Letter from China No. 8

Saturday 3 April, 2018

Letter from China No. 8

Hello again, Friends, Our time in Wenzhou came to an end, all too soon. Yesterday we flew 2 hours and 40 minutes from Wenzhou to Sanya on the southern coast of the tropical island of Hainan, which is located in the South China Sea between Hong Kong and Viet Nam. We are going to have a few days at a resort on the beach before flying north to Beijing and then back to Calgary.

Our final days in Wenzhou were full of interesting work in the hospital, fun and celebration. At morning rounds on Thursday we found out what happened to Dr. Li's free flap and its problem with spasm in the recipient site anterior tibial artery. He said that, after struggling for a while longer, he changed plans and used an end to side anastomosis with the posterior tibial vessels. It worked right away and everything turned out OK. 'All's well that ends well'. It is necessary to have a lot of patience, and to be resourceful, to be a successful microvascular surgeon. Dr. Li is clearly an expert and knew exactly what had to be done to resolve the problem. With Dr. Jiang acting as interpreter, we had a really good discussion about some of the problems of microsurgical reconstructions for post traumatic tibial problems. It is extremely difficult surgery. The soft tissues are badly damaged and the recipient vessels can be very problematic. Many techniques have been tried, over the years, to optimise the situation. I was once invited to State University of New York, in Buffalo, to give a talk on 'The Differences Between Laboratory Microsurgery and Clinical Microsurgery'. I remember discussing this problem Dr. Li encountered in some detail. I remember giving my presentation the very Canadian title of 'So, It Ain't So Easy, Eh!'

Dr. Gao asked when I was leaving. I said Monday. He said that, on the weekend they were putting on a National Microsurgery Course and people would be coming from all over China. They would be discussing the problem of post traumatic lower extremity osteomyelitis and the management of septic non unions. They were, specifically going to be discussing the problem of reconstructing extensive long bone defects and soft tissue loss after large excisions of poor quality tissue. He asked if I could give an introductory talk on osteomyelitis and its treatment on Saturday. I have not brought material on this subject with me but have some images, which I can use, in Powerpoint presentations on microsurgery, replantation and infections that I threw into the computer before I came. I said I would put something together for the occasion.

After discussing this, I gave a presentation on current concepts in the management of Dupuytren's contracture. This is a Caucasian condition and I thought they might be interested although they see no cases. I discussed the anatomy and management options. I looked up the most recent results for the collagenase and percutaneous needle transection techniques. Preparing the Powerpoint, I was a bit surprised to discover a paper indicating that collagenase injection technique had a lot more complications than I realised. I was even more surprised when, at the end of my presentation, one of the senior residents told me he was reviewing the results of 70 cases treated in their hospital. Years ago, SP Chow, then Dean of Medicine in Hong Kong and a hand surgeon, joined me for a day in the operating room in the Toronto General Hospital. I put on a case of surgical resection of Dupuytren's contracture when I discovered he had published a paper entitled '3 cases of Dupuytren's contracture in Asians. I told the Wenzhou resident that he should entitle his paper '70 cases of Dupuytren's contracture in Asians'. I am sure it will be published and it will cause us to re-evaluate our ideas on aetiology. I have seen no patients with the condition since I have been in Wenzhou but Dr. Jiang told me he saw a case in the clinic on Monday.

I spent the rest of Thursday in the operating room with Dr. Jiang. Open reduction and internal fixation of a lateral epicondyle fracture in a 14 year old boy. Open reduction and internal fixation of a clavicle fracture. Shoulder arthroscopy for a rotator cuff repair. Axial pattern dorsolateral transposition flap for skin loss in a finger. Debridement and skin graft (stamp grafts) of a soft tissue injury to a leg. They use a hand held Braithwaite dermatome for harvesting their split thickness skin grafts. They are very skilled with it. Dr. Jiang said that they have a power dermatome but do not use it. They prefer the hand held one and the blades are much less expensive.

At Friday rounds I presented some difficult diagnostic problems in the region of the carpometacarpal joint. We discussed carpal boss and I showed one that turned out to be an osstyloideum. They did not know about this condition and I explained what it was and showed the images of a case, for which I had good CT scans with 3D reconstruction. I showed images of a similar case where the patient had a developmental variant, with a large bony spur from the capitate grinding against the base of the 3rd and 4th metacarpal bases. He did well with resection and than came back and asked if I would do the same thing to his opposite wrist! We also discussed a professional racquet sport athlete with post traumatic 2nd CMC joint arthritis. These cases are easy to treat with excisions and/or fusions but are very difficult to diagnose because the CMC joints do not show up well on plain radiographs and need CT scans or MRIs for diagnosis. There was extensive discussion about their presentation.

