An orthopaedic uncertainty principle

It's not that common for orthopaedic papers to have great titles. There are exceptions though. I always like the sense of existential despair invoked by "The futility of predictive scoring of mangled lower extremities" (a good paper). Likewise, one is inevitably keen to see the X rays in "Late complications of total hip replacement from bone cement within the pelvis. A review of the literature and a case report involving dyspareunia". **

My absolute favourite though is neither peer reviewed nor 'scientific', although it's a genuinely valuable contribution to the specialty: Fergal Monsell's beautifully written "My Journey Into Uncertainty" from BJJ News in 2015, the story of his life in orthopaedics. Possibly the most humble title in any orthopaedic journal, and all surgeons need humility. Not only is it both funny and practical, it contains this gem (he's a paediatric surgeon):

I am also convinced that any operation for Perthes' Disease, DDH and slipped epiphysis is only legitimate if it does not interfere with future replacement of the hip

Terrific advice, if it means avoiding the THR in a 23 year old with a femur deformed by a 'last fling' valgising osteotomy after SUFE.





**In case you're wondering, here's the X ray. Not entirely sure where the dyspareunia came from

*

The science of walking sticks and related matters

Joe Perry of Aerosmith genuinely uses a walking stick!

A minority of orthopaedic surgeons are entirely at ease with biomechanics, I would say. I am in the slightly perturbed majority. However, all orthopaedic 'exit exams' of which I'm aware will include it, reasonably enough. Drawing free body diagrams, explaining joint reaction forces, discussing the rationale of prosthetic design etc

Happily, as Isaac Newton has amply demonstrated, the principles have been established for centuries, and so the two papers here, from 1959 and 1997, seem bang up to date.

The first, by Robin Denham, one of the relatively unsung heroes of British orthopaedics, is as nice an exposition of basic hip mechanics as you could wish for. He references Blount's classic JBJS article "Don't Throw Away the Cane", and the end of Denham's piece has a great little exposition of the use of a walking stick (cane), which includes why patients will intuitively hold it in the opposite hand from the affected hip. The final 9 points in the summary are in a way all you need to understand for both clinical practice and exams.




The second paper, from Richard Brand in Iowa, is more about osteotomies, and relating the mechanics to the biology. Proximal tibial osteotomy for knee arthritis is definitely on the way up again, and periacetabular osteotomy in adults is an essential part of the hip repertoire now. Proximal femoral osteotomy in adults though is not really on the same page. There seem to be very few patients in whom it would be a better bet than a hip replacement. The last one I did was for a varus proximal femur causing stress fractures, ages ago (it did work). The bottom line is, if you absorb these two papers you know a lot about hip mechanics. if you're like me, and you get most of the content, that's enough to function perfectly well.

If you add in Charnley's stuff on wear and head size, you're almost an expert. Almost

Surgical teaching and the mating habits of the pheasant

A tenuous analogy, to be honest

As a trainer, Philosophy #1 is tempting, particularly when you're a new consultant.

The trainees in my deanery have pretty full logbooks, and we get trainer feedback that tells us if we're not giving trainee cases. But, there is an unhappy and impractical obsession with some surgical trainees putting operating as a priority far beyond clinical assessment, ward work, outpatient clinics and all the other stuff that doctors - as surgeons, believe it or not are doctors - should be doing.

To be fair the UK ISCP system using work based assessments does make an attempt to deal with this, albeit there's a limit to how much you can bureaucratise clinical work and clinical education.

At the very least Leo Gordon's phrase: awarding surgical responsibility without demanding (such) knowledge sells the resident short. In a greater sense it sells short the discipline of surgery...merits a little bit of contemplation.

And the penultimate paragraph is 100% true.

A cost rather than an opportunity

Another oldie from Nigel Hawkes, but a good one. Depending on in which part of the NHS you work, I doubt that much has changed.

Years ago I saw a statistic that the city of Cincinatti (population about 300,000) had more MRI scanners than the NHS (UK population about 64 million). I'm sure that the ratio has improved since, but bearing in mind that the innovations behind the clinical use of MRI were primarily British, it makes a good point. In fact, Hawkes makes a very similar point here, in this case about Japan.

