This web site is maintained by the 1998 ABC travelling fellows, it has been updated during our fellowship. The purpose of the site is to document the 1998 fellowship and provide insight into its nature, opportunities and day to day workings. We apologise that we cannot include everybody we have met but we would all like to thank all our American and Canadian hosts as well as our National Orthopaedic Associations. If you have any comments please e-mail the web-master.

(You may wish to disable automatic graphic downloads and be selective in what you view as this site contains a lot of graphic material)

•  Introduction and History
•  Travelling Fellows Personal details
•  Itinerary
•  Centres Visited
•  ABC dictionary of quotations
•  Short term survivorship analysis
•  1998 ABC web master

• Peter Kay, Manchester UK
• Andrew Carr Oxford
• Basil Vrettos, Cape Town South Africa
• Nicola Maffulli, Aberdeen UK
• Timothy Briggs, London UK
• Richard de Steiger, Melbourne Australia
• Peter Devane, Wellington New Zealand

• Iowa City
• Mayo Clinic, Rochester
• Minneapolis
• Chicago
• San Antonio
• LA
• New York
• Ashville
• Duke
• Chapel Hill UNC
• Memphis
• Philadelphia

• Halifax
• Toronto
• Montreal
• Ottawa
• London
• Hamilton

Up at 05:45hrs - early morning transport to Heathrow for 7:00. Tim and Andrew upgraded at great expense. First discussions on practice of orthopaedics in different countries, and on English vs. Scottish practice. Surprisingly easy flight, time passed rapidly. Very hot on arrival in Chicago John Callaghan met us as he returned from a meeting elsewhere. John was an ABC fellow in 1991 and had been appointed by the AOA to organise the US leg of the fellowship. The format for the next 6 weeks was discussed. It was decided that there would be no single leader of the group but rather that the leadership would rotate at weekly intervals. We also decided that we would take the responsibility for formally thanking institutions for hosting us and after dinner speaking in turn. Tim Briggs was therefore placed in charge of the first week (Surname beginning with B). We then flew from Chicago to Iowa. At Cedar Rapids (The Airport), Stuart Weinstein president of the AOA met us. Basil had lost luggage - or rather the airline had. There was a 20-minute car trip to Iowa City, to the Holiday Inn. Dinner was at very pleasant restaurant called Giovanni's with the rest of the faculty followed by a relatively early night after visiting the bar. We discussed the presents we had brought with us and planned how, as a group, we would distribute them over the next 6 weeks - an excellent start to the fellowship (what would Basil wear for the next 6 weeks?).

In the morning we were met at the hotel by John Callaghan & Leslie Jebson at 07:00hrs. Basil got his luggage back in the night. Breakfast was at the Iowa Hospital (800 beds). Jospeh Buckwalter gave a history of Orthopaedics in Iowa - Ayuwha (beautiful land, sleepy ones). First settlement 11000 BC. Orthopaedic clinic started by Arthur Steindler in 1912 (flexorplasty). Dr I.Ponseti came to Iowa in 1941 (graduate student) in the Faculty since 1944. Mike Bonfiglio 1950. Reg Cooper chairman since 1972. The lectures given were as follows:

Stuart Weinstein (ABC 1985) provided a 50 year follow up of scoliosis, treated conservatively. 203/219 (93%) plus 22 patients lost in 1978. 117 of 223 took part. Av FU 51 years. All severe curve. High rate of LBP in scolio pts. Greater pain for longer than control, but no difference between scoliosis patterns. No relation between spine OA and LBP. No difference between scoliosis pts and controls, despite LBP. These patients continue to have high levels of functional ability.

Dr I.Ponseti: concepts of club foot treatment. Correct cavus, adduct and apply counter pressure on head of talus. Correct equinus through subcutaneous section of AT. Do not pronate foot.

John Callaghan surface finish in cemented femoral fixation. Massive lysis at tip of bead blasted or grit blasted. Much better polishing the stem.

Reg Cooper: outlined the structure of Orthopaedics in USA. "When you get too old to hunt, you teach a course on how to read buffalo shit". AOA started in 1887. Membership limited in 1930's: ABOS 1934; AAOS 1933. Academy for education (14900 active members from USA, 23000 in total). Now AAOS has emphasis on politics and economics. ABOS certifies competence: two parts exam, MCQs, clinical, ten yrs time limited exam. Accreditation Council for Postgraduate Medical Education developed 27 Residency Review Committees, with 74 subspecialties. Fellowships regulated only in 1984. Now 8 subspecialties and 178 fellowship programmes with 333 fellows, but dropping.

Lunch with John Staley, Hospital Admin: explanation of differences between VA and hospital, Medicare, Medicaid, Indigent Patient Programme. In the afternoon we visited the laboratories including biomechanics as well as cell mechanics.

PM visit to labs with Dr Brown president of the AORS. At 5.45, off for dinner after working out what presents we had between ourselves.

That evening a faculty meal at Larks restaurant - billed as doing the best steaks in the world - and after sampling them they probably did. The first after dinner talk by Tim - it went down well including the nun joke - .We returned to the hotel for a night-cap at hotel bar. The night-cap was to become a major part of the tour with the only time available to us to discuss the day's activity and plans for the following day.

06.15hrs start, with trauma rounds at 07:00hrs at the Iowa University Hospital. As we arrived at the hospital we realised that Basil was missing. Not a good start for ABC self organisation - we would have to rely on head counts in future. Les went back to the hotel to get him. Case 1: wedge fracture of T12 in 40 yr. vascular surgeon. Neurovascular intact. Two column burst fracture of T12. Immobilisation in TLSO. Also compression fracture of T6 and T10, originally missed (? old at T6). Self fusion of T11-12 4 years post injury.

17 yr female RTA, belt, passenger, neuro intact. Conservative Mx in TLSO. 38 yr. M RTA, splenic laceration repairs, head injury, right knee jerk absent. L2 # dislocation with rotatory component, CT: retropulsion and several fragments in vertebral canal. Fixation with Isola instrumentation.

Talk with Malcom Pope. Visit to Dan Gable. Lunch with Ignacio, then off to Cedar Rapids. Richard had trouble at check in: all our flight numbers were changed. Eventually, we managed to write a few postcards and the thanks letters. Good flight to Rochester through Minneapolis, with Mike Rock(ABC 87) to meet us. Shipped to Mayo clinic on a brand new bus: 100 operating surgeons, 104 theatres, surgery often performed within 24 hours of 1^st. OPD visit. Met Frank Sim(ABC79). Immediate conference on Osteolysis in THA. Excellent presentation, but still no answer. The ABC fellows divided up and stayed with faculty members. Dr Trousdale who was to be one of the hosts had a bad night in the OR with trauma cases. The Mayo is not just elective.

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Early morning rise. Talk on patellar resurfacing in TKA. Probably resurface all in RA, and many in OA. Do not resurface if good articular surface, no inflammation and good alignment. Meeting with Robert Cofield. Metabolic bone disease, microbiology, upper and lower limb biomechanics, oncology, plenty of lab support. Same problems of reduction of residents: now only 10 from 16 in 1970's. Physician extenders: 17, replacing junior residents. ~50% of residents take a fellowship. About 12 fellows in a variety of subspecialties. "Oncology fellows for the good of mankind". Lower rates of surgery in RA.

Driscoll on surface chondrocyte replacement in OA. Paperless office, with immediate communication, and digital radiographs. Mayo was started by doctors, and when tax laws changed became a foundation, with a board of trustees, with a board of directors (10 doctors, 2 administrators) on each site. Each chair responds to the BOD. Salary between 50 and 75 centile of national average. 50% of orthopods have labs, with different % of time that each of them spends in lab. Federal gvt. programmes pay 75% of residents' salary for government pts, who account for 33% of all pts. You can bill for pts treated by residents if non-gvtal, including 15% of assistant fees. On top, there is state funding. All billing is according to the disease and Mx.

Tour with Greg Anthony. About 20% of patients are self- referred. Main switchboard has calendar of all doctors clinics, but authorisation from insurance company required, or a $ 1500 deposit from patient. Pts. from abroad are 6%. In Medcare+aid a flat fee is paid only. Non- collected bills are ~ 3%. THA is $ 10-14K. Charity care ~ 5%. Waiting time for OPD is ~3/12. Surgery is planned and can be executed within 24 hrs. Patients often stay in surrounding hotels. Length of stay in THR is days 5, aim is 3/7.

Notes are stored centrally, and 200,000 are out at any given time. Tests are pre-ordered, some are scheduled through CAD (central appointment desk). Sequencing according to test to minimise waiting. 400 staff in medical records. Each patient receives a full printed itinerary for their visit.

80 radiologists on staff. Films are read and reported, returned etc, within 2 hrs, with live dictation to a secretary.

Plummer building (great architecture) with the library. Biomechanics at Guggenheim building. MCL fatigue and TER. Foot & ankle simulator. Contribution of dynamic stabilisers in mid range of shoulder motion. Gait lab with surface EMG capabilities.

Four labs microvascular, molecular biology (fracture healing), biochemistry and physiology of bone mineral metabolism and histomorphometry, cartilage and connective tissue lab. Each lab led by a PhD, plus medical fellows. Repair, regeneration, allografts, regulation, bone physiology. PCR on site, mRNA, antisense nucleotide inhibition, protein analysis, immunohistochemistry, in situ hybridization. Ovariectomised rat, senescent rat, in vitro rabbit cartilage explants, loading, leaders in US in # healing.

Lunch at Michael's a very pleasant restaurant in town: pecan pie a la mode. Richard was a true expert of all that is sweet - he approved of the pecan pie.

Afternoon academic session: molecular optical tweezers for single collagen molecule stiffness measurement. Current concepts in complex humeral fracture management (M. Torchia): percutaneous with staple; if ORIF: staple and TBW, plate and TBW. Revision THR (Daniel Berry) 400 in 1996 and 400 in 1997. Since mid 90's, uncemented hemispherical acetabulum. Antiprotrusio device in massive defects, bone quality, massive bone loss and pelvic discontinuity. Femoral revision: second generation cement technique. Impaction grafting in selected patients. ABC Richard de Steiger lectured in periprosthetic fractures. Probably best option is revision THR. Infected TJR (AD Haansen): eradication, pain relief, salvage of joint, maintain function. Debridement with prosthesis retention: 30% success should not be attempted in late chronic infection. In TKA, arthrodesis is a good indication. Controversies in reimplantation: delayed reimplant with antibiotic cement. ? wait one year, but 3/12 is probably fine. Articulated spacer in knee unimpressive. Cement spacer with AB probably better. Use hybrid prosthesis. Use post-stabilised TKR.

