At issue: Unification of orthopaedic surgery and trauma departments in Europe
In Europe, orthopaedic surgery and traumatology departments have long been intertwined. In each country, the specialties may be combined, separated or separated unevenly, with some departments ultimately taking on more responsibility as a result. While a European standard for combined or separate departments has been discussed, some say this would prove costly to implement and institutions and physicians would have several obstacles to overcome to make the transition work.
Norbert P. Haas, MD, director of the Center for Musculoskeletal Surgery at the University Hospital Charité in Berlin, has witnessed both sides of this issue at his hospital where, since 2003, orthopaedic and trauma surgeons have been combined for better patient care, increased efficiency and cost savings.
Image: Haas NP
“When I started [at Charité] 20 years ago, both were separated. The trauma surgeons performed … hip prosthesis, knee prosthesis, spine surgery. We were in competition [and] overlapping more than 50%,” Haas told Orthopaedics Today Europe. “You had two big clinics in the same hospital in competition against [one another]. It did not make sense.”
Keeping the lines of communication open between orthopaedic surgery and traumatology is critical. This can be done more effectively in central, rather than periphery hospitals, according to Haas, who noted Charité encountered some problems when resources for both departments overlapped. The orthopaedic and trauma departments were in different buildings and ordered joint replacement prostheses without consulting each other. This resulted in multiple orders placed with different device manufacturers and the hospital lost valuable discounts they would have be entitled to for bulk orders, he said.
A combined approach is also beneficial in providing united patient care, Haas, president of the AO Foundation, said. When trauma and orthopaedics were separated at Charité, a patient with hip pain not indicated for surgery had to schedule separate physician visits for conservative care and physiotherapy via an orthopaedic department acting alone. Their now combined approach streamlines getting the patient the appropriate care they need, he said.
Another difficulty Haas said he saw with separated departments was with fractures in the growing elderly patient population, once considered inoperative. These patients now require a more complicated elective surgery that must be coordinated, Haas said.
“If you want to treat a 90-year-old or an older patient with a hip replacement or knee replacement, today this is already an interdisciplinary approach. If you are not connected to the central hospital, you will have problems,” he said.
Divide and focus
Orthopaedics and traumatology are organized differently throughout Europe mostly because the hospitals and academic departments hold various views of how these specialties should be structured. Some value surgeons who can perform a variety of procedures, such as trauma, vascular or gastrointestinal trauma surgery, over ones specialized in a single area. Others find the combined teams benefit because colleagues can readily communicate about difficult elective and trauma cases and they can share resources.
The concept of combined departments, however, is not accepted throughout Europe. For Peter V. Giannoudis, MD, FRCS, EEC, professor and chairman of the Academic Department of Orthopaedics and Trauma at University of Leeds, United Kingdom, separated departments allow him and his colleagues to focus on their work without the distraction of acute or elective cases.
However, Giannoudis has seen the opposite effect at the university level in his country. The departments were united until 2006, when the University of Leeds decided to follow the Universities of Oxford and Edinburgh in separating the orthopaedic and traumatology departments.
“There are seasonal variations in the number of patients we get with severe trauma, car crashes and so on. Whenever we had these peaks of quite substantial workload, elective patients would be canceled. There was always a burden, sometimes on the elective service, sometimes on the trauma service. Something had to give so we could do the work in such a way to fulfill the expectations of the timing of operative reconstruction in terms of clinical urgency,” Giannoudis said.
Increased trauma case load
Giannoudis heralds the recent separation as sensible and beneficial for both specialties.
“During the past 5 years, more attention has been given to the trauma service. Everyone realized it should be as important as elective orthopaedics because elective orthopaedics used to dominate everything: patients [were] not happy waiting 6 months or 9 months to have a hip replacement or knee replacement and all the politicians were focusing on how they can develop a system to please the public or their voters,” he said.
But, due to recent U.K. legislation, more changes are underway. As of April 1, 2012, new laws caused many university hospitals, including Leeds, to comply with redistricting that will send increased numbers of severe and complex trauma cases from periphery hospitals to the university, according to Giannoudis.
“We are adopting, in essence, the American model of having one or two big hospitals focused on the management of complex fractures, multiple trauma and severe kinds of cases, and the rest of the hospitals will continue to provide service for the bread and butter of orthopaedic and trauma surgery,” he said. Giannoudis told Orthopaedics Today Europe in an interview before the transition he expects a 30% increase in his hospital’s trauma case load after redistricting.
