N°012 - July / August 2021
Interview viewed 31 times
You are the current EFORT President. What does EFORT mean for you personally after its 30-years anniversary?
The 30-years anniversary is for me personally a mixture of memories. I remember all of the founding fathers, some of them are still alive, some of them unfortunately already passed by. I have still a good contact with some of them since I was from 2005 on working for the EFORT portal, which is today’s website of EFORT, and I was helping to construct it. But I had contact with EFORT already in 1995, as I was asked by my former chief Wolfhart Puhl to help organizing the co-congress of the German Orthopaedic Society and EFORT at that time in Munich. From 2005 on, I worked in several different functions for EFORT. I was happy to support the development of the EFORT educational curriculum, which was released in 2015. As an appointed representative of EFORT in a European Union expert group, I could contribute to the development of recommendations on the metal-on-metal issue, which was organized by the European Commission. I was elected to the board as a Member at Large in 2013, where I had the possibility to work as Chairman of the Education Committee and establish the EFORT European Orthopaedics and Traumatology Education Platform (EOTEP). Currently I am acting as President, which is of course a challenge in these critical times. Nevertheless, it is a great honour for me to serve for this organisation. Overall many years of work in committees, task forces and educational groups with many substantial impressions considering nearly 30 years of “my personal” EFORT history.
After sharing your personal experiences what were the milestones for EFORT as a European society over the last 30 years?
EFORT was founded in ‘91 in Marentino by a group of those great old guys. Two years later the first EFORT congress was in Paris 1993. Then the first European textbook on orthopaedic techniques was published in 1997. In 2001 the first European Board Exam of Orthopaedics and Traumatology (EBOT) started. We changed from a biennial congress to an annual congress in 2008. As I already mentioned, the EFORT metal-on-metal statement was a significant activity, visible on the European level in 2012. EFORT created the European Educational Platform (EEP) in 2013 and launched the EFORT Open Reviews Journal in 2015. Moreover, I think, an important milestone was in 2019 when EFORT became a member of the Biomedical Alliance in Europe, which is an association of European scientific societies. EFORT and the European Society of Cardiology are part of the larger groups in this organisation, and the synergy is very important because EFORT could significantly raise its influence in Brussels. With respect to European activities, for me personally a further milestone is the launch of an “Implant and Patient Safety Initiative” in Brussels in 2020. Just recently, EFORT succeeded to be included in a European Union research project (CORE-MD) which is an important initiative on the improvement of registry work.
For years, there was a conflict between EFORT and the speciality societies, which was finally solved and made the content of the EFORT congress and education programs much more attractive.
You are right; this was a substantial issue in the past. But then EFORT created a standing committee with involvement of the specialty societies and once a year the specialty societies meet together with the EFORT leadership. Obviously, since more than 10 years, this collaboration with the specialty societies during the annual congress, but also in other areas, was developing in a very good way. Finally, in 2017 a “Memorandum of Understanding” could be signed together with each of the specialty societies, defining the collaboration formally. From my personal point of view - and I think this is shared by many presidents of the specialty societies – it is a win-win situation for both parties. EFORT is mainly addressing general education aspects and the subspecialty education is managed by the specialty societies. EFORT is providing a platform for them not only during the annual congress but also at a European level. Together with the speciality societies, we are working on minimum requirements for a specialist curriculum, which could finally end up for example with a European-wide acknowledged hip or knee specialist certificate. The conditions as well as the content of the training is of course provided by the specialty societies, as they define the requirements and all the educational issues. The role of EFORT would be to support the recognition of this formal qualification on European level (i.e. UEMS). This example highlights, how the specialty societies and EFORT have finally agreed to develop a win-win situation for both of them. So today, I think the collaboration is very good without any major discrepancies or differences.
How do you see the future role of EFORT?
I see EFORT as an institution with core activities in the fields of education and European health affairs. We are feeling responsible for the support and harmonisation of education on a general level. This means education until subspecialisation, not in subspecialisation, and is mainly concentrated on the general education of orthopaedic and traumatology residents in Europe. With the development of a “Core Curriculum” for this educational structure, EFORT has set a milestone, which is approved by UEMS, and we hope to contribute to further harmonisation of education in Europe in this field. The next main activity for me is that EFORT has become a visible partner on a European level with regard to Health politics. EFORT is able to support the interests of national societies on a European level and can thereby have influence in Brussels. We now have representatives on different EU committees and working groups, which helps us make the orthopaedic and trauma community interests visible in Brussels. This is probably a major step forward. I think these two areas - harmonised education and representation on the health politics level - are the main cornerstones of EFORT’s activity in the future. There are of course additional topics like fighting for patient safety in the context of MDR, supporting research activities, registry work, ethical issues, and other things, but I think many of them are even touching that second level of health politics.
