Orthopaedic art: the ARCP**

Goya: Saturn devouring his son, 1823. Museo del Prado, Madrid

**for non-British readers, the ARCP is the Annual Review of Competency Progression. Nothing to be afraid of. Definitely not.

Alt.orthopaedics: seal clubbing edition

A number of years ago I was in a teaching session with one of the UK orthopaedic greats, Richard Villar, who was the first person that I heard voice publicly what we had all begun to realise, "let's face it, our knee replacements, overall, are just not quite as good as our hip replacements".

He was right, and mostly it was not to do with surgical technique. Like with so many operations, success is predicated on good patient selection. Dissatisfaction is in up to 25% of patients, seriously.

By a poor outcome I don't mean infection, PE or any of the 'standard' complications. I am referring to - as was Ricky - the patient who is never quite satisfied with it, they have chronic non-mechanical pain, it "just doesn't feel right".

If only we could identify this group preoperatively. It would save them (and us) from considerable stress and disappointment.

There have been some valiant efforts. Our Edinburgh colleagues have produced quite a few papers on outcomes, looking at age, concomitant back pain, rather loosely defined 'surgical factors', mental disability, preoperative patient expectations, and 'general physical well being'. With all this data, does that mean we should refuse a TKR to someone with definite pain and severe arthritis, who unfortunately is a male under 55 years with back pain, poor mental health, not in great shape, and who has an expectation that TKR will solve everything?

The objective answer might be 'yes', but when you're with them in the clinic, it's not that simple.

Some Korean surgeons carefully reviewed all this in 2016, and with reference to the vexed issue of personality, stated the following:

Gong and Dong (27) retrospectively investigated the relationship between the outcomes of TKA and patient's personality classified into 4 types: patients with extroverted personality were more satisfied than those with introverted or anxious personality after TKA. In our opinion, however, the influence of personality on the outcome of TKA is not straightforward to determine due to the difficulty of categorizing various human personalities.

They have a point.

...oh dear

What to do?

Well, one of my esteemed colleagues, whom I will refer to as TBN, had been chatting to one of the more senior trainees about this conundrum, and they came up with the following suggestion. See what you think.

If in the outpatient clinic you have decided that someone might benefit from a TKR, they get directed to a separate cubicle, where they watch a video. It shows an Inuit in a snowy barren waste, and before him lies a seal, which he is beating to death with a heavy stick, assisted by a harpoon.

If the prospective TKR patient cries out that it's appalling and no animal should be subjected to that, then you might be better off with a Pain Clinic referral.

If, on the other hand, they say that he's just getting his tea, and in addition he could probably use a warm coat and some new boots**, then they can safely be added to the TKR waiting list.

Clearly this would need to be studied prospectively with an appropriately sized cohort***, but the technology is already there. It's already better than banning people because they're a bit overweight.





**Wikipedia: Traditionally, when an Inuit boy killed his first seal or caribou, a feast was held. The meat was an important source of fat, protein, vitamin A, vitamin B12 and iron, and the pelts were prized for their warmth

***There's already evidence that CBT (Cognitive behavioural therapy) can play a role in improving outcomes of bariatric and spinal surgery. A cure for catastrophising?