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A light-hearted and irreverent podcast discussing different aspects of trauma and orthopaedics. Not affiliated with any institution and views are all Pete's.
orthohub see one do one
season 3, episode 1: Al Getgood, the evolution of sports knee surgery
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We’re back. And we’ve missed you.
After a long hiatus, the See One / Do One podcast returns with a bang—and who better to kick things off than one of the biggest names in knee surgery: Al Getgood.
Recorded in 2022 but released for the first time now ( a long story), this conversation captures Al just before he made another major leap—he was at the Fowler Kennedy Sport Medicine Clinic in Ontario when we recorded this episode, he is now Chief of Surgery at Aspetar in Doha, Qatar.
We’ve updated the intro to reflect this move, but the content remains as compelling and relevant as ever.
From the frosty winters of Canada to the blistering heat of the Marathon des Sables, Al’s journey is nothing short of legendary. In this wide-ranging chat, Kash and Pete dive into:
- The STABILITY trial that revolutionized ACL reconstruction
- Personalised approaches to ACL graft choice and lateral augmentation
- The ongoing challenges in cartilage restoration
- The promise (and pitfalls) of orthobiologics
- The mental resilience it takes to run 250km across the Sahara—and thrive in elite-level orthopaedics
Al Getgood is sharp, insightful, and annoyingly likeable. Whether you’re a fellow knee surgeon, a trainee, or just fascinated by the elite world of sports surgery, this episode is packed with wisdom, humility, and unexpected laughs.
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This episode is proudly supported by our inaugural sponsors, Lavender Medical — a UK-based, family-owned distributor of orthopaedic implants with over 15 years of experience. Based in Letchworth Garden City just north of London, they’re recognised as a true one-stop shop for foot and ankle solutions.
In the past six months, Lavender Medical have expanded into sports medicine, launching Biotech Sports Medicine and partnering with an innovative, family-run Indian company—bringing exciting, exclusive solutions to the UK market. They also supply Xiros (formerly Neoligaments), offering synthetic ligament options including for MCL reconstruction and other knee procedures.
Most excitingly, they’ve recently opened their own cadaveric lab: The Hive Surgical Centre. If you’re at a conference or Congress and spot the Lavender team—go over, say hi, and tell them OrthoHub sent you.
Better yet, go visit The Hive and see what all the buzz is about.
We're truly grateful for their support in helping us keep this podcast going.
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@kashakhtar
Introduction and Podcast Return
Speaker 1Is this thing on Right . As the famous philosopher Timberland once said , it's been a long time . We shouldn't have left you without a dope beat . Step two we can only apologise for the delay , since our last podcast release was over a year ago , but we've been busy working on something exciting and groundbreaking for the next step in the evolution of AuthorHub and recording lots of new content that we'll be able to share with you very soon . But this AuthorHub C1D1 podcast is my baby .
Speaker 1This next podcast is one we actually recorded a couple of years ago and , as you'll soon see , it's a difficult one for me , because our next guest is Al Get Good , one of the biggest names in knee surgery , and since then he's soared even higher and I'd put him in my top five knee surgeons in the world . If you're interested and leave a comment below , I'll tell you on my Instagram who the others are . The reason it's difficult for me is because he who cannot be named is a couple of years ahead and everything I wanted to achieve . He got there before me and did it first , and it burned , as you'll soon find out , and then when , as a Liverpool fan , I found out he was a man United fan , everything was a hundred times worse .
Speaker 1If you're watching this , you'll see we recorded this a few years ago . As you'll see , I'm about twice the size I am right now . All this to basically say we've been really crap and we haven't edited or released the podcast episodes for a huge number of operational reasons that I won't bore you with , but I honestly think this is our best one yet . It's so much fun , so check it out . But first a word from our sponsors Before we get started on our get good . There's a special reason that Pete and I are here in our green screen . You probably can tell it's a green screen from the background .
Speaker 2We're not really on a Star Destroyer after all . By the way , before we get into this , what's going on here ? You've still got the label on this . You can still see the fold marks . Can we remove this please ?
Speaker 1No , this is hacky . I want people to know this is new . This is a special occasion .
Speaker 2Whoa , what happened there ? Something's changed about you . Something's not right . Is this galloping consumption ? What's going on ? It's the pocket square . You've gone from like Mr Potato Head to something really quite different . What's ?
Speaker 1happened . Yeah , you know , they say the camera adds 10 pounds . We had five cameras before and now we're down to one . I think that's the difference . You don't get a body like this overnight .
Speaker 2No , okay .
Speaker 1That's what I would say . Okay , our medicals are in an effort , pete , you know we are . Once a man gets to a certain age , one has to take . This is the new healthy cash .
Speaker 2This is wonderful to see . It's wonderful . Are we going down the gym as well as just ?
Speaker 1hitting the fasting . I'm working the personal trainer Heavy weights three times a week . Wow , 150 grams of protein . Wow , I know I'm on it . Okay , I'm rushing . It's all about the gains . Okay , don't give yourself a kidney stone or anything like that . Gains with a Z , so Pete . Why are we here ?
Speaker 2Why are we here ? Podcasts don't cost nothing . We with podcasts funding themselves with sponsors .
Speaker 1So this is the sponsorship bit , where we say who's ?
Speaker 2sponsoring us and why we love them so much . And who is that ? And our sponsor today is Lavender Medical . What do we know about Lavender Medical ?
Speaker 1Chain sheets . That's a blatant chain sheet . Anyway , I know this will go on my head , but Lav Lambda Medical are a UK family-owned business . Yes , just north of London , letchworth , letchworth .
Speaker 2Garden City . Okay , so that's near Stevenage , right ? Yes , that way . Yeah , near Biggleswade , not so very far from the Cardington hangars , which where they used to build airships . These massive hangars , they're really awesome . These massive front doors that look like fives . These massive hangers , they're really awesome . These massive front doors that look like fives , they're still there . I think it's a film studio now , but just looking at those , it's an awesome building .
Speaker 1So Leavener Medical have recently opened up their own cataract lab called the Hive Surgical Centre . Hive , what's the I for ? It's the .