THR registry: 50000 pts, 5 full time staff to administer the registry (one mail shot per year).

Visit to Mayo House: Victorian, gorgeous.

Short stop at Mike Rock's place, then off to Golf club for dinner. Excellent talk by Bernard Morrey (ABC 1983). Golf joke by A Carr.

Hosted by Dr Michael Rock

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Clinico-radiological-pathological conference at 07:00hrs. Paraosteal sarcoma of the lower femur with massive distal femoral replacement. Fairly good agreements between US and UK.

Extraosseous Ewing sarcoma of the thigh: pre-op chemotherapy, with good reduction in bulk. Excision with removal of anterior 1/3 to 1/2 of periosteum.

Chondrosarcoma of proximal thigh, arising from osteochondroma. Excision. 20 yrs history of recurrent masses and excision. Distal mets, grade 2 chondrosarcoma with mixoid changes, with local excision. Large recurrence, and hindquarter amputation.

Grade 4 MFH. Anterior thigh, ending 19 cm proximal to patella. Wide excision

Rounds at Methodist Hospital: Ewing proximal femur: excision, allograft bipolar partially cemented bipolar hemiarthroplasty. Several infected and loose THRs. Two stage revision advocated for infections (even 12/12 wait).

OR at Methodist Hospital: 55 ORs, of which 10 are orthopaedics, working 24 hrs/day.

Frozen sections read in < 5 minutes! Camera included in theatre light handle

Only in the last two years there has been identification of specialities producing most money, and encouraged to grow, both clinically and academically.

Mayo philosophy: patients come first.

If the patient is still alive, there remains an opportunity for the physician to worsen the condition.

Old age and treachery will always overcome youth and skill.

Visit to Chris Unni: 4000 external consultations per year.

Lunch on 22nd floor Charter House Building, Silver Lake Room.

To the airport by coach: all here!

Flight to Minneapolis very bumpy: Nick and Richard green! At airport, good reception. Evening with hosts. Peter Kay and Nic at Deb & Tom Quanbeck, in Plymouth, a suburb to the West of Minneapolis. Dinner with Tom & Peter at Lord Fletcher, on Lake Minnetonka. After dinner, medical skills put to test with a friend of Tom's who had had a slight hypoglycemia episode after playing volley ball. Good old fashioned Mississipi mud pie cured it.

 Dr Mark Swiniontkowski our host and chief at Twin Cites

University of Minnesota Cancer Center (Advancing knowledge, enhancing care) four ABC lectures (Tim, Peter K, Basil, Richard). Hospital was sold to HMO 18/12 ago, as it was too wasteful, with over investigations and high procedure rate. Now it is called Fairview-University of Minnesota Hospital. Marc Swiontoski (ABC 1989) chairman for 6/12. Financially hospital has turned around.

Visit to Shriners Hospital for children: $23 million 9 yrs ago (cash!) with theatre twice as big as ours. Everything on site but MRI and CT. Shriners is a philanthropic organisation, totally financed by endowments and gifts. 40 bed ward, with adolescent side, pool, etc.

After a vist to Minneaha falls, sandwich lunch at Tackx, and then visit to Mall of America. Lovely evening meal at Deb and Tom's, with a typical American flavour. Tomorrow, for the first time we shall be waking up after 6 am

Muffin breakfast at 8.30 am. bliss, or near there. All together at the Marriot Hotel, then all to golf accept Nic who went for a workout in the biggest club in the MidWest, Lifetest. Beth and Ellen Swiontkowski picked him up from the club, then home to a large detached house (large!).

Golf club excellent. Given the option to walk or take buggies, the Travelling Fellows decided to stand up to their name, and to travel by buggy. Tom Quanbeck started with a birdie, but the only person in proper attire was PK, who brought his golfing shoes all the way from old UK. Everything went downhill from there, and in the match between Northern and Down Under hemisphere, the Brits gracefully allowed the old colonies success. The Northern hemisphere group managed to achieve wheel spin on the buggy. Andy managed to exert his sniping skills by creating a new model of fracture healing in migrating geese.

After lunch, off to the Key Theatre to watch an interactive play (Tina and Tony's wedding): great fun, with some dancing, a gay cameraman and a drunken nun. The evening ended with a pool game across the road from the theatre. Good fun altogether, and a few drinks too many.

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The usual pattern: wake up at 5.30 am, to fly to Chicago, where Mike Simon (ABC 1983) came to pick us up. Tim, Pete and Richard stayed at Mike's place, the rest at the Sheraton. In the morning, architectural tour of Chicago. Amazing mix of architecture, with classical, art deco, post modern, etc all merging into each other. Lunch on our own in a french Diner on Michigan Av: they tried to con us out of $30 : a talk with the waiter sorted it out. Do the ABC Fellows look so gullible?

Afternoon of for some of us, but Tim, Pete, Peter and Richard went for museums.

The night was spent at Buddy Guy's Chicago Legends (Jazz Club): some eight beer pitchers and the most enormous portions of chicken and ribs: even Tim could not finish his. Excellent night with Howard and the White Boys.

Late wakeup, and bagel breakfast on th roof of Mike (a.k.a. Skeeter) and Barbara Simon's place. A short visit at the Hancock building gave us a 25 mile view around Chicago: breathtaking. The rest of the day was spent shopping and resting: much needed. At 5 pm, we went off for the first baseball game of this trip, in the Comiskey Park stadium, Chicago- White Sox vs New York Yankees. The White Sox did not do too well, but we had great hot dog and a guided tour of the stadium, before going to our wonderful seats, in the dugout. The White Sox have not been too great for quite a while, and the stadium, originally planned for 60,000, only hosted 20,000. White Sox lost 12-0, but good fun just the same.

SLAP: sensationally lucrative arthroscopic procedure

Night caps at the Sheraton, with nachos, Pinot Noir and whisky.

Another attempt to con us: Basil was charged $ 382 instead of $ 91 for his washing. A quick chat with reception rectified this, and resulted in a waiver of the Health Club charges ($ 15).

At the Gleacher Center, home of the Chicago Business School, presentation time.

Prof Edward Abraham, University of Illinois (Bone transport in rabbit tibia) Largest medical school in USA, cheapest in Chicago: 300 students per year, largest resident intake. In bone transport, areas of avascular bone with osteoblast activity, a sign of insult. In rabbits, 14% transport, with 2 cm defect. At 2/52, early periosteal callus. Gap filling with clot, but no evidence of cartilage. At 6 to 10/52, some empty lacunae, with barium uptake in cortical bone, with early formation of osteoid seams. Problems at docking site, with translation and atrophic nonunion. Docking problematic: freshen just before docking. Middle segment viability 100%.

Prof. Steve Rabin, Loyola Uni (Oblique osteotomy of the lower limb) Femoral malalignment significanly morbid. Tibial malalignment gives less problems. At fracture site, optimal, but easier healing in metaphyseal area. Osteotomy perpendicular to plane of maximal deformity, and parallel to plane of minimal deformity.

Prof. Mark Gonzalez, University of Illinois (Flap coverage for chronic traumatic leg wound) 42 flaps in 38 pts with > 1/12 probs (1 to 360/12). Free flaps used, as local conditions did not allow local flaps. 81% of flaps survived. Most common cause of problems was vascular compromise. Amputations in 4 pts.

Anthony Romeo, Rush Presbyterian-St Luke's (Anatomic reconstruction of the proximal humerus) Modular head is advised. Centre of humeral head different from centre of humeral shaft.Articular surface is 1/3 of a sphere. Inclination, retroversion, medial and posterior offset are all necessary for anatomic reconstruction. Articular surface retroversion extremely variable.

Jeremy Gilbert, Northwestern Uni (Self reinforced composite materials in Orthopaedics) Application of molecular orientation to improve material properties of PMMA. Modulus is thus increased some 5 times. Hot compaction technique creates a composite of greater modulus than titanium.# strength increase 4 times, bending strength can double, fatigue strength increase 4 times. Woven composite cement is now coating a regular stem to enhance fatigue life of strength (layer of 1.5 mm). UHMWPE treated in the same weight sounds as ceramics. Bone cement gels: two gels, one with initiator, one with activator: minimise mixing porosity. Viscosity can be adjusted. Temperature can be kept in the commercial range and even lower. The amount of monomer is greater than in present bone cement.

John Martell, University of Chicago (Compression mold vs. machined polyethylene in THR: up yo 8 yr FU) Theoretocally, compression moulded twice as good as machined ram extruded, both in vivo and in vitro. No difference between machined or direct mold at 8 years. Previous studies likely reflect the advantages of compression moulding only.

Frank Phillips (Intervertebral disc degeneration adjacent to intertransverse lumbar spine fusion: an experimental model) In general, adjacent segments develp DJD and instability. Present models: annulotomy, or chymopapain. Both are nonphysilogic, with little clinical relevance. Model: NZW with annulotomy, fusion with MMA and 20 gauge stainless steel wire across transverse process of L5, 6, 7. Progressive DJD in levels adjacent to those fused, loss of lamellar distinction and orientation, clefting in annulus. By 9/12, new bone formation within the disc, with decrease in procollagen, and increase in cartilage.

Louis Draganich, University of Chicago (TRAC knee: two radius area contact) Rollback increase quads lever arm. TKR pts lean forward to increase quads lever arm. TRAC knee maximises lever arm. Each condyle has two radii, thus ensuring greatest possible contact area.

Talks by Peter, Pete, Andy and Basil

Lunch at Lizzie's, on the river, with a few anecdotes on previous ABC fellowships (V. Frankel: Total hip: it will never work).

Back to O'Hare Airport for a (late) flight to San Antonio, where a whole bunch of chaps came to pick us up. Tim and Nic stayed with Ken Corley, in Alamo Heights. Big drinks, and beef fajitas at Raco Cabana at 12.30: great. Pete and Peter stayed at Charlie Rockwood's house emptied a fridge full of beer into the early hours of the morning discussing orthopaedics.

Early morning depending on the host Nic went to the Concord Gym with Ken, then off for an American diner's (Jim's). After two days of such early keep fit Nic looked like he might die.