Medics are not particularly slow to innovate, but their plans may well be derailed by management, who, as Hawkes says, generally are slow to innovate - they're usually firefighting. And that's because of the pressure from the government behemoth above them, as much as anything, combined with poor spending decisions, often as not.

You don't have to be Albert Einstein to recognise that "if you always do what you always did, you will always get what you always got", but funnily enough, it was him who said it.

What have the Americans ever done for us?

Jasper Johns, Flag, 1954. MoMA

It's true that the greatest advances in skeletal trauma and orthopaedics are predominantly European in origin (and many of them are British), but our friends in the States catch up quickly. I remember being at the American Academy meeting about 15 years ago, having been doing a lot of MIPPO fixation for damage control for about 3 years, after the Hannover trauma stars like Krettek had published really wonderful papers on it. At the AAOS meeting they had one guy presenting about 10 femoral MIPPO's to a sceptical audience. Now they're completely on top of it.

Areas where they do have a great track record of innovation include spines and an interest of mine, lower limb revision arthroplasty. Kelly Vince on knees, for example, is a truly great surgeon and educator, one of many North Americans (I know he's Canadian) in that field, and there are lots of revision hip stars like Paprosky, the Mayo guys, lots of them.

Which brings me to Charlie Engh, who has graced numerous CCJR meetings. He is the man behind the AML cementless fully porous coated stem, which like Paprosky's Solution stem really cracked the problem of the difficult femoral revision. There are now quite a few imitations. I can't stand modularity on revision femoral stems - I regard it primarily as a marketing ploy for companies, and it pushes the price up - as it's nearly always unnecessary and complicates matters. The AML had a modular head and that was it, although there a couple of variants now. This is not an advert - I use one of its competitors, I'm just paying homage to Charlie.

Anyway, here is a great reminiscence by the man himself, on his career and the development of orthopaedics in the USA over that period. It's followed by a minimum of 10 year follow up on the fully porous coated femoral revision stem - a landmark paper in my view.




That piece mentions the other Engh brother, Gerry, also an orthopaedic surgeon. I once saw him present a case - with videos - of a patient with no arms who drove a car with their feet on the wheel. Gerry did an ACL reconstruction (I think on both knees) followed by medial AND lateral unicompartmental knee arthroplasties. The end of the talk showed a new video - back driving the car. I'm not making this up. Wonderful.


Here's the 10 year outcome paper. Relatively few cases, but difficult ones, and a long follow up. Most surgeons and patients would be happy to get a good 10 years (and more) in cases like this.

The same dudes that you misuse on your way up...

Most people would claim to adhere to this, but do you really? I'm not referring to life in general, but in your ward/office/theatre/teaching session.

Apply it to your workplace!

Do you speak to the cleaners? Do you know their names? How about all the nurses, including the students?

Do you ever have a go at the theatre staff? Did it go beyond the necessary correction?

I try to avoid it, but I have done it. Such is the hierarchy of hospitals, and the status and (residual) power of surgical consultants, we should all be aware that a kind word, a personally addressed comment, involving a student nurse in clinical care - there are hundreds of possible examples - may make their day, make them think well of you and might in some way benefit you too.

I know a consultant who asked of an earnest and trembling junior who had approached him, "what grade are you"? The quiverer answered "senior house officer".

"Go away, I don't speak to anyone less than a registrar".

Hmm. Funny in a way, but not good. If you're not nice to patients and their relatives you might end up in trouble. In part it's self-preservation.. It's how you behave with these other people, who can't hurt you, that is the best judgement.

The old claim that "he may be a bastard, but it's worth it because he's a great surgeon" was always rubbish. Great surgeons show greatness of spirit.

Have you paid your college fees?

Back in 2007, when Modernising Medical careers was fresh and found to be pretty flawed, the reliably insightful Nigel Hawkes wrote a piece in the BMJ wondering:

a. Why did we make this change (see my other post here)?

b. What are the colleges actually for?

He had a point. He still does. A colleague and friend of mine who has spent years labouring for a distinguished college - and attaining high office - recently told me he wasn't sure, other than postgraduate examinations, what his college was for any more. There was a lot of business class overseas travel, and fine wining and dining, but...

