TheMarkPatersonBJJ/EFORTTravellingFellowsMay/June2017Fellows: FarhaanAltaf,London,UK

DerekCawley,RepublicofIrelandSammyHanna,London,UK.

TheMarkPatersonTravellingFellowship2017(supportedbyBJJandEFORT)tookplacethisyearfrom15to30May2017inPortugal,SpainandItalyculminatingintheparticipationintheEFORT18thAnnualCongressinVienna,Austria.Thechosensub-specialitieswerespine(DerekandFarhaan)andlowerlimbarthroplasty(Sammy).LisbonThefellowshipstartedattheHospitalCUFDescobertas–JosédeMelloSaudewherewewerehostedbyProfessorJorgeMineiroandhisteam.Thisnewuniversity-affiliatedprivateclinicisoneofthelargestinLisbon.Wewereimpressedbytheapplicationofahealthyteam-basedapproach,thegenerosityoftimeaffordedtousasfellowsandthepleasanteveningthatwedinedtogether.WetookinsomeofthesightsofLisbonbyclimbingtotheMiradourodaSenhoradoMonte,walkingalongthestreetsofBaixaandjoggingalongthenewquaysattheTejoestuary.Wealsodinedataproperfishrestaurant-whereonepaidbytheweightofthefish,notbytherecipe!

Figure1:ThePonteVascodaGamaafterdawn-greattoescapeworkforawhile!

Figure2:TheteamatHospitalCUFDescobertaswiththePaterson/BJJTravellingFellows.Wejoinedthespineteamintheatreonthefirstdayofthefellowship.ThemostinterestingcasewasthatofapatientwithneurogenicclaudicationandMRIfindingsconsistentwithanheterogenousextradurallesion,mostlikelyatumour.Ourexperiencewasenrichedbytheextensivediscussionsregardingpaediatric,deformityandrevisioncases.Theroutineapplicationofsagittalbalanceprinciplestodiagnosisandrehabilitationinlowbackpainpatientswasinteresting.Thespineteammadeapresentationregardingtheongoingprojectsincludinganteriorspinalfusionresearchandlocalschoolscreeningprogrammesforscoliosis.Thelowerlimbsurgeryteamdisplayedinnovativetechniquesininjectiontherapywiththeuseofplatelet-richplasmaandhyaluronicacidblends.InaccordancewithrecentresearchdemonstratingthebeneficialconjugationofHAviscosupplementationwithPRPregenerativeproperties,theseinjectionsweretrialledattheclinicforpatientswithearlyosteoarthritis.Weawaitthelong-termoutcomes!Theteamalsogavethefellowsanopportunitytopresentsomeofourpreviousresearchprojects.BarcelonaThesecondstoponthetourwasatHospitalUniversitariQuironDexeuswherewewerehostedbyProf.EnricPalouCaceresandhisteam.Casesfordiscussionincludedmanagementofosteoporoticodontoidpegfracturesanddegenerativelumbardeformity–bothofincreasingrelevanceinourhealthsystems.Prof.ManuelRibaswasparticularlyimpressivewithhisdemonstrationoftheSuperPathapproachtothehipwhilstperformingatotalhipreplacementandahipresurfacingarthroplastythroughaposteriorapproach.SpinalresearchwasdiscussedatVald’HebronuniversityhospitalwithProfFerranPelise,includingboththatoftheEuropeanSpinalStudyGroupwhichisbasedatVald’Hebronandlocalprojectsincludingtechniquesinenhancingallograftsandcosmeticassessmentofscoliosis.WeweretreatedtoattendaFCBarcelonafootballgameatthefamousCampNou.TheweekendaffordedustheopportunitytovisitBarcelona’smanytouristsites.

Figure3:Irrigationofthefemoralheadpriortocementationduringatotalhipresurfacingarthroplasty(ProfRibas).Thepertrochantericsuctionventensuredthattheirrigationfluidfromthebladdersyringewasdrawnthroughthefemoralneck,resemblingababy’smouthsuckingabottle!

Figure4:FCBarcelonaattheCampNou(Derek,Farhaan,Sammy)BolognaThethirdstoponthetourwasattheInstitutoOrtopedicoRizzoliinBolognawherewewerehostedbyProfStefanoZaffagnini.ThecityhaslongbeenaseatoflearninganditsstudentsincludedsuchiconicnamesasDante,Petrarch,Galvani,MalpighiandValsalva.Thiscentreeclipsedaglobalpillaroforthopaedicsurgeryintermsofitshistory,itsrangeoforthopaedicservicesanditsadvancesintreatmentanddiagnosis.Itremainsamysteryhowpatientsevermadeitupthehill!TheBibliotecaUmbertoI,thelibrarycreatedbytheoriginalmonksandhandedovertoasuccessionoforthopaedicsurgeons,notleastPuttiwasbreathtakingasitincludedbothmanuscriptsfromtheoriginalanatomytheatresofPadua,Bolognaandthe

