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Day 2 – Kyushu University

26 May – The final academic day of the fellowship was one filled with mixed emotions.

Looking back over the course of just under three weeks we had traveled to 8 different cities in Japan, visited 8 different academic institutions and participated in the JOA Annual Meeting. The last day started off with a small amount of time to gather some last minute things for family and friends at home and then enjoy some typical ramen in downtown Fukuoka.

We then made our way to the hospital for an afternoon of shared learning arranged by Dr. Saiwai. Drs. Balach, D’Alleyrand and Scolaro spent a couple hours with the tumor and trauma faculty going over cases. Both Kyushu faculty and JOA fellows had the opportunity to present. It was a great opportunity to share ideas and treatment techniques to common oncologic and trauma pathology.

Dr. D’Alleyrand sharing a complex case with members of the Kyushu University Ortho Trauma team as part of a discussion about complex infected tibia fractures.

Dr. Ma had the opportunity to accompany the sports team to the operating room where he observed a high tibial osteotomy.

The group reconvened in the evening for the academic session with the entire department with Professor Nakashima moderating. Each fellow presented their selected scientific talk as well as their non-orthopaedic talk. The questions and discussion following each set of talks were excellent.

The day and evening wrapped with our final dinner together with Professor Nakashima and some of the Kyushu faculty at a local Japanese-French fusion restaurant. It was bittersweet as it was the last group dinner that the fellows shared with a host university but as always, it was a great way to solidify the relationships we had all quickly formed over the last couple days in Fukuoka.

We returned to the hotel, packed the vast majority of our belongings up one last time, made sure the suitcases would close, and then wrapped the night up with one final bowl of ramen before heading to bed.

Final Log: The End of the Tour and the Beginning of a Renewed Friendship

May 27, 2023

It is Day 21 of our traveling fellowship, which means it is our final day in Japan. 

In our haste of getting ourselves ready and to the airport, we forgot to take our traditional selfie and so this time it would be with ourselves separate and departing Japan.  We think not having this picture for the blog is somewhat fitting; for the last 3 weeks we have not pictured being apart from one another.  Prior to today, we have often remarked amongst ourselves how fortunate we have been to be able to share this experience amongst the four of us.  We recognize we did not have any say in who our co-fellows would be, but to each one of us, we could not have imagined this tour without one member of our foursome.  It is really rare, at our current stage of life and career, to be away from our families, loved ones, and medical practice, and be open to new experiences as well as develop new life-long friendships;  that is what occurred for the four of us during the 3 weeks together on this incredible tour. 

At the beginning of our last academic presentation yesterday at Kyushu University, Professor and Chairman Nakashima, who is also the current President of the Japanese Orthopaedic Association (JOA), stated that the JOA had looked forward to our tour and opening their country for 3 long years after the start of COVID-19. They looked forward to renewing the longstanding friendship that existed between JOA and the American Orthopaedic Association (AOA). We felt incredibly privileged and honored to be the inaugural group that started this process.

In 21 days, we visited 8 cities, 8 academic centers, and developed too many Japanese friendships to count. We have also discovered that Japan is a country that is very proud of its history but also excitedly looks forward to its future. We feel honored to have been a small part of their orthopaedic history with our tour. We are also excited that we will have the opportunity to be a part of its future as we continue to deepen those friendships that we made including being future hosts to future Traveling Fellows from the JOA.

On behalf of the 2023 Traveling AOA/JOA Fellows, we want to thank the American Orthopaedic Association and the Japanese Orthopaedic Association for an experience of a lifetime. It has been an honor and privilege to be ambassadors for the AOA these past 3 weeks. We feel compelled to say to those of you who have followed our journey the same thing we have said to our JOA friends: it is not “sayōnara,” but rather “until next time!”

Travel Day: Tokyo to Fukuoka

May 25th, 2023

A representative of the JOA’s travel agency met us in the lobby this morning to escort us to our train. We were traveling during the morning rush hour, but our hotel was across the street from the train station and we were able to make our train despite the huge number of people navigating the station at the same time. We made it to the Haneda airport with less time to spare than we are used to, but we have noticed that the Japanese don’t get to the airport as early as Americans do, likely because their airports and process appear to be so much more efficient than ours. The security process was exceedingly fast and we even had time to grab a quick snack for our flight.