Most surgical postgraduate education doesn't need college input, and ultimately one could envisage examinations being dealt with effectively by other bodies, too. The historical precedents set by the colleges are not set in stone. My own experience, and observations from wider practice, are that they are not great at advising government either.

Hawkes' piece is probably more relevant than ever, particularly with the ongoing success of specialty bodies like the British Orthopaedic Association, imperfect though it is. He absolutely gets the mindset:

 The purpose of MMC, it seems to me, was to wrest control of higher training from the colleges, and shape it in ways designed to suit the employers. The colleges were placated (a cynic might say bought off) by allowing their exams and their income flow to continue, at the price of having little further influence. Many of those who take the exams hail from overseas. The colleges did not want this source of income to dry up either, but nor did they want foreign graduates to take up too many of the training opportunities.

A pretty cynical state of affairs indeed. Read the paper - it doesn't take long

Preparing for nemesis***

Brueghel: Landscape with the fall of Icarus (victim of hubris, bottom right) Musee Royaux des Beaux Arts, Brussels, 1560ish **

I once had a consultant colleague who regularly boasted that his hip replacements didn't dislocate. He was a fan of the cementless 32mm Ring implant with a polyethylene cup, done through an anterolateral approach. They all failed after abut 5 years with wrecked abductors, but he was right: they didn't dislocate (much).

This was a perfect example of both the Sin of Denial in Orthopaedics (SODIO) and also hubris. Which is where Leo Gordon's next matrix lesson comes in. Hubris is a word that should be used a lot by surgeons, and not just when discussing their colleagues' errors and complications.

Note the painful description of the attending/consultant: the overeducated overbearing surgical attending who had no insight into his own failures

Ouch.

It also contains one of a number of Leo's references to the mysterious pantheon of the surgical gods. Do not upset them. Heed their warnings. And note also olbos and koros. We've all been there.



**If you're interested in the painting and some poetry (yes, this is orthopaedics), then read this

***Everyone knows nemesis don't they

Deferring death v stupid politicians, AKA what is the NHS for?

I don't want to get party political, as this pretty much applies to all political leaders who make crazy promises about healthcare. It's a global problem, as Obama has found out. This one though is written by Iona Heath, a remarkably insightful President of the Royal College of General Practitioners (2009-2012), and a voice of reason in discussing what she calls 'too much medicine', AKA the overdiagnosis and medicalisation of life. It's not just unaffordable, it actually can cause harm.

This open letter to Gordon Brown, who happened to be the PM at the time, and even by NHS standards was ridiculously spendthrift on things that perhaps were not that useful, is exceptionally good. It's all still applicable. Osteoporosis spending springs to mind, considering Heath's phrase: the extent to which contemporary preventive medicine has got itself trapped on a treadmill of risk factors.

One of the issues I have, as a highly paid NHS staff member, is the constant refrain for more money for the NHS. I'm also a taxpayer and the NHS has buckets of money. It might need more, but before that it needs a review of what it's going on already. So much of the budget is spent on low value interventions and pet projects, spurred on by mysterious 'health planners' in the civil service, various Public Health types, and vested interests.

Picking on my own specialty, in a nutshell, if I do a hip replacement I'm usually providing lasting value.....hip arthroscopy? Not so much.

Avicenna did not have a phone

It's for you, doctor..

This is one of the great Leo Gordon's finest matrix lessons, which is saying something. It is also a near daily decision that I have to make at the hospital, on the wards and in theatre. You just want to be helpful and after all, what harm can it do to answer a phone? The matrix lesson references Dorothy Parker, and the quotation is not dissimilar to Ogden Nash's line: Middle age is when you're sitting at home on a Saturday when the telephone rings and you hope it isn't for you. Which is, rather pathetically, where I'm at - home and work - most of the time. 

 The list of awful possibilities is a long one. Leo provides some classics, I would emphasise my own pet hates: staff wanting to discuss their off duty; relatives wanting an update on someone who is not your patient; the labs raising a potentially important test result about someone whom you have never met or been involved in their care.

