Surgeons Corner | South African Shoulder and Elbow Surgeons

Fellowship Report

It was a privilege and an experience of a lifetime to have spent time during 2007 meeting the many surgeons the world over involved in Shoulder and Elbow surgery.

Courses/ Congresses:
Shoulder Arthroscopy: ValD’Isere, France (January)
My year began with a ‘bang’. I attended the Advanced Shoulder Arthroscopy course toward the end of January. This meeting, held biannually and organized by Daniel Mole, brought together some of the most prominent shoulder surgeons from around the world. The full spectrum of shoulder pathology was discussed at great length over 5 days with plenty of heated discussion and surgical demonstrations. There was still time for skiing of course!!

Live Surgery: Annecy, France (May)
Annecy is worth visiting if only to take in the scenery, especially in the summer months. Laurent Lafosse organizes this meeting, again inviting many well known surgeons to demonstrate live surgery – the surgery takes place at his clinic and is broadcast to a large auditorium filled with the attendees. This time 28 different procedures were shown – far too many I think because it left little time for discussion. Lafosse is certainly a highly skilled flamboyant surgeon who demonstrated both an arthroscopic Latarjet procedure as well as an arthroscopic Latissmus Dorsi transfer – not something too many people will attempt but amazing to see the how far shoulder arthroscopy has come. The highlight for me was watching Sugoya from Japan performing a double row rotator cuff repair – he had perfect suture management techniques but was also so fast that Lafosse has to ask him to slow down so that the crowd could follow the operation.

South African Orthopaedic Congress: Johannesburg, South Africa (September)
I had an opportunity to present the two papers that I had researched together with Shameem Osman. There was no instructional shoulder course this year but it was worth listening to the talks given by Bernard Morrey.

International Shoulder Society Congress: Bahia, Brazil (September)
I am sure people were excited about this venue the minute it was agreed upon. But it was a long trip there. Fortunately the programme was well designed so as to leave the afternoons free to make the most of all the facilities available. In my opinion, the free papers at times left a lot to be desired but the instructional courses were very useful, giving surgeons from all over the world a chance to share their experiences and knowledge. Several local surgeons were also invited to lecture at these teaching modules. For those of you don’t already know – the next meeting is in Scotland (2010) and then Japan (2013).

Fig. 1: Working with Ofer Levy

South African Surgeons:
I tried to visit as many doctors as I could during this time while still trying to hold down a full time job in the state sector. Hopefully I can visit and work with others still in the months and years ahead.

For the most part, I worked with Shameem Osman getting to him at least twice during week.
February: Basil Vrettos and Steve Roche
April: Thys De Beer and Theo Rosch
October: Dinos Kastanos
November: Abe Lamprechts

These visits made for some animated and remarkable discussions, but the most striking part of my experience was how varied the approaches and surgical practices of my hosts were. These men are all authorities and yet they are far from similar. Technically, some were measured and methodical; others were speed demons with no squandered movements. Some rehabilitate their patients in an accelerated fashion; others go very slowly. Some had overwhelmingly demanding operating rooms and clinics,
whereas others’ schedules would be considered undemanding by many. I realized that there is no “right way” to be a shoulder and elbow surgeon. However, there was one common denominator — successful results. At the completion of each case, no matter how varied the path, the final result was outstanding. The patients all appeared pleased with their great results.

Overseas Surgeons:
February: Ofer Levy and Steve Copeland – Reading, United Kingdom
I had a chance to join Steve Copeland while he consulted patients at his rooms – aptly called “The Mansion”. It is always a great experience watching one senior colleagues examine and then discuss the patients problems. We of course discussed at great length the ‘Copeland resurfacing prosthesis’- indications and outcomes. In his hands, humeral head resurfacing alone produces as good results as total shoulder replacement. This team makes multiple small drill holes on the glenoid surface to biologically resurface the glenoid – hoping that some new cartilage will regenerate. He has also studied in depth the Frozen shoulder and feels that they are best treated will skillful neglect. Ofer Levy taught me his ‘Parachute technique’ for rotator cuff repair – essentially his variation of a double row repair. I was also lucky enough to see his prototype for his new implant – The Verso – a reverse prosthesis with a short stem that only occupies the metaphysis of the humerus. At the time I was there, he was meeting with biomechanical engineers who were performing pullout strengths for the glenoid component of this implant He also showed me several patients in whom the Verso had been implanted - he has managed to achieve very satisfactory external rotation – something he feels is not a feature in other reverse designs. This prosthesis was officially launched at the ICSS 2007 in Brazil. Inspite of his exhausting schedule he still found time to go out on several nights for supper. This unit has two permanent shoulder fellows who each stay for a year. They have approximately 100 applicants each year for these posts.

June: Christian Gerber – Geneva, Switzerland
I was lucky enough to spend some time here given that Prof. Gerber has a busy traveling schedule. There was a fellow from Korea who was meant to spend two months here – he had already been there a month and had only met the Prof. for the first time on the weeks that I was there. Most of the work done by Prof Gerber is really revision surgery – be it cuff repairs or arthroplasty. I managed to see several revision arthroplastys where he had to fashion cement spacers for infection and also several cases of rotator cuff repairs - he does not feels that a double row repair makes any difference. He also repairs SLAP lesions if he finds them. During an attempt at inserting the glenoid component of a reverse prosthesis, he unwittingly fractured the glenoid and had to convert to a hemiarthroplasty – using a normal head – he does not feel that there is any benefit in using a CTA type of head which articulates with the undersurface of the acromion. It was interesting to note that he uses a metal-backed glenoid for his total shoulder replacements. These are made only for him and he had been inserting them for approximately eight years – he feels that this is the best option for good long term results but still needs to do longer follow-up before he releases his product to the market. Beside the junior consultants that work with him, he also has a permanent fellow from the US who stays for six months. Not surprisingly, he has a well established support base the many many researchers involved in basic sciences and engineering.

