N°277 - October 2018
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What are the major topics of this Congress?
One of the main topics is digitalisation. We care for everything that is together with computers and electronics, for patients and for hospitals. We have some scientists who are in the field of information technologies and big data who will give some lectures about the close future. Some people from insurance companies will show what is coming in the next 10 years to our patients and doctors. What are the chances? What are the risks? Then the medical topics. A major one concerns implant associated infections. We will discuss measures for improved prevention as well as solution strategies for the therapy of manifest infection. Of course all the usual themes of orthopaedics and trauma will be covered also. What we want this year is to feature more our subspecialty societies and give them sufficient space for presentations and discussions. Our guest nation this year is Great Britain.
What you think digitalisation is going to bring to our practice?
One point is whether it is necessary that we have our implants customised. Is it relevant that we have our implants individualised and made with a 3D printer? What we see in the hospital now, especially in total joint arthroplasty, is that we go back again to assisting systems. Not so much navigation any more but it's now these robots that help control what you cut. Whatever we think of it, maybe it's good may be not, they are back. This must be shown. Then we have training programmes for young residents in the digital world. So, they have these 3D goggles and they can train at an operation as a voice system tells them: now you do this and now you do that; and they do it in a virtual reality. We have a station where you can train surgery in a virtual reality and it's a new project. But this will go further. The Volkswagen company has a department for future. They are looking at what's coming to us in the next 50 years and the head of this department will give an opening lecture of the Congress. What do we have to think new if we want to survive in this new world? It's not only medicine. It's more than that. I was with this guy a whole day in the Volkswagen company and first I thought he will shows us a robot they are developping that helps people who cannot walk. But this is not what he is really interested in. He is thinking totally new ideas where our future goes to. What will mankind do in 30 years? How will we live? Very interesting questions for the medical field.
About the customized implants, who’s going to pay for them?
That's a good question. That's why we invited politicians and the ministry of health, the secretary of this department and we will have a discussion with politicians and insurance companies about how to finance the future. How can we do this? Where do we spend money? What are the possibilities and the hazards. When there is a 4th time revision arthroplasty and you need a special pelvic implant, then it's probably a good idea to have it customized and on a 3D printer. But for a 90 years old lady a standard cemented stem and a cemented cup will do perfectly. So, we have to individualise our indications. We go more and more to treat individual personalities and not a group of somebody. And for individualized surgery, big data can help us to find the right options.
How is the situation regarding the fusion of orthopaedic and trauma societies?
Since some years we are working on the same projects. So, we meet several times a year in the Lufthansa training centre and we have moderators. We try to define what can be the future of orthopaedics and traumatology in Germany and we have found out that we all think it's good we unite this field. In the end, it's three groups. It's the people in private practice, the people in the trauma centres and the people in the orthopaedic centres. And to get them together in one goal it's not so easy. In fact, in the beginning it was people who were grown up in the old world and they could not change. The trauma surgeons would say: We do everything fast and good and we are fighters and those lazy orthopaedic surgeons don't go up and don't do anything. And on the other side, the orthopaedic surgeons say: you just do actions but you don't think before you do your action. So, we try to get the two societies together and the young generation is okay with that. Now, they are not trained to be trauma surgeons or orthopaedic surgeons but they are trained for orthopaedic and trauma and after 6 years then they will specialise. But finally the question could be: Does the total hip specialist need a German Society of Orthopaedics and Trauma? And what we have found out is that they need it for administrative purposes. They need it for certifications. They need it for training programmes and they need it for all registries and all that stuff that we run as a society and they want it for the big meeting once a year where they can get their certificates.
And how important is it for the societies to speak with one voice?
Very important. And that's what many of the subspecialties agree on. Obviously, if we talk with politicians or if we talk with insurance companies, it's a lot better if you represent 17,000 doctors instead of 5,000 and it's more influential and this is one of the reasons why we have to keep the big group together.
Why did you invite Great Britain?
We invited Great Britain because we thought that despite the Brexit we have to keep our British colleagues in Europe. And they said yes, we want that too! So what have they to offer? We’ll see in details from the lectures they are invited for. They have different but pretty interesting experience in total joint arthroplasty. They have an excellent register and the German registry and the British registry have made a contract to work together and pool the data. They have good experience in foot, in hand and in trauma. I am sure they will enrich us with their experience.
They have a great register indeed!