Part of the problem these days in the UK is that in many hospitals bleeps  have virtually been abandoned and random phone calls (and email) have filled that void. Bleeps are good, and it was my fellow consultants who began the trend to leave them in a drawer with the airily offered alternative of "just try my mobile", which doesn't get answered, usually. A good doctor makes themselves available if at all possible.

Which is not the same as answering an unattended telephone.

Revision syndrome

It tends to only be in operations that last more than about 90 minutes. Hand surgeons rarely suffer from it. Acetabular revision and primary joint replacement are usually OK. But be warned, if you're going to start chipping out the femoral cement, do a tumour prosthesis or something a bit challenging/demanding/stressful, then you may well be exposed to this pernicious syndrome.

I understand it. The only person actually having any fun at this point is you, as the main operator. The assistant is in a trance, the anaesthetist has probably 'just popped out', according to the abandoned anaesthetic nurse, but you need, right now, that particular instrument from supplementaries, so you ask for it. The scrub nurse looks shifty and utters the dread words: "you may have to wait a minute, I'm on my own right now".  Many surgeons will be familiar with this. You look around, the circulating nurse has disappeared, the auxiliary is mysteriously absent. Nobody knows where they are.

It was all so different at the start of the operation, the theatre was crowded, a herd of students grazed quietly outside the laminar flow, there was a subtle sense of anticipation at doing 'a big case'. Now, all gone. You're alone. Ten minutes is added to the procedure by the time the instrument has been located and staff have drifted back.

It's revision syndrome. True, it is eventually self-limiting, but boy, is it annoying.

My theatre

Won't somebody think of the children?

It's not that often that one finds one's orthopaedic practice stimulated by The Simpsons, but here it is:

 

 They're not just little adults are they, as the anaesthetists keep telling us that, but I have to say I think it's a bit overdone - with lots of exceptions obviously. However, the subspecialisation of paediatric orthopaedics has been extended into a lot of really pretty straightforward children's trauma. In my view this has lead to a certain amount of potentially unnecessary operating.

Twenty years ago there was actually very little quality literature on fracture remodelling. There's more now, and the oldtimers' claim that you can rely on remodelling in lots of situations seems to me to be mainly true. Again, I don't mean specific potentially problematic injuries like in late teens, displaced intra-articular fractures and so on, but there has been a tendency to overcook the interventions (personal opinion, I accept). Which I think fits with the title of this must-read paper from Nottingham. (The paper references the great Mercer Rang, one of the wittiest and best writers in the history of orthopaedics, of whom more in another post)


 

Trust me, I'm a scientist

They look like proper scientists. 

If you've ever had an ostensibly perfectly OK study rejected by a peer-reviewed journal with criticisms that you find picky or irrelevant, then you might have begun to develop suspicions about the sacred status of peer review. It can mean virtually anything, can't it?

If your magnum opus has then been accepted virtually unchanged by a different peer-reviewed journal, your suspicions may strengthen. But medics have it easy compared to some other areas in science. Anyone remember Climategate?

So, stepping outside of the strictly orthopaedic and medical arena, here's a nice review of why it pays to be sceptical about peer review. It doesn't take long to read.




And while I'm on the subject of research methodology/publishing, what's so great about RCT's? I know that they're allegedly the gold standard, but they are very difficult to pull off in surgery with enough power in the study, and often end up with endpoints of dubious clinical relevance, just because they're easy to quantify. Think of all the utterly irrelevant distal DVT's on scanning in the industry-led thromboprophylaxis trials.

Level 3 or 4 evidence - such as a well-documented cohort study of sufficient size, can be far more convincing (more soon). It may be a bit dry, but this review of RCT's in orthopaedics is worth skimming at least. It's salutary to recall what Lord Rutherford said: "If your experiment needs statistics, you ought to have done a better experiment"

 

I'll post elsewhere on the whole DVT thing, part of the pleasure in it is seeing that antipathy between physicians and surgeons can be universal

Sitting Bull

Master the use of this 

When I was a general surgical trainee, learning the ropes, one of the most technically accomplished consultants was a urologist. He'd actually trained as a thoracic surgeon, and unlike a lot - not all I should add - of the current general surgeons, he was completely unfazed cracking open a chest, say for trauma, even if he'd not done it for 5 years.

