Rekindling Connections and Cultivating Lifelong Mentorship
AOSSM/SLARD Traveling Fellowship was a success despite several years of delays due to the COVID pandemic. The 2024 AOSSM/SLARD traveling fellowship certainly made up for lost time with non-stop clinical fellowship, cultural exposure, and development of lifelong friends, colleagues, and collaborators. Although there are many highlights of the fellowship, we all agree nothing tops the opportunity to have Dr. Jo Hannafin as the godmother as her guidance in life, career, research, and patient care during the fellowship could be described as a priceless opportunity for us.
Days 1 & 2 in Mexico
We were finally excited to be starting our long anticipated AOSSM-SLARD Traveling fellowship. Despite some logistical challenges due to volcanic ash over Mexico City and challenges with delayed baggage, we all made it safe and sound on the first day. We were greeted by Dr. Jimena Prado, MD, who completed medical school and a degree in epidemiology, as well as Jesus, who was our driver.
On the first day, we had an enjoyable tour of the CEMA (Centro de Excelencia Medica en Altura) facilities, in Pachuca, which is about an hour and half north of Mexico City. CEMA, a FIFA endorsed hospital, is a medical facility lead by Dr. Jose Busto and dedicated to the evaluation, treatment, and screening of youth athletes interested in futbol. CEMA is located in the center of Universidad del Futbol and Ciencas del Desporte, which houses over 2000 high school to college athletes to pursue both an education and hopes of a career in futbol.
We observed the screening area, which handles the pre-participation physicals for thousands of local young athletes. Our experience at CEMA included case presentations on a ACL tear and SLAP tear which stimulated much discussion regarding graft selection for ACL and, then, SLAP tear repair versus biceps tenodesis/tenotomy. Case discussions were always following by surgical observations to see the practical application of our collaborative collective treatment recommendations.
In Pachuca, ‘football is life’ and thus we toured “El Mundo Futbol”, the International Futbol Hall of Fame, and Estadio Hidalgo (home stadium for Pachuca soccer club). In El Mundo Futbol, there were several interactive exhibits where one could measure the speed of a kicked ball, test goalie like reflexes, perform a high jump and sprint run, and test one’s accuracy with ‘Soccer Darts’ and penalty kicks (yes we competed and sworn to secrecy the winner but he or she is not from California or Illinois 😉).
The FIFA endorsed International Soccer Hall of Fame was also fascinating, from its design as the world’s largest soccer ball to a complete collection of Salon de la Fama induction trophies. We learned that the rules governing induction into the Futbol Hall of Fame are similar to those of the NFL and that Mia Hamm was the first American and female inducted into the Hall of Fame. We then wen to Estadio Hidalgo, the home of the Club Pachuca, where we received a private stadium tour which included the player’s sideline seating and locker rooms.
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Food was a focus of the Mexico leg of the trip. On the first day we ate at the Bife Sports, which is a restaurant attached to Estadio Hidalgo. While this is typically packed on game day, we had the restaurant all to ourselves and enjoyed a nice spread of local food, including the Octopus Fajita. The following day, we were treated to a great lunch in the presidential suite of the training center by the Grupo Pachuca VP of International Affairs. Several members of the Grupo Pachuca leadership and teachers from the University of Football were in attendance. At the end, we were all presented with a Jersey from the Tuzos soccer team.
We also took part in the exchange of scientific information, through our participation in surgery as well as case presentations. On the first day, we observed a case with Dr. Eduardo ‘Lalo’ Morales and assisted with an ACL reconstruction using a quadrupled hamstring graft. Although it was a high-grade partial tear, for ease of visualization, we removed the ACL remnant and used anteromedial guide drilling for the femoral tunnel. For fixation, we used a fixed loop button on the femur and biocomposite interference screw on the tibia. It was a great experience scrubbing in with Lallo, who had a great collegial personality.
Our fellowship in Mexico was completed spending the day at the Instituto Nacional de Rehabilitacion with world renowned hip arthroscopist Victor Illizaturri, who balances both a public and private practice in the center of Mexico City. Instituto Nacional de Rehabilitacion is a juggernaut of an orthopaedic hospital with 156 beds dedicated to orthopaedic care and 71 orthopaedic residents. Although we are traveling fellows, his five other fellows, many from different parts of Latin America, also benefit from advanced surgical training in both hip arthroscopy and arthroplasty. We witnessed first-hand his peri-portal technique for visualization of the hip joint without performing a capsulotomy.