It's the best. Australia and Sweden are good too. But the Swedish are very limited in numbers of cases and type of operations. In Germany, we have about 70% of our total joint arthroplasties in our register now but it is voluntary. Still 30% are missing. So, we are in talks with our government and probably from 2020 onwards each and every case of a total joint must be in the German registry. There's a certification process that we as a society started, not the government. And we control it and we have now 650 centres that are certified orthopaedic centres who are highly specialized in total joint arthroplasty. We started with hip and knee and now we have also included shoulder, elbow and all the other joints. Everybody has to bring his data in and of course we can learn from the experience of the Australians and the British how to make it perfect. What mistakes can we avoid? There was a surgeon in Australia doing very poor surgeries; the orthopaedic society and the registry have been sued by lawyers because they did not do anything about this black sheep. And so we have learned that if you say: A-we have to get all this data, you also have to say: B-there must be consequences. If you do very good surgery, then the insurance companies should reward you and if you are very bad, you should be punished. You should be taken out of this business. That's something that the Orthopaedic Society with their experts can advise and the government has the power to inforce it. We have found now a way that the government is implicated for all the consequences that come out from the data, but the data are controlled by the Orthopaedic Society. The board has the data which are anonymised and controlled, then the results are given to the government, to the insurance companies or to the industry in the best interest of our patients
You mean that the surgical society first check the relevance of the data?
Yes and it’s essential. I’ll give you one example. We have seen at the first glance that our cemented hips and uncemented hips in old people had different results. In the cemented hips more people were dying in the first year than in the uncemented. So how can this be? You may think that it's related to the use of cement but we found out it’s not. In fact, the old people with good, physical shape they got uncemented and that's why they survived better than the others and not because they got no cement. That's why, we as surgeons must check first. We must analyse the results with the statisticians when they tell you: cemented die more. If you give the raw data to insurance company or politicians, they just pick what they need for their purpose.
There are many educational courses in the program, but do they bring more than a textbook?
Yes, they bring very experienced speakers. We have hand-picked experts with very good lectures that are checked and proven. There you get in one hour the most important information on whatever you want and the young residents like it. They go there and they get a knowledge from a very experienced, well-known and established surgeon and the Congress courses are very popular among young residents. But you can attend not only basic courses but also advanced courses for the specialists where you can really enter the details. And there is the ASG fellow Jubilee. It’s a fellowship from Austria, Swiss and Germany going all over the world and this fellowship gets back American, Canadian and English fellows to Germany, Austria and Switzerland. So, it's in the best sense European and international and this group is now 40 years old. We are celebrating this in Berlin. Every day there is major lectures from 11 to 12:30 and from 2 to 3:30. The biggest topics in the field by the best speakers of the ASG fellow group will be presented every day in a very big room. Overall for our congress there is 13,000 doctors attending and 3,000 of these are international. I’m proud to say that our congress is the biggest specialist congress in our field in Europe.
Where are you practising?
I'm working at Vitos Orthopedic Clinic in Kassel in northern Hesse which is a teaching hospital for Orthopaedics and Traumatology. The department has about 200 beds and we have a big outpatients clinic. We see about 20,000 people on the outpatient clinic and about 8,000 people in the inpatient and do about 7,000 operations a year. We have specialists for all fields. Starts with foot and ankle and ends up with cervical spine. Our focus is on hip and knee and shoulder. About 1,500 total joints in hip and knee. We are certified training centre for big revisions. My special topics are osteotomies around the hip and knee and of course total joint arthroplasty and revision arthroplasty of hip and knee. I do about 400 total hips and knees a year.
Do you propose day surgery for arthroplasty?
Sometimes, for selected patients and if they're very motivated but not for the average patient. I think that for THA it's marketing driven, not patient orientated. Everything we do should be in the best interest of the patient and not in the best interest of the marketing department, the administration or the insurance company. I don't think we should promote this trend because we are dealing mostly with old people and the first 3-4 days we like to watch our patients. If there will be a problem with a case, which is rare, then it is in the first 3-4 days.
Do you have an experience with dual mobility cups?
Yes and I like it. I have learned dual mobility in France, during meetings and also with Joachim Pfeil from Wiesbaden and with his German-French friendship society many years ago. Now each and every third time revision case gets dual mobility, if possible cemented into cages. Also my fracture cases in people older than 80 years get from the beginning a dual mobility cup and I have no dislocations and no problems of stability. Then, you may think it's crazy, but I do dual mobility in very active young men because the 25 year old patients are often so active that they are exposed to dislocation.
You published on robotics for knees some years ago …
We stopped it because the system was not manufactured any more. We did 120 cases with the Maquet robot. The TKA was the Aesculap prosthesis called Search, which was more or less a Miller Galante prosthesis type. The 120 cases were followed up at 5 years, 10 years and now 15 years. Surprisingly enough the results are very good. They are outstandingly good with this prosthesis compared to the results we have from standard techniques. I don't know what's the reason but I think it's the perfect shaping of the surface and then the prosthesis was cemented. We did not do too much releases in these cases. We planned it on the computer and we could bring this 3D panning directly to the bone and this was perfect. Unfortunately we had to stop it because the company was not manufacturing anymore the robots and so we could not use it anymore. I must say it was a little bit more time-consuming. Also our 120 cases do not include major deformities. Anyway, the long-term results are very good.