He gave me two excellent pieces of advice. Firstly, avoid cutting with scissors, use them sparingly, the best surgeons use a knife as much as they can. I still recommend this, although I occasionally permit myself a bit of blunt dissection with scissors - isolating the sciatic nerve for example. I saw him do a nephrectomy very quickly and deftly, without using the scissors once, as far as I can recall. The second piece of wisdom is probably the reason why he switched to urology: always sit down, "as you never know when you'll next get the chance". When he asked me what I wanted to do, and I said probably orthopaedics, he advised me to subspecialise in hand surgery, as "they seem to sit down a lot". He had a point.

We brings me back to Leon Wiltse, who also advised sitting down - primarily to be better at humanising the inevitably hierarchical doctor/patient relationship. A hero of this blog, Leo Gordon, said something very similar, in his usual way, "the most basic of surgical actions":

The orthopaedic intellectual (part 1)

Dr Wiltse confounds this unfair stereotyping

All this exponential growth. There was a time, it is said, when one educated person could reasonably attempt to ingest all the published knowledge in the world. In my youth there were professors of medicine who certainly gave that impression. When one was reading the orthopaedic journals  there would be the British and the American Journals of Bone and Joint Surgery, Clinical Orthopaedics, possibly the Journal of Trauma, Acta Orthopaedica Scandinavica - not that many more of note. You could easily keep up. Now there are hundreds.

Likewise, if you talked about the known experts in the fields there weren't that many really - there was a decent chance you might have actually met a lot of them at conferences. So at that time it was true, in surgery giants really did stalk the earth. Now there are many many more highly accomplished, highly experienced true experts. Exponential growth, powered by the uniquely successful nature of our elective interventions - compared to the rest of surgery in general - has made the orthopaedic world enormous.

Although I'm not a spine surgeon (apart from coccygectomy), I recognise the name of Leon Wiltse as one of these giants, and like many American surgeons, he practised for a very long time.  One of the purposes of this blog is to collate the published wisdom -as opposed to research - of men such as Wiltse, and his review of his life and career, published in 1995, is a gem. The last few pages contain numerous nuggets of clinical and professional gold. I particularly commend the advice (more elsewhere) to sit down when you're with a patient, and the point that if you read an hour of the literature a day, you'll be the best read orthopod in town. The heaps of journals under the beds and on the office floors suggest that not enough of us are heeding it, me included. Dr Wiltse really was a fount of wisdom.

Osteoporosis and orthopaedics - a GP writes

Periodically there is a new thrust to galvanise the orthopaedic community about osteoporosis, the consequences of which we are more familiar with than the average doctor.

It never really appealed to me as an area of practice, but intellectually it didn't really convince either. If the inevitable decline in bone mass which affects all of us (exacerbated by the menopause in women) is causing fractures, then the only really effective measure is probably to maximise one's peak bone mass, and be sensible in the subsequent years. In other words, it's mainly how you eat, exercise and smoke from your teens to your late twenties. The same applies thereafter to a lesser extent, but if you start your descent from a very high altitude....It makes sense to me.

What doesn't make sense is to start people on expensive medication, often with a low compliance rate, in their pensionable years. It strikes me as another industry-driven initiative, at least in part, with some similarities to the aggressive marketing of chemical thromboprophylaxis for arthroplasty, based primarily on surrogate outcomes. One cannot tell an individual patient that it is definitely in their best interests, in my view.

Please note that I am not referring to premature osteoporosis, osteomalacia or any other true metabolic pathology. They are entirely different matters.

Anyway, I'm not alone. Fons Sips died this July, aged 76. He was a pioneering Dutch GP, of great renown. Here is an excerpt from his BMJ obituary:

He has a point

Funny Guy

The joint worst film ever made is Patch Adams, where Robin Williams, with his hallmark excruciating sentimentality, convinces a bunch of crusty old medical school professors (who understandably hate him) that laughter really is the best medicine.