Valuable consult from colleagues
Orthopaedics Today Europe Editorial Board member Morten Schultz Larsen, MD, a trauma surgeon at Odense University in Denmark, said the most beneficial aspect of combined orthopaedic and trauma departments is the valuable daily interactions he has with his elective surgery colleagues specializing in shoulder, elbow, hip, arthroscopy and spine. This occasionally changes his perspective on a case.
“In these cases, we combine our knowledge and get the best treatment for the patient,” Larsen told Orthopaedics Today Europe.
But, the reverse is also true. Often, elective surgeons ask Larsen and his colleagues for a consult. Although the elective surgeon’s knowledge of acute surgery is sufficient for them to be on-call when required to be, it is impossible for them to be completely up to date on all the latest treatments, Larsen said.
Larsen said OR crowding exists at his hospital where elective surgeries are occasionally canceled or rescheduled because a trauma case took precedence.
Jan A.N. Verhaar, MD, PhD, president of the Dutch Orthopaedic Association and professor of orthopaedic surgery at Erasmus University Medical Center in Rotterdam, said crowded ORs are not the result of a combined department, but rather an organizational structure that does not account for varied trauma case patterns.
Surgeons should perform elective procedures during the day when there are less trauma cases, he said. It is difficult to treat regular fracture patients in the evening and at night because they are not urgent enough compared to transplants or cranial bleeding, but need to be treated, according to Verhaar.
“So in many hospitals, you see an increasing tendency to treat fractures during the day.”
Keeping the peace
Larsen mentioned another issue: discontent between surgeons in the department. His hospital’s trauma staff is small enough that orthopaedic surgeons are required to be on-call several nights a week to relieve his staff’s workload.
“A lot of my orthopaedics colleagues in elective fields really do not want to be on-call for the trauma cases. They just want to do their elective cases and nothing else. But, as long as we are in the same department, they have to be on-call,” Larsen said.
One issue in the combined vs. separated department debate is who is responsible for traumatic vs. non-traumatic lesions. Despite fairly widespread agreement that all lesion types should be handled by one specialty, practitioners remain divided over which specialty should take that responsibility.
“The traumatologist has to spread his expertise over a larger area, so I think it is important, [with] the trauma lesions, that the responsibility is with the traumatologist,” Larsen said, noting spine trauma is an exception and it is best handled by spine surgeons.
In the orthopaedic department at Verhaar’s hospital, where the distinction between orthopaedics and traumatology is less clear cut, there is uncertainty if the on-call trauma staff should handle vertebral fractures. “Not every orthopaedic surgeon has been trained enough to take care of every fracture in every case, so there is a need for specialization,” he said. “On the other hand … when you are involved in, for instance, knee surgery and when there is a fracture, an intra-articular fracture, it may help you very much when you are specialized in that joint.”
Having one powerful musculoskeletal department at Haas’ hospital has its advantages, including making it easier to apply for grants and research funding and providing an environment that fosters the development of new ideas.
“If you do spine surgery in the morning and pelvic [surgery] in the afternoon, you have no time to think over new procedures, research programs or the development of new implants or new techniques. [It] is impossible. But, if you work the whole day in one subject — one joint area — you are always thinking about new methods and what you can do better.”
Among the benefits of a separated department is an uninterrupted focus on joint replacement or trauma alone, which Giannoudis said grant funders find appealing. Someone working at an active university, with its own theater environment, bloc and offices, where 3,000 total joint replacements are performed annually, is a more attractive and convincing grant applicant, he added.
“They know your flow will not be interrupted. There will not be any surprises mixing the patients,” he said.
A diverse musculoskeletal education can be had in a combined department that rotates residents every 6 months to a new subspecialty, according to Larsen. “You can give a more varied education to students and young doctors. You can show them different sides, making recruiting for the specialty easier. I think it is a very big advantage and speaks very much in favor of combined departments that education is better,” he said.
Related to this issue, 2 years ago the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) realized its focus was almost entirely on orthopaedic surgery and that trauma surgeons had to dig deep to identify new developments in their subspecialty. In response, the EFORT Trauma Task Force was formed to educate surgeons about trauma in European orthopaedic centers.
“EFORT also deals with trauma topics but they were not so visible,” Haas, chairman of the EFORT Trauma Task Force, said. “The members are from all over Europe and we are working very hard. One year later, we have had a good effect.” The group is also trying to establish national trauma societies in individual countries that will become EFORT members. To that end, Haas said a March 2012 EFORT ExMEx Forum on lower limb trauma in Barcelona was successful and included participants from Spain, Russia, Sweden, Switzerland, Germany and Czech Republic.
“This shows there is a need for separate trauma events in EFORT, ExMEx and other trauma courses. This was not the case in the past,” he said.– by Jeff Craven
For more information:
- Peter V. Giannoudis, MD, FRCS, EEC, can be reached at Great George St., LS1 3EX, Leeds, United Kingdom; +44-113-392-2750; email: firstname.lastname@example.org.