When we arrived in Fukuoka, our local hosts were there to greet us and escort us to our hotel. After dropping off our bags, they took us to a local unagi restaurant. We had eaten unagi, or freshwater eel, at a restaurant at the Tokyo Skytree with our friends from Showa University. At that restaurant, we had eaten unajyu, which is like unadon (unagi donburi) with a layer of grilled eel over rice, but it is served in a lacquered box rather than a bowl. This offers a larger surface area for more unagi and the dish is known for higher quality eel. Here in Fukuoka, we ate hitsumabushi, an eel dish originally from Nagoya. This eel dish can also be served in a lacquer box, but what makes it distinct is how it is eaten. Using a small bowl, one eats a quarter of the eel and rice as is. Then, another quarter is eaten along with garnishes such as wasabi, scallions and nori. A third quarter is then eaten ochazuke style, with a tea or broth poured over the eel and rice, and the final portion is eaten in any manner desired. The meal was excellent and revealed yet another facet of authentic Japanese cuisine for us to savor.

Hitsumabushi. A superb and fun way to enjoy tender freshwater eel.
Phase 3 of the hitsumabushi experience: broth poured over rice, eel and garnishes

After lunch, we visited the Fukuoka City Museum, which gives an excellent and detailed account of not only the city’s history but also Japan’s origins, including its original recognition as a nation by China. The golden seal bestowed by the Emperor of the Han Dynasty in 57 A.D. signified the first known recognition of the Japan as a country. The seal was lost in the 3rd century and discovered almost 1500 years later in Fukuoka Prefecture. That seal, or its replica, is on display at the museum, along with many other artifacts of Japanese history over the last 2,000 years. After the museum, we toured the Fukuoka Tower, giving a commanding view of the city on one side and Hakata Bay on the other.

Once we had taken in the sights, it was time to head to the hotel to check in and get ready for dinner.

Dinner was a mixture of excellent teppanyaki and great company, as we got to meet many of the surgeons from Kyushu University. Several of the surgeons shared a mutual acquaintance with at least one of us, including some of the prior JOA fellows we had met on our tour. Dinner was filled with fun, laughter and friendship and we closed out the night eager to visit Kyushu University in the morning.

The respect for high quality ingredients was obvious as soon as we were seated for dinner.
A fluffy slice of milk bread serves as a serving platter for the food…
…and the bread, infused with teppanyaki essence, is toasted and served with honey at that end of the meal.
Commemorating the end of an excellent evening with our new friends.

Tokyo Day 2: Tokyo Medical University

May 24, 2023

Today, we were greeted in the lobby of our hotel by Dr. Tsunehito Ishida and his associate and we were escorted by taxi to Tokyo Medical University, located in the Shinjuku part of Tokyo. The hospital is in the Skyscraper District of Shinjuku, which means despite having about 1000 beds, it is dwarfed by many of the surrounding buildings.

Our hosts laid out a thoughtful schedule for the day, taking into consideration our sub specialties and their OR schedule that day.

Dr. Ma was escorted to to the OR to observe surgery and give a presentation to the Sports Surgery division on Anterior Cruciate Ligament sensation and its role in proprioception in the knee. Meanwhile, the rest of us remained in their auditorium with representatives of the Orthopaedics department. Professor Nishida, an Orthopaedic Oncologist, moderated the session expertly and the questions from the audience showed insight and engagement. Professor Nishida and Dr. Hanako Tsuji gave us lectures as well. Professor Nishida’s talk was particularly compelling, as he presented innovative solutions to massive bone defects. In a country where allografts are virtually never used, he and his contemporaries have developed many creative, and sometimes heroic, solutions to the bony defects created by large tumor resections.

After the educational portion of the day, we paused for lunch, which was an incredible bento meal from a storied local restaurant.