Speaker 2I for insect . There's something about being close up up to insects . Yeah , just I just think of that . Imagine there's a massive bee right next to you .
Speaker 1It would be pretty there's gonna be a shitload of them behind us right now . Fabio , can you put the bees up for us ? Holy . So hive stands for the hub for innovation , validation and education , and there they've got five stations , including arthroscopic stacks , to host cadaver medical . Okay , right , so it's medical education center , yeah , yeah . So just a bit more about lavender , because we are very grateful to lavender as being our inaugural sponsors . Yeah , they are a UK distributor of orthopaedic implants for over 15 years .
Speaker 2Originally , they focused on Foot and ankle stuff and hand and wrist . Hand and wrist , they're still doing that right . They're still doing it . Loads of like gnarly foot screws .
Speaker 1If fused or your ankle sorted out or your first mtpj replaced , that's your man . And they're still
Lavender Medical Sponsorship
Speaker 1recognized as a true one-stop shop for all foot and ankle solutions . Uh , over the past six months , they've announced partnerships with two innovative sports medicine suppliers . Yeah , the moon warmwood sports medicine . Uh , they've launched the biotech sports medicine range and they're bringing an indian-based and another family owned and run company into the uk as exclusive distributors what's this ?
Speaker 2xeros , or is it kiros ? It's spelled zero z x I r o s , but you're supposed to pronounce it kiros .
Speaker 1Yeah , kiros it's pronounced kiros , so basically greek thing , kiros was formerly neo ligaments , and they do synthetic ligaments okay , and they've become really popular for things like mcl reconstruction . They've been involved in various ligaments around the knee , and so that's something that people should really be interested in .
Speaker 2All right , lavender Medical .
Speaker 1Thank you for sponsoring our podcast and I'd like to say thank you to Steve . Steve's been . I've known Steve . Actually he was . He's a lavender guy , right , he's a lavender guy . So Steve was asking for his trauma rep and he bailed me out of quite a few tricky nailing situations when I was oh nice okay , yeah , so there's a yeah . When someone does that for you , you don't forget it , honestly it is underestimated that if you have a rep who's bailed you out early in your career , there's a bond there for life .
Speaker 2There is it's true it's true , especially if it's on a weekend . Yeah , at a time where you were genuinely desperate and they came and , yeah , in the misery of Padding .
Speaker 1They rode in ? Yeah , but I think yeah . So Steve has been great . So , listen , I'm very grateful to Steve for all his support and sponsoring the podcast and if you see Lavender Medical at a conference or Congress , please go over to them . Please say hi . Do go and visit the hive . I want to come to the hive . Go to the hive and see your insects and say hi to them and say they're all for 100% , you Great . Go along and say hi to them and say that AuthorHub sent you Great . Now go along , I'll get good , I'll get good .
Speaker 3On with the show . Is my head looking ?
Speaker 1okay , yeah , hello everyone . Welcome to the latest edition of the AuthorHub C1Duel podcast , with me Cash Hattar and him Pete Bates . Pete's been a minute since you've had a guest in the studio , isn't it ?
Speaker 2I know it's been a long time . Yeah , it's all been on the line so far , isn't it ?
Speaker 1Yeah , I pretty much forgot what to do because our last three recordings have all been online . We've not had anyone here . And then , all of a sudden and then Al , we've got Dean looking at us . I know Well , not only that , I'm still feeling intimidated because he sent us a CV which was about approach . It's like not compared to what we normally do just Google someone in the morning and have a look at their Twitter and it was 59 pages and it was all killer . No filler . There was no kind of best presentation at E4 .
Speaker 3That's because I never got a best presentation at E4 .
Speaker 1That'll be wise . No teat top , though , is there . Well , literally , they just flopped it on the table and I was just standing there . I was intimidated in the corner . Pete , what are we talking about today ? We are talking about Elf . That's the spelling of Elf . Is it Arabic ?
Speaker 2Elf , I was watching Stranger Things last night . Yeah , it is Well . Today we've got Al Getgood . Well done . Al Getgood is a sports knee surgeon in Canada and you're going to tell us all about him . Well , al , what you'll notice is that whenever we have a sports surgeon come in , cash gets a bit dressed up . He puts his little pocket thing his lapel pocket and he because normally he's just like a bombed out sweatshirt for the newest people , but today you're honoured by his . He's truly . He's truly a proper top of the year . He's absolutely , he's quite warm and he must be sweaty .
Speaker 1He's got like four legs on there . Yeah , I feel like a little out there . No , genuinely so . When ? And you were my top five , good to know . I won't tell you where you were in them , I don't know , but you're on the list just from the very beginning . So our guest today is Alan Martin John Getgood , known to all as Al Getgood . One word , or we Al to his friends , and he's the thinking man's Mubandari . He's a big lad , isn't ?
Speaker 2he , he is a big lad .
Speaker 1yeah , I haven't seen him stabbing out yet I know , kif , you're just getting by the size of the CV , so big shoes . So our get-go is a North Codic surgeon and clinician scientist specialising in complex knee reconstruction at the Fowler Kennedy Sport Medicine Clinic in London , ontario , where he's also the Sports Medicine Fellowship Director and Associate Professor at the University of Western Ontario . If ever I've seen someone who should be a full professor and will be , no doubt , but should be already it's this guy . I don't know what they're playing at in Western Ontario . So he completed his primary medical degree at the University of Edinburgh in Scotland and basic surgical training in Cambridge , followed by orthopaedic residency in Cambridge and a research doctorate and then what we refer to as an MD over here at the University of Cambridge . His fellowship training included time in London , ontario , banff and Alberta and Coventry , uk , with friends of Tim Spaulding and Pete Thompson , before going to Canada for good .
Speaker 1Why did you ever want to leave Coventry for Canada ? I started a bit , a bit and I didn't . It was a tough one . It was a tough one . Well , we shall find out . We shall find out . Well , we shall find out . We shall find out . He successfully secured over $9 million in peer-reviewed and industry-funded grants to build his pre-clinical and clinical research program , and it focuses on the complex ligament reconstruction and joint preservation . He's a board member of the American Orthopedic Society of Sports Medicine and the program chair for ISACOS 2025 . Will that be it ?
