Issue: August 2020
Source/Disclosures
Source: www.efort.org
August 05, 2020
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EFORT Robotics Travelling Fellowship 2020: Fellow experience

Issue: August 2020
Source/Disclosures
Source: www.efort.org
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The EFORT Robotics Travelling Fellowship 2020 supported by Stryker took place February to March 2020.

Fellows David A. George, MBChB, BMedSc, FRCS (Trauma & Orth), and Veenesh Selvaratnam, MBChB, FRCS (Trauma & Orth), CCT (Trauma & Orth), of the United Kingdom give an overview of their experience during the fellowship.

EFORT

Fellowship and hosts

It was our honor to be awarded the first EFORT Robotic Travelling Fellowship, which ran from 23 February until 21 March 2020. During this time, we had the opportunity to visit three centers across Europe and met some fantastic surgeons and their teams, who had a wealth of knowledge regarding robotic-assisted surgery with the MAKO (Stryker) robot, as well as other robots.

We visited Prof. Henning Windhagen and Max Ettinger, MD, at the Orthopaedic Clinic of the Hannover Medical School (DIAKOVERE Annastift), Hannover, Germany, followed by Prof. Pascal Kouyoumdjian at the University Hospital Center of Nîmes, France, and finally Prof. Fares Haddad at University College London/Princess Grace Hospitals, London. Unfortunately, it was not possible to visit Dr. Fabio Catani at Policlinico of Modena University, Italy, due to the COVID-19 outbreak, as was previously planned.

Fellows

George graduated from The University of Birmingham Medical School and is in his final year of specialist trauma and orthopaedic training on the North West Thames rotation. Currently based at the Royal National Orthopedic Hospital, Stanmore, United Kingdom, he is working within the joint reconstruction unit. His subspecialty interest is adult lower limb arthroplasty, including complex primaries, revisions and periprosthetic infection, which is a main focus of his research.

Selvaratnam, originally from Malaysia, graduated from the University of Liverpool and completed his specialist trauma and orthopaedic training (CCT) in 2017 in Liverpool. He has had the opportunity to complete post-CCT fellowships at prestigious centers across the United Kingdom including the Wrightington Pelvic Trauma, Hip & Knee Fellowship, the Bristol Knee Fellowship and the Exeter Hip and Knee Fellowship. His subspecialty interests are pelvic trauma, lower limb revision arthroplasty and knee surgery.

Hannover experience

We spent the first week of our fellowship under the supervision of Prof. Windhagen and Dr. Ettinger. While it is attached to the medical school, the orthopaedic hospital pre-dates the main Hannover general hospital, and remains as a purely elective center for orthopaedics.

scrub in

It was one of the first centers to use the MAKO in Europe and the staff there have been heavily involved in teaching other units its benefits, so it was a pleasure to visit there. They used navigation-assisted surgery for most of their partial and total knee replacements, opting for manual jigs when a custom implant is used.

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Across the week, we were able to scrub up and assist on a variety of cases, including simple varus knees, complex post-traumatic severely arthritic knees and partial medial unicondylar knee replacements. The average was four to five cases per theatre. The team strongly believed in kinematic alignment, which was felt to be better for patella tracking and functional outcome.

We also assisted in other cases, such as primary total hip replacements (done supine, through a Hardinge approach without navigation), revision TKRs requiring custom tibial sleeves and a hinge, distal femoral replacements for periprosthetic fractures, as well as mini-open hip arthroscopies for femoroacetabular impingement.

On the third day, we were invited to present at a mini symposium. The host team presented the results of their research, and the various knee alignment options and outcomes in arthroplasty. David presented the outcome of the use of massive endoprosthesis in infection at the Royal National Orthopaedic Hospital, and Veenesh presented the outcome of using the Exeter femoral stem as a spacer (CUMARS) in a staged hip revision for infection.

Two of the evenings were spent out with the host team in local restaurants, which served typical German cuisine.

Dinner in Hannover
Dinner with the team in Hannover. Windhagen is fourth from right and Ettinger is third from left.

The team members were really hospitable and their grasp of the English language was definitely helpful. We learned a lot about the benefits of computer-assisted surgery, particularly about kinematic alignment around the knee, and it was good to observe other elements of their patient care, in particular the strict infection prevention policies in the operating suite and the swift maneuvering of the staff on the floor.

Nîmes experience

Our second week was spent in the beautiful city of Nîmes in the south of France, under the supervision of Prof. Kouyoumdjian at Nîmes University Hospital. The hospital is a trauma center covering a large area, with the sister hospital based in Montpellier.

Within the department there are three surgeons who use MAKO in their routine hip and knee arthroplasty procedures. We were scrubbed with each of them during the week, gaining hands-on experience using the MAKO. We were able to use the system during total hip and knee arthroplasties, as well as unicompartmental knee replacements.

It was good to see its use in different scenarios as they use it in both direct anterior and posterior hip approaches (in both express and enhanced femoral workflows), combined with the Anato Femoral Hip Stem (Stryker) where special attention must be placed on assessing the preoperative femoral version seen on CT, as the stem comes in a range of anteverted and neutral neck options.

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This allows the surgeon more flexibility when recreating patients’ natural femoral version. Regarding its use in TKR, the set-up was similar to that seen in Hannover and it was good to explore their methods and learn from their “tip and tricks” to improve outcome.

After the operating list on the first day, we were invited to their departmental teaching session in which several of their specialist registrars presented a variety of topics relating to elective orthopaedics, including kinematic alignment of the knee, with most of the presentations in French.

We had the opportunity to spend time with the team away from theatres as Prof. Kouyoumdjian invited us to his favorite rooftop restaurant for dinner one night, which overlooks a Roman amphitheater, and to his family home for a blind wine-tasting challenge and a lovely home-cooked meal. We had also spent a day with Prof. Kouyoumdjian as he drove us to Saintes-Maries-de-la-Mer, a beautiful fishing town on the Mediterranean Sea, and around the Camargue National Nature Reserve.

Dinner at the home of Prof. Kouyoumdjian
Dinner at the home of Prof. Kouyoumdjian (center) who is shown with other members of the department.

It was a pleasure to spend time in Nîmes and with Prof. Kouyoumdjian’s team, which was welcoming and keen to let us operate during our visit. Since our return, we have continued to be in contact with his team and hope to collaborate on some research projects.

London experience

We arrived in London where we had intended to spend the full week at the University College Hospital (UCH) and Princess Grace Hospitals with Prof. Fares Haddad, but unfortunately, the elective operating lists at UCH were canceled due to the COVID-19 pandemic.

The fellows are shown with Prof. Haddad
The fellows are shown with Prof. Haddad.

However, we were able to attend the Princess Grace Hospital for two full day lists and gain further exposure to MAKO-assisted hip and knee replacement, as they began offering robotic orthopaedic procedures in 2016 and were the first private U.K. hospital to do so.

Despite the limited time spent with Prof. Haddad, we had an opportunity to discuss the role MAKO has had in and impacted upon his practice and to learn from his wealth of experience as he has demonstrated significant advantages of using the MAKO in terms of reducing length of stay and lowering pain scores, as well as making more accurate bony cuts with reduced soft tissue releases compared to conventional jig-based techniques.

To conclude, we are grateful to have been awarded the first EFORT Robotic Travelling Fellowship which took us to three great centers across Europe and would thank our hosts for their generosity and excellent care. We would particularly like to thank EFORT for this opportunity and for the help and support from Lidia Sloutskovski who worked hard to ensure the logistics went smoothly, and to thank Stryker for their sponsorship and Mark Vernon, in particular.

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