Afterwards, several members of the department took us on a tour of Shinjuku. Tokyo Medical University Hospital is just down the street from the Tokyo Municipal building, which is a massive structure housing the District Governor and Tokyo’s governmental offices. The observation desk offered astounding views of Shinjuku and parts of the rest of Tokyo.

After taking in the sights, we paused for coffee in the park nearby before heading to Kabukikicho, the nearby entertainment district, which was an overwhelming sea of movie theaters, arcades and other entertainment venues. The air was electric as countless locals were filtering in after they world day to relax and have fun with friends. After exploring the area for a short while, we headed back to Shinjuku for dinner.

Our dinner was at the top of a Shinjuku hotel, with a commanding view of the city. It is difficult to describe the grandeur of the meal, as we enjoyed fine dining with a view of Mount Fuji and the city at sunset. As nighttime came, we continued our meal while looking at a sea of lights scattered over the city like countless stars twinkling up at us. It was a very special meal indeed.

After dinner, as we shook hands with our new friend and esteemed colleagues, our time in Tokyo was coming to an end. It was time to head back to our hotel in Shinagawa and pack our bags for our next and final stop: Kyushu University.

Tokyo Day 1: Showa University

23 May 2023 – On this rainy morning in Tokyo we were met by two of our hosts, Dr. Dodo and Dr. Tsuchiya who brought us to the hospital, where we joined the department’s morning conference where we met our host Professor Yoshiufumi Kudo. We gave our talks to an attentive and engaged audience moderated by Dr. Okano. We were then taken on a tour of the hospital, including a visit to the operating rooms, general wards, the emergency room and intensive care units. It was easy to tell if this is a very busy urban hospital!

We then headed to the Tokyo Skytree where the weather prevented us from having a clear view but did nothing to stop us from sharing a delicious lunch with our colleagues from Showa University. We spent the afternoon sightseeing in the Asakuska and visited the Sensō-ji shrine. After a few more sightseeing stops in Tokyo including a visit to the Tokyo Dome.

An isakaya is a casual style restaurant where a large variety of dishes are served featuring ingredients that are simply yet deliciously prepared. We enjoyed multiple dishes featuring sardines prepared in a variety of ways including as sashimi, tempura, grilled and crispy fried bones. The dinner was a wonderful way to meet new colleagues, exchange ideas, and deepen friendships between our universities!

Education & Travel Day: Sagamihara to Tokyo

May 22, 2023

Today, we checked out of the hotel and brought our luggage to Kitasato University. We had the opportunity to meet the Orthopaedic Department including Department Chair, Professor Masashi Takaso and then to present our lectures to them. Dr. Inoue moderated our session and provided insightful questions after each lecture.

After we concluded the educational portion of the morning, we visited the operating rooms where we were able to observe a femoral nonunion case and review some cases with other members of the department.

Dr. Inoue gave us a guided tour of the Kitasato hospital and campus. The tour was an interesting mix of history and modernization. The University is named for Professor Kitasato, who helped discover Tetanus toxin and the organism responsible for the bubonic plague. The continued reverence for Professor Kitasato was very evident, as was the continued growth of the campus as we gave our talks in one new building and emerged to see another one being built a short distance away on the campus.

Much thanks to Professor Inoue (far right) for the great tour of Kitasato University campus including a stop in front of a statue of Professor Kitasato!

After our tour, we were treated to a wonderful meal of soba noodles and tempura before being driven to the train station.

Dr. Ma enjoys our take-out lunch prior to our departure for Tokyo.

Two short train rides later, we emerged from the Shinagawa station in downtown Tokyo. We made our way to our hotel across the street, checked in and dropped off our luggage. Then we headed out to the Ginza district for dinner at a classic edomae sushi restaurant. The freshness of the sushi and the chef’s technique were superb and we were grateful to be able to start our stay in Tokyo with such a phenomenal meal.

Tomorrow, our fellowship continues with our visit to Showa University and we are excited to meet our next group of local hosts and share knowledge and friendship with them.

