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FELLOWSHIP IN LOWER LIMB ARTHROPLASTY

Fellowship Guide 2014

Prepared By: Associate Professor

Colonel M Suhail Amin

Consultant Orthopaedic Surgeon Combined Military Hospital, Rawalpindi

Contents

Introduction...........................................................................................3 Goals of Lower Limb Arthroplasty Fellowship Program...............................4 Objectives of Lower Limb Arthroplasty Fellowship Program5 Lower Limb Arthroplasty Fellowship CORE CURRICULUM...........................7 Accreditation of Inland Training Centers.14 Eligibility/Selection criteria of the Fellow 15 Stipend/ Funding.15 Responsibilities and Duties of the Fellow16 Supervisory responsibility of the Faculty.17 Vacation/ Leave Policy..17 Discipline Policy.18 Fellowship training at International Centers.19

Introduction
Pakistan Arthroplasty Society is committed to the tripartite mission of pre-eminence in patient care, education and research. By offering inland and international Fellowships to our orthopaedic community, we strive for excellence, innovation, quality and professionalism to accomplish our missions. The Lower Limb Arthroplasty Fellowship is a six month program in primary total joint arthroplasty of the hip and knee. The program objective is to prepare FCPS qualified orthopaedic surgeon for a career in arthroplasty surgery. Training is provided in all aspects of arthroplasty surgery including arthritis, and post-traumatic reconstruction. This is a hands-on fellowship where responsibility is delegated based on demonstration of clinical and surgical maturity and expertise. The program will emphasize the diagnosis of clinical disorders of the bones, joints and soft tissues; the pathogenesis of these disorders; the treatment modalities available for managing these disorders; and the results and complication of such treatment. The fellow will assume a major role in the continuing care of patients and have progressive responsibility in patient assessment, preoperative evaluation, operative experience, and postoperative management and rehabilitation.

Goals of Lower Limb Arthroplasty Fellowship Program

Further develop the skills and enhance the experience of trained orthopaedic surgeon in the specialized care of patients with disorders of the hip and knee. Increase the proficiency of fellows through improved understanding and application of new techniques and technologies related to adult reconstruction. Advancement of medical knowledge for fellows along the continuum of patient care. Enhance research opportunities for fellows in the area of arthroplasty.

Objectives of the Lower Limb Arthroplasty Fellowship Program

The adult reconstructive service at the Inland and international centers recognized by Pakistan Arthroplasty Society is centered on the care of adults with simple and complex disorders of the hip and knee in a tertiary care environment. By combining the surgical and clinical experience of at least two faculty members, didactic training, clinical research experience and ongoing mentoring and evaluations from the faculty the fellow will be afforded every opportunity to achieve the goals of the program. Clinical Training o Through experience in the clinic, the fellow will be able to perform preoperative assessments of all patients, determine a differential diagnosis and offer treatment options to the faculty and patients including surgical and non-surgical treatment. o The fellow will be able to be proficient in the use of diagnostic radiographic and laboratory studies to create a preoperative plan of treatment for all patients. o The fellow will be able to identify the best possible use of appropriate implants for patient treatment and exercise a high level of skill in using those treatment options &/or procedures.

o The fellow will be able to treat patients including: primary hip and knee replacements under supervision.

o The fellow will manage the short and long term follow-up of surgical and non-surgical patients, including the utilization of necessary rehabilitation modalities. o The fellow will be proficient in all areas of patient record keeping and documentation. o The fellow will improve his understanding of the social and economic issues that affect orthopaedic patients along the continuum of care.

Research Training As an active member of the team the fellow will be prepared to have at least one article prepared for peer review journals/ presentation in National ORTHOCON. The fellow will be actively maintain National Joint Registry Pakistan NJRP.

Lower Limb Arthroplasty Fellowship CORE CURRICULUM

ANATOMY and BIOMECHANICS OF THE LOWER EXTREMITY The fellow will be familiar with relevant anatomy of the lower extremity including: o Bones o o o o o Joints Musculotendinous units Ligaments Nerves Blood vessels

Describe the biomechanics of the lower extremity during the gait cycle. EVALUATING DISORDERS OF THE HIP AND KNEE The fellow will be able to outline appropriate history taking skills for patients with hip &/or knee problems. Describe a complete physical examination of the hip &/or knee including: Inspection Palpation Range of motion including:

Hip Flexion Extension Internal and external rotation Abduction & adduction Knee Flexion Extension Ankle ankle dorsiflexion (knee straight) ankle dorsiflexion (knee bent) ankle plantar flexion hindfoot inversion and eversion Neurovascular assessment Special diagnostic studies Diagnostic Studies Identify the indications for ordering and appropriately interpret the following imaging studies of the hip &/or knee: o X-Rays

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o Full weight bearing series where indicated o MRI o CT scans o Bone Scan Identify common hip &/knee deformities. Hip and Knee Trauma For the traumatic injuries of the hip and knee the fellow will be able to: o Describe the typical mechanism of injury and physical examination findings. o Identify and interpret appropriate imaging studies. o Describe viable treatment options including their risks and benefits. o Outline the prognosis Diagnosis of disorders of the hip &/or knee o Determine diagnosis and establish treatment plan based on diagnostic findings to include both conservative &/or surgical options o Establish preoperative treatment plan.

