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| Goya: Saturn devouring his son, 1823. Museo del Prado, Madrid |
**for non-British readers, the ARCP is the Annual Review of Competency Progression. Nothing to be afraid of. Definitely not.
Tuesday 17 December 2019
Orthopaedic art: the ARCP**
**for non-British readers, the ARCP is the Annual Review of Competency Progression. Nothing to be afraid of. Definitely not.
Alt.orthopaedics: seal clubbing edition
A number of years ago I was in a teaching session with one of the UK orthopaedic greats, Richard Villar, who was the first person that I heard voice publicly what we had all begun to realise, "let's face it, our knee replacements, overall, are just not quite as good as our hip replacements".
He was right, and mostly it was not to do with surgical technique. Like with so many operations, success is predicated on good patient selection. Dissatisfaction is in up to 25% of patients, seriously.
By a poor outcome I don't mean infection, PE or any of the 'standard' complications. I am referring to - as was Ricky - the patient who is never quite satisfied with it, they have chronic non-mechanical pain, it "just doesn't feel right".
If only we could identify this group preoperatively. It would save them (and us) from considerable stress and disappointment.
There have been some valiant efforts. Our Edinburgh colleagues have produced quite a few papers on outcomes, looking at age, concomitant back pain, rather loosely defined 'surgical factors', mental disability, preoperative patient expectations, and 'general physical well being'. With all this data, does that mean we should refuse a TKR to someone with definite pain and severe arthritis, who unfortunately is a male under 55 years with back pain, poor mental health, not in great shape, and who has an expectation that TKR will solve everything?
The objective answer might be 'yes', but when you're with them in the clinic, it's not that simple.
Some Korean surgeons carefully reviewed all this in 2016, and with reference to the vexed issue of personality, stated the following:
Gong and Dong ( 27) retrospectively investigated the relationship between the outcomes of TKA and patient's personality classified into 4 types: patients with extroverted personality were more satisfied than those with introverted or anxious personality after TKA. In our opinion, however, the influence of personality on the outcome of TKA is not straightforward to determine due to the difficulty of categorizing various human personalities.
They have a point.
What to do?
Well, one of my esteemed colleagues, whom I will refer to as TBN, had been chatting to one of the more senior trainees about this conundrum, and they came up with the following suggestion. See what you think.
If in the outpatient clinic you have decided that someone might benefit from a TKR, they get directed to a separate cubicle, where they watch a video. It shows an Inuit in a snowy barren waste, and before him lies a seal, which he is beating to death with a heavy stick, assisted by a harpoon.
If the prospective TKR patient cries out that it's appalling and no animal should be subjected to that, then you might be better off with a Pain Clinic referral.
If, on the other hand, they say that he's just getting his tea, and in addition he could probably use a warm coat and some new boots**, then they can safely be added to the TKR waiting list.
Clearly this would need to be studied prospectively with an appropriately sized cohort***, but the technology is already there. It's already better than banning people because they're a bit overweight.
**Wikipedia: Traditionally, when an Inuit boy killed his first seal or caribou, a feast was held. The meat was an important source of fat, protein, vitamin A, vitamin B 12 and iron, and the pelts were prized for their warmth
***There's already evidence that CBT (Cognitive behavioural therapy) can play a role in improving outcomes of bariatric and spinal surgery. A cure for catastrophising?
He was right, and mostly it was not to do with surgical technique. Like with so many operations, success is predicated on good patient selection. Dissatisfaction is in up to 25% of patients, seriously.
By a poor outcome I don't mean infection, PE or any of the 'standard' complications. I am referring to - as was Ricky - the patient who is never quite satisfied with it, they have chronic non-mechanical pain, it "just doesn't feel right".
If only we could identify this group preoperatively. It would save them (and us) from considerable stress and disappointment.
There have been some valiant efforts. Our Edinburgh colleagues have produced quite a few papers on outcomes, looking at age, concomitant back pain, rather loosely defined 'surgical factors', mental disability, preoperative patient expectations, and 'general physical well being'. With all this data, does that mean we should refuse a TKR to someone with definite pain and severe arthritis, who unfortunately is a male under 55 years with back pain, poor mental health, not in great shape, and who has an expectation that TKR will solve everything?
The objective answer might be 'yes', but when you're with them in the clinic, it's not that simple.
Some Korean surgeons carefully reviewed all this in 2016, and with reference to the vexed issue of personality, stated the following:
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| ...oh dear |
Sunday 10 June 2018
Achilles, Pascal, Occam, TUNC and Bonini
In the world of eponyms in surgery - Monteggia, Fournier, Chiari etc - I actually prefer the non-medical ones.
