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Hospital Healthcare Europe

EFORT: collaboration across Europe in orthopaedic research

Philip MacDonald
1 January, 2008  

Philip MacDonald
Supervising Editor
Hospital Healthcare Europe

In a part of the world, Western Europe, where an ageing population is bringing with it an increase in attendant musculoskeletal disorders (MSDs), such as the many forms of arthritis, orthopaedic surgery is coming increasingly to the fore.

Orthopaedics, and its related discipline traumatology, have come a long way from the treatment of children’s skeletal deformities, pioneered by Jean-André Venel in the 18th century. In parallel with advances in anaesthesia, the world wars of the last century in particular acted as a catalyst for technological developments in orthopaedics, such as splinting, traction and the use of intramedullary rods to treat femur and tibia fractures.

The postwar years saw a new wave of progress, such as Dr Masaki Watanabe’s work in the field of arthroscopy and minimally invasive procedures, as well as the revolution in joint replacement surgery.

Although – thankfully – there is not the same widespread military conflict in Europe to give impetus to further research in the treatment of trauma and injuries, it nevertheless is an exciting time for the specialism. The increasing professionalism and competitiveness of sports, for example, are presenting new avenues of research into sports-related musculoskeletal conditions.

Current trends
Nowadays the trend in surgical orthopaedic procedures is towards minimally invasive surgery, with arthroscopy of different joints, endoscopy of the spine and the field of joint replacements increasing, according to Wolfhart Puhl, professor and chairman, Department of Special Orthopaedic Surgery, at the Klinik Oberstdorf, Germany. “All these techniques have had a fast evolution, and this is to the benefit of both patients and the public. Further research and development will increase with close cooperation between industry and orthopaedic surgeons, especially those who are related to research areas of universities.” Joint-preserving procedures are becoming rarer, he adds.

Nonsurgical treatment, too, is extremely important and common, including treatment of pain syndromes such as back pain, says Prof Puhl. Paediatric orthopaedics necessitates a high degree of training, due to the difficulties of diagnosis and treatment, and infection prophylaxis and infection management, linked so frequently to joint replacement, are also becoming more and more important.

Changing social trends, too, are increasing the prominence of orthopaedics. It was the socioeconomic impact of MSDs, through the frequent disability and loss of employee productivity they cause, that prompted the World Health Organization (WHO) to declare the years 2000 and 2010 to be the “The Bone and Joint Decade” (BJD). The BJD was formally launched in January 2000 by the WHO’s then director-general, Gro Harlem Brundtland, with a workshop on the global burden of musculoskeletal diseases. In a WHO bulletin of November 2003, the organisation drew further attention to the BJD. In the editorial, Lars Lidgren, professor of orthopaedics, University Hospital Lund, Sweden, declared MSDs to be “the most common cause of severe long-term pain and physical disability affecting hundreds of millions of people around the world”. With joint diseases accounting for more than half of all chronic conditions in people above the age of 60, and back pain being the second-leading cause of sick leave, MSDs, Lidgren argued, were not receiving the attention they required from the medical profession and authorities alike.(1)

Since the inauguration of the BJD, fresh impetus has been given to the field of orthopaedic research, with many papers being written in response to the WHO’s call for action.

A report in September 2007 by the UK think tank the Work Foundation, found that MSDs had a serious negative impact on UK labour productivity. The study claimed that MSDs, a term that includes conditions ranging from arthritis and back pain to tendon, muscle and joint damage, affected twice as many people as “stress”, accounted for up to a third of GP consultations, caused 9.5 million lost working days and cost the UK £7.4bn a year. Furthermore, the authors of the report claimed that early intervention and emphasis on keeping MSD sufferers in work would reduce the figure of 2.6 million people claiming incapacity benefit in the UK.(2)

Growing international collaboration
The opportunities and demand created by orthopaedic surgery and traumatology are fostering a spirit of cooperation among specialist physicians across Europe. The work of the European League Against Rheumatism (EULAR), for example, has since the 1940s contributed to international collaboration in the discipline.

One comparatively recent organisation seeks specifically to tackle the issue of collaboration between national orthopaedic and traumatological institutions. The European Federation of National Associations of Orthopaedics and Traumatology (EFORT), was founded in Marentine, Italy, in 1991, as a nonprofit organisation under Article 60 ff of the Swiss Civil Code.

