Reflection

Three weeks of travel, hospital visits, giving talks, socialising, eating. It has been a great experience. What have we learnt? Americans like cementless, tapered stems, x-linked poly, tantalum revision cups & melted cheese in all their food. They do their hips through a variety of approaches & disagree as strongly as we do about which is the best. Many, but not all, perform mini-incision approaches. This doesn’t happen so much in Canada where healthcare is not market-driven. There is a message there somewhere. Resurfacing is becoming more popular but the old hands are letting the young guys take it on – too old to change or too wise to jump in? Ceramic is not popular because of squeaking.

We have become experts in negotiating airports, know the cheapest, if not safest way to get from airport to hospital in many major cities.

We have met some of the most famous names in orthopaedics over the last 30 years.

The hosts were all unbelievably generous with their time, putting us up in some really nice hotels, allowing us to hack divots in their golf courses & tolerating our explanations of why cricket is better than baseball.

Karen Andersen of the Hip Society did a great job arranging our travel as did Bill Hozack with the itinerary. Steve MacDonald, Joe McCarthy, Doug Padgett, Bill Hozack, Wayne Paprosky, Don Garbuz, Tom Schmalzried & Bill Maloney made our Fellowship a once in a lifetime experience & we are very, very grateful.

Mukesh has been a pleasure to travel with. We have had a load of laughs along the way & kept each other going with cricketing & orthopaedic anecdotes all across the USA & Canada. We must thank our wives & children who have had to cope without us for 3 weeks without ever making us feel in any way guilty about our absence. Thank you Sarah & Deepika.

I hope this blog hasn’t been too dull & that someone other than my secretary (who had no choice) has found it interesting.

Jim Wimhurst. LAX Airport 22/09/07

Hip Society, Pasadena

21/09/07 – 22/09/07

Returning to the car park that is Los Angeles after a delay at San Francisco airport, we were delighted to find that the venue for the Hip Society meeting was in a very nice hotel in leafy Pasadena.

Having arrived too late to get to the reception at Larry Dorr’s, we took the opportunity to have a relatively healthy dinner, not involving steak or cheese. Unfortunately the “traditional” French onion soup contained more cheese than soup or onion.

The meeting itself was excellent. It was fantastic to hear surgeons such as Drs Harris, Ranawat, Paprosky, Engh, Dorr, Bourne, Duncan, Berry & Callaghan talk, & put faces to such famous names. Even better when they disagreed.

Having received the program on arrival, we were only slightly surprised to find “Travelling Fellows Report” on the agenda for 5pm on the first day. After a quick download of photos from our cameras & plagiarism of our other talks, we managed to put together an acceptable presentation which we spent the following day rehearsing during interludes. Come 5pm we were ready…. And treated to a report of the 2006 American Travelling Fellows trip to the UK! Remarkably similar to what we had prepared but with Old Trafford substituted for Shea Stadium & Haggis for Cheese Steaks. Still, it helps to be prepared for next year’s BHS.

The guest speaker at the dinner was a famous sports commentator whose great love was college (American) football.  Needless to say much of his talk was lost on us. We must get Aggers or Blowers for the BOA so we can return the favour for the American travelling fellows next year.

18/09/07-20/09/07

Stanford, CA

After LA’s motorways, Stanford came as a very pleasant surprise. A university campus endowed by a 19^th Century Industrialist, it is set amid parkland that is given an Antipodean feel by the huge numbers of feral eucalyptus trees (one was introduced & spread itself freely) and vineyards. The hospital is within the university campus, the latter being based around a central quad that might remind one of Oxbridge were it not built in an Italianate style with a Floretine Basilica. The whole thing has been rebuilt on a couple of occasions after major earthquakes, the San Andreas Fault being only a couple of miles away.

We spent our time with Bill Maloney, Stuart Goodman & James “Hutch” Huddlestone. We were made extremely welcome, even during the 2 hour “Grand Round” that had been set up for us to comment on difficult cases & give 30 minute lectures each.

The rest of the time was spent in theatre with Dr Maloney (Epoch stem, in which he also was involved on the design team) and x-linked poly, campus tour, research meeting with Dr Goodman (intra-cellular messengers for osteoblast/clast precursors) preop-planning & arthritis service meetings.

16/09/07 – 17/09/07

Los Angeles

LA came as a bit of a culture shock after Vancouver where we had been able to walk everywhere. If New York is a city that never sleeps, LA is certainly a great big freeway. Our hotel was at the side of a 10-laner. The only walkable destination was a Taco Bell on the other side of the road, but you’d have to be ridiculously hungry to risk crossing.

We met Tom Schmalzried at St Vincent’s Hospital. His first case was a resurfacing using the DePuy ASR system he has been involved in designing. Unlicensed by the FDA over here, it is part of a trial. Good discussions about our metal on metal experiences in Norwich ensued. He then performed a THR using the Summit stem (which he again helped design), a taper with a conical distal geometry paired with an x-linked poly cup in a Pinnacle shell.

