- Email: [email protected]
Surgeons who have influenced my surgical career
The Spine Journal 16 (2016) S5–S11
Editorial
Surgeons who have influenced my surgical career John K. Webb, FRCS* Department of Spinal Surgery, Queen’s Medical Centre, The Old Rectory, 4, Church Lane SAXELBYE Leics LE143PA, Nottingham, UK Received 2 November 2015; accepted 19 November 2015
I was asked if I was prepared to discuss a paper that had a profound influence on my surgical journey. I have given this some considerable thought and I cannot identify a specific paper that had such influence on my surgical journey. There are numerous papers that have affected my surgical practice in different ways; each paper has had an influence that has caused me to alter my surgical approach to certain clinical conditions, but there is not one paper that I can identify that has changed my way of working. There have been papers written that have caused me to modify my approach to low back pain and scoliosis. The concept of segmental instrumentation developed by Eduardo Luque influenced my concepts of surgical correction of spinal deformities. This concept led Max Aebi and myself to develop the Universal Spinal System, which would allow individual segmental correction. The papers written by Jean Debousset on balance caused changes in approach to deformity as did Klaus Zielke’s anterior instrumentation, the French surgeons reigniting the pelvic parameters and their importance on sagittal balance. To my mind, the most profound changes in my surgical life have been influenced by surgeons who I have been fortunate to meet. I trained at the London Hospital and embarked on a career in orthopedics and trauma at an early stage in my career. While at the London Hospital, I had the difficulties of passing the primary and final fellowship, both in those days with a pass rate in the region of 8%–10%. I was fortunate to pass both the first time; more luck than judgment I suspect. I was advised that if I wished to pursue a career on orthopedics and trauma, I should try and obtain an appointment at the Birmingham Accident Hospital. I worked for a Mr P S London, who wrote a book entitled A Practical Guide to the Care of the Injured [1]. A fascinating man, rather like a colonel, immaculately dressed without a hair out of place, bulled toe caps, and a white coat with numerous pockets, each for a specific object, top right three biros in blue, green, and FDA device/drug status: Not applicable. Author disclosures: JKW: Nothing to disclose. * Department of Spinal Surgery, Queen’s Medical Centre, The Old Rectory, 4, Church Lane SAXELBYE Leics LE143PA, Nottingham, UK. Tel.: +44 1158967655. E-mail address: [email protected] http://dx.doi.org/10.1016/j.spinee.2015.11.067 1529-9430/© 2016 Elsevier Inc. All rights reserved.
red, and a pocket for a tape measure and another for a small patella hammer, etc. We would change them around when he was in theater; next time he appeared, they would be in the correct pocket. I think he rather enjoyed the charade. He was particularly meticulous in his management of trauma and his regime was very set; arriving at 8 o’clock precisely, and if I had not already visited the intensive care unit and reviewed all our patients, he would then sit down and write reams of notes to make a point that I should have been there before 8 o’clock. He was a meticulous surgeon and planned the surgical technique with diagrams before taking the patient to the operating theater. An important learning lesson. This was some years before the teachings of Arbeitsgemeinschaft fur Osteosynthesefragen (AO). Not only did he influence my surgery but the hospital was an experimental concept, and as such was involved in surgery appertaining to all aspects of trauma, including burr holes, thoracotomies, abdominal surgery, etc. This exposure gave me considerable experience in the seriously injured patient. However, it became apparent with more specialization that it was not appropriate for surgeons to perform occasional thoracotomy when it should be performed by cardiothoracic surgeons. He led by example and remained in the casualty department until 12:00 midnight, at which time we ate bacon and eggs and drank a glass of perry from a cast in his office. We then cleared casualty. He was very demanding, but if one performed well he would always acknowledge his or her efforts, and was supportive in one obtaining another surgical post. This example I continued by giving praise to my Fellows. If they performed their clinical work, research, or surgical work to a high level, it is important that they should be complimented. When my wife gave birth to our first child, London allowed one day off work to visit my wife, the birth occurring at the London Hospital. At that time, surgeons in training had to do 1 year of surgery, 6 months in a surgical specialty, and mine was urology and 6 months in accident and emergency. I then went to various hospitals: Bristol Royal Infirmary, Sheffield Royal Infirmary, and Harlow Wood Orthopaedic Hospital. In Sheffield, I was fortunate to work for Mr D K Evans and Mr W J W Sharrard. Evans was again a very precise surgeon and taught me many tricks of the trade on
S6
J.K. Webb / The Spine Journal 16 (2016) S5–S11
straightforward orthopedic procedures. I remember him saying “If you can do a good Kellers operation you will never be poor.” Afternoon tea was taken at one of the smaller hospitals I visited to assist at surgery. Cucumber sandwiches without the crust, of course. Those were the days!! I gained considerable experience in the management of various conditions under the instruction of Sharrard, who happened to be a brilliant pianist. Sharrard, with an eminent surgeon Professor I Zachary, had developed a large spina bifida practice. This was
partly because the hospital received many patients with spina bifida with open defects. Parents brought their children considerable distances for their spina bifida defect to be closed. We would often close two children’s defects a night. Thank God it is very rarely seen. The spina bifida clinics would often continue until 8:00 pm or 9:30 pm. The children would have multiple pathologies, such as club feet and vertical talus, from which one could learn the techniques of correction. I wrote a paper on “supramalleolar osteotomies in such children [2].”