Arabworld,allatleast500yearsold.Furthermore,ProfZaffagniniarrangedawalkingtourofBolognaandwejoinedhimfordinneratPiazzaSantoStefano,theSquareofSevenChurches.TheteammembersentertainedusinstylebybringingustoaFCBolognamatch,gaveusatouroftheIsokineticcentre(aFIFAmedicalcentreforsportsrehabilitation)andtothelocalDucatimotorbikemuseum.TheyshowedustherealsideofBolognaandjoinedusfordinner-althoughwecouldnotmanagetherawhorsemeat!ThelocaltechniqueforanteriorcruciateligamentreconstructionwaspopularisedbyProf.Marcaccimanyyearsbefore,whichincludesadoublebundletechniquethatattemptstoreproducethekinematiceffectsofboththeanteromedialandposterolateralbundlesoftheACL.ThishassincebeenavailedofbymanyathletesincludingSerieAItaliansoccerplayers,backtoplayingwithin3monthsinsomecases.Additionalstabilisationoftheantero-lateralligamentcanbeachievedbyemployingthe‘overthetop’techniquewhichusesasinglebundlegraftthatispassedthroughtheintercondylarnotch,aroundthelateralfemoralcondyleandfastenedtotheanterolateraltibia.25-yearresultswillbepublishedlaterthisyear.ThespineteamofDrdiSylvestreoperatedonmanycomplexcasesduringourstayincludingproximaljunctionkyphosis,stagedproceduresforsevereidiopathicscoliosisandiatrogenicflatbackdeformity.WorkingwithDrVomare,thetwosurgeonswereveryimpressiveastheyworkedsimultaneouslyinstrumentingbothsidesofthespine.DrGassbarinibroughtustonearbyFlorenceforatotalenblocspondylectomyforaT6osteogenicsarcoma.

Figure5:OutsidetheRizzoliInstitute

Figure6:Intra-operativeimageofaposteriorscoliosiscorrection.Thetraditionamongstthespinalteamsthatweobservedwasfortwooperatorstoworksimultaneouslyforeverycomplexcase.Thesurgeon’shandsareevidentinsertingpediclefinderstotheconvex(left)andconcave(right)aspectsofthespinalcurve.

Figure7:Severescoliosiscase-left:CTreconstruction,right-intra-operativefluoroscopydemonstratingmultilevelpediclescrewsandontheconcaveside,adynamicmagneticrodforgraduatedpost-operativedistractionpriortothesecondstageofthesurgery.

Figure8:Theoriginaloftherecognisablesplintedcrookedtreemetaphor,oneofthemanyinterestingmanuscriptscollectedbyProfPutti.

Figure9:TheAnatomicalTheatreoftheArchiginnasio,wasmostlyreconstructedafterWW2,butwhoseoriginstracebacktotheUniversityofBolognawhichwasfoundedin1088.Thesurroundingwallsdepictwoodenstatuesoffamousphysiciansofancienttimeswiththe“Spellati”orskinnedstatuessupportingtheteacher’schairandthedissectiontableatthecentre.

Figure10:Totalen-blocresectionofamid-thoracicosteogenicsarcoma:left-intra-operativeimageofaposteriorapproachtothespinedemonstratingwideretractorsplaceddeeptothespinalcolumnandsuperficialtothegreatvessels,thehighspeedburrwhichisdemarcatingposteriorresectionmarginsandthelevelsofthevertebraetoberesected,right-intra-operativefluoroscopydemonstratinganexpandablevertebrectomycageandpediclescrews-at3levelsbelowand2levelsabovethevertebrectomyandascrewinsertedinthecage.ViennaTheEFORTconferenceinViennawasasuitablefinaletoanenjoyablelearningexperience.Whileattendingthesub-specialityworkshops,researchpresentationsandstate-of-the-artdiscussions,ourEuropeanexperienceallowedusagreaterappreciationofdifferentperspectives.ItwasenjoyabletohearaboutongoingprojectsincountriesthatwouldnottypicallyfeatureintheUK/USdominatedliterature.WewerealsoinvitedtoeveningeventshostedbytheBJJ/EFORTandMedacta/EFORTAlumni.Thefellowshipwasavaluableandthoughtprovokingexperience.Weweretreatedverywellandwewereallowedprivilegedaccesstotheatresandclinicsatcentresofexcellence.Theinformalconversationswithexperiencedsurgeonsprovedaseverarealinsightintotheexperiences-bothgoodandbadthatarenotalwaysaswelldescribedintheliterature.WewouldencouragealltraineeorthopaedicsurgeonstoavailofeducationalopportunitiessuchastheMarkPaterson/BJJEFORTTravellingFellowship.

Figure11:TheEFORTfellowswithSanniHiltunen,thededicatedandtirelessorganiser.ThankyouSanni!