Speaker 3Sure it couldn't be in your program . I gave it to Brussels or Munich I 2025 . Will that be the end ? Surely it couldn't be in your prologue , Either Brussels or Munich . I mean time will tell the pissing boy .
Speaker 1Yeah , in Brussels , the bruise , yeah , yeah , there's people who did always . Went to the statue of a young boy fountain where he's peeing . It's rather than .
Speaker 2I'm not sure what the story was . There's a story , why is it worth it ? We need to find that out .
Speaker 3It's on every T-shirt and key .
Speaker 1Exactly , yeah , particularly . Achievements for Al Getgood include being awarded the J Edward Sampson Research Award from the Canadian Orthopedic Foundation , which is the premier research award in Canadian orthopedics , the American Orthopedic Society of Sports Medicine O'Donoghue Sports Injury Award and the Janik Gilquist Award and the Albert Triat Young Investigator Award , both of Issacos , for the Stability Trial I did that bit again the Stability Trial , which is an international multi-centre randomized control trial looking at reducing the risk of ACL graft failure in young active individuals . It's quite possibly the most valuable piece of research and evidence for you , just ahead of the discovery of penicillin , which was a turn-in flu which was not peer-reviewed . Al has authored over 140 peer-reviewed articles , many book chapters and has given over 200 national and international conference presentations , lectures and demonstrations , including many live surgeries . I mean there's quite a few live surgeries there and they're not minor operations either . Oh , I've searched for some fun ones . I mean it's hard not to believe in cadaveric surgeries and they were that fun demonstrating that in their life surgery .
Speaker 1He's a member of the AOSSM Board of Directors and sits on the Knee Preservation Committee in Missicos . He's a member of the prestigious Diet Care Society , which Andy Williams is in as study group which will be the program chair next year . I'm desperate to join the ACL study group . It's desperate to be in the IT .
Speaker 2Please invite me On merit , if you could help a brother out program chair .
Speaker 3The iron day abstracts we'll find something .
Speaker 1And a founding member of the International Meniscus Reconstruction Forum . Al is also a visiting surgeon at the International Knee and Joint Clinic in Abu Dhabi , uae , and the Asparta Sports Medicine Clinic in Doha , and he is the proud owner of a Hungarian Vistula Vistula oh .
Speaker 3Best I heard . What did it like ? Wow , this looks like a Hungarian pointer . No , it doesn't Still he runs a lot .
Speaker 1It runs a lot , yeah , and I'm going to finish with this personal testimonial that I've received . It says he is a rare breed .
Meeting Al Getgood: Career Introduction
Speaker 1He's not only academically and clinically very able , but he's also extremely kind , personable and generous with both his time and knowledge . Thanks for the tip . Yeah , we cannot do that one , I can't tell you Frankly , it makes me sick . Al welcome to Author Hub Towers .
Speaker 2Welcome , welcome , Thanks guys . Right , Because you've gone from the UK over to Canada , you've got one of these like f***ed up accents . Just cannot . I mean that in a nice way . Yeah , Are you Scottish ?
Speaker 1Because you trained in English . Are you Scottish ? I think he's Scottish . I'm pretty sure he's Really . Yeah , I've always thought you were Scottish , but I can never place your accent on the video Northern Ireland .
Speaker 3Northern Ireland . You about scott , really ? Yeah , I've always thought you're scottish , but I can never place your accent on the video . Northern ireland , northern ireland , right ? No , nine , so belfast . Well , just like I said , belfast , let's bring it with them . Four , okay , but they say that all in so many different places that I really know yeah , yeah , can you say four , four , well , I mean not four , and I feel like four as well . Yeah , okay , a couple of beers and whole the changes .
Speaker 1All the changes that it comes out .
Speaker 2It's the right Northern Ireland . So what took you from there to Edinburgh ? Why did you go to Ashland ?
Speaker 3It was pretty common for us to leave Northern Ireland and go across the water for higher education . That was a pretty common spread . Scotland was an easy matter to travel . It was only a quick boat across the Irish Sea and so you didn't have to worry about spending a lot of money on flights , so it was very easy . You could get on from North Ireland and Edinburgh was just a pretty place to go and it didn't have to be a metabusiness , so it was a pretty easy transition .
Speaker 2How were Northern Irish people received in Scotland ? Because our English people are like a pretty foul taste , frankly , in the mouths of Scottish people , but Northern Irish people are better received over that .
Speaker 3I'd say probably Northern Irish people are received pretty well anywhere . So you know , it's true , it's true , it's true , yeah , yeah , it was a great place to live .
Speaker 1The Irish generally as a whole North and South , but Northern particularly raise no antibodies anywhere . Yeah , that's right . I met Bertrand Sarnicotte the other day . He was an English bastard and that was in reading . And so the Northern Irish are very popular people . They're nice people .
Speaker 2What was it like ? So you were during the Troubles , I guess . Correct , yeah , what was that like ?
Speaker 3It was interesting . It was interesting . It was interesting . I mean I was very lucky .
Speaker 3I lived in a middle-class background , lived in the countryside , really didn't have a lot of first-hand lead issues , but of course when we'd go into the cities we had a big military presence all the time . So seeing a six-man military patrol walking down the center of your town was just normal . Lisburn had the major army barracks , the thiefle barracks . We had a massive bomb there one day when I was at school and it was a grammar school and the little dining hall window shook and there was a tin drop in the room . So there were times it was pretty scary . Other times it was just business as usual , it wasn't really a big issue and we just got so used to it . I think when I would bring friends over from Scotland from you know , at that university they were totally freaked out . You know seeing a siren sometimes drives down the road fastest . You know it wasn't a normal sort of day-to-day activities . But you know , I think the electric cars were very friendly to us . For sure it wasn't an idea .
Speaker 2When you go back now . I mean , how often do you go back ?