Unfortunately the rest of his cases for the day were cancelled so we headed off to The Pacific Dining Car, an LA medical institution as it is opposite one of the other hospitals (Good Samaritan) & never closes, 24 hours a day 365 days a year.  Excellent lunch, although after 2 ½  weeks of eating for Britain, we found that selecting a tuna salad is no guarantee of a light meal. They find a way to get some coronary-blockers in with bacon-bits & of course, cheese.

13/09/07-15/09/07

Vancouver

Vancouver is a beautiful city, rather similar in feel to Sydney. At least it was for our visit, with clear skies & sun, although the locals all say it rains a lot.

At Vancouver General Hospital we met Don Garbuz at 6.30am to present at their arthroplasty meeting prior to going to theatre (OR as they insist on calling it, the list being a “slate”).

After 2 weeks of primaries through small holes it was great to see an x-ray of a grossly loose, jumbo cementless cup above a well-fixed long cementless stem on the viewer.

We made polite enquiries about discontinuity & unsurprisingly the pelvis was in 2 separate & mobile parts. Don had the luxury of one of his 5 colleagues who do nothing but trauma come in & put a posterior column recon plate on for him before getting on with the revision. First glimpse of the famous trabecular metal cup after a medial mesh & some impacted morsellized allograft medially. It was a whopper at 78mm diameter & coupled with a 36mm face-changing liner, produced a stable construct and reduction. Really good to see a proper, difficult revision & the result looked excellent.

Because of the discontinuity, the revision had taken longer than expected. It being Friday & a public health system, murmurs started about not being able to do the last case. Sure enough, after a primary (M/L taper, x-linked poly), the last case was cancelled. We should offer to lend them KT to persuade their lists to continue a little longer!

Off to LA on Sunday but today free to explore Vancouver. Fortunately the time difference means we are up bright & early to make the most of the day.

11/09/07 – 12/09/07

Chicago

Flying into Chicago on the 6^th anniversary of the Twin Towers attack was unsurprisingly delayed by some heightened security. When we eventually arrived, we joined host Wayne Paprosky at the Central DuPage Hospital in Winfield Illinois. This was a very smart private hospital with the plushest theatre coffee room I have ever seen. Dr Parosky was doing a series of THRs through a mini posterior approach, again with 2 fellows in 2 theatres. He used a stem he has designed called the Epoch, which is a scratch-fit, composite, isoelastic stem with a full coating, requiring power reaming of the proximal shaft. The theory behind the modulus of elasticity is a reduction in thigh pain.

Whilst being driven through Chicago later that evening, we were stopped by the raising of one of the huge bridges, but despite our encouragements, Dr Paprosky was unwilling to recreate the scene from Blues Brothers to prove whether his Merc had “pick-up”.

The following day was spent at Rush Medical Centre in Chicago, starting with the arthroplasty meeting with Drs Paprosky, Jacobs, Galante & Della Vale, a pretty impressive crew, before theatre to see minimally invasive hips & knees performed with instruments designed in their department.

09/09/07-11/09/07

Philadelphia

Pleasant journey by train to Philadelphia. Very nice to not have to remove shoes, belt etc & be able to carry more than 200ml fluid.

Jefferson University Hospital is in the centre of downtown Philadelphia. Off to a flying start on Monday morning with Dr Bill Hozack, whose double list started at 7am. He managed 8 joint replacements (7 hips, 1 knee) by 1pm with the aid of a senior fellow who essentially ran one room (theatre is not a term used here), opening, closing & preparing the femur & acetabulum with Dr Hozack implanting all the components (all private patients). He uses a mini Smith-Peterson incision for most patients which gives a good acetabular exposure but the femoral mobilization looked like it required a few tricks. The beauty of this inter-muscular plane approach was the closure which required only some vicryl sutures to the fascia. Tapered, proximally coated stems were again used with metal on x-linked poly bearings for all but the youngest patients for whom ceramic on x-linked poly was used.

One of Dr Hozack’s colleagues was also running 2 rooms. He had, amongst other cases, 2 revision THRs. Neither required revision of well-fixed cementless stems or cups. One he grafted through the drill holes of the cup for osteolysis & the other was a head & liner change for instability.

They feel that revisions of this sort are becoming more common, with well-fixed components left in situ.

After presenting our talks that afternoon, we were taken to a Philadelphia steak house, with enough meat for a small army, made even more difficult to finish by the fact that Bill had insisted we had Philly “Cheese-steaks” for lunch. These are essentially coronary artery-blocking sandwiches of sliced beef & melted cheese. Small wonder Americans are large (Dr Hozack is not, but he’s Canadian).

07/09/07 – 09/09/07

New York

Arrived in New York on the evening of 06/09/07, staying at the Hospital for Special Surgery. It really is a city that never sleeps, the plumbers working on the floor above our rooms were certainly busy all night.

Revived by plenty of New York coffee & a bagel, we met Doug Padgett in this famous joint replacement centre.