July: Gilles Walch and Laurent Nove-Josserand – Lyon, France
Dr Walch works with three other surgeons – performing approximately 30 – 40 cases per week - easy to see why they have such great experience and skill. The youngest, Lionel Neyton had recently joined after having spent a year each with Boileau, Lafosse and Walch himself. They pool their cases and have a dedicated research team to push out papers – and each paper has all of their names on it!! In the time I spent with them, I watched them doing about 8 Latarjet procedures – an operation they firmly believe is the answer for anterior shoulder instability – their results speak for themselves. Gilles has done more than 2000. He makes no attempt to repair the CA ligament to the capsule and leaves the graft intra-articular. He also has a series of patients for which he done both anterior and posterior bone block procedures for multidirectional instability. Also watched them use the Spider arm holder for almost very operation – given that they do almost all procedures without as assistant. Gilles has a single Fellow who works with him for a year.

Fig 2: Shoulder arthroplasty with Christian Gerber

There were many controversial topics brought up for discussion during my time with the various surgeons. I will share some of the more interesting topics that were debated.

Double row vs. Single row Rotator Cuff Repair
It is unclear whether there is any advantage conferred by a double row technique. It certainly takes longer and costs more. Sugaya demonstrated his technique at Annecy – he first repaired the cuff with a lateral row, the inserted the camera into the glenohumeral joint and abducted the arm demonstrating how much the cuff lifts off the footprint. He the added a medial row and repeated the move showing that the cuff now stays pasted to the footprint, a pretty convincing argument.

Total Shoulder Replacement vs. Hemiarthroplasty
Most surgeons agree that TSR give far superior results in terms of pain relief. The only centre that felt equal results were achievable with a hemiarthroplasty was Reading (Copeland & Levy). This may be related to the fact that it is bloody near impossible to implant a glenoid with the head still is place.

Biceps /SLAP lesions
More and more surgeons feel that these lesions are being overdiagnosed. The French surgeons certainly feel that the patient is better off with a tenodesis than a SLAP repair.

Management of Frozen Shoulder
Best managed by skillful neglect.

Arthroplasty for Cuff Deficient Shoulders
Copeland firmly believes that that there are two categories of patients – those who have compensated and are able to abduct using their deltoid and those that are uncompensated. He believes that an extended head which articulates with the undersurface of the acromion is satisfactory for compensated cases while a reverse type implant is needed for uncompensated patients. However many others do not buy into this argument and will use a reverse design for all cuff deficient shoulders.

Biological resurfacing of the glenoid
I was lucky enough to be present when a patient who had his glenoid resurfaced with a Graftjacket underwent an arthroscopy at three months – the graftjacket had completely resorbed with no evidence that it had ever been there. Although these are some centres in the States with good results (most notably Wayne Burkhead), most of the European surgeons do not feel that this is a viable option.

Biological augmentation for large rotator cuff tears
Almost everyone that I spoke to was against using any of these biologic implants to augment repairs or to act as interposition grafts in massive cuff tears.

I presented the following papers at the South African Orthopaedic Congress (September 2007).

- The Latarjet Technique for the Revision of Failed Bankart Repairs
- Arthroscopic Stabilisation of Type II Superior Labral (SLAP) lesions: Outcome to 2 years

These papers were also accepted as a presentation and poster for the 2009 ISAKOS meeting in Osaka, Japan.

Memorable Quotes:
“ I do not know when I last repaired a rotator cuff arthroscopically” – In a world where everyone wants to show off their arthroscopic prowess, it was refreshing to hear this from Thys De Beer who backed up his reasoning with some solid anatomical research.

“I cannot tell you what works – it is best that you try for yourself and follow up your patients” – Gilles Walch explaining that there were many ways to skin a cat.

“I do not follow up patients for too long – I rather spend my time seeing new patients who I can operate on” – Anonymous tip regarding private practice.

Special Thanks:
I am of course grateful to everyone who helped and taught me along the way but I must make special mention of these few people:

Shameem Osman: He really became my ‘guru’ during the last two years. He never hesitated to teach me and motivate me - not only about surgery but life in general.

Basil Vrettos: always full of helpful advice and encouragement.

Steve Roche: without whom I would have not had a clue about who to meet and where to go.

Prof. S Govender : for many years of guidance.

Fig. 3: Basil busy between cases

While the amount sponsored by the society went a long way to meeting the many expenses incurred during the year, I also received some funding by the following companies.

Smith and Nephew – sponsored the flight to Val D’isere (+- R10 000.00)

Orthomedics – Flights and accommodation to Brazil (+- R20 000.00)

Zimmer – accommodation in Geneva during my visit to Prof. Gerber.

Fig. 4: Val D’Isere with Shameem & our wives

Suggestions and Conclusion:
I do feel that an attempt ought to be made to create a fixed overseas rotation – possible two weeks each with Ofer Levy, Gilles Walch and one other surgeon. This will make it far less daunting for the next fellow when he plans his year. One of the bigger companies has talked about sponsoring the fellow completely – I think we should seriously consider their offer as the funds from the society are quickly swallowed up in the overseas trips. This may also make it possible to offer the Fellowship as a fulltime job for six months rather than having the fellow try to squeeze visits in while still attempting to work a normal job.

In conclusion I would like to thank the society one again for the fantastic and unique experience that they have afforded me. It was exciting year and an honour to learn so much from so many experienced surgeons is shoulder and elbow surgery!!