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Canadian-French-Belgian-Swiss (CFBS) Fellowship Diary
October - November 2002
Geoffrey Dervin, M.D., FRCSC
2002 CFBS Fellow
Ottawa, ON October 14 - 15: Hôpital Avicenne, Paris
I arrived in Paris after an overnight flight and was met by a resident from the orthopaedic service. He escorted me directly to the hospital that is situated in the northeast outskirts of Paris where I met Professor Thierry Begue and two travelling colleagues from Belgium: Drs. Tom Lootens from Gant and Johann de Schepper from Genk. Avicenne is a referral base for infected fractures with soft tissue loss and we saw several during the ward rounds that took place that day. Their strategy typically includes aggressive resection of the devitalized and/or infected sequestrum, myocutaneous coverage, and antibiotic-impregnated cement spacer, which is implanted for a minimum of six weeks. The cement spacer is fashioned as much as possible to mimic the bony defect they wish to later fill with posterior iliac crest autograft. The cement spacer incites a foreign body reaction and as such, forms a vascularized envelope into which the autograft is placed and is rapidly invaded. We saw a few cases of bridge vascularisation of free flaps by reverse saphenous vein graft from the femoral artery into the flap. This is reserved for chronic cases where the cicatrisation would imperil safe direct anastomosis in the leg.
 | | Hôpital Avicenne, Paris. From L to R: Dr. Jo de Schepper, Head Nurse Trouvain, Professeur T. Begue, Dr. Tom Lootens, Dr. Geoff Dervin. |
October 16 - 17: Hôpital Ambroise Paré, Paris
With jet-lag wearing off, we set out to Boulogne, west of the city, to meet Professor Lortat-Jacob and his team, largely dedicated to traumatology but with a busy referral service of infected total joints and the septic and orthopaedic complications of paraplegia. They are fortunate to have three operating rooms (each with a preanaesthetic room). Professor Lortat has made this his specialty since he began in 1974. He now treats approximately 65 total joint infections a year (40 hips and 25 knees). He impressed us with the depth of his knowledge in microbiology and the nuances of bacterial resistance and sensitivity, and his versatility in soft tissue coverage. (He, himself, does 90% of that which is needed). We watched him do second stage TKR revision in 55 minutes, made simpler by routine tibial tuberosity osteotomy, which is performed at the debridement stage to allow for more thorough resection. He was a delight to meet and his sense of humour appears good to maintain morale for all of the support staff.
Our stay concluded with the "staff" meeting during which all of the following week's cases are presented by the residents and are reviewed by the entire staff. I was impressed with this and see several benefits. First, the team redefines and affirms the indication for surgery and the potential hazards. Second, the residents are introduced to the cases with ample time to prepare and any missing data from the file can be noted with enough time for completion.
October 18: Hôpital de la Pitié Salpetrière, Paris
This is apparently Western Europe's largest hospital, spanning one square kilometer with 6000 beds. Medical residents bike between Emergency and the wards when they are on call. The orthopaedic strengths are related to spine surgery and trauma once again. (All three hospitals are part of the Association of Public Hospitals of Paris and are all trauma centres.) We were treated to an unexpected surprise when we arrived at morning rounds. Joel Matta was there as a guest lecturer, reviewing some highlights of his 1000 personal cases of pelvic and acetabular trauma. We then went to the OR and saw the use of the Judet table for a total hip replacement through the lower half of Smith Petersen approach, which will be of interest to those inclined to the wave of minimally invasive hip arthroplasty. The table is no longer manufactured but Dr. Matta is working to develop a similar model.
October 21 - 22: Centre Hôspitalier Universaire, Bordeaux
We were graciously received by Professor Dominique Cheauvaux upon our arrival in Bordeaux, a pretty city turned upside down due to the construction of a new tramway. His group holds particular interests in foot and ankle surgery. He shared with us the rationale and design of a total ankle replacement, which they have used since 1989 (see www.orthopedie/fr.akile). It has evolved with some changes over the years and has a mobile bearing polyethylene component and relatively conservative bone cuts. They have also adopted perimalleolar tendinoscopy for evaluation of the peroneal and tibialis posterior tendons and excellent visualization is afforded. Their most recent passion has been to adopt the percutaneous correction of Hallux Valgus credited to an American podiatrist named Isham. The cases they presented were impressive but are reserved for mild and moderate cases only.