DK Evans
WJW Sharrard
For my orthopedic training, I worked at the Robert Jones and Agnes Hunt Orthopaedic Hospital and encountered many well-known orthopedic surgeons. Friday mornings were teaching ward rounds and then an afternoon conference with a guest lecturer. Many well-known orthopedic surgeons would attend the hospital, participating in ward rounds and conferences,
Sir Reginald Watson-Jones
After relatively alcoholic dinners, we would retire to the billiards room and play a rough game called “Oswestry billiards” after Friday dinner. Individuals had to reach the white ball while it was still moving and try to hit the red ball. If the ball stopped before you reached it, you were out! Foul play was normal to prevent an individual reaching the ball.
and would then give a lecture. This was followed by a visit to a local hostelry, followed by dinner—no wives allowed! It was very convivial and also deep discussions were held on the merit of certain treatments. Surgeons who visited were Sir Henry Osmond Clarke, Sir Reginald Watson Jones, W Law, Lloyd Griffiths, and JIP James.
PH Newman
Sir Henry Osmond-Clarke
One particular Aussie would hold and bite people; Sir Reginald broke his hip!! It was while I was at Leighton Hospital (on the first year at Oswestry as a resident, one had to work at a peripheral hospital, either Hereford, Rhyl, Aberystwyth, or Shrewsbury) that I worked for Mr T McSweeny, one of the most kind
J.K. Webb / The Spine Journal 16 (2016) S5–S11
men I have worked for. A heavy smoker who would sit on the side of a patient’s bed to explain the reason for a particular operation. He would take out a cigarette, light it, then hold the ladies’ hand and discuss the operation. Not allowed today, no smoking! No touching! I really believe that sitting with a patient who was obviously stressed by the forthcoming operation, just touching them communicates empathy. I still do it. I believe it gives patients a sense that the surgeon understands their concerns. I still do this despite sisters saying I should not touch patients. Infection! That will be avoided if you wash your hands after seeing each patient. What rot!!! Mr McSweeney was an extraordinary man with an infinite knowledge of orthopedics, in particular the spine and spinal injuries. He stimulated me to write my first spinal paper, “The Hidden Flexion Injury of the Cervical Spine.” What did I learn, apart from gaining a great deal of knowledge of the spine? I learned the importance of gaining the confidence and trust of patients. Thank you Terence McSweeney. McSweeney suggested that I visit the first AO course in the United Kingdom, which took place in Stoke-on-Trent. He told me to turn up, giving his name because I had not registered. That was a turning point in my life. I wrote to Professor Allgower implying that I had considerable difficulty accepting their outstanding results after reconstruction of severely damaged joints as these were not the results of reconstruction of joints that I was seeing in this country. Professor Allgower suggested that I visit Switzerland for 4 months. While at Oswestry, I visited Switzerland for 4 months, which turned out to be nearly 6 months. Professor O’Connor arranged for me to continue my salary while I visited Davos and Basel for 6 months. Apart from learning the art of fixing fractures, my family learned to ski! This was the time when I became involved with the AO organization, in particular Professor H Willinegger, Professor M Allgower, and Professor ME Muller. Having learned the AO surgical techniques, I began to organize AO trauma courses in the Royal College of Surgeons. The most influential person I met in Switzerland was Professor Maurice Muller. He was a member of the Magic Circle and was one of the most technically able surgeons I have had the pleasure to watch. We spent a few late nights in Davos drinking Chivas Regal and mint tea; being a member of the Magic Circle, he would perform tricks. Very entertaining! Muller explained how the Group was founded. He actually would visit smaller hospitals and offer his services to fix fractures. I quickly realized that he was ambidextrous, and by using both hands he was able to use instruments in both hands and reduce the amount of time asking for nurses to pass instruments. Although I was reasonably ambidextrous, I practiced a great deal so I could use my left hand as well as my right, and that was a tremendous advantage at surgery because I could hold two instruments in my left hand and flick from one to the other, as well as use my right hand, and this speeded up my surgery. I also learned to tie knots with my left hand, and when operating on the spine to use my left hand in certain situations rather than my right hand to expose the spine; it was very helpful. I have advised my Fellows that they should try and use their non-
S7
dominant hand as well as their dominant hand. Unfortunately, many surgeons do not seem to have that ability.
Professor ME Muller
One other thing I learned, particularly from the Swiss, is that they did not want to retire and they wished to continue to hold the reins of the AO Foundation. That taught me that once I reached a certain age—65—I would retire from all committees and would not have any influence on them, unless I am asked for my opinion. I think it is wrong that a surgeon should try and influence the next generation. It is their future. If they would like advice, then I will willingly give it, but it is my opinion that you should not sit on committees and try to influence decisions when you will not be there in the next 20 years. I think it is important to try to retire gracefully and let the next generation make the decisions. I attended the AO courses in Davos, and when I returned to Oswestry I was soon arranging trauma courses in the United Kingdom. I invited such surgeons as Professor Sarmiento from Miami, who introduced functional bracing, and Professor John Paul Harvey. While I was studying at Oswestry, I realized that a few of the consultant orthopedic surgeons could not accept that they had some limitation in their knowledge. I remember very well presenting a patient with proximal femoral deficiency. I asked how this condition should be managed. Some of the answers given by one or two consultants were totally incorrect, with no grasp of the basic concepts of the treatment, missing the important decision to undertake an arthrogram to identify if the femoral head was present. At this stage I realized the importance, although many of my friends may not identify that in my personality, that if you do not have the knowledge state quite clearly “I do not know.” It seems to me that many surgeons do not have the ability to acknowledge that in certain areas they have lack of knowledge. I think from that I learned the word “humility,” and I have taught my fellows that humility is important; it is the quality of having a modest or low view of one’s importance. While I was at Oswestry, probably the other most influential person in my career was Professor O’Connor. O’Connor was a short Australian with a very incisive mind, being able to intellectually run rings around anyone. After the Second World War, he abandoned his studies to work on board a Swedish ship.