Scientific programme at the Health Science Centre Medical School (sixth best NIH funded orthopaedic dept in USA). James Heckman is the chairman, and president of the AAOS. San Antonio is the ninth biggest city in USA, with 60% of people being hispanic. HSC is 25 years old, and the Medical School is 30 years old. A total of 30 residents. Five teaching hospitals, with a level 1 Trauma Centre, a VA , a Methodist and a children hospital. All take care of indigent patients.10 full time academics, 6 PhD focussing on biochemistry, biomechanics and biomaterials. Green, DeLee, Rockwood, Wirth the Travelling Fellows of the dept. Academic programme:-

Ultrasound and fracture healing (James Heckman) First studies in Brazil by Duarte. in 1990, Pilla in NY performed a better study. They both showed a significant faster healing.Bolander found more abundant and stronger callus in rat femoral #. Fracture stimulation with 30-50 mW/mm2. In San Antonio, RCT in tibial # patients, multincenter, placebo controlled study. 20' US treatment/day for 20/52 or clinical healing: acceleration of healing. Similar study by Kristiensen on Colles # (61 patients): 38% acceleration of healing. Also, less residual angulation. In Germany, similar studies in callotasis, with similar results. Possible mechanism- micromotion, cavitation, thermal effect.Yang and Bolander 1995 Gene expression in soft callus.US treatment probably at its best with smokers. Us can accelerate # healing by 25%. Role in Mx of non-union not established. Indicated for some fresh # (scaphoid).

Creating computer generated presentations (David Green) In 1950 lantern slide cover glass, then slides, then carousel, then double carousel, now computer.

Charles Rockwood the shoulder(ABC 1967)

Michael Wirth (ABC 1997): pictures of trip

Jesse DeLee (ABC 1983 ): Hamstring ACL reconstrunction. Lesser morbidity, problems at harvesting sites.

Charles Rockwod (ABC 1967) Non-operative Mx of rotator cuff injuries in senior citizens. Orthotherapy successful. Four phases: no pain, stretches, specific programme to supplement supraspinatus and infraspinatus (compression effect of infraspinatus and subscapularis), maintainance. Incidence of asymptomatic subjects with MRI proven cuff probs: 55%.  

Lunch at the Golf Club, then off to the Rockwood Ranch yee-ha!.

Dr Rockwood picked a patient up in his pickup. The patient said "You can train monkeys to do hip and knee arthroplasty, but for shoulder surgery you need a real surgeon". I wonder who told the patient that!

The whole afternoon and evening were spent at Rockwood's ranch: big walk with him and the boys shown the boars, a spring, creeks etc: really a cowboy in the best possible sense of the word.

Dinner was barbecued stuff (great cat fish), where the whole faculty joined in. At the end, we had a guided tour of San Antonio by night by Fred: lovely town, with a lot of character.

Up at 06:00hrs to Wilford Hall Medical Centre conference with Charles Rockwood and Michael Wirth. The only USAF Hospital to train orthopods.

Does a medial epicondylectomy weaken the MCL? (Major William Dineberg) O'Driscoll's technique: no!

Progression of thoracic curves in patients with idiopathic King I type scoliosis treated with anterior spinal fusion of the lumbar curve (Major Richard Bauman) 9 pts, 2 failures, small, immature, > 10 degrees apical thoracic rotation.

The prognostic value of CT in developmental DDH (Major Paul Maynard) Many procedures in 114, with 73 CTs, radius of femoral head increased with increased Severin grade,

Safe pin placement for hybrid external fixation of the distal radius (Major Blake Curd) K wires are fine in this location.

Tim gave a talk about Churchill. Explained that Churchill had originally been too stupid to do anything else but join the army - probably not the thing to say on a military base - still they were very nice about it and did not shoot us.

Lunch (Tex-Mex) at Casa Rio in central San Antonio on the river walk, with visit to the Alamo and to the Mexican market. After a quick return to the Medical Centre, then off to LA via Phoenix. Dr Finerman (ABC1977) and Jay Lieberman (ABC 1997)met us to bring us to the Hilgard House Hotel.

Meeting at a decent time (08.30hrs.) at the Centre for the Health Sciences at the UCLA Campus. There are 200 medical students, and 400 beds, with 30 orthopaedic residents. Academic Programme:

Total elbow arthroplasty (Roy Meals) 16 pts (mainly RA) in 10 years. Pain relief in all pts, significant increase of rotation, but no effect in fixed flexion contracture. Massive heterotopic ossification in a pt who had TEA after #. RA pts better survival than other pathologies. Loosening does not appear to be a problem, but instability and dislocation are. Non-constrained implant: good ligaments, good bone, high demand, semi-constrained implants in all others.

Biomechanical consequences of ACL graft substitution (Keith Markolf) Through tibia. Increase in force exerted to ligament in full ext and hyperextension.Internal torque loads ACL more than external torque. Hyperext + int torque worst. Hyperflexion also causes increases torque. In MCL section, significant increase in load to ACL, both with valgus stress and external torque. Overtensioning of graft does not change the moment required to extend the knee. External torque causes significantly more stresses in grafted ACL. 3 mm apparent graft shortening.

Twenty years of progress and endoprosthetic reconstruction (Jeffrey Eckardt) Endoprosthesis in pts with grade III disease give good survival. Porous coating probably at the wrong site: it should be outside the bone, to prevent migration of debris in the cement-bone interface.

Peter and Richard gave lectures

LA has five Med Schools. ~ 45% of the LA population is Hispanic.

Lunch at the Faculry building, then Getty Museum and a tour of Bel Air and Sunset Boulevards, and houses at $ 10 million.

After a rest, the evening was spent at the Golf Country Club (OJ was a member), with all the faculty and the wives: a good mixed bunch. A night-cap at the Western Marquee, in front of the hotel, with an average of two whiskies and six ports each: good going. Andy was to regret it the next day.

Scientific session at the Orthopaedic Hospital. Founded early 1911 for the treatment of crippled children, then developed as a hospital in 1917 by Dr. Lohman, and fully operational in 1922. Theatres close to plaster room, OR with windows. Very fast surgery. Present hospital built in 1964. New Orthopaedic Hospital to be built in Santa Monica, with a research Institute of 60,000 square feet. Academic programme:

Ulna collateral ligament instability of the elbow (Frank Jobe) Most common in baseball, but possible in javelin and tennis. CL more commonly injured in LCL. Early diagnosis and conservative Rx to be mainstay of treatment. Anterior bundle is the key. Isometric inferior bundle of anterior portion. Superior band non isometric. Acute injury in pitching. Chronic: microfailure. Four stages: oedema and inflammation, dissociation, calcification, ossification. DD with ulnar nerve neuritis. Tenderness at distal insertion of UCL. Milking sign (O'Brien). Stress Xray: not diagnostic. MRI: OK, but physical examination is key. Plain Xray: associated abnormalities (calcification).Spurs suggest UCL injury, but is not indication for surgery. Rest 2-4/52. Throwing programme at 3/12. Pain free from 75-100% of pitching velocity: fine. Surgery for acute complete rupture, and for failure of 3/12 of conservative Mx. Split in pronator muscle. to reach the ulnar nerve. Drill holes at isometric location, with figure of 8 passage of plantaris. Post op: early motion, rememebr shoulder. No throwing for 4/12. FROM at 1/12. Full rehab at 12/12. No need to transpose ulnar nerve, and results worse when this is done.

Gene Therapy with BMP producing bone marrow cells (Jay Lieberman) Ex vivo approach. BMP part of TGF beta superfamily, and present in all animals. Regional gene therapy with osteoinductive cells (bone marrow cells) that themselves respond to BMP. Adenoviruses are epichromosomal, so no incorporation in recipient genome. 5 million cells enough. In adeno-BMP, thic trabeculae. In BMP alone, thin trabeculae, hence BMD in adenoBMP was greater than in BMP alone. Cell carrier: demineralised bone matrix. Bone formation may only require limited duration or protein delivery.

Periacetabular osteotomy (Joel Matta) For young adults, a better alternative than THR for dysplastic hip. Problems in dysplastic hip: overload, instability, labrum lesion. Advantages of osteotomy: extensive correction, pelvic inlet unchanged, single approach (Smith-Petersen), minimal internal fixation, functional after treatment possible. Posterior portion of the bone is left intact. Cuts: infracotyloid (incomplete with 30 degrees osteotome), pubis (as close as possible to acetabulum), ilium (with saw and II, about 15 mm above joint), quadrilateral surface, retroacetabular surface, ischium (from inside to ouside with 30 degrees osteotome). Correction: lateral rotation, antiversion, anterior rotation, medialisation. Mistake: lateralisation, retroversion. 4.5 mm screw fixation with positioning screws, not lag screws. Look for restoration of Shenton line. In 59 pts, one pelvic non-union, metal removal, 3 THR, 28% patients with fair or bad results.

The development of an extremely wear resistant UHMW polyethylene for THR (Harry McKellop) Solution of wear problem: short term not reduce wear resistance; long term to improve wear resistance Oxidation reduces wear resistance, cross linking improves wear resistance. With irradiation, if O2 present, acceleration of oxidation; with no O2, free radicals form Xlinks, and improve resistance to wear. Gamma UHMWPE irradiation may have higher wear rate in the long term. A two step process of irradiation and remelting is what is advocated.

Vascularised bone and joint transfers (Neil Jones) Survival of graft is independent of recipient site, with osteocytes remaining viable. Healing resembles fracture healing. Free vascularised joint transfer mainly using foot joints, mainly in children and young adults. Toe to hand transfer further indication, such as trauma and congenital disorders (amniotic band syndrome, transverse and longitudinal defects.

Tim and Andy gave lectures.

The afternoon spent at Universal Studio, Lunch at Hard Rock Cafe, then Jurassic Park (wet), Backdraft (hot), ET, and Back to the Future, with a guided tour of the studios. In all, good fun. Dr Finerman must have felt he had seven little boys - or he may have been one himself!.

Evening spent with the residents at the Sky Bar (LA High Life): a tip of $ 20 each just to get in. Reward: plenty of long legged babes, silicone and style (politically dubious statement). The bill: $ 317. Typical of the States, we (Black Basil, don Carr, the Italian Scot and the Welsh Mancunian) were taken for a ride by a taxi driver who did not have a clue on where the hotel was. We ended up in low Santa Monica Blvd, before getting to a Beverly Hills hotel from where we reached the Hilgard Hotel at about 2.15 am for a well deserved rest.

31^st. May (Sunday) day 16 

In the morning, most of us were not quite 100% (Peter was 110%), and some (Tim) very close to desiring death. At LAX, after saying good bye to the UCLA people, we had to change the terminal, and the plane was late. What a life!

