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A great opportunity
Traveling Fellowship Report
A Great Opportunity Humberto Augusto Papale´o Mena, M.D.
T
his fellowship was an opportunity that God granted me and I will be eternally grateful to all of the people who made it possible to participate in this chance of a lifetime. First of all, I would like to thank my wife Marina, my daughter Beatriz, and my son Lucas for their continuous love and support during this journey. Without them I would not be writing this. I am very grateful to the Arthroscopy Association of North America Board of Directors and the Board of Trustees of Arthroscopy. In particular, I would like to thank Ms. Skulskie, Managing Editor, for her patience in dealing with my language barrier and geographic location. I cannot leave out thanking my boss, Dr. Nadia Romariz, director of Mandaqui Hospital in Sa˜o Paulo, Brazil, for her support and encouragement. In her own words, “If God gave you this opportunity, I will help you to reach your objectives.” I obtained my medical degree from Faculdade de Medicina do ABC in 1989 and did my orthopaedic residency at Hospital Anchieta in Sa˜o Paulo, Brazil. It was where I started to take interest in arthroscopic surgery. During my residency, most arthroscopic procedures were done using direct arthroscopic view. As I was following the development of arthroscopic surgical procedures, I realized that I wanted to learn more about the intricacies of sports medicine procedures such as ACL and PCL reconstructions, and shoulder procedures. I was reading an article about arthroscopic surgery in 1997, written by Dr. David N. M. Caborn, Medical Director of Sports Medicine at the University of Ken-
From the Hospital Anchieta, Sa˜o Paulo, Brazil. Address correspondence and reprint requests to Humberto Augusto Papale´o Mena, M.D., Rua Demo´stenes no. 636, Apto. 162, Campo Belo, Sa˜o Paulo, S.P., Cep. 04013-014, Brazil. E-mail: [email protected] © 2000 by the Arthroscopy Association of North America 0749-8063/00/1608-2673$3.00/0 doi:10.1053/jars.2000.19935
tucky, when I took a chance and wrote him a letter telling him of my interests. After several days, I received a quick reply from him inviting me to come to the United States to spend 2 months with him. I was so impressed with what he was doing and the equipment available that I purchased my own camera system and shaver equipment. After that I started to do some procedures such as ACL reconstruction using either bone–patellar tendon– bone or hamstring autografts and meniscus repairs using the arrow system as he had shown me. I began to realize that I was in need of more intensive training in order to improve my arthroscopic skills and knowledge. That was when I started a subscription to Arthroscopy. While reading an article in the journal, I saw an announcement about the Traveling Fellowship. I thought that this would be a wonderful opportunity to develop my knowledge and improve my clinical and surgical skills. I completed an application form and mailed it to the Journal. I must honestly say that I did not expect to receive this award. In April 12, 1999, I will never forget this date, I received a letter explaining that I was recipient of the Arthroscopy Traveling Fellowship. My wife read that
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 8 (November-December), 2000: pp 849 – 851
849
850
H.A.P. MENA
letter and said,“We must go.” I admit that this was a difficult decision since I would have to quit my job for a year and move to the United States and leave my patients that I was taking care of, but I kept thinking, with God’s help I could overcome any adversity. Through a good friend, William H. Adkisson, Jr., PA-C, I worked out the details, and Dr. Caborn was very receptive to the idea of my spending a year with him and his colleagues. I started my Fellowship with Dr. Caborn in May 1999. I do not have words to express my personal gratitude to him for the first time that I came. First of all, he is an authentic Scottish gentleman. He exhibited tremendous patience with me and spent a great amount of energy working diligently to ensure that I understood everything that he was teaching me. He is highly motivating and understands the difficulties that a foreigner faces being in another country with another language and another culture. During my time with him, I viewed many procedures in the operating room, with particular interest in his double-bundle arthroscopic PCL reconstruction using anterotibialis allograft. It is amazing to arthroscopically visualize the dynamics of stability that this and many other procedures afford patients, which allow them to function at high levels of athletic competition once fully rehabilitated. Other procedures that were of interest to me were arthroscopic repair of rotator cuff tears and Bankart repairs