Speaker 3Pretty rare . I don't have any family back to North Laos . I have a social education school friends and a couple of university mates . So it's been a long time since I have been back and it's changed massively . I mean it's fantastic . I mean when I lived there it wasn't a very diverse culture . I think that's really changed and there's been a ton more investment , a lot more . Just , the culture has completely transformed . A lot of the places that I would have always gone to because it was maybe too dangerous are now a tourist attractions . It's really really interesting . So that's a great testament .
Speaker 1We had the BOA there a couple of years ago . It was lively it was lively , wasn't it ?
Speaker 2It was . You then went to Cambridge . Why Cambridge ?
Speaker 3I wanted to move to outside . I was actually dating a girl at that moment , so there was definitely a move From easy to come . Yeah .
Speaker 1And is this your wife now ? No , it's not .
Speaker 3I actually met my wife in Cambridge . I can see that's a . Are you yeah , I don't know Rescued that one mate ? Yeah . But yeah , I was applying for an SHO job . So I was trying to get a job in England , in Iceland , emergency , and then I wanted to get onto a basic surgical training program and so Jumped on it , stayed there , did my SHO training as well , did the West Piddock program back , so it was kind of seamless . Tell us about Cambridge .
Speaker 2Great place which is not dissimilar to Edinburgh in some ways , isn't it ? Very beautiful town , not massive . You can walk around it . It's absolutely beautiful Stuff for tourists .
Speaker 3Yeah , I mean that's a phenomenal place , but I mean I guess , like a lot of times I would say I did the same in Edinburgh in many ways . So when you live somewhere you don't necessarily take in all of the history as well . At the time , a lot of the tourist attractions . We only started doing that just before we left Cambridge , you know , did one of these walking tours and learned so much more about the city and the architecture .
Speaker 1How come the council doesn't do that ?
Speaker 3I mean it's fascinating but Fascinating . But I think if you haven't been there as an undergraduate then sometimes it can be a little bit more difficult to get into the college culture . For me it was great because I was able to do my postgraduate degree there . I was at IND there , so at least then I got an experience of the college . Which college was that ? At Magdalen , Very nice , yeah , that was an interesting experience going to Magdalen for dinner and having to wear the rose Just for dinner . I was in my late 20s , early 30s . It was just , you know , a chat call , but whatever .
Speaker 2And were you sporty ? Were you like rugby ? Do I football ? Go on .
Speaker 3I played rugby . So I played rugby right through school and then in Edinburgh as well . So I was playing the first 15 for a number of years of those dog injuries . So second , round . That's not very actually Okay , that was my next guest . Yeah , so I'm , and I had a great time . Tour of Australia , so that must be a version of the India . I'm actually a blast there . 30 guys on rugby tour , yeah yeah , on the East coast of Australia , it's not hard Saying .
Speaker 3I'm there you go what goes on Thursday is on Thursday , it has . But yeah , we had a lot of fun , but it was a great place to be .
Speaker 2SDR Trading was in Cambridge , yep , and then Fellowship was in Camberley , correct ?
Speaker 3And what took you there ? Yeah , I think I looked around . What was , you know where most soft-to-seal resurgence were , what fellowships they were doing from the UK . The majority were going to Australia , new Zealand . Great fellowships , great opportunities . But , yeah , I would say that a lot of people were coming back with very similar training , very similar skill sets .
Speaker 3And I think , at an early stage , I thought I wanted to do something slightly different , because my plan always was to come back to the UK and say , yeah , practice in the UK , in the UK . And so , yeah , practice in the UK . But I wanted to try and offer something different and I thought going to North America would be the way to do that . The US was a little bit tough enough to crack and I didn't have USMLEs , yeah , and Canada would accept my training . So , and I focused two different things out of my fellowship I wanted to have sort of an academic side of things that worked .
Speaker 3But also , you know , my wife and I we wanted to have some fun , yeah , so we did six months in London , where I currently am , and planned there was six months and never go back , really . Um , but we had fabulous six months and there , you know , we learned an awful lot enjoyed the time there . And then we did six months in Bound during winter and I'm whacked . I love skiing . Yeah , I'd never had an opportunity to do a skiing season , but this was a great opportunity and for six months we skied hard and worked incredibly hard . I did more ACL reconstructions in six months than I think I could ever dream of .
Speaker 1And who were you in fellowships with in Ontario and Bound ?
Speaker 3So , so , so , so , so , so , so , so , so , so , so , so , so , so so . Soric Kennedy League , so Bob Lachau , paul Giffen the guys I was working with and then Mark Hurd Mark's just one of these . He is a real unique person , very , very talented surgeon , but just a real mountain guy . He's just one of my favourite people .
Speaker 3I've spent so much time in the backcountry and it was a very interesting fellowship in that we'd spend Monday in the UR and then the next day we'd be out ski tour and we would do six hours in the back country talking about what we did the day before , talking about life . You know just a very different feel to it . It felt it wasn't all about work and you know it extended outside of that . And then you know we'd finish . We'd get some turns in in the powder .
Speaker 3It was amazing he was bringing his dog with us Really cool dog actually . It was this dog called Jackson and he'd just he would come ski , he'd just come skiing with us . So we'd be hiking up the hill and Jackson would be in our trails and then on the way down I could just be in the powder down through those little years putting us on the putter , and actually my son was my second son , freddie
From Northern Ireland to Global Expert
Speaker 3his middle name is Jackson laughed at me that Indiana Mark Jones , mark was very special . And then after the ski tour , when we come back back to the hospital , did a quick word round and every patient we'd see . The first few conversations would be about the turns that we had in the hills .
Speaker 2It's really hard to match that in London . Well , you don't need any of that stuff , true experience .
Speaker 3So from badge to commentary Absolutely , absolutely .
Speaker 2And I know Cash doesn't find this difficult to believe . But what pulls you into sports , into sports in the ? What was the draw ?
