EFOST 2009 Team Physician Travelling Fellowship Report
By Mike Carmont, Omer Mei-Dan.
DJO sponsor EFOST’s European and US Travelling Fellowships in alternate years. In this report, Dr Mike Carmont (UK) and Dr Omer Mei-Dam (Israel) share with us their experience from their US tour which started at AAOS in Las Vegas in February.
We were both delighted to be selected as Travelling Fellows of the European Federation of National Associations of Orthopaedic Sports Traumatology (EFOST) at the meeting in Antalya in November 2008.
We are both young surgeons involved in team sports in our respective countries, have completed formal Fellowship positions and were once involved in sports ourselves. I am a keen mountain biker and runner and Omer a well known extreme sports athlete performing base jumping, skydiving, skiing and rock climbing.
The Fellowship was kindly sponsored by DJO but even so there was plenty of preparation to be done to make sure we made the most of this unique experience. The Fellowship was arranged by Francois Kelberine who worked with the other EFOST committee members to arrange all the venues, selected for their academic excellence, involvement and expertise in team sports.
We started at the AAOS Academy Speciality Day in Las Vegas. We were amazed at the size of the Venetian Ballroom at the Convention Centre and even more to hear that literally thousands of surgeons had been present during the meeting in the preceding week. During the day we took the opportunity to ask questions and I was impressed by the experience and the standard of the presenters. These were world leaders giving their opinions, current thoughts and debate on controversial topics in sports surgery e.g. return to play following ACL injury and ankle ligament reconstruction. We had an excellent day and met many of our hosts over the next two and a half weeks as well as some innovators and living legends in sports surgery.
Scott Dye’s presentation upon receiving the Kennedy Lectureship made us wince at the thought of him performing knee arthroscopy whilst awake without intra-articular anaesthesia1. Having increased our enthusiasm for academic surgery we regrouped in the hotel and prepared for our travels around the US.
The two EFOST Travelling Fellows meeting Scott Dye at the AOSSM Speciality Day, Las Vegas.
University of Washington, Seattle
Our first stop was the University of Washington Sports Medicine Unit in Seattle where we were picked up punctually at the airport and handed an impressive itinerary whilst the airline searched for Omer’s bag that had gone missing.
We then enjoyed cocktail drinks overlooking the lake from Carol Teitz’s House2, met the other surgeons and learned a lot about the University and Sports Medicine Centre.
Our first task was to give a presentation at Grand Rounds at the Harborview Medical Center. This was indeed an honour as their Trauma Service is revered all over the world. Ted Hansen3 and Bruce Sangeorzan4 were some of the iconic figures in the audience. We were then given a tour of Harborview and heard about the tertiary trauma service they provide for an area about the same size as Europe. We then toured Bainbridge Island and Snoqualmie Falls impressed that one of the fantastic hosts Trey Green5 had been able to take time away from his busy clinical schedule.
We visited the University of Washington Medical Centre to see ACL surgery performed by Roger Larson6. Our hosts seemed apologetic that they had “just an ACL” for that session. We appreciated that all surgeons have different tricks and techniques and there was constant discussion about why and how they do certain things. Exhausted by the constant thinking and discussion we retreated to our hotel for a run around the University of Washington. We had ambitious plans of an hour’s exercise a day in an attempt to battle the generous portions and outstanding hospitality!
On the final evening we had dinner with our host’s family, a chance to exchange gifts and were taken to see the University of Washington vs. Seattle University Basketball game. Our hosts were Team Physicians for the Huskies (Washington Uni.) and we were given passes to sit on the bench with Dr Chris Wahl7. The game was fast and furious with deafening noise from the passionate fans in “the dog pound”.
Early next morning Trey Green was there again to take us to the airport to catch our flight to LA before returning for a day of surgery. That man has real stamina.
The Kerlan Jobe Clinic, Los Angeles
We were greeted at the airport by our host’s glamorous assistant, Serena, welcomed to LA and whisked to the Kerlan Jobe Clinic. Rather than being based at a University this was a privately run Sports Medicine Clinic. Our host, Clarence Shields, former AOSSM President8& was in clinic that afternoon and every patient asked about the welfare of celebrity patients Kobe Bryant and Tom Brady. The unit was clearly used to having lots of visitors. We were also introduced to the HEAL (Helping Enrich Athlete’s Lives) programme, a non profit sports programme in local schools supported by the Kerlan Jobe Clinic.
Surgery consisted of an ACL reconstruction and knee arthroscopy with lots of questions and discussion. That afternoon we focussed on our exercise regime and were joined by our host along the Venice and Santa Monica beach strip. After an hour we were starting to struggle but Clarence looked fresh gliding along on his roller blades.
