But I like doing uncemented...

The title of one of the worst films ever to achieve fame is the same as one of the best papers I've read in the last few years. It's in Bone & Joint 360, and it takes a careful, evidence based and pragmatic look at the use of uncemented total hip replacement in the NHS. It's not particularly pretty reading.

Put simply, it's not possible for uncemented hips to achieve better survivorship than the Charnley or Exeter, partly for statistical reasons (you could never have a study with adequate statistical power, unless we all start living to be 130). There is no evidence of better function - unlike, say, the much maligned resurfacings. There is evidence of higher complication rates - pain, leg length discrepancy, dislocation, periprosthetic fracture. Generally speaking they cost more. There is no consistent evidence that because you can in theory do them more quickly, you'll do more on a list. Not in the NHS anyway.

So why do them at all? Obviously they're great for many revisions, and there are specific cases - awkward anatomy, femoral shortening, the very young - where they make sense. There are quite a few uncemented stems with great survivorship, although not better than the cemented rivals.

If they're not being done for clinical reasons, or because they're cheaper, then it must be because the surgeon says so. Not ideal really. The UK still has a predominance of cemented stems, because of hybrids, but the commonest single combination is uncemented, albeit it's coming down slightly. Bizarre. Here's the NJR data:

And here's the Inconvenient Truth, followed by a short film on how to put them in:

The metaphysics of nursing (part 1)

I am very specific in my clinical instructions. I frequently write them in by hand on the ward round, always in theatre, the drug kardex etc. I speak to the relevant staff. I don't rely on people reading my mind, or following "that's what he always does". There are always important exceptions cropping up: if they already take aspirin I don't want them on rivaroxaban and aspirin; if I very occasionally want 'none weight bearing' I make it clear.

But...

....after a complete, documented and thorough ward round I will frequently get bleeped 10 minutes later to be asked if a patient can mobilise. I will find patients being sent home on subcutaneous heparin injections - which I never do. The wrong consultant's name will remain above the bed despite daily requests to change it. There are many, many examples.

This is one of Leo's funniest matrix lessons, he really gets going in the second half. It touches on metaphysics and welding. It is also entirely true.

The Surgical Gods

Cancel this case!

Much as I would like to think otherwise, I am not a surgical god. In fact, I don't know any, but they do occasionally get in touch. This is a genuine warning in practice, call it the subconscious if you will.

Any surgeon who's done enough operations will be aware of a rare feeling that something isn't right. You want to feel this before you start the case.

I can't put it any better than Leo Gordon. There are lots of orthopaedic examples as well as generic ones. "Why am I removing this humeral shaft plate?" is one that springs to mind.

Cancelling a case is not the worst thing in the world.

Verify it yourself, get the old notes

How often have you, as a clinician, either been told a dud bit of information - or conveyed one- when discussing a clinical case? We probably all have. It's the equivalent of idle chit chat, which in gossip can cause emotional and other harm, but in clinical care it could kill. Such misinformation has almost certainly lead to doing unnecessary operations, tests etc

I had a patient who kept getting put on theatre lists for 'wound excision and exploration'. He had been labelled as a case of pyoderma gangrenosum for years, by various doctors, including dermatologists. This 'clinical meme' had stuck to him. He quoted it himself. He certainly had intermittent cutaneous sepsis, but PG is a very specific condition, the treatment for which includes immunosuppression, which no-one had quite got round to. It all seemed very unlikely to me. It certainly wasn't a classical presentation.

So I got the old notes - they were pretty thick. The meme had been repeated on many occasions, but never proven. No histology, no test of treatment, yet here he was continually turning up and getting listed for surgery for possible deep infections, with this impressive label stuck to him. The notes told a long and confusing but very helpful story, if you took an hour to read them.

I sent him back to see a new, very thorough dermatologist. No evidence of PG. It turned out to be self-inflicted, AKA dermatitis artefacta. A completely different sort of problem.

Likewise, if you do a lot of revisions (I do), you will encounter plenty of patients who have undergone multiple surgeries - occasionally into double figures - with different implants, approaches, rationales etc. There is no more useful exercise in planning treatment than summarising the relevant old notes and imaging - often going back years - and sending a copy to the GP. Clarity is everything here. It can be extraordinarily revealing. It's one reason why when I first meet a patient with a problem joint replacement one of my first questions is: why was this done, did they ever have painful arthritis in the first place? That may sound daft, but it is incredible how frequently the answer to their dissatisfaction lies in a poor original decision to operate.

So back to our wise surgeon, Leo Gordon. The Four F's are a bit outdated, and there's a mention of something called the World Wide Web, but this is the voice of experience. Get the old notes!