Surgery as a zero sum game (Hadden's Law)

This is probably a historical law, rather than one that applies to current orthopaedic elective practice. It fits more with the days when the treatment for hip and knee arthritis was osteotomy and fusion rather than our zinging arthroplasties.

But.....

I have recently been reviewing detailed audit outcomes data from parts of elective orthopaedics outwith our gold standard joint replacements, and it's not such a pretty sight. I won't say exactly what it refers to, but essentially at 6 months and 1 year there's an approximately 30% patient dissatisfaction rate with surgery.

Is that good? Is it better than the natural history of the condition with conservative treatments? The trouble is that we orthopods are very self-critical. Our only rival in the life-changing elective procedure stakes is cataract surgery. A 30% dissatisfaction rate, I would hazard a guess, might be quite a favourable result in some other specialties. Breast implants, anyone?

Anyway, back to Hadden's Law. It is named after one of those rare surgeons who is not only a very fine clinician and operator, but also a mentor, in this case Bill Hadden, now retired, but one of the most humane and likeable surgeons that I have ever met. Neither Bill nor I are sure who invented it but it was he who introduced me to the concept nearly 30 years ago. It's straightforward:

For every operation you do that does good, award +1

For every operation you do that does harm, award -1

For every operation you do that probably makes no difference in the long run, it's zero

If, over the course of a list, a working week, month or whole career you're achieving a slight positive surplus, then you've done alright.

I know, I know, it sounds awful and nihilistic, and if you're knocking in Exeter hips all day you'll be very positive indeed. But look around you: is it completely wrong, even in 2017?

Early neurosurgery. They "all did very well" (thanks to Hieronymus Bosch)

Celebrity orthopaedics: U2

....specifically their dreaded singer Bono/Bonio. This is when he fell off his bike in Central Park in late 2014.

The talented trauma surgeon whom you can blame for Bonio's ongoing career is Dean Lorich at HSS in Manhattan. To quote the sanctimonious caterwauler himself: "The recovery has been more difficult than I thought. As I write this it is not clear that I will ever play guitar again."

Well he made it. Nice X rays, Dean

The Bonio distal humerus

An orthopaedic Christmas Carol, sort of

With a nod to Charles Dickens, this is about the ghosts of Orthopaedics Past, Orthopaedics Present and Orthopaedics Future. The reminiscences and reflections of surgeons late in their career or at retirement are a regular feature of this blog (label: wise surgeon). They really are  fascinating, and a treasure trove of useful thoughts.

This is Gordon Bannister, one of the best known British orthopods of the past 30 years, a very fine trainer and researcher, and generally a good guy, part of the Bristol centre of excellence.

He is no Luddite, but I draw your attention to a few things:

1. In the old days "senior consultant staff..had long since delegated acute trauma to their registrars. As a result, registrars acquired a wealth of experience". That's what happened to me much of the time. It doesn't happen now, which is both good and bad.

2. "At that time (the 80's) a 1:2 rota was common, occasionally tiredness ensued. The number of trainees increased whilst their experience declined". There is no way round this fact - you have to do the operations (and see the acute presentations) to get good. Most of my rotas were actually 1:3.  The promotion of the surrogate experience of 'simulated surgery' tells you how far things have gone. Note this from the former president of the RCS, Norman Williams. My view is that the New Deal has been even more damaging to training, morale and running a unit than the EWTD.

3. It was (and still should be) a lot of fun. If it consistently is not, then you may be in the wrong job.

4. I could not agree more that the demise of the true generalist to be replaced by self-anointed 'superspecialists' has been both stupid and damaging. It will be interesting to see what all the hip arthroscopy specialists will be doing in 10 years time.

Lastly, I would highlight the segment on NHS management and the conclusion. It's actually surprising how many empathetic and quality managers you encounter, but the long lasting damage wrought by the bad ones (and their political masters) is quite something.




(Thanks to BJJ News, September 2015)

Celebrity orthopaedics: Paul Stanley

Post THR exercise routine

One of my occasional pleasures is seeing how once youthful rockers grow old, get ill etc. I remember a picture of Rod Stewart coming out of a New York pharmacy clutching a large box of anti-inflammatories. A few weeks ago we had Joe Perry with his walking stick.

Well, here's Paul Stanley (65 last month), the guitarist with the star on his face from Kiss. He's an orthopaedic case history:

"What I do has taken its toll. I've had both my rotator cuffs surgically repaired. They're all similar to sport injuries. I've torn my meniscus in both knees and had a hip replacement. This is all from onstage performances. It's like doing a triathlon with a guitar around my neck. You have to jump, sing, swing your arm and play the right chord. With that combination, anything can go wrong. I used to jump up in the air and land on my knees. It didn't hurt then, but it does now."

He was 52 when he had his hip done. Last year he had a torn biceps fixed, with all the vital technical details:

Not only that, he identified the difficulty deciding whether to undergo a hip replacement in a tweet after bandmate Gene Simmons was critical following Prince's OD on analgesics for his hip disease (keep up):

As he said about his own decision:

"I wound up postponing my hip surgery and, you know, it's like reading in the newspaper your own death, you know, when you keep reading about your hip surgery, and I haven't done it, but I'm just postponing it for awhile. I have, you know, every intention of continuing doing what I've been doing, but little by little I'm turning bionic."

Interestingly Paul did have a complication - recurrent dislocation. Money can't guarantee that you avoid it. When I did private medicine I always felt my complication rate was slightly higher in the private sector. . It would be interesting to know what the salvage procedure was, because he looks like he's functioning at a pretty high level. Although...

"You know things did not go as well as they could have or perhaps should have. Hip replacement is major surgery yet it's fairly routine. It's done so often. The actual procedure has changed so much that you basically have the surgery and are walking that day. But there's a saying, minor surgery is what somebody else is having. This clearly was not minor surgery and the first one did not go well and kept pulling out or dislocating almost immediately. So within two months I went back and had it done again, which seemed to fix one problem and start others. The recovery has taken way longer and been more painful than I expected. It will never be great."


And that fits with the evidence that although patient satisfaction after dislocation soon catches up - if the hip is stabilised - the functional scores are frequently less than in the uncomplicated hip arthroplasty. 

I'm not a huge fan of Kiss, though I kind of like the whole trashy metal showbiz thing. Here they are in 2014. That's a 10 year old revision hip in a 62 year old you're looking at. Not bad.