Speaker 3I guess from being involved in rugby at an early stage . I always wanted to be involved in sports . And then my first house job actually was in Livingston , just outside Edinburgh , and I worked with a guy called Graham Lawson and Graham was at the time one of the doctors for the Scottish Rugby Union . So he would run Monday or I'm not sure what day it was , but then lunchtime sports injury fit . I'd have a time with him over lunch and it was just great just seeing some of these athletes and working with the players and thought , yeah , this is something I'd really like to get into . It just grew from there and I looked after the Cambridge Rugby team and it was just good .
Speaker 3I think the motivation of athletes to get back to the sport is something I really enjoy . It's great that after maybe older people and you want to get them back to the normal activities of daily living , but I think with athletes they just provide a slightly different challenge and they're a very challenging position . And then the knee . I did knee and shoulder . Initially I always thought I was going to do a knee and shoulder surgeon but I dropped shoulder after about two years of practice I realized that's probably a better knee surgeon .
Speaker 1And also the shoulder patients generally , are quite mental . The animals wearing sunglasses in the waiting room are laughing .
Speaker 3It's honest , it's when you try and shake their hand and it's like that was a great outcome .
Speaker 1So this I made this Well done hand and it's like that was a great outcome . So , listen , this right , well done , that's good . How'd you end up in coventry ? Tell us about your fellowship there , how long were ?
Speaker 3you there . I was there for six months with tim and pete , with tim and pete , and so that was planned . I mean , that was planned all along . As you know , there's an awful lot of luck , I guess , in the way I've gone through my training , um , but just everything worked out very well in terms of the year and Canada has given me an awful lot of experience to have just beat opera and volume and then going to commentary , you know 10 , I think , likes to think of it as finishing school and I think the head really truly is , because the practice is very complex and because I had a decent amount of cases you know that behind me . You know I could actually get on and do some work and certainly had your own operating list .
Speaker 310 was at that time again was variety , was buildings practice and those transplantations who have been probably been through solid graft every . We had two , probably two a week . It was just insane numbers , huge numbers , and , um , I knew it did this . You know that that fall in him just grew and grew and then we stayed on for over six months to look until there out of the university , and that was fabulous because that was the transition between leaving and going to Canada . So I wasn't trying to build anything , I was trying to grow my practice . I just needed to work for six months and Tim just fed me an awful lot of big cases . So I was straight off the bat . I was doing a very complex surgery knowing that Tim and Pete were there to help me out if I had any problems . You'd be daft , but they're full backing . So again , the membership , because you couldn't ask for anything greater . And so then when I moved to Canada , I was heading the right , absolutely outrunning the parents . That was a really very seamless transition .
Speaker 1And what year were you at Camping Coventry ?
Speaker 3That was 2011 , 2012 .
Speaker 1Yeah , so you would be in the fellowship . That was a time that I thought I'm still quite sore about this . So I wanted to do that fellowship with Tim Spaulding and we'd presented a basket . That's a man got the job . Yeah , you didn't have a UCB . I was applying for like a year off two years after that , but I wanted to apply at that time and basically we were at basketball , we presented together and then I went up to Tim afterwards and I said I'd really like to apply for your fellowship and he refused to even discuss it with me and I did forget . I had never even got an application form and I still feel he discussed it with me , did he ?
Speaker 3No , I found out .
Speaker 1I found out , I ended up winning Best Presentation in the same section that he was in , so I think he was a bit sore about that . But the irony now is , 10 years on , that's what it was . I had nothing to do with calibre , no , but 10 years on now we're partners and colleagues at Cleveland State , london . So you know I always play the long game . So you were set up , you'd had great training , you had a really strong senior year even at that stage and you were basically living with Sultan here , yeah , so you're going to end up as a consultant here in the UK . So then , all of a sudden , how did you end up in Canada ?
Speaker 3So when I was in London , just finishing my fellowship in London , so they asked me how to work in London , ontario , they asked me whether I'd be interested in coming back , and that was totally out of the blue . I didn't expect that coming at all and in many ways it was an offer that I couldn't refuse . And when I didn't move back to the UK and spent some time in Coventry Coventry was a great place I had an opportunity to stay on there and it was difficult . It was a difficult decision , yeah , yeah , there were and there were pros and cons of of each , but I think what really swung it was , um , you know , canada is a very unique place to work in many ways and there are great things about it . There's some negatives about it , um , but what was very obvious is that as soon as you set up shop , you could build , uh , a complete complex and you practice very quickly .
Speaker 3Um , and also , I mean , there are multiple reasons . You know you have opportunities for doing research , opportunities for , um , you know , probably a better work-life balance in many ways . So , sure , but one practice that you have to focus on you don't have a private practice as well , um , just about partners , I think , phyllis , both you know guys I worked for at the time um , maybe a bit of a flicking comment they , it's pretty important . They were all on their first wife . I mean , that's that's huge , right . You know they were all happily married , you know , with , with , with children , and I , yeah , we looked at that , thought , well , that's , that's that's important , right ? So if you could see that from a family point of view , or operating days through 30 . And so you know , I could be home in the evening and spend it time with family . So many many different reasons , but I think that was the most of the main things I've ever decided .
Speaker 1That's good . It's a very good point . People , no more white for you on Sir . That's still a number one . That's a clear lack of ambition .
Speaker 2And not wanting to focus on negatives . What are the ?
Speaker 3downsides of working counter . You know , I guess , access to infrastructure . So for operating times , probably the biggest issue is getting your patients into the operating room time there . We have massive additions with that right now , so we have a finite amount of operating time available , so a huge waiting list . But it's very difficult to get patients in , particularly who are needing acute care . So a lot of time would be juggling these lists .
Speaker 3I do , and the main person that does multiple treatment in reconstruction . That all has to be fitted into my elective timing . It varies from hospital to hospital as to how they're set up in terms of their trauma provision . So you know , I think the major advantage for a patient is that you're not going to be mid-bicro by being sick but at the same time , if you don't have a really acute urgent problem , you can be waiting for a very long time for access to care . Yeah , and as a physician that's pretty challenging . So you have to manage your resources and you could also . The flip side of that is that we have great autonomy . I can decide what my list will be if I do have an acute problem that has to be sorted out . I don't have a manager that says under me you can't do that . So there's a lot of shuffling around , but I'd say probably the accent that was to operating peers is probably the biggest challenge .
