Travelling Fellowship Reports
Foot and Ankle
Executive Summary: “This Fellowship was spent at the Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics in Kurgan, Russia, where in the last century, Gavriil Abramovich Ilizarov discovered and applied the principle of ‘tension-stress."
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.
Executive Summary: "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."
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.
Executive Summary: "Upon learning that I had been awarded a BOA travelling fellowship I was extremely proud to have been selected. I knew it was a competitive process and that if I was to be able to gain the funding to go ahead with my plans to undertake a travelling fellowship to visit the units that I had long planned to visit, upon the completion of my training in trauma and orthopaedics, I would need to complete a good application with a clear view of what I planned to do."
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.
Executive Summary: "The last year has been an eventful year, with both my husband and I sitting and passing the FRCS at the same time (despite all our friends, family and colleagues thinking we were mad), securing two international fellowships, battling family illness and relocating our family temporarily to Cambodia after I received a BOA travelling fellowship. I have spent the last 6 months at the children’s surgical centre in Cambodia, where I have undertaken both a clinical and training role. I have implemented a paediatric orthopaedic curriculum and an AO style practical course in basic fracture management for the rotating residents, which will continue to roll on a 6 monthly basis once I leave, using the digital resources supplied."
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!
Executive Summary: "I was awarded £1500 to visit centres of excellence in sports and reconstructive knee surgery in the USA."
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.
Shoulder and Elbow
Executive Summary: "It was a great honour to have been awarded the BOA’s Zimmer Upper Limb Fellowship to pursue my interest in the USA."
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.
Executive Summary: "I was delighted to be awarded a BOA / Zimmer travelling fellowship, which led me to Texas during July. It came about following a chance meeting of David Ring and Kevin Bozic whilst in Boston in 2014. Both had just been recruited to Dell Medical School to develop a value-based healthcare system. This provided me with a fantastic opportunity to meet and observe someone who has helped drive our understanding of elbow pathology, particularly of trauma, and also see first-hand what the new wave of value-based medicine and integrated practice units practically means."
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.
Executive Summary: "This invaluable travelling fellowship included visits to two prestigious upper limb centres in North America in November."
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.
Executive Summary - "On the 4th February 2020, I embarked on a two-month travelling fellowship to the USA, sponsored by the BOA and the estate of the late Mr Sorab (Soli) Jamshed Sorabsha Lam. I used this opportunity to further my deep interest in spinal surgery and visited a number of notable centres of excellence, including Columbia Children’s Hospital of New York (CHONY), Mount Sinai Hospital, Thomas Jefferson University Hospital and the Shriners Children’s Hospital of Philadelphia. I was able to observe cases and attend clinic with Drs Lawrence Lenke, Mike Vitale, Baron Lonner, Alex Vaccaro, Josh Pahys, Steven Huang and Amer Samdani, all of whom are key opinion leaders in the field of Spinal Surgery."
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!
Executive Summary: "I visited the Spinal Unit, University of Hong Kong renowned for its research and teaching in October 2019. The unit is headed by Professor Cheung and based on two sites, the Queen Mary Hospital, Pokfulam Road and the Duchess of Kent Hospital, Sandy Bay. I have an interest in spinal deformity and wanted to gain a deeper understanding into the Hong Kong approach to scoliosis management. I also intended to compare our system in the NHS with the Hong Kong system and bring back any new aspects that would be useful to our patients and disseminate this information."
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.
Executive Summary: "I spent 5 months in a large children’s hospital in Colombo, Sri Lanka, gaining experience in children’s orthopaedics. In a resource limited hospital, I learned how to manage a lot of things non operatively, and how to deal with the significant occasional complications from such a strategy. We saw over 150 patients at each clinic, and operated on 5 cases in a half day list, with truly impressive work ethic and motivation evident among all staff. I logged 187 operations total, including 63 supracondylar elbow fractures, 9 SUFEs, and 12 operations for DDH, which is amazing exposure in a short space of time."
Executive Summary: "During the period of August 2019 to February 2020 I worked at The Children’s Surgical Centre in Phnom Penh Cambodia."