BJJ News Issue 13

BJJ News | I ssue 9 | D ecember 2015

BJJ News from The Bone & Joint Journal

70 years of orthopaedic excellence

BJJ News | I ssue 13 | A ugust 2018

Issue 13

Notes from the road

Orthopod’s view

The future of elective hip and knee arthroplasty in the NHS J. Palan p2

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Improvements in orthopaedic care and training in Ethiopia D. H. A. Jones p10

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CELE JJ BRA 70 YE TING ARS

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BJJ News

Issue 13

from The Bone & Joint Journal

August 2018

Editorial Editorial

A. Ross

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The future of elective hip and knee arthroplasty in the NHS

J. Palan

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BOA Presidential Address 1995: the sickness of health

C. L. Colton

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BOA Presidential Address 1995: a commentary

F. Monsell

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Orthopaedics in Canada

J. P. Waddell

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Orthopod’s view

Notes from the road Ice cold in Addis: David Jones reports on significant improvements in orthopaedic care and training in Ethiopia

D. H. A. Jones

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Me and my clavicle: What goes through an injured orthopod’s mind?

D. Warwick

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Your starter for ten

G. Charnley

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Hand disorders in pianists

P. Richardson

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Flex, bugs, and rock ‘n’ roll: an orthopaedic registrar’s experience of music and medicine

M. O’ Reilly

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Michael A. R. Freeman (1931-2017)

G. Scott

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Robin Ling OBE (1927-2017)

G. Gie

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Peter A. Ring (1922-2018)

J. Ring & S. T. Donell

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Henry Vernon Crock (1929-2018)

S. P. F. Hughes

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Arts

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Obituary

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Edited by: Mr Alistair Ross Consultant Or thopaedic Surgeon, Bath

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BJJ News | I ssue 13 | A ugust 2018

A. Ross

Editorial

ditors of publications such as this one live in ‘interesting times’. Apart from the usual matter of articles arriving within minutes of (or after) the specified deadline, which leads to a frantic copyediting session, there are the serendipitous moments, such as when I received the first four articles in this issue and realized, albeit not for the first time, that the problems we face in attempting to deliver a first-class healthcare service to our patients remain unchanging and ubiquitous.

The sequence of events ran something like this: late last year, I buttonholed James Waddell over dinner and requested an article on the current state of orthopaedics in Canada, since he had spoken on this topic with great insight and humour at the preceding meeting of the Editorial Board of The Bone & Joint Journal. Some months later, Christopher Colton and Fergal Monsell had clearly been in correspondence, during the course of which Chris sent Fergal a copy of his 1995 Presidential address to the British Orthopaedic Association, which Fergal appears to have received just after addressing the Paediatric Orthopaedic Society of India. He emailed me from Chennai airport (as one does) remarking on how the problems in delivering orthopaedic care appeared to be the same as those 23 years earlier. Naturally, I took the opportunity to request his response to this in the form of an article. At much the same time, I had asked Jeya Palan to address a subject dear to his heart as a younger contributor, which was the future of the NHS. Not only have they all come up with excellent articles, as anticipated, but, more remarkably, a very consistent and coherent view on the problems that face orthopaedic surgeons in their pursuit of excellence. Despite the efforts of many in the profession, these seem to be persistent and widespread.

Nonetheless, the best in our profession somehow manage to achieve great things. In this issue we celebrate the lives of three British pioneers of joint replacement surgery, Michael Freeman, Robin Ling, and Peter Ring, and an outstanding Australian spinal surgeon and anatomist, Harry Crock, all of whom have sadly died in the past months. Having known them all to a greater or lesser extent, I can say

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with some confidence that they had a number of things in common. They were all deeply and devotedly involved in the care of their patients, applied themselves formidably to the understanding and development of the art and science of orthopaedic surgery, and had the ability to communicate those developments clearly and with infectious enthusiasm.

The resulting affection of those who worked with them is evident in the four appreciations.

The extracurricular interests of orthopaedic surgeons and indeed those who work with them never cease to amaze me either in their scope or their level of expertise. In this issue, Godfrey Charnley reveals his appreciation and knowledge of Victorian art in the story of Lord Frederic Leighton and his painting Flaming June. Peter Richardson, until recently the Managing Director of the British Editorial Society of Bone and Joint Surgery, and currently Chairman of the Medical Music Society of London, himself an amateur pianist, writes about the hand conditions that have affected eminent pianists of the past. Marc O’Reilly, a new name to me as someone stuck somewhere between the late Renaissance and high Baroque in terms of music, but undoubtedly familiar to some of our more broadminded younger readers, explains what it is like to crack the modern music scene and reflects on the long-standing relationship between music and medicine.

Hopefully, then, something to interest, inform, and perhaps enlighten all of our readers.

I would reiterate a point previously made in these pages.

We genuinely welcome articles submitted by orthopaedic surgeons at any stage of their career. This is now the 13th issue of BJJ News. We have covered topics from robotics to deerhounds, and genetics to sculpture. No subject matter is too arcane! We look forward to hearing from you.

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Alistair Ross, FRCS, Consultant Orthopaedic Surgeon, Bath, UK alistairrossfrcs@hotmail.com

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Orthopod’s View

The future of elective hip and knee arthroplasty in the NHS

n 2 January 2018, NHS England issued an unprecedented edict for the cancellation of all non-urgent elective operations, including hip and knee arthroplasties, for the whole of the month and beyond. Department of Health (DoH) estimates stated that this would involve deferring around 50 000 operations. The reason was to free up capacity for the so-called ‘winter crisis’, which led to enormous pressures on Emergency Departments (ED) throughout the United Kingdom, and indeed prompted one ED consultant, Dr Richard Fawcett, to send an apology via Twitter: “As an A&E consultant at University Hospitals of North Midlands NHS Trust I personally apologise to the people of Stoke for the third world conditions of the department due to overcrowding”.

I say ‘so-called’ because the term ‘winter crisis’ seems to have expanded beyond the usual seasonal definition of winter, and now appears to include spring, summer, and autumn. This crisis has not taken place all of a sudden as a result of seasonal flu or excessive cold weather, but as a failure on the part of successive governments to acknowledge the causative factors that have led to this situation. The NHS is celebrating its 70th birthday later this year; the health landscape of Nye Bevan in the 1940s and 1950s has changed beyond all recognition. The simple truth is that, as a result of a growing elderly population with complex medical and social needs, advances in medical technology and treatment options with their associated expense, a lack of long-term forward planning by politicians, and unrealistic patient expectations and demand, the NHS is now facing an existential threat.

The fundamental questions are as follows.

What do we, as a society, expect from the NHS? How do we fund it in the longer term? And what, realistically, can the NHS deliver without compromising standards of clinical and social care, given that the purse strings are being pulled tighter?

Within our own specialty, it has stimulated debate about how the NHS will continue to provide hip and knee arthroplasties for thousands of patients within the arbitrary 18-week targets.

This dire situation was brought into focus very sharply by the recent BBC series, Hospital, filmed

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at the height of the crisis at Nottingham University Hospitals NHS Trust earlier this year. It showed dozens of patients waiting on trolleys in corridors outside the Emergency Department for beds that were not available. By contrast, the elective orthopaedic theatres were sitting idle, as the elective orthopaedic wards were full of medical outliers. The financial cost to trusts was enormous as the income usually received for undertaking hip and knee arthroplasties was lost, having a significant impact on the many trusts that were already struggling financially. For example, the University Hospitals Leicester NHS Trust is estimated to have lost £10 million just as a result of cancelling operations in January 2018.

At the heart of all of this, however, is the patient. We must never forget that beyond the logistical and financial implications, there are patients who are struggling with crippling pain together with a loss of function and independence. Osteoarthritis affects millions of people in the UK, and the need and demand for hip and knee arthroplasty is rising sharply. It is also a fact that hip and knee arthroplasties are the second and third most cost-effective operations after cataract surgery.1 Our patients are now waiting longer for their operations, and waiting times now routinely extend to 12 months or more.

The dreaded ‘R’ word (rationing) is never mentioned yet is, in reality, the driving force behind the decisions of clinical commissioning groups (CCGs) in some regions, who are using Oxford Hip Score (OHS), Oxford Knee Score (OKS), and body mass index as criteria for referrals to orthopaedic surgeons. Three CCGs in the West Midlands have proposed reducing the number of people who qualify for hip arthroplasty by 12%, and for knee arthroplasty by 19%.

The Oxford scores were never designed as a screening tool to determine whether or not patients were eligible for hip or knee arthroplasty. A body mass index greater than 35 kg/ m2 has also been used by some CCGs as a barrier to prevent access to hip and knee arthroplasty, despite strong evidence to suggest that obese patients gain significant improvements in pain, function and quality of life, satisfaction, and fulfilment of expectations after joint arthroplasty surgery.2,3 This is rationing by any other name.

J. Palan

The 18-week referral to treatment target (RTT) appears to have been largely abandoned

by NHS England. On the frontline, patients being listed for a hip or knee arthroplasty do not even question the fact that they may have to wait for up to a year for their operation. All of this appears to have taken place under the radar with barely a mention in the press. For many units, elective work has only just started getting back to normal and, indeed, I am aware of several hospitals where, for the last few years, elective work has been stopped for three months or so from December until February as the norm.

This situation is clearly untenable.

This also has a significant knock-on effect on surgical training, as Trauma and Orthopaedic (T&O) trainees are expected to have carried out 40 primary hip and 40 primary knee arthroplasties as a requirement for their Certificate for Completion of Training (CCT). If routine hip and knee arthroplasties are now being cancelled every year, the exposure to such operations will shrink, making it harder for trainees to gain the required surgical experience, and possibly increasing the duration of their training.

What are the possible solutions? First, I believe there needs to be an open and honest debate about the future of the NHS, bypassing

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party-political lines, with cross-party agreement on how best to take the NHS forward for the next 20 years, and how best to fund it. The NHS is too important an organization to be left to the whims of political expediency. A non-political group, akin to the independent Monetary Policy Committee at the Bank of England, made up of key stakeholders including clinicians, managers, and patients, should be formed to help develop a longer-term strategy and vision for the NHS over a ten- to 20-year timeline. Can the NHS truly continue to provide everything to everyone, or should the NHS concentrate on providing world-class treatment for critical and urgent conditions such as emergency care and cancer?

Other conditions, such as osteoarthritis, may need to be managed differently and potentially outside the NHS. The current 18-week target should be abandoned in favour of an alternative, more realistic timeframe. My own feeling is that patients should be offered a hip or knee arthroplasty within six to 12 months of being put on a waiting list. If patients wish to have their operation done earlier, they may need to fund that cost privately, with the NHS subsidizing the cost.

I am well aware that many politicians would baulk at the mere mention of the words ‘privatization’ and ‘NHS’ in the same sentence, but this is the reality of the situation and we need to confront it head on. The public needs to be educated to plan for their own health and wellbeing, to take personal responsibility for themselves but with the knowledge and reassurance that the NHS will always be there for the emergency and acute conditions, and for all children and the elderly. In many ways, we should be planning for our own inevitable ageing and its consequences, just as we plan for our pensions when we retire.

Second, I support the creation of extra separate ring-fenced elective-site NHS orthopaedic hospitals, given that the vast majority of hip and knee arthroplasty patients are fit and healthy with low rates of mortality and postoperative complications.4 As such, it is safe to undertake such operations in hospitals without needing the whole repertoire of medical specialties found in an acute district or teaching hospital set-up. There are already examples of this taking place in the UK, including the South West London Elective Orthopaedic Centre (SWLEOC) model. There are several advantages to creating separate elective-site units: ••

Better clinical outcomes (reduced infection rates because of ring-fenced beds) and consolidation of expertise in hip and knee arthroplasties;

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•• •• ••

Increased capacity for patients to be seen and treated, freeing up resources for higherrisk patients to be operated on in larger acute units with critical care facilities; Increased financial income and reduction of costs; Reduced cancellation rates improving the patient experience; and Ring-fenced capacity, improved utilization, and improved length of stay will support flow throughout the system.

Finally, what is the role of industry and the independent sector in providing facilities to meet the demand for hip and knee arthroplasty? Independent treatment centres already have a business model designed to meet the increasing volume of NHS ‘choose and book’ work for hip and knee arthroplasty. Up to a third of all hip and knee arthroplasties are carried out in the independent sector, with companies such as BMI, Spire, Circle, and Nuffield. Of these cases, 22% are NHS-funded. In the West Midlands, the Royal Orthopaedic Hospital reduced operations from 2284 to 1554 in 2015/2016, while BMI grew hip and knee operations by 72%. In Nottinghamshire, almost 75% of NHS hip and knee arthroplasties are carried out in private hospitals, according to analysis of National Joint Registry (NJR) data by Candesic, a healthcare consultancy firm.

Large multinational companies have also started to dip their corporate toes into the ‘water’ of managed healthcare services. One example is the new partnership between Johnson & Johnson Managed Services and Guy’s and St Thomas’ NHS Foundation Trust. As part of the contract, Guy’s Hospital orthopaedic unit will be expanded and redeveloped, providing more capacity to see and treat patients. Plans are underfoot to build an additional operating theatre in the first year, and eight new state-of-the-art theatres by the end of year three. As part of this contract, procurement of devices, surgical instruments, and implants will be streamlined. In other words, there will be a significant requirement to use Johnson & Johnson and DePuy Synthes products and implants, although to what extent remains unclear. How this model works in the longer term, in terms of providing excellence in clinical care while being cost-­ effective, remains to be seen. As with the debacle of Private Finance Initiatives (PFIs) and the consequent crippling repayment schemes facing NHS trusts, careful scrutiny and due diligence of the contract will be essential and the devil will be in the detail.

In summary, the demand for hip and knee arthroplasty will continue to rise inexorably. What is required is an open honest discussion with the

public, together with a clear vision for the future on how such services can best be provided and funded. If private sector involvement is going to increase, there has to be a greater emphasis and requirement that orthopaedic training also takes place, with trainees following their trainers to the private sector in order to gain exposure to hip and knee arthroplasty. The private sector has a legal and moral obligation to facilitate surgical training: this requires contractual lock-in between NHS trusts and independent sector providers.

Groups of orthopaedic surgeons, anaesthetists, musculoskeletal radiologists, physiotherapists, and specialist nurses may come together in the future to form clinical ‘chambers’ that are commissioned to provide local and regional orthopaedic care to NHS trusts, akin to barristers’ chambers providing legal services. The blueprint for this already exists, with radiology reporting services out of hours already being increasingly outsourced to private firms, often formed from groups of NHS radiologists, working as part of the Any Qualified Provider (AQP) system. The future will involve changes to the traditional way of how and where we work.