We were also impressed with the spine service under the direction of Jean Charles Lehuec. He holds a PhD and has a wet lab adjacent to the main hospital where he hones skills and runs courses in minimally invasive and video-assisted thoracolumbar spine surgery. He has also aided in the development of a metal on metal lumbar disk prosthesis called the "Maverick" distributed by Sofamor Danek. His indications include patients younger than age 60, with lumbago credited to discogenic disease, confirmed on MRI, and for L5S1, pain that is relieved by short trial of a fixed lumbosacral brace that flexes the hip to 30º. Preop MRI angiogram also allows evaluation of iliac vessels to ensure it can be done safely through an anterior, retroperitoneal approach which he elegantly demonstrated to us.
October 23 - 25: Clinique Livet, Lyon
A wonderful dinner with Professor Cheauvaux was followed by an overnight train ride to Lyon, which, rightfully, has an international reputation for knee surgery. The first case was a revision ACL following a failed synthetic graft in a patient with a previous subtotal medial meniscectomy. Professor Philippe Neyret performed a combined opening wedge tibial osteotomy (taking care to decrease the tibial slope) and ACL reconstruction using a patellar tendon autograft. They have long advocated correcting coronal and sagittal knee malalignment concurrent with ligament reconstruction. They quantitatively assess these variables with single stance weight-bearing lateral and AP radiographs. His comfort with osteotomy was obvious, as he performed it without fluoroscopy (being repaired) and yet the postoperative radiograph was quite satisfactory.
The following day's programme included a lateral approach with tibial tubercle osteotomy for a Valgus total knee using the HLS (Hôpital Lyon Sud) rotating platform posterior stabilized prosthesis. Second was an ACL reconstruction in an 11-year-old boy using iliotibial band in over the top fashion. Finally, a case of excision of a popliteal cyst using a less invasive posterior approach described by Roger Bardet that uses a small L-shaped posterior incision and a proximal split of the medial gastrocnemius muscle to access the posterior joint line. That evening, the incoming Fellow treated me to a wonderful cheese fondue. Despite the wine consumption, I was still able to attend Friday's list, the highlight of which was an ACL revision with intraarticular (contralateral patellar tendon) and extraarticular (Lemaire iliotibial band) reconstruction. I was particularly impressed with my visit to Lyon given my personal interest in knee surgery, but I thoroughly enjoyed the other stops along the way during my stay in France.
October 26 - November 1: Belgium
I arrived in Brussels on Saturday, October 26th and was able to use the weekend to re-energize in the well-appointed hotel Amigo located 100 meters from Brussels' famous square: the "Grand Place". On Sunday, Dr. Frederick Schuind, a former CFBS Fellow, met me and we toured several sites including the Music Museum with collections dating back some 400 yrs.
 |  | | An alternative to total hip arthroplasty designed in Brussells. | On Monday I joined him and Professor Burny at ULB (Université Libre Bruxelles) - Erasme for rounds and a review of their clinical interests. Dr. Burny is one of the pioneers into the use of external fixation for fractures, with large series of open and closed tibial fractures, as well as humeral fractures. Of interest was the evolution of strain gauges which he affixes to the external fixators. Measurements of fixator torque at pin-rod interface help guide patient weight-bearing instructions. Micromotion is used to stimulate earlier, more robust enchondral ossification. The measurements are now digitized and the next proposed evolutionary step is the development of telemetry to monitor torque. I was struck as to how this would be of use for more difficult fractures with bone loss or comminution, to guide the timing and amount of weight-bearing.
Tuesday I visited ULB - St-Pierre, an inner city hospital which dates back some 800 years, having begun as a leprosy sanitarium. I spent the morning in the OR where Professor Delincé and I discussed their favorable experience with the Corail hip replacement. The titanium HA coated stem has demonstrated excellent longevity and trivial amounts of thigh pain. They have also published several retrieval studies documenting bony ingrowth and gradual resorption of the HA coating concomitant with new bone apposition.
Wednesday I ventured to UCL (Université catholique Louvain) just north of Brussels where I met with Dr. C. Deloye before going off to the OR where a 85-year-old woman was undergoing a hip revision two years following primary arthroplasty with a ceramic zirconium femoral head which had fractured catastrophically. Third body wear on the trunion and liner required revision of the stem and liner respectively. In the afternoon, I visited Professeur DeLoye's lab and bone bank, which stores both frozen non-irradiated structural allografts and lyophilized irradiated, cancellous grafts. The latter are prepared in an industrial clean environment and come from retrieved femoral heads, primarily from arthroplasty cases.