of the shoulder. When I followed him in the clinic, I learned when and why to order bone scans and other ancillary tests to confirm solid indications for surgery. In the field of research, we studied the biomechanical comparisons of pullout strength of 35-mm bioabsorbable interference screws, which were used by Dr. Caborn for ACL reconstruction to secure the grafts. With this type of fixation of soft tissue in a bone tunnel, we studied the effectiveness of fixation with and without an Endopearl. We concluded that allograft ACL reconstruction using this technique with the Endopearl could significantly increase ultimate fixation strength when using interference screw fixation. After 6 months with Dr. Caborn, I switched my Fellowship to Dr. Darren L. Johnson, Chairman of Orthopaedic Surgery at the University of Kentucky, where I continued to develop my clinical skills. He taught me to do a thorough history and physical examination and to make a diagnosis at the time of the subsidiary exam. If any tests are necessary to confirm your diagnosis, then do them. If you are sure of your diagnosis, then pursue your clinical options. I must say that the thought processes that I learned during my Fellowship will be the most useful tools obtained from
my experience. It had been my experience to proceed with tests no matter the expense involved, but I can truly attest that this is not always necessary in offering superior care to patients in the sports medicine field. We cannot make excuses to our patients that our clinic is too busy and we do not have enough time to spend with them. They are the reason we need to continue our medical education and they deserve 100% of our attention. In the operating room with Dr. Johnson, I was privileged to view many procedures. Among those of most interest to me was the high tibial osteotomy combined with an ACL reconstruction. This proved to be an excellent procedure to prolong the need for total knee arthroplasty in young patients with chronic instability and medial joint gonarthrosis. The results were encouraging and I was able to observe patients with long-term follow-up. Another procedure that I was able to observe was meniscal transplant. I was able to see long-term results of this procedure as well. In one patient, Dr. Johnson had done a meniscal allograft 2 years prior and the patient was completely asymptomatic with nearly normal MRI. Another technique that was amazing to follow was mini-open rotator-cuff repair to an acute lesion. Being quick in making the right diagnosis gives fast results in the patient’s recovery period. In the field of research with Dr. Johnson, we wrote an article about recurrent proximal tibiofibular joint dislocation, a rare case, that was treated with an open procedure using a strip from the biceps femoris tendon passed through the proximal tibia and fibular head to stabilize the joint. This procedure was a definite alternative to arthrodesis or fibular head resection and seemed to alleviate the complications of delayed union, loose or broken internal fixation, and chronic ankle pain. With Dr. Scott Mair, I observed many shoulder decompressions and AC joint resections using arthroscopic techniques. This too proved to be a low-complication procedure, without damaging other tissues that would be traumatized with open procedures. I was able to follow many cases of knee dislocations in which he had done a repair of the ACL and PCL at the same time. This surgery was perhaps the most challenging in which I participated. I also developed the ability to give assistance to athletes on the playing field and to realize the importance of this when related to prevention and acute treatment. The direct relationship between physicians and athletic trainers can prevent many injuries. I could say that with these three doctors, their
TRAVELING FELLOWSHIP REPORT Fellows, and orthopaedic residents, I had many chances to observe almost every variety of current arthroscopic procedures and related techniques. I return to my country with a certainty that I have started a journey that I have yet to finish. I would like to develop my skills even more and begin to pursue research in related topics that I had the opportunity to observe during this Fellowship. I am constantly reminded of what my professor Dr. Ma´rio Andreucci said to me: “The road of knowledge is difficult and endless.” I have also developed an interest in ankle arthroscopy. During my Fellowship, I was able to practice many procedures in the lab on cadaveric specimens. Soccer is the most popular sport in my country. We love soccer and I see many patients with ankle problems; there are so many injuries related to the ankle that could be treated using arthroscopic techniques. Another area of interest that I learned more about during my Fellowship is the use of cadaveric grafts, allografts. I hope to pursue their use in my country because they have proven to be an effective alternative to bone–patellar tendon– bone autografts for ACL and PCL reconstructions. I know that there are many orthopaedic surgeons in my country who have great manual skills, but they have not had the same luck that I have had. It is important to keep continuing medical education as a cornerstone in the development of orthopaedic surgeons around the world and to continuously exchange knowledge and wisdom with residents and partners. We must continue to share our victories and defeats to further develop this amazing and challenging field of medicine. What we need is more access to equipment and the support of medical companies to enhance the