S8
J.K. Webb / The Spine Journal 16 (2016) S5–S11
He worked as a professional acrobat. His training involved working with Aboriginal communities, United States, and Sweden. He had a tremendous presence and was a natural leader. His unique presence was expressed in sartorial elegance, and his immense drive and energy were as memorable as his ability to slice through red tape. As a gifted teacher, he inspired a generation of orthopedic surgeons. He was instrumental in allowing me to go to Switzerland. I wished to broaden my knowledge by studying in America. Many consultants were opposed to this; however, O’Connor insisted that I should go.
BT O’Connor
When I returned to Oswestry from Switzerland, I was planning a career in pediatric orthopedics and had arranged a Fellowship in Salt Lake City with Dr Sherman Coleman until Mr John O’Brien arrived at Oswestry from Hong Kong. His arrival changed my direction from pediatric orthopedics to spinal surgery. It was a new surgical world. I learned to perform anterior approaches to the spine, from the odontoid to the sacrum. A considerable amount of my surgery involved using anterior approaches. I was fortunate enough to work with John O’Brien for 3 years and it was a revelation. His particular interest was low back pain, and with Bill Park (Consultant Radiologist) we were involved in basic research projects.
JP O’Brien
I had learned anterior surgery, which I considered the gateway to the spine. I could and still do not understand why
spinal surgeons are not trained in anterior approaches. Regrettably, training time has been shortened, and there is no longer enough time for surgeons to be trained in such techniques. If one does not have the ability to undertake anterior approaches as well as posterior approaches, decisionmaking in planning the various options for surgical is limited. There is a well-known saying: “If you do not change direction you may end up where you do not wish to go.” So new doors were opened. Oswestry was for me and many others an exciting place. Living near the hospital with multinational trainees, mainly from Australia and America, it was a place to learn. This multinations hospital created a great bond between us, which has lasted. Many of us still communicate with each other. Parties were awesome, often lasting into the early hours of the morning, and in the summer often until morning. We did not have to work on Sundays. During this time, John O’Brien encouraged me to become involved in spinal societies, and in particular the International Society of the Lumbar Spine, which at that stage was a society with limited membership. Many of the most influential spinal surgeons and physicians at that time were studying low back pain. I made many friends, people like Dr Harry Farfan, Dr Vert Mooney, and Professor Alf Nachemson, to name but a few. In the scoliosis area, I met Dr Jean Debousset, Dr David Bradford, Dr Bob Winter, Dr John Lonstein, and Dr Daniel Chopin. I visited many of the major spinal centers in Europe and America; many of them visited Nottingham. I operated in Lyon and that evening we visited Professor Stagnara’s house. He cooked Lyonnaise sausages on a fire at his home. He then took us on a guided tour of his vineyard. He had built a sophisticated cooling system for his wine vats, the water coming from a nearby lake. We drank excellent wines; I am now an addicted French wine buff. Other people who have influenced me include Dr Jean-Pierre Farcy, a brilliant surgeon, with tremendous knowledge of sagittal plane surgery and deformity, with a wonderful wife. Along with JP, another technically brilliant surgeon was Daniel Chopin and I would travel to the Berck Plage to watch him operate. Although not speaking much French at the time—and I am not much better at the present time—he was a brilliant surgeon and I learned a lot of little techniques, and he introduced me to Cotrell Debussy (CD) before the Universal Spinal System. He came to Nottingham on numerous occasions. Klaus Zielke came to Nottingham many times, as did Eduardo Luque, sharing his experience and techniques. In 1995 to 1996 I took up my Fellowship to work at Rancho Los Amigos. I studied under Professor Mooney, Professor Nickel, and Professor Jacquelin Perry. These were exceptional people. Dr Perry in her mid-70s was still teaching every Monday morning at 7 o’clock—surgical anatomy—which was again very relevant to one’s practice. Jacquelin Perry and Vernon Nickel produced the halo for the management of severe deformities, which was published in the Journal of Bone &
J.K. Webb / The Spine Journal 16 (2016) S5–S11
Joint Surgery, “The Halo. A spinal Skeletal Traction Fixation Device.” [3]
S9
to mention it. It is, therefore, most important that all your staff work as a close team. During one conference, I called Nickel a primitive man, hence the photograph.