There is, for example, Achilles' Dilemma in hip resurfacing ("to choose whether to live a short and glorious life or live a long and boring life"); Occam's Razor in diagnostics; Pascal's Wager in avoiding hip dislocation (just use an elevated lip - there is no down side). In case you're wondering, TUNC theory is an acronym not an eponym, for any confused readers.
Here, though, is a new one for me. Bonini's Paradox (courtesy of Kevin Williamson, writing on US politics).
Let us consider hip replacement first. A sphere sits within a hemisphere, as a near perfect fit. It can move freely in any direction for everyday function. It has intrinsic stability by nature of its shape. It is a fairly accurate facsimile of a real hip in many ways. It is a simple design philosophy, if subject to highly sophisticated manufacturing. It is very forgiving in practice, if you put it in slightly askew.
Not so knee replacement. Here there are several radii of curvature in coronal and sagittal planes, not one. A highly complex ligamentous arrangement ensures stability and translational movement. The lateral tibial plateau is smaller in life than the medial side. The lateral plateau has convexity. The shock absorption from the menisci varies between the two sides. Yet the knee prosthesis has a symmetrical biconcave tibial plateau with no difference in impact resistance, no benefit from the cruciates (except in those cruciate retaining cases with a pristine PCL), and relies on a difficult-to-consistently-get-right 'balancing' of the intact collaterals. It is a very unforgiving scenario, so no wonder that pretty much everyone admits these days that knee outcomes are poorer overall than those from hip replacement, particularly in high activity patients.
Attempts to make more complex knee replacements incorporating these issues have generally failed, with either poorer results or at best, unpredictable ones. It's not been for lack of trying by implant companies (1, 2).
Back to Bonini, who is a business professor at Stanford University, looking at reproducing complex systems, for example, a computer model of the brain:
And this is Bonini's Paradox: The less information a model carries about its subject, the less useful it's going to be in helping someone understand that subject. And yet, the more information a model carries about its subject, the less useful it's going to be in helping someone understand any single point of that subject. Any sufficiently detailed map of a region is going to be just as dense and difficult as the region itself. Any sufficiently detailed model of a brain is going to be a brain.
...and any sufficiently detailed model of a knee is going to be a knee. Wikipedia quotes French poet and philosopher Paul Valery, with a similar take, from years earlier in 1937: "Everything simple is false. Everything which is complex is unusable."
Indeed, a hip replacement is undoubtedly 'false', but it nearly always works. A more complex knee replacement is also false, but it just edges a little bit along the spectrum towards unusable.
Another quote from the Gizmodo article already cited: Any model, of anything, is in an act of editing. It picks out what we think is important regarding the subject, and directs our attention to how that important thing can be manipulated.
Even orthopaedic surgeons aren't gods. I suppose
There is, for example, Achilles' Dilemma in hip resurfacing ("to choose whether to live a short and glorious life or live a long and boring life"); Occam's Razor in diagnostics; Pascal's Wager in avoiding hip dislocation (just use an elevated lip - there is no down side). In case you're wondering, TUNC theory is an acronym not an eponym, for any confused readers.
Here, though, is a new one for me. Bonini's Paradox (courtesy of Kevin Williamson, writing on US politics).
Let us consider hip replacement first. A sphere sits within a hemisphere, as a near perfect fit. It can move freely in any direction for everyday function. It has intrinsic stability by nature of its shape. It is a fairly accurate facsimile of a real hip in many ways. It is a simple design philosophy, if subject to highly sophisticated manufacturing. It is very forgiving in practice, if you put it in slightly askew.
Not so knee replacement. Here there are several radii of curvature in coronal and sagittal planes, not one. A highly complex ligamentous arrangement ensures stability and translational movement. The lateral tibial plateau is smaller in life than the medial side. The lateral plateau has convexity. The shock absorption from the menisci varies between the two sides. Yet the knee prosthesis has a symmetrical biconcave tibial plateau with no difference in impact resistance, no benefit from the cruciates (except in those cruciate retaining cases with a pristine PCL), and relies on a difficult-to-consistently-get-right 'balancing' of the intact collaterals. It is a very unforgiving scenario, so no wonder that pretty much everyone admits these days that knee outcomes are poorer overall than those from hip replacement, particularly in high activity patients.
Attempts to make more complex knee replacements incorporating these issues have generally failed, with either poorer results or at best, unpredictable ones. It's not been for lack of trying by implant companies (1, 2).
