Achilles, Pascal, Occam, TUNC and Bonini

In the world of eponyms in surgery - Monteggia, Fournier, Chiari etc - I actually prefer the non-medical ones.

There is, for example, Achilles' Dilemma in hip resurfacing  ("to choose whether to live a short and glorious life or live a long and boring life"); Occam's Razor in diagnostics; Pascal's Wager in avoiding hip dislocation (just use an elevated lip - there is no down side). In case you're wondering, TUNC theory is an acronym not an eponym, for any confused readers.

Here, though, is a new one for me. Bonini's Paradox (courtesy of Kevin Williamson, writing on US politics).

Let us consider hip replacement first. A sphere sits within a hemisphere, as a near perfect fit. It can move freely in any direction for everyday function. It has intrinsic stability by nature of its shape. It is a fairly accurate facsimile of a real hip in many ways. It is a simple design philosophy, if subject to highly sophisticated manufacturing. It is very forgiving in practice, if you put it in slightly askew.

Not so knee replacement. Here there are several radii of curvature in coronal and sagittal planes, not one. A highly complex ligamentous arrangement ensures stability and translational movement. The lateral tibial plateau is smaller in life than the medial side. The lateral plateau has convexity. The shock absorption from the menisci varies between the two sides. Yet the knee prosthesis has a symmetrical biconcave tibial plateau with no difference in impact resistance, no benefit from the cruciates (except in those cruciate retaining cases with a pristine PCL), and relies on a difficult-to-consistently-get-right 'balancing' of the intact collaterals. It is a very unforgiving scenario, so no wonder that pretty much everyone admits these days that knee outcomes are poorer overall than those from hip replacement, particularly in high activity patients.

Attempts to make more complex knee replacements incorporating these issues have generally failed, with either poorer results or at best, unpredictable ones. It's not been for lack of trying by implant companies (1, 2).

Back to Bonini, who is a business professor at Stanford University, looking at reproducing complex systems, for example, a computer model of the brain:

And this is Bonini's Paradox: The less information a model carries about its subject, the less useful it's going to be in helping someone understand that subject. And yet, the more information a model carries about its subject, the less useful it's going to be in helping someone understand any single point of that subject. Any sufficiently detailed map of a region is going to be just as dense and difficult as the region itself. Any sufficiently detailed model of a brain is going to be a brain.

...and any sufficiently detailed model of a knee is going to be a knee. Wikipedia quotes French poet and philosopher Paul Valery, with a similar take, from years earlier in 1937: "Everything simple is false. Everything which is complex is unusable."

Indeed, a hip replacement is undoubtedly 'false', but it nearly always works. A more complex knee replacement is also false, but it just edges a little bit along the spectrum towards unusable.

Another quote from the Gizmodo article already cited: Any model, of anything, is in an act of editing. It picks out what we think is important regarding the subject, and directs our attention to how that important thing can be manipulated.

Even orthopaedic surgeons aren't gods. I suppose

...OK, everybody got that?

Classifications are often rubbish

I used to pride myself on knowing lots of orthopaedic and trauma classifications. Many of them still provide a useful lingua orthopaedica when discussing cases, a few - such as Lauge-Hansen - definitely guide treatment, and a lot of them eg femoral revision classifications, are usually fairly pointless for me in practice, much as I admire their authors

I gave a lecture on revision hips where I introduced a new classification - at least I'd not seen it used in this way before. I actually do use the broad categories, say for the acetabulum, where cavitary bone defect, rim defect and pelvic discontinuity, do have some sort of practical meaning. But I definitely prefer this one, which I presented  at a lecture in Budapest in 2007. A year later I saw someone - who'd been in the audience - repeat it word for word, without due credit. Such is life.

Here are the slides from that PowerPoint (with the odd redaction):

Anyway, I mention it because I saw of of my pet hates suitably challenged recently, on Twitter of all places. The pet hate is the question that it seems all medical students are routinely taught to ask: "on a scale of 1 to 10, how bad is your pain?"

