The 654 year old surgeon

The oldies we quote are usually Hippocrates, Galen and folk like that. Here is a new one for me:

Guy de Chauliac makes some good points. It gets a bit tricky towards the end for some surgeons, perhaps. He appears to have been an early proponent of simulated surgery or skills labs, according to Wikipedia:

 "It was seemingly from books that [Chauliac] learned his surgery.... He may have used the knife when embalming the bodies of dead popes, but he was careful to avoid it on living patients".

Dead popes can't be easy to come by.

Bearing in mind the bafflingly poor knowledge of anatomy in UK undergraduates now, he makes another observation:

"A surgeon who does not know his anatomy is like a blind man carving a log"

I've assisted at operations like that.

Probably not peer reviewed. 

Orthopaedic heroes: the sage of Oswestry

Back in the day, about the time when the FRCSOrth examination changed from being voluntary, with a less structured format, to compulsory (though even then it was still a moderately agreeable experience), there were relatively few examination preparation courses. This was the mid 90's, and the main course, I would say, was the one run in Oswestry, overseen by a relatively small group of surgeons, one of whom was David Jaffray.

He was an eye opener to many of the attendees, for quite a few reasons. He had an unreconstructed North East Scottish accent, an unusually informal approach to meeting strangers ("is NAME REDACTED still ******** NAME REDACTED?" he immediately enquired when learning which hospital we'd been working in), a very caring attitude to trainees and patients, and he was an awesomely good teacher. Quite superb, and very funny.

An example might illustrate some of this,  I think I remember it accurately.  He'd been up for a job in the university department of orthopaedics at my hospital, quite a few years before, as Senior Registrar/Lecturer. He came up the day before, to have the standard look round, and try to meet people (still essential, by the way). In the course of this, he began to feel that he didn't particularly want the job. He probably hadn't met the cream of the department, to be honest, but I knew exactly what he meant. The trouble was, he was manifestly the best candidate, and was almost certain to get it offered to him. Backing out at this point was considered very bad form, and difficult to explain. As he put it "I realised that I had no choice. I had to sabotage my own interview". The next day dawned, and the interview panel was the usual mix of university, management, potential NHS colleagues, an external and so on. The questions began, and it came to the turn of the extremely famous and acerbic professor of general surgery, representing 'undergraduate education'. "Mr Jaffray, tell me, what would you suggest to improve our undergraduate course in orthopaedics ?"

I will pass you over to DJ's words, which I still recall: "This was my opportunity, I had to act fast. I looked at him and said firmly 'abandon it!' " This apparently did not go down too well.  "It did the trick. After that I had no chance".

Perfect. And there are lots of other similar anecdotes .

I can't say I knew him really, but we had the odd contact about trainees. He was unfailingly helpful and completely up to speed on all aspects of training, as well as being very frank. Ask around, the man is a bit of a legend.

All of which leads me to the short memoir he put into BJJ News, which is a pure and perfect gem.

If you read this blog, you'll see that one of its themes is the value of listening to the wise older surgeons, many of whom are both highly rated as surgeon/clinicians but also funny, smart and charismatic figures. There are lots of fine surgeons about. There are probably fewer really gifted  trainers. There are even fewer who combine the two at a very high level.

The paragraph on the right is a tad pessimistic , and I can vouch from my own experience that being ...er...candid  (as opposed to confrontational) is often welcomed by senior management who may be as sick of the daft aspects of bureaucracy as you are. Meeting colleagues face to face is nearly always the best way of dealing with issues. Beyond that, the whole article is laden with  reflections, wisdom, humour and practical tips, culminating in a profound final bit of maternal advice.

Read and learn!

Old farts may be correct shocker!!

From a recent BMA News (normally awful), presented without comment, other than to say: good points, well made.

True dat

Our orthopaedic ancestors

Could you think up an operation like this?

There are an awful lot of very good surgeons about these days. And of course we all consider ourselves at least slightly above average - I know, a statistician's nightmare - but how many great surgeons, or surgical pioneers are there?

Answer - not many.

So when you meet these people, or more probably, when you work with one of their previous trainees, you should cherish it and realise that you are indeed the recipient of significant accumulated orthopaedic wisdom. It is a privileged position,

In my own case I worked with Colin Howie, who worked with Robin Ling (Exeter hips for young readers), and I learned a lot. I also worked with David Rowley, who worked with Reg "not quite a genius" Elson, who worked with the ne plus ultra of hip arthroplasty, Sir John Charnley. In addition, David Rowley worked with John Insall on developing the next stage of the enduringly good Insall Burstein knee replacement. These are not negligible figures. I learned hands from John Dent who worked with Harold Kleinert  and  Graham Lister. I worked with Jimmy Innes who'd been a colleague of Marvin Tile and Robert Salter. I learned  a lot of trauma surgery from Jeremy Martindale, who worked with Chris Colton and the whole AO group. My own AO course involved Alan Apley (possibly the most natural teacher I ever heard speak), Maurice Muller, Hans Willenegger, Tom Ruedi and many more. I'm old enough to have met and heard lecture Bernie Morrey, Emile Letournel, Allan Gross, Gus Sarmiento, Charles Rockwood, Reinhold Ganz (a legend), Derek McMinn and quite a few others.