From the primitive man Centre back row: V Mooney Front row: V Nickel, J Perry
Vernon Nickel was a big man with a big vision. He had created Rancho Los Amigos to be the leading rehabilitation center in America. American trainees wished to work there for 6 months, but he insisted that if you worked there toward the end of your 6 months there would be Saturday morning meetings and the residents had to present a paper. If a resident did not, he would not be signed up as having completed his rehabilitation program. The resident would have to return to repeat the 6-month program; everyone therefore presented a paper. Good presentations were turned into papers for journals. That taught me that when in the future I have a Fellow, if he wishes to be fully trained, he must learn to write papers, and fortunately most of my Fellows have written papers while they have been working for me. One day he asked me to remove a secondary breast tumor in C2, and I said that I would require some help and he told me that he would be with me. I started the surgery and 5 hours later finished; I did not see Professor Nickel. The patient woke up with slight weakness in the shoulder area. That evening there was a party at his house and he greeted me in his shorts and shirt, with a pair of underpants over his shorts emblazoned on them “the home of the big whopper!” Vernon Nickel’s great friend owned the Burger King chain, the home of the big whopper. I explained that I was surprised that he did not come and help. He replied “John, I was with you in mind, all the time.” I told him I had a slight complication; he told me that he knew that the patient had slight weakness on the right shoulder. That taught me two lessons. One: have confidence in your trainee’s ability and allow them to perform operations that are within their surgical ability, always stressing that if they have the slightest difficulty stop and shout for help. If they created a problem without asking for help, they would be in “big trouble.” Second, and equally important, one must have a well-trusted team.Your sisters will tell you if there is a problem with a patient because sometimes your Fellows may absently minded forget
Finally at Ranch Los Amigos was Professor Vert Mooney. He was one of the most intellectually interesting persons I have worked for, and sadly he died quite recently. He was particularly interested in lower back pain, and at Rancho every day between 4 and 5 o’clock each specialty had a weekly conference. The low back conference with Professor Mooney was always interesting and innovative. Cases were presented, and if he did not know the answer I realized that he would ask the Fellows to tell them about this rare case “to educate the Nurses and the Physiotherapists.” I realized he had no more idea than I of the condition and that this was a way of him learning. He would very often say “I have no idea how to deal with this case,” or he would say “I don’t know the answer.” I learned at that stage that silence is better than bullshit, but unfortunately I am surrounded by some people who have the latter. Monday evenings we visited Professor John Paul Harvey as he was known. A clinical conference for 2 hours took place at LA County Hospital, covering such topics as perilunate dislocations, non-unions of the femur, etc. Each patient had suffered multiple injuries and fractures. These discussions were memorable, stimulating, and were very well organized. The poor internists must have been up half the night putting the cases together. Woe betide if they made a mistake during a presentation! This experience had an influence on how to organize clinical conferences and the way they should be conducted. Research That is something which I think in a way I have failed on because I spent 10 to 12 years building up a spinal unit, traveling the world teaching, arranging for Fellows from Australia, South Africa, and America to come and work at our unit, and presenting papers at the Scoliosis Research Society (SRS) and other international meetings, which made our unit internationally known, and this encouraged a high quality of Fellows. Finally I was appointed at The University Nottingham. I have to thank Professor Mulholland, who was the instigator of me being appointed at the University Hospital in
S10
J.K. Webb / The Spine Journal 16 (2016) S5–S11
Nottingham. He has been most supportive in my appointment, and throughout my career I would ask him for advice and he would always give a well-considered opinion. He remains a very kind and generous man. Even these days, he still is as bright as a button, and although one does not see him as often as one would like because he spends his life sailing he still is an incredibly knowledgeable surgeon, still writing. Basic research I was fortunate that in our hospital was Professor G Burwell. He was a professor of orthopedics at the Royal National Orthopaedic Hospital, but because his inclination supported research rather than surgery he ultimately left and was appointed at the University Hospital as a senior lecturer in anatomy, ultimately becoming Professor of Human Morphology. He always had Research Fellows, and I worked hand in hand with him, and he still, in his late 80s, is writing papers. He is a very good friend and a person who has had a major influence on the papers coming out of our unit. And finally, probably the brightest, most intelligent surgeon I have ever been proud to be associated with is Max Aebi. He is a tower of knowledge and I have had the privilege to work for him for maybe 30 years. We have designed most of the implants for AO spine and written two AO spine manuals. He remains my friend and I know he will never retire. I know he has recently bought a small villa in Alba and I certainly hope to visit him and drink some good wine.
Max Aebi and Paul Pavlov
I apologize if I have left out other people who I should have included in this paper, but I am still not certain whether this type of article is of any benefit for the young surgeons. I was asked to write such a paper, and I believe it shows an era of training, which no longer exists, moving from center to center, absorbing knowledge and different techniques, so that at the end you can apply what to your own mind is the most appropriate technique for the surgical condition. I have been profoundly fortunate to have worked with such outstanding surgeons, many of whom have remained my friends. Many scoliosis surgeons in this country have also become great friends. These surgeons founded the British Scoliosis Society and surprisingly remain good friends.
Frank Dowling Alan Gardiner
Mike Edgar, Andy Randsford, Tim Morley
J.K. Webb / The Spine Journal 16 (2016) S5–S11
I have been fortunate to have a very supportive wife and children. We lived in 17 different homes before we settled in Nottingham. My wife, Kate, said she did not care how hard I worked during the week. However, midday on Saturday until Sunday evening was family time. That worked out well and we remain married after 47 years and have a wonderful family.
S11
References [1] London PS. A practical guide to the care of the injured. Edinburgh: E. & S. Livingstone; 1967. 790 pp. 10×7 in. with 1194 illustrations. [2] Sharrard WJ, Webb J. Supra-malleolar wedge osteotomy of the tibia in children with myelomeningocele. J Bone Joint Surg Br 1974;56:458–61. [3] Nickel VL, Perry J, Garrett A, Heppenstall M. The halo. A spinal skeletal traction fixation device. J Bone Joint Surg Am 1968;50:1400–9.
