From April 8th to 12th, 2024, the International Trauma Master’s China Visit 2024 had been successfully conducted in Guangzhou University of Chinese Medicine Dongguan Hospital (Dongguan Hospital of Traditional Chinese Medicine). After nearly half a year, Prof. Freude, President Elect (2025) of the Austrian Society of Surgery and Head of the Clinic for Orthopedics and Traumatology, University Hospital of Salzburg, once again visited the Department of Trauma and Orthopaedics in Dongguan Hospital of TCM as an international visiting professor, and conducted a series of academic exchanges activities in the hospital, including difficult case consultations, ward rounds, surgical guidance, department management discussions, discussion on key and difficult cases, and master open class.

On April 8, 2024, in the midst of the vibrant spring season, the Chinese hospital held a welcoming ceremony for Prof. Freude. President DENG Weijun of the hospital, Director of the Ortho Trauma Wards, LU Guoliang, Director of Department of Traumatology, LIANG Haobiao, Director of Department of Foot and Ankle, XIE Qingxiang, as well as the backbone members of trauma and orthopaedic departments greeted Prof. Freude warmly for his second visit to the hospital and the Trauma Department. President DENG Weijun briefed Prof. Freude on the development of the Department of Trauma and Orthopaedics in the past five months and introduced the new building to be completed as Ortho-Trauma Center by the end of 2025. A series of visiting professor exchange projects have been lauched in the ortho-trauma departmens in the past five years, making them align with the international leading diagnosis and treatment standards. When this is coupled with the hospital's centuries-old legacy of Chinese medicine and bone-setting essence, the ortho-trauma department in the hospital would be expected to become distinctive and top-level specialities.

After the welcome ceremony, Prof. Freude and the team of Director LIANG Haobiao immediately engaged themselves in disussion on difficult cases and checking of patients in the wards. The inpatient cases at the moment amounted to 56, indicating a huge workload for the week but also a fruitful outcome of this visit. Director LIANG shared a polytrauma case involving pelvic fractures, traumatic shock and bladder rupture with Prof Freude. Then they discussed how they would select the approach and the sequence of reduction and reconstruction for such cases during surgeries. They also shared their views on the management of the patient's bladder and urinary tract infections, which in this case, already affected the treatment of the pelvic fracture.

As the population ages in China, fractures in the geriatric population will become more and more common, Prof. Freude has profound clinical experience in treating fractures in the geriatric population and during his one-week visit in the hospital, he shared his knowledge and experience on the topic with Director LIANG, detailing how he managed to prevent, diagnose and treat trauma and fractures in the geriatric population and how to take care of the patients in post-op stages.

Prof. Freude then had ward round with Director LIANG and the Trauma team to check some polytrauma patients, communicated with the patients and discussed subsequent surgical treatment options for them.

In between one difficult case discussion, Prof. Freude noticed that there is an anatomic structure difference in the pelvis between Chinese people and Europeans, especially Germans, which is the difference in shape and thickness. He proposed to conduct a multi-centre double-blind controlled study with Director LIANG's team in this spot. He detailed that each of them can collect a certain number of cases for comparative study in their own centre, and the effective results obtained could be published in international journals. If this works, the research result would not only expected to contribute to the development of the scientific research programs of Guangzhou University of Traditional Chinese Medicine Dongguan Hospital (Dongguan Hospital of Traditional Chinese Medicine), but may also provide important references for further studies on treatment of pelvic fracture reduction in different ethnic groups and even for subsequent  development of related implants.

Showcase of Pararectus Approach for Pelvic Fracutre Surgery

In the morning of April 9, Prof. Freude and Director LIANG Haobiao joined the OR and performed a pelvic fracture ORIF surgery with pararectus approach. They discussed and planned the surgery in detailed the day before and checked the patient's body.

Prof. Freude demonstrated how he measured the incision and did the cut under pararectus approach for Director LIANG's team. During the operation, Prof. Freude explained on how to incise the muscles and ligaments under this approach and how to protect the surrounding nerves and blood vessels. He then exposed the view and checked the fracture regions.

Then, Director LIANG picked up the baton and placed a plate on the fracture area and then worked on fixation, and the surgery was a great success. This surgery is the witness of construcitve exchange on surgical treatment between Chinese hospital and European one, and how Prof. Freude teamed up with Director LIANG and his colleagues in the OR. And it is a great chance for Director LIANG's team to learn the pararectus approach, while Prof. Freude also experienced the efficient teamwork of Director LIANG's team in the OR.

Department Management Discussion

In the afternoon of the same day, Prof. Freude talked with Director LIANG's team in the office of the Department and discussed with them about his thoughts on the management of a department. Prof. Freude introduced that his department has a monthly report on major injuries and fatalities, in which all his colleagues analyse the cases of ineffective outcomes, postoperative infections, and even of major injuries and fatalities, to identify whether there are any errors or omissions in treatment procedures, and to find out how can they improve. Prof Freude concluded that it is advisable to analyse and improve from such case report. Then, Prof. Freude and Director LIANG discussed and exchanged views on cost control, organisational structure, personnel selection, training of young doctors and other major issues related to the management and operation of the department.

Difficult Case Discussion

On April 10, Prof. Freude and Director LIANG first conducted ward round in the morning for the patient who was to undergo surgery on the following day. The patient suffered from an unknown genetic or gene mutation disorder, giving rise to severe deformity of her lower limbs, poor bone quality due to osteofibrous dysplasia, and needed to be operated on for fracture on the proximal femur.

After assessing the patient's underlying disease, along with a physical examination on her genetic history, Prof. Freude proposed to fixate the fracture with elastic nails to help the patient to reduce the pain and hopefully achieve bone healing.

