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

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

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.

Country music meets total joint replacement

Nobody closes over an actively bleeding surgical site. Do they?

In my handwritten operation note it says 'haemostasis' followed by a tick symbol. In the dictated note I use the authoritative phrase 'haemostasis secured', which has a nice feel to it. Obviously I won't get any postoperative haematoma, and if I did, which I won't, it wouldn't be my fault. Or something.

So I will never have to use the phrase  'it was dry when I closed'.

In this matrix lesson, Leo Gordon notes the unusually fruitful use of Country & Western lyrics as applied to surgery, thus creating a new composition: 'Don't the Fields All Get Drier at Closing Time'. It's true that near the end of a big case you often just want to get out of there.  Songwise, one might add 'Does My Ring Hurt Your Finger' by Charley Pride, when examining for anal tone in a patient with a spinal presentation, or 'Life Has Its Little Ups and Downs' for when the MMC results come out (which has just happened)....



....I digress. Basically, not all complications are preventable, but bleeding is one that certainly can be. It doesn't help that in orthopaedics we've been trapped by what Gus Sarmiento aptly called 'the orthopaedic-industrial complex' as a variation on the medical-industrial complex theme (AKA Big Pharma), such that we dose all our arthroplasties with chemicals of extremely dubious value on the recommendation of physicians who are, to put it politely, remote from the consequences for the patient who has a bleeding complication.

Leo also describes the dreaded 'knee-jerk suspicion of surgical sloppiness' that we cannot banish from our mind when we confront the offending haematoma. Our own suspicion, and inevitably that of our friends and peers.

I blame Big Pharma, it was definitely dry when I closed.

The Germans have a word for it

um....nice screws

There is an orthopaedic 'walk of shame', more literally a walk in the old days before digital X rays, when one had to go to the front of the room in the morning trauma meeting to put up the latest X rays of one of your hip dislocations. Every man/woman and his/her dog will then opine confidently on impossible-to-verify topics such as "your cup is too anteverted on that X ray". Their faces betray no hint of sympathy for your pain, and indeed that of the unfortunate patient. Disappointingly, there may be seen traces of joy. Dislocation, being so blatant on X ray, is probably the best example of this meme.

Thanks guys, I never knew you were all so expert on this.

However, they will regret it.

Many years ago, one of my bosses who was an erudite and witty man, and something of a Germanophile, introduced me to the now ubiquitous subject of schadenfreude. I have seen countless examples since then. If guarded against, it induces the salutary virtue of humility, something all doctors, especially surgeons, should cultivate.

Schadenfreude is a human response, but also a human failing. As Leo Gordon tells us in his vivid example below:

The gods of surgery giveth, and the gods of surgery taketh away.

You have been warned.

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....

Surgery as a zero sum game (Hadden's Law)

This is probably a historical law, rather than one that applies to current orthopaedic elective practice. It fits more with the days when the treatment for hip and knee arthritis was osteotomy and fusion rather than our zinging arthroplasties.

But.....

I have recently been reviewing detailed audit outcomes data from parts of elective orthopaedics outwith our gold standard joint replacements, and it's not such a pretty sight. I won't say exactly what it refers to, but essentially at 6 months and 1 year there's an approximately 30% patient dissatisfaction rate with surgery.

Is that good? Is it better than the natural history of the condition with conservative treatments? The trouble is that we orthopods are very self-critical. Our only rival in the life-changing elective procedure stakes is cataract surgery. A 30% dissatisfaction rate, I would hazard a guess, might be quite a favourable result in some other specialties. Breast implants, anyone?

Anyway, back to Hadden's Law. It is named after one of those rare surgeons who is not only a very fine clinician and operator, but also a mentor, in this case Bill Hadden, now retired, but one of the most humane and likeable surgeons that I have ever met. Neither Bill nor I are sure who invented it but it was he who introduced me to the concept nearly 30 years ago. It's straightforward:

For every operation you do that does good, award +1

For every operation you do that does harm, award -1

For every operation you do that probably makes no difference in the long run, it's zero

If, over the course of a list, a working week, month or whole career you're achieving a slight positive surplus, then you've done alright.

I know, I know, it sounds awful and nihilistic, and if you're knocking in Exeter hips all day you'll be very positive indeed. But look around you: is it completely wrong, even in 2017?

Early neurosurgery. They "all did very well" (thanks to Hieronymus Bosch)