Editorial
Surgeons who have influenced my surgical career John K. Webb, FRCS* Department of Spinal Surgery, Queen’s Medical Centre, The Old Rectory, 4, Church Lane SAXELBYE Leics LE143PA, Nottingham, UK Received 2 November 2015; accepted 19 November 2015
I was asked if I was prepared to discuss a paper that had a profound influence on my surgical journey. I have given this some considerable thought and I cannot identify a specific paper that had such influence on my surgical journey. There are numerous papers that have affected my surgical practice in different ways; each paper has had an influence that has caused me to alter my surgical approach to certain clinical conditions, but there is not one paper that I can identify that has changed my way of working. There have been papers written that have caused me to modify my approach to low back pain and scoliosis. The concept of segmental instrumentation developed by Eduardo Luque influenced my concepts of surgical correction of spinal deformities. This concept led Max Aebi and myself to develop the Universal Spinal System, which would allow individual segmental correction. The papers written by Jean Debousset on balance caused changes in approach to deformity as did Klaus Zielke’s anterior instrumentation, the French surgeons reigniting the pelvic parameters and their importance on sagittal balance. To my mind, the most profound changes in my surgical life have been influenced by surgeons who I have been fortunate to meet. I trained at the London Hospital and embarked on a career in orthopedics and trauma at an early stage in my career. While at the London Hospital, I had the difficulties of passing the primary and final fellowship, both in those days with a pass rate in the region of 8%–10%. I was fortunate to pass both the first time; more luck than judgment I suspect. I was advised that if I wished to pursue a career on orthopedics and trauma, I should try and obtain an appointment at the Birmingham Accident Hospital. I worked for a Mr P S London, who wrote a book entitled A Practical Guide to the Care of the Injured [1]. A fascinating man, rather like a colonel, immaculately dressed without a hair out of place, bulled toe caps, and a white coat with numerous pockets, each for a specific object, top right three biros in blue, green, and FDA device/drug status: Not applicable. Author disclosures: JKW: Nothing to disclose. * Department of Spinal Surgery, Queen’s Medical Centre, The Old Rectory, 4, Church Lane SAXELBYE Leics LE143PA, Nottingham, UK. Tel.: +44 1158967655. E-mail address: [email protected] http://dx.doi.org/10.1016/j.spinee.2015.11.067 1529-9430/© 2016 Elsevier Inc. All rights reserved.
red, and a pocket for a tape measure and another for a small patella hammer, etc. We would change them around when he was in theater; next time he appeared, they would be in the correct pocket. I think he rather enjoyed the charade. He was particularly meticulous in his management of trauma and his regime was very set; arriving at 8 o’clock precisely, and if I had not already visited the intensive care unit and reviewed all our patients, he would then sit down and write reams of notes to make a point that I should have been there before 8 o’clock. He was a meticulous surgeon and planned the surgical technique with diagrams before taking the patient to the operating theater. An important learning lesson. This was some years before the teachings of Arbeitsgemeinschaft fur Osteosynthesefragen (AO). Not only did he influence my surgery but the hospital was an experimental concept, and as such was involved in surgery appertaining to all aspects of trauma, including burr holes, thoracotomies, abdominal surgery, etc. This exposure gave me considerable experience in the seriously injured patient. However, it became apparent with more specialization that it was not appropriate for surgeons to perform occasional thoracotomy when it should be performed by cardiothoracic surgeons. He led by example and remained in the casualty department until 12:00 midnight, at which time we ate bacon and eggs and drank a glass of perry from a cast in his office. We then cleared casualty. He was very demanding, but if one performed well he would always acknowledge his or her efforts, and was supportive in one obtaining another surgical post. This example I continued by giving praise to my Fellows. If they performed their clinical work, research, or surgical work to a high level, it is important that they should be complimented. When my wife gave birth to our first child, London allowed one day off work to visit my wife, the birth occurring at the London Hospital. At that time, surgeons in training had to do 1 year of surgery, 6 months in a surgical specialty, and mine was urology and 6 months in accident and emergency. I then went to various hospitals: Bristol Royal Infirmary, Sheffield Royal Infirmary, and Harlow Wood Orthopaedic Hospital. In Sheffield, I was fortunate to work for Mr D K Evans and Mr W J W Sharrard. Evans was again a very precise surgeon and taught me many tricks of the trade on
S6
J.K. Webb / The Spine Journal 16 (2016) S5–S11
straightforward orthopedic procedures. I remember him saying “If you can do a good Kellers operation you will never be poor.” Afternoon tea was taken at one of the smaller hospitals I visited to assist at surgery. Cucumber sandwiches without the crust, of course. Those were the days!! I gained considerable experience in the management of various conditions under the instruction of Sharrard, who happened to be a brilliant pianist. Sharrard, with an eminent surgeon Professor I Zachary, had developed a large spina bifida practice. This was
partly because the hospital received many patients with spina bifida with open defects. Parents brought their children considerable distances for their spina bifida defect to be closed. We would often close two children’s defects a night. Thank God it is very rarely seen. The spina bifida clinics would often continue until 8:00 pm or 9:30 pm. The children would have multiple pathologies, such as club feet and vertical talus, from which one could learn the techniques of correction. I wrote a paper on “supramalleolar osteotomies in such children [2].”