“It is not the most intellectual of the species that survives; it is not the strongest that survives; but the species that survives is the one that is able to adapt to and to adjust best to the changing environment in which it finds itself.” – Leon C. Megginson (often attributed incorrectly to Charles Darwin in his book On the ­Origin of Species).

References 1. Jenkins PJ, Clement ND, Hamilton DF, et al. Predicting the cost-effectiveness of total hip and knee replacement: a health economic analysis.

Bone Joint J 2013;95-B:115–121.

2. Xu S, Chen JY, Lo NN, et al. The influence of obesity on functional outcome and quality of life after total knee arthroplasty. Bone Joint J 2018;100-B:579–583.

3. Andrew JG, Palan J, Kurup HV, et al.

Obesity in total hip replacement. J Bone Joint Surg [Br] 2008;90-B:424–429.

4. Hunt LP, Ben-Shlomo Y, Clark EM, et al. 90day mortality after 409,096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis.

Lancet 2013;382:1097–1104.

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J. Palan, FRCS (Tr&Orth), UHCW Lower Limb Arthroplasty Fellow, UHCW NHS Trust, Coventry, UK jeya_palan@hotmail.com

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C. L. Colton

Orthopod’s View

BOA Presidential Address 1995: the sickness of health Editorial note The text that follows is Professor Christopher Colton’s 1995 Presidential Address to the British Ortho­ paedic Association, unedited with the exception of a small number of explanatory clarifications, which are given in square brackets. A commentary, written by Fergal Monsell, follows Professor Colton’s address.

he ground upon which our political masters seek to rebuild the NHS is shifting incessantly. This is largely because there is an awareness of the need for change, yet there has been no public analysis of why, or how. There is a pandemic of health reform. Those countries with organized health services are pursuing change because the ‘Shangri La’ of health for all, free at the point of delivery, has become an impossible dream.

We, as a profession, must bear much responsibility. We have created a technological armamentarium far beyond any nation’s ability to pay for it. Universal health care has ‘engineered’ itself out of the market. In Britain, the government is thrashing around for a quick fix! The frenzy of these last few years has been badly planned, poorly conceived, and incompetently executed, with no clear target. We are merely beset by pious, unrealistic charters and requirements. We are bombarded with statistics that tell us that all is well, when we at the coal face know our NHS is sick.

We are beset by the politics of illusion – caught in the crossfire of a propaganda war. I cannot find a statement of the objectives of the reforms. That may be because the real objectives are politically unacceptable and a nettle that our administration is unwilling openly and publicly to grasp. Mrs Virginia Bottomley said in June 1995 [at which time she was Secretary of State for Health]: “The basic values of the new NHS are a commitment to a comprehensive service, equity in treating patients and in distributing resources according to need, to improving the health of the nation, to supporting research and teaching, and to focusing on clinical outcomes.”

Apart from the bit about outcomes, this is a mere reiteration of the 1948 aims of the NHS. It is not a statement about the objectives of the NHS reforms. We certainly do not need the current chaos just to focus on clinical outcomes!

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Brian Abel-Smith, health economist, recently stated: “If it is true that the growth in the use of expensive technology lies at the root of the escalation of health-care costs, then none of the attempts to restrain costs, other than restricting its availability, gets at the root of the problem.” This is the political dilemma – rationing of health care is the only answer. In 1993, the BMA [British Medical Association], the Patients’ Association, and King’s Fund held a conference on health care rationing. Opening that meeting, Virginia Bottomley, the then Secretary of State for Health, said that Government had a role in broad strategic shifts of resources, but not in “priority setting”; that had to be done locally. This failure of leadership has meant that this country has not had, as Richard Smith, the editor of The BMJ [from 1991 to 2004], puts it, “the broad, deep, informed and prolonged debate on rationing that is needed.”

Klein described rationing as a “complex interaction of multiple decisions taken at various levels.”

Health is in competition with other statefunded activities. Is it given the priority that we as doctors believe it should have? This is beautifully encapsulated by a postcard I saw recently which said, “if only hospitals and schools had all the money they need and the soldiers had to hold jumble sales to buy their guns!”

Crude rationing may be either explicit, or implicit.

Explicit rationing is the central imposition of fixed global budgets, establishing clear priorities, and limiting benefit packages.

Implicit rationing includes allowing waiting lists to grow, having individual, or groups of, doctors working within constrained budgets and requiring them to ration.

For the politician, the attraction of implicit rationing is that its effects can be blamed on others.

Aristotle’s concept of change was that it should be driven by a clear objective – his final cause – and by three subsidiary factors, which he called the material cause, the formal cause, and the efficient cause.

John Kitzhaber, an American politician and primary care physician, one of the architects of the Oregon experiment [see below], explained the Aristotelian concept in terms of the task of finding a place to live. To achieve the change from ‘no house’ to ‘house’ – the final cause – the three additional factors could be: •• •• ••

“What is it to be made of” (lumber) – the material cause; “What form will it take” (the blueprint) – the formal cause; and “How will it be done” (the carpenter) – the efficient cause.

What is the final cause of the NHS reforms? Is it to deliver efficient health care? Is it to improve the health of the nation? Or is it to scale down the NHS to reduce spending? No-one has said.

One suspects the latter.

But whatever the final cause, to allow health costs to soar, as they inevitably would, is not the way to any of these objectives. So back to rationing – this must become an open debate.

Professor Chris Ham of the Health Services Management Centre at the University of

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Birmingham wrote only three months ago [i.e. in June 1995], “With politicians setting the broad national framework for priority setting, but leaving the interpretation of this framework to health authorities, it seems that no one is prepared to take the lead. In view of the unpopularity of rationing, this is unsurprising.”

Do you recall the recent case of the ten-year old girl [Jaymee Bowen, also known as Child B] refused a second bone marrow transplant in Cambridge? This is a prime example of the buck being passed to the Health Authority to ration.

Whether the decision was right could only be answered by valid outcome studies, which presumably don’t exist, otherwise they would have been quoted to justify the decision.

Ham calls this the British alternative – ­rationing by muddling through.

To do better, we must answer three questions: •• •• ••

Who is covered.... (the material cause)?

What is covered.... (the formal cause)?

How is it covered.... (the efficient cause)?

Who is covered?

All citizens This is the British, New Zealand, and Canadian ideal; “services should be available to every citizen on the basis of clinical need, regardless of ability to pay” (Patient’s Charter – William Waldegrave, 1992).

Some citizens Medicaid is a programme for certain categories of poor people, but not all poor people – for example, poor families with dependent children, the blind, the disabled. Poor men and women without children are ineligible even though impoverished. Medicare is available to all over the age of 65 years in the USA and is not means-tested. This has the effect that, for example, retired multi-millionaires get free health care funded in part by the working poor, themselves ineligible for Medicaid.

Exclusion of risk groups Heavy smokers; drug addicts; the obese; alcoholics; those covered by managed care companies; those able to pay – the burden of this could be offset by subsidizing health insurance with tax incentives to both purchasers and providers.

What is covered?

Any rationing must be cost-efficient. Transsexual surgery, liposuction, pure cosmetic surgery

are all examples of treatment currently not universally covered by the NHS. We need to ask if complex organ transplants, heroic cancer surgery, and the like can be afforded. Can we afford beta-interferon for all MS sufferers in UK at a cost of £100 million per annum for questionable gain? Does abortion on demand and, alternatively, fertility treatment, including IVF, make fiscal, or societal, sense?

Probably not, although they may have humanitarian value. Who may judge?

In the state of Oregon in the late 1980s and early 1990s these issues were addressed. Using Current Procedure Technology codes (CPT-4) and ICD-9 codes, a list of nearly 800 condition/ treatment pairs were defined, e.g., appendicitis/appendicectomy. By a process of state-wide consultative conferences and community meetings, the items on this list were grouped into

expensive than, the resourced range, would have to fund the difference. Continuing research into new alternatives would of course be needed to avoid stagnation of practice. The same arguments could apply to families of drugs.

categories of socio-medical importance and carefully prioritized. Factors such as effectiveness were taken into account.

Using actuarial expertise, the provision of each of these condition/treatment pairs was costed for the state. In 1991 the Oregon Legislature allocated funds for the year to resource the top 587 condition/treatment pairs, producing a benefit package with strong emphasis on primary and preventive services. The Oregon legislature also took full responsibility for its choices, indemnifying doctors from prosecution for failing to provide care that society had decided not to fund.

This experiment has been reviewed annually; it seems to be working and provides a proactive, carefully-planned approach, clearly distinguishable from the British reactive muddle. If only our administration had sought advice from professionals as did Oregon.

I should like to think that the work of the National Casemix Office in refining HRGs [Healthcare Research Groups] could lead to a logical approach such as the Oregon Health Plan. We must work with the National Casemix Office and develop valid HRGs for orthopaedics, steering the course, not merely following it.

Given clearly defined priorities, it is possible further to refine rationing, by limiting the range of choices within a given treatment.

In hip replacement, for example, it should be possible to decide on a small range of well-tried cemented and uncemented prostheses, and fund only those. Indeed, Bupa’s recent guidelines for total hip replacement address this technique, although the range of choice of recommended prostheses is by no means evidence-based and reflects more the market advantages of such a choice. Any surgeon, or perhaps patient, wishing to use a prosthesis different from, and more

Are we as orthopaedic surgeons affected?

Yes. There is pressure to treat more and more patients as day cases. But where are the enhanced primary care services needed to continue management in the community? Why, the government have only recently declared war upon GPs’ provision of out-of-hours care. Had we not ourselves already embraced day surgery as a concept where we saw it as the best alternative for the patient? Did we really need some quasi-governmental theorists to tell us that a certain percentage of our work can be undertaken on this basis? Do we really need a British Association of Day Surgery (BADS)?

The latest target of 60% of orthopaedics to be done on a day-care basis is palpable nonsense and we must stand up and say so. We don’t have parks, shop doorways, and cardboard cities in which to sequester our failures; too much day surgery with inadequate primarycare backup results in high readmission rates and the law of diminishing returns operates.

Shift from secondary (hospital-based) to primary care This sacred cow of our current government is a theoretical money-saving device. Nobody has shown that it contributes more effectively to the health of the nation. Unquestionably, it has been a disaster in the psychiatric world, filling up public areas, such as Lincoln’s Inn Fields, with the mentally sick and homeless to the extent that the fields had to be ringed with metal railings. Comparable examples can be repeated elsewhere.

Reduction in the number of doctors Those that determine and deliver health care are the doctors. We spend vast amounts of money.

Politicians could be forgiven for seeing a restriction of doctors’ work as a technique for cost control. This could never happen here, you may cry. But it is. The New Deal on junior doctors’ contractual hours is a means whereby restricting junior doctors’ hours reduces their pay. Put some of the money saved into the window dressing of Task Force-funded jobs and you produce the illusion of a caring administration working hard to ease the juniors’ burden and to boost consultant numbers. Canada recently announced that the government were reducing

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entry to medical schools as a means to reducing doctors’ numbers and, thereby, cutting costs.

Hardly likely to generate major improvement in the health of the nation! Germany now has great medical shortages after rushing into such a policy.

Finally, you could drive doctors out of the system. How? Offer them early pension entitlement, or perhaps abolish the pension system altogether. Will locally determined pay be superannuable? It is the government’s stated intention to phase out the Doctors’ and Dentists’ Review Body and national pay scales. I am in little doubt that the consultants of the future will have to fund their own pensions. Combine this with short-term contracts and no security of tenure and there will be little remaining incentive to continue to work in a struggling and politically dominated NHS, once a consultant becomes established with a reasonable private practice. Furthermore, if the healthcare provision by the NHS is indeed to be subject to rationing of one sort or another, there will be no shortage of those prudent enough to take out private health insurance – much of it employment-linked.

Having deprived the doctors of their security of employment and of an attractive superannuation scheme, now confuse them.

A year ago, local pay bargaining was the buzz. The government finally backed off and, in meaningful consultation with the profession, produced the remodelling of the C award system to Consultants’ Discretionary Points. The NHS Executive [NHSE] agreed to a number of elements essential to any workable scheme.

These included “maintenance of a national pay structure, determined by the Doctors’ and Dentists’ Review Body [DDRB]”. The CCSC [Central Consultants and Specialists Committee] felt that, the NHSE’s having accepted the various essential elements, “the scheme offers the prospect of a long-term solution to the disruptive issue of local pay, maintaining a national pay

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scale and the role of the DDRB, while giving a legitimate input to local management”. The CCSC’s only caveat, in its document to BMA members of August 1995, was: “While the wording of the guidance (AL(MD)6195) is firm, the goodwill of trusts in adhering to it, and the resolve of the NHSE in enforcing it, remain to be tested. Ultimately, the success of the scheme will depend on the efforts of the profession to ensure that it is implemented fairly and with full professional input at local level”. Notwithstanding, it seemed that local pay-bargaining, with all its warts, should have disappeared from the agenda.

However, in his first press release, the new Secretary of State [for Health], Stephen Dorrell [appointed in July 1995], said “I see the introduction of local pay as one of the most important issues facing the NHS today. The Government’s commitment to local pay is clear, we shall not be deflected from this course. Local pay helps staff recruitment and it helps retention.”

Finally, he makes it a dismissible offence publicly to criticize one’s trust, whilst requiring doctors, as a contractual obligation, to report the failings of other doctors.

What is the way forward?

Rationing is here in a crude and covert form. It will stay – but it has to change. We must work to underpin our treatment choices with valid evidence. Not ‘Mickey Mouse’ audit, which only tells you what you are doing (be it right or wrong), but not what you should be doing.

We have all recently received publicity about the new journal [BMJ] Evidence-Based Medicine [launched in 1995]. It will be interesting to observe its evolution.

We must devise valid outcome expressions and conduct well-designed, prospective evaluations. An active research base is one of our bastions against administrative control of clinical freedom. We shall only be allowed such

freedom when we can demonstrate that its exercise is in the balanced interests of the patient and the system.

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We must help to develop and evaluate Health Resource Groups as a basis for comparative costing of our activities.

We must help to develop and evaluate common data systems, so that we all sing from the same hymn sheet!

We must work to achieve the required expansion of the Consultant grade and so liberate our time, not only to teach, but equally to navigate change. The profession will soon have a legal right and duty to conduct specialist training and certification.

This could well prove itself a valuable tool in energetic and well-guided hands.

We must work to make CME [continuing medical education] a reality. We have a duty of care and that care must be the best that we know how to give in a changing clinical environment.

We have to accept some limitation of treatment choices. If that be the case, we, not political transients, must design them.