I have never used this stupid question in practice, as it is almost a definition of why we're advised to avoid non-parametric data in research. It means almost nothing in every case that it's used. I've seen it asked, and more than once heard the sullen deadpan reply of '11'. Of course. Probably just after the phrase "I have a high pain threshold you know, doctor, but..."

So I was delighted to see the following, made available by cancer survivor and wit, @TeaLady24. It just needs to be provided in a wipe clean laminate (with the numbers removed), at every outpatient clinic. 

"...just point to the one which represents your feelings best..."

genius, in it's way (click to enlarge)

Heraclitus and the European Working Time Directive

Here's a post from a guest author - a highly regarded NHS stalwart - who is nearer the end of his consultant career than the beginning. A role model, no less, if you aspire to be a great orthopaedic surgeon without losing your humanity and affability. I haven't identified him, intentionally, but he's not me. 


He's responding to a post in the BMA news. There's lots of this stuff out there (1, 2, 3, 4, 5), and I even blogged on it myself.  See what you think. By and large he's right - this is real world medicine from a real world expert.


Front Page of BMA News:     

“One I am terribly sorry to have to say this but we have to train our young doctors to be prepared for life in the real world and not for life in some utopian fantasy land. I agree that the life of a trainee is less satisfactory nowadays than it was in the 1970s and 1980s where although hours of work were much longer and more arduous, and pay for overtime was only 1/3 of the basic rate, and when you could be on call on a 1:2, 138 hours in a week, you were valued, cherished, appreciated, helped by your seniors and by experienced nurses. You would live in the “Mess” with fellow housemen experiencing the same joys and hardships. These times have gone. 

At that time Housemen and Housewomen were expected to take on, and did take on responsibilities that our current young doctors would baulk at, but it prepared them well for the future. I fail to see how “sleep deprivation” can possibly be a problem in a situation where our trainees work shifts and never work more than 48 hours average a week. These are young, generally healthy, men and women.  Why should they be any less able to deal with a bit of hard work than we were? 

We have gone too far in our efforts to adhere to European Working Time Directives especially when those who travel in Europe and elsewhere know that the trainees there (in common with trainees in America, Australia, Canada and New Zealand) work much longer hours without complaint as they realise that it is the only way to become experienced enough to deal with the rigors of a senior appointment. 

I had the unedifying experience of hearing young trainees described as “Babydocs” by someone in our Deanery which I felt was not only demeaning to the mature men and women who had spent 5 years at University and another year as an FY1, but indicative of the lack of insight in our educationalists who do not begin to appreciate that the sooner someone stands up and takes responsibility for their own actions, the better equipped they will be in later life to deal with the difficult decisions that come to all of us. 

Medicine is not an easy job. People who can’t manage to cope with the stresses and strains, with the long hours and challenges may be better to be advised at an earlier stage to consider an alternative career."

The great man has just looked at the New Deal regulations...

You may think it's harsh, the voice of an old fart, perhaps, who doesn't get the groovy new way of doing things. I'm afraid though, that some aspects of medicine don't change. Two of our most effective operations today, for example, were practised by Hippocrates and his pals, in not dissimilar ways to our current techniques - amputation and draining abscesses. 

Note that part of this relates not to service delivery or alleged risks to patients from 'tired doctors', but to the happiness and job satisfaction of the medics themselves. However physically and mentally challenging work has been, there is immense satisfaction from having done it and done it well. A point neatly encapsulated by another experienced medic, Theodore Dalrymple, in a classic Spectator piece:

No one wants to be treated by a dog-tired doctor, but even less does he/she want to be the parcel in the medical game of pass-the-parcel that is now commonplace in our hospitals. The European Working Time Directive has transformed doctors into proletarian production-line workers, much to their dissatisfaction with their work and to the detriment of their training and medical experience. It means that doctors no longer work in proper teams, patients don’t know who their doctors are and doctors don’t know who their patients are. The withdrawal of the directive would improve the situation.

Medicine in general, and surgery in particular, is ruled by Eternal Verities**, whatever the New Deal, the EWTD and the BMA say. 

