Samuel Morganalmost 2 years ago
Once again, we have the great privilege of hearing from one of our surgical mentors.
Enjoy this instalment.
Where did it all begin for you/what started your interest in surgery?
I was always interested in medicine. From the time I was young I wanted to be a country GP as I grew up in central Queensland and the GPs formed a significant part of the local community and provided a vital service.
When I was sixteen I had a significant rupture of all the ligaments in my knee in a work injury and this required a big operation on my knee and a long recovery process through my senior year at school. This gave me an insight into being an actual patient of a surgeon. I am still very good friends with that surgeon Dr Terence Maguire.
Following on from that when I went to Townsville as an Intern I became much more interested in surgery, then in particular orthopaedic surgery. This was provoked by the group of orthopaedic surgeons at the Townsville Hospital who were a disparate bunch, but all were happy to teach and share their knowledge. In particular, Dr Bruce Low, shared an incredible amount and taught me a huge amount of my early orthopaedics. This was further reinforced by a young orthopaedic surgeon in Toowoomba, Dr Bob Ivers. Bob provided much advice about career pathways and managing the training programme demands.
Can you tell us a bit more about your pathway after you finished your tertiary studies, where did you spend time working and sharpening your skills?
Following passing my orthopaedic Fellowship exam in 1993 I did a year as the Hand and Upper Limb Fellow at the Princess Alexandra Hospital. This was under the instruction of Dr Peter Millroy, Dr Steve Coleman and Dr David Gilpin. We also had the benefit of Dr John Carney, a Plastic Surgeon, who taught me a lot about hand surgery from a plastic surgical point of view.
I then travelled to England to work in Nottingham in the Nottingham Shoulder Unit which at first was at a place called Harlow Wood. Harlow Wood was an English Hospital in the countryside dedicated solely to elective orthopaedics. This unfortunately shut down after six months and we had to move back into Nottingham where there was trauma which interfered to the ability of the service to always get an operating theatre.
I worked there under the instruction of Professor Angus Wallace, a very interesting character who commanded a lot of respect from his colleagues despite his Scottish heritage. There were other people in the unit, in particular, Professor Simon Frostick and Mr Lars Neumann who taught me a huge amount whilst Angus was travelling the world as he was want to do.
Talking laterally for a moment, what are some invaluable skills and experiences outside of medicine that have made you the surgeon you are today?
My time growing up on a sheep and cattle property taught me a lot about dealing with difficult situations and coping with limited equipment and/or help. I spent the majority of my university holidays and school holidays working on the property with my mother and father and learning all about everything it takes to run such a property. This included all aspects of the work involved. I still use some of the fencing techniques in particular a thing called ‘cobb and co’ wire knot which is extensively used in building posts and wire fences.
When times get tough during the long rotations, what was the driver that kept you going?
Nothing special except an underlying seemingly built in desire to complete whatever task was at hand.
My experience as a youth in having to deal with many long hours at the workplace particularly long days on the back of a horse without food or water and doing this day in day out for months at a time made me realise that in many ways what we do in medicine is fairly easy compared to what a farmer or grazier goes through to keep things going.
If you could change one thing about the Australian Surgical Pathway, what would it be and why?
I would take away the safe hours restrictions currently impeding (in my opinion) the proper training of our young surgeons. When the vast majority of surgeons my age and older were trained it was not uncommon to do sixty to eighty or even longer hours per week dealing with the workload. The big benefit of such long hours was remarkable exposure to many different situations, operations and techniques in surgery.
The current situation to me is such that often our younger surgeons are in danger of not being exposed enough pathology and/or operations and/or techniques prior to fully graduating as a surgeon.
What advice can you given to the next generation of budding surgeons as they prepare in their penultimate or ultimate years study?
In the words of the greatest cycling cheat of all time (Lance Armstrong) “go hard or go home”. Surgery and orthopaedics is a tough game and the best thing to do if it all seems a bit hard when you are studying then you should realise that it actually gets a lot harder when you start working.
Talking specifically about your specialty with regard to frozen shoulder as evidence develops and more accurate histological relations are made. What do you consider to be the best management and why?
Frozen shoulder to me is still a conundrum and hasn’t really been sorted out histologically or otherwise. However, it is a simple condition in many ways in that it is not going to harm the patient and it is almost always going to go away with the passage of one to two years.