We must challenge robustly all administrative and political stupidity, via our professional bodies. Be vigorous and active in your support of the British Orthopaedic Association, the BMA, HCSA [Hospital Consultants and Specialists Association], and the [Royal] Colleges. We cannot afford to sit back.

Decide what you want, patient-centred management, or management-scented care!

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C. L. Colton, MB, BS, LRCP, FRCS(Eng), FRCS(Edin) colton1937@googlemail.com

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F. Monsell

Orthopod’s View

BOA Presidential Address 1995: a commentary

o quote the opening words of L. P. Hartley’s novel The Go-Between: “The past is a foreign country; they do things differently there.”

In 1995, Mr Major was the Prime Minister, Barings Bank had just suffered an ignominious collapse, and Monsieur Cantona had aimed one of the most memorable kicks in the history of Association Football at a Crystal Palace supporter.

Professor Christopher Colton was a leading trauma surgeon and educator with a global reputation, and, in his Presidential address to the Annual Meeting of the British Orthopaedic Association (BOA), he demonstrated the combined attributes of Nostradamus and Cassandra.

This was a State of the Union address, in which he divided his observations into a number of areas. He predicted that rationing was likely to become a reality and that we would have to accept some limitation in treatment choices. He anticipated that there would be very significant issues with the consultant contract, as well as difficulties in workforce planning and retention of doctors at all levels. He concluded that we must develop as a profession, evaluate common data systems, and work to achieve an expansion of the consultant grade, stressing the need for a robust defence against “administrative and political stupidity” in what was a call to arms to the BOA, the British Medical Association (BMA), the Hospital Consultants and Specialists Association (HCSA), and the Royal Colleges.

Since this address, there have been five Prime Ministers, ten Secretaries of State for Health, and 11 White Papers about the provision of health care. It is very difficult to maintain professional equilibrium during a time of constant revolution, and, in addition to this, we have had to negotiate centrally imposed diktats including Modernising Medical Careers, Agenda for Change, National Project for IT, Choose and Book, and Independent Sector Treatment Centres.

The organization has mushroomed. Currently, the NHS employs more than 1.6 million people with a total expenditure that has increased from £941 million in 1997 to £2.35 billion in 2013. The average rate of increase during this period has been 7.5% per annum but, despite this, recent figures demonstrate an

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overspend of £1.2 billion with an ever-­ increasing demand for services.

Professor Colton warned about the pernicious effects of implicit rationing, with individuals or groups of doctors working either de facto or de jure within constrained budgets. As predicted, rationing has arrived and, although an obscenity in the political lexicon, includes arbitrary measurements of pain as a basis for total hip arthroplasty, and body mass index (BMI) and smoking status to withhold this cost-­ effective and life-changing treatment.

He saw merit in rationalizing rather than rationing health care, limiting the range of choices within a given treatment. He recommended more detailed evaluation of orthopaedic implants by independent groups and the introduction of metrics to ensure that what was subsequently referred to as “more bang for your buck” became a reality, with improved qualityadjusted life years (QALYs) per unit cost.

The type of data acquisition demanded by Professor Colton has arrived in part, and the exemplar is the National Joint Registry (NJR), which collates sophisticated data to inform important clinical and fiscal decisions. The Getting It Right First Time (GIRFT) initiative has, however, identified a variance in practice, which has an impact on clinical outcomes and expenditure, and is likely to form the basis for future cost savings.

The difficulties associated with attracting future orthopaedic surgeons, and the problems with retention of the current coterie have also materialized. These are complex and inevitably compounded by the vagaries of contract negotiations and alterations in pensions during the period since 1995.

In addition to losing those at the end of their career, we struggle to attract junior doctors into training grades: nearly three quarters of all medical specialties had unfilled training posts in 2016. In addition, the number of applicants to UK medical schools decreased by more than 13% in 2016, with applications to the Foundation Programme also falling as more junior doctors elected to take career breaks.

In the 23 years that have elapsed since this prescient disquisition, very little has changed and the same concerns continue to animate the

profession. There are ongoing impediments to cohesive planning and there have been alterations in the structural hierarchy that are generally perceived, by doctors of all ages and grades, as a deterioration in working conditions.

There is, however, plenty of very good news with the rationalization of care that has led to a year-on-year improvement in survival for major trauma in adults. Elective orthopaedic surgery continues to improve the quality of life for increasing numbers of patients and, while the societal benefits that were enjoyed by our professional grandparents may have contracted, there is more than enough to compensate for the administrative irritations and white noise that are associated with working in a complex and changing environment at such an interesting time.

I strongly suspect that if this issue is revisited in 2040, the same conversations will be rehearsed. It is worth remembering the view of Aldous Huxley: “That men do not learn very much from the lessons of history is the most important of all the lessons of history.”

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F. Monsell, MB BCh MSc PhD FRCS (Orth), Consultant Paediatric Orthopaedic Surgeon, Bristol Royal Hospital for Children, Bristol, UK fergal.monsell@btinternet.com

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J. P. Waddell

Orthopod’s View

Orthopaedics in Canada

hree issues have recently dominated orthopaedic surgery and the work of orthopaedic surgeons in Canada: physician unemployment, patient access to care, and physician compensation.

To understand the state of orthopaedic surgery in Canada requires a brief primer on the way in which Canadian health care is delivered. The rules around hospital and physician services are mandated by the federal (central) government but delivered by the provinces and territories.

This results in 13 different jurisdictions for health care, all with slightly different policies, implementation strategies, and fiscal constraints.

All of these plans have a central concept regarding physician reimbursement. The prohibition of private practice is universal throughout Canada. This prohibition has been challenged, with limited success, in some jurisdictions but the great majority of health care is delivered though a publicly funded system. Physicians are paid fee-for-service at a fee negotiated with the provincial government. The fees vary by specialty, by procedural complexity, and depending upon the provincial jurisdiction. Some provinces have excellent government-physician relations, while others (such as Ontario, where I work) have terrible ongoing relations.

Government control of medicine extends beyond hospital and physician reimbursement to include postgraduate education. All postgraduate (resident/registrar) physicians are funded by the provincial government. The Ministries of Health in these jurisdictions determine the number of funded postgraduate positions in that province; it also determines the percentage of these positions devoted to individual specialties.

Beginning 15 years ago, governments recognized that the ageing population would pose an increasing burden on orthopaedic care and responded by increasing the number of training positions for orthopaedic surgery. This led to a major increase in the number of orthopaedic surgeons available to enter practice.

This influx occurred at the same time as the great recession (2008-2009). The financial downturn had two effects. First, practising

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surgeons who had previously contemplated retirement kept working as their personal savings decreased significantly. Physicians in Canada do not, as a rule, have work-related pensions and must provide for their retirement through personal savings. Second, governments did not have the resources to increase hospital expenditure in order to broaden patients’ access to care. This led to the paradox of unemployed orthopaedic surgeons in the face of rapidly increasing patient volumes and unacceptably long waiting times for surgery.

The unemployed graduates found additional training as clinical fellows, thereby increasing their skill level while earning some income. The increased skill level attained with these fellowships led to significantly improved patient care at local or community hospitals.

Where subspecialization was once mostly restricted to larger academic centres, having recent graduates with subspecialty training has allowed a considerable increase in specialty care in smaller centres, with a significant decrease in patient referrals to larger centres.

The number of training positions has recently been decreased to limit the number of newly graduating surgeons. Job sharing between senior surgeons and recent graduates has become much more common over the past few years. This permits a mutually beneficial transition from full-time to part-time practice and eventual retirement for the senior surgeon, with the recent graduate fully integrated into the hospital practice by the time the senior partner retires. This model has been widely adapted in academic centres and is also increasingly popular in community hospitals.

The issue of patient access to care continues to be a major problem. Orthopaedic surgeons in Canada deliver high-quality care; however, barriers to access to this care for patients are frequent. The recent decision to decrease the number of training positions will almost certainly have a negative effect on access to care as the surgeon population ages and the economic picture brightens. This encourages older surgeons to consider retirement.

There have been substantial efforts to improve the efficiency of care at the hospital level

so as to improve access. These efforts include pre-consultation screening to ensure appropriate indications for surgical care, rapid recovery protocols for hip and knee arthroplasty patients to decrease the length of stay in hospital, and the increasing use of same-day outpatient surgery for complex procedures. Ambulatory fracture care, total ankle arthroplasty, and total shoulder arthroplasty are all now routinely carried out on a same-day discharge basis.

The balance between government spending for health care and patient access (and satisfaction) will be familiar to all readers of this article.

Canadian surgery has some unique perspectives in the lack of private practice, but there are also issues around physician compensation or remuneration that contribute to some difficulties in terms of delivery of care.

Because Canadian orthopaedic surgeons derive their income from fee-for-service, there is therefore a lack of a salary or pension scheme for practising surgeons. In addition, there is no mandated number of consultant positions at the hospital level and no mandated retirement age in public hospitals. The surgeons are consequently responsible for providing for their own retirement benefits independent of specific government support for retired physicians. As I mentioned, healthcare spending is delivered and paid for at the provincial level but mandated at the federal level. In order to decrease physician demands for higher fees for service, a

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number of provinces encouraged physicians to incorporate their practices. This is a strategy available to small business owners in Canada, which permits preferential tax advantage to money earned and retained within the corporation. Thus, a practising surgeon, by incorporating his practice, becomes a salaried employee of that corporation and the difference between the income paid to him or her by the corporation and the amount of money paid into the corporation on the fee-for-service basis can be retained within the corporation at a preferential tax advantage. There are further benefits as to how this retained income can be invested, used to support family members or employees of the corporation, and used to manage the expenses of practice.

While this was an excellent deal for the provinces, allowing a de facto decrease in the tax burden and therefore a potential increase in available income for practising physicians, it eventually became a very bad deal for the federal government, which is responsible for tax collection in Canada. Thousands of physicians had incorporated their practices as a

consequence of the rulings in the provinces and the lost revenue to the federal government was being calculated in billions of dollars. In order to counter this, the federal government passed legislation that significantly restricted the number and scope of these private corporations. The Canadian Medical Association, the umbrella group of all physicians practising in Canada, launched a political campaign against these changes. As a result, the original rather draconian federal legislation outlawing these tax reduction strategies has been softened somewhat, but the benefit to the practising physician is no longer as great as it once was, leading to increased physician dissatisfaction with the public healthcare system. Furthermore, by decreasing physician income in this way, older surgeons have been encouraged to stay in practice, thus potentiating the problems of physician unemployment and relative oversupply of orthopaedic surgeons.

These three issues of physician supply, patient access, and physician compensation are universal in government-run healthcare systems. The root of the problem remains a divide

between patient expectation, the government’s ability and willingness to pay for timely quality health care, and hospital priorities in care delivery that often continue to follow traditional models of resource allocation as opposed to using current demographic data and patient demand to determine the allocation of resources.

The challenges for care delivery may be slightly different between Canada and other countries, but I suspect there is more in common than is immediately apparent.

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J. P. Waddell, MD, FRCSC, Professor, Division of Orthopaedic Surgery, University of Toronto, Toronto, Canada and Staff Surgeon, Division of Orthopaedics, St. Michael’s Hospital, Toronto, Canada waddellj@smh.toronto.on.ca

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Notes from the Road

D. H. A. Jones

Ice cold in Addis: David Jones reports on significant improvements in orthopaedic care and training in Ethiopia

n January, I made my third visit to The Black Lion Hospital (BLH) in Addis Ababa on behalf of World Orthopaedic Concern (WOC), with the invaluable support of The Bone & Joint Journal. I was accompanied by James Berwin, a third year orthopaedic registrar from Bristol, also sponsored by WOC, and Susan Hendrikson, a plastic surgery registrar, again from Bristol and, incidentally, James’ fiancée. They were excellent companions and were undaunted by the sights and sounds of Addis and the unmet orthopaedic and trauma needs of the local population and beyond. It’s always rewarding to encourage young surgeons to look further than their local training programmes and spend even a short time in a country where resources are limited and demand overwhelming.

My first visit was in 2015, reported in BJJ News as ‘A Faranji in Addis’.1

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I am pleased to report continuing progress in the delivery of orthopaedic care in Ethiopia, with many agencies and individuals around the world contributing to this. WOC’s efforts, albeit modest compared with those directed at infrastructure projects or supply of equipment, are significant in relation to the immense problems in teaching and training.

There are 92 residents based at BLH alone, all hungry for teaching and training before their exit exam and resettlement around the country as consultants. The local surgeons are very good but there is no way that there are enough of them, as of yet, to cope with this demand. Therefore, the help of visiting surgeons, indeed all members of the orthopaedic team, is invaluable.

Last year, 18 residents qualified as consultants, with five remaining at BLH and the others returning to their provincial hospitals. This year, there will be 27 final-year residents eligible for the exam. Of these, ten will also sit the College of Surgeons of East, Central and Southern Africa (COSECSA) examination, which adds considerably to a young surgeon’s CV. Last year, four Black Lion residents (including three women) took this examination and all passed. Fortunately, there is no obvious trend for young surgeons, once appointed or eligible for consultant posts, to leave

Ethiopia. Similarly, the previous concern of orthopaedic surgeons gaining overseas experience and remaining there is unfounded. As examples of this, Drs Geletaw and Sami returned from their fellowships in Toronto and are having a major impact in improving trauma care, with a special interest in pelvic and acetabular fractures.

Two provincial cities in particular, Hawassa and Bahir Dar, are developing their own services with newly qualified surgeons from BLH and are

Fig. 1 Boy with a neglected Ewing’s sarcoma of the forearm and a probable orbital secondary.

Fig. 2 Three-year-old girl with pelvic and femoral fractures. From left to right: before external fixation, after external fixation, and following removal of the fixator.

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Fig. 3 Gustilo IIIB injury after delayed primary debridement.

Fig. 4 Coffee ceremony at Lalibela. keen for external help. At the former, there has been a major contribution from the Northwest Orthopaedic Trauma Alliance for Africa (NOTAA),2 with Tony Clayson as one of its founders and first Chairman. It was established with full charitable status as a recognized subgroup of WOC UK to engage with all staff groups working in orthopaedic units in the Northwest, enabling them to work together and support the development of sustainable orthopaedic trauma services in Africa.

Bahir Dar has been visited by the Leicester team as part of their regular commitment to Gondar, and it is planned that WOC surgeons going to Addis will include Bahir Dar in their programme. Laurence Wicks continues to work hard in coordinating these visits.