DJO had organised a dinner with the KJ Fellows which gave us a chance to see their research and make our presentations. Enthusiastic conversation followed with lots of questions and exchange of ideas.
Theatre next day was with Dr Neal ElAttrache and some shoulder arthroscopy. As the designer of the Biotenodesis screw we had the chance to discuss its advantages and use9. A visit to the ice hockey followed to see the local Anaheim Ducks against the Dallas Stars, one of the many teams for which KJ provides medical cover.
University of Iowa Sports Medicine, Iowa
We were treated to some real mid west wet weather flying into Iowa and greeted by Paul Etre, the Personal Assistant of our host Prof Ned Amendola10. We had dinner with an impressive collection of Fellows, overseas visitors and Travelling Fellows and learnt about the University Sports Medicine Unit in Iowa. Brian Wolf joined us looking bleary eyed after just returning with the University Basketball Team. University sport is big business in the US with the NCAA series getting TV coverage and requiring professional sports medicine cover too. UISM sends an Orthopaedic Surgeon and a Sports Physician to each game. He would only have a couple of family days before his next trip.
Days in the Unit started early with Consultant led teaching at 7am and clinic starting at 8am. The operating theatre followed and over the next two days we saw both medial and lateral meniscal allograft transplants together with high tibial and distal femoral osteotomies. Brian Wolf demonstrated a Fulkerson’s osteotomy performed by one of the senior residents.
We were shown around the University of Iowa Sports Centre and talked briefly to some of the football team as they did pre-season testing. These men mountains weighed 383lb/174Kg, had amazing sprint speed and would form a formidable offensive line. The University Centre facilities were impressive and would rival those of Premier League Clubs within the UK.
We were given a guided tour of the awesome Research Unit in Iowa. The Orthopaedic and Sports Medicine Unit had recently been awarded a $9million NIH grant. Glenn Williams showed us around the Biomechanics Unit. The facilities were on a par with the sports facilities including a 3T MRI scan for research purposes; it is no wonder so many papers come out of the Mid West10-12. Before we left Iowa, we had the privilege of meeting Iowa’s best known surgeons. The work done by Prof Ignacio Ponseti in the treatment of club foot has virtually ruled out the requirement for surgical intervention for this disabling condition13. Manipulation and cast moulding is cost effective and has now been adopted worldwide. He is now 95 years of age and we met him briefly in his office and had the pleasure of accompanying him and his wife for dinner.
The Cleveland Clinic, Cleveland
Having been stunned in Iowa, our next stop was the US’s second largest private hospital, the Cleveland Clinic. We met for dinner in the Intercontinental Hotel in the centre of the hospital. The Cleveland Clinic receives patients from all over the world and many stay pre and post operation in the hotel which has special suites for Royalty and Presidents.
Tony Miniaci met us early next day at the Sports Medicine Centre and was keen to demonstrate his Arthrosurface joint replacements before he travelled to ISAKOS14. We also saw an ACL reconstruction and debridement of insertional Achilles tendinopathy. Afternoons consisted of tours of the training facilities of the Cleveland Browns and Cavaliers. Lebron James is locally known as “The King” in Cleveland and is responsible for Cleveland being at the top of the NBA league.
We participated in Ground Rounds presentations organised by Robert Dimeff, the Head of Primary Care Sports Medicine, meeting again our Co-Travelling Fellows Bill Wind15 and Michael Rauh16 and again toured the Research Facilities. We visited the Cavaliers Stadium to see an NCAA Basketball tournament and were allowed to visit the locker room with named changing area - unfortunately the chairs and shoes were just too big.
Our final day with John Bergfeld15 was a traditional US sports day of clay shooting and fly fishing. We were given strict instructions on how to avoid shooting our host, and although the fly fishing was relaxing, the absence of interest from the fish was almost too much for extreme Omer.
After an amazing few weeks we returned to the airport for our flights home and to prepare for the return to our own practices. The Fellowship had been an amazing experience and had surpassed our expectations. We had seen some outstanding surgery, fantastic hospitals and amazing research facilities. We were now exhausted from two weeks of constant exchange of different ideas, principles and surgical techniques. All the centres we visited had their individual character and personality and placed different emphasis on different aspects of care. We had seen the Sports Medicine care of all aspects of US sport from individual recreational athletes to professional sports teams. The overriding impression was the dedication and professionalism of the surgeons at the centres we visited. They put an immense amount of time into their Team Physician practices and as a result deliver an outstanding level of care.
