Travelling Fellowship Reports

I aimed to gain experience of this method in a high volume centre, understand the scope of its application, meet surgeons from a variety of international backgrounds, gain historical perspective in an area of interest to me and ultimately use this to benefit patients in the UK.

This was a 4 week structured Fellowship that was comprised of theatre time, case discussions, lectures and workshops with Saturday mornings reserved for sawbone work. There was the opportunity to scrub in and assist with cases in theatre.

Surgeons were extremely experienced with techniques and circular frames were applied efficiently with a heavy reliance on knowledge of anatomical landmarks over intra-operative radiography. They were supported by a multi-disciplinary team, with patients often staying at the centre for their entire duration of time in circular frame, giving them access to optimised nursing care and rehabilitation.

The pathology observed was varied and included traumatic and elective conditions in both the paediatric and adult population. Examples included limb lengthening, non-union surgery, acute fracture fixation in the upper and lower limbs, the management of the diabetic foot and bone infection. Whilst the majority of the work performed at the centre uses the Ilizarov apparatus, internal fixation is available for certain cases, as is joint replacement surgery.

In summary I felt that my objectives for going were achieved and also that the visit took place at the right time as I had attained CCT and had Fellowship experience in this technique prior to the visit. I would like to thank the Ilizarov Scientific Centre for hosting me and also the BOA for the generous award of the Zimmer Travelling Fellowship. 

I spent two weeks at the Institut de la Main in Paris, a private centre of excellence for hand and wrist surgery. I visited in the final months of my specialist training and I was hosted by Prof. Mathoulin and Drs. Leclercq, Gras and Arnout. Prof. Mathoulin has pioneered many arthroscopic wrist operations and Dr. Leclercq is an expert on the management of Dupuytren’s disease and upper limb spasticity.

In addition, it was clear I would need to be focussed and come through an interview process that would ask some searching questions about my career, my plans, and what I wanted to get out of a travelling fellowship. I was aware that the itinerary I had put together was quite ambitious and potentially quite expensive, but also that if I was unable to secure part-funding for my travels, I would be willing to self-fund, as it meant a lot to me. I was therefore delighted to be awarded the Zimmer Upper Limb travelling fellowship by the BOA fellowships committee.
The three units that I planned to visit were far apart. The first of these was the Institut de la Main, Paris, France, followed by The Beth Deaconness Medical Center at the Harvard School of Medicine, Boston, USA; and finally to Ganga Hospital in Coimbatore, India. I had for a long time wanted to visit these places, not least because they are centres of excellence in their own right and the surgeons I planned to visit and learn from had experience and expertise in the hand and upper limb pathologies and techniques that interest me, but also they are in interesting countries with different healthcare systems, with significant differences from the my own country and the NHS.

In Cambodia there are very little elective paediatric services; there is no screening for DDH and very late diagnosis is the norm. I spent a lot of time raising awareness and training local staff in screening for DDH, principles of practical management of DDH and training in western procedures for paediatric surgeons including femoral and pelvic osteotomies. In addition to this work, I have educated the Khmer surgeons to recognise and treat paediatric conditions such as congenital vertical talus and congenital pseudoarthrosis of the tibia - last month we did the first periosteal grafting and Paley X type procedure in Cambodia. 
Cambodia’s main mode of transport is the motorbike and, due to a paying healthcare system and high levels of poverty, many who come off their motorbikes seek traditional medicine or no care at all. The Khmer surgeons here see and successfully treat very high volumes of infected non-unions, plexus and peripheral nerve/plexus injuries. Similarly, obstetric and paediatric care is difficult to access and of variable quality resulting in a spectrum of cerebral palsy type cases either at birth or post meningitis. I have been able to expand my personal cross speciality experience in nerve injury and tendon transfer in brachial plexus injury, microsurgery, selective denervation for spasticity and congenital hand.
This experience has been both life and career changing and am extremely grateful to the BOA and the Chatterjee fellowship. I would thoroughly encourage anyone considering overseas work to take a leap of faith - it will be a rewarding decision!

The first place was Rush Medical Center in Chicago Illinois, observing Dr Brian Cole for a week. I observed him operate on two days as well as in clinic. Highlights included observing 3 osteochondral allografts transplantations, multiple ACL reconstructions and osteotomies. I was also able to go to a Chicago Bulls basketball match with Dr Cole as the team doctor for the evening.

The second half of the trip involved visiting Dr Robert LaPrade at the Twin Cities Orthopaedics Center in Minnesota. Dr LaPrade has arguably published more and helped progress the specialty of reconstructive knee surgery more than any other surgeon of his generation. It was a privilege to observe some his named procedures first hand. The majority of his cases were revisions, referred from other states and around the world. His diagnostic skill was excellent and use of stress radiographs, which is not done in most centres in the UK, was vital to his practice. His knowledge of anatomy was excellent and this helped in performing complex cases efficiently.

Overall, I feel very lucky to have been able to observe both institutions. I learnt a lot clinically, surgically but most of all, how to set up and joint clinical and academic practice to really advance your own skills and those of others. I have also made good contacts that I hope to use for future support and collaboration.

The first week was spent with Dr Bassem Elhassan in Mayo Clinic, Rochester, who I met in Harrogate BESS 2019. I was fascinated by his utilisation of tendons transfer as a treatment to irreparable rotator cuff tears or in brachial plexus injuries. A particular procedure I was fascinated by was lower trapezius transfer to supraspinatous footprint, a technique he pioneered. I saw patients in his clinic who had this procedure to treat pseudoparalysis with remarkable outcomes.