Speaker 1It is there as well , but you know so for the most of it it's one I knew in mind to put them on a tour list , but luckily I have a tour list I have access to . But you were right . In the ways that this is growing it should be here now , obviously post-COVID , if and so that's an issue . But having now seen the Canada practice , the UK practice and US practice I mean you're intimately familiar with all of those Is Canada in the middle somewhere ?
Speaker 3Yeah , I mean it's very , very hard to put it into one specific area because it excels in some areas and in other areas it's pretty poor . I mean I said London are waiting time for a joint replacement right now . It's about two and's pretty poor . I mean our , you know our , I said in London , our wait time for a joint replacement right now is about two and a half years . I mean that's , that's crazy , that's nice . So again , the UK was like 34 years ago . So , yeah , um , you know that's .
Speaker 3I think that's inappropriate and the real downside is that patients don't have choice , right . You know it's not like they say , well , okay , I don't want to wait for 10 , 15 years , so I'll go to the prime sector . There really is no prime sector . I'll go to the US , I'll go to the US and that can bring its own issues right . It can be very , very extensive and , depending where you go , the quality of care may not be quite as good . And I say that very carefully because the care down there can be excellent . It's variable , it's variable , but I think there's variability everywhere in Ottawa and fallout's difficult when it's about hundreds of miles away , right , yeah .
Speaker 3Where is Ontario on the map ? I'll give libraries . So it's right between the Great Lakes . So if you imagine Toronto and Detroit , we're right in the middle of the two . It's the east side , so it's on the east coast , Right ? It's not the east coast , Right , so it's on the east coast , but it's right . If you imagine you go to Lake Ontario , Erie and Huron , it's right in the middle .
Speaker 1Is it ? Does it snow a lot there ? It ?
Speaker 3does . We're actually in a snow belt because of the lake-fired snow Right , so we get a lot of snow , a lot of snow , so it's cold a lot of the time . It's cold , yeah , but that's really really cool . It's beautiful , Blue sky day , it's 30 , and it's gorgeous . You get bears , got bears rocking . They're not quite dynasties . It's a little bit too south , but again a little bit northern Ontario to show you the black bear shit . Yeah .
Speaker 2Which are the Grizzlies , man Grizzlies . We don't play Grizzlies , ontario and Grizzlies , okay . So let's just . Let's just have some scenarios . You confronted With a black bear , a lot of grizzlies , a black bear in front of you , you're out in the woods , it's insane . And it's just you and the black bear . What are you supposed to do ? What are the ? What's the standard mantra Of what you're supposed to do ?
Speaker 3Black bears in this listening time at the tenure I'm calling me down by this , and a bear has it .
Speaker 2One of Vince's old feet .
Speaker 3You know , it's kind of interesting . I think with BlackBerry you might be really loud , okay . So essentially I'm like like the whole way you know , you would just make lots and lots of noise . It was the same work . Mark Ford told me this when I go for a jog when I was learning out west , he would just say I just keep making lots and lots of noise and make a whoop every so often . So I'd be running along , whoop , whoop . I still to this day think he was taking the piss and he's probably sitting at home having to get a laugh over a beer . He's like whooping his way down .
Speaker 1Everyone else . Again , there's that nutter .
Speaker 3So I mean , that was the talking joke
Moving to Canada: Challenges and Opportunities
Speaker 3, maybe , but no , you make a bit of noise , right . Grizzlies , on the other hand , don't work , right . You know , ultimately you just don't want to meet a grizzly . You get between a grizzly and can , can cub your stuff , yeah . And then if you're really in trouble , I mean obviously bear spray , hopefully , but that verse where you get down on the ground , you cover your back and you just play down .
Speaker 1Grizzly's , the ones where you're not supposed to move . Is that the one ? Yeah , you lie down and you just play down . Alright , what's the difference between ? I'll share my ignorance here . I don't think the difference between a black bear and a grizzly bear . One's pretty grizzly , that's the one there . But how Are they a different colour ?
Speaker 3So one's black . There's a clue in that I'm a skewer of the black , but I'm trying to look at how I get on grizzly . I couldn't tell . I think the crisis goes slightly longer . I've never actually seen one up close and personal in the wild . Actually , that's the lie . I saw one in Vail once . I was at a course in Vail and we were hiking with my fellow a attacking with my fellow guy called Bard from the links , from Belgium , and we were hiking down the mountain . We see this thing off from the distance . I'm like looks like it , looks like a grizzly cub and he goes oh , let's go take a look . I was like nope , cut grizzly word went that way .
Speaker 1See how it's supposed to punch the grizzly on the nose . Is that a way ? Always supposed to ? Ah , they might be , it's a shock .
Speaker 3It's a great white shark , so you try and fight the black bear . Yeah , I'm going to fight the grizzly , I think . Yeah , there'll be one winner . There'll be one winner , mate .
Speaker 2It's French right . Ontario is French .
Speaker 3There's parts of it . The very far east side of Ontario , down in Quebec , is definitely the fair side to it , okay , but the rest of it is not French now .
Speaker 2Okay , is French . Do you get a lot of patients coming through who speak French , their own language ?
Speaker 3No , we have some French Canadians , for sure , and there's a lot of people who are bilingual . Yeah , I'm not , so don't ask me to start speaking in French . You have to be very tasteful , but you know , quebec has a massive influence on the whole country , isn't it Right ? Well , quebec has a massive influence on the whole country , as a Right ? Well , yeah , it's kind of projecting . Yeah , all the sides are in French , everything's . So you get a cereal box one side's in English , the other side's French . So there's any government documentation , there's always a French auction and there's the English auction . Yeah , go to Quebec . No , it's just all French . So I don't know , but that's great as well , you go to Quebec . I guess that's as close to Europe as we can get . I'll enjoy that .
Speaker 2It's a technically unfair question to ask you , but how are Quebecians received in France ? Do the French ? Is there like a natural sort of fraternity between the two countries , or do they get on , not get on ?
Speaker 3Probably they get on pretty well . I'm trying to show you probably better off asking .
