From left: Bharath Loganathan, MBBS, D.Ortho, MS (Ortho), MRCS (Edin); Atul F. Kamath, MD; Derek F. Amanatullah, MD; and Matthew J. Wilson, MBBS (Lond), FRCS (Eng), FRCS (TR&Orth)
Courtesy of Matthew J. Wilson, MBBS (Lond), FRCS (Eng), FRCS (TR&Orth)

AAOS Now

Published 7/1/2016
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Matthew J. Wilson, MBBS (Lond), FRCS (Eng), FRCS (TR&Orth); Derek Amanatullah, MD; Atul F. Kamath, MD; Bharath Loganathan, MBBS, D.Ortho, MS (Ortho), MRCS (Edin)

Taking the Big Bite

Rothman-Ranawat Traveling Fellows chew on their lessons
"If you're going to chew on something for a long time, make sure you take a big bite!" So advised William H. Harris, MD, director emeritus of the Harris Orthopaedics Laboratory at Massachusetts General Hospital in Boston, during a once-in-a-lifetime lunchtime meeting. This message on how to approach research and career opportunities, rather than simply our sandwiches, was a fitting take-home message for all of us.

We are four young orthopaedic surgeons from around the world, the proud recipients of the Hip Society's prestigious 2016 Rothman-Ranawat Traveling Fellowship. Derek Amanatullah, MD, is from the Stanford Hospital and Clinics in California; Atul F. Kamath, MD, is from Penn Medicine in Philadelphia; Bharath Loganathan, MBBS, D.Ortho, MS (Ortho), MRCS (Edin), comes from Ahmedabad, India; and Matthew J. Wilson, MBBS (Lond), FRCS (Eng), FRCS (TR&Orth), is from Exeter, United Kingdom.

My colleagues and I spent more than 5 weeks and traveled more than 12,000 miles across the United States and Canada, discussing outstanding orthopaedic research and observing world-class surgery across a number of facilities. The opportunity to spend time with key thought leaders in hip reconstruction and arthroplasty was invaluable.

In addition, the chance to take an extended period of time away from orthopaedic practice and to immerse ourselves in this fellowship was career-changing. Each of us underestimated how much we would challenge our attitudes and perception on managing our lives, both professionally and personally, as well as our practices.

Teamwork works
Teamwork was a strong theme in every unit we visited. All too often, as surgeons we think only about and our patient, our incision, and our surgery. We lose our focus on the wider picture: the support staff—surgical, nursing, and clerical—who play an immensely important role in keeping a service efficient, effective, and, most importantly, safe.

As the burden of bundled payments increases pressure on hospitals and surgeons to improve efficiency, including operating room utilization, we all took home lessons on how to make this happen in a coordinated, measured, and safe way.

THA research
At every center, we had the opportunity to present some of our own research on total hip arthroplasty (THA). Dr. Amanatullah spoke on outcomes in patients who underwent revision surgery with either modular or nonmodular uncemented stems. The issue of modularity and metal ion debris was a frequent point of discussion.

Additionally, we observed numerous revision THAs being performed due to the patient's adverse reaction to metal debris. For most of these revisions, nonmodular, fluted, tapered stems were used. Although these systems are powerful, they require significant experience to implant properly. Modularity, in this titanium-on-titanium stem design, may offer advantages to the infrequent user.

Dr. Kamath presented the issue of obesity in arthroplasty. He raised the question about having a threshold for body mass index given the increased risks involved to the reconstruction and the patient. There are no firm answers, but there was a great deal of discussion. Almost everyone agreed that guidance from The Hip Society, The Knee Society, the American Association of Hip and Knee Surgeons, and the American Academy of Orthopaedic Surgeons is needed. Such guidance could be used for reviewing the current literature, interfacing with healthcare payers, and informing patients about the true risks posed by excessive weight.

Dr. Loganathan presented a thorough summary of THA bearing options, with some excellent historical quotes and images from the beginning development of hip replacement. Clearly, bearing surface remains the biggest challenge, and many of the issues faced today by revision hip surgeons are home-grown. Large heads, taper corrosion, metal ion toxicity, ceramic fractures, and squeaking all developed long after the era of the 22-mm head, monoblock, stainless steel Charnley THA. In essence, all of us would do well to review the history of arthroplasty when planning its future.

Dr. Wilson spoke about the management of infection in hip arthroplasty, an issue that causes surgeons many sleepless nights. He presented the excellent results from the Exeter Hip Unit, where only cemented primary femoral stems are used. Following infection, reconstructions involve femoral impaction grafting.

He also presented Exeter data on the use of a cemented articulating spacer that functioned well enough to obviate the need for second-stage reimplantation in more than two-thirds of patients (effectively resulting in a functional one-stage procedure). These observations have led to a pragmatic, randomized controlled trial (already begun in the United Kingdom) of one- versus two-stage revision THA for infection.

The personal is professional
Personal time with our hosts also proved thought-provoking. Their wisdom and the memories we made will be with us for a lifetime. An evening at the beautiful, art-filled home of Richard H. Rothman, MD, and his wife was a particular treat and a chance to meet the numerous surgeons who comprise The Rothman Institute, all of whom share a great philosophy of research and outstanding patient care.

During dinner with Chitranjan S. Ranawat, MD, at the Union Club in New York City, each of us was asked where he saw himself in 5 years. We all had similar professional goals, which centered on being the best possible surgeon, doctor, colleague, and person. The take-home message from Dr. Ranawat was leadership. Being a leader in national roles is something all four of us aspire to, but first we need to be leaders in our service, our units, our hospitals, our families, and our communities.

We would like to take this opportunity to thank all of our hosts and their colleagues, the members of The Hip Society, and the sponsors of this traveling fellowship, particularly Drs. Rothman and Ranawat. The generosity of time and effort by Adolph V. Lombardi, Jr., MD, deserves special recognition. We owe him a debt of gratitude for the formation and continued growth of this traveling fellowship. The organizational skills of Lisa DuShane and Olga Foley at The Hip Society in creating our insane schedule cannot be overstated. Finally, each of us owes a debt of gratitude to our colleagues and families, because without their unwavering support, this trip would not have been possible.

We four will remain friends forever and will develop our orthopaedic careers together, despite being separated by thousands of miles. In applying for this fellowship and taking time away from our families and colleagues, we all took a big bite, and now we all have something to chew on for a very long time.

Drs. Wilson, Amanatullah, Kamath, and Loganathan are the 2016 winners of The Hip Society Rothman-Ranawat Traveling Fellowship.

Apply Now
The Hip Society is currently accepting applications for the 2017 Rothman-Ranawat Traveling Fellowship. The Fellowship is open to four young orthopaedic surgeons (board-certified with less than 2 years in practice) from North America and throughout the world. The traveling Fellows will visit 10 to 12 sites in North America within a period of approximately 4 to 5 weeks, beginning on Saturday, March 18, 2017, in San Diego, Calif., immediately following the AAOS 2017 Annual Meeting and Specialty Day.

The complete application packet must be submitted via email to The Hip Society at hip@aaos.org and is due by Aug. 15, 2016, by 11:59 p.m., US CDT. Incomplete applications or applications received after the deadline will not be considered. To access the application, go to http://www.hipsoc.org/hipsoc/#education

Direct any questions to The Hip Society at (+1) 847-698-1638 or hip@aaos.org