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)