How did you become an orthopaedic surgeon?
My medical school was in Munich. And then I started general surgery with Heberer in 1982 in Munich and I moved to orthopaedics with Michael Jäger and Carl Wirth. Jäger was a great guy but unfortunately he died too early at 48. Wirth was my boss and we did research together and I did my basic training up to the orthopaedic surgeon. When the head of the department Michael Jäger died, Wirth the deputy head was not elected to be heading in Munich but in Hannover. So he took two guys with him to help him build up the department in Hannover: Dieter Kohn and me. In Hannover we were in a big hospital with 180 beds only for orthopaedics. And so we got a great experience and a lot of good training in this place.
What was your field of research at this time?
Discectomy by Laser. We brought it from experimental work and animal work to the clinics and we did a lot of disc surgery cases. We improved it to endoscopic techniques but eventually we left the laser for electrocautery because it was easier and cheaper. But we also used Laser in the knee in arthroscopy. We did a lot of knee arthroscopies. As I remember we started this type of laser assisted arthroscopy already in the early Eighties in Munich. Anyway there came a time when I started thinking in Hannover to go somewhere else.
Couldn’t you stay in Hannover?
Yes, I could stay but there were many interesting things going on at this time. As a person I wanted to influence everything as good as I can and really get my ideas done and I had so many ideas. At the time in Hannover I really wanted to do things differently and so I had to go my own way. I applied to several universities to become the head of the department there in East and West Germany. And it looked like I woud have good chances but then there was this opportunity in Kassel, which was very attractive. I came here and I saw this department: very big with 220 beds and a lot of possibilities including a good contract. I was very young, only 39 years old.
You were quite young …
Yes. I went here and took over this department. It was very conservative here. Not many operations, not so many patients. Of course, in the beginning, there was a lot of work. I was here from 6 o'clock in the morning to 10 o'clock in the evening. But we could keep the number of beds and increased the number of patients very much. We could keep the place and all the setup. We have more people working here now today than before. A lot more of outpatient operations. I had to make some changes and at the beginning the administrators did not always understand why but now they are very happy with the results.
Running such a big department requires more than surgical skills…
W.S.: Sure but I was not only trained as a medical doctor. I also had a Masters degree in business administration. I had started my business administration degree already in Hannover and I finished it here. I wanted to do this because I knew that hospital administrators are not always understanding the language of the doctor. In this way I could manage at my best and influence them better.
Where did you get the time to do all this?
At night! Fortunately my wife is the daughter of a surgeon. Her father was a trauma surgeon and he was hardly at home…When I came here the people wanted a surgeon who knows everything. Of course with my training I could do everything in orthopaedics but here I started immediately to separate the sports medicine department, to separate a foot and a hand department. To get smaller fields with better quality. I always thought that specialisation and good quality is rewarding and that it is a miscalculation to have the cheapest prices and the cheapest doctors. I think good quality will be paid by the patient and in the end also by the society and insurance companies. Quality is one of the things that you have really to fulfill and you also must try to think like your patients. You must find out who is your patient, what’s his personality, what he wants and whether it's good to give it to him or better say to him don't do this because it's not good for you. The key is to listen to the patient. I learned that because I started as a young psychiatrist. As a medical student I did a lot of psychology.
Why, because the prettiest girls where there?
Most probably. Anyway, I did my first thesis in psychiatry. It was about the situation in psychiatric hospitals in Bavaria. At that time it was not a good situation for the patients. I went in the psychiatric hospitals to ask the patients about their situation. How they are living there? How they feel the therapy and so on? And what I did was rather crazy because I spent nights inside of this closed psychiatry department together with the patients. There was nobody else there. Just the patients and me, because at that time, for 3 wards, there was only one nurse at night. The conclusions of this thesis were that the situation is not good and that we had to do something to improve this. My professor of psychiatry was very happy with this thesis and maybe we could influence the politicians a little bit to improve the situation of our patients. I did a little bit of psychiatry but then I realized it was not for me and I applied in general surgery. The Professor of surgery, Heberer, he said to me: well, I understand this because I have also started in psychiatry; but it's much easier to cure somebody with the knife than with words. I fully agreed on Professor Heberer’s words and started my carrier in surgery.
Published in N°277 - October 2018