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ISAKOS PF Traveling Fellowship, 2010
The Patellofemoral Tavelling Fellowship started in 2005, with Fred Almqvist and Ryosuke Kuroda travelling in 2005, and Elvire Servien and Christina Stukenborg-Colsman in 2007, began under the aegis of the Patellofemoral Foundation, and the selection committee of the Scientific Committee of the ISAKOS. The very first Travelling Fellow was Jason Koh, before ISAKOS was involved. Until this year, only one Travelling Fellow was selected.
At the 2009 ISAKOS Meeting, in Osaka, Japan, there was the much welcome surprise that three Travelling Fellows were to travel with a Godfather. On this occasion, the Fellowship was to take place in the spring of 2010. The four Patellofemoral Traveling Fellows 2010 made their way to San Francisco from different parts of the world. Dr. Petri Sillanpää from Tampere, Finland and Dr. Philip Schöttle from Zurich, Switzerland met the Godfather, Prof. Nicola Maffulli from London, England, at Heathrow Airport, and proceeded together to San Francisco. Petri and Nicola travelled in economy, and Philip exerted his charm on the check in ladies to get an upgrade to business class. This was a sign of things to come!
Dr. Christian Lattermann from Lexington, Kentucky, joined us in San Francisco, where we received an extremely warm personal welcome by Dr. Scott Dye. The initial two days of the Travelling Fellowship coincided with the Easter weekend. Dr. Dye and his wife Anne made this a memorable unique and personal experience: they made us feel part of their family by taking us to their annual Easter brunch in a wonderful setting above the roofs of San Francisco, followed by a lively cabaret show. It was a wonderful start of the fellowship, and reset our overall "trip homeostasis" to within our strained envelope of function. The initial fun was followed by the visit of the new UCSF Sports Medicine facility, where Drs. Benjmin Ma, Christie Allen and Brian Feeley worked at full steam on Easter Monday performing a variety of knee surgeries. In the afternoon, we had a rigorous and exacting scientific session focussing particularly on patellar tendinopathy, one of the special interests of the Godfather.
Our second leg of the journey was a visit with Dr. Elizabeth Arendt at the University of Minneapolis. Philip was hosted in the Presidential Suite of our hotel, the other common mortals in ‘normal’ rooms. We were deeply impressed: Dr. Arendt organized our presentations to be given in front of more than 100 colleagues, residents and physical therapists using latest technology to broadcast the session to two remote sites. Even more enjoyable were the ensuing case presentations given by Dr. Arendt’s residents. This session quickly dove into the depth of the present controversies of patellofemoral treatment over the importance of predisposing factors for patellar dislocation, including trochlear anatomy and femoral rotation. During this session the Fellowship became a true learning and teaching experience which left us all energized. Dr. Arendt captured this spirit by inviting us down to the Anatomy Laboratory where she had prepared a cadaveric dissection focused on the anatomy of the medial patellofemoral ligament (MPFL). We spent two hours carefully dissecting the medial structures of the knee, and agreed upon the triangular configuration of the MPFL with its base along the upper medial border of the patella and its insertion at the distal femur. While all of us have slightly different surgical techniques, the consensus was reached that the MPFL is best reconstructed using a double bundle construct. The importance of the distal femoral insertion and its relationship to the adductor tubercle was also felt to be critical. We also demonstrated a distal femoral derotational osteotomy and a chevron type tibial tubercle osteotomy on the cadaveric knee to illustrate the potential effects of these interventions on patellar tracking. The session sparked vivid discussions about diagnostic and therapeutic approaches to patients with patellofemoral instability. Subsequently, we were given a tour of the impressive new MRI facilities featuring a 16.4T (!) experimental magnet. The personal welcome at Dr. Arendt’s home for a final dinner was a highlight. We were able to meet her husband (a great cook!), and other close colleagues.
While in San Francisco, the Godfather, trying to defeat advancing age, agreed to perform a session of power yoga with Dr Latterman. Delayed onset muscle soreness in some fairly important part of ambulatory anatomy ensued, and Prof Maffulli ended up limping in pain. Never one to follow doctor’s advice, he refused any painkillers, and struggled along unaided, until, on reaching JFK airport in New York, he agreed to be wheeled around in a wheelchair to the car rental company, where we rented a car and drove to Rocky Hill, CT, to meet Dr John Fulkerson, the uber-mentor of the Travelling Fellowship, and the person who conceived the idea of the Fellowship itself. After a relaxing evening, Dr Fulkerson took us to his clinic in Hartford, where we observed him perform several tubercle osteotomies and an MPFL reconstruction. Our "European" thinking produced excellent discussions, and we realized that the old truth remains: there are many ways to skin a cat. Just after lunch time we had to leave for New York we met Dr. Ron Grelsamer. He invited us to a fine Italian restaurant which he knew extremely well, as he lives in the same building, and the evening ended in a great discussion on the Beatles, a common much loved theme between Dr Gresalmer and the Godfather. Eventually, the Travelling Fellows sampled a small slice of New York night life thanks to the special insight and great instinct that Philip has for the finer things in life. The next morning, Drs. Grelsamer and Flatow had assembled a great group of colleagues and researchers for an animated discussion on patellofemoral instability and tendinopathy. The three hours of intense discussion and talks passed quickly, and we were left with a thorough impression of consensus between the European and American approach to patellofemoral instability (can there be a consensus after all?).