As a reminder of BJJ’s invaluable help in training and teaching, the journal gives £6000 annually towards travel and accommodation expenses for visiting surgeons, and this figure is matched from WOC funds. This has allowed for a planned programme of support that integrates with other agencies who visit BLH. In addition, BJJ gives free online membership to all orthopaedic residents at BLH. Since these arrangements began, there have been regular sponsored visits to BLH. Aside from myself, the surgeons included Steve Mannion, Laurence Wicks, Sally Tennant, Simon Bennet, and Sanjay Gupta. Sanjay’s expertise in orthopaedic oncology was particularly useful, as the facilities for treating bone and soft-tissue sarcomas in Ethiopia are very basic and allow for surgical ablation only, with little prospect of chemotherapy or prosthetic replacement (Fig. 1).

Fig. 5 Lalibela. External (top) and internal (bottom) views of Bet Medhane Alem, the largest monolithic church in the world, which is protected from erosion by a huge roof.

Another outstanding need is the development of a spinal unit, and pressure for this is growing from orthopaedic and neurosurgeons. Laurence Wicks is helping to facilitate input from the UK. Initial meetings have taken place and there has been interest from Nottingham, with Oxford to be approached. It is hoped that a spinal trauma and infection course will be run later this year.

Paediatric orthopaedics at BLH is fortunately well supported by The Cure Hospital, with Rick Gardner and Tim Nunn to the fore. As well as providing a tertiary service for complex cases from BLH, they contribute to its teaching programme and take residents on short-term appointments.

Rick has plans to establish a paediatric fellowship for residents and to create a separate subspecialty examination in paediatric orthopaedics at COSECSA, supported by surgeons from the UK and Toronto, Canada.

Finally, WOC UK ran a successful session at the British Orthopaedic Association (BOA) Congress in September 2017, themed on Ethiopia. The guest speaker was Dr Biruk L. Wamisho, Head of the Department of Orthopaedics and President of the Ethiopian Society of Orthopaedics and Traumatology (ESOT). He endorsed the positive impact of WOC UK in Ethiopia and how it continues to bear fruit. Dr Biruk also attended the BOA President’s dinner, together with Steve Mannion, WOC UK Chairman.

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Fig. 6 Timkat in Lalibela. Pilgrims and tourists around St George’s Church.

Fig. 7 Timkat in Lalibela. Two of the processions.

To return to our visit, the Ethiopian Airways flight, travelling overnight on Saturday, was good value. Our accommodation was The Iliana Hotel,

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not quite up to its website claims but nevertheless welcoming, comfortable, and a 20-minute walk from BLH. Across the street from the hotel was Tamoca, the original Ethiopian coffee-house and shop, and the equivalent of a World Heritage Site for coffee buffs. The espresso made my fillings rattle but the macchiato, made with milk, was gentler to the taste and a standard drink among those standing (no seats here) to discuss the affairs of the world.

On arrival at the trauma meeting on Monday morning, we were expected and welcomed by Dr Biruk and all present, which included around 50 residents. The organization of the department is much improved, with a clear weekly timetable and structured teaching programme. The daily trauma meetings are well run, with computer projection of clinical photographs and images. There is no shortage of smartphones, tablets, and laptops among the staff, and the injuries and skills in their treatment were clearly shown (Fig. 2). Drs Geletaw and Sami are particularly active in teaching and interrogating the residents who are keen and eager to learn.

Dr Biruk, as head of department, has a good vision for its future. He is raising the profile of orthopaedic surgery at government level and increasing the local consultant force. Within the department, it was reassuring to note that the library – its old journals and books no longer useful, and which last year was full of discarded furniture, radiograph, and anaesthetic machines – is being converted to office space for consultants. A new building is going up alongside the orthopaedic block and this will include a much-needed replacement for the overwhelmed emergency department at the hospital.

Despite this progress, the hospital remains hugely under-resourced for its workload and this is compounded by regular failures in its infrastructure and supply chains, exemplified by failures in power and water supply, autoclave breakdowns, and equipment shortages. With such setbacks, it might be easy to lose heart but the aspirations of the orthopaedic department remain undaunted. The continuing need for external support in clinics, wards, theatres, and formal teaching programmes remains, and our contribution was much appreciated.

After each trauma meeting, we set ourselves to work where most needed. With my paediatric experience, I had a daily commitment to a clinic or ward round, where residents and medical students were keen to learn. I also undertook informal tutorials for medical students on orthopaedic topics generally.

Thursdays were set aside for the residents’ training programme and all had to attend unless in theatre or on-call. We contributed fully to these.

On the first Thursday, James and Susan ran a particularly useful and interactive session on open tibial fractures, sharing their knowledge of management of the bony injury and soft-tissue cover with the experience of the local surgeons.

On our second Thursday, Susan ran a journal club on papers that considered outcome in relation to time to debridement in open tibial fractures. At Southmead Hospital in Bristol, she is involved in a multicentre study to investigate this aspect in Gustilo IIIB injuries. She and James recruited BLH into the study and their outcomes will be interesting, as many patients have to travel long distances to get there and, even after arrival, may have a long wait before theatre space is available. Their time to debridement, therefore, can be days rather than hours (Fig. 3).

We also found time for a half-day teaching visit to Addis Ababa Burn, Emergency and Trauma (AaBET) Hospital (St. Paul’s), which has a significant trauma load and its own residency programme. Our presentations were well received, and future WOC visitors to Addis will include AaBET in their programme. A positive spin-off was that BJJ agreed to offer the AaBET residents free online subscriptions.

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Fig. 8 Lalibela. Susan Hendrikson and James Berwin at the spectacular Ben Abeba restaurant, which specializes in Shepherd’s pie.

Our mid-visit weekend coincided with Timkat, the Ethiopian Orthodox Epiphany and a celebration of the baptism of Christ. It is the major festival of the Ethiopian calendar and, although a huge event in Addis, we were advised to experience it in Lalibela, around 700 km to the north. We were lucky to get a flight there and found accommodation in a local guest house, complete with its traditional coffee ceremony (Fig. 4).

Lalibela is a World Heritage Site on account of its amazing monolithic, rock-hewn churches, created during the reign of King Lalibela in the 13th century (Fig. 5). The spectacle of Timkat was unforgettable. On the first of three days of celebration, the Tabot (symbol of the Ark of the Covenant containing the Ten Commandments) is taken out of the monastery and becomes the basis of huge daily processions of monks, priests, and pilgrims (Fig. 6). The monks and priests all shake sitras (religious bells) and blow horns, and the pilgrims add to the noise by chanting, dancing, and banging sticks (Fig. 7).

On both evenings, we ate at spectacular restaurants with sunsets to match, and, overall, we had an unforgettable weekend break (Figs 8 and 9).

In relation to the title of this article, many of you will remember the war film Ice Cold in Alex, in which the stars endured all kinds of hardship and danger before achieving their longed-for reward, namely an ice-cold beer in Alexandria.

Despite difficulties and setbacks, the efforts of so many to improve orthopaedic care in Ethiopia are bearing fruit and are truly praiseworthy.

I’m not suggesting that we had to endure anything like the hardships of the heroes in the film, but thought our modest efforts deserved a celebratory beer (Fig. 10) at the end of the trip (not to mention a few along the way, plus some very drinkable Ethiopian Cabernet Sauvignon!).

The development of orthopaedic services and training in Ethiopia is most encouraging. Those who visit are rewarded by positive memories of their efforts and travels, and BJJ continues to make a significant contribution to the story.

References 1. Jones D. A Faranji in Addis. BJJ News 2015:8;15-16.

2. No authors listed. Northwest Orthopaedic Trauma Alliance for Africa. nota4africa.org.uk (date last accessed 12 June 2018).

Fig. 9 Sunset in Lalibela.

Fig. 10 James Berwin and David Jones enjoying an icecold beer in Addis Ababa.

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D. H. A. Jones, (FRCS, FRCSEd(Orth), Honorary Consultant Orthopaedic Surgeon, Great Ormond Street Hospital, London, UK davidhajones@hotmail.co.uk

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D. Warwick

Notes from the Road

Me and my clavicle: What goes through an injured orthopod’s mind?

here I was, riding my mountain bike with two friends on a sunny Sunday morning at 10.6 mph (I know this because my Garmin recorded a very sudden stop). The next thing I knew, I was in a bush with an increasingly painful crunching clavicle. It turns out that I had caught my front wheel in a rut hidden by a florid bush.

Several thoughts invaded my mind. Ever the pessimist, I thought this could be bad. I was therefore relieved to find that the initial tingling in my arm had promptly gone, so no plexus injury. When I moved my shoulder joint passively, it seemed smooth without crunching. No life-changing intra-articular fracture either. How about my bike, my 29” carbon-fibre pride and joy? Fortunately, it was unscathed.

By now, the shoulder was becoming rather painful and I was getting a bit worried. Worried about cancelling work and cancelling a holiday, not being able to drive or bathe or keep fit, letting down people who had booked in to see me, being a burden on my family, realizing it could have been a lot worse if I had damaged my plexus, neck, or shoulder joint, and so on and so forth. These worries took weeks to subside.

Then it dawned on me that I needed to be retrieved from the gutter.

So my two mates picked me (and my bike) up, and hauled me to the nearest road. I made three phone calls: one to the ambulance service (giving them the Sat Nav position from the Garmin – such a great toy), one to my wife and daughter (primarily to come and pick up the bike, of course), and finally – probably most importantly – to my dependable shoulder surgery colleagues. One was in Spain on holiday but the other was around. “But”, he said, “I can’t help you – I have got a few days off at home and so I haven’t got an operating list this week.” “Oh, but you have,” I retorted. “I have a list on Tuesday and I am pretty certain I won’t be needing it.” So, as it happened, it ended up with me in my own day ward being operated on in my own theatre by my own theatre team.

The ambulance arrived. I didn't fancy morphine but gladly and voraciously sucked in Entonox, although not until I had established that my wife and daughter (who came to pick up the bike and to tell me off for my stupidity) knew I was OK, and that the ambulance crew were happy to drive a bit further than the nearest casualty department so that I could be dumped in my own hospital, which, I am proud to say, I trust implicitly.

When I got to hospital, someone had tipped them off so I was met by one of my anaesthetic friends, who stuck in a drip and gave me an opiate (my clavicle was horridly sore by now) and by one of my emergency department (ED) colleagues, who had me examined and x-rayed promptly. Fortunately, being a Sunday morning, the place was empty so there was no need for favouritism or cronyism. The radiographs were then photographed and ‘WhatsApped’ (a great way to send patient data securely) to my eagerly awaiting shoulder surgeon friend.

My wife took me home, me dopey and both of us grumpy. My shoulder surgeon friend popped round that evening to discuss treatment. And here at last we get to the point of this hitherto pointless article: do I have surgery or don’t I?

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I am well versed in fully informed consent, not least because of a fairly busy medicolegal practice and a chilling recognition of the spiralling costs of litigation, which drain the NHS. So I know every operation has risks and benefits. I know we should, in general, always favour nonoperative treatment, all other things being equal. Plates are not cheap and we are all custodians of healthcare resource; money wasted on my shoulder could be far better spent on a worthy cause.

But the one thing foremost in my sad Type A workaholic mind was: how soon can I get back to work?

My NHS and private work were both compromised: there are patients midway in their follow-up; operations booked for which patients had rearranged their own lives; new patients to see to maintain the flow of my practice; a Registrar and Fellow to whom I must teach as much as I can within a short six-month attachment; and my own mortgage and car loan to service, not to mention my private anaesthetist, who suddenly has a gaping hole in his income.

So, I read up a few papers and discussed this with my shoulder surgeon. My starting point was that I trusted his skills without question. I have worked with him for years and know his meticulous demeanour and reputation for excellent outcomes. How many patients coming in off the street and subject to random allocation of the next available non-­specialist surgeon, or even trainee, can have that justified confidence?

I also trust the technology. Locking plate fixation, when done properly, works. The bone is held so dependably you can get the joints moving. So, I needed no persuasion there.

What does the literature tell us about return to function? Coincidentally, a meta-analysis of six randomized control trials (RCTs) comparing non­ operative with operative fixation for mid-shaft clavicle fractures had recently been published,1 which reported that the chance of a nonunion is much lower with plate fixation (relative risk (RR) 0.14). While, at one year, outcome scores were similar between each group, there was no mention in the

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abstract of relative patient satisfaction or outcome scores at an earlier stage.

Is this not a shortfall in the way we provide readily available information that tells patients what they really want to know? So I dug deeper and found the UK Clavicle trial.2 Satisfaction scores, Constant Score, and Disabilities of the Arm, Shoulder and Hand (DASH) score were all overwhelmingly in favour of surgery at six weeks and still in favour at three months, but by nine months there was no difference. By nine months, the chance of a nonunion was 0.8% in the surgical group and 15% in the non-surgical group.

There were no infections and no surgical disasters, so, unusually for me, I made up my mind rather easily. Surgery was a no-brainer.

The last thing I wanted was to wait months with the dysfunction and pain of an ununited clavicle fracture, and then have surgery in any event.

My professional obligations and psyche, let alone bank balance, would not tolerate that. If, in the future, I needed the plate removed because it rubs on my rucksack straps, then so be it – I could schedule that at the beginning of a two-week holiday and incur no time off work.

I am intuitively risk-averse (i.e. a wimp). I knew that my surgeon would not drill my subclavian vein (although he has since confessed to a sleepless night prior to the operation). I am, at my post-pubescent age, pretty clear of the acne bacteria that can infect the plate. Anyway, my liver and kidneys will tolerate a hefty dose of prophylactic antibiotics. General anaesthesia is scrupulously safe, so the prospect of surgery did not really worry me.

I concluded that, from a health economic perspective, getting me back to work with surgery, and paying tax even a week sooner (let alone several weeks), would more than cover the cost of the plate and anaesthetic drugs.

After all, the theatre resource is cost-neutral because all the salaries, heating bills, and real estate would have been paid for anyway. One only actually realizes cost savings if the staff are sacked and the hospital building is sold off for housing. This fundamental point seems to be consistently overlooked in cost-effectiveness calculations by academic papers or government health economists or Commissioners. The same thoughts might be considered for the utility of other procedures that dramatically accelerate return to function in the first few weeks, but not months, after treatment, such as volar plating instead of K-wires for wrist fractures, collagenase clostridium histolyticum (CCH) instead of surgery for Dupuytren’s contracture, and percutaneous screws rather than plaster for scaphoid fractures.

These treatments may, on a superficial cost analysis, be denied to patients at great expense to the self-employed and the Treasury.

