The 2008 Austrian-Swiss-German (ASG) Traveling Fellowship, sponsored by the American Orthopaedic Association, commenced on Monday, April 6, 2008, and was completed on Sunday, May 4, 2008. Dr. Richard Iorio, a specialist in adult reconstruction surgery, and Dr. Robert Hart, a specialist in spine surgery, were joined on the tour by Mr. Stanley Jones, a consultant orthopaedic surgeon from Sheffield Children's Hospital in the United Kingdom. The fellows traveled for three weeks in Germany and one week in Austria.
At the first stop, Wurzburg, Germany, we were hosted by Jochen Eulert, MD, Professor and Chairman at the Orthopaedic Institute of the Konig-Ludwig-Haus. Professor Eulert is stepping down as director of the ASG Fellowship in Germany this year. Dr. Hart and Mr. Jones joined Professor Eulert in the operating room on the afternoon of April 7. Dr. Iorio's arrival was delayed because of weather issues, but eventually all three fellows convened for a tour of Wurzburg. A dinner was held with a group of Dr. Eulert's Oberarzts, or junior attending surgeons. After we had sampled the local beer and wine, plans were made for the following day's experience in the operating room and clinics.
In the operating room at Wurzburg, Dr. Eulert demonstrated several total joint replacement procedures. Of note, all of the cemented knee replacements were done with antibiotic-impregnated cement. Additionally, all of the total hip replacements were performed with the patient in a supine position and with use of a modified anterior approach to the hip joint. Mr. Jones attended the pediatric clinic, and Dr. Hart participated in a triple arthrodesis and lumbar spinal fusion. After the day in the operating room, we toured the Orthopaedic Center for Musculoskeletal Research, where we were hosted by Drs. Franz Jakob and Norbert Schuetze. Topics of interest included studies in gene expression for various musculoskeletal conditions and osteoporosis.
The academic portion of the day ended with lectures by the three traveling fellows. Dr. Hart presented his lecture entitled "Failed Spine Surgery Syndrome in the Life and Career of John Fitzgerald Kennedy." Dr. Iorio gave his paper concerning "Orthopaedic Surgeon Workforce and Volume Assessment for Total Hip and Knee Replacement in the United States: Preparing for an Epidemic." Mr. Jones presented his work on the Scarf osteotomy for hallux valgus. The day was concluded with an outstanding social function at the Steinberg Restaurant on one of the highest points in Wurzburg overlooking the Main River. Professor Hans-Werner Springorum, the secretary of the ASG Fellowship in Germany, also accompanied us to the dinner along with his wife and several other faculty members from Wurzburg. It was a wonderful exchange of political, orthopaedic, and cultural information. Starting with this evening and throughout our visit, we found that our German and Austrian hosts were particularly fascinated with the 2008 American presidential campaign and political process, although we were not able to lend much clarity to these issues.
On Wednesday, April 9, we spent the morning in the operating room at Wurzburg. Dr. Olaf Rolfe performed a posterior cruciate-retaining total knee replacement, and Dr. Eulert performed a total hip replacement using a minimal access anterior approach. The morning concluded with a very spirited discussion concerning the use of large femoral heads in hip replacement, the cost of alternative bearing surface materials, and the longer hospital stays in Germany compared with those in the United States.
We left Wurzburg and after a two-hour train ride arrived in Munich, where we were hosted by Drs. Reiner Gradinger and Andreas Imhoff. We were taken from the train station to the Technical University of Munich, where we watched Dr. Maximilian Rudert perform a proximal femoral replacement with a constrained acetabular liner following a tumor resection. We then observed Dr. Imhoff perform an arthroscopic rotator cuff repair with biceps tenodesis, one of the few sports medicine procedures we observed during our tour.
On Thursday, April 10, we met with the three orthopaedic services at the Technical University of Munich as they came together for grand rounds. Dr. Hart participated in a spinal reconstruction for metastatic tumor as well as a transnasal endoscopic resection of the dens with Dr. Bernhard Meyer of the neurosurgery service. Mr. Jones and Dr. Iorio observed a wide spectrum of orthopaedic care at the university with Dr. Rudert. A proximal femoral replacement was performed for a renal cell carcinoma in addition to a total knee arthroplasty, a Scarf osteotomy for hallux valgus, and a proximal femoral varus osteotomy for hip deformity.
