The earthquake dislocated my hip replacement

When I was training, one of my distinguished bosses, an academic, used to tell me about one of his trainers back in the 70's who used to listen to the occasional patient in the clinic who'd not had a good outcome. He'd acknowledge their unhappiness, and indeed, empathise very effectively. When the frustrated patient eventually left the consulting room, he'd turn and face his registrar (my boss) and say sadly:  "funny fellow that".

The moral of the story - as it was emphasised to me - was never blame the patient.

Own your own mistakes and bad results. Be brave, dig deep. Good advice, I suppose.

Later, as my boss approached retirement, he'd show me an X ray - often of a knee replacement who'd got some residual pain - and say something like "I can't see much wrong with it. He's a strange fellow though. You never succeed with people like that"

For any one case he may have had a point, but he'd forgotten his own advice. Never blame the patient.

So blame can be an issue. Not in the medicolegal sense, more in terms of peer respect and apportioning embarrassment. Maybe that patient fell because your hip replacement dislocated, rather than your assertion that it dislocated because they fell. We're only human after all.

So in the spirit of making excuses for cock ups, I give you a short video of a  handy set of excuses for the next time you have had a hand in a surgical complication.  One of them will apply, I'm sure.

Parachutes and the pelvis

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That old saying, that an X ray is just a 2-dimensional snapshot of what actually happened, is true.

When the acetabulum fractures, the femoral head may have been halfway across the inside of the pelvis before it bounced back to where it sits on the X ray, to give one example. The injury is everything that got damaged then, not just what that 2D X ray shows. The average pilon fracture is equivalent to a small explosion in your ankle.

Most of this less obvious damage is soft tissue of course, hence the appeal of Oestern and Tscherne's slightly clunky classification of soft tissue injury, as a counterpart to Gustilo in open fractures. It seems fairly accurate, but does anyone actually use it?

A lot of pelvic ring fractures and related injuries are essentially internal dislocations of the pelvis through the symphysis and SI joints. They spring back usually, even the vertical shears to a large extent, but can you imagine what it's like at the moment of injury?

Well, imagine no more.

A big hit at the moment is Admiral William McRaven's very short and readable set of life lessons, expanded from his speech to graduates at his alma mater, the University of Austin, Texas. Rest assured, it's not a mindfulness manual. McRaven was the chief of the US Navy SEALs, and ran the operation that took out Bin Laden.

In fact it's not unlike Leo Gordon's matrix lessons, a staple of this blog.

The more general point that McRaven is illustrating with the following excerpt is that we all need help sometimes, and success in something is rarely down to ourselves alone. He describes his very tough rehab after what I think was a very bad 'open book pelvis', which happened in midair. Honestly. His description is pretty vivid...





....the book is genuinely worth reading. This particular episode confirms what we don't know from discharging people three months after injury, but one does rapidly learn doing medicolegal reports - all trauma has rehabilitation challenges, and many injuries leave you with lifetime symptoms, long after your injury has officially 'healed'.

Celebrity orthopaedics: Gabriel Batistuta, Marco van Basten and a disquisition on pain

Here's a scary description:

I left football and overnight I couldn’t walk. I wet the bed even though the bathroom was only three meters away. It was 4am and I knew if I stood my ankle would kill me.I went to see Doctor Avanzi (a world-renowned specialist in Orthopaedic trauma) and told him to cut off my legs. He looked at me and told me I was crazy.I couldn’t bear it any longer. I can’t put in to words just how bad the pain was.
I chose the right leg (to be operated on) as the doctor couldn’t do both.I didn’t care. My problem is that I have no cartilage or tendons. My 86 kilos are supported by bones alone. That’s what generated the pain.

And here's the author of that description, in action, wrecking his ankles, for our benefit...



Batistuta was probably the best striker of his day, and one of the best ever. If I can quote from the well known biting South American striker of today, Luis Suarez:

The ultimate? Gabriel Batistuta. He was a spectacular No 9 - great at finding space, shooting from outside the box, good in the air. He was always a reference for me and I used to watch the way he played. He took free-kicks as well. I don’t get to take them here! (laughs) but I’d copy him and watch videos of him all the time.

I agree with the sharp toothed Uruguayan. Not only was Batistuta an awesome player, he was a modest appealing person, who always looked super cool. He scored 300 club goals, and 56 for Argentina in 78 games, which is better than Messi.

However, he was wrecking his ankles. He had numerous steroid injections to get him through, and they probably didn't do him any favours in the longer term. 

The assessment of pain severity is one of the hardest things in orthopaedics - one man (or woman's) agony may be another's "well it hurts but I try to ignore it", and yet it's the basis on which we offer complex operations with significant complications. 

Most surgeons would recognise the claim "I have a very high pain threshold, doctor" as probably meaning that the opposite is true. For what it's worth, I never use the VAS 1-10 scale. A waste of time. However, Batigol's description is pretty good, as is (most of) his understanding: My problem is that I have no cartilage or tendons. My 86 kilos are supported by bones alone.

It sounds to me like he had an ankle fusion, not, note, an ankle arthroplasty. He had "two screws surgically placed into his ankle to help alleviate the pain and support his movement" and the outcome?  "Since I’ve had the screws put in, I’m much better now than I was three years ago.” 

"I left football and overnight I couldn’t walk", rings true. Batistuta actually had a long career, 1987-2005 at the top level. I've seen quite a few professionals with completely wrecked knees play into their mid-thirties by limiting training, watching their diet, NSAIDs and probably most importantly, great positional sense. They run about that bit less. When they stop playing though, it goes downhill quickly.


Everyone thinks of knees, with ACL's and menisci, when considering sporting injuries, but ankle problems prematurely wrecked the career of all time Dutch great Marco van Basten, although worringly, he blamed the surgeon. He also appears to have had a fusion, he certainly had bone fragments removed from the joint, back when the unnamed maligned surgeon was trying to salvage things. When the weight bearing surface area is as small as it is, then you know that's going to be associated with major problems. I've done hips and knees on relatively youthful ex-footballers, who still play in kickabouts with no problem. Ankle fusion is not that good, but it's not bad either.

In case you're wondering how good van Basten was...




Here is van Basten's description of his pain. Not dissimilar to Batistuta:

After three years of pain I wanted a normal life again. Just imagine feeling pain every minute of the day, somewhere in your body. And that for three years! It dominated my life. From my ankle the pain bounced back into my whole body. As long as there's still hope you can still recover, you're willing to accept the torture, but after so much treatment and so many medical experiments I finally realised I was running up a dead end street.

And the outcome?

Now I'm glad I made the decision, because I'm finally free of pain and I'm dealing better and better with my handicap

It all goes to show how lucky we are that knee and hip replacement are so good. These other procedures don't really come close, but it's all about the pain.

Remember kids, low impact activities are best when you're old