Speaker 1Yeah , yeah , we don't want to start . It's not because they don't do that , it's because they don't have more than I do . But listen to what I have to say .
Speaker 3I can tell you about my advice . That's as far as you go .
Speaker 2Okay , can I start down a rabbit hole quickly ? Sure , in trauma we often get , there is a particular injury where you have someone who is extremely overweight and they are literally just walking along . It's often a female , but not always . They'll just walk along , they stumble and their knee completely dislocates .
Speaker 1And they end up with a super physiological .
Speaker 2How do you manage those patients ? Because they are often the anti-athlete , the person you were describing earlier , who's well-motivated and just wants to get better and wants to return to bed . They're often not of that mindset , are they ? How do you manage those patients ? Thankfully ?
Speaker 3I have to . I mean , certainly in the US . Some of my colleagues in the deep south would see an awful lot more so , like Mark Miller who's written about it extensively . That's a big part of practice which is kind of crazy . Most of the times the challenge really is the first and I'm sure you see this in time zero is just keeping the knee reduced . They often don't fit in a break . So I think the yeah , one of the types of patients where I do advocate for an expect .
Speaker 3Yeah , I don't like external fixators generally for knee dislocations , um , but no scenarios . That's sometimes the only option that you have . I don't . I don't actually work at level one trauma center so that the trauma guys will deal with most of those cases , uh , from of early management and they haven't referred over . So if they were referred over with an external fixator on , I'll often just leave it on for about six weeks , take it off , do a manipulation under anaesthetic and then see what their laxity pattern is after that .
Speaker 3The interesting thing with them is that you don't necessarily need to do a three ligament reconstruction if they fall three ligaments or fall four ligaments . They often really just need collateral ligaments , particularly patients you know the obese patients . Often , whether or not they're in valvus or not , they often have a functional valvus just because of the size of their text . Yeah , so if they're medial size out , which is often the case , they just need a medial post so that they can really , so they can ambulate . So , yeah , I posts so that they can really , so they can ambulate .
Speaker 3So , yeah , I'll use a synthetic graft , for example . I just put a synthetic in so they just so that they can walk . You know , try to keep them . You know , using biological tissues it's challenging because they can't necessarily stand crutches for a long period of time . Yeah , yeah , so they present with their own unique issues . Yeah , and you have to be able to sort of pizzeria and those , and , uh , I'm done at the entry port and right I mean , we , we see a fair few those in london , actually , they're really as , you're right , the functional valves .
Speaker 1Their thighs are so large , it pushes the legs and the calves push the legs into valgus . You can't often use a toilet tail . Then , you're right , you can't reduce them in a brace or even a plaster . Um , and there's a high incidence of vascular neurological injuries with this , right , yeah , um , and so you're right , I'm being on using some catics for this , because I just want a bit of road , the the strongest that you can get , and even still , it's under a lot of tension .
Speaker 2What are we going to accomplish these days ? The nirvana of orthopedics has always been to find a carton replacement of some sort . Where are we with cartilage at the moment ? I mean , it's a good question , what's ?
Speaker 3your question . Yeah , it's a good question and certainly , like in my early stages , like at the end of my MD , was in articular peristalsis , tissue engineering . So my goal was to set up a carpenter restoration program in Malta . I did to a certain degree . We did some early research around , some out of the studies and all sorts of stuff and it was cathco . But the clinical translation for that has has been relatively slow and you know I still am a proponent of cartilage restoration . I do a lot of osteocondyl allograft , which is really good . I think that's probably the major thing that's really translated over the last back , probably the last decade , is more people doing osteocondyl allografts with with availability of tissue grafts . When I trained in the uk we didn't have that . Now that is accessible . It is , yeah , absolutely , and that's probably a game changer for Europe being able to access osteoclastic out-of-drafts . It was in Northern Europe . We've had it for decades .
Speaker 2So , just for some of the listeners , that's basically taking a dead person's knee joint , taking a lump of cartilage and a little bit of bone with it yeah , the papilla , yeah , and then you plug that into your patient . True , and what happens to the cartilage ? I mean , how long has this patient been dead for ?
Speaker 3So it depends on the tissue . So actually a lot of the original work came from Toronto . So this guy called Alvarez , yeah , and Al's still working and he still runs , they still have the program there . So I've accessed a lot of my tissue from from the toronto program and it's viable cartilage , so the cells are still alive . Okay , so by the time of transplantation you're probably around about 60 70 percent viability , right um , and ultimately you're hoping that that carton stays alive .
Speaker 3The bone itself will get demodelled through creep substitution . So the idea is that you end this really good only procedure that you can resurface with true high-light cartilage , whereas everything else , whether it's cell-based therapy or some sort of myostimulation , it's all fire cartilage and so if it works , probably paid 5% , like everything else , or the good X-ray results , good XSCT results . So it can be a very attractive tool but it's very expensive and it's not accessible to everybody . So that's probably the biggest challenge with it . In terms of all the cell-based therapies , like orthobiologics I mean , that's taking off massively , particularly in the States . Orthobiologics is the hot topic , whether that's autologous cells or alginic cells . You know that is you know , and there's a lot of regulatory pathways that need to be navigated through that and you know we're seeing a big growth area there .
Speaker 3From an evidence-based point of view , the evidence is definitely lacking behind it . Yeah , and you know there's . You know we could talk about 2Rs and PRP . I mean that's still a treatment that's still looking for a clear indication . Yeah , you know there's no question that it can help certain individuals or certain scenarios . Big question always is whether it's cost-effective . You know there's so many . Even the flavours of PRP .
Speaker 1I mean , there's like 20 different flavours .
Speaker 2But fundamentally , as you say , cartilage is highline cartilage that we wait , we wait down has a very , very characteristic structure , doesn't it ? And as soon as bone , the bone is able to remodel itself quite quickly because it's got a lot of supply going through it , whereas cartilage doesn't . And so recreating that unique structure in cartilage which basically formed the teeth , ears or eyes or whatever it formed when you were an embryo and then it kind of that's what you've got , it's very difficult . Well , has anyone managed to reproduce that , that structure in other than an allograft in the light , by putting , you know , culture in cells , or putting them in your knee or has anyone used the political translation Indian mate or has anyone ever met we don't use the political translation into humans ?