- Norbert P. Haas, MD, can be reached at Augustenburger Platz 1, Charité-Campus Virchow Klinikum, D-13353 Berlin, Germany; +49-30-450-552012; e-mail: email@example.com.
- Morten S. Larsen, MD, can be reached at Sdr. Blvd. 9, 5000 Odense, Denmark; +45-613-035-48; email: firstname.lastname@example.org.
- Jan AN Verhaar, MD, PhD, can be reached at s-Gravendijkwal 230, 3015 CE, Rotterdam, Netherlands; +31-10-703-6161; email: email@example.com.
- Disclosures: Giannoudis, Haas, Larsen and Verhaar have no relevant financial disclosures.
Which approach — separate or combined orthopaedic traumatology and surgery departments — leads to better delivery of musculoskeletal care? Why?
Separate departments, better results
When I began in practice a nail cost US$90, MRI had not been invented and the approach to the abdomen was a long midline incision. In the United States, general surgery and orthopaedics have for at least half century been separate disciplines. General surgeons fix the bowels and orthopaedists operate on bones.
In Central Europe, the trauma surgeon does both and today European departments of trauma surgery and orthopaedics are joining together with one advanced certification. My teachers have been Europeans: great masters like Prof. R. Szyszkowitz in Graz, Dr. Med. Dietrich Hempel in Hamburg and Prof. Klaus Klemm in Frankfurt all told me they stopped caring for bowels and blood vessels to do osteosynthesis really well. I agree.
As we move to more complex solutions in both our specialties, the requirement to drain the subdural, take out the spleen and nail the femur are no longer compatible. I take better care of my fracture patients not because of a ‘team approach.’ There is no real dialogue with our general surgery colleagues — they want us to fix the bone in less than 20 minutes, fight us for our OR time and have peculiar ideas about antibiotics and operative blood loss.
I know even less about laparoscopic intra-abdominal surgery. No, sicker trauma patients survive these days and the lurking threat of lawsuits makes me pleased to focus on the skeleton and do my job of fixing bone really well. Placing broken bones in orthopaedics and ruptured guts in surgery leads to better delivery of care to the injured.
David Seligson, MD, is a professor and is Vice-chairman of Orthopaedic Surgery at the University of Louisville in Louisville, Kentucky, USA, and is an Orthopaedics Today Europe Editorial Board member.
Disclosure: Seligson has no relevant financial disclosures.
Specialized trauma needs support
During my 30 year career, I have visited and worked in several models in Europe, North America and Australasia. As a result, I am very much in favor of the specialized orthopaedic trauma department (SPOT) vs. the general orthopaedic department (GO) where trauma is part of general orthopaedics. The main reasons are a SPOT has a clear focus in training, teaching and research, sharp department profile and trauma-focused utilization of OR and intensive care unit (ICU) resources.
In GO departments, where trauma is one of many other subspecialties, the case load from other subspecialties and the economic pressure due to unattractive reimbursement of trauma diagnosis regulated groups lead easily and frequently to circumstances where the trauma patient does not have the priority he should have. However, this requires certain conditions be fulfilled:
- Department size (staff, OR, ICU and bed capacity) must be adequate and fueled by sufficient patient volume and catchment areas;
- A SPOT must be embedded in a hospital setup which has the full setup of a tertiary referral hospital including on-site subspecialties with emergency service, mainly cardio-thoracic, ob-gyn, pediatrics, plastic surgery, including replant service, ICU capacities, granted access to operating theatre and on-site helipad;
- There should be financial independence;
- A functioning training rotation to general orthopaedics, general surgery, plastic surgery, ICU, ER is needed;
- Research facilities must be available; and
- Quality control and benchmarking mechanisms should exist.
At the Hannover Medical School Orthopaedic Trauma Department, about 60% to 70% of cases are trauma patients (acute, immediate post-acute, and late post-traumatic reconstructions). The rest of the OR capacity is used by us for other musculoskeletal entities, like degenerative, deformity and tumor problems. Within the trauma subspecialty, where all trainees get a broad trauma background, we focus and further subspecialize in hand and foot, shoulder, spine, pelvis and acetabulum, hip and knee. This model also poses attractive career opportunities as orthopaedic trauma surgeons trained in this setup are highly sought after by headhunters for chairman positions in large orthopaedic trauma departments.
Christian Krettek, FRACS, FRCSEd, is a professor and the chairman of the Trauma Department at Hannover Medical School in Hannover, Germany.
Disclosure: Krettek has no relevant financial disclosures.