In Denver, we spent a couple of hours on the tarmac waiting for NY to give the go ahead, as tornadoes were going on in La Guardia. On arrival, we were welcomed by a mighty shower, and a limousine - the airport then shut again. The Crown Plaza Hotel, in front of the UN Building, welcomed us at 12.30 am. Tim, Pete, and Peter went for a Chinese meal and a drink at Donohue's - what stomachs!

An early start to get to Hospital for Special Surgery for 07:00hrs. (up at 06:00hrs - equivalent to 03:00hrs having just come from LA) Three lectures given by the ABC Fellows (Tim, Nic, and Basil) no local lectures. Nothing formal had been arranged - visit to the operating theatre. After this we all dispersed to reconvene at Hospital for Joint Diseases that afternoon following a trip up the Empire State Building. The founder of the HJD had been on the Titanic. There were 60 residents on the training programme. HJD does 8500 procedures per year, with about 85 orthopods on staff, of which 40 are of full time staff. Two more ABC lectures were given Peter and Andy.

That evening a quick walk to the Metropolitan Life Building (the old PanAm building) for dinner at the Sky Club (An old fashioned club - not like the LA sky bar)- a magnificent view of Manhattan. A meal with many of the other surgeons from New York as well as a lot of after dinner jokes.

Returning back to the hotel, the travelling fellows tried to have a night-cap at Donohue's only to find that it had closed down for good: PK, PD and TB were the very last customers the night before - any connection?.

Picked up at 07:00hrs by Evan Flatow(ABC95) and taken to Columbia Presbyterian Hospital, at one stage the largest private biomedical centre in the world, funded in 1866. It was the first centre to have an integrated hospital and medical school. Now has 1100 beds, one of the largest hospitals in NY.The department has its own library, open 24 hr per day with FT librarian. Lectures were given on the following:

Tendon injuries in the elbow (Robert Strauch) Distal biceps tendon probs: fixation with anchors 

Streaming potentials response of human lumbar anulus fibrosus is altered with disc degeneration (Mark Weidenbaum) Originally described by Quincke in 1859. Streaming potential related to composition and structure, and a sensitive index of disc degeneration.In L2-L3 disc in cadavers, statistical but no clinical difference in SP with static load. With sinusoidal loads, significant doubling in SP in degenerated discs.

 Outcome measures (Michael Vitale)

 Recent developments in rotator cuff surgery (Evan Flatow) The unrepairable cuff is like the unrunnable marathon, the unreturnable serve, the unchugable beer. Emphasis is restore muscle-tendon unit. Partial repair better than no repair. Save the coraco-acromial arch. Static grafts generally give poor results.

Effect of temperature on the polymerisation rate and on the mechanical properties of bone cement (Michael Parks) Temperature may alter the biomechanical properties of bone cement. Increased temperature may decrease porosity and operating time. Increased temperature: minor variation in modulus of elasticity, either improve or no effect on ultimate tensile strength, no effect on # toughness, decrease in porosity. In general, no adverse effect, and all changes were beneficial.

Trauma training centre (Maurizio Herrera)

Microsurgery laboratory (Yelena Akelina)

Orthopaedic research laboratory (Van Mow) Cartilage and arthritis research Consilience: things in life are governed by only a few fundamental laws. Consilience in joint mechanics, and the like. He showed us a formula explaining everything - spookily everything became clear. We were to see the same symbols in the Egyptian section of the Ottawa museum at the COA.

After a free afternoon, evening at the Lunt-Fontanne Theatre to watch" Titanic the musical". This was a fantastic performance - before the performance we went to a bar for a drink. Tim asked for a drink of milk - the barman could not believe it - Tim was obviously starting to crack under the strain!

3^rd. June (Wednesday) day 19

A very early start (4 am) to go to La Guardia Airport, where we boarded a flight to Atlanta, a stopover to reach Asheville, where we stayed at the Grove Park Inn, a lovely big lodge on a mountain ridge. After a lunch on the balcony with views of the countryside. Nic had to go to a dentist (lost a crown), while the rest of the team spent the afternoon around the pool or playing tennis. The inaugural session of the AOA was a formal affair with introductions of the ABC fellows, we managed to get a photograph with all the presidents of the English speaking orthopaedic associations, a unique event. An open-air buffet allowed us to renew friendships, and to make a few new acquaintances, before, exhausted, crashing to bed.

 4^th. June (Thursday) day 20

The fellows attended the lecture sessions of the AOA:

Sports and Shoulder session. Rotor cuff tears uncommon, but are subsequent to degenerative changes. Charles Rockwood advocates rehab and non-operative 'orthotherapy' on older pts. pain control, shoulder motion, shoulder strength; maintenance of motion and strength. Pts. can function without supra and infraspinatus if the other muscles are competent. Supraspinatus can be vicaried by subscapularis to allow overhead elevation.

Autologous puzzle pavement cartilage-bone graft (K Draenert). Essentially, a mosaic plasty using a press fit cylinder. This will provide primary cancellous bone healing. At 2/52, no significant neo-vascularisation of the graft, but cells are still viable.

Mx of displaced three part #es of the proximal humerus (Evan Flatow). In good bone, ORIF. In old pts, hemiarthroplasty. If surgical neck # reduced OK, bone suture used, at times with Ender with holes at the top. In suture, incorporate cuff, and repair tuberosities. This Mx resulted in better motion in bone suture than hemiarthroplasty.

Rotator interval contracture after instability repair (Louis Bigliani) Rotator interval lesions are a cause of instability, and some authors advocate closure as the only Rx of instability. Tight imbricated rotator interval causes stiffness, and there is an inferior pouch. With tightening, release interval contracture, and appropriate capsulolabral repair.

ACL reconstruction: a medical outcome study (G. Poehling) Auto- and allografts used At 6/52, allograft higher level of activity, and autograft more pain. At 1 and 2 yeras, no difference. Allograft $200 less expensive, as length of time for surgery was decreased, and day case surgery more frequent with allografts.

Strategies of Rx in non-unions of the humerus in older pts. (Jessie Jupiter) 22 pts. av. age 72, with established non-union (av 28/12). All with extensile exposure, antero-lateral. Long plate, at least 11 holes, often with blade plates. At times, intramedullary plates were used. Also, wave plates are an option.

Lunch with Paddy and Helen Mulligan, before going with Black Basil (name earned due to sinister black hat purchased in Texas) to town by bike. In the best of tradition, it started to rain, and we ended up soaked. A quick round of Golf was slipped in.

The fellows attended the lecture sessions of the AOA: Raining again, but it became clear enough for the golf tournament not to be cancelled. A quick call at the congress, and, after lunch, Nic went off to town with Paolo Aglietti. Peter, Pete and Tim played golf with Chit Ranawat - his golf is as good as his hips. In the evening, President's dinner at the Biltmore estate: sure the Vanderbilts had a lot of money. Pleasant end of the evening with Chit Ranawat in the bar: a master of wisdom and of university politics.

The fellows attended the lecture sessions of the AOA: J. Urbaniak: Facilitate and interchange of ideas and joint action with other major orthopaedic organisations.

Afternoon playing tennis and fitness, before going to the Great Gatesby Gala Ball: early night after some dancing!

 7^th. June (Sunday) day 23

Early start (4.45), for a flight to Atlanta (why do we keep going to Atlanta - for the grits!) to reach Raleigh-Durham at 9.30. We hired a GMC Suburban, where we managed to fit with some difficulty. Dick (a partner of Jim Urbaniak (ABC1973)) came to see us at the Washington Duke Inn and Golf Club, before coming to play golf at the Treybuern Club where Jim Urbaniak is President. After a light lunch, off to golf. Nic tried to hit a ball: it went the best part of 4 yards, and, in the process, the health and safety of Pete was severely threatened. The country club is nothing short of princely, and the course one of the toughest in the USA. The winners by one stroke were TB, PD and PK: a baseball cap. Evening at Jim and Muff Urbaniak's, with the Weinsteins and the Callaghans: lovely evening, with excellent food, service, company. Nic gave a vote of thanks, with, as per usual, John Callaghan chipping in. Richard played the piano.

Morning at Duke's University, evidently rated 3rd in the USA, started in 1930. Totally private, the fee is $ 39,000/ year, with 9 residents/year and 100 medical students. Since 1982, the campus has had its own monorail system, floating on air. The present development programme is for $130 millions. Lectures given:

 Ilizarov for tibial malunions and non-unions (Robert Fitch) 23 pts, 6 previous infections, 12 initially open. Ilizarov 23/12 post injury. Angular deformity 22 degrees, shortening 2.3 cm. Corrected and union in all using distraction hinges.

 The effects of coronally slotted femoral prostheses on cortical bone strain (Parker Vail) slot may decrease thigh pain, but effect on load transfer unknown. Sintered beads proximally, with distal beads proximally, and distal part solid, or with slot 1/4, 1/3 or 1/2 slotted. No significant effect on stress-shielding whether or not a slot was used. Medial assembly strain increases with greater length of slot. Therefore, with slotted stem, there is longitudinal tension medially and anteriorly, and compression laterally and posteriorly.

Farshid Guilad: animal and cellular models of OA. ACL and MM ablation, with allograft: still OA ensues. Threshold of loading for OA determination.

Diet and fitness centre at Duke. John Feagin: examination with knee flexed. Radial meniscal extrusion test. Prognostic examination of the knee: varus thrust, ACL as medial-lateral stabiliser and predictor of femoro-tibial OA.

Basil gave a lecture on behalf of the fellows.

That evening at Larry Dahner's(ABC91) place, in Chapel Hill, for a Pig Pickin' evening with the Chapel Hill Faculty: lovely.

 9^th. June (Tuesday) day 25

Morning at Chapel Hill. 15 attendings, 4 residents, with research park of 6000 acres in the Triangle (Raleigh, Duke, Chapel Hill). Lectures given:

Wounding in vivo and PDGF-BB in vitro stimulate tendon surface cell migration and loss of connexin 43 expression (Donald Bynum) Injury to tendon disrupt tissue architecture and vascularity. Tendon epitenon more than internal tendon cells migrate in vivo to a wound as an initial rsponse to trauma. Notch wound model created, and epitenon cells were first to migrate in week one from injury. Internal tenocytes less involved. Little DNA synthesis in migrating cells. Combined IGF1 and PDGFBB cause greater additive effect on migration. Migrating cells down regulate connexin 43 production, and re-express it as migration slows.

Imaging in patellar tendonitis (Louis Almekinders) MRI oversensitive: even in asymptomatic knees, 24% showed altered MRI signals. tendon width: 5/1.7, defect width 3.9/1.9, tendon length 36 mm. Non articular/articular ratio: lower pole longer in symptomatic pts.