The surgery went well, but did it hurt! I was given bags of oramorph and dihydrocodeine and paracetamol (no ibuprofen though, in case nonsteroidal anti-inflammatory drugs (NSAIDs) slow bone healing), and I used the lot. The trouble is that after a shoulder operation you cannot sleep. Lean on the injured side and it compresses and hurts, lean on the other side and it distracts and hurts. Curl your forearm under or behind your head and it rotates and hurts. So you have to sleep propped up in a v-shaped nest of pillows, which is so awkward and unfamiliar that you can’t sleep anyway. And it still hurts.

I was back at work five days later. I could competently, if slowly, manage a simple clinic. Protracting my shoulder to sign my name was surprisingly sore. I could examine a hand or wrist. If someone needed an injection I arranged to bring them back a few weeks later or asked a colleague. I did not venture into surgery at all for four weeks, at which point I was absolutely safe to do simple carpal tunnel or trigger finger-type cases. By six weeks, I could carry out wrist arthroscopy and metalwork fixation (which would otherwise until then have been quite a burden on the shoulder). I drove when I was entirely safe, at three weeks. Until then, I had to engage

my daughter, fortunately home from university, as a chauffeuse. She was willing to do this on the usual terms of borrowing the car when she wanted to, with Daddy paying for the petrol (which was just about affordable) and the insurance (which, for a 19-year-old, was certainly not).

The night pain was bearable after a couple of weeks, and, by six weeks, radiographs showed the fracture to have healed. After that, it was quite sore on overuse for a couple of months but otherwise more or less better.

By eight months, the weird infraclavicular numbness has almost entirely dissipated (can a nerve scientist tell me how on earth the territory of several divided nerve endings can be re-innervated?). The scar – a testament to my choice of surgeon – is invisible. And that is important too; our patients will surely deduce that if the wound looks like a wild animal attack, perhaps the underlying surgery is of dubious quality.

What about cycling? Well, I am back on the bike, much to the chagrin of my wife. I had missed the excitement, adventure, fitness, fresh air, and banter. I have taken Vitamin D ever since the fall, so perhaps that will make my bones less fragile. I am rather more cautious now (or, as my compassionate cycling mates more accurately describe me, a ‘slow chicken’), and the rucksack straps are not abrading on the plate.

As for being a patient, in a strange way, I am glad this happened. Never again will I strut onto the ward or barge into theatre like an entitled peacock.

All the staff on that helpless day treated me as a normal patient and overlooked my past misdemeanours. Moreover, and most humbling, the whole episode has made me more sympathetic towards my injured patients – your life can change so suddenly and you become very vulnerable. I realize that my injury was, despite all the pathetic fuss I made, very trivial and essentially fixable. I cannot imagine how I would have coped with a more serious and permanent life-changing injury. Yet I have tortured myself with the shameful thought that, until now, perhaps I had never deeply and fully empathized with the thousands of more seriously injured patients who had come my way. Chastened, I will try and make up for this for the rest of my career.

Of course, you are dependent on the technical skill of the orthopaedic surgeon who treats you. I was privileged enough to choose my hospital and surgeon (for most patients, it is pot luck). But at least as important for the patient is the surgeon’s non-technical skills: the calm demeanour, confidence yet humility, empathy, and diligence. I will henceforth practise these and hope to give my future patients the reassurance that I felt from ‘my’ surgeon.

Indeed, the term ‘my’ shows the intense personal relationship that we surgeons have to nurture with each and every patient whose damaged body comes to us for help. I will do my best not to betray that privilege.

References 1. Woltz S, Krijnen P, Schipper IB. Plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a meta-analysis of randomized controlled trials. J Bone Joint Surg [Am] 2017;99-A;1051–1057.

2. Ahrens PM, Garlick NI, Barber J, Tims EM, Clavicle Trial Collaborative Group. The Clavicle Trial. A multicentre randomised controlled trial comparing operative with non-operative treatment of displaced midshaft clavicle fractures. J Bone Joint Surg [Am] 2017;99-A:1345-1354.

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D. Warwick, MD, BM, FRCS, FRCS (Orth), Eur Dip Hand Surg, Consultant Hand Surgeon, University Hospital Southampton, Southampton, UK davidwarwick@handsurgery.co.uk

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G. Charnley

Arts

Your starter for ten

n January 2018, the British Orthopaedic Study Group (BOSG) celebrated its Golden Jubilee, in Zürs, Austria.

Fifty years earlier, this meeting in the Arlberg had been convened to share advances and topics in orthopaedic surgery in their broadest terms. Presentations on this occasion covered surgical techniques and basic science, as well as foot, spine, hip, knee, trauma, and hand surgery.

In keeping with tradition, the scientific programme gives way, on the final night, to a more social event for members, their guests, and partners. Such are the talents of the BOSG that the ‘entertainment’ can include nonmedical lectures, poetry, music, and song!

Having limited musical talent myself – well, absolutely no such talent – I thought I would challenge the group with a passion that has interested me away from the operating theatre, that is, Fine Art. I would set them a typical University Challenge picture quiz, ‘Your Starter for Ten’.

The audience were asked to link five pictures. These included a dashing fellow on a Vanity Fair card, a sombre bearded gentleman, a young chap in his best school blazer, a bar of soap, and an image of the well-known student quiz (Fig. 1). What could possibly link these images?

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The dashing fellow was Frederic Leighton. A financially well-off Victorian, the son of a physician from Yorkshire whose grandfather had been physician to the Czar of all Russias.

Leighton decided not to pursue a career in medicine but one in art, spending his formative years in France and Italy.

On his return to England, he developed an artistic style described as Neoclassical. His work was more restrained than that of the other artists of the era, the more ‘radical’ PreRaphaelites. Perhaps due to his upbringing, he developed influential friends including the Prince of Wales, became successful, and was made a Fellow of the Royal Academy of Art. He lived just off Kensington High Street, close to Holland Park, where he had an imposing home and studio. The ground floor of his home, Leighton House (today open to the public), contained Arabic wall tiles that he had imported from the Middle East and he often entertained at his home as well as using it as his place of work.

In 1879, a young 19-year-old girl, Ada Pullan, appeared outside Leighton’s studio and found work as an artist’s model. Over the next 25 years, she became Leighton’s main model and muse. Leighton was unmarried and tongues started to wag, suggesting that there was more to their relationship than art.

Leighton refuted this, perhaps because he was

becoming more and more successful, and had been both knighted and made President of the Royal Academy of Art. Ada wished to better herself and become an actress, and Leighton supported her in this endeavour, funding her elocution and acting lessons, and taking his friends along to plays in which she had minor roles. Ada changed her name to Dorothy Dene at the suggestion of Leighton.

His excessive and vociferous support seemingly inspired George Bernard Shaw, the gentleman in the photograph in Figure 1b, to create Pygmalion. Shaw disapproved of the relationship that Leighton had with Dorothy and her limited acting ability.

Leighton’s health was declining due to angina; in 1892, he painted five major works for what was to be his final submission to the Royal Academy Summer Exhibition. One of these was of Dorothy, slumbering in a stunning orange gown, a painting named Flaming June, which is widely considered to be his greatest work (Fig. 2). This canvas was exhibited, along with the other four, but, despite being the President, Leighton was too unwell to attend.

The following January, shortly after being created Lord Leighton of Stretton, he died and his funeral was held at St Paul’s Cathedral. Dorothy and several of her sisters, also models for Leighton, received a bequest from his estate of almost a million pounds. However, Dorothy did

Fig. 1 A selection of the images given in Godfrey Charnley’s picture quiz, ‘Your Starter for Ten’. From left to right: a caricature of Lord Frederic Leighton on a Vanity Fair card; George Bernard Shaw, image courtesy of the National Portrait Gallery; and University Challenge, image courtesy of REX/Shutterstock.

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Fig. 2 Flaming June by Frederic Leighton.

Fig. 3 A study for Flaming June by Frederic Leighton. Image courtesy of Sotheby’s.

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not live long to enjoy this, dying of peritonitis three years later.

Flaming June was sold to the Bass brewing family and, in time, was loaned to the Ashmolean Gallery in Oxford in the 1930s to celebrate the centenary of Leighton’s birth, before later vanishing from view. Around this time, Victorian art was no longer popular.

The canvas re-emerged in 1962 in a house renovation and clearance off Clapham Common, South London. It was put up for sale for the princely sum of £50 and a young schoolboy tried to buy it, but his grandmother would not forward him the funds. He had already spent too much of her money, in any case, on Victorian novels! The boy, Andrew Lloyd-Webber, was very frustrated. The canvas was instead bought by Jeremy Maas, an art dealer, and sold to the State Museum of Art in Ponce, Puerto Rico, where it still hangs.

It was only from the mid-1960s onwards that Victorian art started to be recognized for its true worth, not only in terms of artistic merit but also financially. Many of the original works of art had been bought in the Victorian age by those with new wealth. The collectors of Leighton’s work and the work of his contemporaries were successful politicians and wealthy industrialists such as Sir Henry Tate, Lord Farringdon, Sir Arthur Graham, and Lord Leverhulme, the son of a wholesale grocer from Bolton.

Leverhulme made his fortune selling Sunlight soap. Around his factory in Port Sunlight, near Birkenhead, he set up an art gallery to educate and stimulate his employees. When his own collection of art from his home, Thornton Manor on the Wirral, was sold off in 2001, an unknown study for Lord Leighton’s Flaming June (Fig. 3) came to the art market. It was snapped up by a new, modern-day Industrialist, Perez Simon, a Mexican telecommunications billionaire, who is probably the largest current collector of all types of Fine Art, from the Renaissance via the Pre-Raphaelites, to the Surrealists and Impressionists.

His only rival in collecting Pre-Raphaelite and Victorian art is the now not-so-young Andrew Lloyd-Webber, who, on the strength of his musicals, has over the past 40 years collected an astonishing amount of art, including the works of Leighton, Edward Burne-Jones, John William Waterhouse, and others.

Finally, what could University Challenge have to do with Dorothy Dene and Flaming June? In 2014, Bamber Gascoigne, the original quizmaster, inherited a small stately home in West Horsley, Surrey, from his great aunt, the Dowager Duchess of Roxburghe. This 50-room house

BJJ News | I ssue 13 | A ugust 2018

Fig. 4 A chalk study for Flaming June by Frederic Leighton. Image courtesy of Sotheby’s.

needed some considerable restoration work and, to fund this, most of its contents needed to be sold. In one of the upper bedrooms was a chalk study, unknown to the art world, of the head of Dorothy Dene (Fig. 4), which helped Bamber by realizing a hammer price of over £160 000. Much to the delight of the musicos in the audience, this is now the new home of the Grange Park Opera!

To complete the story, the five late masterworks of Leighton, including Flaming June, and paintings from the collection of Andrew

Fig. 5 Frederic Leighton’s five late masterworks, exhibited in Leighton House in 2017. From left to right: Candida, Lachrymae, The Maid with Golden Hair, Twixt Hope and Fear, and Flaming June. Image courtesy of Leighton House Museum, the Royal Borough of Kensington and Chelsea. Photograph by Kevin Moran.

Lloyd-Webber, along with works including the study owned by Lord Leverhulme, were all reunited in Leighton House in 2017 (Fig. 5).

For myself, as an admirer of Victorian art, this was a perfect note on which to end, and I was delighted that at the beginning of my talk, none of the esteemed members of the BOSG managed to find the common link between the images of ‘Your Starter for Ten’.

The link was Dorothy Dene, an artist’s muse, who beguiled Lord Leighton, irritated George Bernard Shaw, stimulated an artistic

passion in Andrew Lloyd-Webber, was keenly sought by Victorian and modern-day Industrialist art collectors, and, most recently, helped a ‘down-at-heel’ quiz show host revamp a stately home he had unexpectedly inherited.

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G. Charnley, MBBS FRCS FRCS (Ed) FRCS (Orth), Springfield Hospital, Springfield, Chelmsford, UK godfrey.charnley@hotmail.co.uk

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P. Richardson

Arts

Hand disorders in pianists

n October 1979, Naomi Graffman, wife of the celebrated American concert pianist Gary Graffman, was at home in New York listening to her husband practising Brahms’ Second Piano Concerto, a monumentally difficult piece that nonetheless he had played to great acclaim on many occasions. But now she could hear errors that made listening almost unbearable.

She encouraged him to take a break from his practice and enjoy a stroll with her in the Manhattan autumn sunshine. Having walked several blocks in silence, he suddenly blurted out: “Something’s wrong. It’s been wrong for a long time, and it’s getting wronger and wronger.”1

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In many ways, this was a relief for Mrs Graffman, who had noticed a decline in her husband’s playing over the previous few months. A tricky passage in Rachmaninov’s Second Piano Concerto, and another in Prokofiev’s Third Piano Concerto, neither of which had previously given him any trouble, had begun to sound unpractised in recent concerts. The truth was that he had redoubled his practice schedule to compensate for a problem in his right hand, whereby the fourth and fifth fingers were curling into his palm, and gradually becoming useless. The problem dated back to 1977. At a concert that year with the Berlin Philharmonic, he had sprained the fourth finger of his right hand while trying to make himself heard above the orchestra on an unresponsive piano. On that occasion, he had had to refinger the entire performance at the last minute, playing righthand octaves between his thumb and third finger (rather than the fourth or fifth finger, as is far more common). As a side note, some pianists have enormous hand spans, with Rachmaninov being able to stretch a 12th comfortably, i.e. from middle C to G in the octave above! Other top pianists, such as Daniel Barenboim and Vladimir Ashkenazy, have a much smaller stretch, and so there appears to be no necessary correlation between the size of a pianist’s hands and their technical ability.

After consulting many different specialists, Gary Graffman was eventually seen by the neurologist, Dr Fred Hochberg, and orthopaedic surgeon, Dr Robert Leffert, at Massachusetts

Fig. 1 Pianist Gary Graffman. Image courtesy of Carol Rosegg.

General Hospital (MGH) in Boston. Both avid music lovers, Leffert and Hochberg were frequently consulted at their multidisciplinary clinic by many musicians with intractable hand problems.

The problem with Graffman’s right hand was initially thought to be due to weakness of the extensor muscles of the fourth and fifth fingers, leading them to curl under his hand involuntarily as he played. Extensive tests were performed, including videotaping him playing, and he was given a bio-feedback machine and muscle-strengthening exercises. Much later he was diagnosed with focal dystonia, a painless disorder of motor control arising from multiple repetitions of the same movements, leading to involuntary muscle contractions. Its incidence is estimated to be one in 200 musicians.2 It is thought that the composer Robert Schumann (1810-1856) may have developed the same condition following the use of a mechanical contraption to exercise the fourth finger of his right hand independently of the others. Schumann even wrote a specific piece (Toccata, Op. 7) that requires extensive use of the fourth finger of the right hand, but his hand suffered permanent damage.

