The Asean-American Orthopaedic Association (AOA) travelling fellowship aims to foster international relations between Asean and American orthopaedic surgeons with visits to centres of excellence in the USA. We arrived in Boston on Thursday, 15 May 2008 to start the 17th Asean-AOA traveling fellowship. Representing Asean (Fig. 1) were Dr. Sharaf Ibrahim (Malaysia) Dr. Pham Dang Nhat (Vietnam), Dr. Ramesh Subramaniam (Singapore), Dr. Emiliano Tablante (Philippines), Dr Dwikora Utomo (Indonesia) and Dr. Siwadol Wongsak (Thailand).
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Fig. 1 (from left to right) Dr Dwikora Utomo (Indonesia) , Dr. Ramesh Subramaniam (Singapore), Dr. Pham Dang Nhat (Vietnam), Dr. Siwadol Wongsak (Thailand), Dr. Emiliano Tablante (Philippines), Dr. Sharaf Ibrahim (Malaysia). |
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Tufts University
Boston
Thursday 15 May – Monday 19 May
Dr John Richmond, orthopaedic chairman of the New England Baptist Hospital and his chief residents (trainees) as well as attendings (consultants) of Harvard and Boston Universities gave us a warm welcoming dinner upon arrival.
Our programme started the next morning in Tufts Medical Center with a tour of the hospital with the chief residents. The scientific presentations began after breakfast with Dr Charles Cassidy, orthopaedic chairman of Tufts Medical Centre speaking on scaphoid fractures, Dr. Elizabeth Matzkin on clavicle fractures and Dr Eric Smith on trauma care in Afghanistan. Our presentations were on non-vascularised fibular graft for the treatment of neglected femoral neck fractures (Dwikora Utomo), the use of lidocaine-epinephrine infiltration as an alternative for tourniquet use in open reduction and internal fixation of forearm fractures (Emiliano Tablante), peripheral nerve blocks in total knee arthroplasty (Ramesh Subramaniam), management of burned hands (Pham Dang Nhat), accuracy of digital images to predict knee implant sizing (Siwadol Wongsak) and orthopaedic training in Malaysia (Sharaf Ibrahim). We had a lively discussion with the residents and fellows who attended the meeting.
The afternoon was free for us to explore downtown Boston - a city of 600 000, founded in 1630 with its charming colonial architecture. The evening ended with a sumptuous seafood dinner with Dr Charles Cassidy and his chief residents. The baseball game on Saturday afternoon between Red Sox of Boston and the Milwaukee Brewers introduced us to the American passion for the game – Red Sox won by 5-3. The rest of the weekend was spent visiting Harvard University and sightseeing in Boston.
Our final day in Boston was in New England Baptist Hospital starting with presentations by Dr Mininder Kocher on paediatric knee injuries, Dr David Kim on the genetics of pain in patients with degenerative lumbar disc disease, Dr Carl Talmo on knee arthrodesis, Dr John Richmond on tissue engineering of the anterior cruciate ligament, Dr Andrew Terrono on rheumatoid arthritis of the hand and Dr Suzanne Miller on superior labral anterior and posterior lesions of the shoulder. We had a video teleconference on total knee arthroplasty done by Dr James Bono without navigation and Dr John Siliski with navigation. Our presentations were on revision surgery for developmental dysplasia of the hip (Sharaf Ibrahim), vascularised fibula graft for segmental bone defects (Pham Dang Nhat), triple arthrodesis of neglected clubfoot (Emilio Tablante), anterior cruciate ligament reconstruction (Dwikora Utomo), lateral condylar hypoplasia of the distal femur in patients undergoing total knee replacement (Ramesh Subramaniam) and accuracy of digital images for knee implants (Siwadol Wongsak).
Yale University
New Haven
Monday 19 May – Wednesday 21 May
We arrived in New Haven after a 3-hour train journey along the scenic New England coastline. Dr Gary Friedlaender, chairman of the Yale orthopaedic department gave us a surprise as he was at the station to accompany us to our hotel. We learnt that the residency programme is very competitive and only five residents are selected annually out of nearly 400 applicants. In Yale, residents from the 3rd to 5th years are given approximately 10 weeks of research time annually. A unique feature of the orthopaedic programme in Yale is the book club for the residents hosted regularly by Dr Friedlaender at his home as part of their holistic education.
The next morning was spent visiting Yale Medical Center while in the afternoon we went on a guided tour of Yale University. Dinner with the chief residents was another surprise. It was in Bintara - a Malaysian restaurant. The chief residents were a lively group and we enjoyed their company.