Back to Bonini, who is a business professor at Stanford University, looking at reproducing complex systems, for example, a computer model of the brain:
And this is Bonini's Paradox: The less information a model carries about its subject, the less useful it's going to be in helping someone understand that subject. And yet, the more information a model carries about its subject, the less useful it's going to be in helping someone understand any single point of that subject. Any sufficiently detailed map of a region is going to be just as dense and difficult as the region itself. Any sufficiently detailed model of a brain is going to be a brain.
...and any sufficiently detailed model of a knee is going to be a knee. Wikipedia quotes French poet and philosopher Paul Valery, with a similar take, from years earlier in 1937: "Everything simple is false. Everything which is complex is unusable."
Indeed, a hip replacement is undoubtedly 'false', but it nearly always works. A more complex knee replacement is also false, but it just edges a little bit along the spectrum towards unusable.
Another quote from the Gizmodo article already cited: Any model, of anything, is in an act of editing. It picks out what we think is important regarding the subject, and directs our attention to how that important thing can be manipulated.
Even orthopaedic surgeons aren't gods. I suppose
 |
...OK, everybody got that? |
Classifications are often rubbish
I used to pride myself on knowing lots of orthopaedic and trauma classifications. Many of them still provide a useful lingua orthopaedica when discussing cases, a few - such as Lauge-Hansen - definitely guide treatment, and a lot of them eg femoral revision classifications, are usually fairly pointless for me in practice, much as I admire their authors
I gave a lecture on revision hips where I introduced a new classification - at least I'd not seen it used in this way before. I actually do use the broad categories, say for the acetabulum, where cavitary bone defect, rim defect and pelvic discontinuity, do have some sort of practical meaning. But I definitely prefer this one, which I presented at a lecture in Budapest in 2007. A year later I saw someone - who'd been in the audience - repeat it word for word, without due credit. Such is life.
Here are the slides from that PowerPoint (with the odd redaction):
Anyway, I mention it because I saw of of my pet hates suitably challenged recently, on Twitter of all places. The pet hate is the question that it seems all medical students are routinely taught to ask: "on a scale of 1 to 10, how bad is your pain?"
I have never used this stupid question in practice, as it is almost a definition of why we're advised to avoid non-parametric data in research. It means almost nothing in every case that it's used. I've seen it asked, and more than once heard the sullen deadpan reply of '11'. Of course. Probably just after the phrase "I have a high pain threshold you know, doctor, but..."
So I was delighted to see the following, made available by cancer survivor and wit, @TeaLady24. It just needs to be provided in a wipe clean laminate (with the numbers removed), at every outpatient clinic.
"...just point to the one which represents your feelings best..."
I gave a lecture on revision hips where I introduced a new classification - at least I'd not seen it used in this way before. I actually do use the broad categories, say for the acetabulum, where cavitary bone defect, rim defect and pelvic discontinuity, do have some sort of practical meaning. But I definitely prefer this one, which I presented at a lecture in Budapest in 2007. A year later I saw someone - who'd been in the audience - repeat it word for word, without due credit. Such is life.
Here are the slides from that PowerPoint (with the odd redaction):
Anyway, I mention it because I saw of of my pet hates suitably challenged recently, on Twitter of all places. The pet hate is the question that it seems all medical students are routinely taught to ask: "on a scale of 1 to 10, how bad is your pain?"
I have never used this stupid question in practice, as it is almost a definition of why we're advised to avoid non-parametric data in research. It means almost nothing in every case that it's used. I've seen it asked, and more than once heard the sullen deadpan reply of '11'. Of course. Probably just after the phrase "I have a high pain threshold you know, doctor, but..."
So I was delighted to see the following, made available by cancer survivor and wit, @TeaLady24. It just needs to be provided in a wipe clean laminate (with the numbers removed), at every outpatient clinic.
"...just point to the one which represents your feelings best..."
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| genius, in it's way (click to enlarge) |
Saturday 10 March 2018
Heraclitus and the European Working Time Directive
Here's a post from a guest author - a highly regarded NHS stalwart - who is nearer the end of his consultant career than the beginning. A role model, no less, if you aspire to be a great orthopaedic surgeon without losing your humanity and affability. I haven't identified him, intentionally, but he's not me.
He's responding to a post in the BMA news. There's lots of this stuff out there (1, 2, 3, 4, 5), and I even blogged on it myself. See what you think. By and large he's right - this is real world medicine from a real world expert.