Again, a fantastic research set up with an amazing retrieval lab, housing some 18000 implants. If you want to see explanted hips & knees, this is the place. We looked at “unbreakable” ceramics (broken) & scratched “unscratchable” oxinium before watching a demonstration of their impaction grafting in vitro study, using graft substitutes (TCP & HA). They also use the Ortech software for data collection.

After a very interesting morning we were entertained by Occupational Health, who wanted to know our rubella titres etc before allowing us into theatre to observe. Good to know that the US surgeons have the same healthy respect for this beurocracy and the same vocabulary that we do, judging by the Anglo-Saxon expletives from our hosts when they heard that this is what we had to do.

35 orthopaedic theatres (17 inpatient) meant plenty of choice for observing. Mukesh was able to lend a hand, explaining the Wrightington method of bulk autografting for a dysplastic acetabulum in detail. The surgeon appeared interested but put in a cementless cup all the same.

That evening we attended a New York Mets baseball game at Shea Stadium (next to Flushing Meadow), the sports team looked after by the Hospital for Special Surgery. Great game, with the Mets hammering the Houston Astros. Fascinating to see huge billboards advertising HSS at the game in the same way you would see Carlsberg adverts at Liverpool or Flybe at Norwich. A different world.

Saturday was our first free day and Doug Padgett proved to be an extremely entertaining and generous host. A round of golf at the Westchester golf club was not done justice by JW’s hacking on what is a PGA tour venue.

05/09/07-06/09/07

Boston

Arrived in Boston after a slight delay for fog in Detroit. Taxi driver refused to accept that the Hotel we were going to was actually open but after some encouragement, took us anyway. Turns out the Liberty Hotel (formerly Suffolk County Jail) had only opened that day. Fantastic galleried entrance hall, barred windows Alibi Bar & restaurant called “Clink” but most importantly less than 20 yards from Massachussets General Hospital where we met Henrik Malchau & had a tour of the Harris Biomechanical Lab.

This is the lab where highly cross-linked poly was developed & they are currently working on impregnation with Vit E to scavange free radicals & prevent ongoing oxidation & deterioration of mechanical properties. Also they are working on hyrogels (PVA) as potential a biomaterial for cartilage replacement, amongst other applications.

Visited the “Ether Dome” where Morton, a Boston dentist, gave the first general anaesthetic for removal of a neck lump by a Dr Warren in 1846. The amphitheatre-like building is still decorated & set out as in the C19th.

Next to theatre with Dr Andy Freiberg to see a mini modified lateral approach for a cementless THR (metal on x-linked poly of course) in a man of 6’8” weighing 260 pounds.

The following day was spent with Dr Joe McCarthy at Newton–Wellesley Hospital watching hip arthroscopy, a day that would have been good enough even without the fact that they were having a “clam bake” which turned out to mean that all hospital staff were given a traditional New England (free) lunch of clam chowder & lobster. Didn’t seem to notice two Limeys slipping into the queue (sorry, line). Certainly a distinct improvement on UK hospital canteen fare. Perhaps we could do the same with Cromer crab?

03/09/07-04/09/07

LondonOntario

Arrived London on the afternoon of 3^rd September after a connection in New York.

It’s Labor Day in the USA & Canada, a Bank Holiday to honour the workforce, celebrated by no-one doing any work. Wonder if we could transfer a similar concept to the UK & have a “Trauma Day” Bank Holiday where no-one hurts themselves & the Trauma Theatre has a day off?

London is about a 35minute flight from Toronto, a University Campus (University of Western Ontario) & we have arrived at the beginning of “Frosh” (Freshers’ week), so the bars are all heaving. Dinner at the wonderfully-ambigously named “Blue Ginger”. Fortunately Canadians are blissfully unaware of Cockney rhyming slang.

The unit at University Hospital was made famous by Cecil Rorabek & Bob Bourne. We are being hosted by Steve MacDonald & spend the 4^th in theatre with Steve, Doug Naudie (Ganz-style open debridement & MoM THR with Summit stem & Pinnacle cup via Hardinge approach) & Jim McCauley (Summit & Pinnacle THR with ceramic on x-linked poly bearing via Hardinge approach).

We were shown their very impressive research facility with wear-stimulators & RSA lab plus introduced to their IT guy who has developed a software program (ORTECH) for saving data in an orthopaedic surgeon-friendly manner. Fantastic tool for recalling data & setting up studies, eg, you can pull out all male patients with a BMI of 36 who had a cemented stem in their left hip etc, etc & see their Womac, Harris score etc in excel or graphic form. Makes preparing presentations & papers very easy. 2 full-time joint replacements nurses collect the data, entered by a full-time clerk.

Dinner at The London Club, an MCC style gentlemens’ club (which now does allow ladies, not that there were any seen) before an early night prior to a 5am rise for the trip to Boston via Detroit. Breakfast at the ubiquitous Tim Hortons (Ontario coffee shops founded by an Ice Hockey player who was afraid of flying, but died when he fell asleep at the wheel driving to a game in the US). Usual, “oh yeah, two British Doctors, empty your bags” at customs whilst the hoodies, multiply-pierced & tattooed waltz through. Fortunately no pointed  pulling on of latex gloves..yet.