DK Evans
WJW Sharrard
For my orthopedic training, I worked at the Robert Jones and Agnes Hunt Orthopaedic Hospital and encountered many well-known orthopedic surgeons. Friday mornings were teaching ward rounds and then an afternoon conference with a guest lecturer. Many well-known orthopedic surgeons would attend the hospital, participating in ward rounds and conferences,
Sir Reginald Watson-Jones
After relatively alcoholic dinners, we would retire to the billiards room and play a rough game called “Oswestry billiards” after Friday dinner. Individuals had to reach the white ball while it was still moving and try to hit the red ball. If the ball stopped before you reached it, you were out! Foul play was normal to prevent an individual reaching the ball.
and would then give a lecture. This was followed by a visit to a local hostelry, followed by dinner—no wives allowed! It was very convivial and also deep discussions were held on the merit of certain treatments. Surgeons who visited were Sir Henry Osmond Clarke, Sir Reginald Watson Jones, W Law, Lloyd Griffiths, and JIP James.
PH Newman
Sir Henry Osmond-Clarke
One particular Aussie would hold and bite people; Sir Reginald broke his hip!! It was while I was at Leighton Hospital (on the first year at Oswestry as a resident, one had to work at a peripheral hospital, either Hereford, Rhyl, Aberystwyth, or Shrewsbury) that I worked for Mr T McSweeny, one of the most kind
J.K. Webb / The Spine Journal 16 (2016) S5–S11
men I have worked for. A heavy smoker who would sit on the side of a patient’s bed to explain the reason for a particular operation. He would take out a cigarette, light it, then hold the ladies’ hand and discuss the operation. Not allowed today, no smoking! No touching! I really believe that sitting with a patient who was obviously stressed by the forthcoming operation, just touching them communicates empathy. I still do it. I believe it gives patients a sense that the surgeon understands their concerns. I still do this despite sisters saying I should not touch patients. Infection! That will be avoided if you wash your hands after seeing each patient. What rot!!! Mr McSweeney was an extraordinary man with an infinite knowledge of orthopedics, in particular the spine and spinal injuries. He stimulated me to write my first spinal paper, “The Hidden Flexion Injury of the Cervical Spine.” What did I learn, apart from gaining a great deal of knowledge of the spine? I learned the importance of gaining the confidence and trust of patients. Thank you Terence McSweeney. McSweeney suggested that I visit the first AO course in the United Kingdom, which took place in Stoke-on-Trent. He told me to turn up, giving his name because I had not registered. That was a turning point in my life. I wrote to Professor Allgower implying that I had considerable difficulty accepting their outstanding results after reconstruction of severely damaged joints as these were not the results of reconstruction of joints that I was seeing in this country. Professor Allgower suggested that I visit Switzerland for 4 months. While at Oswestry, I visited Switzerland for 4 months, which turned out to be nearly 6 months. Professor O’Connor arranged for me to continue my salary while I visited Davos and Basel for 6 months. Apart from learning the art of fixing fractures, my family learned to ski! This was the time when I became involved with the AO organization, in particular Professor H Willinegger, Professor M Allgower, and Professor ME Muller. Having learned the AO surgical techniques, I began to organize AO trauma courses in the Royal College of Surgeons. The most influential person I met in Switzerland was Professor Maurice Muller. He was a member of the Magic Circle and was one of the most technically able surgeons I have had the pleasure to watch. We spent a few late nights in Davos drinking Chivas Regal and mint tea; being a member of the Magic Circle, he would perform tricks. Very entertaining! Muller explained how the Group was founded. He actually would visit smaller hospitals and offer his services to fix fractures. I quickly realized that he was ambidextrous, and by using both hands he was able to use instruments in both hands and reduce the amount of time asking for nurses to pass instruments. Although I was reasonably ambidextrous, I practiced a great deal so I could use my left hand as well as my right, and that was a tremendous advantage at surgery because I could hold two instruments in my left hand and flick from one to the other, as well as use my right hand, and this speeded up my surgery. I also learned to tie knots with my left hand, and when operating on the spine to use my left hand in certain situations rather than my right hand to expose the spine; it was very helpful. I have advised my Fellows that they should try and use their non-
S7
dominant hand as well as their dominant hand. Unfortunately, many surgeons do not seem to have that ability.
Professor ME Muller
One other thing I learned, particularly from the Swiss, is that they did not want to retire and they wished to continue to hold the reins of the AO Foundation. That taught me that once I reached a certain age—65—I would retire from all committees and would not have any influence on them, unless I am asked for my opinion. I think it is wrong that a surgeon should try and influence the next generation. It is their future. If they would like advice, then I will willingly give it, but it is my opinion that you should not sit on committees and try to influence decisions when you will not be there in the next 20 years. I think it is important to try to retire gracefully and let the next generation make the decisions. I attended the AO courses in Davos, and when I returned to Oswestry I was soon arranging trauma courses in the United Kingdom. I invited such surgeons as Professor Sarmiento from Miami, who introduced functional bracing, and Professor John Paul Harvey. While I was studying at Oswestry, I realized that a few of the consultant orthopedic surgeons could not accept that they had some limitation in their knowledge. I remember very well presenting a patient with proximal femoral deficiency. I asked how this condition should be managed. Some of the answers given by one or two consultants were totally incorrect, with no grasp of the basic concepts of the treatment, missing the important decision to undertake an arthrogram to identify if the femoral head was present. At this stage I realized the importance, although many of my friends may not identify that in my personality, that if you do not have the knowledge state quite clearly “I do not know.” It seems to me that many surgeons do not have the ability to acknowledge that in certain areas they have lack of knowledge. I think from that I learned the word “humility,” and I have taught my fellows that humility is important; it is the quality of having a modest or low view of one’s importance. While I was at Oswestry, probably the other most influential person in my career was Professor O’Connor. O’Connor was a short Australian with a very incisive mind, being able to intellectually run rings around anyone. After the Second World War, he abandoned his studies to work on board a Swedish ship.