  **although he didn't invent the term, Greek philosopher and writer, Heraclitus, from about two and a half thousand years ago, was the father of the Eternal Verities. He realised that reason and wisdom are what leads to contentment, with all the moral, metaphysical and religious implications that might flow from that. Somewhat more profound than complaining after not getting a mandatory 30 minutes break following 4 hours of work (or whatever this week's formula is).

Naaman orthopaedics: avoiding the complex option

Ferdinand Bol, Elisha refusing the gifts of Naaman, 1661. Rembrandthuis, Amsterdam

Most orthopaedic surgeons are renowned biblical scholars, so they will be aware that the earliest example of "keep it simple, stupid" in medicine, was probably in the Book of Kings in the Old Testament, so around 600 BC.

The story in question is that of Naaman. A recap:

Naaman was a general in the pagan Syrian army, and a confidant of the king. Unfortunately he was also a leper, a big deal then (and now). he happened to have a slave girl who was a captured Israelite, who pointed out that back where she came from - Samaria - there was a prophet who could cure him, Elisha. As nothing else had worked, Naaman went for it. He loaded up with gifts and a fancy retinue, and headed south. His first mistake was to go to the king of Israel, who got mad when Naaman quizzed him, on the reasonable grounds that he couldn't cure leprosy, so the Syrians were clearly at it.

Elisha got wind and sent a message to have Naaman visit him. So the whole convoy ended up at Elisha's place. I'll let the scripture take over here:

Elisha sent a messenger to him, saying, “Go and wash in the Jordan seven times, and your flesh shall be restored to you and be clean.” 11 But Naaman was furious and went away and said, “Behold, I thought, ‘He will surely come out to me, and stand and call on the name of the LORD his God, and wave his hand over the place, and cure the leper.’ 12 “Are not Abanah and Pharpar, the rivers of Damascus, better than all the waters of Israel? Could I not wash in them and be clean?” So he turned and went away in a rage.

I can understand it, I suppose. However, the unnamed slave girl was not impressed:

“My father, had the prophet told you to do some great thing, would you not have done it? How much more then,when he says to you, ‘Wash, and be clean’?” 

So he did, and it worked. No more leprosy. And I believe that the long term clinical outcome remained satisfactory, although I don't have the PROMS data.

Thank you for sticking with me this far. Why does this matter in orthopaedics? Well, here are a few examples:

1. The CSAW RCT showed that operating on subacromial pain was not really any better than not operating

2. The PROFHER trial, even at 5 years, showed no benefit in operating on proximal humeral fractures than not operating (I accept that there will be some self-evident exceptions to this)

3. The DRAFFT RCT found no benefit of locking plate fixation over MUA and K wires for distal radius fractures (I accept that there will be some self-evident exceptions to this, too)

4. (my favourite) Complex, expensive and fiddly revision femoral stems are no better than the unfashionable monobloc ones, which are also much easier to use. Modular may also have more implant specific complications.

I am very far from being a surgical Luddite, nor do I tend to favour conservative management - although it's a skill we need to teach more in certain areas. But...

...there is no intrinsic merit in complicating treatments, although there are many intrinsic potential risks.

Alt.orthopaedics: 10 things I hate about you

Orthopaedic surgeons are well known for being romcom fans, of course, so it seems appropriate to reprise the title of one of the more adventurous examples of the genre - given that it's a straight lift from Shakespeare's Taming of the Shrew - which is 10 Things I Hate About You.

This post derives from a recent conversation with consultant colleagues from various other hospitals, the chat turning to the most annoying habits/traits/actions of trainees. We're not saints ourselves, we know we annoy, frighten and upset our trainees occasionally - no gain without pain etc.

In fact we love our trainees, really, but sometimes you end up meeting situations that are really, really annoying. It's best to know these things, both to amend one's errant behaviour now, if as a trainee you recognise yourself in the list, or just as importantly, to prepare yourself for the weighty responsibilities of being a consultant, and having to yourself nurture the delicate talents of future generations.