Our final day in Yale started with our presentations on congenital constriction band (Sharaf Ibrahim), neglected clubfeet (Emiliano Tablante), neglected femoral neck fractures (Dwikora Utomo) and on the humanitarian mission in Jogjakarta following the earthquake in 2006 (Ramesh Subramaniam). Next was the case discussion presented by the trauma chief resident on gunshot injury to the shoulder and a patient with multiple fractures. I attended the oncology and paediatric clinics while the rest were in theatre to observe a total ankle arthroplasty and a distal radius fixation.
We had an interesting discussion during dinner with Dr Gary Friedlaender on politics and orthopaedic training on our last evening in New Haven.
State University of New York
Syracuse
Thursday 22 May – Friday 23 May
We took the early morning flight to Syracuse. Airport security was tight and we had to take off our shoes and remove the computers from our bags to be scanned separately. Dr Mike Sun from the State University of New York met us for lunch followed by a walking tour of Syracuse, visiting the art museum, the courthouse and the Erie Canal museum. On Friday, we were welcomed by Dr Stephen Albanese, professor and chairman of the orthopaedic department in the State University of New York.
I spoke on orthopaedic training in Malaysia and the humanitarian mission to Lebanon followed by a surgical session where we observed surgery for tibialis posterior dysfunction, a knee and a shoulder arthroscopy. We then visited the Institute for Human Performance. This is an impressive centre for basic science and clinical research. We were shown the bioengineering laboratories where biomechanical research on the hand, spine and arthroplasty were conducted. Following lunch, we continued with our presentations on gigantism of the lower limbs due to Klippel-Trenaunay syndrome (Sharaf Ibrahim), neglected clubfoot (Emil Tablante),vascularised fibula graft and the tensor fascia lata flap (Pham Dang Nhat), neglected femoral neck fracture (Dwikora Utomo), peripheral nerve block for total knee arthroplasty (Ramesh Subramaniam) and digital imaging (Siwadol Wongsak). The chief residents next presented cases of a gunshot injury of the tibia, an infected non-union of the tibia and a rare case of hydatid disease of the femur.
We ended the evening with a lovely dinner with Dr Tim Damron , Dr and Mrs Stephen Albanese on our last evening in Syracuse.
Memorial Day Weekend
New York City
Saturday 24 – Tuesday 27 May
We flew from Syracuse to New York City on Memorial Day weekend. Staying in Manhattan, I found New York a truly cosmopolitan city with its multi-ethnic citizens speaking a babel of languages. It is a city of contrasts where skyscrapers with glitzy neon advertisements overshadow the poor who beg for a living and where the homeless sleep on the streets. It is not only the people who are diverse. The weather in America was just as varied. While we were having bright sunshine in New York city, tornadoes were devastating part of the mid-west, bush fires were blazing in California and snow was falling in the south-west. I visited Central Park, the American Museum of Natural History with its amazing exhibits, Battery Park for a view of the Statue of Liberty and the Metropolitan Art Museum. Contrary to expectations, most people were helpful when asked for directions. New York City lives up to its tagline as a city that never sleeps with the subway and many restaurants open 24 hours.
University of Medicine and Dentistry New Jersey
Newark
Wednesday 28 – Thursday 29 May
New York City to Newark took 17 minutes by train across the Hudson River. We were welcomed by the chief residents and had dinner with them in a nearby restaurant. As with the other previous universities, it was interesting having dinner with the chief residents as we get to know more about them and their training programme. Dr Michael Sirkin and Dr Sheldon Lin were at the hotel early the next morning for our visit to the New Jersey medical school. Thursday mornings are for academic presentations.
Five chief residents and two fellows presented their completed research projects. The papers presented were on the natural history of non-operatively treated SER II ankle fractures, comparison of locked 3.5 mm plates versus 4.5 mm plates for the treatment of complex tibial plateau fractures, biomechanics of cervical lateral mass injuries, intramedullary fixation for distal radius malunion, a biomechanical study on talus fractures, a comparison of phenol and argon beam coagulation as adjuvant treatment in benign bone tumours and displacement of the sustentacular fragment in intra-articular calcaneus fractures. The residents are required to submit their papers for presentation at the American Academy of Orthopaedic Surgeons meeting next year. We presented our papers and then met Dr Elizabeth Moran, head of orthopaedic research, who showed us her new laboratory in the cancer research centre.
The case discussion after lunch were on post-traumatic glenohumeral arthritis treated by hemiarthroplasty with biologic resurfacing arthroplasty of the glenoid, giant cell tumour distal tibia treated by resection, intramedullary nailing and bone transport, osteosarcoma distal femur treated by resection and a growing endoprosthesis, refracture of a radius/ulna in a child and knee ligament reconstruction after traumatic dislocation.