Sagamihara and Enoshima

21 May 2023 – We met up in the morning with Dr. Inoue as well as some of the Kitasato residents and staff to journey to Enoshima Island. This is a small island south of Kamakura in the Sagami Bay. This is a popular spot for both locals and tourists to visit. The train ride gave us the opportunity to continue to learn about Kitasato, including the fact that it is one of the few places on Japan with a well established allograft bone bank that it utilizes for orthopaedic procedures.

Once we traversed the bridge to the island, we followed the small narrow main street up to a series of stairs which led us to the Enoshima Sea Candle which provided some very impressive views of the surrounding area.

On our way down we enjoyed tako senbei which is composed of flattened octopus and a light batter that is pressed into a thin cracker-like form. It is one of the most famous things to eat on the island and after a morning of walking, it hit the spot.

We then jumped onto the Enoden train line which is well known for its scenic course right along the water, to the Shichirigahama Beach area where we had lunch. The fellows enjoyed the hospitality and company of the Kitasato team as we compared notes on everything from our orthopaedic practices to typical recreational weekend activities in the United States and Japan.

That evening we had a lovely traditional robatayaki Japanese style, dinner with faculty and residents featuring spectacular Miyazaki beef. The jovial conversation that included many orthopaedic topics and friendships formed were the highlight of the evening!

Travel Day: Kobe to Sagamihara

May 20th, 2023

We finished our time in Kobe by spending the morning with a few of the Kobe University surgeons in the downtown area. We toured a local department store and picked up some souvenirs for our families, including some sports memorabilia from the local Major League teams. Then, we had the opportunity to check another box on our culinary list: udon noodles. Luckily, our hosts took us to the restaurant in time to beat the lunch crowd, as the line was fairly lengthy by the time we were done. After we were finished eating, we were escorted back to the hotel, which was conveniently located at the train station. We picked up our luggage and made our train without issue, enabled by our hosts who made sure to take us all the way to the door of the train to ensure we didn’t get lost.

A hearty bowl of udon to start our travels in the right frame of mind. Including shrimp and octopus tempura for garnish.

True to form, the Shinkansen was smooth, quick and comfortable, getting us to the Shin-Yokohama station in two hours. When the train doors opened, a representative from the JOA travel agency was standing there to greet us. Our guide then helped us swiftly navigate the train station, allowing us to make our connection to the local city train without any issue. After a quick ride to the Machida station outside Sagamihara, we met our local hosts from Kitasato University waiting for us at the gate. They took us to our hotel in Sagami-Ono and after ensuring we were checked in, they gave us some time to rest up before dinner.

Dinner was an authentic Chinese restaurant near the hotel, where we got to meet several members of the Kitasato Orthopaedic Department. The surgeons who dined with us represented many of the sub-disciplines of Orthopaedics, including pediatrics, shoulder & elbow, arthroplasty and spine. It was interesting to see how the paths of Orthopaedic Surgeons are intertwined between the JOA and AOA. For instance, Professor Inoue was a JOA-AOA traveling fellow in 2019 with Dr. Matsumoto from Kobe University and Dr. Kemmoku was an ASES Asian Exchange Fellow a few years ago and toured multiple institutions, including UPenn and HSS, where Dr. Scolaro completed his residency and Dr. Ma completed his fellowship, respectively. As a result, Dr. Kemmoku knew many surgeons who were mentors and/or friends of several of us. The time passed quickly as we discussed mutual friendships and got to know each other better over a delicious meal. Tomorrow, our hosts have a full day of sightseeing planned for us, so after dessert we ended the evening early so that we could rest up and better prepare for the day ahead.

The team from Kitasato University were fun and gracious hosts. Professor Inoue (back row, second from right) was a JOA-AOA traveling fellow in 2019. Dr. Kemmoku (back row, far left) was an ASES traveling fellow and shares several mutual acquaintances with us at U.S. hospitals.

Kobe – Day 2

19 May 2023 – Our second day in Kobe began with an opportunity to visit one of Kobe University’s affiliated hospitals to watch Professor Kuroda perform an arthroscopic meniscal repair. Between cases we sat down with Professor Kuroda to learn more about his sports practice as well as the relationship that the orthopaedic department has with affiliated hospitals in the area. We also learned about a new tool being developed by members of the department to measure knee instability which they are hoping to expand to other joints, as well.