Please note, any trainees/residents who read this, I am very happy to publish your Top 10, 9, 8  whatever, things you hate about consultants, attendings etc. Just get in touch or add something in the comments

So, in no particular order:

1. Inappropriate familiarity

I don't think most surgeons are too up themselves. Friendliness and camaraderie are by far the commonest features of the trainer/trainee relationship, in my experience. Most trainees recognise that there is an assumed (and inevitable) hierarchy, and that it's there for a reason. One day they will sit at the top of it. Not all trainees seem to get it though. The famous incident that springs to mind relates to a shoulder surgeon painstakingly dissecting in the axilla in an unusual and complex trauma case. As the axillary vessels came into view, with the theatre atmosphere quiet and a little tense, the trainee exclaimed "...whoah! Easy there, tiger".

Not good.

2. Obsequiousness.

It doesn't hurt the patient, but boy, can it be irritating. My favourite example is the experienced and highly regarded surgeon who'd been pestered by a visiting surgeon in the department to allow him to scrub in, to which he assented, out of courtesy. The visitor's attitude was grovelling from the start, larding praise on unremarkable observations in a particularly annoying way. The nadir came early, when after starting a standard total knee replacement, the visitor lavished praise on the execution of the incision.

Too much. Way too much.

3. Telling the surgeon how other people do it

Actually, all of us gain the odd pearl from our trainees, based on what they've encountered elsewhere. Indeed, it can add to the camaraderie.

But...

Some trainees have a tendency - possibly induced by nervousness - to spend operations telling the boss how someone else they've come across does the procedure. It doesn't matter that you're the world expert with thousands of cases under your belt, they're still going to persecute you with tidbits that frankly you don't want, nor need, to hear. Reps do it too.

My worst ever offender had done 6 months in a bone tumour unit. It's amazing how virtually every procedure has a bone tumour link, if you try hard enough.

4. Tiredness

Actually, I've never had this happen to me, but there have been occasions when during a busy on call the boss asks the trainee if they'd like to do the case and they reply, something on the lines of "not really, I'm pretty tired". It may be true, it may even be 'prudent' (on dubious safety grounds), it may have the virtue of candour.

However, it is highly unlikely to make your boss admire you more.

5. Not taking advice (or instruction, as it's otherwise known)

If I say to the trainee, this ankle fracture would benefit from a stronger plate such as a  DCP on the fibula, and a syndesmosis screw (a real example), it is only in part a fascinating clinical discussion. It is also a not-very-coded instruction to actually do that. When the postop X ray shows a third tubular plate and no syndesmosis screw, it creates mysterious feelings of anger and disappointment. When, on questioning, the trainee says that they did it because an even more junior trainee said "that's all it needs", these feelings well up and may lead to unpleasantness.

If you decide not to follow instructions, then let your boss know at the time. Another interesting discussion will ensue.

5. Economy with the truth

A phrase which reached maturity in the heady days of the Thatcher era. It does not sit well in clinical practice. An example will suffice:

Trainee arrives late for the first theatre case, but seems to be expecting to do the operation...

"Why are you late?"

"I was at the trauma meeting"

"I didn't see you there"

"I was on the ward"

"Oh, what was Mrs Smith's last haemoglobin?"

"...er...12.5"

You know where this is heading. The wretched trainee had not been in the trauma meeting, on the ward, or seen Mrs Smith. There is no need to lie, as it's normally called. But once you do, you will easily be found out, if your boss can be bothered. Your card is marked. You now have a (deserved) reputation. Being late is a far lesser crime than lying.

6. Picking on underlings.

One Saturday night, in the middle of a weekend on call, a Junior House Office (F1 doctor in today's money) knocked on my office door, and was weeping profusely. She stated that she'd had enough, and was quitting medicine. This had two effects on me at the time. One was a genuine sympathy given the real distress that she was feeling. The other was the annoyance at being landed with a problem of this kind at the wrong point in the week. What had happened to her?

Well, as is often the case in acute surgical practice, a patient had become profoundly unwell postoperatively. I forget the details at this point, but she'd struggled with both diagnosis and initial management, and had called the registrar, quite correctly. He quickly sorted things out then had a go at her, concluding with the stinging rebuke "you nearly killed this patient", which wasn't remotely true. He had major self aggrandisement traits, average surgical skills, and a tendency to be jovially matey with the consultants. Wrecking his colleague's week was meat and drink to him. It wasn't the first time.