The day ended with dinner in an elegant riverside restaurant opposite Manhattan with Dr Joseph Benevenia, Dr Mike Vives, Dr Sheldon Lin and Dr Mike Sarkin.
Cornell University
New York City
Friday May 30 to Monday June 2
We took the train again from Newark to New York City and met Dr Anil Ranawat for a visit to the Hospital for Special Surgery, which is affiliated to Cornell University. This hospital was established in 1863 to treat musculoskeletal diseases and now has more than 50 orthopaedic surgeons training 40 residents and 40 fellows. A unique feature of their programme is their annual scientific meeting where alumni present their papers in the hospital. The evening ended with dinner hosted by Dr Anil Ranawat and his chief residents.
We visited Stryker headquarters in Mahwah, New Jersey the following morning and observed the production of their hip and knee prosthesis as well as the training centre with a state-of-the-art operation theatre for cadaveric surgery. The rest of the weekend was spent shopping, sightseeing and watching a Broadway musical.
We were at Lenox Hill hospital on Monday to meet Dr Amar Ranawat and his father, Dr Chitranjan Ranawat. We observed the guru performing total knee and hip arthroplasties. In the evening, he spoke on the history of total knee arthroplasty and total knee replacement in the valgus knee. Over dinner with a visiting group of Asian and European surgeons including Dr Tai from University Malaya, Dr Ranawat discussed his philosophy in surgery and in life, which is to continue improving oneself everyday.
Canadian Orthopaedic Association – American Orthopaedic Association Combined Annual Congress.
Quebec City
Tuesday 3 June – Saturday 7 June 2008
We arrived in Quebec City, which is celebrating its 400th anniversary and took a guided walking tour in old Quebec. Old Quebec is a Unesco World Heritage Site and most of the buildings had been preserved to reflect the French and British heritage of the city. The opening ceremony of the combined congress was held on Thursday and we met up with Dr Suthorn Bavonratanavech of the Thai Orthopaedic Association, Dr Francis Altarejos of the Philippine Orthopaedic Association, the American British Canadian traveling fellows and the Japanese Orthopaedic Association visiting fellow. This was the second combined congress between the Canadian and American Orthopaedic Associations. We had a meeting with Dr Mary O’ Connor who chairs the Asean-AOA fellowship committee and invited the AOA to participate in our national orthopaedic meetings as well as the Asean Orthopaedic Congress. The scientific programme was excellent and I enjoyed attending the symposia and memorial lecture on orthopaedic education and mentoring which stresses the importance of good leadership, mentoring residents and guiding the professional development of junior colleagues.
Conclusion
This was my first visit to academic orthopaedic departments in the United States and we were warmly welcomed in all the hospitals we visited. We presented and listened to lectures in all the universities we visited. In addition, we participated in case discussions, research presentations and visited the laboratories.
There was interest in orthopaedic training in Asean and my lecture was based on the recommendation by previous fellows. Future fellows from each Asean country should include this lecture in their presentation. The academic departments were well staffed with excellent clinical and research programmes. There were similarities and differences between the American and Malaysian training programme. The number of residents accepted for training yearly ranged from four to ten in the different universities. The first year is in general surgery with the remaining 4 years rotating in the different subspecialties of orthopaedics. There are certain practices that we could emulate. For instance, all 5th year residents become chief residents who will oversee the junior residents. Most residents undergo a further one-year fellowship in another hospital after completing their residency. Grand rounds consist of lectures given regularly by an eminent invited speaker. The orthopaedic board certifying examination consists of two parts. The first part consists of multiple-choice questions taken at the end of residency while the second part is the oral examination taken after the fellowship. Many senior faculty members remained in academia and this was evident from the glowing testimonials of former residents and the numerous photographs that adorned the walls.
Our fellowship was the 17th in the series. It had been a two-way learning process and we have made new Asean and North American friends. Ms Lisa O’ Brien of the American Orthopaedic Association and Ms Tomi Gaudio of Progressive Travel Management were extremely helpful in arranging our academic programme and travel itinerary respectively. We thank all our host institutions for the wonderful hospitality and the Asean and American Orthopaedic Associations for successfully organizing the fellowship.
Overall, this fellowship had achieved its aim of fostering international relations. My fervent wish is for the Malaysian Orthopaedic Association and the Asean Orthopaedic Association to continue supporting this event. Last but not least, I thank my family and colleagues in the orthopaedic department for their support. |