Next Stop: Peru
Our Peru experience was phenomenal cultural, culinary and academic experience. Our primary hosts were Dr. David Torres, who is the incoming president of SLARD and has a knee and shoulder practice, and Dr. Christian Lozano, who mainly has an upper extremity practice and is an avid runner. We were introduced to an enlightening discussion regarding how the Peruvian medical system compared to the US.
In Peru, there is both a public and private system. The private hospital in which our hosts Drs. Torres and Lozano worked was the Clinico Anglo Americana, accredited by the International Joint Commission. For many of countries we visited in South America, it is mandatory that two attending surgeons scrub for each cases, and Peru was no exception. There is also a significant amount of attention paid to lowering implant cost, as even with insured patients implant costs may be passed down to the patient. This is particularly important in the public sector as well, where the hospital would need to absorb all implants costs.
During our time at Clinco Anglo Americana, we observed a shoulder instability case for which they performed a loose body removal and arthroscopic Bankart repair. The public hospital was Hospital del Lima Esta Vitarte, which serves an 800,000 district in Peru and sees about 150-400 patients/day in the ER. In addition to our two hosts, our experience was complemented by Claudia Arias, a complex knee surgeon, and Jose Castro, an upper extremity surgeon.
At Vitarte hospital, we observed an ACL reconstruction with BTB autograft and partial lateral meniscectomy as well as another arthroscopic Bankart repair for shoulder instability. Fellows also participated in case discussions, review of imaging studies, and discussions of treatment options.
Following the cases, we were treated to a tour of the hospital. While in Peru, we had the chance to present our work at scientific sessions held at the Sonesta del Olivar Hotel and Vitarte Hospital which included lively discussions focused on topics such as nonoperative versus operative management of knee PCL injuries.
On the first day were treated to a phenomenal dinner at the Country Club Hotel, which was founded in the 1920s. We tasted several local dishes including Peru’s world famous ceviche and lomo saltado, and were treated to popular drinks including pisco sour and Inka Cola. We also enjoyed dining at the Alado restaurant, a contemporary Peruvian restaurant located in the posh San Isidro district of Lima where the food and ambience were phenomenal.
We leaned on our hosts local knowledge who ordered family style allow us to sample the many unique dishes. We learned about Lucuma, native to the Andean valleys of Peru, which is incorporated into many Peruvian dishes and is the most popular ice cream flavor in Peru.
Another highlight of our culinary experience was the Panchita restaurant, located in the nearby upscale Miraflores district, which is also home to many of Lima’s hotels. The restaurant is led by Peruvian celebrity chef Gaston Acurio, who owns 40 restaurants, including several in the US. His story is interesting in that he originally went to Paris to study law to follow his father’s footsteps, but subsequently changed paths and graduated in cooking at the world renown Le Cordon Bleu. The French influence in his Peruvian dishes is palpable, and we really enjoyed the variety, flavor and quality of all the dishes. Dinner at Amor a Mar restaurant was yet another highlight, where we were treated to several local seafood specialties and Pisco flavors, including chilcano, algarrobina and sour.
Apart from the scrumptious and mouth-watering culinary experiences, the social component of our Peru experience was incredible. The highlight was our trip to Paracas, a beach town in a sheltered bay south of Lima. The town was founded by the Paracas culture, an ancient Andean society with extensive knowledge of water management and irrigation.
Following our arrival at Paracas, we hoped on a boat tour of the Ballestas Island, which serves as an important sanctuary for many bird species and mammals in the region, including the blue-footed booby, sea lions and Humboldt penguins. The island is also famous for its “Guano”, the bird droppings that cover these ocean islands that are still mined for this resource as a rich fertilizer. We also saw the mythical Paracas Candelabra, found on the northern face of Paracas bay, with several theories about its creation.
