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Radiographs of a 19-year-old Cambodian man with severe kyphoscoliotic deformity secondary to neurofibromatosis, who was treated by Dr. Weinstein in Ho Chi Minh City.
Courtesy of Stuart L. Weinstein, MD

AAOS Now

Published 12/1/2009
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Annie Hayashi

Teaching surgeons to do more than surgery

Exchange program provides vital instruction in spine, adult reconstruction

“In all my travels, the Hospital for Trauma and Orthopaedics (HTO) in Ho Chi Minh City was the most overcrowded and under resourced of any hospital I have ever seen,” said Stuart L. Weinstein, MD. “But the doctors do a wonderful job.”

As part of the AAOS-VOA Visiting Faculty and Development Program, Dr. Weinstein spent 9 days in Ho Chi Minh City giving lectures on various spine procedures, presenting case studies, and performing surgery. His host was Vo Van Thanh, MD, chief of orthopaedics at HTO.

“Dr. Thanh is a wonderful person for whom I have great respect and admiration,” said Dr. Weinstein. “It is really quite amazing what he and his staff can do, given the profound lack of infrastructure and even the most basic levels of support.”

HTO has only 440 beds, but 900 to 1,000 inpatients. The hospital’s operating rooms are used 24 hours a day, 7 days a week; 24,000 major surgeries and 36,000 minor surgeries are performed there each year.

“The magnitude of the spinal deformities is much more severe than we now see in the United States,” said Dr. Weinstein. “When I started my practice 37 years ago, I had cases that were comparable to what I saw in Vietnam.”

Challenging spinal surgeries
According to Dr. Weinstein, the Vietnamese orthopaedic surgeons rarely see patients during the early stages of a disease. “They see them at the end of the disease processes,” he said.

In addition to examining more than 60 patients, Dr. Weinstein performed four very complex surgical procedures in a crowded operating room that was not air conditioned.

One patient was a Cambodian man with neurofibromatosis and a very large kyphoscoliosis. “It was an extremely severe case. I’ve done a lot of neurofibromatosis cases in my life but this was the most severe I’ve ever treated,” he said.

“The assistant surgeons all had excellent technical capabilities and were very dexterous,” he added.

Dr. Weinstein also operated on a patient with a congenital hemiverte-bra, one with adolescent idiopathic scoliosis, and a scoliosis patient with Chiari malformation. In every case, the condition had progressed beyond the usual stage when surgery would have been recommended if the patient had been in the United States.

As the quality of health care in Vietnam continues to progress, Dr. Weinstein hopes there will be more education on the importance of recognizing, diagnosing, and treating patients early in the disease process.

Reconstructing joints
While Dr. Weinstein was in Ho Chi Minh City, Miguel E. Cabanela, MD, was lecturing on total hip and knee arthroplasty, conducting case presentations and surgical skills workshops, and performing surgery at St. Paul Hospital in Hanoi. Dac Nghia Nguyen, MD, served as his host.

Dr. Cabanela found the type of pathology he encountered in Vietnam was very different than what he sees in the United States.

“The majority of the hip pathology was related to osteonecrosis. I saw very little primary degenerative disease and virtually no dysplasia,” explained Dr. Cabanela.

“In the knee, degenerative disease was common,” he added. “But the treatment of knee pathology significantly lags behind the treatment of hip pathology. The Vietnamese have limited knowledge and access to knee replacement technology, and patients are very reluctant to consider this type of surgery.”

Radiographs of a 19-year-old Cambodian man with severe kyphoscoliotic deformity secondary to neurofibromatosis, who was treated by Dr. Weinstein in Ho Chi Minh City.
Courtesy of Stuart L. Weinstein, MD
Surgical skills lab conducted by Dr. Cabanela with Dr. Nghia providing simultaneous translation.
Courtesy of Miguel E. Cabanela, MD
Dr. Weinstein performed a very challenging spine procedure in this crowded operating room at HTO.
Courtesy of Stuart L. Weinstein, MD

Although challenging, the cases Dr. Cabanela encountered were not as severe nor were the conditions at St. Paul as extreme as those Dr. Weinstein faced at HTO.

“The surgeries went uneventfully and reasonably fast, despite the fact that I stopped many times to teach each step,” said Dr. Cabanela. “The surgeries were transmitted via three cameras to a classroom and participants could communicate with Dr. Nghia, who was with me in the operating room. Dr. Nghia translated and transmitted every question and answer.”

The operating room was air conditioned with three to four assistants for each procedure, and Dr. Cabanela was impressed with the strict operating room etiquette.

“The assistants changed with every case to allow as many registrants to participate as possible. Although I had to restart teaching with each case, it was very enjoyable because of the tremendous interest of the surgeons,” he said.

Dr. Cabanela performed five primary total hip replacements and two primary total knee replacements. One of the patients who received a hip replacement also had ankylosing spondylitis. Although more difficult than the others, the procedure went well.

“The patients are extremely tough and take virtually no postoperative analgesics,” Dr. Cabanela reported. He was also very impressed by the level of care provided by the nurses and particularly by the dedication of Dr. Nghia.

“Dr. Nghia was especially charming with the patients and they obviously liked him very much,” Dr. Cabanela said.

Lessons learned
The surgeons at St. Paul Hospital, recognizing that their high rate of postoperative infection was a serious issue, asked Dr. Cabanela to lecture about infection after total hip arthroplasty.

“At this point, Vietnam doesn’t have nearly the level of sophistication in management of infection that we have in the United States. Most infections are handled by resection—that is, removal of the arthroplasty—which is a very challenging and disabling procedure. My presentation generated a huge number of questions,” he said.

Months later, Dr. Cabanela learned the potential impact of his presentation when Vo Song Linh, MD, an orthopaedic surgeon from St. Paul Hospital, came to the Mayo Clinic to work with him as a visiting scholar.

Dr. Linh proudly reported that St. Paul Hospital had just opened a new operating room dedicated exclusively to hip and knee replacements. He believed a contributing factor to the infection rate was the poor quality of the operating rooms and was confident that this new operating room would help lower that rate.

In Vietnam, surgeons are trained to only focus on the surgery and do not have a background in basic science, anatomy, body mechanics, or clinical examinations.

“Because the patient load is overwhelming, surgeons tend to spend very little time with each patient. They make decisions based on radiographic data, with minimal interaction or examination of the patient,” said Dr. Cabanela.

Dr. Linh said the most valuable lesson he learned from Dr. Cabanela was to consider more than the radiographic findings. “If a radiograph confirms degeneration of the hip but the patient is not in pain, the patient doesn’t need surgery,” he said. “It is important to talk to the patient about whether he or she is in pain.”

Annie Hayashi is the senior science writer for AAOS Now. She can be reached at hayashi@aaos.org

Editor’s note: This is the last in a series of articles on the Visiting Faculty and Professional Development Program organized by the AAOS and the Vietnam Orthopaedic Association (VOA). For more information on the program, see “Building bridges over once-troubled waters” and “Forging new alliances”.