Gary Graffman has not been able to resume a full concert career, but has continued to perform pieces requiring only the left hand. The

Fig. 2 Composer and pianist Sergei Rachmaninov.

best known of these is Ravel’s Concerto for the Left Hand, commissioned by the Viennese pianist Paul Wittgenstein, who lost his right arm in the First World War. Scriabin, Britten, Korngold, and many other composers have also written pieces exclusively for the left hand. Graffman’s career has continued successfully and he is President of the famous Curtis Institute in Philadelphia, where his students have included the pianists Lang Lang and Yuja Wang.

Another American pianist and close associate of Graffman, Leon Fleisher, had similar symptoms in his right hand, with the fourth and fifth fingers curling under and digging into his palm. Having given up playing with his right

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Fig. 3 Pianist Leon Fleisher. Image courtesy of Eli Turner. hand, he took to conducting, as well as giving concerts of left-handed repertoire. He was also treated by Drs Hochberg and Leffert at MGH, where he was diagnosed in the summer of 1980 with carpal tunnel syndrome. Dr Leffert operated on Fleisher in January 1981, with a recording of Mahler’s First Symphony (which Fleisher was soon due to conduct) playing in the operating theatre!3 Fleisher’s doctors believed that his carpal tunnel syndrome had arisen from gripping the conducting baton too tightly, and was not directly related to the earlier pianistic injury.

Nonetheless, the fingers in his right hand improved following surgery, to the extent that he was able to resume his two-handed pianistic career in 1982. He was due to return with a comeback concert in Baltimore, playing Beethoven’s Fourth Piano Concerto, a work in which even fully fit pianists sometimes admit to feeling ill at ease, but he substituted the somewhat easier (and shorter) Symphonic Variations

by César Franck. This was not the triumphant comeback he had hoped for, and he was in tears in his dressing room before the concert. His right hand had still not fully recovered, and he reverted to left-handed repertoire for his remaining comeback concerts that year. Finally, in 1995, he was diagnosed with focal dystonia, and began treatment with Botox injections.

Gradually, he was able to resume a two-handed playing career, until by 2005 he was playing 40 concerts in 31 cities, and in 2006 he played at New York’s famous Carnegie Hall.3 Graffman and Fleisher are two of the highest-­ profile pianists to have experienced debilitating and potentially career-ending problems that were eventually diagnosed as focal dystonia. Other musicians with the condition have included: Keith Emerson (the keyboard player with Emerson, Lake & Palmer); Tom Adams, the bluegrass banjo

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Fig. 4 The Swiss Orthopaedic Quartet. From left to right: Ronny Spiegel (violin), Fritz Hefti (piano), Josef E. Brandenberg (viola), and Luzi Dubs (cello). player; and Alex Klein, principal oboist with the Chicago Symphony Orchestra.

Why is the right hand more often affected in pianists? It nearly always carries the melody, which often needs to be heard above the orchestra, and the fourth and fifth fingers of the right hand are relied upon when playing chords – this is especially the case in the major concertos by Tchaikovsky, Rachmaninov, Brahms, Prokofiev, and Beethoven. The same fingers are also used in octave passage work (e.g. in Tchaikovsky’s First Piano Concerto, or in the famously difficult passage in Liszt’s B minor sonata). As noted above, Gary Graffman was forced to refinger octaves using his third finger instead, a most unusual and difficult manoeuvre for all but the most gifted of pianists!

Pianists also suffer from a wide range of conditions more amenable to treatment by hand surgeons. The hand surgeon (and excellent amateur pianist), David Evans, told me: “I have treated pianists with Dupuytren’s, osteoarthritis, tendon pathology, actual injuries, problems arising from the neck or peripheral nerves, and of course disorders that are more elusive to diagnose and may be ‘overuse’, ‘misuse’, etc.,

and are not confined to one occupation. The one condition that is commoner in musicians than others is focal dystonia, which is not a surgical condition but needs to be recognised by surgeons.”

There was an excellent review of hand disorders in musicians by Sheibani-Rad, Wolfe, and Jupiter in The Bone & Joint Journal in 2013.2 The authors reviewed a range of disorders, including overuse syndrome, entrapment neuropathies, focal dystonia, osteoarthritis, joint hypermobility, and thoracic outlet syndrome.

Finally, orthopaedic surgeons sometimes take to the piano themselves, with highly successful results! Professor Fritz Hefti, Co-Editor of the Journal of Children’s Orthopaedics (now published by Bone & Joint Publishing) is the pianist in the Swiss Orthopaedic Quartet. Together with two other Swiss orthopaedic surgeons (Josef E. Brandenberg, viola, and Luzi Dubs, cello), they are joined by Ronny Spiegel, a professional violinist. The quartet have recently made a recording of Vinzenz Lachner’s Piano Quartet in G minor, and the result – highly professional in both playing and production – can be seen on their recently released YouTube video.4

BJJ News | I ssue 13 | A ugust 2018 References

3. Walker L. Leon Fleisher: ‘My life fell apart…’

1. Dunning J. When a pianist’s fingers fail to

The

obey. The New York Times, 1981. https://www.

independent.co.uk/arts-entertainment/music/

nytimes.com/1981/06/14/arts/when-a-pianist-

features/leon-fleisher-my-life-fell-apart-1984408.

s-fingers-fail-to-obey.html (date last accessed 14

html (date last accessed 14 May 2018).

May 2018).

4. Lachner V. Piano Quartet in g minor op. 10

2. Sheibani-Rad S, Wolfe S, Jupiter J. Hand dis-

(1846). YouTube, April 2018. https://www.youtube.

orders in musicians: the orthopaedic surgeon’s role.

com/watch?v=KroL3KAoog8 (date last accessed 14

Bone Joint J 2013;95-B:146-50.

May 2018).

Independent,

May

2010.

https://www.

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P. Richardson, Chairman Medical Music Society of London, UK; Publishing Consultant and former Managing Director, The British Editorial Society of Bone & Joint Surgery, London, UK

Editor-in-Chief Professor Fares S Haddad University College London Hospitals, UK

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M. O’ Reilly

Arts

Flex, bugs, and rock ‘n’ roll: an orthopaedic registrar’s experience of music and medicine

hen a colleague of mine suggested that I write a piece discussing my own story with music and medicine, I wasn’t quite sure about it. Where would I start? What would I discuss? Would anyone be interested? Anecdotally, I was aware of the connection between the arts, music, and medicine, but a little more research led me to this quote by Therese Southgate: “Medicine and art have a common goal: to complete what nature cannot bring to a ­finish [...] to reach the ideal […] to heal creation.

This is done by paying attention. The physician attends the patient; the artist attends nature […]

If we are attentive in looking, in listening and in waiting, then sooner or later something in the depths of ourselves will respond. Art, like medicine, is not an arrival; it’s a search. This is why, perhaps, we call medicine itself an art”.1

W

Growing up, I was always surrounded by music as a constant presence in our house. My father and uncle formed a folk rock band called Loudest Whisper back in the late 1960s, and enjoyed both national and international success. Being exposed to this as a child ignited my passion for the guitar and music in general.

I took some lessons from the age of nine but no formal training. I quickly became consumed by composition and songwriting, my interests shifting slightly in my late teenage years due to the discovery of beer and girls. Music was not something I could, or wanted to, pursue at university level, and so medicine raised its head during my secondary school years owing to an older sister who had chosen it as her own path.

During my first year at medical school, I fronted an alternative indie rock trio. Filled with the naivety and ambition of youth, and fully convinced that this band was going to ‘make it’, I wanted to leave medicine after the first semester. Thankfully, I listened to the wisdom of my parents who emphasized the importance of having a qualification before diving head first into such a volatile and unpredictable industry. And so I continued with my studies, the ‘rock ‘n’ roll’ dream becoming ever more distant. My guitar, however, always remained close by.

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After graduating, I completed my internship and went on to do my basic surgical training and membership exams with The Royal College of Surgeons in Ireland. My parents, knowing that music was such a large part of me, began to ask, “When will you give the music a go?” on a regular basis. So I did. Initially, I started doing locum cover as an orthopaedic house officer and subsequently registrar, and began writing, recording, and touring my first solo album. The allied forces of a manager, agent, and band soon followed and led to extensive touring across Ireland, the UK, Europe, the Balkans, North America, and Australia. Highlights include performances at festivals like Glastonbury and Electric Picnic, as well as recording sessions at the BBC’s famous Maida Vale Studios and Peter Gabriel’s Real World Studio. Then came the contract with a major record label, Virgin Records Germany, and a publishing deal with Kobalt Music. This led to more touring and has culminated in nearly two million streams on Spotify. I am now four solo albums in, and orthopaedics – like my guitar before it – remains ever present, with regular locum work in between the studio time and live performing.

This connection between music and medicine has always interested me. We know that music and medicine have been closely linked since ancient Greek and Roman times: Apollo was god of medicine, music, and poetry; Homer applied the use of music in surgery.2 We also know that throughout history there have been many famous physician musicians such as Herman Boerhaave (Boerhaave’s Syndrome), Hector Berlioz, Theodor Billroth, Fritz Kreisler, Albert Schweitzer, Aleksandr Borodin, and Jeffrey Tate.2,3 There is a lot in the literature about music as therapy but very little about why so many doctors play music.3 Numerous doctor orchestras exist around the world but the same does not apply when it comes to other professions such as accountants, architects, or software engineers.4,5 Perhaps there is an overlap between aptitude for science and for music, with a paper in The Lancet suggesting that “the giving, the service – in music and medicine – is a natural connection”.4 I certainly don’t pretend to have the answer, but from my own experience there is a

definite symbiosis that exists between the disciplines. The uninhibited, free, and creative nature of music versus the scientific, black-and-white, pragmatic style of medicine leads to hugely stimulating and contrasting experiences. This is what I personally feel has been such a positive for me.

The work ethic instilled in me throughout medical school and my junior doctor career has been invaluable; applying this to my music has enabled me to achieve certain goals. Equally, the delegation required when one is a band leader has helped me greatly in the hospital setting. The performance nature of medicine, whether it be presenting a case to a consultant in clinic or a topic discussion at ground rounds, borrows much from my experiences playing live shows.

The necessary practice and hands-on approach required to attain surgical skills is equally as relevant when trying to advance my technical guitar abilities.

The link between music and medicine certainly requires more probing, and, for the moment, perhaps we can only be satisfied with the thoughts of Arnold Steinhardt, “that there seems to be a mysterious and powerful underground railroad linking medicine and music”.3 So why the title ‘Flex, bugs, and rock ‘n’ roll’, then? ‘Flex’ depicts the importance of range of motion, ‘bugs’ reflects the orthopaedic obsession with infection, and ‘rock ‘n’ roll’?

Well, it may not be rock ‘n’ roll – but I like it!

BJJ News | I ssue 13 | A ugust 2018 References

3. Simon HB. Music as Medicine. Am J Med

1. Scott PA. The relationship between the arts

2015;128:208–210.

and medicine. Med Humanit 2000;26:3-8.

4. Ofri D. Thoughts on a G string. Lancet

2. Cerda JJ. Art in medicine: musicians, physicians

2009;373:116–117.

and physician-musician. Trans Am Clin Climatol Assoc

5. Moshman SE. Reflections on a medical school

1993;104:228-234.

symphony orchestra. Am J Med 2011;124:1090–1091.

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M. O’ Reilly, Surgical Research CoOrdinator, Midlands Regional Hospital Tullamore, to Graduate Entry Medical School, University of Limerick, Ireland marcoreilly@gmail.com

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G. Scott

Appreciation

Michael A. R. Freeman (1931-2017)

ichael Freeman was appointed to The London Hospital as a part-time consultant in 1969, succeeding Sir Reginald Watson-Jones. His initial undergraduate training had been at Corpus Christi College, Cambridge, from 1950 to 1953, where he achieved First Class Honours in the Natural Science Tripos, before proceeding to the London Hospital Medical College and completing his clinical studies in 1956. It was at Cambridge that he shared rooms with John Insall (Fig. 2), who was to become a lifelong friend and sometime collaborator in the field of knee arthroplasty. As an undergraduate, his entrepreneurial instincts got the better of him and he attempted to become a restaurateur, but this enterprise failed. Perhaps it was this experience that provided him with such resilience.

Michael’s journey from graduation to consultant was extraordinarily rapid and accomplished. House jobs were completed at The London. By 1959, he had passed his FRCS. The following year he undertook a period of National Service in the Royal Army Medical Corps (RAMC) that included a stint in Jamaica. Thereafter, his orthopaedic training took place at The London, Westminster, and Middlesex Hospitals. In parallel, he pursued an interest in biomechanics. The Imperial College website describes the Engineering in Medicine Laboratory as having been established in 1963.

Michael was involved from its outset and co-founded the Biomechanics Unit with Professor Sydney Swanson. Michael’s research involved studies into the mechanical properties of cartilage and bone, and their relevance to the development of arthritis. It is hardly surprising that this should lead to the designing of prostheses. During this period, he also completed an MD thesis, entitled ‘Ligamentous Injuries’, which was presented in 1964.

His findings on the relationship of mechanoreceptors to the contraction of the gastrocnemius (in the cat) remain the foundation of nonoperative rehabilitation of the ligamentous injuries of the ankle. That year, he received the Robert Jones Medal from the British Orthopaedic Association (BOA). In 1968, he was an ABC Fellow.

With his accompanying interest in biomechanics, one can understand how he could only accept an eight-elevenths consultant contract in 1969. His initial developmental work on foot and ankle arthroplasty was subsequently abandoned with disappointment that these could not be made to work with the biomaterials which were then available. His interests progressed with hip and knee arthroplasty, resulting in the first condylar knee arthroplasty, the Freeman–Swanson, being implanted at the London Hospital in 1969. The early 1970s saw the arrival of the Imperial College London Hospital (ICLH) hip resurfacing, which used an ultrahigh-molecular-weight polyethylene (UHMWPE) acetabular component and a cobalt chrome head. The production of implants by the Biomechanics Unit was not well received by the University authorities. Consequently, in 1978, he supported his senior laboratory team, Mike Tuke and Bill Day, in establishing Finsbury Instruments Ltd. Michael was fastidious in documenting change, and recorded the outcome of every patient he treated. From this constant scrutiny, he made modifications to rectify any deficiencies he identified. By the early 1980s, he had concluded that hip resurfacing was also unreliable with the c­ ontemporary

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Fig. 1 Michael Freeman.

biomaterials and that it should be abandoned. He then proceeded with the development of his full neck-retaining total hip prosthesis.