851
needs of patients. For example, Jeff Stayton of Smith & Nephew was a specialist in video/endoscopy equipment who voluntarily offered his services to repair my personal arthroscopy equipment and offered suggestions for the care and repair of the equipment after my return to Brazil. I think that this is a praiseworthy endeavor of this journal to provide an avenue for physicians from other countries to improve the care of their patients. I have seen it done in the right environment. This in itself will promote the name of arthroscopic surgery. The journal Arthroscopy is doing a great job with its openminded views and wealth of wisdom. It has been an honor to share time with so many talented people. I thank you for giving me this opportunity. I would like to say to all future recipients of this Traveling Fellowship, have no fear, keep your goals in mind, and, with God’s help, you can overcome any adversity that the challenge will present you. I took the option of doing my Fellowship in one institution instead of making a lot of trips and just being an observer. I liked being a real Fellow and I reached many of my goals. This was the reason I began my Fellowship 15 days after I received my letter of acceptance. Perhaps future recipients will think differently, but for me this was a good option. While attending the 67th Annual Meeting of the American Academy of Orthopaedic Surgeons, I realized that almost every variety of current sports medicine procedures presented were done during my Fellowship at the University of Kentucky. I could not finish this report without expressing my deepest gratitude to my father Agostinho Mena, who will live forever in my heart, and to my mother Jacyra Papale´o Mena. Thank you very much for everything.
A Great Opportunity Humberto Augusto Papale´o Mena, M.D.
T
his fellowship was an opportunity that God granted me and I will be eternally grateful to all of the people who made it possible to participate in this chance of a lifetime. First of all, I would like to thank my wife Marina, my daughter Beatriz, and my son Lucas for their continuous love and support during this journey. Without them I would not be writing this. I am very grateful to the Arthroscopy Association of North America Board of Directors and the Board of Trustees of Arthroscopy. In particular, I would like to thank Ms. Skulskie, Managing Editor, for her patience in dealing with my language barrier and geographic location. I cannot leave out thanking my boss, Dr. Nadia Romariz, director of Mandaqui Hospital in Sa˜o Paulo, Brazil, for her support and encouragement. In her own words, “If God gave you this opportunity, I will help you to reach your objectives.” I obtained my medical degree from Faculdade de Medicina do ABC in 1989 and did my orthopaedic residency at Hospital Anchieta in Sa˜o Paulo, Brazil. It was where I started to take interest in arthroscopic surgery. During my residency, most arthroscopic procedures were done using direct arthroscopic view. As I was following the development of arthroscopic surgical procedures, I realized that I wanted to learn more about the intricacies of sports medicine procedures such as ACL and PCL reconstructions, and shoulder procedures. I was reading an article about arthroscopic surgery in 1997, written by Dr. David N. M. Caborn, Medical Director of Sports Medicine at the University of Ken-
From the Hospital Anchieta, Sa˜o Paulo, Brazil. Address correspondence and reprint requests to Humberto Augusto Papale´o Mena, M.D., Rua Demo´stenes no. 636, Apto. 162, Campo Belo, Sa˜o Paulo, S.P., Cep. 04013-014, Brazil. E-mail: [email protected] © 2000 by the Arthroscopy Association of North America 0749-8063/00/1608-2673$3.00/0 doi:10.1053/jars.2000.19935