I spent the day in the operating room with Dr. Yan. He had to start the day at an administrative meeting, so I supervised the resident internally fixing a proximal phalanx fracture in a little finger. These can be surprisingly difficult. The resident was very capable and we had a good conversation about the problems of the hype-extension deformity they have. It is is difficult to see it on plain radiographs but it must be corrected to prevent late PIP flexion deformities, which will not respond to physiotherapy. He asked me to show him my technique for putting on an ulna gutter splint, which was applied at the end of the case. They have faster setting plaster than us! I was lucky to get it molded before it went hard! We operated on the patient we saw earlier in the week with multiple gouty tophi. It took us a while. He had so many. Between cases I went into the next room and saw Dr. Li do a subcutaneous ulna nerve transposition at the elbow. He was keen to show me how he preserved the small vessels, which we always see going to the nerve. They are always right at the most awkward place for this operation and it is difficult to know what to do with them. He quickly dissected them out as a vascular pedicle, with enough length to stay intact and without tension after the transposition. Unlike Dr. Li, I usually do a submuscular transposition, which I think is better but there is a massive amount of controversy about which procedure is best. We did not get into this discussion. It was more fun discussing the vascularity of the nerve. Dr. Li's next case was a carpal tunnel decompression. He uses Susan MacKinnon's short palmar incision technique but does extensive subcutaneous dissection so that the nerve if well released. Do Yan then did another carpal tunnel decompression using the Chow endoscopic technique. I then did an open carpal tunnel decompression with a Camitzopponensplasty for the woman we saw in the clinic with severely wasted thenar muscles. Three different ways of releasing carpal tunnels in one afternoon! My Camitz tendon transfer was the only tendon transfer procedure I saw done while I was in Wenzhou. I had expected to see more. We discussed the criteria necessary for a tendon transfer to work satisfactorily. With the Camitz, it is necessary to ensure that the line of pull is correct. The textbooks say that it does not have much excursion but previous cases I have done have had more than anticipated.

It was a busy day. After all these operations, I went with Dorothy to the 8th floor and did another English language class with the nurses. A lady from hospital administration presented us with Certificates of Appreciation. It turned out that she had a Master's degree from my own University of Edinburgh. Her subject (and job) was teaching English as a second language.

In the evening there was a banquet for us. It was a really nice evening. The food was good and the company was great. There were some other guests as well. Professor Xie Zhao and three other members of his staff from the Army Medical University in Chingqing were there. They came for the Saturday course. I was told that Professor Zhao uses IM rods and internal fixation plates during his management of infected lower extremity long bones! Professor Gao made a speech about the Normal Bethune Scholarship. He said some really nice things. It was clear that he thought it has been a great success. He, and the other surgeons I interacted with, obviously want to repeat this. He honoured me and gave me a momento. I made a brief speech as well and said that it had been a fantastic experience and that I was going to strongly recommend that the relationship between the Wenzhou Medical University Division of Orthopaedic Surgery and the Canadian Orthopaedic Association continues for a long time.

On Saturday morning I hurriedly put together a Powerpointpresentation on osteomyelitis and the principles of managing the adult post traumatic long bone version (which is frequently septic non union of the tibia) with medical treatment as well as radical and multiple surgical excisions followed by soft tissue free tissue transfer and various options for rebuilding the skeletal defect. I discussed my preferred technique of using a free muscle transfer and split thickness skin graft with Ilizarov bone transportation. I explained the indications for other skeletal reconstruction methods including the Masquelet technique, which Dr. Li likes, and vascularised bone grafting. The presentation went over well. they had a really good English to Chinese interpreter.

Professor Zhao, who spoke very littleEnglish, indicatedthat he liked what I said. He went on to tell me that they see 400 cases a year in his hospital!! He does a very aggressive resection, removing all dead and infected tissue. He then reconstructs the bone with IM nails and/or plates and antibiotic impregnated cement. The construction is then covered with a cutaneous free tissue transfer. Later, the cement is removed and the skeleton is rebuilt using a tissue engineered bone graft with, or without a Masquelet bone graft technique. His pictures were very impressive, especially the images of the tissue engineered long bone grafts. He invited me to go to his hospital and see it done. Alas, this trip does not allowfor this. Someone from Canada (perhaps the next Norman Bethune Scholar) should, however, go to Chongqing and find out the details of what they are doing.

Next day I discovered that after the end of the course, at the end of the afternoon, they all went out for dinner. After that they went to the hospital and, late at night, Professor Zhao did two 2 hour operations on infected tibias, with others watching on live CCTV!

Sunday, our last day, Dr. Jiang took us to see the hospital's research laboratories. The hospital has a laboratory building on its campus, rather like the one, where I shared a lab with Bob Salter, at Sick Kids in Toronto, years ago. They have a PhD scientist who has job security because she is salaried by the hospital but she said she still has to struggle to raise grant money, like scientists everywhere. She is researching various aspects of cell growth. There is also a microsurgery teaching laboratory on the building. Dr Li was starting a month long microsurgery training course on the day we visited. Leica had provided the microscopes. The course is held every year. This would be an excellent place for someone in Canada to come to learn microsurgery. There is a great lab course and much more clinical material to learn from than we have.

So, my reader friends, there you have it. The 2018 Normal Bethune Scholarship. It has been a great experience. It has been the two way exchange of information it was designed to be. Everyone appears to think it was very successful. I am going to strongly recommend that it continues in future years. The Wenzhou surgeons are a fantastic group and very keen to maintain and develop the friendship.

It has been a great honour for me to have been chosen to be the one to come her. One of you said she was hoping to experience China through my eyes. I hope these letters have achieved that end and that you have all enjoyed travelling on this amazing journey with us.