S8
J.K. Webb / The Spine Journal 16 (2016) S5–S11
He worked as a professional acrobat. His training involved working with Aboriginal communities, United States, and Sweden. He had a tremendous presence and was a natural leader. His unique presence was expressed in sartorial elegance, and his immense drive and energy were as memorable as his ability to slice through red tape. As a gifted teacher, he inspired a generation of orthopedic surgeons. He was instrumental in allowing me to go to Switzerland. I wished to broaden my knowledge by studying in America. Many consultants were opposed to this; however, O’Connor insisted that I should go.
BT O’Connor
When I returned to Oswestry from Switzerland, I was planning a career in pediatric orthopedics and had arranged a Fellowship in Salt Lake City with Dr Sherman Coleman until Mr John O’Brien arrived at Oswestry from Hong Kong. His arrival changed my direction from pediatric orthopedics to spinal surgery. It was a new surgical world. I learned to perform anterior approaches to the spine, from the odontoid to the sacrum. A considerable amount of my surgery involved using anterior approaches. I was fortunate enough to work with John O’Brien for 3 years and it was a revelation. His particular interest was low back pain, and with Bill Park (Consultant Radiologist) we were involved in basic research projects.
JP O’Brien
I had learned anterior surgery, which I considered the gateway to the spine. I could and still do not understand why
spinal surgeons are not trained in anterior approaches. Regrettably, training time has been shortened, and there is no longer enough time for surgeons to be trained in such techniques. If one does not have the ability to undertake anterior approaches as well as posterior approaches, decisionmaking in planning the various options for surgical is limited. There is a well-known saying: “If you do not change direction you may end up where you do not wish to go.” So new doors were opened. Oswestry was for me and many others an exciting place. Living near the hospital with multinational trainees, mainly from Australia and America, it was a place to learn. This multinations hospital created a great bond between us, which has lasted. Many of us still communicate with each other. Parties were awesome, often lasting into the early hours of the morning, and in the summer often until morning. We did not have to work on Sundays. During this time, John O’Brien encouraged me to become involved in spinal societies, and in particular the International Society of the Lumbar Spine, which at that stage was a society with limited membership. Many of the most influential spinal surgeons and physicians at that time were studying low back pain. I made many friends, people like Dr Harry Farfan, Dr Vert Mooney, and Professor Alf Nachemson, to name but a few. In the scoliosis area, I met Dr Jean Debousset, Dr David Bradford, Dr Bob Winter, Dr John Lonstein, and Dr Daniel Chopin. I visited many of the major spinal centers in Europe and America; many of them visited Nottingham. I operated in Lyon and that evening we visited Professor Stagnara’s house. He cooked Lyonnaise sausages on a fire at his home. He then took us on a guided tour of his vineyard. He had built a sophisticated cooling system for his wine vats, the water coming from a nearby lake. We drank excellent wines; I am now an addicted French wine buff. Other people who have influenced me include Dr Jean-Pierre Farcy, a brilliant surgeon, with tremendous knowledge of sagittal plane surgery and deformity, with a wonderful wife. Along with JP, another technically brilliant surgeon was Daniel Chopin and I would travel to the Berck Plage to watch him operate. Although not speaking much French at the time—and I am not much better at the present time—he was a brilliant surgeon and I learned a lot of little techniques, and he introduced me to Cotrell Debussy (CD) before the Universal Spinal System. He came to Nottingham on numerous occasions. Klaus Zielke came to Nottingham many times, as did Eduardo Luque, sharing his experience and techniques. In 1995 to 1996 I took up my Fellowship to work at Rancho Los Amigos. I studied under Professor Mooney, Professor Nickel, and Professor Jacquelin Perry. These were exceptional people. Dr Perry in her mid-70s was still teaching every Monday morning at 7 o’clock—surgical anatomy—which was again very relevant to one’s practice. Jacquelin Perry and Vernon Nickel produced the halo for the management of severe deformities, which was published in the Journal of Bone &
J.K. Webb / The Spine Journal 16 (2016) S5–S11
Joint Surgery, “The Halo. A spinal Skeletal Traction Fixation Device.” [3]
S9
to mention it. It is, therefore, most important that all your staff work as a close team. During one conference, I called Nickel a primitive man, hence the photograph.