At the end of the day, representatives from all of the Munich orthopaedic services were together for a dinner celebration at the Hofbrauhaus, which is notable for its association with Octoberfest and as one of the first places where Adolph Hitler spoke publicly. The social program was preceded by lectures from the ASG fellows concerning orthopaedic workforce issues, functional effects of lumbar spine stiffness following fusion, and the Ponseti method for the treatment of clubfoot.
On Friday, April 11, the fellows traveled to the Ludwig Maximilian University and Grosshadern Hospital. Both the Technical University of Munich and Ludwig Maximilian University are enormous institutions in comparison with American hospitals. The Grosshadern Hospital at Ludwig Maximilian University has 1300 beds with 800 staff physicians and ninety orthopaedic beds. Dr. Iorio and Mr. Jones observed Dr. Volkmar Jansson, the Chairman of the Department of Orthopaedic Surgery, perform a total hip replacement with a ceramic head and a polyethylene liner and utilizing a Hardinge approach with the patient in the supine position. Dr. Hart participated with Dr. Christof Birkenmaier in a posterior spinal fusion for a patient with scoliosis following a two-level total disc replacement performed at another hospital. This was followed by an academic session including discussions of external fixators for trauma in children by Mr. Jones, the functional impact of stiffness following lumbar fusion by Dr. Hart, and orthopaedic workforce issues by Dr. Iorio. Following the academic presentations, the ASG fellows were hosted by Dr. Chlodwig Kirchhoff at a dinner at the Spatenhaus in the center of Munich near the Opera House.
The ASG fellows were then treated to a cultural weekend by our hosts at the Technical University of Munich and Ludwig Maximilian University. Drs. Hans Roland Durr and Kirchhoff served as our guides. We were taken to the Bavarian lakes region at the foot of the Alps and toured Neuschwanstein, the fanciful castle designed and commissioned by King Ludwig and later made famous by Walt Disney. On Saturday evening, the fellows escaped German culture and watched an American film in English together in Munich.
On Sunday, April 13, Dr. Durr took us to the train station where we began our journey to Berlin. The train journey from Munich was a six-hour tour through the former East Germany. The reunification and reintegration of East Germany and East Berlin into modern German culture is a triumph of recent German history. The integration of health care from the German Democratic Republic into the Western medical style of modern Germany was equally fascinating. In Berlin, we were hosted by Professor Norbert Haas and Professor Carsten Perka.
German orthopaedic training programs have recently begun integrating musculoskeletal trauma with orthopaedic surgery. Musculoskeletal trauma had previously been managed by general trauma surgeons in the German-speaking countries, while orthopaedic surgery training programs consisted mainly of musculoskeletal tumor, spine, adult reconstruction and foot and ankle surgery, and pediatric orthopaedics. Currently, residents can choose a four plus two-year combined training program with an emphasis on either trauma or orthopaedic surgery. Dr. Haas, an orthopaedic traumatologist, has been one of the leaders in promoting this transition.
There are three major hospitals in Berlin, which are considered separate campuses of the Medical University of Berlin, and the largest, Charité Hospital, is located in the former East Berlin. Dr. Perka was our host on our first day there, where we watched several adult reconstruction operations performed with navigation and a revision total hip arthroplasty. During the afternoon, we headed out on our own for a sightseeing tour of Berlin. We observed remnants of the Berlin Wall, saw the Kaiser Wilhelm Memorial Church and the Holocaust Memorial, and toured the museum at Checkpoint Charlie, which is dedicated to the history of the Berlin Wall and to the many individuals who risked their lives crossing this border.
One of the highlights of our trip was an evening in Berlin with Drs. Perka and Haas. We first toured the Reichstag, the meeting place of the German Parliament. Following the tour, we enjoyed a wonderful dinner at the Kafer restaurant located on top of the Reichstag, which permitted an amazing panoramic view of the Berlin skyline, including the Charité Hospital in the distance. It truly was a memorable evening, ending in a drenching thunderstorm for which none of us had brought appropriate rain gear.