The extensive database he created became a magnet for fellows and registrars from across the world who wished to study with him. He readily shared his ideas and was receptive to those of others who sometimes challenged his views. He encouraged his trainees and visitors to explore the database and insisted that both good and bad results were reported. He published prolifically in peer-reviewed journals, wrote a number of books and contributed many chapters. For those who collaborated with him, this could be an exacting experience. He was a master of the language, and every paper went through multiple revisions until a polished manuscript was produced, from which any ambiguity had been expunged.

In 1982, he left Imperial as the opportunity arose to transfer his research to the Bone and Joint Research Unit in the newly constructed Arthritis and Research Council building at the London Hospital Medical College.

It is hard to imagine that he found time to sit on grant-awarding committees for the Arthritis and Rheumatism Council, the Medical Research Council, and the Panel for Medical Research of the Department of Health and Social Security. Additionally, he served as a member of the Board of Governors of the London Hospital and on the Brent and Harrow Area Health Authority. He served a term as a member of the Editorial Board of what was then the Journal of Bone & Joint Surgery [Br], and he was the first European Editor-in-Chief of the Journal of Arthroplasty from 1996 to 2001.

His extensive publications and contributions to scientific meetings brought him international recognition, and, from 1983 to 1985, he was President of the International Hip Society. He recognized the need for a

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Fig. 2 Michael Freeman (left) and John Insall (right). similar body in the UK. In conjunction with Hugh Phillips and Robin Ling, he established the British Hip Society, serving from 1989 to 1990 as its first President. He was President of the British Orthopaedic Association from 1992 to 1993. He also felt it was inappropriate that European colleagues had no proper forum to exchange ideas without travelling to the United States. Working initially with Jacques Duparc, he helped garner support from European national orthopaedic bodies to establish the European Federation of National Associations of Orthopaedics and Traumatology, being EFORT’s second President from 1994 to 1995.

In 1996, he retired from clinical practice, remarking that throughout his career, when he had designed prostheses and replaced joints, he had never really understood how the knee worked! It would be at this point his ‘real’ work would start as he sought to resolve his lack of understanding.

He embarked on a programme of anatomical and MRI studies of cadaver and living knees, identifying the three-dimensional shapes of the articular components of the joint. This opportunity had only occurred through a chance remark at a scientific meeting. What would evolve was an extensive collaboration with the Charles University in Prague, working with Dr (now Professor) Vera Pinskerova. Over a number of years with co-workers, he published the detailed findings about the mechanism of lateral femoral rollback and medial femoral stability. His findings have been applied to a certain class of knee prosthesis stabilized by a medially spherical femoral condyle mated with a matched tibial concavity, while the lateral compartment remains unconstrained (Fig. 3). It is with a tinge of sadness that the specific features of these designs have only just, and firstly, been recognized as a class of implants deserving their own category, by the Australian Orthopaedic Association National Joint Replacement Registry.

He was rightly acknowledged for his contributions to orthopaedics and received numerous awards, including Honorary Fellowship of the BOA in 2003 and an Honorary Membership of EFORT in 2007.

Those who worked directly with him enjoyed a great privilege. The personal tuition during ward rounds, in clinic and theatre, was unbelievably enriching. He could break down complex issues into simple manageable matters, which could be addressed in a logical progression. At the Tuesday afternoon clinical conference, he could be relied upon to explain how biomechanical principles could be applied to problems involving the upper limb and trauma, as well as his preferred field of lower limb arthroplasty. However, the most important lesson was to confirm what the

Fig. 3 The knee prosthesis inspired by Michael Freeman’s findings. Image courtesy of Medacta. patient saw as their problem and obtain their opinion on what they would like to have done. This was always the order of events before proposing any treatment. Much is now written about managing the patient’s expectation; clearly, Michael was ahead of the game. Life was never dull, as he would often arrive for the ward round with last night’s brainwave, which was going to be pursued in theatre that afternoon. On one occasion, a Charnley stem required revision. The implant was slightly shorter than his own preferred design, but there followed some quick templating. The amount by which his stem required shortening was calculated to avoid clearing the extensive cement plug. Once this information was known, the stem for the afternoon list was shortened in the hospital’s laboratory and sterilized ready for use.

He recognized the difficulties often experienced by a patient in comprehending the magnitude of a medical problem. To help them, he made himself available for extended consultations to supplement the usual outpatient appointment.

He had great forbearance in managing the actions of his sometimes ham-fisted registrars. If anything went wrong, he was unhesitating in offering an apology and inviting the patient to suggest the remedial steps.

This approach generally diffused any potential difficulty in the doctorpatient relationship and resulted in an amicable resolution. He also possessed a wonderful sense of humour for which many of us were grateful following our serial transgressions.

His knowledge and charisma were also an asset to any scientific congress where he was in demand as a chairman. His astute observations could stimulate discussion even after the dullest of presentations.

Those of us fortunate enough to have worked under his guidance share fond memories of a man whose principles in orthopaedics can be readily applied to life in general.

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G. Scott, MBBS, FRCS, Consultant Orthopaedic Surgeon, The Royal London Hospital, London, UK g.scott@qmul.ac.uk

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G. Gie

Appreciation

Robin Ling OBE (1927-2017)

obin Ling, a truly brilliant but humble man, died in Wells, Somerset, on 9 October 2017. He was able to live at home, cared for by his loving wife Mary, until the last few weeks of his life. He will be remembered primarily as the inventor of the Exeter Total Hip Replacement (Fig. 2), presently the most implanted cemented hip replacement in the world (1.75 million to date). Despite his failing health, he maintained a keen interest in what his successors were up to until the very end. The funeral was a quiet family service in Wells on 25 October 2017. This was followed by a memorial service to celebrate his life in Exeter Cathedral on 23 February 2018. The respect in which he was held was reflected by the fact that the cathedral was packed and surgeons had travelled from all corners of the world to attend. It was a truly memorable day. A formal obituary has been published in The Bone & Joint Journal. What follows is an appreciation of the life of a perfectionist, an unassuming master hip surgeon with absolute integrity, an innovator, a scientist, and a true gentleman.

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Katy Ling (Robin’s daughter) writes: It is hard to try to encapsulate my father’s life and character in a few words. He was undoubtedly a paradoxical person, shy and yet friendly, self-effacing and yet extremely determined, modest and yet with immense self-belief, incredibly hard working and single-minded about orthopaedics and yet passionate about his non-professional interests, too. Above all, he was the most loving and generous of fathers and grandfathers.

It was early on in my life that I realized that my father was not really like my friends’ fathers. He worked very hard, leaving the house early and returning late. He often worked on Sunday mornings, too. I didn’t mind it that much, as we were used to it, and it made me feel immensely proud of him.

Once, during a non-authorized foray into his study at the age of about five or six, I discovered two shiny silver objects on his swivel chair. Far from scolding me for my encroachment into his private domain, he explained to me that these were artificial hip joints, the Charnley and the McKee–Farrar, that his job was to put them into people, and that he was trying to think of ways to make them more effective. He spoke about it with such intensity that the scene has remained fixed in my mind ever since.

One way for my sister and me to spend a little more time with him at the weekend was to accompany him on the domiciliary visits or ‘doms’, as he called them, that surgeons still carried out in those days. We would sit in the back of his car, and watch him disappear down the garden paths of countless houses, with radiographs and medical notes stuffed under his arm. As we drove from one house to the next, he would sing songs to us, and he certainly had a lovely, albeit totally untrained, voice. One of his favourites was the sixties hit, ‘Winchester Cathedral’, and he did a mean imitation of Louis Armstrong.

On Sundays, lunch would not be served until he returned home from the ward round or more doms, or whatever he had been doing that morning in his relentless pursuit of his patients’ welfare. As we attacked our

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Fig. 1 Professor Robin Ling OBE.

roast, he would begin to relax, and, after lunch, he would play us his favourite hits from the 1940s and 1950s. We would all dance to the music.

Jenny and I would stand on his feet as he tried to teach us the proper steps.

His other passions, rugby and sailing, had to be crammed into those few precious Sunday hours, as well.

His love for rugby began early. He can be seen in the front row of the formal photo of his prep school’s first XV in 1940. This must have been just before his departure for Canada at the age of twelve. He later played for Magdalen College, Oxford, and St Mary’s Hospital, London. In later life, his involvement was more as a spectator, but nonetheless a very committed one. Woe betide anyone who expected to engage him in conversation during an international fixture!

It is possible, though, that his love of the water outstripped even his love for rugby. In the early 1970s, on those rare Sunday mornings when he was not working, he would take my sister and me water-skiing on the River Teign, and he certainly cut a dash on his monoski! However, it was from sailing that he derived the greatest serenity and joy. During his time in Canada during the war, he had taught himself to sail, and some of our happiest moments together were spent in craft ranging from the dinghy he bought us as young children, to Enfin, the beautiful Sadler Starlight that he finally acquired in his early sixties. Colleagues who had known him only in his role as a surgeon before joining him for a day’s sailing on board Enfin were astonished to discover that his prowess as a sailor was as great as his skill as a surgeon.

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I remember being completely enthralled at the age of around eight when my father, to our astonishment, unmasked his hitherto unrevealed talent for drawing boats and rigs. He filled the pages of an exercise book with sketches of every different kind of rig, all entirely from memory, along with charts depicting the correct handling of the mains’l under different wind conditions. As we sailed together over the years, I came to understand that he had an uncanny ability to identify boats of all kinds.

How he had acquired this knowledge, and, above all, how he retained it all in his mind over so many years, I never quite knew.

His understanding of the mechanics of sail and ropework, and his ability to manoeuvre Enfin in and out of harbour at Dartmouth without the assistance of the engine would have been worthy of an 18th-century sea captain. It was really awe-inspiring at times. Sometimes, though, he took things a little too far: the system of ropes and pulleys that he devised for hoisting one of our dinghies up to the ceiling in the garage was so complex that no one other than him could ever get the dinghy down again!

One of the most valuable lessons I ever learned from my father was that it is not necessary to be engaged in a formal educational setting to acquire mastery of a subject. His knowledge of sailing alone amply demonstrated this, but he was an autodidact in the field of engineering as well. I recently discovered in his study an old lever arch file dating from the late 1960s, full of his notes on stress and strain, Young’s Modulus, and the tensile strengths of innumerable metals and alloys. This is why he first started getting up at four in the morning: he was teaching himself from scratch to understand the field of engineering.

He also took great delight in the work of Keats, but believed that the humanities side of his education was not complete. Indeed, with characteristic modesty, he once told me that he felt he “did not know much”. He regretted, for example, that he did not speak another language, and harboured a secret ambition to be able one day to deliver a paper in French.

This was something that he did not quite manage to achieve, but I once accompanied him to a conference in Paris, where he introduced himself and his paper in halting French, before apologizing and reverting to English for the paper itself. The round of applause that he received was deafening and his gesture was met with great appreciation. After his retirement from the NHS, he and my mother spent a summer at a language school near Nice where he worked assiduously on his verbs.

His final decade was tragically dogged by increasing mobility problems and the after-effects of radiotherapy. His international life of travel became more circumscribed, and his beautiful sailing days were over, but I did not once hear him complain about it. He found great joy in watching his grandchildren grow up and set a marvellous example of good humour and stoicism in the face of increasing and irreversible mobility loss. The sunniness and buoyancy of his mood in his final weeks was possibly one of the greatest of the many gifts he gave his family.

Graham Gie, Robin’s successor at Princess Elizabeth Orthopaedic Hospital, writes: I arrived in Exeter in June 1985 as a trainee from South Africa, on the recommendation of two of my senior colleagues that I should not miss out on the opportunity of working with Robin Ling. It didn’t take long to find out why. Assisting him in theatre, with his bifocals teetering on the end of his nose, one could only be amazed by his courteousness, calmness, patience, surgical skill, and exposure of the hip. At the end of my first week, approaching the end of a long day operating, Mr Ling (as he was to me then) found a large cyst in the rim of the acetabulum, usually ignored by surgeons I had worked with up to that time. Robin proceeded to excise

Fig. 2 Exeter Total Hip Replacement. the cyst and reconstruct the acetabular rim with a block graft from the femoral head, before proceeding with his meticulous cementing technique, which has become the standard of the day. No matter what the time of day or evening (normal working hours in those days), his work was never rushed and no patient ever came off the operating table without the best job possible being done.

At that time, he was smarting over the matte stem saga and eagerly awaiting the re-introduction of the polished stems, which were being prepared for re-release. Although he called the matte stem experience a disaster, the survivorship of these stems at ten years was 90%, achieving what would today be a 10A orthopaedic data evaluation panel (ODEP) rating. It’s just that they were significantly inferior to the polished stem outcomes. However, the matte stem error, and the lysis associated with the stems, led to us developing femoral bone impaction grafting. Professor Tom Slooff (of acetabular impaction grafting fame) informed Robin in February 1990 that his unit was about to begin experimental femoral grafting in goats. Robin’s response was that there was no need. We had performed the procedure in 40 larger animals, i.e. humans!

It wasn’t long before my wife and I, along with other trainees, had our first invitation to join Mary and him for dinner at their favourite restaurant, The Carved Angel, in Dittisham. This practice continued long into Robin’s retirement, when he would make a special effort to welcome new arrivals to the orthopaedic unit. Despite him now being internationally famous, the telephone call would begin, “Hello, I’m Robin Ling, a retired orthopaedic surgeon.”

Other less welcome telephone calls followed. Once or twice a week, the phone would ring before 6am with that easily recognizable voice on the other end wanting to discuss a brilliant new idea he had, or what he’d read in the latest journal at 4am. Expecting to find Robin awake, a trainee once called him at 6am, only to realize that he’d woken the great man from a deep sleep. Having politely answered the question, Robin asked,

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“What time is it anyway, lad?” On hearing the time, his response was “Good God! I should have been up hours ago.”

On another occasion, a weary trainee fell asleep while assisting at a hand operation, his chin hitting the back of Robin’s head. His response: “Oh, I’m sorry. Would you like a closer look in the wound?”

It wasn’t just in the operating theatre that Robin was so thorough.

At that time, trauma patients were treated in a separate hospital and were looked after by the consultants on a weekly rotation. Sunday was changeover day. The ward round would start at 9am and would usually be completed by about 11am, with the senior registrar presenting the patients to the consultant. Robin, however, insisted on examining every patient himself and the ward round would frequently run beyond 3pm.

Robin was a very keen sportsman in his younger days and thereafter loved watching cricket and rugby when his busy schedule allowed. However, his greatest love was sailing, which was the reason he applied for a job in the West Country. Although he sailed with friends, and, indeed, completed a couple of Fastnet races, it was only after he retired that he purchased his own yacht, aptly named ‘Enfin’.