We then took off to Lyon. We duly missed our connection in London, where we learnt that, unknown to the group, it was the Godfather’s birthday. This resulted in a light lunch at his home, where his son, Giuseppe, took a liking to Philip. The Godfather decided there and then that, in the fullness of time, Giuseppe would have listed Philip as his first choice match for orthopaedic residency training.
We eventually made it to Lyon, where Prof Philippe Neyret and his colleagues picked us up and immediately took us to dinner in the "Bistro de Lyon". Well fed and wined the new "(De) jour" began with a "race" to the operating room. Dr. Dejour had listed 6 outstanding cases, each of which he used to demonstrate a specific novel or special technique out of his arsenal of never ending innovation. We were thoroughly impressed by the efficacy of his team and the spectrum of procedures performed, ranging from MPFL reconstructions to a double bundle anterior cruciate ligament reconstruction to a total knee replacement. The highlight for the Travelling Fellows was the last case, when Dr Dejour performed the "Lyon trochleoplasty." Prof. Neyret organised a lively afternoon scientific session that lead to animated discussions concerning rotational alignment of the lower limb and the role of muscle derotation in a patient with chronic patellar dislocation in flexion. After a spectacular day, we had a wonderful dinner in a cosy French restaurant.
The remaining four days we spent in London, where we were introduced to the International Patellofemoral Study Group. Many of the discussions and ideas that we carried with us were exposed during the meeting. Under the outstanding organization of Prof. Amis, the Travelling Fellowship ended with a most impressive tour and dinner at the Royal College of Surgeons of England. The visit to the Natural History Museum was a once in a lifetime opportunity to see, touch and learn about our ancestry with regards to the development of the knee joint. Even though at the beginning of our tour we did not know what "Eyjafjallajokull" stands for, by the end everyone it certainly became another interesting part of our fellowship, imposing the scenic route back home. The Godfather only had to catch the Tube to return to his family, but the Travelling Fellows found themselves as novel Phileas Foggs when they had to use their wits to return home.
Once again, Philip’s cunning proved useful: learning that British airspace would have been closed for several days, he succeeded to book the last available ticket for the Eurostar out of London on the Saturday evening, reaching Paris at the turn of midnight. Some of his many friends hosted him overnight, and on Sunday Philip went by train to Strasbourg, enjoying the French country side. There, his father picked him up, and they drove to Zurich together.
Christian, who had held out with his parents in northern Germany for a couple of days returned to London only to find that 4 days into the volcanic saga his flight now had also been cancelled. Teaming up with two dear colleagues, Drs. Daniel Green and Jack Farr, they decided to drive a rental car to Madrid. As direct flights from Madrid where not only scarce but also extraordinarily expensive it took a minor diversion through Bogota, Colombia to Miami and back to Lexington producing a carbon footprint worthy of a volcano eruption.
Petri followed Philip’s Eurostar by getting out of London on the next day, Sunday, reaching Lille, Brussels, Amsterdam and eventually Hamburg – yes, all this by train within 12 hours. Petri’s trip back to Scandinavia continued then very quickly to Copenhagen by driving a rental car with a speed limited only by other cars on the German autobahns. A Swedish train took then Petri all the way from Copenhagen to Stockholm. While the last connection was by ferry from Stockholm to Helsinki, the time spent to travel from UK to Finland was ranked as the fastest in the unofficial round table discussions in the fully crowded ferry’s restaurant, though still being almost 2 days slower than 3 hours flight.
The Travelling Fellowship allowed us to spend three weeks of total immersion in the patellofemoral joint. Following that, all fellows agreed that MPFL reconstruction seems a most appropriate surgeries to stabilise the patella, when the ligament is torn, and should be performed using a double bundle construct inserted at the appropriate anatomical location in the femorus point. Concerning patellofemoral degeneration, Philip started to consider slight anteromedialisation of the tibial tuberosity to decrease the load to the lateral patellofemoral compartment.
Following discussion with the other fellow, a study protocol was produced to study whether trochlear dysplasia is an important factor leading to failure of conservative management in patellofemoral instability, and a brain storming session was undertaken about a clinical and imaging examination for patellofemoral diseases. Christian Lattermann and Philip Schöttle are writing the first review article about patellofemoral degeneration for the journal of the German speaking group of arthroscopy (AGA).
We had an experience of a lifetime, and we can only express our greatest gratitude to the Patellofemoral Foundation for having bestowed onto us the great honour of the Travelling Fellowship. We all thank our families for having endured without us. We made lifelong friends, and started great collaborations. May they long continue.
Patellofemoral Travelling Fellows 2010
Nicola Maffulli, Godfather