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Day 20 – departure

Back to the United States after 3 amazing weeks in Japan!

Day 19 – Tokyo

We spent the day at the famous University of Tokyo Hospital. This hospital had the first orthopedic department in Japan in 1906.

It remains a very busy medical center seeing >3000 outpatients per day.

We visited the Orthopaedic clinic first and continued our discussions regarding the Japanese healthcare system. For example, we were surprised to learn that although they have a universal single payer government system, their EMR system is not universal. Similar to the U.S. they experience challenges of these many different systems communicating.

Dr Kato took us to his spine clinic. He estimated ~30 mins for New Patient visit and <15 minutes for followup visits. He also explained that all workup (imaging, labs etc) should be done in the outpatient setting for billing purposes. The inpatient reimbursement is based only on diagnosis and thus any additional services (e.g. inpatient imaging) is not reimbursed. It seemed somewhat similar to our DRG-based system.

We then toured the Rehabilitation center with a very interesting area focused on return to ADL activities including a bathroom, kitchen and laundry:

We then visited the Operating room:

The case we observed was a cervical “Double door” (or “French door”) laminoplasty for 73M with OPLL who had a fall and sustained an incomplete spinal cord injury. The laminoplasty levels were C4-6.

The technique was developed by Prof Kurokawa at this hospital. It involves making bilateral partial corticotomies in the laminae.

Then completely splitting the spinous process and sequentially opening with a lamina spreader:

The split is hold open by placing hydroxyapatite block spacers

The spacers are then sutured in:

The afternoon was spent touring the historic university campus.

The evening finished off with a final group dinner:

Day 18 – Tokyo University (May 31, 2018)

Today is an academic day and our host is Tokyo University. This university is one of the most competitive medical schools in Japan.

Following a breakfast at the hotel, we were greeted by our hosts, Professor Soma (Spine) and Dr. Yuji (Foot and Ankle).

We then headed toward Tokyo University where we toured the Medical facilities and attended the orthopedic morning ward conference.

A girth of interesting cases were presented including leg Liposarcoma (above left) and knee Chondrosarcoma (above right) resections and complex reconstructions. Additionally cases of Multi-ligament knee injuries reconstructions, cervical laminoplasty for incomplete spinal cord injury, lumbar osteodiscitis, C1-2 instability in Trisomy 21 Patient, junctional kyphosis of the thoracolumbar junction, pediatric patient with Larsen Syndrome associated hip & knee dislocations were also presented (Pictures below).

Around noon time we joined the entire Orthopedic team for interactive lectures on:

1- Elderly Acetabular Fractures: Joshua Gary, MD

2- Extreme Nailing for Distal Femur and Distal Tibia Fractures: Conor Kleweno, MD

3- Fun Talk: Atul Kamath, MD

4- Fun Talk: Chadi Tannoury, MD

Lunch (Sushi) & coffee with the orthopedic faculty and trainee followed the presentations. We then toured the impressive orthopedic department basic science lab.

Tokyo Sightseeing:

Drs. Yano and Oichi chaperoned us around the city of Tokyo. We visited the Tokyo Skytree, the tallest tower in the world (634m) from which we enjoyed observing Tokyo city from a bird’s eye view!

We also toured Tokyo’s Roppongi district including the Roppongi Hills & Mori Art Museum featuring a fascinating exhibition on Japanese Architecture history.

Dinner:

Professor Tanaka and his colleagues invited us to a delicious traditional Teppanyaki style dinner. This concludes our last full academic day of the 2018 JOA tour.

Day 17 – Toyama to Toyko

Today we departed Toyama — translated as land of abundant mountains — towards Tokyo. The newly built Shinkansen line made for a quick journey from the idyllic setting of Toyama to the bustling capital city of Tokyo.

We spent our free day in Toyko exploring the city and catching up with our friends made during our initial visit to Toyko two weeks prior. The sites and sounds of Ginza, Akihabara, Shibuya and other districts were unforgettable.

Day 16 – Toyoma Medical University

The day began with morning report and conference at the medical school. New cases were presented to the entire group including a complex case of severe neuromuscular scoliosis in a 14 year old male.

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We then proceeded to the operating theater and joined several different surgeries. Atul joined a total knee arthroplasty. Conor observed a total hip arthroplasty using a posterior piriformis-sparing approach.

Chadi and Josh went with Dr. Kanaguchi for a lumbar laminectomy, posterolateral fusion and TLIF for a patient with lumbar stenosis and spondyloisthesis.

We continue to be impressed by the attention to every detail of the Japanese orthopaedic surgeons. Every part of the procedure from planning to positioning to instrumentation to closure is meticulously planned.