I have received messages about Robin from orthopaedic surgeons across the globe, and would like to finish by quoting one received from Australia: “I’m so glad we went to see Robin in June. I’ve been thinking about it a lot but you know he timed everything perfectly. When to stop operating, travelling, lecturing, and, I think, living. He was proud and did not want to be dependent. He got out of his chair and walked outside to say goodbye to us. It was a struggle but he was strong. If I die at 90, having changed the world in the company of my family, I’ll be happy. He changed our lives for the better.”

Robin is survived by his wife Mary and two daughters, Jenny and Katy, as well as four grandchildren.

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Professor Robin Ling had a remarkable career. His heavy schedule of clinical, scientific, and teaching work did not prevent him from contributing in all areas of professional life. He was President of the British Orthopaedic Association, British Hip Society, International Hip Society and British Orthopaedic Research Society, and Vice-President of the European Orthopaedic Research Society, as well as Honorary Professor of Bioengineering at the University of Exeter. He was awarded numerous visiting Professorships at Universities around the world. In 1992, he was appointed Officer of the Order of the British Empire and awarded an Honorary Fellowship of RCS of Edinburgh in 1989. He was awarded corresponding fellowships/memberships of the Australian Orthopaedic Association (AOA), New Zealand Orthopaedic Association (NZOA) and Hip Society (USA), and honorary membership of the BOA, as well as the Mid-America Orthopaedic Society. He presented the inaugural Sir John Charnley Memorial lecture in 1986 and was joint winner of the first Maurice Müller Prize for excellence in orthopaedic surgery in 1989. He was a member of the board in orthopaedic surgery of the RCS Edinburgh for ten years, as well as an examiner for the Fellowship for the same length of time. He was also President of the Wishbone Trust for ten years and a Trustee of the Northcott Devon Medical Foundation for 11 years, including being Chairman for five of these. Additionally, he sat on the editorial boards of multiple journals and travelled internationally to teach.

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G. Gie, MBChB, FRCS, FRCSEd (Orth), Consultant Orthopaedic Surgeon, Exeter, UK ggie@me.com

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J. Ring S. T. Donell

Obituary

Peter A. Ring (1922-2018)

he death of Peter Ring on 16 March 2018, aged 95, filled us with sadness, and brings to a close the era of the pio­ neers of total hip arthroplasty from the 1950s and 1960s. His major contribution was the development of his eponymous uncemented hip arthroplasty.

Peter Alexander Ring was born on 30 December 1922, in Finchley, Middlesex, a northern suburb of Greater London. His father was a ship manager. He attended Christ College, Finchley, and studied Medicine at University College, London, qualifying in 1945, and gaining the Alexan­ der Bruce medal for Surgery and Pathology. He undertook posts as a house surgeon at University College Hospital, London, and registrar at the Royal National Orthopaedic Hospital, Stanmore, continuing his registrar training under Mr J. S. Batchelor at Guy’s Hospital, London. Under Mr Batchelor’s tutelage, he developed his interest in surgery of the osteo­ arthritic hip, publishing a paper on the outcomes of operative surgery from the unit, which predates total hip arthroplasty. He then returned to University College Hospital as a senior registrar to complete his training.

From 1956 to 1959, he was the Laming Evans Senior Research Fellow at the Royal College of Surgeons of England, with a stipend of £1900 per annum and expenses of £300. The subject of his research was inequalities of limb length. During this time, he published extensively and worked on the epiphysis of rabbits, specifically on limb-length inequality resulting from paralytic poliomyelitis.

In 1960, he was appointed Consultant at Redhill General Hospital, Surrey. He provided a general orthopaedic service as well as managing trauma. He wrote a paper in The Lancet in 1964 on the work of an accident unit. This followed reports from the British Orthopaedic Association (BOA) (1959) and the Accident Services Review Committee (1961), which stressed the benefits of more centralization of management of the injured patients in accident units of larger general hospitals. The main increase was due to a rising number of road accidents. The paper provided an overview of the service at Redhill, with sections on the epidemiology of accidents and the injuries incurred. He published a book on the care of the injured in 1969. He also wrote papers on fractures, venous thrombo­ embolism and anticoagulation, and fat embolism. However, he is best remembered for his contribution to total hip arthroplasty.

The 1960s was an exceptional decade for British orthopaedics, and spawned a healthy rivalry between John Charnley, Ken McKee, and Peter Ring. He described going to the BOA Spring Meeting in Manchester in April 1961 where both McKee and Charnley were present, one demon­ strating the metal-on-plastic hip, and the other the metal-on-metal (MoM).

It occurred to him that they were both making a rather simple job difficult by using bone cement, which was a relatively untried material at that time.

Since the Austin Moore prosthesis gave reasonable results in the treatment of hip fracture, he felt a firmly fixed matching cup might be all that was needed. He favoured an uncemented design with a conical countersunk acetabular component with a long screw held in the iliopubic bar, linked to a modified Austin Moore femoral stem (Fig. 2). He developed these in what became a long and fruitful relationship with Maurice Down of Down

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Fig. 1 Peter Alexander Ring.

Fig. 2 Radiograph and image of the Ring metal-on-metal uncemented total hip arthroplasty.

Brothers. Later models had an all-polyethylene acetabular component. He found that these had a higher failure rate from wear than the original MoM articulations. From 1968 onwards, he published extensively on the results and complications of his uncemented total hip arthroplasty.

He subsequently developed an uncemented resurfacing knee arthro­ plasty, which preserved the cruciate ligaments, and he implanted these in

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patients from 1974 (Fig. 3). The metal was titanium with a polyethylene insert. The tibial plate was anchored with screws. The resurfacing only covered the tibiofemoral joint. He published his results in 1988. In the late 1980s and 1990s, he withdrew gradually from clinical practice, but main­ tained his lifelong interest in orthopaedics.

Outside of work, he was a gifted pianist, a keen dinghy sailor, and adept at the broad brushstrokes of gardening. His first wife, Stella, was a child psychiatrist with whom he had four children. Of these, the eld­ est boy, Nicholas, followed Peter into medicine and became a consult­ ant radiologist; his daughter Judy worked as both an occupational therapist and physiotherapist; the two younger boys, Chris and Jim, became, respectively, a university lecturer and an author. He is sur­ vived by his children, by his second wife Sheila, whom he married in 1969, and by four grandchildren – one a consultant oncologist – and five great-grandchildren.

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Fig. 3 Image of the Ring uncemented total knee arthroplasty.

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S. T. Donell, Professor of Orthopaedic Surgery, Norfolk and Norwich Hospital, Norwich, UK simon.donell@nnuh.nhs.uk

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S. P. F. Hughes

Obituary

Henry Vernon Crock (1929-2018)

enry (known as Harry) Vernon Crock died peacefully on 21 April 2018.

Harry was born in Perth, Western Australia, and studied medicine at the University of Melbourne, where he trained with his twin brother Gerard William Crock (1929-2007), who later became Professor of Ophthalmology at the University. In 1949, Harry was Gold Medallist in Anatomy at the University of Melbourne, an honour he received jointly with Gerald.

He graduated with honours in 1953 and began his medical career at St. Vincent’s Hospital, Melbourne. In 1957, he was appointed Nuffield Dominions Clinical Assistant in Orthopaedic Surgery at the Nuffield Orthopaedic Centre in Oxford, and Lecturer in Orthopaedic Surgery at Oxford University. The latter position, in Professor Josep Trueta’s department, was where he developed a lifelong interest in the anatomy of the blood supply of bone. He returned to Australia in 1961 and was appointed to the post of Senior Honorary Orthopaedic Surgeon at St. Vincent’s Hospital, Melbourne. There, he helped to build an orthopaedic unit with a particular interest in spinal surgery.

In 1970, he published a paper in the Medical Journal of Australia,1

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which led to a radical change in the surgical management of intervertebral discs – some 40 years later, this paper is still cited as a seminal paper on spinal surgery. In 1973, he published work on the venous drainage of the human vertebral body,2 and in 1976, he introduced the concept of the isolated disc resorption as a cause of nerve root stenosis.3 These three papers were major landmarks in the understanding of spinal anatomy and surgery.

In 1986, he returned to the United Kingdom, joined the staff of The Cromwell Hospital, London, and was appointed an Honorary Consultant Orthopaedic Surgeon and Honorary Senior Lecturer at Hammersmith Hospital and the Royal Postgraduate Medical School, London. I had met Harry at international spinal meetings and had read most of his work.

Indeed, one of the reasons I left Edinburgh in 1991 to take the chair of orthopaedic surgery at the Royal Postgraduate Medical School was to work with him, where we operated together and also undertook research into the neurovascular supply of the vertebral endplate.4 Throughout his life, Harry made considerable contributions to spinal surgery. His interest in anatomy was developed at an early stage in his career when he was senior demonstrator in anatomy at the University of Melbourne. On his return to the UK, he was appointed as a visiting lecturer and Arnott Demonstrator in the Department of Anatomy of the Royal College of Surgeons of England. One of Harry’s significant anatomical contributions was the method he developed of special injection and photographic techniques in order to illustrate the blood supply of the human skeleton and the spinal cord. This led to many publications, of which the last – An Atlas of the Vascular Anatomy of the Skeleton and Spinal Cord – is the most comprehensive and beautifully illustrated.5 It can clearly be said that Harry Crock was a master surgeon of the spine, who produced new information on the arterial supply of the vertebrae, spinal cord, and nerve roots. Indeed, his classical demonstration of

Fig. 1 Harry Crock.

venous congestion of the nerve roots resulting in nerve root stenosis has stood the test of time and continues to be applied in spinal nerve root decompression.

He was also someone who was prepared to create new approaches.

He embraced the retroperitoneal approach for anterior lumbar surgery, designing special instruments in order to achieve an interbody lumbar fusion. In 1983, he published a classic book on spinal surgery, which is still essential reading today for spinal surgeons.6 He was also actively involved in the teaching of orthopaedic surgery, especially spinal surgery, both to undergraduates in his early days, and later to postgraduates. He trained numerous spinal surgeons from around the world, particularly from the Far East, Australia and North America and, unsurprisingly given his gentle wit and easy charm, was a popular lecturer throughout the world, notably in Europe, the United States of America, Japan, China, and India.

Harry deservedly had an international reputation as a spinal surgeon and lecturer, receiving many awards and prizes, including several from the Australian Orthopaedic Association and Royal Australasian College of Surgeons. He was also a member of the Editorial Board of The Journal of Bone and Joint Surgery [Br].

In 1984, he was made an Officer of the Order of Australia for services to orthopaedics (his twin brother Gerard was made an Officer of the Order in 1985). In 1985, he was elected President and was a founding member of the International Society for the Study of the Lumbar Spine. In 1990, he was elected a corresponding Fellow of the Japanese Orthopaedic Association and, in 1997, was made an Honorary Fellow of the Royal College of Surgeons of Edinburgh. In 2009, he was awarded the DSc (honoris causa) from the University of Melbourne.

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In 1993, Harry established the charity Discovering Innovative Solutions for Conditions of the Spine (DISCS) to fund research into the causes, mechanisms, and management of back pain, with the help of Lord Brabourne, The Countess Mountbatten of Burma, and Dame Beryl Grey. He later became President of DISCS. Working with Harry was always a pleasure. His surgical skills were obvious and his overriding principles of humanity and care for the patients he treated were paramount. That said, he could be extremely stubborn if he didn’t agree with the views that were being put forward by others, and could be critical of other surgeons’ standards. It also never ceased to amaze me that, in the joint spinal clinics we ran at Hammersmith with other consultants, Harry only managed to see six or eight patients in a clinic, while the rest of us, albeit with the help of a number of junior staff, would regularly see anything up to 100 patients in a morning. Only once he had retired and I inherited his patients did I learn the secret: Harry asked the patient a few questions at the beginning of the consultation and then allowed them to talk for 20 minutes or so before examining them and proposing a plan of treatment. This method reflected both his patience and tolerance and also his understanding of patients with complex spinal problems resulting from long-standing back pain. A naturally kind man, the only time that I ever saw him become angry was when his new brown shoes were stolen from the theatre changing room at Hammersmith Hospital, with the result that he had to go home in theatre boots.

Harry had many interests besides spinal surgery, in particular a collection of the work of the English painter David Smith, who had been the official artist to the British Antarctic Survey. Several of the paintings in Harry’s home in Earls Court in London were by David Smith, who also painted Harry’s portrait, which is in the National Portrait Gallery in Canberra. In retirement, he developed a new career, becoming an enthusiastic mosaicist.

Harry’s pleasure in people and genuine regard for their interests meant that he had a knack for making friends. Some, such as Sir Roy Calne FRS, who first met Harry in 1957 when they were in Oxford, were lifelong, while others were those whom he taught or collaborated with or who

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simply enjoyed the company of this most humane of men. Most of all, however, he will be missed by those who were lucky enough to be his patients, who valued not only his surgical skills but also his patience and the way in which he willingly gave of his time.

He will be sorely missed by his family, particularly his wife Carmel, also medically qualified, who married Harry when they were in Oxford in 1958, and worked closely with her husband throughout his career. They had five children, two of whom are medical doctors, and another of whom completed a PhD in the ethics of AIDS nursing care.

His many contributions to spinal surgery and spinal anatomy will live on in the shape of the annual Henry V Crock lecture, now held at the annual meeting of The Society for Back Pain Research.

References 1. Crock HV. A reappraisal of intervertebral disc lesions. Med J Aust 1970;1:983-989.

2. Crock HV, Yoshizawa H, Kame SK. Observations on the venous drainage of the human vertebral body. J Bone Joint Surg [Br] 1973;55-B:528-533.

3. Crock HV. Isolated lumbar disk resorption as a cause of nerve root canal stenosis. Clin Orthop Related Res 1976;115:109-115.

4. Brown MF, Hukkanen MV, McCarthy ID, et al. Sensory and sympathetic innervation of the vertebral endplate in patients with degenerative disc disease. J Bone Joint Surg [Br] 1997;79-B:147-153.

5. Crock HV. An Atlas of Vascular Anatomy of the Skeleton & Spinal Cord.

London: Martin Dunitz, 1996.

6. Crock HV. Practice of Spinal Surgery. New York: Springer-Verlag Wien, 1983.

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details

S. P. F. Hughes, (MA MS FRCSEd(Orth) FRCS FRCSI, Emeritus Professor Orthopaedic Surgery, Imperial College London, London, UK seanfrancishughes@imperial.ac.uk

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