Front Page of BMA News:
“One I am terribly sorry to have to say this but we have to train our young doctors to be prepared for life in the real world and not for life in some utopian fantasy land. I agree that the life of a trainee is less satisfactory nowadays than it was in the 1970s and 1980s where although hours of work were much longer and more arduous, and pay for overtime was only 1/3 of the basic rate, and when you could be on call on a 1:2, 138 hours in a week, you were valued, cherished, appreciated, helped by your seniors and by experienced nurses. You would live in the “Mess” with fellow housemen experiencing the same joys and hardships. These times have gone.
At that time Housemen and Housewomen were expected to take on, and did take on responsibilities that our current young doctors would baulk at, but it prepared them well for the future. I fail to see how “sleep deprivation” can possibly be a problem in a situation where our trainees work shifts and never work more than 48 hours average a week. These are young, generally healthy, men and women. Why should they be any less able to deal with a bit of hard work than we were?
We have gone too far in our efforts to adhere to European Working Time Directives especially when those who travel in Europe and elsewhere know that the trainees there (in common with trainees in America, Australia, Canada and New Zealand) work much longer hours without complaint as they realise that it is the only way to become experienced enough to deal with the rigors of a senior appointment.
I had the unedifying experience of hearing young trainees described as “Babydocs” by someone in our Deanery which I felt was not only demeaning to the mature men and women who had spent 5 years at University and another year as an FY1, but indicative of the lack of insight in our educationalists who do not begin to appreciate that the sooner someone stands up and takes responsibility for their own actions, the better equipped they will be in later life to deal with the difficult decisions that come to all of us.
Medicine is not an easy job. People who can’t manage to cope with the stresses and strains, with the long hours and challenges may be better to be advised at an earlier stage to consider an alternative career."
You may think it's harsh, the voice of an old fart, perhaps, who doesn't get the groovy new way of doing things. I'm afraid though, that some aspects of medicine don't change. Two of our most effective operations today, for example, were practised by Hippocrates and his pals, in not dissimilar ways to our current techniques - amputation and draining abscesses.
Note that part of this relates not to service delivery or alleged risks to patients from 'tired doctors', but to the happiness and job satisfaction of the medics themselves. However physically and mentally challenging work has been, there is immense satisfaction from having done it and done it well. A point neatly encapsulated by another experienced medic, Theodore Dalrymple, in a classic Spectator piece:
No one wants to be treated by a dog-tired doctor, but even less does he/she want to be the parcel in the medical game of pass-the-parcel that is now commonplace in our hospitals. The European Working Time Directive has transformed doctors into proletarian production-line workers, much to their dissatisfaction with their work and to the detriment of their training and medical experience. It means that doctors no longer work in proper teams, patients don’t know who their doctors are and doctors don’t know who their patients are. The withdrawal of the directive would improve the situation.
Medicine in general, and surgery in particular, is ruled by Eternal Verities**, whatever the New Deal, the EWTD and the BMA say.
**although he didn't invent the term, Greek philosopher and writer, Heraclitus, from about two and a half thousand years ago, was the father of the Eternal Verities. He realised that reason and wisdom are what leads to contentment, with all the moral, metaphysical and religious implications that might flow from that. Somewhat more profound than complaining after not getting a mandatory 30 minutes break following 4 hours of work (or whatever this week's formula is).
Front Page of BMA News:
“One I am terribly sorry to have to say this but we have to train our young doctors to be prepared for life in the real world and not for life in some utopian fantasy land. I agree that the life of a trainee is less satisfactory nowadays than it was in the 1970s and 1980s where although hours of work were much longer and more arduous, and pay for overtime was only 1/3 of the basic rate, and when you could be on call on a 1:2, 138 hours in a week, you were valued, cherished, appreciated, helped by your seniors and by experienced nurses. You would live in the “Mess” with fellow housemen experiencing the same joys and hardships. These times have gone.
At that time Housemen and Housewomen were expected to take on, and did take on responsibilities that our current young doctors would baulk at, but it prepared them well for the future. I fail to see how “sleep deprivation” can possibly be a problem in a situation where our trainees work shifts and never work more than 48 hours average a week. These are young, generally healthy, men and women. Why should they be any less able to deal with a bit of hard work than we were?
We have gone too far in our efforts to adhere to European Working Time Directives especially when those who travel in Europe and elsewhere know that the trainees there (in common with trainees in America, Australia, Canada and New Zealand) work much longer hours without complaint as they realise that it is the only way to become experienced enough to deal with the rigors of a senior appointment.