The next day, we again observed surgery at Charité Hospital. Dr. Hart participated with Dr. Michael Putzier in a fusion procedure in a young man with severe scoliosis due to neurofibromatosis. Cases of adult reconstruction and foot surgery were attended by Drs. Iorio and Mr. Jones. One interesting point of discussion was the fact that the Charité Hospital was famous as the site of the development of the lumbar total disc replacement, which bears its name, but that prosthesis is no longer utilized at the Charité.
We then enjoyed a tour of the Julius Wolff Institute, the basic-science laboratories located on the Benjamin Franklin campus of the Charité. With eighty PhD-level faculty, the institute is named for one of the university's most famous graduates, who described "Wolff's law" in 1892. Ongoing projects include implantable telemetered force transducers embedded in shoulder, hip, knee, and spine prostheses. There was an impressive large-animal veterinary surgical suite and a tissue-engineering laboratory. Academic lectures were then given concerning John Fitzgerald Kennedy, external fixators for trauma in children, and displaced femoral neck fractures. The following day, we spent the morning in cultural activities including a visit to the German Historical Museum to explore the roots of Hitler's rise and eventual takeover of the German government in 1932.
We then boarded a train to Düsseldorf for our longest stay of the fellowship, in the heart of the Rhineland region. Our first exposure to the medical community in Köln was a visit to a university fraternity, where we were introduced to the famous Kölsch beer of the Rhineland area. The next morning, we were met by Professor Rudiger Krauspe, the Chairman of the Düsseldorf University Orthopaedic Clinic. Dr. Krauspe performed a spinal fusion for neuromuscular scoliosis using the classic Luque technique and was assisted by Dr. Axel Schartstadt. We also observed Dr. Markus Jager perform a Tönnis osteotomy for congenital dysplasia of the hip. This operative experience was then followed by another series of lectures by both Dr. Krauspe's faculty and the ASG fellows.
On Friday, April 18, we journeyed to Neuss, where we were hosted by Professor Jorg Jerosch whose expertise includes humeral head resurfacing with use of the inlay type of prosthesis. We also observed a hip arthroscopy performed for femoral acetabular impingement. Our academic presentations that day were Mr. Jones' talk on the Ponseti method for the treatment of clubfoot, Dr. Hart's discussion of the Wiltse bilateral-lateral approach for posterior fusion of the lumbar spine, and Dr. Iorio's presentation on "The Boston Red Sox, the Curse of the Bambino, and the Bloody Sock." While we learned that the German people were intimately familiar with the Red Sox and Yankees rivalry, their preference for athletics tended toward Formula-1 car racing, soccer, downhill skiing, and basketball. As there were no American sports available on German television, Mr. Jones' devotion to Premier League soccer was indulged by Dr. Hart and Dr. Iorio during our downtime.
Over the weekend of April 19 and 20 in Köln, we were hosted by Dr. Jager who took us on a tour of the city. This was one of the highlights of the trip, and included a guided tour of Köln Cathedral, personally led by one of the cathedral's priests. We learned that construction of the cathedral had been started in 1248 but was not complete until 1880, at which time it was the world's tallest building. Köln is an ancient city founded by Rome and rebuilt many times in successive layers. We finished the evening watching a soccer match in a Kölsch brew house, where we had been led by Mr. Jones.
On Sunday, April 20, we took a boat tour of Köln along the Rhine River and then enjoyed a jazz brunch at Papa Joe's Jazz Emporium. By this time, we had become accustomed to traditional German food, which typically consists of some preparation of pork, cabbage, and potato. We therefore decided to indulge ourselves in some American food at a sports bar in downtown Köln. As we enjoyed our dinner, we realized that barbecued spare ribs, cole slaw, and French fries also consist of pork, cabbage, and potatoes, which made the world seem a smaller place.
On Monday morning, April 21, we reported to the University Hospital of Köln, where we were met by Dr. Peer Eysel and attended several surgeries including a hip resurfacing. Following completion of the day's operative schedule, Dr. Eysel and his wife hosted us at a reception at their home featuring delicious local fare and champagne. From there, we drove to a dinner party in downtown Köln, which was attended by representatives of the orthopaedic departments from Neuss, Düsseldorf, and Köln.