From the primitive man Centre back row: V Mooney Front row: V Nickel, J Perry
Vernon Nickel was a big man with a big vision. He had created Rancho Los Amigos to be the leading rehabilitation center in America. American trainees wished to work there for 6 months, but he insisted that if you worked there toward the end of your 6 months there would be Saturday morning meetings and the residents had to present a paper. If a resident did not, he would not be signed up as having completed his rehabilitation program. The resident would have to return to repeat the 6-month program; everyone therefore presented a paper. Good presentations were turned into papers for journals. That taught me that when in the future I have a Fellow, if he wishes to be fully trained, he must learn to write papers, and fortunately most of my Fellows have written papers while they have been working for me. One day he asked me to remove a secondary breast tumor in C2, and I said that I would require some help and he told me that he would be with me. I started the surgery and 5 hours later finished; I did not see Professor Nickel. The patient woke up with slight weakness in the shoulder area. That evening there was a party at his house and he greeted me in his shorts and shirt, with a pair of underpants over his shorts emblazoned on them “the home of the big whopper!” Vernon Nickel’s great friend owned the Burger King chain, the home of the big whopper. I explained that I was surprised that he did not come and help. He replied “John, I was with you in mind, all the time.” I told him I had a slight complication; he told me that he knew that the patient had slight weakness on the right shoulder. That taught me two lessons. One: have confidence in your trainee’s ability and allow them to perform operations that are within their surgical ability, always stressing that if they have the slightest difficulty stop and shout for help. If they created a problem without asking for help, they would be in “big trouble.” Second, and equally important, one must have a well-trusted team.Your sisters will tell you if there is a problem with a patient because sometimes your Fellows may absently minded forget
Finally at Ranch Los Amigos was Professor Vert Mooney. He was one of the most intellectually interesting persons I have worked for, and sadly he died quite recently. He was particularly interested in lower back pain, and at Rancho every day between 4 and 5 o’clock each specialty had a weekly conference. The low back conference with Professor Mooney was always interesting and innovative. Cases were presented, and if he did not know the answer I realized that he would ask the Fellows to tell them about this rare case “to educate the Nurses and the Physiotherapists.” I realized he had no more idea than I of the condition and that this was a way of him learning. He would very often say “I have no idea how to deal with this case,” or he would say “I don’t know the answer.” I learned at that stage that silence is better than bullshit, but unfortunately I am surrounded by some people who have the latter. Monday evenings we visited Professor John Paul Harvey as he was known. A clinical conference for 2 hours took place at LA County Hospital, covering such topics as perilunate dislocations, non-unions of the femur, etc. Each patient had suffered multiple injuries and fractures. These discussions were memorable, stimulating, and were very well organized. The poor internists must have been up half the night putting the cases together. Woe betide if they made a mistake during a presentation! This experience had an influence on how to organize clinical conferences and the way they should be conducted. Research That is something which I think in a way I have failed on because I spent 10 to 12 years building up a spinal unit, traveling the world teaching, arranging for Fellows from Australia, South Africa, and America to come and work at our unit, and presenting papers at the Scoliosis Research Society (SRS) and other international meetings, which made our unit internationally known, and this encouraged a high quality of Fellows. Finally I was appointed at The University Nottingham. I have to thank Professor Mulholland, who was the instigator of me being appointed at the University Hospital in
S10
J.K. Webb / The Spine Journal 16 (2016) S5–S11
Nottingham. He has been most supportive in my appointment, and throughout my career I would ask him for advice and he would always give a well-considered opinion. He remains a very kind and generous man. Even these days, he still is as bright as a button, and although one does not see him as often as one would like because he spends his life sailing he still is an incredibly knowledgeable surgeon, still writing. Basic research I was fortunate that in our hospital was Professor G Burwell. He was a professor of orthopedics at the Royal National Orthopaedic Hospital, but because his inclination supported research rather than surgery he ultimately left and was appointed at the University Hospital as a senior lecturer in anatomy, ultimately becoming Professor of Human Morphology. He always had Research Fellows, and I worked hand in hand with him, and he still, in his late 80s, is writing papers. He is a very good friend and a person who has had a major influence on the papers coming out of our unit. And finally, probably the brightest, most intelligent surgeon I have ever been proud to be associated with is Max Aebi. He is a tower of knowledge and I have had the privilege to work for him for maybe 30 years. We have designed most of the implants for AO spine and written two AO spine manuals. He remains my friend and I know he will never retire. I know he has recently bought a small villa in Alba and I certainly hope to visit him and drink some good wine.
Max Aebi and Paul Pavlov
I apologize if I have left out other people who I should have included in this paper, but I am still not certain whether this type of article is of any benefit for the young surgeons. I was asked to write such a paper, and I believe it shows an era of training, which no longer exists, moving from center to center, absorbing knowledge and different techniques, so that at the end you can apply what to your own mind is the most appropriate technique for the surgical condition. I have been profoundly fortunate to have worked with such outstanding surgeons, many of whom have remained my friends. Many scoliosis surgeons in this country have also become great friends. These surgeons founded the British Scoliosis Society and surprisingly remain good friends.
Frank Dowling Alan Gardiner
Mike Edgar, Andy Randsford, Tim Morley
J.K. Webb / The Spine Journal 16 (2016) S5–S11
I have been fortunate to have a very supportive wife and children. We lived in 17 different homes before we settled in Nottingham. My wife, Kate, said she did not care how hard I worked during the week. However, midday on Saturday until Sunday evening was family time. That worked out well and we remain married after 47 years and have a wonderful family.
S11
References [1] London PS. A practical guide to the care of the injured. Edinburgh: E. & S. Livingstone; 1967. 790 pp. 10×7 in. with 1194 illustrations. [2] Sharrard WJ, Webb J. Supra-malleolar wedge osteotomy of the tibia in children with myelomeningocele. J Bone Joint Surg Br 1974;56:458–61. [3] Nickel VL, Perry J, Garrett A, Heppenstall M. The halo. A spinal skeletal traction fixation device. J Bone Joint Surg Am 1968;50:1400–9.