Another example. The urology registrar wanted the image intensifier for calculus removal, fair enough.  However, the radiographer was just about to start a hip fixation, and the urologist wanted to get home (this was a Saturday morning). His next tactic, with the 'lowly' radiographer? "If my patient suffers because of this delay, I'll make sure that you're sacked!"

I had no idea the lad had so much power. Typically though, when I phoned him to point out his 'behavioural issues', he turned into full grovel mode, and claimed he was just worried for his patient. Of course he was.

As the saying goes: The same people you misuse on the way up, you'll meet up with -  on the way down




7. Not visiting the bedside.

This got a whole post devoted to it. The problem is getting worse. Recent examples include: a patient with back and leg pain, previous disc prolapse and intermittent difficulty in peeing. The neurosurgeon, busy playing the odds, said at the end of the phone "doesn't sound like a cauda equina problem". He didn't come to see the patient. Another: possible necrotising fasciitis (treated mortality ~ 25%, untreated mortality ~ 100%) in an oncology patient (not an 'orthopaedic' problem in our hospital), the plastic surgeon said "it's cellulitis", we're not seeing it. Ho hum.

Read the post.

8. Complacency.

In the UK, if you get an orthopaedic training job in what is called 'run through training' - for which the competition is fierce - then you're set up for 8 years, barring death, emigration, imprisonment, or possibly, these days, a new career in reality TV.

This happy state does have some negative consequences, however. Here's just one example. In the days when you had to reapply for a job after three years you might be trying harder to impress. In my case this would mean that after two years as a registrar I would (reasonably) expect a trainee to know all the common fracture classifications, apply them, and discuss the 'classic' papers (eg femoral nailing: 1, 2), plus the most recent journal stuff of note. That will all come from self learning, which with the internet is easier than ever.  And it does happen, sometimes. Often as not though there'll be blank looks at the trauma meeting. People tend to view this stuff as exam preparation - which it is - as opposed to helpful in practice - which it is as well.

Complacency actually stops people from discovering what a treasure trove the published literature - old and new - actually is. If you don't know the Lauge-Hansen classification after two years of training jobs, you are officially complacent.

9. "Yes, I know how to do this"

Actually quite a nuanced complaint, raised by an esteemed colleague. When a trainee is starting out with a new boss, however experienced the trainee is, there will still be things you can learn (good and bad). Therefore when, at the start of your first lists together, your boss says something like "can you do a knee replacement", an answer along the lines of "yes, no problem" may in fact be counterproductive. Particularly if the boss is fairly expert in the procedure.

Far better to say that yes, you've done quite a few, but there's always stuff you can pick up, and it would be great to assist in the first instance, to see how the boss likes it to be done.

A small distinction, you might say, possibly even pandering to someone's surgical ego, God forbid. But one of the greatest virtues you can take into your burgeoning surgical career is humility. For lots of reasons.

10. Ingratitude.

The state has probably trained you in medicine to the tune of about £250,000 (for UK readers). After that you've been paid well, with years of job security,  and you are possibly on the way to become an actual expert, courtesy of the taxpayer. People have let you practice on their bodies, potentially to their detriment. Unless you royally screw up, the chances are that you'll have guaranteed and well remunerated employment - with a handsome pension, paid sick leave, study leave, maternity/paternity leave, parental leave - for 20-30 years.

Not bad, eh?

So when you reach the consultant pinnacle, it doesn't look that great, when you either:

a. Declare that you don't do procedures X, Y and Z, even if they work and are needed in the population you serve, because you only want to do procedure A. This is often dressed up in a spurious 'safety' argument. It is a common example of entitlement, a harbinger of troubles to come.

b. Disappear into private practice.

Seriously, spend a few years honing your general skills, getting peer credibility and respect, and gradually establishing an authentic subspecialty expertise. It's only fair.

...this is what it was like in the 1980's, kids...

Old farts strike back: surgery and bible edition

...obviously not ALL the old stuff is good

If I may get biblical,  from the Book of Job, 12:12 - With the ancient is wisdom; and in length of days understanding.