On April 22, Dr. Iorio and Mr. Jones attended an operative program at the University Hospital of Bonn that was hosted by Professor Dieter Wirtz. Dr. Hart returned to the University Hospital of Köln to observe a cervical total disc replacement and a lumbar spine fusion performed by Dr. Eysel and Dr. Rolf Sobottke, respectively, which had been delayed because of medical issues from the prior day's schedule. Dr. Hart then joined the other fellows in Bonn by early afternoon. The day concluded with a presentation by Dr. Iorio on workforce issues and several research papers by the faculty at Bonn. Following the lectures, the ASG fellows toured the museum located at the birth house of Beethoven in Bonn. We then had a final dinner on our own at the famous Haus Schwan in Köln, the favored choice of local host Hans-Philipp Springorum.
On Wednesday, April 23, the ASG fellows traveled from Düsseldorf by air to Vienna, Austria, where we were met by Dr. Stephan Schenk. That evening, we enjoyed a dinner at Mayer am Pfarrplatz, hosted by faculty of the Medical University of Vienna including Dr. Ronald Dorotka. This proved to be a delightful dinner of traditional Viennese cuisine including local beers and wines. The location is noted for a connection to Beethoven, who lived there for a time during his early career in Vienna.
On Thursday morning, we were hosted at the Medical University of Vienna by Dr. Rainer Kotz. We observed a computer-navigated total knee arthroplasty by Dr. Alexander Giurea, as well as a revision tumor resection of the proximal part of the femur by Dr. Martin Dominkus. In the afternoon, a scientific session was held at the Museum of the Private Office of Professor Adolf Lorenz. Among his other accomplishments, Dr. Lorenz served as the first chairman of the Department of Orthopaedics at the Medical University of Vienna, was one of the cofounders of the German Society of Orthopaedic Surgery, consulted with Franklin Delano Roosevelt regarding the treatment of his poliomyelitis, and was the father of Nobel Prize winner Konrad Lorenz.
The talks on Thursday were given by Dr. Hart who described the variability in screening and processing techniques of structural allograft bone, Dr. Iorio who discussed unicompartmental arthritis of the knee, and Mr. Jones who described the Scarf osteotomy for hallux valgus. In addition, we were treated to an outstanding presentation by Dr. Dominkus regarding the evolution of orthopaedic tumor surgery in Vienna. The data he presented clearly demonstrate the improvement in survival rates that has occurred at the Medical University of Vienna over the past four decades.
Following the academic day, we enjoyed a delicious dinner with Dr. Franz Grill, Dr. Michael Ogon, Dr. Kotz, and Dr. Dorotka at the Hotel Sacher in central Vienna, complete with a sampling of the famous chocolate torte originated by the hotel. That evening the ASG fellows were treated by Dr. Kotz to a performance of Salome by Richard Strauss at the Vienna State Opera House, another highlight of our trip.
On Friday, April 25, we were hosted at the Orthopaedic Hospital Speising in Vienna by Drs. Grill and Ogon. The day started with a breakfast of cakes and coffee in Dr. Ogon's office and then proceeded to the operating room. The fellows were able to participate in an anterior-posterior procedure in a child with grade-IV spondylolisthesis. We then proceeded to the academic presentations, which included a presentation by Dr. Hart regarding trans-sacral fixation for high-grade spondylolisthesis, a presentation by Dr. Iorio on unicompartmental arthritis of the knee, and a presentation by Mr. Jones on spatial frame fixators for pediatric trauma. Dr. Ogon presented the experience of Orthopaedic Hospital Speising with lumbar total disc arthroplasty. The day concluded with a delicious lunch with Dr. Ogon and Dr. Grill at the restaurant Napoleonwald, which included the seasonal favorite of white asparagus.