Let’s move to your personal career. You studied in Munich and did your surgical training in the south of Germany. How did you manage the cultural shock when you moved to Dresden in the North of Germany?
This is a good question! I was born in the Bavarian alps, near Oberstdorf, and I grew up as a south Bavarian mountain guy. After my university education in Munich and surgical training in Traunstein, I spent one year at the Balgrist in Zurich as a research fellow. From there I went to Ulm in Baden-Württemberg and worked in the University Department of Orthopaedics for 13 years. In 2002, I moved from Ulm, which was of course also in the south of Germany, to Dresden. However, I think that Dresden cannot be recognised as a city in the “North” of Germany. It is in the southeast of the former Democratic Republic of Germany and I personally consider it more or less as a city with “southern” flair. It is a city, which has a beautiful culture and surrounding. The Saxonian wine grows here; especially the white wine is fantastic. Historic steamboats cruise on the Elbe river. You can go mountaineering into the so-called “Saxonian Switzerland”. Everything that you need for your leisure and for your happiness at the weekend - from wine to climbing in the mountains, to sitting on a steamboat on the Elbe river - is just perfect here. Therefore, I would compare Dresden more with other cities in the South, like Wurzburg or Freiburg for example. In addition, you may know that Dresden is called “Florence on the Elbe”, due to many buildings with Italian architecture you can find in this beautiful city. So, altogether you can enjoy kind of a southern spirit and a southern feeling of life and culture, which makes it very attractive to spend your life here.
You moved to Dresden in 2002 and the merger between trauma and orthopaedics at your department happened in 2013. How difficult was this journey for you?
I was appointed as the Chairman and Professor of the Orthopaedic Department at Dresden University in 2002. At that time, Professor Hans Zwipp was the Chairman of the trauma department, and I immediately developed a very close collaboration with him. In Germany, it took some time and some effort for Orthopaedics and Traumatology to grow together and even in Dresden it was difficult to develop a concept for unification of the disciplines, since many staff members were not enthusiastic about this new perspective. When Hans Zwipp and I organized together the German Congress of Orthopaedics and Traumatology in 2009, we were able to speed up the development and finally, we merged the departments in 2013 here into the University Centre of Orthopaedics and Traumatology. Two years later, Prof. Klaus Schaser from the Charité was appointed as new trauma chair and together with him, I could successfully continue the process of unification, which resulted in a significantly growing combined unit of orthopaedics and traumatology. Just 1 year ago, we could together with Prof. Adrian Dragu integrate in addition a Department of Plastic and Hand Surgery, so now we offer here the full spectrum of orthopaedics, trauma and plastic surgery. Overall, this was really a demanding but exciting development and finally it turned out to be successful.
With all that experience and the successful merger you did in Dresden, I guess you are a strong believer that this was the right decision for the future.
Personally, I am convinced that there is no real good alternative. Following the merge of historically separated disciplines and creating one specialty - as it exists also in most other European countries - allows to integrate strong orthopaedics and strong traumatology into one centre, if possible together with plastic and hand surgery. By achieving a large enough combined unit, this provides also the possibility to build up strong subspecialisation teams as well. In our Dresden “University Center of Orthopaedics, Trauma and Plastic Surgery” all formerly separated subspecialties from musculoskeletal trauma over foot and ankle, knee, hip, shoulder, spine, paediatric orthopaedics, oncology and septic surgery now work closely together in growing teams. As the collaboration and exchange of knowledge is very stimulating, not only numbers of treated patients have increased, but also the quality of care. Personally, I am an absolute believer in that model, and I think it is a successful development. However, it needs certain prerequisites, which include a given minimum of staff size, support from the hospital leadership, and – what is probably most important - a good relationship between the chiefs on a personal level. The success of a combined centre needs people, who act together, respect each other and are not interested to fight against each other. If they understand, that the combination of core competencies of orthopaedics and trauma (and if possible also plastic surgery) is stronger than the formerly separated disciplines, the outcome in terms of treatment quality and economic impact as well will be positive.
Let’s move to your scientific career. You did your habilitation in Ulm in 1997. Was the topic already hip, or was it something different?
It was totally different. My scientific work started very early in two areas, epidemiology of osteoarthritis and experimental studies in the field of bone regeneration. Finally, due to a good experimental infrastructure in Ulm, I could do my habilitation with experimental research on substitute materials and bone transplants - which is a very good basis of course for many clinical applications in orthopaedics and traumatology. In Ulm I was also undergoing a classical orthopaedic and a little bit of trauma education. I was involved in all musculoskeletal fields and could mainly practice in paediatric orthopaedics, spine, foot and hip surgery.
Has your scientific career something to do with your research fellowship in Balgrist in 1998?