With this in mind, although I've nothing against him personally, when I'm urged to read Atul Gawande's books about aspects of surgical practice, particularly outwith the technical skills, I wonder what makes him such an expert.

Here's the evidence:

Qualified in Medicine at Harvard in 1995 aged 30
Master of Public Health degree in 1999, then 6 years of residency training in surgery - ie. junior doctor acquiring experience - till 2003.
He spent quite a bit of time from the late 80's involved in writing magazine articles and working in Democratic politics.

His first book, Complications: A Surgeon's Notes on an Imperfect Science, came out in 2002, when he was still a junior doctor in training, far from the finished product. The next one Better: A Surgeon's Notes on Performance, was released 5 years later. I assume he'd been busy in clinical practice for this time, with possibly some of the previously noted extracurricular activities getting in the way occasionally.

An NHS consultant surgeon, 5 years in, working in a busy hospital is, in my view still very much on the learning curve. 'Surgical maturity', I would say, is at least 10 years in. Some people never get there.

Gawande's Wiki entry implies that from about 2009 onwards he was doing more and more non-surgical things, fair enough, he seems an interested and accomplished fellow, but I feel very strongly that the way you get better in medicine is, I'm afraid, long hours, year in year out, in the wards, the theatres and the clinics. It's a lifelong thing, even if - as I do - one has plenty of other interests.

One of the classic scenarios in the NHS is the consultant who having got to the top - as it was perceived in the old days - realises that he or she wants to get out. Often 'management' and 'governance' are the dubious beneficiaries of their career move, which amazingly usually involves telling working clinicians what to do. Not that I'm accusing Gawande of that, but some individuals closer to home, certainly.

Anyway, this preamble is to praise the benefits of long, hard won clinical experience, especially of the surgical kind. There is a significant difference between prescribing a drug - which could do harm - and opening someone up with a knife, which is intrinsically harmful before it gets better, even if everything goes well.

Is there a plausible alternative to working the hours? I think not. Don't get me started on the world of 'simulated surgery'.

All of which brings me to a fascinating interview with both Stephen Westaby (69), heart surgeon and Henry Marsh (67), neurosurgeon. Both have a public profile, both have performed thousands and thousands of challenging high end operations, for the NHS. With respect to the aforementioned competition, these are the guys that I want to hear from. They've also written books for the general public, as it happens.

There are numerous gems in the interview, here's some tasters:

HM:  We have this very complex relationship with patients. It’s not one of straightforward altruism at all; it’s a very difficult relationship. You have to be both hard and soft at the same time. You certainly don’t want to be empathetic. If empathy means you actually feel what your patients are going through, actually . . . you can’t do it.

...the problem is you could spend the entire national income on healthcare and everybody still dies — there is 100 per cent mortality — so you have to decide somehow where to set your artificial floor on that bottomless pit.

...[When he was PM] David Cameron made this speech about we must have “zero harm” in the NHS, which struck me as the most incredibly stupid thing to say because it suggests that when anything goes wrong, therefore somebody’s to blame. The whole point about medicine is it often goes wrong. The decision whether to operate or not, to recommend an operation or not, is all about probabilities, and these are very subjective, difficult judgments. Everything we do is in the face of uncertainty and a lot of the time patients come to harm. It doesn’t necessarily mean that anybody’s at fault. So I thought that was a very, very naive and rather silly thing to say.

SW:  The job is difficult enough without having the press and everybody else on your back. A British heart surgeon had the idea when he became the medical director of the NHS that surgeons’ death rates should be published and available for the newspapers. Let me ask you: which surgeons would have the highest death rates, the worst ones or the best ones? The best surgeons attract the worst patients like a magnet. So if you want to make your best surgeons defensive, you start counting the bodies and putting it into the public arena. My particular branch of the profession is now risk-averse. Fewer heart surgeons want to come to Britain to do heart surgery and the British especially don’t want to do heart surgery. They’re long operations, you can end up operating all night, every day of the week, and it’s taxing and it’s rotten when people die. It’s totally rotten to have to go out of an operating theatre and tell a couple of young parents that their baby’s just died on the operating table. It’s misery. None of us lose patients because we’re careless or don’t care. So I’ve seen my profession wrecked, I’m afraid.