Following our boat ride, we traveled to the Tacama winery, where we were given a tour of the beautiful landscapes and were treated to wine tasting. The head of the winery, or enologist, was trained in France and explained the science behind making good wine. He explained the importance of controlling the water supply appropriately to concentrate flavor and how greater diurnal temperature shifts can serve to better preserve the grapes natural aromas and acidity. Following the tasting of a spectrum of wines, we were treated to a Peruvian paso horse show while eating lunch at the Tambo de Tacama restaurant.
This was capped off by a visit to the sand dunes of Huacachina and its fascinating natural desert oasis, where we were afforded an exhilarating and adrenaline filled Dune Buggy adventure. The driver would make sudden turns and race down sand dunes at breakneck speeds, adding to the excitement of the experience. Furthermore, we got to practice sandboarding and experience a breathtaking sunset overlooking the desert sand mountains and lush valley below.
Ultimately, we had a very rich and fulfilling social and culinary experience during our time in Lima. We were very fortunate to have such hospitable hosts in David and Christian, who went out of their way to ensure we had the absolute best, most memorable traveling fellowship experience possible. We formed strong friendships with our many hosts that will last a lifetime.
Cali, Colombia
After passing through Bogota, we landed in Cali, Colombia and were greeted by one of our hosts Juan Pablo Martinez. Cali is a city situated between mountain ranges about 90 minutes from the pacific coast of Colombia. Much of the local infrastructure and economy in Cali revolves around the sugar cane industry. This vibrant agricultural focus allows for lush green landscapes, whereas the numerous schools in the region make for quite a bit of traffic in the mornings.
Each morning in Cali we had the pleasure of observing surgeries at Fundacion Valle del Lili hospital where they treat patients with both private and national health care insurance. The hospital itself is similar in size to a large urban city’s medical center in the US and includes 5 other satellite locations around the great Cali area.
Fundacion Valle del Lili hospital has received accreditation by The Joint Commission in the United States and is ranked 1st among hospitals in Colombia and 4th best hospital in Latin America by America Economia magazine. Furthermore, in 2022 the world’s best hospitals were ranked by Newsweek magazine and Fundacion Valle del Lili ranked 149, a position that was above many US hospitals.
The medical environment at this facility is such that there are no restrictions on what kind of implants surgeons can use, but appropriate implant stewardship is still valued. Research is a fundamental activity at Fundacion Valle del Lili where patient outcomes for the numerous research studies currently underway are rigorously tracked across a multitude of medical specialties. Upwards of 100 individuals are full-time employees making up the robust researcher infrastructure including statisticians, study coordinators, public health specialists, and patient health advocates.
The first day’s operative cases performed by Dr. Paolo Llinas included a unicompartmental knee replacement, a superior capsule reconstruction using autograft long head biceps tendon, and an allograft PCL reconstruction. Paolo is a member of the Rotator Cuff Study Group an international group of surgeons focused on optimizing the treatment of rotator cuff injuries worldwide. Paolo’s typical surgical team for each procedure consisted of two orthopaedic surgeon fellows, a scrub technician, and an implant representative.
Implant representatives being more closely integrated into the surgical team served to facilitate efficiency as this individual ensured that any necessary implants were always available, ready for use, and inserted using the proper technique. There is no need for an in-service demonstration for your staff when the person giving the instruction is already a member of your surgical team.
Day two at Fundacion Valle del Lili consisted of a combined MPFL and MPTL reconstruction for patellar instability in the setting of patella atla with Juan Pablo Jiminez. This new-to-us technique adapted from Juan Pablo’s experience gained during his ISAKOS Patellofemoral Traveling Fellowship included new fixation strategies that gave us food for thought regarding how to address this problem that has a multitude of described treatments options.
Day two concluded with a 2 vs. 3 golf competition using a Scottish scramble format at the Club Campestre de Cali golf club where we encountered some local animals on the course including iguanas, agouti, and ducks.
Popular in Cali, chantoduro or peach palm is a local fruit eaten in combination with salt or honey, and is often viewed by others in Colombia (not from Cali) as an acquired taste. Henry decided to take the bull by the horns and bite into this local fruit without the recommended salt/honey pairing. He survived and subsequently was still able hit the ball straight down the fairway somehow. We will never know who the true victors were for this golf outing, but needless to say many memorable shots were made… and missed, and a rematch is inevitable.