Prof. Freude then had case discussions with the team on a number of complicated cases. These included a patient with polytrauma combined with muscle injury following fall from 4th floor, resulting in paralysis of his extremities and dislocation of his left elbow, open fracture of the right ulnar and olecranon, and fracture of the right medial epicondyle of the humerus. Given the complexity of the case, Prof. Freude emphasised the timing and technique of placing an external fixator, stressed the importance of debridement and medication to prevent calcification of the fracture regions, and suggested that the patient should undergo training to regain his strength by gripping some bouncy balls in hands under physical therapist’s instructions.

Throughout the case discussion, they explored diagnosis and treatment concepts on a wide range of cases, including dislocated elbow fractures, longevity and long-term surgical outcomes of elbow prostheses, reduction and reconstruction of the elbow after Mason type II fracture, and the treatment of complicated cases with ploy-trauma injuries to the sacrum, right femur, pelvic fracture, dislocation of the right shoulder joint, and comminuted wrist fracture after falling from height.

Lectures for the Team

In the afternoon of April 10th, Prof. Freude delivered two lectures on Elbow Fracture and Elbow Soft Tissue and Talus and Pilon Fractures - Diagnosis, Indication, Approach to the Trauma team in the hsopital.

Prof. Freude presented the golden standard of treatment for obtaining elbow stability again after elbow dislocation or fracture and detailed the systematic treatment of bone non-union as well as stiffness after elbow reduction.

Subsequently, Prof. Freude also introduced the surgical treatment idea and reconstruction concepts of talus fracture, as well as the approach and ORIF sequence for Pilon fracture in his lecture on Foot and Ankle Fractures.

A Challenging Intramedullary Nail Fixation Surgery

In the morning of April 11th, Prof. Freude performed an intramedullary nail fixation with Director LIANG's team. This surgery is medical treatment for a patient with proximal femur fracture due to osteofibrous dysplasia, and the surgical plan and physical examination were discussed for the patient yesterday.

There was already severe s-shaped deformity in the patient's femur and the cortex of the femur was in minimal quality, and this made both intra-operative imaging to check nail entry and placing of intramedullary nails extremely challenging.

During pre-op preparations, Prof. Freude, together with Director LIANG and Director WU Xiankui, measured the position of the greater trochanter using a mesh and identified the nail entry point.

During the operation, Prof. Freude and Director WU worked together to place the intramedullary nails and discussed with Director LIANG about the solutions while there were difficulties in drilling the nails into the fracture. Finally, the femoral fracture was fixed by three elastic femoral intramedullary nails and the operation was successfully accomplished.

In the afternoon, Director LIANG's team discussed in detail with Prof. Freude the causes of femoral head necrosis after operative treatment for proximal femoral fracture, exploring whether necrosis is associated with history of smoking and anti-osteoporosis medication, and how damage to the three major blood-supplying areas of the proximal femur affects blood supply to the femoral head.

Afterwards, Prof. Freude delivered a lecture on Treatment on complicated long bone fractures, with emphasis on how to conduct corresponding external fixator and internal fixation treatment and treatment after the incidence of bone defects. This is a lecture in which Prof. Freude explored systematically from the classification of periosteal bone mass and the size of the defect so that he could determine when and how to act against bone defects, and the management protocols of the bone defects (eg. four grafting options, cell biological concepts to achieve local regulation of bone healing, local anatomic factors, blood supply, how to check the systemic factors affecting fracture healing and analysis of systemic factors and mechanical stability of implants), and so on. Dealing with bone defects induced after surgery is one of the major challenges in orthopaedic traumatology, and therefore aroused a lot of questions and discussions among the team.

Sino-Euro Ortho Trauma Open Class

April 12 was the last day of this academic exchange week. Prof. Freude checked some of the patients in the ward as usual and then discussed related treatments for them. The team also checked the recovery of the patient who was operated on yesterday. Prof. Freude and Director LIANG had a discussion on post-op external support and movement of the patient, hoping to help this patient to achieve bone healing and pain relief as soon as possible.

In the afternoon, the second Sino-European Ortho Trauma Communication Seminar of Guangzhou University of Traditional Chinese Medicine Dongguan Hospital (Dongguan Hospital of TCM) was successfully launched. This seminar was chaired by Director LIANG, with contributions from Prof. Freude as guest specialist. Director LU Guoliang of the Ortho Trauma Department, the Ortho Trauma team of the hospital, and directors from other brother hospitals in the region (Dongguan No. 8 People's Hospital, Dongguan Donghua Hospital, and Dongguan Shijie Hospital, etc.) also participated in the seminar.

The seminar centered on topics related to orthopaedic trauma, covering the management of acetabular fractures, pre- and post-operative treatment and care of fragility polytrauma in the elderly, hyperextension tibial plateau fracture, femoral neck fracture, and special types of ankle fracture.

Prof. Freude's lectures covered topics such as approaches and their intraoperative views along with respective reduction and internal fixation techniques under certain approach for acetabular fracture. And most importantly, some reflections on selecting ORIF or hip replacement for the elderly when it comes to certain types of acetabular fracture.

While listening to the lecture on Femoral Neck Fractures, Prof. Freude suggested that there should be different internal fixation treatments for proximal femoral neck fracture and upper trochanteric femoral neck fracture, which further deepened the understanding of the attendees on the surgical management of femoral neck fracture.

This seminar and open class offers a platform for sharing the concepts and experiences of orthopaedic trauma surgery and it is also an opportunity to introduce advanced diagnostic and treatment concepts from Europe to Dongguan region. The seminar came to a perfect closure with the ending of Prof. Freude's one-week visit, and we believe that this academic exchange activity can boost up the development of orthopaedic traumatology in Dongguan region.