Fig. 1 Dr. Sweeney working with program participants on arthroscopic techniques on knee model. Photo
courtesy of Howard J. Sweeney, MD


Published 11/1/2009
Annie Hayashi

Forging new alliances

AAOS offers arthroscopy educational exchange program with Vietnam

Hue Central Hospital in Vietnam is unlike any hospital in the United States, according to Pietro M. Tonino, MD. “Without actually being there, it’s difficult to grasp the enormous number of people who need care. It would be like announcing a free medical clinic and people just showing up,” Dr. Tonino said.

Dr. Tonino was a faculty member in a 9-day intensive training program in knee and shoulder arthroscopy at Hue Central Hospital. He was joined by Howard J. Sweeney, MD, and Nguyen Trong Anh, MD, the founder of the Vietnamese Arthroscopy Society, who also served as an interpreter.

Creative approaches to training
Although arthroscopic surgeries have been performed at Hue Central Hospital since 2003, many Vietnamese surgeons are not proficient in this technique.

The training for the 38 participants began with pretests, and included lectures on arthroscopy and the diagnosis and treatment of meniscal and anterior cruciate ligament (ACL) injuries.

Dr. Sweeney held knot-tying labs and conducted surgical skills workshops on knee and shoulder arthroscopy using “saw bones” models (Fig. 1). “In the late 1970s, I made a model to teach arthroscopy by operating on lettuce, cabbages, and flowers under water,” he said. “Such a model would work well in Vietnam, because it’s inexpensive. I’m working on a newer model that can be reproduced in Hue.”

The educational program included not only patient case studies but also surgeries—open rotator cuff repairs, open shoulder instability procedures due to multiple dislocations, ACL reconstructions, and meniscal repairs.

Because of the volume of patients and limited resources, Vietnamese surgeons often rely on just two or three radiographs rather than a complete patient history and full diagnostic evaluation before surgery.

“I think they do a very good job of providing care based on limited information,” said Dr. Tonino. “We would want to do more testing. But the Vietnamese surgeons make good diagnoses with the available resources and provide very appropriate medical care.”

Patient safety and communication
In grand rounds and the outpatient clinic, Dr. Tonino talked with and examined patients. He took patient histories, performed diagnostic tests, explained surgical procedures, and answered patients’ questions—demonstrating the critical role of physician-patient communications.

He also reinforced patient safety practices. “It’s essential to take a ‘time-out’ before the surgery and ‘sign the site,’ check the wristband, and make sure everything is in order to minimize errors,” he said.

Dr. Tonino performed or assisted in all of the surgical procedures (Fig. 2). Although two patients were scheduled for arthroscopic shoulder surgery, he performed open procedures. “These patients had probably experienced 20 or more dislocations. In Vietnam, I learned a ‘few’ really means ‘many.’ Patients just don’t complain,” he said.

Following the surgeries, Dr. Tonino talked to the patients’ families. “Since there are no chairs in the surgical waiting room, families sat on the floor until the surgery was finished,” he said. “I think they liked being close to their family members. The family is very important to the Vietnamese, and you saw that on a daily basis when caring for patients there.”

The patients’ families presented Drs. Tonino, Sweeney, and Anh with gifts to express their gratitude.

Fig. 1 Dr. Sweeney working with program participants on arthroscopic techniques on knee model. Photo
courtesy of Howard J. Sweeney, MD
Fig. 2 Dr. Tonino performing shoulder arthroscopy while program participants observe. Photo
courtesy of Howard J. Sweeney, MD
Fig. 3 Drs. Tonino and Hau at Hue Central Hospital.

The Vietnamese surgeons gave the program high marks, particularly “in gaining new knowledge that will benefit my patients immediately” and “in meeting all of my learning objectives.” The post-tests demonstrated significant improvement in the participants’ knowledge.

Learning—A two-way street
It was hard to believe that Le Thua Trung Hau, MD, was on his first trip to the United States as he sat eating chicken fried steak with eggs in a Chicago suburban restaurant. “They give you much more food here in America than they do in Vietnam,” commented Dr. Hau, in fluent English.

Dr. Hau was completing Phase II of the AAOS-Vietnam Orthopaedic Association (VOA) Visiting Faculty and Professional Development Program with Dr. Tonino. He valued every part of the experience—from observing several different surgeons perform shoulder arthroscopic procedures to attending a course at the OLC sponsored by AANA.

“We are just beginning to use arthroscopy at my hospital in Hue. I liked coming here to learn more about shoulder arthroscopy and to see how it is done, particularly the surgical styles of different surgeons,” he said.

While at Loyola Medical Center, Dr. Hau observed almost 20 shoulder and knee arthroscopic procedures performed by Dr. Tonino and his partners, Douglas A. Evans, MD, and Guido Marra, MD.

“It was good for me to see how Drs. Evans and Marra do shoulder arthroscopies. I learned how to perform arthroscopy from the beach chair position and from a lateral decubitus position. We have been doing both open and mini-open procedures at my hospital,” he said.

Patient safety and communication were other lessons Dr. Hau learned. “Before Dr. Tonino came to our hospital, we never signed the site. Now I always sign the site and I encourage all my colleagues to do the same.

“I also learned how important it is to talk to the patient before the operation, to ask questions and get information,” continued Dr. Hau. “This information can be helpful during the surgery. It is also important to explain the procedure to the patient and the family. It is good for the patient and the family to know everything that has been done. I will do that now,” he stated.

But the experience that Dr. Hau enjoyed the most was his AANA course at the OLC. “Instead of just observing, I worked directly on the cadaver. I had the opportunity to work on an actual specimen. The instructor helped me learn exactly what to do when I had a problem. The course was very well organized.”

What was the “take-away”?
If Dr. Hau could take one thing back to Vietnam, it would be the OLC, especially for training younger surgeons. “I liked your program very much,” he said with a broad smile. “I would like to bring some Vietnamese to the OLC. It would be good for us.”

Instead, he will take his memories of Dr. Tonino (Fig. 3). “I learned so much from Dr. Tonino—to really talk to my patients and to listen to them. I learned about arthroscopic surgery and being an orthopaedic surgeon. I learned about Chicago Bears football and Sox baseball. I went to his home and had dinner with his family. He was very kind. I like him very much,” Dr. Hau concluded.

Dr. Tonino also learned many lessons. He was invited to have dinner in a faculty member’s home when he was in Vietnam. “The housing is very basic—about one tenth the size of an American home. They have a fraction of what we have in this country. It makes you appreciate everything you have,” he said.

“In 3 years, we will be turning this program over to the Vietnamese. We are the instructors now but we will be transitioning it to them. Even though I was a faculty member, I learned as much from the Vietnamese as I taught them,” Dr. Tonino noted.

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