“Similar to political Europe, it was necessary to build up European structures in the different fields of medicine,” says Prof Puhl, who is also President of EFORT. “A small group with a vision came together in 1991, brought together all the others, created statutes, and finally the European Federation of Orthopaedics and Traumatology was founded and the first congress organised in 1993, together with the Société Française de Chirurgie Orthopédique et Traumatologique (SOFCOT) in Paris, and a second in 1995 with the unlimited help of the German Orthopaedic Scientific Society (DGOT) in Munich.”

Past and future congresses
EFORT’s memorable seventh congress, held in Portugal in 2005, saw a debate on scientific developments. New techniques in the formation of cartilage from stem cells and the specifics and development of subspecialisations within orthopaedics and traumatology came under discussion. Six thousand orthopaedists attended the event, organised by the Sociedade Portuguesa de Ortopedia e Traumatologia (SPOT), sharing their knowledge and experiences, including in prosthetic reconstructive surgery, arthroscopy and the treatment of cartilage damage.

Next year, the ninth EFORT Congress is planned to take place from 29 May to 1 June 2008, at the Acropolis Palais des Congrès, in Nice, France. A range of topics will be discussed, across all the major fields. Tackling solutions to current hip problems, the conference will address dysplasia and impingement of the hip, arthroscopy, complications and bearing surfaces. Patello-femoral disease and prosthetic revision tactics will be among the themes addressed in knee orthopaedic surgery. In the shoulder subspecialism, rotator cuff tears will be discussed, and flat foot and total ankle arthroplasty will be among the highlights of the conference’s look at foot and ankle orthopaedics. Trauma, paediatrics, sports, hand and wrist, bone and joint tumours, and general topics will also be covered.

Aims and programmes
EFORT, which now represents 35,000 orthopaedists in 34 countries, aims to promote the exchange of knowledge and experience in the field of prevention and both conservative and surgical treatment of musculoskeletal injuries. The association organises conferences and courses in Europe in association with universities and other institutions, as well as supporting research. Governed by a legislative body known as the General Assembly, comprised of delegates from the national associations, the organisation aspires to be regarded as a good example of scientific globalisation in the service of the common good, and is pursuing projects in the implementation of uniform European examination standards and a common implant register.

“EFORT works on behalf of the European orthopaedic and traumatology community, to secure mobility, musculoskeletal health and quality of life,” says Prof Puhl.

Describing the organisation’s key programmes, Prof Puhl says that EFORT planned to optimise communication and cooperation between it and its member societies, as well as specialist European societies.

“Two mechanisms have to realised also in this sense,” he says. “It is the EFORT textbook and the EFORT journal, both scientific and educational activities, which will help to educate and harmonise, but also to build up a more intensive network between orthopaedic surgeons in Europe.

“The third big activity,” Prof Puhl continues, “will be European lobbying. The public has to realise how important musculoskeletal conditions and musculoskeletal trauma are as a burden to the patients, but also a financial burden to the public.”

The mission of EFORT is not without difficulties. The specialism of orthopaedic surgery must continue to attract talented physicians dedicated to spending many years of training in their profession. Also, international collaboration in research is hindered, says Prof Puhl, by “political and language borderlines”, which reflect a Europe that is not harmonised to the desired degree.

On the positive side, there are many favourable circumstances to cooperation. “Without the cooperation of member societies and specialty societies, the European Federation is not thinkable,” says Prof Puhl. “In addition, we have to have in mind that musculoskeletal conditions are also diagnosed and treated by other groups. Close cooperation with the intention to encourage patient care has been started and will be continued. In the same sense, but under a slightly different view, cooperation with overseas societies has to be addressed.”

Prof Puhl does not have plans to extend EFORT’s membership beyond Europe. “The answer is a clear ‘no’. The membership is limited to European scientific orthopaedic societies. Others could have an observer status to facilitate fruitful discussions and create worldwide cooperation.”

Turning to the years ahead, research in orthopaedics is offering exciting possibilities, says Prof Puhl, being focused on new materials in implants, minimally invasive techniques, tissue engineering and the use of stem cells in different MSDs. “The main focus will always be to increase or bring back mobility to the patient. In this sense, prevention will have a very important role in the future.”


  1. Lidgren L. The Bone and Joint Decade 2000–2010. Bull WHO 2003;81(9):629
  2. Bevan S, Passmore E, Mahdon M; The Work Foundation. Fit for work: musculoskeletal disorders and labour market participation. 2007. Available from:…