HM:  Forty years ago, the power structure in hospitals in this country was very simple. There was a senior doctor, a senior nurse and one manager, and basically the hospitals are run more or less by the senior doctors, for better or for worse. Now you have a whole series of competing pyramids. The management, the doctors, the nurses — more or less autonomous now — the other paramedics and physios and people like that, so there’s a real sense of nobody being in charge. I would go to work in the morning and I wouldn’t know what I was going to do that day because it all depends. Is there a bed? Is there an intensive-care unit bed? Is there a bed on the high-dependency unit? You have to negotiate with each of these individual power structures, it’s deeply chaotic

...Another example is that, after the Stafford scandal [over nursing care] and the Francis inquiry [into it], the General Medical Council wrote to all the doctors saying that when a mistake is made you must apologise and then it said that this is usually the duty of the senior clinician; in other words, whoever makes the mistake, muggins here has to go and say sorry. And then thirdly it added that for an apology to be meaningful, it must be genuine. If the GMC can’t see there’s a problem here — if an apology is compulsory, how can you force it to be genuine? Well, the answer is that it is genuine if the senior doctors have a sense of authority, if they feel they’re trusted and then they do feel responsible for what happens in their department.

Just superb, and not calculated or self-serving, simply real world experience of something very important. Westaby's line "The best surgeons attract the worst patients like a magnet" is very very true.

I'm also ending with a bit of biblical advice, Jeremiah 6:16 - put yourself on the ways of long ago and enquire about the ancient paths: which was the good way? Take it then, and you shall find rest

Trainees, your aged consultants will guide you in 'the ways of long ago'. Catch them before they retire.

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

The surgical ego

You probably need to have a degree of egotism to be a good surgeon, albeit one that is cloaked with a true essential for surgical practice: humility.

Not an easy balancing act. We all meet surgeons who have an excess of the former. I doubt think that I've ever met one who had an excess of humility (myself included, he added humbly).

Anyway, our patients and their complications will help provide the latter, hence the well known perils of schadenfreude.

I give you the following short video from Steve Martin's The Man With Two Brains to illustrate the problem.




 Indeed the whole film is something of a surgical primer, and is one of the more accurate representations of neurosurgery that I've seen. The little girl in this clip is at least an ST2.

Why did you want to be an orthopaedic surgeon?

According to Wikipedia, a Venn diagram is a diagram that shows possible logical relations between a finite collection of different sets."  History buffs will further be fascinated to know that Venn diagrams were introduced in 1880 by John Venn in  a paper entitled On the Diagrammatic and Mechanical Representation of Propositions and Reasonings in the "Philosophical Magazine and Journal of Science", about the different ways to represent propositions by diagrams.

The author takes his role in applying such concepts in science and graphical representation to this blog very seriously.

So here, according to Facebook, I believe (not my scene), is the genesis of an orthopaedic surgeon...

Makes sense to me.

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

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

GO A S Y P

Here's an edited email from another specialty about a patient with an ischial pressure sore. There are no patient or doctor identifiers. The writer of the email had not seen the patient concerned.

Thank you for your email. I have discussed this with the registrar who received a phone call  from a Foundation doctor regarding this patient.

Note the sniffy tone. What was the F1 doctor meant to do? The specialty concerned refuse to carry pagers, and are routinely a hassle to track down. The point of all the specialties being under one roof - which is called 'a hospital' -  is undermined by such difficulties in access.

Advice was given with regards appropriate dressings, ensuring good nutrition (albumin of 21 is not optimised) and appropriate pressure relief with mattress, cushion, turning, etc.

As the ward nurses concerned said to me: "appropriate dressings and nutrition! Brilliant. We'd never thought of that". Furthermore, the patient was verging on being morbidly obese. Malnutrition was not an issue. Isolated albumin results are not the gold standard. This was an obvious 'end of the bed assessment' point.