Voltaire, for whom I have a lot of time, stated the "the art of medicine consists of amusing the patient while nature cures the disease", about which more on another day. His short novel Candide is genuinely hilarious for a 257 year old work.

So does humour have a role in medicine? Well, be careful.

Quite a few years ago I did bilateral hip replacements on a rather feisty lady in her 50's. A couple of months later she appeared in the review clinic. We had a nice chat, there were a couple of students there, a nurse, and the patient's husband. Just as I was leaving the room she called after me, "oh, one more thing doctor, what about sex?"

It was a gift really. Perhaps I should have hesitated, but:

"Well it's a pretty busy clinic, but if you want to come back at the end I'll see what I can do."

Luckily, as they say, we all managed to see the funny side of it. 10 years later at the audit review she repeated the story - with embellishments - to a new audience.

As ever, Leo Gordon has the wise advice. In fact his second example has some similarities with the above. Note especially the last two paragraphs:

A little politics: MMC and dumbing down

It's that time of year again, when doctors just over one year out of medical school are being nudged into a straitjacket of specialty training before they've even experienced a small percentage of their possible career options. Yes, it's the annual expression of MMC (Modernising Medical Careers, from 2005).

Very many of us felt it was an unnecessarily doctrinaire and remarkably bureaucratic approach to careers, particularly when you're dealing with some very high achieving individuals who would not gain from stifling their career options, and nor would the taxpayer who paid for their education. In addition, Ken Calman's late 90's superb postgraduate training reform programme had only just bedded in, and it was a fantastic improvement from what had gone before. It was abandoned prematurely by the self-appointed 'great and the good' of UK medicine. Their mantra was 'something must be done for the SHO's'. In fact many SHO jobs were deservedly popular for lots of reasons, and it's a pretty odd motive for reorganising the whole training structure (again).

So why did we bother with MMC? Apart from glory hunting by ageing clinicians eager to reduce their clinical commitments, consultant oncologist (and top irritant of governments) Clive Peedell  thought it was fairly obvious: to save money. He might be right.

I take the view that this was the then government's plan to undermine all those professions which retained the public's affection/respect despite their faults: teaching, the clergy, medicine and others. I still think that. Everyone has to be similar/dumbed down, everyone has to become primarily an employee, as opposed to a vocationally minded self-motivating highly expert clinician. It went in tandem with the disastrous and extraordinarily cynical changes to the GP contract - which has wrecked much of out of hours care - and the awful New Deal/EWTD that has badly damaged essential apprenticeship-style training. Simulated surgery is not the answer (I might return to that in another post).

The GMC did their bit by - in conjunction with the government - radiating an aura that doctors probably were not to be trusted after all, and the "presumption of innocence" rule in complaints and Fitness to Practice investigations virtually disappeared.  Read the heartfelt comments at the end of this piece on the GMC's own website.

Anyway, back to Clive. This 9 year old piece still resonates.

Get orthopaedics out of the ITU

They don't do well

When I was starting out we saw a lot of blunt polytrauma. A lot, sometimes with several badly injured people at once. It's much rarer now, and that's one of the many reasons to concentrate it in designated trauma centres, North American style.

Then we used to fix everything as early as possible, with plenty of 12 hour all-nighter sessions, which were fun in a masochistic way. You certainly felt you'd achieved something.

A few days later, in ITU, I would often wonder why, with lots of closed fractures, the patients got septic so easily, and why it was often Gram negative septicaemia. It kept them in for ages, if it didn't kill them

Which brings me to one of the most exciting (yes, I mean that) papers that I've ever read, by John Border, from the year before he died, 1995. Border explains it better than I can, with a chronological ride through 20th century trauma surgery. I once met a Swiss AO trauma surgeon who made his money as an expert in Nissen fundoplication. An alien concept to UK surgeons, but Border was also a general surgeon -  in Buffalo - who ended up as an AO expert because he was determined to improve the management of trauma victims. He succeeded.

21 years on a lot of this is established practice and the lactate champions see it as commonplace, but back then it was revolutionary: fix fractures so they can sit up, breathe and eat. A magnificent (and beautifully written) testament to a great clinican, surgeon and researcher.