I had the unedifying experience of hearing young trainees described as “Babydocs” by someone in our Deanery which I felt was not only demeaning to the mature men and women who had spent 5 years at University and another year as an FY1, but indicative of the lack of insight in our educationalists who do not begin to appreciate that the sooner someone stands up and takes responsibility for their own actions, the better equipped they will be in later life to deal with the difficult decisions that come to all of us.
Medicine is not an easy job. People who can’t manage to cope with the stresses and strains, with the long hours and challenges may be better to be advised at an earlier stage to consider an alternative career."
 |
| The great man has just looked at the New Deal regulations... |
Note that part of this relates not to service delivery or alleged risks to patients from 'tired doctors', but to the happiness and job satisfaction of the medics themselves. However physically and mentally challenging work has been, there is immense satisfaction from having done it and done it well. A point neatly encapsulated by another experienced medic, Theodore Dalrymple, in a classic Spectator piece:
No one wants to be treated by a dog-tired doctor, but even less does he/she want to be the parcel in the medical game of pass-the-parcel that is now commonplace in our hospitals. The European Working Time Directive has transformed doctors into proletarian production-line workers, much to their dissatisfaction with their work and to the detriment of their training and medical experience. It means that doctors no longer work in proper teams, patients don’t know who their doctors are and doctors don’t know who their patients are. The withdrawal of the directive would improve the situation.
Medicine in general, and surgery in particular, is ruled by Eternal Verities**, whatever the New Deal, the EWTD and the BMA say.
**although he didn't invent the term, Greek philosopher and writer, Heraclitus, from about two and a half thousand years ago, was the father of the Eternal Verities. He realised that reason and wisdom are what leads to contentment, with all the moral, metaphysical and religious implications that might flow from that. Somewhat more profound than complaining after not getting a mandatory 30 minutes break following 4 hours of work (or whatever this week's formula is).
Tuesday 27 February 2018
Sunday 11 February 2018
Naaman orthopaedics: avoiding the complex option
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| Ferdinand Bol, Elisha refusing the gifts of Naaman, 1661. Rembrandthuis, Amsterdam |
Most orthopaedic surgeons are renowned biblical scholars, so they will be aware that the earliest example of "keep it simple, stupid" in medicine, was probably in the Book of Kings in the Old Testament, so around 600 BC.
The story in question is that of Naaman. A recap:
Naaman was a general in the pagan Syrian army, and a confidant of the king. Unfortunately he was also a leper, a big deal then (and now). he happened to have a slave girl who was a captured Israelite, who pointed out that back where she came from - Samaria - there was a prophet who could cure him, Elisha. As nothing else had worked, Naaman went for it. He loaded up with gifts and a fancy retinue, and headed south. His first mistake was to go to the king of Israel, who got mad when Naaman quizzed him, on the reasonable grounds that he couldn't cure leprosy, so the Syrians were clearly at it.
Elisha got wind and sent a message to have Naaman visit him. So the whole convoy ended up at Elisha's place. I'll let the scripture take over here:
Elisha sent a messenger to him, saying, “Go and wash in the Jordan seven times, and your flesh shall be restored to you and be clean.” 11 But Naaman was furious and went away and said, “Behold, I thought, ‘He will surely come out to me, and stand and call on the name of the LORD his God, and wave his hand over the place, and cure the leper.’ 12 “Are not Abanah and Pharpar, the rivers of Damascus, better than all the waters of Israel? Could I not wash in them and be clean?” So he turned and went away in a rage.
I can understand it, I suppose. However, the unnamed slave girl was not impressed:
“My father, had the prophet told you to do some great thing, would you not have done it? How much more then,when he says to you, ‘Wash, and be clean’?”
So he did, and it worked. No more leprosy. And I believe that the long term clinical outcome remained satisfactory, although I don't have the PROMS data.
Thank you for sticking with me this far. Why does this matter in orthopaedics? Well, here are a few examples:
1. The CSAW RCT showed that operating on subacromial pain was not really any better than not operating
2. The PROFHER trial, even at 5 years, showed no benefit in operating on proximal humeral fractures than not operating (I accept that there will be some self-evident exceptions to this)
3. The DRAFFT RCT found no benefit of locking plate fixation over MUA and K wires for distal radius fractures (I accept that there will be some self-evident exceptions to this, too)
4. (my favourite) Complex, expensive and fiddly revision femoral stems are no better than the unfashionable monobloc ones, which are also much easier to use. Modular may also have more implant specific complications.
I am very far from being a surgical Luddite, nor do I tend to favour conservative management - although it's a skill we need to teach more in certain areas. But...
...there is no intrinsic merit in complicating treatments, although there are many intrinsic potential risks.
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