Non-contact ACL injury mechanisms (William Garrett) Women at greater risk of ACL injury (2.5x in soccer, 5-8x in basketball). Eccentric action of the quads produces anterior tibial displacement sufficient to rupture the ACL.

Contracture and growth in ligamentous tissue (Laurence Dahners) Fibroblasts have more actin than motile cells. Other musculo-skeletal muscles grow at a 'growth plate'. Ligament length increases throughout the length of the ligament, interstitially. Same results in tendons. Some growth occurs even without tension. Collagen fibrils contain interfibrillar bonds, and fibroblasts have contractile cytoskeleton. Contracture occurs without stress.

 Dislocation and diameter in total hip replacement (Scott Kelley) ? small head predisposes to high dislocation rate. Smaller heads greater dislocation rate (15% vs 3.5%) than 28 mm. In a RCT, this was confirmed. All dislocations occurred in 22 mm heads, with acetabular greater than 56 mm. Mismatch to patients anatomy, with mismatch of small head to anatomical head. ? larger heads must displace more before dislocating. for 50: 22, 54: 26, 56: 88, 62: 32.

Short visit to the labs and to the Kenan Sports Medicine Center, to see John Feagin, a great diagnostician (a breath of freshness), before flying to Atlanta and to Memphis, where we stayed at the Peabody Hotel and had dinner (double serving of pork ribs) at the Rendez-vous, in front of the hotel.

 10^th. June (Wednesday) day 26

Picked up by the residents and taken on a visit to the Campbell Clinic. 28 surgeons, 3rd busiest trauma centre in USA, 1st for ortho trauma. Very aggressive fixation of everything. 50 acetabulae per year. Two trauma teams (white and orange). Not much AO. 4 dedicated OR for trauma. Two staff trauma surgeons on duty over the day. Only trauma centre in 200 miles. Hand is taken by the ortho trauma team, but reimplants are done by plastic surgeons. Trauma is not necessarily managed using ATLS criteria. Trauma ICU with 25 beds. Visit of the New Campbell clinic, started in Georgetown 6 yrs ago, led by Terry Canale. PT and Ortho OPD all on ground floor, in a nice relaxed atmosphere of progressive halving of pts numbers as pts progress from reception to cubicles. Orthotics are manufactured on site, with own hand PT and OT. KinCom and Biodex isokinetic dynamometers. Homeward Suites at Campbell Clinic is the hotel of the clinic, and pts receive a 25% discount. Staff recruited in the clinic are required to buy 100 shares of the clinic, and are salaried, with no incentives but for trauma attendance and consultations.

Quick lunch, and off to the Chicksaw Country Golf club with Jim Beatty- Jim's son will be a golf professional one day - he is good.

Conference at the Campbell foundation. All the ABC fellows talked, followed by a barbecue in the clinic. The night was spent in Beal St, in two brilliant bars, in the company of two residents. Richard played the piano, and Andy Carr was invited to dance by one of the girls in the audience, earning him a comment from one of the residents (Is he out on the prowl?), and the nickname of 'The Prowler' for the rest of the trip. In the other bar, good music, plenty of beer and Jack Daniels, and to bed at 1.30 a.m, after a frantic search for Nic who got lost; went to make a phone call in a dark spot of the bar. (he says!)

 11^th. June (Thursday) day 27

Visit to Smith & Nephew factory. Jani Shilesh, of the R&D Dept, told us about medico-legal issues in implants. Lunch at Luby's, typical American diner on Elvis Presley Blvd before visit to Gracelands (the whole works: thrown into a 70's dream, or nightmare!). Historical tour of the Sun Studio, with a very intense native American guide. After a stop over in Atlanta (Atlanta again!), we got to Philly to be welcomed by Jo Iannotti and Williams. Raining like mad, we got to the Penn Tower Hotel totally drenched at 1.30 am.

 12^th. June (Friday) day 28

After four hours of sleep, off to Presbyterian Medical Centre, part of the University of Pennsylvania (Ivy League) with Jo Iannotti for an allograft reconstruction of the rotator cuff. Only 8 ORs - Andrea Michi, from Bologna, as a visiting fellow. 50% of surgery is day case. OR for a previously operated supratentorial antero-inferior instability, Mxed with a shrinkage and removal of a loose suture.

University Dept. is now in Medical School, but is going to move to Pennsylvania Hospital next year in a phased redevelopment, occupying a whole building in the centre of town. 27 full-time orthopods on the staff. The Medical School is ranked 3rd in the USA for NIH grants. 11,000 square feet of otho. lab space, originally funded through a donation by McKay (750 k). Labs in renovation, to be opened by 3/99. Two residents per year get in the lab, but at one time 8 did. In the last four years, the internal funding has decreased to 20% of what it was, and most research is funded through external granting. Greater industrial interactions.

Conference in Children's Hospital.

Welcome and introduction (Robert Fitzgerald) Connection with Edinburgh and London. Good talk on the history of the Dept.

Why do some people form two skeletons? (Frederick Kaplan) Fibrodysplasia ossificand progressiva (FOP), about 1 in 2 million people. Spontaneous mutation, autosomal dominant with various penetrance. First ray malformation: short hallux valgus. First manifestation is lump over dorsum, with great vascularity, forming mature bone through endochondral ossification, with formation of osteochondromatas. Misdiagnosis is common, with 89%. Normal bone is formed, which can fracture. Patterns of FOP is not random, following a spatial and temporal gradient. Morphogens play a role. Drosophile model: decaplentaplegic (dpp) is hologous to BMP4, and in multiple copies mutant disrupted patterns similar to FOP develops. Inflammation seems to play a definite role in FOP, and over expression of BMP4 in lymphocytes following trauma seems to be the main lesion. Heterogeneity of FOP, from study of 4 families. Inhibition can be a therapeutic possibility.

Overuse injuries of the rotator cuff tendons in an animal model: a histologic and biomechanical study (Louis Soslowski) Rat model used, using repeated eccentric contraction. This produces profound histological changes, and increase in cross-section of the animals exercised, with decrease of mechanical properties.

Surgical management of proximal humerus malunions (Gerald Williams) Dependent on personality of malunion, with options for CT and MR scanning. Both soft tissue and bony problems should be addressed at the same time. Main indication should be pain.

Dysfunctional instability of the elbow treated by semiconstrained total elbow arthroplasty (Matthew Ramsey) Tricky operation, given the number of previous ops, with contracture of soft tissues. Unstable non-union and bone loss are two different groups. Morrey TEA was used, and bone graft incorporated nicely.

Long-term results of large segment endoprosthetic reconstruction of the distal femur after tumour resection (Philip Wirganowicz) Cemented prostheses used (46) in a series of 392 endoprosthetic replacements all over the body. Bushing failures rare. Function extremely good. Pts twice as likely to die as to require a revision. If revised, they do well.

The PCL: save, sacrifice, or substitute: a balanced view` (Paul Lotke) Save: stability, roll back, absorb. Not always possible. PCL substitution may result in smoother axis of rotation. Difficult to get tension right. Whatever done in their 246 consecutive pts no difference in clinical scores, but, if it was substituted, ROM was greater. Long term survivorship same.

Basil, Nic Pete and Tim gave lectures.

After an afternoon that went on to 5 pm, we managed to get 1 hr of rest before setting out to the Bellevue Hotel, of Legionnaires' disease fame, for the formal dinner with the faculty. The do included the graduation of the residents, and speeches went on for 90'. The celebrations when on well into the night.

 13^th. June (Saturday) day 29

A leisurely late wake up (08:00) for formal breakfast at the Four Season Hotel in the middle of town - a touch of colonial decadence, We then visited a chipped bell and the buildings that are the hallmark of US Independence. We then rushed to the airport with a flight via Toronto to reach Halifax at 6 pm: This proved to be the most difficult of our flights we sat on the ground at Toronto for over 1 hour in an electrical storm the airport was closed. When we did get into the airport Pete and Nic did not have a seat on the plane to Halifax. Various people were bribed with $300 or a free ticket to anywhere in the US - the seats were found - In the end, we managed to get on the flight, and we were only 2 hrs late. That evening we had dinner at John Hyhndam and Mike Gross's place on a very foggy coast, at Shebucto Head - a fantastic meal. After the meal we were billeted with various faculty members and finally retired to bed.

A day of R & R. All met at Dr Gross's house with a beautiful view of the water. We then set off together to sail the Amasonia (Lorne's yatch). We set off from Lorne's cottage (possibly the most beautiful place on earth) close to Lunenburg, an old German fishing town, where we saw the Blue Nose II (famous boat). Great fun - Nic turned green on a few occasions. That evening all together at the Saraguay club, for a barbecue with the residents and faculty.

 15^th. June (Monday) day 31

A 07:00 hrs start with lectures at the New Halifax Infirmary, Royal Bank Theatre with the following:

Gait and its perambulations (Lorne Leahey) Influence of limb length discrepancy on maximal O2 consumption. Static LLD and dynamic LLD (while walking). Static LLD with shoe lifts, and measurement while walking with 0, 2, 4, 6 cm. Control free-walk velocity and subject selected velocity measuring VO2. Walking velocity decreased with increased LLD, and VO2 increased at selected velocity. Dynamic LLD is ~ 50% of static LLD. 4 cm enough for subject to walk slower. Lorne had also analysed the ABC fellows ability to steer the boat the day previously (using the gait analysis equipment) - the ABC steering committee the results showed that Tim was most consistent driving the boat, Nic most consistently sick .

 Interpretation of COM gait signals. Aberrations can be determined by portable apparatus in 3 dimensions. ACL deficient knee: preliminary report with gait analysis (Lorne Leahey) Pts move more laterally, and no effect of bracing.

 Mass, kinetics, and soft tissues (William Stanish) Rest produces atrophy in all musuloskeletal tissues.

 Biomechanical gait analysis of morbidly obese women before and after gastroplasty surgery (Ron Al Hawary) Preop, slower walking, decreased stride length, increased % stance than non-obese subjects. Ankle and hip kinematics not different from normal patients. Maximum stance knee flexion less than in non-obese. Obese women's gait is adapted to obesity.

 Glucosamine knee study (William Oxner). Alternative medicine: use of glucosamine sulphate in knee OA.

 Joint position sense and balance of male and female basketball players and normal controls (Barbara O'Neil) No difference between males and females, and between athletes and non-athletes: possible difference in active and passive motion.