tucky, when I took a chance and wrote him a letter telling him of my interests. After several days, I received a quick reply from him inviting me to come to the United States to spend 2 months with him. I was so impressed with what he was doing and the equipment available that I purchased my own camera system and shaver equipment. After that I started to do some procedures such as ACL reconstruction using either bone–patellar tendon– bone or hamstring autografts and meniscus repairs using the arrow system as he had shown me. I began to realize that I was in need of more intensive training in order to improve my arthroscopic skills and knowledge. That was when I started a subscription to Arthroscopy. While reading an article in the journal, I saw an announcement about the Traveling Fellowship. I thought that this would be a wonderful opportunity to develop my knowledge and improve my clinical and surgical skills. I completed an application form and mailed it to the Journal. I must honestly say that I did not expect to receive this award. In April 12, 1999, I will never forget this date, I received a letter explaining that I was recipient of the Arthroscopy Traveling Fellowship. My wife read that
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 8 (November-December), 2000: pp 849 – 851
849
850
H.A.P. MENA
letter and said,“We must go.” I admit that this was a difficult decision since I would have to quit my job for a year and move to the United States and leave my patients that I was taking care of, but I kept thinking, with God’s help I could overcome any adversity. Through a good friend, William H. Adkisson, Jr., PA-C, I worked out the details, and Dr. Caborn was very receptive to the idea of my spending a year with him and his colleagues. I started my Fellowship with Dr. Caborn in May 1999. I do not have words to express my personal gratitude to him for the first time that I came. First of all, he is an authentic Scottish gentleman. He exhibited tremendous patience with me and spent a great amount of energy working diligently to ensure that I understood everything that he was teaching me. He is highly motivating and understands the difficulties that a foreigner faces being in another country with another language and another culture. During my time with him, I viewed many procedures in the operating room, with particular interest in his double-bundle arthroscopic PCL reconstruction using anterotibialis allograft. It is amazing to arthroscopically visualize the dynamics of stability that this and many other procedures afford patients, which allow them to function at high levels of athletic competition once fully rehabilitated. Other procedures that were of interest to me were arthroscopic repair of rotator cuff tears and Bankart repairs of the shoulder. When I followed him in the clinic, I learned when and why to order bone scans and other ancillary tests to confirm solid indications for surgery. In the field of research, we studied the biomechanical comparisons of pullout strength of 35-mm bioabsorbable interference screws, which were used by Dr. Caborn for ACL reconstruction to secure the grafts. With this type of fixation of soft tissue in a bone tunnel, we studied the effectiveness of fixation with and without an Endopearl. We concluded that allograft ACL reconstruction using this technique with the Endopearl could significantly increase ultimate fixation strength when using interference screw fixation. After 6 months with Dr. Caborn, I switched my Fellowship to Dr. Darren L. Johnson, Chairman of Orthopaedic Surgery at the University of Kentucky, where I continued to develop my clinical skills. He taught me to do a thorough history and physical examination and to make a diagnosis at the time of the subsidiary exam. If any tests are necessary to confirm your diagnosis, then do them. If you are sure of your diagnosis, then pursue your clinical options. I must say that the thought processes that I learned during my Fellowship will be the most useful tools obtained from
my experience. It had been my experience to proceed with tests no matter the expense involved, but I can truly attest that this is not always necessary in offering superior care to patients in the sports medicine field. We cannot make excuses to our patients that our clinic is too busy and we do not have enough time to spend with them. They are the reason we need to continue our medical education and they deserve 100% of our attention. In the operating room with Dr. Johnson, I was privileged to view many procedures. Among those of most interest to me was the high tibial osteotomy combined with an ACL reconstruction. This proved to be an excellent procedure to prolong the need for total knee arthroplasty in young patients with chronic instability and medial joint gonarthrosis. The results were encouraging and I was able to observe patients with long-term follow-up. Another procedure that I was able to observe was meniscal transplant. I was able to see long-term results of this procedure as well. In one patient, Dr. Johnson had done a meniscal allograft 2 years prior and the patient was completely asymptomatic with nearly normal MRI. Another technique that was amazing to follow was mini-open rotator-cuff repair to