Actually, this was a key element in my curriculum. I started my professional education as a young surgical resident in the trauma department of Traunstein, which is near Salzburg, and I worked there about 3 years. That time was very intensive and young residents could learn a lot. I was flying on the rescue helicopter and was heavily involved in trauma surgery. From a clinical point of view, this was a really great time, but I missed scientific activities. I also realised, that it was not possible to apply from that county hospital to a large university hospital: no university professor was willing to accept my application. I took all the money I had at that time and was travelling three months through the United States where I was visiting several friends and was working at their departments for free. From there, I applied for a research fellow position at the Balgrist, because I knew some people at this prestigious institution. They accepted me, and I did a one-year research fellowship in spine surgery. This turned out to be successful - when I wrote my applications for German university hospitals from the Balgrist, suddenly positions were available! It was a way around to get into a more scientifically oriented education. Overall, it has been a good time in the United States and also Balgrist was great, but finally I got an application in Ulm at the university hospital.
You did a fellowship in 2001 in the Harvard Medical School. Was this the start for your scientific interest for hip surgery?
Being “leitender Oberarzt” at Ulm University (under Prof. Wolfhart Puhl) at that time, I applied for the “Brigham and Women’s Fellowship”, because it was an internationally visible knee and hip joint fellowship. I was already involved in research on epidemiology of hip and knee osteoarthritis including joint replacement since some years. This could be intensified in Boston, when I worked on joint replacement together with Thomas Thornhill and Richard Scott as fantastic mentors. I had the chance to go with my family and it was a very good time for all of us in Boston. When I returned to Germany, I applied for the Chair position here in Dresden and I left Ulm one year later. In Dresden, I could specialise more and more in hip surgery and since that time, I am mainly covering primary and revision hip arthroplasty as well as joint preserving hip surgery. In order to concentrate on these fields and being clinically as well as scientifically successful, I felt it would be better to consecutively stop all my other activities in paediatrics, knee surgery, spine surgery and whatever.
Was there a special event, or a special point in your career when you fell in love with hip surgery?
I would say I had the chance to work some days with Dietrich Tönnis and some days with Reinhold Ganz in the early 90s and these two people raised my interest in joint-preserving surgery. In the field of hip arthroplasty I had contact with several other colleagues, who impressed me, like Harlan Amstutz or even Paul Dieppe, who has not been a surgeon, but an enthusiastic rheumatologist and epidemiologist with main interest in outcomes after hip surgery. It was not a moment’s decision, it was more a growing decision, but I would say the initial contact with Dietrich Tönnis and Reinhold Ganz motivated a strong interest in joint preserving surgery.
Let’s move to your political career. We mentioned already that you were President of the German Orthopaedic Society in 2009 and you stayed active as an executive board member for a long time. In 2011, you were president of German arthroplasty society – AE. You are very active in this society until now. Can you explain a bit what this German arthroplasty society AE means and what it is?
The Germany Society for Arthroplasty is a kind of special construct in Germany, which is a little bit singular in Europe. Many other European countries have speciality societies of hip surgery or knee surgery, and mostly the arthroplasty surgeons are active in a knee or a hip arthroplasty society. In Germany, about 25 years ago, some very ambitious surgeons - Rudi Ascherl, Wolfhart Puhl, and some other colleagues - founded a “working group of arthroplasty”. This group was at the beginning mainly driven by Orthopaedic and Trauma Surgeons, who shared an interest in joint replacement. They did not divide hip from knee arthroplasty, they just put it together, and later also included shoulder arthroplasty. This group was very active and developed a fascinating training and education program. Due to the increasing success of this initiative, it was later decided to call it “German Society of Arthroplasty (AE)”, and today it is a section of the German Society of Orthopaedics and Traumatology. The AE is a very strong section with several hundred members of experienced arthroplasty surgeons. A substantial motivation from the beginning was that it not only concentrated on German surgeons, but also included Austrian and Swiss arthroplasty surgeons building an association of the German-speaking countries. I think this strengthened very much the links between Austria, Switzerland and Germany in Orthopaedic Surgery. And finally, it overcame the boundaries between orthopaedics and traumatology. Probably the reason for the success of this group is the very early identification of synergies between different fields, which contributed to a huge success.
You are also one of the founding members of the German Arthroplasty Registry - EPRD. How difficult was it to set it up in Germany, and what is the international position of the EPRD after 6 years?