 Kyphosis and spina bifida: the development of a surgical solution (John Hyndman) Luque rods with sublaminar wires, inserted in the vertebral body of the lower 3 lumbar vertebrae. 17 pts, FU 4 yrs, range of age at op 2 to 17 yrs. Probs with migration: if it happens, rod it extracted with no loss of correction.

 Free vascularised fibula graft for tumour reconstruction (Michael Gross) Good operation for 15 pts. Clinical outcomes, waiting lists, and measurements (Michael Gross) Important for surgeons to collect their own data.

 What the ministry collects on orthopods (A Ministry person with no name) In Nova Scotia, in general waiting list decreased. But nobody knows how much to allocate to each procedure.

 Osteoclasts, debris and hip replacement (Gail Anderson) In vitro studies using polyethylene, hydroxyapatite, bone cement. Alendronate reduces osteoclast resorptive activity. The various particles inhibit osteoblasts differentiation. 5 lipoxygenase inhibitor decreases osteoclast activity.

 Current trends in orthopaedic education (Catherine Coady) Self directed, centred on learner, facilitated by focusing on a task, tested appropriately. From novice to expert: modelling, coaching, scaffolding, articulation, reflection, exploration. Aptitude, cognitive, psychomotor. Surgical techniques probably better learned in a lab setting. OSATS: objective structured assessment of technical skills. Professional development to be preferred to medical education.

Richard, Nic, Basil, Peter, Pete, Andy and Tim gave lectures.

After the meeting, a quick run to the Halifax International airport in the rain and mist to get to Toronto at the Delta Chelsea. Halifax airport providing live lobsters by the gates - sampled by Andy and Richard. On arrival in Toronto those with stronger constitutions ventured out to take refreshment at a sports bar in an attempt to understand the finer points of baseball.

A 07:30 start to the day with various visits to hospitals depending on fellows special interests. Tim Peter and Pete when to Mount Sinia with Dr Al Gross (ABC1977) and saw a massive allograph for acetabular bone loss - an excellent operation. Afterwards we had "street food" with him before being taken round the university. In the afternoon we attended St. Michael's Hospital, for lectures on the following:

 Randomised trials in Orthopaedics (Susan Jaglal). Other project to test early discharge of hip # pts. At present, average length of stay 14/7. If everything is fine and pts. ambulant, they are discharged at 5/7.

 Impaction grafting and pelvic reconstruction for acetabular revision (Paul Wong) 54 in 53 pts in 14 yrs, av FU 5 yrs. 86% radiographic success rate. Indicated in contained cavitary defect in elderly or low demand pts.

 Case presentation (Tom Hupel) # distal radius, after previous #. Both Mxed by ext fixation. Now malunited and restricted ROM and pain. Intercalary bone graft and T plate, dorsally.

 Proximal femoral stress fracture after multiple procedures for a subtroch femoral # (Peter Weiler) Fixed with a intramedullary cephalomedullary nail.

 # talus off a horse: explosion of talus with # med malleolus (Ahmed Al-Omair) Fixed through antero-medial incision with plate for med. malleolus and K wires for the talus.

 Experimental IM tibial nailing (Emil Schemitsch) Canine tibia model, using reamed, minimally reamed and unreamed, and tight or loose fitting nail. Loosely fitting nail better for blood flow. At 11/12, no effect of reaming, but limited reaming short-term. Bone formation same in all groups. Best case scenario limited reaming.

Basil and Richard gave lectures.

That evening dinner at the York Club, with most of the Toronto and surrounding ABC fellows, including the last remaining one of the 49ers: brilliant. On return to the hotel we discussed the day in the bar.

The second day in Toronto. The morning spent at Sick Children Hospital. Mercer Rang sat quietly in the audience - a great man. The academic session included lectures on:

 Blood transfusion in total hip arthroplasty: the University of Toronto experience (John Murnaghan) Large inter-institutional variation, with overall rate of transfusion of 69% In Toronto, 6 centres vary from 2% to 71%. Autologous donation was most predictive factor for transfusion: autologous donors 12 times more likely to receive a transfusion..

The surgical management of the rheumatoid wrist (Earl Bogoch - a gentle giant) Symptoms dictate management more than Radiographs dictate Mx. Excision of distal ulna resolves most wrist pain. Total wrist fusion is a good operation. Dorsal wrist synovectomy generally relieves pain, but 10-30% show some radio-carpal subluxation following distal ulnar excision. Partial fusions are more used. Dorsal wrist synovectomy and radiolunate fusion new op with promising results. Bone graft rarely needed (autologous). Bilateral wrist fusion acceptable.TWR an option, but limited evidence of efficacy.

An unusual cat bite (John Murnaghan) 57 yo woman bite R wrist. On penicillin. Slow to settle: Pateurella + Staph epidermidis. Radiogrphs normal. Add clyndamycin. at 1/52, stiff wrist and pain extending to thumb. After debridement, OK. After 8/52, recurrence of probs. Oblique showed erosion of the radial styloid: Spongy inflamed material in a crater: most likely periosteum innoculation of Pasteurella, resistant to penicillin, Mixed with long term ampicillin.

 Rheumatoid forefoot reconstruction (Tim Daniels) 111 pts of 179 contacted. FU up to 16 yrs. Most Malposition could be a problem. Extensive resection defunctions the toes.

Hindfoot deformity (Tim Daniels)

Developmental dysplasia of the skeleton (William Cole) Single gene disorders give some insight in genetics of such diseases.

 The historical background and reasoning that led to the origination of the biological concept of continuous passive motion (CPM) (Robert Salter) against usual knowledge of immobilisation (plaster entrapment syndrome). A possible treatment does not make it desirable. The training of a doctor is such that it makes him amenable to question tradition (Perkins 1952). Bob Salter has a brother who is a business executive. CPM should stimulate mesenchimal cells to differentiate into articular cartilage. The one who says that it cannot be done should never interrupt the one who is doing it.

 A potential treatment for clubfeet based on growth factor blockade (Ben Alman) Growth factors inappropriately expressed in Dupuytren's. Cryopreserved tissues from club feet, and PCR and Western blot to identify growth factors (PDGF, TGF beta), growing cells with neutralising antibodies. For growth factors Type 3 collagen maximally expressed in the medial structures of talipes. PDGF and TGFbeta more expressed. Direct injection of antibodies to joints (Fukvi 1998).

 Outcomes research at the Hospital for Sick Children (James Wright) Geographic area variation: hip #low area variation, TKR and caesarean section high area variation. In TKR, probably unmet need even in areas of high utilisation of the procedure.

 Osteotomy for rotational patellar instability (John Cameron) Rotational can be associated with patella alta. Assess hip rotation, tibial rotation, patellar height. Stay away from femoral and tibial osteotomy combined. In rotational patellar instability, tibia is externally rotated. Osteotomy above the insertion of the patellar tendon, transverse, fixed with one or two staples.

 Modes of failure in total knee replacement (Jeff Gollish) About 7% of TKRs in Ontario are revisions. Mode of failure, pre-op planning, surgical technique. Loosening (septic, aseptic), wear. Structures: bone, prosthesis, soft tissues. Interface failure, mechanical failure, non-mechanical failure. Bone-prosthesis: septic-aseptic. Prosthesis-prosthesis: polyethylene, metal. Mechanical failure: instability, stiffness. Instability: angular, rotational, translational. Stiffness: technical factors (malalignment, joint line, soft tissues (fibrous motion restriction, arthrofibrosis, ligament, i.e. PCL, imbalance). Non-mechanical failure (pain, extensor mechanism probs, periprosthetic #, miscellaneous, such as myositis ossificans and recurrent rheumatoid).S

 Articular cartilage injury as a function of time from ACL to the time of cartilage grading (Paul Marks) Association with bone bruises: 60% of knees with geographic bone bruise develop OA. 88 pts, interval from ACL injury 6 to 240/12. Linear relationship between length of wait and grade of degeneration of cartilage. ACL risk equation: instability, subcortical infraction, meniscal damage, growth factors, proprioception, others.

 Andy and Peter gave lectures

We had lunch at the Sick Kid's hospital and in the afternoon walked over to the Mount Sinai Hospital. The academic session here consisted of lectures in:

Fresh osteochondral allografts for post-traumatic joint defects (Allan Gross) Comprehensive programme at Mount Sinai: 260 in trauma pts in last 12 years. Chondrocytes are immunogenic, but are protected by matrix. Fresh osteochondral allografts are impalnted within 24 hrs using rigid internal fixation. Malalignment corrected at the same time of allografting. CPM post-op, bracing for 1 yr. Alignment major determinant of success. If malalignment, collapse develops fast. In partial osteochondral grafts, no Charcot joint develops. Risk of viral transmission: 1:0.5 million HIV.  

Patient based follow up in pts with unipolar osteochondral allograft in the knee (Zoe Agnidis) 5 yrs minimum FU. 47 pts, 25 with meniscal grafts, and realignment in 21. About 80% of pts reported a successful outcome in returning to work and sport.

Learning the technical skills of surgery (Carol Hutchison) Bioskill lab. Repetitive practice not possible, and lesser public tolerance for error. Bench model simulations inexpensive, reproducible, portable, OSAT: multistation timed exam.  

Non-arthroplasty management of knee OA (Wayna Marshall) Hyaluronan and hylans (cross-linked: hyaluronan) visco-supplementation. Chondroprotection, chondrogeneration. May salvage failure of arthroscopic debridement from TKR. Likely anti-inflammatory effect as well. Absolute indications: poor candidates for TKR, too young, too old. Relative indications: high demand, post Ax failures, Ax candidates with no mechanical derangement.

 Osteochondral transplantation (Tony Miniaci) At times, taken from opposite knees. Less than 5-6 mm in diameter, stay away from 8-10 mm plugs. Take from edge of patellofemoral joint. Harvest difficult arthroscopically: at beginning of learning curve, use small arthrotomy. Plugs harvested at least 2-3 mm apart, and inserted 1 mm from each other. Do not leave plug proud: cartilage dies, leave level to surrounding cartilage. 6/52 protected WB with crutches. OCD: excellent; trauma: good; PFJ: fair.

 Predicting the clinical behaviour of osteosarcoma using molecular alterations (Jay Wunder) Multiple mechanisms of drug resistance, with cross-resistance. Drug is pumped out of the cell, with no activity of the drug. MDR1 gene involved, and its expression predicts behaviour of osteosarcoma. However, no relationship between this protein expression and prognosis. P-glycoprotein expression related to tumour aggressivness. Other mechanisms of drug resistance may play a more critical role.