In the second part of my visit, I travelled to Phoenix to visit Dr John Tokish, a Sport Medicine Professor in Mayo Clinic. I attended the annual Comprehensive Shoulder and Elbow Conference presented by legendary Mayo faculty such as Dr Morey and Dr O’Driscoll. I spent ten days shadowing Dr Tokish in his operating room and clinic. I also attended two academic journal meetings chaired by him. I had the opportunity to discuss latest research and differences in training systems between the USA ad UK. Dr Tokish arranged a morning in the cadaveric laboratory to allow me to practice newly learnt surgical techniques.

The experience I gained during these three weeks were invaluable and I am confident that I shall incorporate it into a formative Shoulder and Elbow Surgery Career. Furthermore, I strongly believe that that the links I have made will result in lasting mentorships, friendships and future collaborations in research.

The most striking features of my time in Austin, was their clinics. Surgeons were another team member. Dieticians, psychologists, physiotherapists and occupational therapists all had an input. A large proportion of the population served were not US citizens and spoke little English. There was therefore a huge drive to meet all healthcare needs at one appointment and limit the lead for follow ups. It’s not uncommon for fractures to be fixed in a little theatre adjacent to clinic. Almost every patient was enrolled in one of more research study, and the use of outcome scores was very impressive.

I also had the opportunity to visit Stephen Burkhart – the Godfather of shoulder arthroscopy. I was able to watch him both in clinic and in theatre and enjoyed a dinner with him in his favourite restaurant. This all happened in the week that he announced his retirement: not doubt a huge loss to the shoulder community!

I had a fantastic time visiting the units in Texas, and I hope to bring back some great ways of working to my consultant post.

Firstly, I visited the world-famous Steadman Clinic in Vail, Colorado, where I spent time with leading surgeon, Dr Peter Millett. Both himself and his colleagues have operated on and successfully treated leading world athletes from a variety sports and activities. Millett designed the widely-used Speedbridge ‘double-row’ repair for rotator cuff tears and has been integral in the advancement of superior capsular reconstruction (SCR) for irreparable cuff tears. He also created the minimally-invasive Complete Arthroscopic Management (CAM) procedure for advanced OA in active patients who wish to post-pone arthroplasty. 

I then spent time with the highly-respected Prof George Athwal in the Roth McFarlane Hand & Upper Limb Centre in London, Ontario. The centre was established in 1992 by its two founders and has gone on to become Canada’s leading upper limb centre. Following his time working in France and collaborative work with European upper limb surgeons, Athwal has gone on to be recognised internationally for his expertise in shoulder arthroplasty and instability.

I gained a great deal from both Dr Millett and Prof Athwal (Figure 1). In addition, I had the opportunity to spend time in clinic and theatre with their orthopaedic colleagues, also world leaders in their fields. The experience as a whole was both unique and priceless with regards to the tips and techniques learnt that will no doubt contribute to both my ability as an upper limb surgeon.

I returned to the UK on the 14th March after the remainder of my trip was cut short by the COVID-19 crisis. Despite missing the opportunity to visit Dr James Sanders and attend the AAOS meeting, this travelling fellowship not only fulfilled my educational needs, I was also able to gain a fantastic insight about the US healthcare system and create a network of professional contacts I am sure will be of significant value to me
and my patient’s in the future. I not only wish to thank the BOA and the estate of Mr Soli Lam, but also my wife, Marilena, for her unwavering
support during this time, and throughout my training. Thank you!

I attended the scoliosis clinics and learnt important aspects of bracing including how compliance is monitored in Hong Kong. Bracing and physiotherapy are known to reduce the need for surgery. I attended all activities including the Grand Rounds (Wednesday), Pre-operative planning (Friday) and a pan-Hong Kong meet (Saturday) and played an active role. During my visit the MB Lee Visiting Professor was Prof. Matsuyama from Japan, who is current President of the Japanese Society for Spine Surgery and Related Research (JSSR)(Fig 4). We visited Shenzhen Hospital, a 2000 bed unit with modern facilities. I attended the Hong Kong Orthopaedic Association Annual conference and presented four podium presentations based on my work in St. George’s Hospital on Vertebral Body Tethering and Scoliosis. This was very well received, and I received a personal invitation from Prof. Matsuyama to present at the JSSR meet in Nagoya, Japan. Overall, this has been an amazing experience for me both professionally and personally. I have gained experience which will help not only my own patients but hopefully all the patients of my unit and all of UK. I have formed ties that will be invaluable to not only my own career but to future trainees who may wish to visit the unit. Hong Kong as a city is a wonderful mix of Great Britain and China and I enjoyed every moment thoroughly and recommend it for a visit. I am very thankful to the British Orthopaedic Association and PGO for granting this wonderful opportunity to gain so much from this travelling fellowship and hope to use all the experience and knowledge to benefit of our patients in the NHS every day.

The fellowship was cut short by Covid-19, but it was still a valuable and enriching experience, which has significantly increased my confidence and will add value to the rest of my training. I would highly recommend something like this to anyone who wants to be a children’s orthopaedic surgeon.

I undertook this fellowship along with my wife, Sara, who is also a paediatric orthopaedic surgeon and my son who was two. The clinical experience and non technical skills learned during this placement were phenomenal and I would highly recommend this kind of experience to anyone. I found myself in a limb reconstruction role of complex neglected trauma whilst Sara mostly dealt with the congenital paediatric population. Whilst at CSC we started an orthopaedic curriculum roughly mapped to the UK curriculum in order to give back some knowledge to the institution as described below, we ran basic fracture management courses for the residents and organised a number of case conferences with Bristol to discuss challenging cases with. I believe that we were at the best possible place in our careers to do this sort of placement as just post exam we are probably at the most knowledgeable about general orthopaedics prior to subspecialisation and competent to perform the majority of operations encountered. I hope to make visits to CSC a continuing part of my practice life long.