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INDICATIONS AND CONTRAINDICATIONS Fellow will be able to outline all relevant indications and contraindications for all surgical procedures. Knowledge of pertinent biomechanical considerations for each specific joint is essential. Fellow will be expected to be familiar with the functional anatomy and biomechanics of the joint they are replacing. Fellow will understand function and essential design principles of the implant systems available so that they can select the optimal implant to correct the problem. MATERIALS The fellow will be knowledgeable of: Non Metals o Ultrahigh molecular weight polyethylene o Ceramics o Composite Materials Metals o Stainless Steel

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o Cobalt-Based Alloys o Titanium and Titanium-Based Alloys o Combinations of Metals PRE POSTOPERATIVE CARE The fellow will become knowledgeable and facile with the following: Preoperative Radiographic Considerations: o Radiographic evaluation o Evaluation of MRI for hip &/or knee pathology o Radiographic templating Complications: o Infection o Dislocation o Aseptic loosening

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Surgical Approaches/ Techniques: Primary total joint arthroplasty techniques Common surgical approaches for hip and knee surgery Assessment of appropriate implant options Familiarization with instrumentation systems Appropriate techniques Cement or cementless TJA Impact bone grafting techniques Avascular necrosis Staging Treatment options Conservative / Surgical Implant removal Infectious disease process / prophylaxis, treatment Post-operative care In house patient care to include Daily rounds Wound care Postoperative pain management Rehabilitation o Range-of-motion exercises are performed postoperatively, with or without the assistance of a CPM machine. o Lower extremity muscle strengthening. o Gait training, with weight bearing as allowed by the

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particular joint reconstruction. o Instruction in performing basic activities of daily living. Medical care related to indicated anti-coagulation. Complications DVT Infection Gait abnormalities Pain

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Accreditation of Inland Training Centers

1. Centers shall be identified by Executive Board of PAS on the basis of: a. Volume of arthroplasty b. Availability of recognized faculty 2. Volume of arthroplasty: Centers where at least 100 joints are replaced per annum would be considered for accreditation. 3. Availability of faculty: Centers where at least two faculty members are available shall be given preference for accreditation. 4. Accreditation status of centers shall be reviewed each year because of possible unavailability of faculty members.

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Eligibility/Selection Criteria of the Fellow

1. The Fellow shall ideally be between 30-35 years of age but not more than 40 years old. 2. He should be holding qualification of FCPS / FRCS in the discipline of Orthopaedic Surgery. 3. The selection of Fellows shall be on the basis of Curriculum Vitae and interview. A committee nominated by Pakistan Arthroplasty Societys (PAS) executive board will be responsible for selection of fellows. Candidates with strong academic and research credentials shall be given preference. 4. The Fellowship shall commence 1st February and 1st August each year. Number of Inland slots will be decided by the Executive Board of PAS according to availability of faculty members and number of centers fulfilling accreditation criteria in the country each year. 5. The Fellow shall be required to become a life time member of the PAS at the commencement of Fellowship. 6. The Fellow should have completed THA and TKA workshop conducted by PAS.

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Stipend / Funding
The Fellow shall be paid Rs. 100,000/- per month for the whole duration of Fellowship. The Funds shall be arranged by the PAS.

Responsibilities and Duties of the Fellow

The Fellow is required to complete the following duties: 1. Assisting in arthroplasty cases. 2. Rounding on all inpatients on daily basis. 3. Assisting with the evaluation and management of outpatient arthroplasty patients. 4. Pre-operative planning of all surgical cases and coordinating for special implants or equipment needed in the OR. 5. Completion of at least one research project to be submitted for presentation at an National orthopaedic meeting and/or peer review journal. 6. The Fellow shall be required to maintain surgical log book Fellowship training. 7. The Fellow will be responsible for maintaining National Joint Registry Pakistan.

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Supervisory Responsibility of the Faculty

The fellowship program functions within a preceptorship model which is designed to provide one on one feedback between the faculty member and the fellow. By working with the fellow in this model the faculty member can make careful observations, provide proper mentoring, and needed supervision &/or instruction of their assigned fellow while also providing feedback and suggestions as they progress through the training.

Vacation / Leave Policy

The Fellow shall be entitled to a total of 3 weeks vacation / leave during the Fellowship duration. Any fellow absent for more than one month (not including vacation) will be required to extend training to make up lost time.

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Discipline Policy
If the faculty incharge deems a fellows performance or conduct to be deficient, and the ordinary elements of the educational program or evaluations appear unavailing, the faculty should informally counsel or administer corrective action to the fellow. Such communication may come in the form of an oral or written warning that failure to improve will result in formal discipline under this policy. The PAS Executive board and Faculty incharge to which the fellow is assigned shall be responsible for discipline. The faculty incharge will meet with the fellow and provide oral or written justification for discipline. If a second disciplinary action is required, the following examples of disciplinary actions may be utilized: Oral notification to fellow with details of the problem; Written notification to fellow with details of the problem which could include copies of documents or other materials, such as evaluations, letters of complaint, attendance logs, written response and submission of materials from fellow; Additional supervision or specific directives for fellow with clear educational goals and performance expectations; Counseling, medical evaluation, and/or unpaid leave of absence; Probation leading to formal disciplinary action of suspension or dismissal.

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Fellowship training at International Centers

Fellows completing inland fellowship successfully and in good standing shall be considered for placement at International centers of excellence in countries like UK, Singapore and Malaysia for continued training in adult reconstruction. The placement liaison and funding shall be the responsibility of the PAS. Executive board of PAS taking into consideration performance during Inland Fellowship program shall do the selection of fellows for International Fellowships.