Santiago, Chile
Set between the ski mountains of the Andes, and the beaches of the Pacific, Santiago is the heart of Chile and the center piece of orthopedic community in all of Chile. Three large hospital systems worked together to welcome the traveling fellows to their sports medicine culture, and lifestyle.
After a 6 hour flight from Colombia in which we caught up on much needed rest, we joined the APKASS (Asian Pacific Knee, Arthroscopy, and Sports Medicine Society) Traveling Fellows. We soon realized that English was their common language as each APKASS fellow primary language was different (Joe (Chih-Hao) Chiu – Taiwanese, Ling Samuel Ka Kin – Cantonese, Toyooka Seikai – Japanese, and Xuesong Dai – Mandarin).
Combining with the APKASS fellowship allowed for each of us to expand our fellowship beyond Latin American, as over dinners and breakfasts we discussed all aspect of each other’s practice, family, politics, and resource utilization. Mainly, we allowed ourselves to learn even more by sharing recent publications from each other and discussed way to improve arthroscopic treatment of sports related injuries across continents.
Drs. Sebastain Irarazaval, Maria Jesus Tuca, and Raimundo Vial welcomed us at the Academic Center of Pontificia Universidad Catollica de Chile in which we discussed treatment strategies of focal chondral defects between all the countries while Dr. Irarazaval performed a live surgery utilizing an osteochondral autograft transplantation technique (OATS). As is common in Latin America the surigical team including 2-3 surgeons during most surgeries was further reinforced in Chile.
Dr. Christian Fontbate introduced the fellows to the Centro de Innovacion at Clinica MEDS where they not only perform return to play testing, but have been focusing on neurocognitive recovery in athletes following treatments such as an ACL reconstruction. Their real time visual feedback to the athletes was impressive and unlikely anything we had ever seen. In the evening, the academic session at Clinical Alemana hosted by Dr. Francisco Figeroa included numerous surgeons from different practice settings all over Santiago which resulted in a great discussion of contemporary clinical issues such as the utility of the lateral extra-articular tenodesis and anterolateral ligament procedures to augment ACL reconstruction.
From hiking the foothills of the Andres to racing up Saint Cristobal Hill to watch the sunset, we had some much needed exercise and adventure. Exploring the city of Santiago is incomplete without hiking on top of one of its several hills including Saint Lucia Hill in the center of Santiago. We were welcomed in the homes of Drs. Alex Vaisman and Francisco Figeroa for a taste of traditional Chilean food including amazing Umica which is like a flavorful moist tamale without meat.
Overall, our visit to Chile was adventurous and we clearly appreciated their innovative ideas and resources that we had not seen in other countries.
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Final Stop: Buenos Aires, Argentina
Our final stop on the AOSSM Traveling Fellowship was in Buenos Aires, Argentina where, along with the APKASS Traveling Fellows, we participated in the SLARD (Sociedad Latinoamericana de Artroscopia, Reconstruccion Articular, y Trauma Deportivo) Annual Meeting. During this 3-day annual meeting, we had the opportunity to see many of our new friends from across Central and South America.
One highlight was the Female ACL Session where we had the chance to learn from a number of our fellowship hosts including Maria Tuca, Claudia Arias, and, our godmother (Joe Hannafin), who shared their extensive knowledge and experience regarding the management of these injuries in female athletes.
We also joined many leaders from the AOSSM, including current AOSSM president, Dr. Dean Taylor. We were each honored to present our clinical and research interests at the SLARD meeting which included conflicts of interest and inherit bias (Hannafin), Suture Bridge technique for osteochondral injuries (Ellis), use of fluoroscopy when reconstructing lateral knee structures (Kremen), and meniscus repairs (Athiviraham).
The finale of our trip was traveling to the countryside of Argentina with the surgeons of SLARD to watch a polo match while enjoying traditional Argentinian asado and Malbec wine.
As the 2024 AOSSM/SLARD Traveling Fellow, we would like to thank the AOSSM for honoring us with the privilege of this priceless experience. We would also like to the thank SLARD and our gracious hosts during our visit and we invite all of the amazing individuals we met along the way to come visit us at each of our cities, our practices, and our homes, to let us share our culture with you in the future.
With much gratitude -
Aravind, Henry, Tad and Jo (The Godmother)
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Check our Instagram for more pictures and details about our adventure!