 Nic, Pete, Andy, Richard and Tim gave lectures.

The meeting ran a little late Peter and Basil volunteered to pass up the opportunity to give their lectures has they had already lectured earlier that day. One does have to make sacrifices occasionally.

That evening we went by boat to the Royal Yacht Club on the Island in front of Toronto. The view was magnificent as was the company. Dr Bateman was there the father of the bipolar - an amazing man. Concern was expressed about him as he used a stick, we wanted to make sure he was OK getting home - he had the last laugh - he was picked up from the jetty by a very attractive lady in a big car - you cannot beat experience!

 18^th. June (Thursday) day 34 (Andy's Birthday)

An early morning flight to Montreal, arriving at the Sheraton Central Hotel. We had time to have breakfast, which was very large but also very good. Andy was presented with a birthday cake - Happy 40^th. We were met by two of the residents who took us to visit the Shriners Hospital for Children, with visit to the lab guided by Robin Poole. Lab. looking at molecular biology financed by MRC and NIH. Two fellows every year. 5 basic research teams for OA in Canadian Arthritis network: biotechnology. Lab with protein sequencing facilities, peptide synthesis, antibody production, oligonucleotides, computer modelling of antibodies tridimensional structures. Synovitis monitored through comp activity. Chondrocyte regulation in degeneration and regeneration of cartilage. Proteases (cathepsin K implicated in osteoclast activation) in OA. Auto-immunity programme, focusing on aggrecan and link proteins. PCR work using animal models for OA, looking at upregulation of proteases by proteases themselves. Immuno-localisation assays and in situ hybridization on site.

The academic session consisted of lectures on:-

 Regional bone graft harvesting in anterior spine surgery (Philip Downer) Bone harvested from vertebral body. Use cylinder 18 x 22 mm, for a total of 6 cc. Self designed tools, with diamond tip drill. Cadaveric study, total of 75 samples. Approach safe, with no breaching of posterior wall of vertebra, but breach of end plate in 4 cases because of under-estimation of lumbar lordosis. Biomechanics studies of the vertebra from which the graft was taken showed decrease in strength in flexion-compression. When tested in a multi-segment fashion with the defect filled with bone cement, tantalum or SRS, strength increased to normal.

Investigation of advance technologies for reconstructive orthopaedics (Dennis Bobyn) Revived interest on metal on metal THR (cobalt-chrome vs cobalt-chrome). Volume of debris much lower than metal onplastic (100 times less). Polar bearing should be looked at. Surface roughness should be minimised. Porous surfaces in THR unsuitable as structural devices. Porous tantalum highly porous. Tested in several models. Transcortical implants allow bone in growth. No differences in bone in growth according to pore size. Good results in femur and in acetabulum. Subcutaneous implantation of tantalum shows incorporation of tantalum in ligaments.

 Cartilage degeneration in arthritis: new therapeutic approach (Robyn Poole) Proteoglycan degradation not as important as collagen degradation in OA, and specific inhibitors have been used to block collagen degradation. Serum monitoring of OA, and effect of anti-inflammatory drugs.

3-D spine biomechanics (T Steffen) Percutaneous insertion of pins in spinous processes of L3 to L5, connected with electromagnetic sensors to calculate and visualise 3D motion. Coupled movement often greater than main motion.

Hand based autografts for scapho-lunate ligament replacement (Edward Harvey) For chronic conditions, use carpo-metacarpa ligament of the 3rd MC. ? steal from Peter to pay Paul.

Peri-prosthetic osteolysis (David Zukor) Not reversible. Apoptosis or necrosis in osteolysis? Apoptosis good in organ regression, elimination of DNA mutation, osteoporosis, bad in AIDS. Significant apoptosis in periprosthetic membrane. Particles probably induce apoptosis, and bisphosphonates can prevent and possibly reverse osteolysis by inducing apoptosis in osteoclasts.

Role of growth factors in limb lengthening (Reggie Hamdy) TGFbeta application did not exert any action.

Peter and Basil gave lectures on behalf of the ABC fellows

 That evening we dined at the Club St Denis (Old French Canadian Club) with the Department of Orthopaedics, before getting to the Winston Club, in down town Montreal, for a few beers. Evening concluded at the pool table. Happy birthday to Andy Carr.

This was to be the first really free day! Leisurely breakfast on the 37th floor of the Sheraton with panoramic views of the city of Montreal. Andy and Richard went off to seek culture, Basil to investigate the city. Peter, Pete, Nic and Tim arranged to go on a Montreal bus tour. We visited the Cathedral which to say the least was both impressive and very French. We next visited the docks - we thought we were very clever as we dodged in front of a very slowly moving freight train to get to the water front. However when we came to get back to the bus the train was still going. It went on and on and on - in fact it was just like the trains you see in guide books about Canada. It must have been 2 miles long - and guess what? When the train had passed the tour bus had gone, and that was the end of the tour. To make amends we had a lobster lunch at Le Maree and horse ride back to the hotel. Montreal had a wonderful feel to it - the old world and the new combined - That night we had dinner at Le Maison du Cari with the residents - yes a curry house a truly awesome feast. We returned to the Hotel to play pool in the bar and discuss the day.

  20^th. June (Saturday) day 36

We departed from Montreal at 10:00hrs. Originally our flight was planned for 06:30hrs because of the relative proximity of Montreal and Ottawa we decided to hire a bus rather than get up too early - we also wanted to see some of the countryside. We stopped at Montebello for lunch, at the Chateau Montebello evidently the largest log built structure in Canada it was amazing. We arrived in Ottawa, at the Lord Elgin Hotel, by 4 pm. We attended the opening ceremony of the Canadian Orthopaedic Association and we were introduced by Dr Johnson the ABC organiser for Canada. After the formalities of the opening ceremony we attended a reception, meeting up with many of the surgeons we had encountered in our travels. Following this we returned to our Hotel and had dinner in the Connaught restaurant and discussed the day's activities.

  21^st. June (Sunday) day 37

The first day of the Canadian Orthopaedic Association. The fellows attended various sessions on Hip and Knee surgery and a Shoulder Instability Course. The shoulder course included the following:

The unstable shoulder (Larry Colghan) Static stabilisers are mainly active and control range of motion: inferior glenohumeral ligament main stabilisers at 90 degrees (ant and post bands, and inf pouch). Concavity compression keeps head in place in midrange activities. Negative pressure keeps head in (capsular venting) Instability: anterior, posterior, and multidirectional.

History: frequency, direction, onset, volition, and degree. Complain shoulder goes out; position of arm at time of dislocation, pain with throwing, dead arm syndrome. Physical exam: apprehension, relocation, translation (side to side), sulcus sign. Most often, examination most evident under GA. Laxity tests: load shift, drawer, apprehension test, relocation test. With the arm in maximum external rotation, there is stress on the ant capsule, and cuff impingement between head and glenoid. Occult instability: internal impingement, post labral tears: apprehension test produces pain. Probably, it is traction overload. In pts. with anterior subluxation, there is a cross over of symptoms with impingement syndrome.

Sulcus sign typical of MDI. Imaging: MRI unreliable and bony indices not altered. Post instability: distinguish between laxity and instability. Most pts. with post sublux are able to sublux voluntarily. Stabilisers: posterior band of IGHL, rotator interval. Soft tissue procedures: 90% success with posterior labral repair, reverse Putti Platt.

MDI: pain with ADL, general ache, looseness, neurological symptoms, self reduce; in end stages: instability during sleep. Physical exam: neck, scapula, joint laxity (50% of pts. hyperlax). Rotator interval: patulous inf capsule. Repair through ant approach, with capsular shift, Bankart repair, rotator interval repair.

Ant instability: Bankart on its own not sufficient to produce instability: plastic deformation of ligs necessary as well. Most repair decrease ext rotation. or ant repair, capsulotomy vertical, and humeral or glenoid based. Horizontal arm first. If Bankart present, go for vertical glenoid, if not, vertical humeral. Shift inf to sup, and sup to inf. Post op complications: axillary nerve, loss of ext rot, increase compression, OA. Optimum repair should avoid tendon or bone transfer, and metal. ? role of acute repair, bioabsorbable implant, thermal shrinkage.

Stiff post-operative shoulder (Tony Miniaci) Higher goals at present. Loss of motion: procedure, pathology, presenting complaint. History, with details of operation and rehab. Determine contractures. Ancillary tests such as MRI not indicated in majority of pts. Motion restricting procedures: Putti Platt, Magnusson Satck, vertical capsulorraphy. Motion saving: Bankart, capsular shift. Bristow procedure may result in loss of ext rot. Correct placement of anchors should be at articular cartilage edge: most often, they are placed medially to this, thus producing an East-West capsular shift. Idiopathic stiffness: difficult to manage. Post surgery loss of motion: not benign, not all due to scarring. Stiffness and pain: determine location of contractures, then release, possibly arthroscopically. But if extracapsular, arthroscopy not good. Deltoid is often scarred down to vone: release through deltopectoral approach. Further procedures: separate conjoined tendon, lengthen subscap in cronal plane. Capsular contractutres: consider Ax release.

Stiffness, pain, OA: Common with tight ant repairs. Release of subscap beneficial. End result is TSR. Stiffness, instability, pain: flask deformity following capsular shift, with east west shift, but inferior pouch problem not addressed.

Later that day Peter and Tim visited the Canadian Military Museum, a most impressive museum with a wealth of information and exhibits. We learnt a lot about Canadian history - the balance between the French and British influences is fascinating.

That evening the COA dinner was held at the Museum of Humanity across the river from the City of Ottawa in Hull. This consisted of a buffet consumed amongst the Egyptian and Historical Canadian exhibits - truly magnificent. There was considerable opportunity to meet the orthopods we had met during our travels and discuss our various visits and research.

 22^th. June (Monday) day 38

Second day at the COA. The fellows attended various sessions on tendon injuries and revision hip surgery and heard Mark S. from Minniapolis give his talk on outcomes. We demonstrated our web pages to the British and Australian presidents. In the afternoon we played golf. Andy, Pete and Basil in the COA competition with Dr Minniachi. Peter and Tim had not enrolled for the competition and by now there were no places left: however Dr Huckle a previous COA president arranged for us to play golf with him at Eagle Creek - a most enormous and amazing golf course with the largest water hazards ever seen. The round took so long it was almost 20:00hrs before we returned to Ottawa - this is what happens if you get led astray by a previous orthopaedic president. Interestingly enough Dr Huckle's father was also a past president of the COA a real orthopaedic dynasty. Nic visited Little Italy. After a cocktail at the Westin, DJ evening dinner at the Chateau Lauren. There, PC Ho from Japan gave a harmonica concert. We returned to our hotel The Lord Elgin and as usual discussed the day's events in the bar.