None of this makes me as good as these guys, but they are 'names' for a reason. Of course, I also worked with several outstanding surgeons who may not be quite as storied, but are just as great as surgeons, mentors, colleagues and teachers,

My point is this - treasure such encounters and listen to the details, the 'small print' of their lives and careers. They are potential treasure troves that will benefit you and your practice.

Most recently I met Diego Fernandez, the multilingual Argentine working in Switzerland, now in his seventies, and still working hard. He was charming and friendly - not everyone of these big names is -  and gave a marvellous talk on his life as a surgeon. Clearly brilliant technically, the unspoken messages were: be humble, think laterally, retain an interest in general orthopaedics, commit to a problem case, and have other facets to your life - in his case, incredibly, ocean surfing, still. Also, don't retire if you don't want to.

I mention Dr Fernandez partly because of this recent encounter, but also because of his influence on my practice. Let's face it, most of our reading - BJJ, JBJS, CORR, JArthroplasty, J Trauma etc etc - contains papers of some interest, but only very rarely something that changes one's practice. At the end of this post is Diego Fernandez' outstanding and exceptionally original paper on correcting post-traumatic problems of the distal radius, and doing it properly (ie. anatomically). Simply outstanding, and I use these techniques to this very day.

Graham Lister's comments at Harold Kleinert's death are what we would all like to have said about us, as surgeons and trainers: he had a profound effect on me as a person, on my career, and on how I approach the many problems we deal with in our discipline.

Cherish your orthopaedic lineage!

!!!!!!???????

This may be a dying problem, particularly if the admonitions of GO ASYP are not heeded.

Have you ever been irritated by a differential diagnosis in the notes, for a basically simple clinical  presentation, such as chest pain:

?angina
??MI
??? PE
???? reflux
?????Boerhaave's
?????? Tietze's syndrome

I could keep adding. It tends to be less of an issue in orthopaedics, rather than acute medicine and general surgery, if only because it's hard to look past a broken femur.

That said, Leo Gordon provides some rich examples, noting the history of punctuation, and the philosophy underpinning this nonsense. More usefully, he suggests punishments for this terrible crime. If I may add a few musculoskeletal essay titles to make offenders think before they do it again:

Discuss the public health debate regarding osteoporosis

Discuss the suggested 'treatments' for osteoporosis, and the evidence for their use

Discuss the similarities between osteoporosis and wrinkles

Discuss Camilla Parker Bowles' public statements on osteoporosis

I could probably find some more. Unlike Leo Gordon, I have fewer problems with exclamation marks, they rarely seem to be used in orthopaedics and trauma. We are a phlegmatic, calm bunch, ordinarily speaking.

However, if electronic records really catch on, I expect to see emojis all over them.  Perfect for that dislocated hip replacement.

My broken leg

At the morning trauma meeting, a closed spiral distal diaphyseal tibial shaft fracture was presented for tibial nailing. Working male, <25% displacement, good alignment, minimal shortening, no rotational deformity.

He was consented for internal fixation, with a nail. That is of course routinely referred to as informed consent, and if you're being appropriately thorough (not pedantic), the information required to make a balanced decision would have included the pros and cons of conservative treatment in a cast or brace. Traction, external fixation, plating are all in the mix, but lets stick to conservative v nailing.

Is there any published evidence worth having?

Why, yes there is.

What do you think the incidence of knee pain is after tibial nailing? Patients frequently mention it, and it can be a real problem. 10% would be OK, 20% perhaps. Well, in a very good study from Vancouver's ace trauma unit, of 56 patients at a minimum of 12 years, it was 73%.  That's knee pain, related to the nail, not fracture site pain. Of course, there are quite a few other potential problems with surgery and anaesthesia.

OK, there are still plenty of arguments for nailing, but I actually knew one surgeon who put circular frames on instead of nailing, because of anterior knee pain. A little extreme, but it makes the point. Here's the Vancouver paper.




But is there any good evidence for conservative treatment in this group of isolated fractures?

How about nearly 1000 patients treated with early functional bracing? Sarmiento's study is pretty impressive, with acceptable angulation, shortening and union rates. I won't go through it all, read it for yourself. Not the same follow up, but the point is, while each treatment has its own advantages and disadvantages, they are both valid, and should both be available to the patients. We have emphatically not 'moved beyond' tibial bracing because of our brilliance at tibial nailing.



For what it's worth, in these isolated  closed fractures, I would indeed fix those with an intact fibula - they nearly always angulate too much - and the very comminuted ones, plus the compartment syndromes. Everything else is up for discussion. Nailing is often 'fix and forget', and casting/bracing is not necessarily easy, but that's not the point. I've seen plenty of complications of nailing. It's not always in the patient's best interests.

Back to the trauma meeting. No-one seemed able to quote  a paper on either treatment. When asked "what would you have done if it was your tibia?", only one person spoke up. It was the anaesthetist, who'd had a problematic infection after orthopaedic surgery.  "Stick it in a cast" was her response.

And if consent was truly informed, a few other patients might well join her.

I always fix them in polytrauma, personally