Celebrity orthopaedics: U2

....specifically their dreaded singer Bono/Bonio. This is when he fell off his bike in Central Park in late 2014.

The talented trauma surgeon whom you can blame for Bonio's ongoing career is Dean Lorich at HSS in Manhattan. To quote the sanctimonious caterwauler himself: "The recovery has been more difficult than I thought. As I write this it is not clear that I will ever play guitar again."

Well he made it. Nice X rays, Dean

The Bonio distal humerus

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)

Celebrity orthopaedics: Paul Stanley

Post THR exercise routine

One of my occasional pleasures is seeing how once youthful rockers grow old, get ill etc. I remember a picture of Rod Stewart coming out of a New York pharmacy clutching a large box of anti-inflammatories. A few weeks ago we had Joe Perry with his walking stick.

Well, here's Paul Stanley (65 last month), the guitarist with the star on his face from Kiss. He's an orthopaedic case history:

"What I do has taken its toll. I've had both my rotator cuffs surgically repaired. They're all similar to sport injuries. I've torn my meniscus in both knees and had a hip replacement. This is all from onstage performances. It's like doing a triathlon with a guitar around my neck. You have to jump, sing, swing your arm and play the right chord. With that combination, anything can go wrong. I used to jump up in the air and land on my knees. It didn't hurt then, but it does now."

He was 52 when he had his hip done. Last year he had a torn biceps fixed, with all the vital technical details:

Not only that, he identified the difficulty deciding whether to undergo a hip replacement in a tweet after bandmate Gene Simmons was critical following Prince's OD on analgesics for his hip disease (keep up):

As he said about his own decision:

"I wound up postponing my hip surgery and, you know, it's like reading in the newspaper your own death, you know, when you keep reading about your hip surgery, and I haven't done it, but I'm just postponing it for awhile. I have, you know, every intention of continuing doing what I've been doing, but little by little I'm turning bionic."

Interestingly Paul did have a complication - recurrent dislocation. Money can't guarantee that you avoid it. When I did private medicine I always felt my complication rate was slightly higher in the private sector. . It would be interesting to know what the salvage procedure was, because he looks like he's functioning at a pretty high level. Although...

"You know things did not go as well as they could have or perhaps should have. Hip replacement is major surgery yet it's fairly routine. It's done so often. The actual procedure has changed so much that you basically have the surgery and are walking that day. But there's a saying, minor surgery is what somebody else is having. This clearly was not minor surgery and the first one did not go well and kept pulling out or dislocating almost immediately. So within two months I went back and had it done again, which seemed to fix one problem and start others. The recovery has taken way longer and been more painful than I expected. It will never be great."


And that fits with the evidence that although patient satisfaction after dislocation soon catches up - if the hip is stabilised - the functional scores are frequently less than in the uncomplicated hip arthroplasty. 

I'm not a huge fan of Kiss, though I kind of like the whole trashy metal showbiz thing. Here they are in 2014. That's a 10 year old revision hip in a 62 year old you're looking at. Not bad.

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:

The metaphysics of nursing (part 1)

I am very specific in my clinical instructions. I frequently write them in by hand on the ward round, always in theatre, the drug kardex etc. I speak to the relevant staff. I don't rely on people reading my mind, or following "that's what he always does". There are always important exceptions cropping up: if they already take aspirin I don't want them on rivaroxaban and aspirin; if I very occasionally want 'none weight bearing' I make it clear.

But...

....after a complete, documented and thorough ward round I will frequently get bleeped 10 minutes later to be asked if a patient can mobilise. I will find patients being sent home on subcutaneous heparin injections - which I never do. The wrong consultant's name will remain above the bed despite daily requests to change it. There are many, many examples.

This is one of Leo's funniest matrix lessons, he really gets going in the second half. It touches on metaphysics and welding. It is also entirely true.

The Surgical Gods

Cancel this case!

Much as I would like to think otherwise, I am not a surgical god. In fact, I don't know any, but they do occasionally get in touch. This is a genuine warning in practice, call it the subconscious if you will.

Any surgeon who's done enough operations will be aware of a rare feeling that something isn't right. You want to feel this before you start the case.

I can't put it any better than Leo Gordon. There are lots of orthopaedic examples as well as generic ones. "Why am I removing this humeral shaft plate?" is one that springs to mind.

Cancelling a case is not the worst thing in the world.

Verify it yourself, get the old notes

How often have you, as a clinician, either been told a dud bit of information - or conveyed one- when discussing a clinical case? We probably all have. It's the equivalent of idle chit chat, which in gossip can cause emotional and other harm, but in clinical care it could kill. Such misinformation has almost certainly lead to doing unnecessary operations, tests etc

I had a patient who kept getting put on theatre lists for 'wound excision and exploration'. He had been labelled as a case of pyoderma gangrenosum for years, by various doctors, including dermatologists. This 'clinical meme' had stuck to him. He quoted it himself. He certainly had intermittent cutaneous sepsis, but PG is a very specific condition, the treatment for which includes immunosuppression, which no-one had quite got round to. It all seemed very unlikely to me. It certainly wasn't a classical presentation.

So I got the old notes - they were pretty thick. The meme had been repeated on many occasions, but never proven. No histology, no test of treatment, yet here he was continually turning up and getting listed for surgery for possible deep infections, with this impressive label stuck to him. The notes told a long and confusing but very helpful story, if you took an hour to read them.

I sent him back to see a new, very thorough dermatologist. No evidence of PG. It turned out to be self-inflicted, AKA dermatitis artefacta. A completely different sort of problem.

Likewise, if you do a lot of revisions (I do), you will encounter plenty of patients who have undergone multiple surgeries - occasionally into double figures - with different implants, approaches, rationales etc. There is no more useful exercise in planning treatment than summarising the relevant old notes and imaging - often going back years - and sending a copy to the GP. Clarity is everything here. It can be extraordinarily revealing. It's one reason why when I first meet a patient with a problem joint replacement one of my first questions is: why was this done, did they ever have painful arthritis in the first place? That may sound daft, but it is incredible how frequently the answer to their dissatisfaction lies in a poor original decision to operate.

So back to our wise surgeon, Leo Gordon. The Four F's are a bit outdated, and there's a mention of something called the World Wide Web, but this is the voice of experience. Get the old notes!