This is a very good question. The founding of the EPRD about six years ago through the German Society for Orthopaedics (DGOOC) was not the beginning of its activities; they started already 10 or 15 years down the road. It was not easy to develop the registry, because at that time it was still difficult to bring the main players - surgeons, industry and insurance companies - together. Finally, all registries of course cost some money and politics was not willing to pay for it. So it was necessary to find a way for industry, insurance companies and hospitals to establish a budget. The final model of success was that arthroplasty manufacturers and two large insurance companies provide financial support, and in addition participating hospitals pay registration fee. Due to the relative high number of arthroplasties performed in Germany, it grew very quickly and about more than 1 million patients are included in the registry already, covering about 80% of German arthroplasty surgeries. Therefore, ERPD was very soon recognised on the international level and today we have a strong partnership with the English registry, the National Joint Registry (NJR) and are member in the International Society of Arthroplasty Registers (ISAR) as well as the Network of Orthopaedic Registries in Europe (NORE). The strength of the Germany arthroplasty registry is a very well developed classification and product library, which together with the British has merged to a new classification system. This will probably become the international standard for arthroplasty registries.
This brings me to one of the latest points of your political engagement. You are a member of the Expert Panel of the European Community for the Medical Device Regulation. How do you see the development of the MDR and how do think the problems with implementation in daily practice can be solved?
You are touching a difficult and sensitive issue. I think the original goal of the MDR, which was to maintain and even improve patient safety, is appropriate. We of course agree, that we need the highest possible patient safety, but some events in the past have shown us, that we have still some issues with safety in the field of medical implants. Therefore, I think the MDR is basically a good initiative. However, it is combined with a lot of bureaucracy and additional formal burden, which makes it to a challenge for many players, including surgeons and biomedical companies, especially smaller ones. It is much more difficult than previously to achieve re-certification of existing implants and instruments, and to develop new products. The requirements, to bring new products on the market and to obtainre-certification of proven and already established implants and instruments is higher, probably even sometimes too high from my point of view. We may need pragmatic ways to enhance these processes without endangering patient safety. One of the activities of EFORT and one of my personal activities is, to work in this area and to support the MDR-implementation. At the end, it should be a positive development not only for patients, but also for surgeons and the biomedical industry. It is not easy and as always, the European bureaucracy is a challenge, but we must make the best out of it.
It is a huge amount of work and a lot of enthusiasm from people like you to find a good solution and compromise.
You are absolutely right. There we may come back to the question, what the main activities of EFFORT are. We are turning to be more successful in that area and luckily a dedicated group of colleagues like Per Kjaersgaard-Andersen, Rob Nelissen, Søren Overgaard and others are mainly involved in those topics. It is also a stimulating activity and we are just now immediately before launching the first results of our “EFFORT Implant and Patient Safety Initiative”, which develops recommendations on the introduction of new implants, Mix & Match and off-label use as well as the analysis of retrieved implants during revision surgery. We hope to contribute with these activities – which are supported by many colleagues in European countries - to patient safety and the implementation of MDR as well. This is a fascinating activity and I enjoy really the interaction with colleagues in this European affair.
This brings me to your private life. Listening to you and looking at your CV, I wonder how could you balance your tremendous activities in the orthopaedic field with your work-life balance?
This is probably the most challenging question in the whole interview! We all strive to find the right balance between a professionally stimulating activity on one side and an intact family and personal health situation on the other side. I have a wonderful wife and two children who are now going their own ways. I try to play sports as often as possible, read good books and newspapers outside of medicine and visit the opera and the theatre in Dresden as often as I can – at least before the pandemic. Therefore, I do not miss anything in my life. I was very, very lucky up to now, and thanks god, I have had no big health challenges so far. This is something I am grateful every day for as it can change every day, we all know that. This is also one of the reasons why the main theme of this annual EFORT congress 2021 is “Sustainable Professional Practice”. For all of us it is a challenge to maintain sustainability in our personal as well as professional life, but it is probably one of the most important issues. I was lucky enough to maintain this up to now and I can only hope to continue this for some more years.
What will be your advice when a junior doctor will ask you “what are the key points which will help me to be a good orthopaedic and trauma surgeon in the future”?
I think there are several key points, which need attention. Some of them may be even outdated, but I personally think they contribute to be a successful surgeon. The first key point is to enjoy working with patients and colleagues people every day; if you do not enjoy this you will never become a good surgeon. The second point is that you should be prepared for investing more than the limited working time regulations suggest. You can obtain of course sufficient practical and theoretical knowledge within formally regulated working time directives, but additional success and knowledge, which may come with a combination of ambitious clinical and scientific work, need extra time. Although this will continue to be a challenge, it is reality. The third key point – which is closely related to the second one - is to always try to combine clinical practice with scientific education. Only the combination of those two pillars will help you to use surgical skills appropriately and to reflect the success of your work in terms of real outcome for patients. The final and probably most challenging key point is to always respect your personal balance and health as good as possible.
Professor Gunther thank you very much. It was a very interesting and personal interview. I wish you all the best for your future.
Published in N°012 - July / August 2021