Professor Kuroda (center), Dr. Nakano (far left) and Dr. Tsubosaka (far right) with JOA fellows.

We then returned to the city center to a harbor front restaurant for a lunch of, of course, a Japanese-style Kobe beef sandwich. Marinating Japanese precision, we quickly made it to the train station for a brief ride to Himeji city. Our hosts then arranged for a brief tour of the city by Japanese jinrikisha (origin of the English word rickshaw) where we visited a nearby Shinto shrine before heading to the castle entrance. The rainy weather, which had been with us most of the day, cleared up, affording us an opportunity to put away our umbrellas as we met our tour guide. Himeji castle (also known as Shirasagi-jō or white heron castle) is the largest and most visited castle in Japan, a UNESCO World Heritage site and one of the country’s twelve original castles. We toured the castle grounds learning about castle history and architecture as we ascended up multiple narrow paths and steep stairways (designed strategically with castle defense in mind) to the top floor for some spectacular views of the surrounding area. After making our way back down to the main gate, we closed out our journey with a visit to the Kokoen gardens adjacent to the castle grounds for a breathtaking and relaxing stroll.

JOA fellows with our wonderful Kobe University hosts in front of the Himeji castle.

We completed the day with a train ride back to Kobe city where, after a brief break, we had beautiful and engaging dinner with Drs. Matsumoto, Matsushita, Hara and Oe. It was a very busy but amazing day of orthopaedic surgery and local history and culture. The hospitality provided by the Kobe residents, faculty and staff was top notch!

Travel Day: Osaka to Kobe

May 18, 2023

Today was a full day starting with our drive from Osaka to Kobe. We left after breakfast and made good time getting to our hotel in Kobe, where our local hosts were waiting for us. They had thoughtfully arranged a full day of local culture and scientific education, and to enable this they had arranged for a very early check in. After we changed into business attire, we were taken to a fantastic lunch at a local steak restaurant serving, as one would expect, authentic Kobe beef. Unlike most of Japan, where beef is typically served thinly sliced yakiniku style, the classic Kobe beef preparation is to cut the steak beef into bite-size chunks while grilling it on a steel flattop teppan. After enjoying a superb teppanyaki meal, we headed to our next stop: the local professional rugby team’s training facility.

True Kobe beef cooked teppanyaki style. Served with sea salt and wasabi, it was a very special and delicious meal with great friends.

When we arrived at the Kobe Steeler’s facility, we encountered a group of physical therapy students from Hong Kong who were also visiting Kobe University. As a large group, we were taken on a tour of the facility by the Steeler’s head Athletic Trainer and two of their team doctors both Orthopaedic Surgeons from Kobe University. Touring their locker room, their weight room, and other aspects of the facility, Dr. Ma and the Steeler’s team has an in-depth conversation about the differences in training and injury prevention between their respective institutions.

At the end of the tour, we all visited a local sake brewery to learn about the brewing process and to taste some of the local products. A perfect segue into an evening of scientific lectures! After our apertivi, we headed to Kobe University to meet with Professor Kuroda and his team. We then transitioned to their conference hall for the scientific portion of the evening. Professor Kuroda is himself an JOA-AOA fellowship alum, having toured US hospitals in 2011 along with Dr. Minoda from Osaka Metropolitan Hospital. Another member of the faculty, Dr. Matsumoto, is also a JOA-AOA alum, having done his fellowship in 2019. As one would expect with two senior JOA faculty in the room, the lectures were well facilitated and questions were thoughtful and insightful.

Dr. Ma holding court as he presents his research on ACL grafts.

After the seminar, we went down to the waterfront to pay our respects to the 1995 Kobe earthquake memorial and then went to dinner nearby. We truly enjoyed our meal of authentic Chinese food and getting to meet a lot of the Department faculty and graduate students. After dinner, we finished the night with some melodious team building. Tears were shed, mistakes were made, but in the end we emerged victoriously from the Thunderdome known as… Karaoke.

Drs. Scolaro and D’Alleyrand had the opportunity to meet Kobe University’s robust trauma service.