The best management is to have the patient fully informed and confident in this. The patient also needs to be confident in the knowledge that if things get really bad something can be done surgically. However, I consider operating on frozen shoulder to be an absolute last resort and I really frown on surgery being considered as frontline management without much effort being made on the part of the surgeon to get the patient through without an operation.
I have seen many significant complications arising from frozen shoulder surgery and to me it is almost criminal to expose someone to the risks of an operation in a condition that is benign with a known end point.
My management is to counsel the patient and reassure them that we can get them through it and that surgery is available should things get out of hand pain wise. A lot of people only need this and of course, investigation to make certain that they aren’t diabetic. There is a very strong and close association between diabetes and frozen shoulder.
Simple cortisone into the joint under ultrasound guidance with a small amount of local will give 50% of people significant relief allowing the physiotherapist to gently restore motion over a three to six month period. The pet hates that I have so to speak with regard to treatment for frozen shoulder are twofold. One is physio’s that keep the patient coming back and coming and coming back. The patient invariably gets a lot better in the week or two between physio visits and then the physio stirs things up. These people are often very relieved when I tell them that physio is the last thing they need.
The other pet hate I have is this scourge from the radiology departments of Victoria which is called ‘hydrodilation’. It is amazing that otherwise intelligent people can believe that a joint capsule that it is rigid and stiff and solid can be ‘dilated’ by simply putting fluid in the joint and applying pressure. What happens is that it hurts the patient considerably until the rupture of the rotator interval capsule occurs and then all the local anaesthetic and cortisone runs out of the joint. The patients that I have spoken to that have had it consider it one of the most painful experiences of their entire lives.
Its success rate is the same as just putting in cortisone and this study has been done by one of the main proponents of the procedure from Victoria, Dr Simon Bell. His work proved what we have always been saying is that the hydrodilation does absolutely nothing other than hurt the patient.
As a last resort I will offer the patient an arthroscopic release of the capsule and a ‘synovectomy’ which is essentially debriding all of the joint capsule and synovium injection from the process. It is not true synovitis.
Following on, why do you see it as critical that physiotherapy stops during the red (painful) stage?
It is critical because there is no absolutely and utterly no evidence that physio provides any benefit for the patient during the painful stage. What it provides is a lot more pain and no further movement and costs a lot of money. There is no benefit to the patient at all that I am aware of. It is therefore critical that physio allows the patient to save their money and come back when they need the physio during the non-painful stiff phase either after cortisone or after the disease process runs its course.
In your experience what have you found clinically are some generalisations, for example, ‘the sixty year old man with a supraspinatus tear presentation’?
The biggest problem I have with this is that there is a community (and some surgeons are the same) expectation that simply because something is torn that it needs an operation to repair it. This is incredibly far from the truth.
In America there are some 4.5 million people over sixty with rotator cuff tears and only 200,000 of them have actually had surgery. The other 4.3 million haven’t had surgery. My question for people that are rushing to operate on these patients is why don’t you try non-surgical treatment because if they convert to someone with a painless tear then they don’t need surgery?
A hypothetical; a 28 year old male presents with shoulder pain to ED after a traumatic event, the resident performs a standard shoulder examination and finds reduced range of motion, tenderness on palpation consistent with a large contusion on the anterior surface of the shoulder. Special tests have not been performed and the resident is considering involving the orthopaedic team. In your eyes, as the consultant, what would you want done next and why?
The first thing obviously is to have an x-ray which will tell you whether it is dislocated or fractured.
Where do you see the future of surgery heading regarding robotics and other technological advancements?
Robotics currently are relatively expensive but the cost is coming down. Most of us don’t have much experience with it, but from what I have seen it can be incredibly useful.
The big problem in shoulder surgery in particular is that the people that need the robot to help them put things in the shoulder can’t actually expose the shoulder joint well enough to have the thing put in.
Those of us that are lucky enough to expose the shoulder all the time don’t need the robot to help us we know where things are.
Having said that, there are some complex reconstructions done after fracture or for revision purposes where robotics and/or pre-op computation of models and 3-D printing will be greatly helpful. This is already being used now by myself and others in our town.
The best use of robotics that I have ever seen to date was in uni-compartmental knees where it made the operation so perfectly done that it actually made it a whole lot more reliable than a total knee replacement for appropriate patients. Prior to the use of the robot the uni-compartment was a difficult one to get exactly right with a surgeon simply using jigs or his eyes.