The full day in the OR was followed by a group of fellows lectures to the faculty, residents, and students of Toyoma Medical University.

Dr. Gary lectured on reduction and fixation of young femoral neck fractures. Dr. Tannouri’s talk on the Anterior to Psoas (ATP) approach for anterior spinal surgery was very well received by the spine team at Toyoma.

Dr. Kamath spoke on obesity and complications, a topic the Japanese do not see much in their clinical practice and are extremely surprised to see.

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Dr. Kleweno spoke on acute total hip arthroplasty for geriatric acetabular fractures, a fracture very commonly seen in the elderly and osteoporotic population of Japan.

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A dinner hosted by Professor Kimura and Dr. Kawaguchi and many members of the department followed by some karaoke was an outstanding finish to our visit!

Day 15 Toyama

We started the day with Prof Kawaguchi taking us to Toyama University Hospital and Toyama University, located ~5 miles outside of downtown. It was built in 1980 and sits atop a hill.

Professor Kawaguchi is a spine specialist and was recently featured on National television. We rounded with him on a preoperative patient that traveled all the way from Hiroshima to pursue care under him for surgical treatment of lumbar stenosis. According to him, the breakdown of specialty care of spine in this region is 80% Orthopaedics and 20% neurosurgery.

We then joined multiple faculty members, residents and medical students at the weekly Monday morning indications case conference. We had a lively academic discussion in the spirit of the Socratic method. The residents presented a series of cases including:

65F with primary degenerative joint disease in a PCL deficient knee scheduled for PS total knee. We were interested to learn that all patients scheduled for TKA or THA get preoperative CT scan for 3D templating and MRI scans to evaluate the cruciate ligaments (and admittedly for research purposes).

75 F scheduled for THA. The arthroplasty surgeons at Toyama U prefer the posterior approach.

67 M with cervical spondylotic myelopathy with stenosis at C3-7 and T2-weighted signal changes at 5/6 scheduled for laminoplasty.

85M with L2-L5 stenosis, spondylosis with instability below a DISH segment. Chadi lead a spirited discussion of selecting fusion levels and adjacent segment degeneration.

60F with a small finger intra-articular Proximal phalanx malunion scheduled for osteotomy, bone graft and fixation.

We discussed Orthopaedics care in Toyama including the breakdown of patient access to public university and private hospitals. In the Japanese system, there is universal government health insurance but variations in locations of care delivery. The university hospital is utilized for higher risk, larger surgeries whereas simpler cases are triaged to the private hospitals. The triage process is primarily made by the physicians and not the hospitals. However, there is a financial incentive for the physicians to refer their cases to private hospitals. Although the government health insurance plan pays the same regardless of location, the decrease in cost associated with the private hospitals (higher efficiency, less labor cost, overall less overhead), allows for increased compensation.

After the conference we took a tour of the hospital as well as the university campus including an interesting the Center for Medicinal Plant Research.

We also visited the university martial arts gymnasium where Chadi demonstrated his expertise.

After the tour, we had lunch at a typical udon noodle house:

We spent the afternoon touring the World Heritage site Shirakawa-go. It is famous for “gassho” style houses built in the 1800’s.

Gassho style houses are wood houses with steeply sloped thatched roofs meeting at a peak, with architectural symbolism implying hands meeting in prayer.

The houses are built North-South to accommodate the prevailing winds and the steep roofs designed for the heavy winter snows.

The high roofs also allowed ample space for silkworm breeding.

Back at hotel, we had a quick sunset conference:

The night was capped with an amazing sushi dinner. Toyama is known for seafood given its location with Toyama Bay feeding into the Sea of Japan.

Day 14 – Kobe to Toyama (May 27, 2018)

The JOA annual meeting adjourns today, and we will be traveling from Kobe to Toyama.

We started the day with a breakfast at the Kobe Portopia Hotel and then packed our luggage in preparation for the travel.

We headed to the train station (Shin-Kobe) and after a 4-hour trip with 2 uneventful connections (Kyoto and Kanazawa) we made it to Toyama. The scenery of the mountains, the exotic sanctuary landscapes, and rice fields along the way were captivating yet relaxing.

At the Toyama station, we were greeted by Professor Kawaguchi (University of Toyama) who picked us up and kindly drove us to the hotel.

Toyama is recognized as a national and international “environmental model city” since it turned away from being a car-oriented society and moved toward sustainable energy production.

Dinner:

Professor Kawaguchi and his family graciously treated us to a delicious Japanese-Korean barbecue dinner followed by green tea and home made desserts.