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The Young Orthopaedic Surgeon

I have often been asked how my philosophies of medicine – in particular orthopaedic surgery – will be perpetuated.

 

To that end I invited a young orthopaedic surgeon to coffee in my office.  He had returned from two foot-and-ankle fellowships, Baltimore and Britain.  He had seemed to believe that any professional associated with him could only be the better for it.  My offer was the free benefit and ultimate inheritance of an extremely large patient base, national and international, together with a highly refined administrative structure and its staff.  This cut no ice with him and instead he muttered about (possibly) being able to acquire from me, in very general terms, “wisdom”.

 

Whatever “wisdom” might mean, far more important to him should be the definite specifics of the journeyman craft which is orthopaedic surgery.  This incision should be there for that reason.  Not a millimetre different because that has been tried before.

 

On the desk was a foot-print and on the screen a radiogram.  He would deny vehemently that these represented “case discussions”, but that, in reality, is what they were.  Any case discussion arrives at a bottom line of policy, however short or protracted and argued that discussion might be, whether in the lecture hall, at the bedside, or in the operating room.

 

 

I pushed the foot print forward.  It demonstrated collapse of the mid-tarsus and high cuboid and cuneiform pressure.

 

“That is a big problem” he said.  The presentation was over.  He failed.

Why?  Because it was not a problem. There is a single, predictable surgical cure which can be performed as a day case on a walk-in-walk-out basis, with little pain and without the need for cumbersome casting, crutches or boots – all these would be impractical ( and cruely unfair)  in an 80 year old.

 

Then the X-ray.  This showed bilaterally marked metatarsus varus of all the rays in a mature adult.

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“This is a big problem” he said. Fail.

 

Why? Because he did not know what the problem was.  He was making the assumption that both feet had to be “corrected” and made “normal” by total reconstructed – a massive intrusion involving multiple osteotomies, internal fixation and a protracted and unpredictable convalescence.  But the real problem was that he did not know what the problem was.  This patient had spent his entire life walking on these “abnormal” feet which had served him well. The young surgeon had no idea why this patient had consulted me. The reality was that this patient had a tiny focal problem, easily solved and which did not require any major surgery.

 

He then presented a case himself, and with pride showed me a photograph of a plantar plate that he had meticulously reconstructed.

 

“Why was it torn?” I asked.

 

“Well I suppose it just tore” he said.

 

Fail.  There are very definite and specific reasons why the plantar plate tears, as it commonly does.  To repair it without correcting the underlying cause is asinine. The plantar plate is a frail structure, which, marvellously, sustains the huge and extensive long term loads of the foot.  If it tore once, unless the cause is removed, it would simply tear again.

 

When I last heard he had joined a practice with glamorous offices. His scrub nurse told me had been engaging in elaborate “reconstructions” of the foot requiring multiple osteotomies and complicated metallic implants.

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