There are many people we would like to thank for the Fellowship. First of all we would like to thanks our hosts: Trey Green, Clarence Shields, Ned Amendola and John Bergfeld for their superb hospitality. We would also like to thank their Surgical Colleagues and Fellows who all took time out of busy surgical schedules to look after us during our travels.
From Europe we would like to thank Francois Kelberine and the EFOST committee for organising the Fellowship.
Finally we would like to thank DJO for sponsoring the EFOST Team Physician Travelling Fellowship.
This was an outstanding educational opportunity in which we have been very fortunate to participate. We now use the principles, skills and attitudes we saw on a daily basis and can only hope other surgeons have this chance in the future.
1 Dye SF, Vaupel GL, Dye CC. Conscious neurosensory mapping of the internal structures of the human knee without intra-articular anaesthesia. Am J Sports Med 1998;26(6):773-7.
2 Teitz CC, O’Kane JW, Lind BK. Back pain in former intercollegiate rowers. A long term follow up study. Am J Sports Med 2003;31(4):590-5.
3 DiGiovanni CW, Kuo R, Tejwani N, Price R, Hansen ST Jr, Cziernecki J, Sangeorzan BJ. Isolated gastrocnemius tightness. J Bone Joint Surg Am 2002;84(6):962-70.
4 Sangeorzan BJ, Benirschke SK, Mosca V, Mayo KA, Hansen ST Jr. Displaced intra-articular fractures of the tarsal navicular. J Bone Joint Surg Am 1989;71(10):1504-10.
5 Larson RV, Ulmer T. Ligament injuries in children. Instr Course Lectures 2003;52:677-81.
6 Wahl CJ, Nicandri G. Single Achilles allograft posterior cruciate ligament and medial collateral ligament reconstruction: a technique to avoid osseous tunnel intersection, improve construct stiffness and save on graft utilization. Arthroscopy 2008;24(4):486-9.
7 Orendurff MS, Rohr ES, Segal AD, Medley JW, Green JR 3rd, Kadel NJ. Regional landing foot pressure during running, cutting, jumping and landing. Am J Sports Med 2008;36(3):566-71.
8 Grossman MG, ElAttrache NS, Shields CL, Glousman RE. Revision anterior cruciate ligament reconstruction: three to nine year follow up. Arthroscopy 2005;21(4):418-23.
9 Park MC, ElAttrache NS, Ahmad CS, Tibone JE. “Transosseus-equivalent”rotator cuff repair technique. Arthroscopy 2006;22(12):1360e1-5.
10 Wright RW, Preston E, Fleming BC, Amendola A, Andrish JT, Bergfeld JA, Dunn WR, Kaeding C, Kuhn JE, Marx RG, McCarty EC, Parker RC, Spindler KP, Wolcott M, Wolf BR, Williams GN. A systematic review of anterior cruciate ligament reconstruction rehabilitation: part 1: continuous passive motion, early weight bearing, post operative bracing and home based rehabilitation. J Knee Surg 2008;21(3):217-24.
11 Wright RW, Preston E, Fleming BC, Amendola A, Andrish JT, Bergfeld JA, Dunn WR, Kaeding C, Kuhn JE, Marx RG, McCarty EC, Parker RC, Spindler KP, Wolcott M, Wolf BR, Williams GN. A systematic review of anterior cruciate ligament reconstruction rehabilitation: part 2: open versus closed chain kinetic exercises, neuromuscular electrical stimulation, accelerated rehabilitation and miscellaneous topics. J Knee Surg 2008;21(3):225-34.
12 Wright RW, Dunn WR, Amendola A, Andrish JT, Flanigan DC, Jones M, Kaeding CC, Marx RG, Matava MJ, McCarty EC, Parker RD, Vidal A, Wolcott M, Wolf BR, Spindler KP: Moon cohort. Anterior cruciate ligament revision reconstruction: two year results from the MOON cohort. J Knee Surg 2007;20(4):308-11.
13 Ponseti IV. Treatment of congenital club foot. J Bone Joint Surg Am 1992;74(3):448-54.
14 Miniaci A, Martineau PA. Technical aspects of osteochondral autograft transplantation. Instr Course Lectures 2007;56:447-55.
15 Wind WM Jr, Bergfeld JA, Parker RD. Evaluation and treatment of posterior cruciate ligament injuries: revisited. Am J Sports Med 2004;32(7):1765-75.
16 Rauh MA, Clark LD, Shah H, Krackow KA, Mikalko WM. The effect of drill hole size on the fixation strength of a cemented prosthetic patellar button. Orthopedics 2008;31(6):541.