He also made it clear that we do not routinely operate to close pressure sores, and would certainly not do so in the presence of osteomyelitis.

This was not requested. The specialty concerned are just one part of the appropriate multidisciplinary input the the patient needs (and can reasonably expect). A bedside review would be the obvious first step

I have reviewed the recent MRI scans, which show destruction of the ischial tuberosity and oedema of the surrounding muscles.

'destruction' suggests something dramatic. In reality it was typical superficial osteomyelitis at the base of a sore. The ischium was essentially intact. MRI is very sensitive and needs to be interpreted with care

He should continue with dressings and antibiotics. The pressure sore will never heal unless the osteomyelitis is adequately treated.

The first bit is misleading,  he definitely needs an operation, which is why the second bit is true. Established osteomyelitis is not treated by antibiotics without surgery. If there's pus, let it out (the old ones are the best).

As it turned out, the pressure sore was excised and the osteomyelitis debrided back to healthy bone, there was plenty of soft tissue to allow a tension-free closure, so there were no secondary soft tissue reconstructions needed. This was exactly what could be expected from even a brief visit to see the actual patient. 

Hence the title, GO A S Y P  or 'goasyp' to keep it catchy. Go and see your patient.

This is not picking on any one specialty - we are all capable of making this mistake. I don't, to give a common example, think you can properly assess an acute abdomen without a bedside assessment. In that example and in others more orthopaedic, like possible compartment syndrome, it may easily need several such visits. That's your job.

Once the problem has been referred to you, it becomes to a variable degree your patient. Act accordingly. When was the last time you let Kwikfit sort out your car over the phone?

Being easily available (why do people not want to carry their pagers - mobiles are no substitute?) makes a huge difference and will enhance your reputation.

This is not just  kind and humane - the patient always appreciates a bedside visit - but how the hell can you make a key decision without all the relevant facts? You can't, at least not consistently. Relying on data from your work PC instead is part of what I call Google Medicine (more another time). Anyone can look stuff up. It is not equivalent to taking a history and examining your patient. How could it be?

Not only is this advice good for the patient, it is good for you too. It will protect you when if, one day, there is a clinical mishap because of advice given over the phone or by email, though there had been nothing stopping you from actually doing what every doctor since Hippocrates has been routinely taught.

GO A S Y P !!!

....old school (in every way). Note that the surgeon is at the patient's bedside.

Surgery is a serious business

I was searching for a suitable metaphor to encapsulate certain aspects of surgical training, particularly - as in orthopaedics - those areas that require the use of potentially injurious high tech equipment.

I think I've found it.

Enthusiasm alone is no substitute for adequate training, and if trainers lack interest in their trainees, failing to assess their capabilities and not showing the necessary respect between colleagues, bad things can happen....

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)

But I like doing uncemented...

The title of one of the worst films ever to achieve fame is the same as one of the best papers I've read in the last few years. It's in Bone & Joint 360, and it takes a careful, evidence based and pragmatic look at the use of uncemented total hip replacement in the NHS. It's not particularly pretty reading.

Put simply, it's not possible for uncemented hips to achieve better survivorship than the Charnley or Exeter, partly for statistical reasons (you could never have a study with adequate statistical power, unless we all start living to be 130). There is no evidence of better function - unlike, say, the much maligned resurfacings. There is evidence of higher complication rates - pain, leg length discrepancy, dislocation, periprosthetic fracture. Generally speaking they cost more. There is no consistent evidence that because you can in theory do them more quickly, you'll do more on a list. Not in the NHS anyway.

So why do them at all? Obviously they're great for many revisions, and there are specific cases - awkward anatomy, femoral shortening, the very young - where they make sense. There are quite a few uncemented stems with great survivorship, although not better than the cemented rivals.

If they're not being done for clinical reasons, or because they're cheaper, then it must be because the surgeon says so. Not ideal really. The UK still has a predominance of cemented stems, because of hybrids, but the commonest single combination is uncemented, albeit it's coming down slightly. Bizarre. Here's the NJR data:

And here's the Inconvenient Truth, followed by a short film on how to put them in: