook blade: €157,52 Subtotal: Surgical Instrumentation: orthopedics and Traumatology                  Cutter Key-Horsley

angular Holtex (26 cm cutter): €314,75 Box surgery bone Holtex: €2165,52 Box big orthopedics Holtex: €2896,76 Box small orthopedic Holtex: €2339,70 Box to ask the Holtex pins: €1441,40 Box for Femur Holtex: €2132,61 Box for the Holtex elbow: €1905,15 Box for the Humerus Holtex: €1905,15 Box for the Holtex knee arthrotomy: €1938,36 Box for sciatica Holtex: €2197,42 Box Neurosurgery (Laminectomy) Holtex: €2899,26 Box herniation Holtex: €2211,47 Box Cloward Cervical Holtex: €484,52 Box pituitary Holtex: € 895,28 INCL. VAT Box Trepanation Holtex: €2032,98 Box surgery of the skull Holtex: €2447,36 Box for the Holtex ball: €2980,13 4919.37 €, including VAT Source: http://www.doksinet 27              Box for the Holtex ankle: €851,74 Box Scaphoid (hand and foot) Holtex: €626,69 Box trauma Holtex: €1847,36 Box for the Holtex leg surgery: €1905,15 Box for spine Holtex: €2888,13 Box for plaster Holtex:

€389,10 Box for meniscus Holtex: €1079,90 Box for the Holtex hip surgery: €1727,66 Box surgery shoulder - Bankart Holtex: €1302,94 Box for Ablation of the Holtex pins: €745,18 Box for small surgery Holtex: €44.25 Electric plaster Holtex saw: €821,94 Blade electric cast saw. Holtex: €5759, including VAT Subtotal: 47475.45 €, including VAT Diagnostic equipment and accessories      Ultra-slim LED x-ray Viewer: €1264,8 Bone densitometer Medical ECONet Sonost 3000: €8710.91 Brightness amplifier - RollBar surgical CARMEX ITA-CARMEX: 71 €880.00, including VAT System scan to plates at phosphorus: 61627,19 €, including VAT Radiological film developer COMPACT 2: 9 €000.00, including VAT Subtotal: 152482.9 €, including VAT Medical furniture            Medical front lighting MedLed Sapphire: €2345,71 Lighting ceiling light lamp, surgical Marled E3: 2 €791,8 Review lighting wall/mobile operating block, Marled

E3: 3 €994.51, including VAT Mobile review for medical office lamp: 2 €478,96 Large transfer Chair Swifi Promotal: €1585,44 Chair of sample rotation + variable height Deneo, circular base: €3117,6 Examination couch electric height variable, Trendelenburg positions, electric record Quest: €3320,64 Pedestal tables care 2 trays: €420,55 Surgeon leather stool: €154,44 Tractor - orthopedic trolley for table Operation: €2388,00 Universal operating table MAQUET model VELOX 1114-00: €2,040.00, including VAT Subtotal: 24637, 65 €, including VAT For the manufacture of Orthopedic Implants a) Milling i. Spawningrouter H 700 mm x P 500 mm: 90 €000.00 ii. Support and technical updates - price per year: €2640, including VAT iii. Installation of the milling machine - 1 technician for 2 days - training on the milling machine: €6996, including VAT Source: http://www.doksinet 28 iv. Proposed mixed blocks - 20 PCs AFO / wrist: €460 (free) b) Rectification i. The full

version of the rectification software Rodin4D CAD/CAM - support and updates included - price per year: €8460,00, including VAT c) Scanning i. Scanner M4D - Laptop is not included: 19 €188,00, including VAT ii. Full version for M4D - included foot support, comprehensive reports.: 8 €268,00, including VAT d) Training and shipping i. The neo - 1 person software training 2 days - transportation and accommodation included: 3 €540.00, including VAT Subtotal: 139,092 €, including VAT Total: 369,842.69 €, including VAT