an acute lesion. Being quick in making the right diagnosis gives fast results in the patient’s recovery period. In the field of research with Dr. Johnson, we wrote an article about recurrent proximal tibiofibular joint dislocation, a rare case, that was treated with an open procedure using a strip from the biceps femoris tendon passed through the proximal tibia and fibular head to stabilize the joint. This procedure was a definite alternative to arthrodesis or fibular head resection and seemed to alleviate the complications of delayed union, loose or broken internal fixation, and chronic ankle pain. With Dr. Scott Mair, I observed many shoulder decompressions and AC joint resections using arthroscopic techniques. This too proved to be a low-complication procedure, without damaging other tissues that would be traumatized with open procedures. I was able to follow many cases of knee dislocations in which he had done a repair of the ACL and PCL at the same time. This surgery was perhaps the most challenging in which I participated. I also developed the ability to give assistance to athletes on the playing field and to realize the importance of this when related to prevention and acute treatment. The direct relationship between physicians and athletic trainers can prevent many injuries. I could say that with these three doctors, their
TRAVELING FELLOWSHIP REPORT Fellows, and orthopaedic residents, I had many chances to observe almost every variety of current arthroscopic procedures and related techniques. I return to my country with a certainty that I have started a journey that I have yet to finish. I would like to develop my skills even more and begin to pursue research in related topics that I had the opportunity to observe during this Fellowship. I am constantly reminded of what my professor Dr. Ma´rio Andreucci said to me: “The road of knowledge is difficult and endless.” I have also developed an interest in ankle arthroscopy. During my Fellowship, I was able to practice many procedures in the lab on cadaveric specimens. Soccer is the most popular sport in my country. We love soccer and I see many patients with ankle problems; there are so many injuries related to the ankle that could be treated using arthroscopic techniques. Another area of interest that I learned more about during my Fellowship is the use of cadaveric grafts, allografts. I hope to pursue their use in my country because they have proven to be an effective alternative to bone–patellar tendon– bone autografts for ACL and PCL reconstructions. I know that there are many orthopaedic surgeons in my country who have great manual skills, but they have not had the same luck that I have had. It is important to keep continuing medical education as a cornerstone in the development of orthopaedic surgeons around the world and to continuously exchange knowledge and wisdom with residents and partners. We must continue to share our victories and defeats to further develop this amazing and challenging field of medicine. What we need is more access to equipment and the support of medical companies to enhance the
851
needs of patients. For example, Jeff Stayton of Smith & Nephew was a specialist in video/endoscopy equipment who voluntarily offered his services to repair my personal arthroscopy equipment and offered suggestions for the care and repair of the equipment after my return to Brazil. I think that this is a praiseworthy endeavor of this journal to provide an avenue for physicians from other countries to improve the care of their patients. I have seen it done in the right environment. This in itself will promote the name of arthroscopic surgery. The journal Arthroscopy is doing a great job with its openminded views and wealth of wisdom. It has been an honor to share time with so many talented people. I thank you for giving me this opportunity. I would like to say to all future recipients of this Traveling Fellowship, have no fear, keep your goals in mind, and, with God’s help, you can overcome any adversity that the challenge will present you. I took the option of doing my Fellowship in one institution instead of making a lot of trips and just being an observer. I liked being a real Fellow and I reached many of my goals. This was the reason I began my Fellowship 15 days after I received my letter of acceptance. Perhaps future recipients will think differently, but for me this was a good option. While attending the 67th Annual Meeting of the American Academy of Orthopaedic Surgeons, I realized that almost every variety of current sports medicine procedures presented were done during my Fellowship at the University of Kentucky. I could not finish this report without expressing my deepest gratitude to my father Agostinho Mena, who will live forever in my heart, and to my mother Jacyra Papale´o Mena. Thank you very much for everything.