I traveled to Lièges Wednesday evening to meet Professeur Philippe Gilet who recounted his excellent experience as a Fellow to Dr. Alain Jodoin in Montreal in the 1980s. After joining morning rounds, I observed him revise a total hip in which the cemented all-polyethylene cup was intra-pelvic. A vascular colleague began with an anterior retroperitoneal approach, isolated the iliac vessels (in particular the vein), which were touching but not adherent to the cement. A posterior approach followed with removal of the cup and revision by a reinforced ring cup and cemented liner. I joined Dr. Popovic in clinic for the afternoon and then that evening, joined the entire team for weekly rounds before concluding with dinner.
Friday, November1st was a national holiday to remember the deceased. I met with Dr. Tom Lootens in Gant who showed me his city, and then off to Brugge for the remainder of the weekend. Brugge is a beautiful city which was economically more vibrant in the Middle Ages but whose charm has been preserved. It is partitioned by various navigable canals, hence its designation as "Venice of the North". All told, the Belgian delegation was extremely hospitable and was able to share much of their experience, despite it being a holiday week for the children.
November 3 - 9: Switzerland
I was met in Lausanne by Prof Leyvraz and joined him and his team the next day at the Hôpital de la Suisse Romande - a general hospital. The orthopaedic department has been housed in a separate building since 1997. It runs on a separate budget and thus has the autonomy and responsibility of its management. There are obvious advantages to this arrangement and it allows great independence in developing the operational programme. Although it is a public hospital, there are a number of patients with private insurance, which permits them a private room and the choice of their surgeon. The department uses these extra funds to support the research activities of their research arm which they cosponsor with the EPFL, one of two national engineering schools rapidly gaining notoriety for their design of the Swiss entry Alinghi into the Americas Cup. I joined Dr. Siegrist in the OR in the morning for surgery and then we moved on to the Engineering School in the afternoon to evaluate the site and the numerous projects underway.
I moved on to Geneva on Tuesday and observed a case of tibial osteotomy. I also assisted Professeur Pierre Hoffmeier (grateful for his Fellowship training in Vancouver some years ago) with an open capsular shift of an unstable shoulder. We concluded the day with rounds and a workshop on the UFN nail. I had a nice dinner and discussion that evening with local housestaff.  | | View from train in Switzerland. |
On Wednesday I travelled by train to Zurich where I first attended the Schulthiss clinic, an orthopaedic-only facility housed in a splendid building. The operating suite consists of one large open room in which there are four modules where surgeries take place. This makes observation for a visitor ideal. There are also anesthetic induction rooms to help speed up turnover times between cases. There are a large number of private patients and the atmosphere was decidedly different from what I had observed at other sites. The next morning I visited Balgrist, literally around the corner from Schulthiss and spent a stimulating day observing the activities of the service directed by Christian Gerber. I found a similar operating suite arrangement and saw a number of open and arthroscopic shoulder surgeries, including rotator cuff repair, stabilization, and reverse shoulder arthroplasty. I was initially struck by the incidence of biceps tenotomy and they explained that their philosophy sees the biceps pathology as a cause of intractable symptoms that hinders the success of rotator cuff repairs by adhering to the overlying cuff. The day concluded with a presentation by Dr. Notzli, trained in Berne, who reviewed their approach for evaluation and treatment of femoral neck and acetabular dysplasia, including the indications for hip dislocation and debridement of femoral neck and labral tears as well as periacetabular osteotomy. One could not help but be impressed by the quality of work at Balgrist and the gracious way in which I was received at an institution which receives more than 100 visitors annually. My best lessons from the Swiss were their commitment to research and the strong base in anatomy and biomechanics that shaped the foundation of their approach.
November 11 - 15: SOFCOT Annual Meeting, Paris
I enjoyed this very interesting meeting which is the world's largest orthopaedic meeting, second only to the American Academy. They have their share of instructional courses and several sessions of problem case discussions, which are very instructive and something we should perhaps consider for our own Annual Meeting. My wife joined me in Paris for the week - what better place for a reunion after a month away from home.
Overall, I enjoyed the Fellowship immensely and was well received everywhere I went. The approaches are different enough to warrant observation and reflection. Future surgeons will no doubt continue to benefit from this experience. I wish to thank the Canadian Orthopaedic Association for this excellent opportunity. |
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