On Saturday, April 26, we did some shopping for our families in Vienna and then departed by train for Salzburg. We were met at the train station in Salzburg by Dr. Ulli Dorn, the chairman of the Department of Orthopaedic Surgery at the Salzburg General Hospital. Dr. Dorn hosted us with a reception at his house accompanied by his lovely wife, followed by a dinner at the M 32 restaurant on top of the Museum of Modern Art, which offered a panoramic view of Salzburg. While in Salzburg, we stayed at the Hotel Schloss Arenberg. This extraordinary facility is a historic castle that has been refurbished as a teaching facility dedicated to international exchange. A number of prominent organizations have partnered with the American Austrian Foundation to develop teaching programs hosted at Schloss Arenberg dedicated to spreading medical knowledge, musical and fine art education, and studies in media and diplomacy.
While in Salzburg, Dr. Dorn also hosted us on a visit to Hangar-7. Designed and built by a local businessman associated with the Red Bull beverage company, the museum houses a collection of historic aircraft as well as motorcycles and Formula-1 racing cars. The following day we attended the Orthopaedic Surgery Department at Salzburg General Hospital, again hosted by Dr. Dorn. In addition to the fellows' presentations, the lectures included a presentation by Dr. Dorn on the triple pelvic osteotomy as well as recollections of his own experience as an ASG Fellow.
On Monday, April 28, we departed for Innsbruck by train. We were greeted on arrival by Dr. Martin Krismer, who hosted us at a welcoming dinner at the restaurant Solo Vino. On Tuesday, April 29, we participated in an academic conference at Innsbruck Medical University, which included video-based observation of a minimal access total hip replacement. Presentations by Dr. Krismer's faculty included discussions of a number of clinical research initiatives. In particular, Dr. Gerold Labek gave a very interesting presentation regarding the benefits of total joint arthroplasty registries, including an update on the efforts of the European Arthroplasty Register.
While in Innsbruck, we toured the tomb of the emperor Maximilian, again hosted by Dr. Krismer. We then had lunch at a restaurant located at the top of the Bergisel, the ski jump used in the 1964 and the 1976 winter Olympic Games held in Innsbruck. Following the academic presentations, we enjoyed a final dinner together with Dr. Krismer and his faculty at Lichtblick restaurant.
On Wednesday, April 30, we departed from Innsbruck by train to Baden-Baden. On arrival at Baden-Baden, we registered for the Congress of the German Society for Orthopaedics and Orthopaedic Surgery. We then enjoyed the local environment in Baden-Baden, including a visit to the historic casino, where Dr. Iorio was able to demonstrate his unbeatable strategy at winning roulette.
On May 2, we were driven from Baden-Baden to Heidelberg, where we were met by Dr. Wolfram Wenz, a senior faculty at Heidelberg University. In addition to demonstrating his extraordinary techniques in correction and fixation of foot deformity, Dr. Wenz hosted us on a tour of Heidelberg in what he described as "an American convertible." The vehicle in question turned out to be a World War II vintage Willys Jeep. After a fairly terrifying tour of the city, we arrived at Heidelberg Castle, where we had a delicious lunch. After a final break for shopping in downtown Heidelberg, Dr. Wenz drove us back to Baden-Baden, thankfully in an enclosed vehicle.
We spent our final day in Baden-Baden at the ASG symposium at the Congress. We gave a final presentation of our papers including, much to the relief of Mr. Jones and Dr. Iorio, Dr. Hart's last discussion of the history of John F. Kennedy's lumbar spine problems. The session was concluded by Dr. Hans-Werner Springorum who asked and answered the hypothetical question, "How would history have been different if it had been Khrushchev instead of Kennedy who was assassinated? One thing I think is certain—Onassis would not have married Mrs. Khrushchev."
The final formal event on the fellows' schedule was a lunch at the Congress attended by German, Swiss, and Austrian alumni of the ASG fellowship. The lunch included a presentation by the 2008 German-speaking ASG fellows of their travels through North America and England. Among the highlights of this presentation was our commiseration with the travails of our counterparts as they described their extensive familiarity with North American airports, encounters with inclement weather, hotel stays, and their somewhat repetitive diet of steak and potatoes during their visit.
On May 4, we went our separate ways from the Frankfurt airport to our respective homes and families (Fig. 1). We all agreed that the ASG fellowship was a unique and remarkable experience. We look forward to maintaining the connections established with our hosts in Germany and Austria, as well as among the three English-speaking fellows. We hope to share our experience with many more ASG fellows in the future and look forward to maintaining our ties to our Germanic brethren.