Up at 06:00hrs for an early morning flight to London. We were met by Ces Rorabeck's wife and taken to the Windermere Manor Conference Centre, with Pete staying behind in Ottawa to give his paper in 5 minutes - none of the rest of the fellows felt that this would be at all be possible. We were able to watch a very old episode of "Star Trek" before setting off for golf . Nic attended the OR with Peter Fowler and Robert Lichfield. That evening we went to Cec Rorabeck's for an informal but rather impressive barbie meeting the rest of the faculty - all the final year residents had passed their exams. Following this we returned for a night-cap at the Windermere Cafe' and put the world to rights.

 24^th. June (Wednesday) day 40

We were met at 07:30 hrs by Cec and Graham King (ABC 1997) and taken to the University hospital for the academic session. We started with some very enjoyable case presentations.

Case 1. 40 yo F, clerk, right handed. Holiday fall, with 4 part # right proximal humerus. ORIF following day, with plate and screws, with rotator cuff repair. Incomplete axillary n palsy resolved in 6/12. 10/12 after, pain and reduced ROM. Wasted muscles, neuro intact. Now plate broken, non-union, back out of screws. Travelling fellows advocate hemiarthroplasty. Stuart Paterson did a blade plate with bone graft.

Case 2. 35 yo F. 3 yrs bilat hip pain, with ? Perthes at age 7. Bilateral femoral head collapse, and OA. Bilateral THR uncemented (28 mm head, 48 mm acetabulum. Area of lysis in acetabulum, with cavity, but asymptomatic. Peter Kay would revise with grafting. Peter Devane would revise with changing of liner and bone graft through cap holes and through a windows. Caesar Rorabeck did that, with downsize of the head from 28 to 26.

Case 3. 16 yo M club foot. 2 incision release as a child. Hindfoot valgus, midfoot supination, flexion of first ray. Impossible to find shoes. Oblique ankle joint line. NM advocates supramalleolar osteotomy, with progressive proximal to distal correction, and calcaneal osteotomy and first ray osteotomy with tib ant release

Case 4. 6 yr old boy, with spiral fracture of femur Mx in traction and Ender nailing x 2 removed at 9/12. 2 yr FU: 0.5 cm LLD (affected leg longer).

Cec Rorabeck introduced the department and explained that the residency had been started by Dr. Kennedy (LAD), who insisted on subspecialisation.

The lectures included:

The extended trochanteric osoteotomy in revision total hip arthroplasty (MacDonald) Hardinge approach + extended trochanteric osteotomy. Leave intact sleeve of vastus lateralis posteriorly . Osteotomy of 30% of femoral diameter. Ant. cortex, post. cortex proximally, transverse limb. Osteotomised fragment retracted posteriorly, address acetabulum, remove cement from femoral canal, insert component, fix with wires, test with ROM of hip. 22 pts, FU 1.5-9 yrs, av age 70, up to 6th revision. Long op, up to 5 hrs. At times, bony bridge seen across osteotomy. Maintains abductor sleeve, and allows controlled fracture, avoiding lengthy cement removal.

Management of displaced radial head fractures (Graham King) Surgery if motion blocked, fragment > 1/3 radial head and displaced > 2 mm. 3D reconstruction helpful. Indomethacin 48 frs rectally, then orally for 6/52, extension splint for 6/52. Radial head excision if stable fixation not achievable, and fragment > 1/3 radial head. Radial head offset from neck about 4.5 mm, and is an ellipse. Do not use silicone replacement.

Intramedullary nailing of paediatric forearm fractures (David Pugh) Open reduction (mini), then retrograde insertion for the radius. 30 such fractures 1987-1996. Radial bow: Schemitsch & Richards 1992 JBJS.

Management of segmental defect of the tibia (Mark MacLeod) Soft tissue, duration of treatment, multiple procedures, joint stiffness, muscle atrophy, rehab, complications, psychological upheaval. Sort soft tissue out first. Intramedullary nail and ipsilateral fibular transfer an option. Ilizarov option: 2 fixation points per ring, 3 per terminal ring. Graft docking site 2 cm from touch down.

Management of varus gonarthrosis: what's new (Robert Lichfield) HTO: opening wedge. Valgus overcorrection is a problem. Medial opening wedge more anatomical.

Two fellows presentations were included by Andy and Tim

In the afternoon we divided up ;Nic in theatre with Robert Lichfield, for a shoulder stabilisation and a mini-open rotator cuff repair. Andy and Basil with Graham King for an elbow replacement, Tim and Richard with Cec for a knee replacement and revision hip and Peter and Pete with Bob Bourne to discuss research. Later that afternoon Pete visited his in Laws - he had married a girl from London whilst a fellow - its amazing what you pick up!

That evening we went to a restaurant called Jack Astor's with the residents and had a great meal. Both Andy and Peter had to stand on a chair as happy birthday was sung - old Ontario custom. After dinner the fellows retired back to the hotel - the last night that we would all be together at the Windermer Manor Bar. We had heard that Jessie Delee had predicted with great accuracy what would happen to the fellows in his ABC trip and so to maintain this custom Richard acted as the foreteller of our destiny which was written on serviette - this has been retained for later reference. Despite talking incessantly for the previous 6 weeks we had surprisingly little to say that night - perhaps we had said it all or maybe whilst looking forward to home we were sad at parting - Mixed Emotions!

 25^th. June (Thursday) day 41

Breakfast in London - for once a leisurely breakfast, then drive in two packed Ford Tauruses to Hamilton, to be met by Justin de Beer our local Host. We stay at the Hotel Royal Connaught downtown. After a quick check in its off to Heron Creek golf course for a game and dinner with the faculty. Andy has to leave us and misses the golf. He has to be best man at a wedding - we have given him more jokes than can be imagined - but whether he is able to use them will be down to his own judgement. The golf course is magnificent being the local course of Frank Smith one of the local Orthopods - he joins us with his son, as Brett Dunlop (director of the orthopaedic programme at McMaster) has to leave to go to a graduation. On the course Tim takes 10 dollars off Richard, Pete, Peter and Basil play using a highly complicated scoring system which when calculated meant that Basil owed Peter one dollar and Pete 10 dollars despite the fact that Basil had actually gone round in less strokes! On the last 2 holes Peter produced the two longest drives of the tour and altered the shape of one golf ball in the process. Andy was missed - he would have enjoyed the course.

 26^th. June (Friday) day 42 (Peter's Birthday)

At last a sensible start to the day - the academic session starts at 9.30, at St. Joseph Hospital chaired by Justin De Beer and Dr Dunlop. Lectures are given on:

Hamilton hip fractures (A Papaioannou) Mortality and morbidity of hip fractures in Hamilton in 1993: 500 cases. In Canada, 25000 cases/year. Retrospective chart review. FU at home, with 90% recall rate of alive pts. Only 1.7% of pts. had a diagnosis of osteoporosis in their discharge notes, with 10% of them suffering another # within 18/12 of the hip #. 20% of community pts. died within 12/12, but in long term care, 40% of pts. died within 12/12.

Sequential bilateral total knee arthroplasty in geriatric patients (Todd Bentley) Same team operating on one knee after the other during the same anaesthetic. Retrospective review in pts older than 75 yrs. 45 pts. (34 F), FU mean: 29/12. Most pts. had cardiovascular co-morbidities. Av. No. of complications per pts was 0.6. Telephone FU survey showed high satisfaction levels, comparable with unilateral TKR. Comorbidity does not predict post-op complications.

Ilizarov versus a standard HTO for the treatment of medial compartment osteoarthritis (Anthony Adili) Comparison with standard closing wedge HTO. 15 pts. each group, 1 yr follow up. 3 ring construct, with opening wedge on medial side and compression on lateral side. Significant longer op time with Ilizarov. No difference in appearance of leg and in satisfaction. Better pain relief and function with Ilizarov.

Nic, Peter, Pete, Tim and Richard give their lectures but time runs short as the lecture theatre is needed and Basil and two local talks are posponed -

(Reamed versus non-reamed IM nailing of lower extremity long bone fractures: meta-analysis (Mo Bhandari) Pre-operative epidural fibrosis (Markus Bishoff))

after the academic session a visit to the Henderson Hospital with Justin with a review of research including outcomes. The problems of Vancomycin resistant enterococcus is discussed followed by a light lunch..

After lunch we are off to Niagara Falls with Justin. Quite spectacular - we go under the falls in the Maid of the Mist. On our way back to Hamilton we stop at the Queen's Landing Hotel at a place called Niagra on the lake and celebrate Peter Kay's 40th birthday with a bottle of Champagne and an impromptue but very violent game of catch with a baseball ball in a field - a great way of letting of steam.

That evening we attend a barbie at Brett Dunlop's house celebrating the graduation of the local residents who all passed their exams. We exchange presents on the poolside. The food and drink is excellent. We returned to the hotel at 23:00hrs but decide that we must eat together again and have our last proper meal at Frank's, the hotel's restaurant: plenty of chicken wings, meats, hamburgers, and some sadness. Those of us with remaining energy (Peter, Nic and Richard) managed a short visit to the bar with a local live band before bed at 2 am.

The last day of the fellowship - Tim and Andy having already departed. It seems strange with only five of us. The last breakfast on the fellowship - in an attempt to make up for the others departed we eat as much as possible - a power feed! An attempt is made to connect the various computers to exchange digital pictures but this proves difficult. Obviously English, South African, Australian and New Zealand computers have the same difficulties we do at times - we just cannot understand what each of us is saying. We write our last thank you letters to our local hosts. Pete and Richard depart the Airport first as they have earlier flights. Peter, Nic and Basil leave at 16:00 hrs after some further shopping and an hour in an Internet Café answering some late e-mail. Despite leaving 2 hours for the journey time we get to the airport in 40 minutes and say our goodbyes - to meet again in South Africa in 5 years time!

• Someone who's lost it - "the hamster is dead but the wheel is going round"
• A smooth operator - "That man thinks he sh*ts ice cream"
• Not going very far - "He's just circling the drain"
• Career progression - "When you get too old to hunt, you teach a course on how to read buffalo sh*t".
•  If the patient is still alive, there remains an opportunity for the physician to worsen the condition.
• Old age and treachery will always overcome youth and skill.
• SLAP lesion: sensationally lucrative arthroscopic procedure