Speaker 3I'd say no . I mean there's lots of good studies looking at the animal literature where there's some stuff that's pretty close , yeah , but the ability , you know , the interesting thing with animals is that we can use a lot of different tissues , we can use a lot of different cell types . We can use a lot of biologics , yeah , and that can be recombinant proteins , the and that can be recombinant proteins . The real challenge for us and for our patient population is getting that translated into clinical practice and being able to navigate through those regulatory hurdles . I did more research with a recombinant human protein , with FGFA15 , really interesting product .
Speaker 3Just to get through into clinical practice takes so many years . It's such a huge amount of investment . You know there's been so many studies that have been performed , whether cell-based therapies , whether it's your complex proteins that has got boom so far , but then haven't been able to go to the next level because of the lack of funding , the difficulties in being able to do studies . But you know that's showing clear clinical benefit , so so it's not like coming up with a new bearing surface . Yeah , you know this is really , really high-tech stuff . This would you know . I'll get a leash , but it's going to be challenging .
Speaker 2Is that different in Canada ? So in the US you've got the FDA . You both have to set the rules on these things . Does Canada reflect the FDA Very similar .
Speaker 3We have Health Canada have to set the rules on these things . That does this can reflect the fda . What did you have ? Very similar , we have health canada , and health canada , um , probably was a little bit more , um , closer aligned to european legislation . Yes , and I probably might , as I become a little bit more aligned with the fda , um , so we're probably that's somewhere where we probably do sit in the middle of it , yeah , and we do have access to certain therapies that the US wouldn't have . Equally , we don't get some technologies that count in it because there's no output remuneration . That's one of the , you know , another challenge that we have that now there's just no , there's no paying system to be able to pay for these really expensive something like Macy for so you know , the average is the tallest constant in implantation . We can only really do products like that through rather most simple trials like FED regnant gas .
Speaker 1Even on an ice cloud . That's you know . For the last 20 years it's been an energy-emissive part of a trial . Yeah , then the matrix got withdrawn . The fact is that the people on ICRS and the UFO they are still very big on these cell-based treatments . I would argue clearly that evidence is still lacking long-term . The fact is , I don't feel we've made huge leaps in cartilage restoration over the last 20 years . There's great work going on , but the fact is clearly a plug with bone and cartilage , be it from your own knee , from a non-weight-bearing part or from a donor is still , I think , the most reliable treatment we have . It probably is .
Speaker 3But I mean I think you've got to give those people credit as well . I mean they keep working , they keep innovating , they are doing more and more study . Today , hopefully we'll see it's baby steps right and it's not something that you've got to see a massive change in a few years . It does . It does take them in , it's taking decades . But you know , ultimately if they don't try
Cartilage Restoration and Research Developments
Speaker 3we'll never achieve it . And I think I hope at some stage we will get to a point where we have a more reproducible , maybe off-the-shelf option that would be able to get and the patients they out of a pain relief and , you know , improvement . So they need I mean .
Speaker 1I mean the work that goes into . It is also . I've been to the couple of icos meetings , international carter society , you know there's strong scientific work being presented . The one thing that people generally at home should know , though , is that , essentially , it's accepted now that there's no real role for microfracture . Would you agree with that ?
Speaker 3Yes , but unfortunately it still has to be utilised as a part of our majority of studies that we do so . I very rarely do that , apart from when I'm involved in RCN teeth , so that we do so , um , I very rarely did it , apart from when I'm involved on rct , um , um , so yeah , and micro fracture in itself has changed . I mean , it's not the old micro fracture that we used to do and you know , things have changed from the mini wood , from self , um now to fracture and very inside the tech eggs and build around music pick , I mean .
Speaker 1So the needle just keeps changing and yeah , that can't be such a bad and and you can now also get your aim make as well , where you can drill some very small holes . So we used to use these chondral picks . You basically press the bone , you destroy , I think , a wide area and you just fill the hole that you made with all the cards that would fall in like an avalanche , yeah , whereas now we use quite small drills to leave a painted path from the subchondral bone marrow all the way out , yeah , um , and then you can add a membrane over the top , um , to try and sort of contain it a bit , contain it a bit and give it a scaffold , almost as you were . But the cartilage , I think , is still the thing that we we struggle with the most in in knee surgery .
Speaker 3Yeah , I mean , I mean , I think over time we'll probably be focusing , certainly a lot of my research tonight , sort of focusing more towards what happens at times . Zero of injury , I mean , that's the only grail already . Can you actually prevent it from breaking down in the first place ? That's when it became a change of think , rather than trying to actually break it down .
Speaker 1See , I'm loving your questions . You can see now how much thought and engagement and discussion goes into what we do In your world . There's no nuance , there's no discussion of evidence that we do with patients regularly . Yours is bone broke , me fix it is . I don't really have a choice .
Speaker 2In trauma you could always get away with patient consent . I know it's a terrible thing to say , but the choices aren't really there for the majority of trauma operations .
Speaker 1You must be discussing evidence with patients on a regular basis . Yeah , yeah , it's something that comes up when we're talking about , eventually , anything that we do . Even when you do a lactation research , which we will come to , you will talk about the evidence , as I do , and say well , I know that we can reduce your re-injury rate . And I must say , with these elective procedures , the patient doesn't have to have them . Procedures this , the patient doesn't have to have them . There is a misdemeanor , exactly , um , but they can just modify their activities for a lot of them , and so there's a lot more discussion nuance into it .
Speaker 2Yeah , okay , I believe so now can I ask some stupid questions , sure , well , uh , you've got a young athlete , uh , who's ? Let's say that they're not elite , they are just an enthused person who liked perhaps what you were when you were aged 22 . And he's saying I wasn't a flit .
Speaker 3He heard that .
Speaker 2And so a keen sports person who does their ruptured thoracic isolation injury and they are coming to you because their knee is unstable and you are choosing to . You're saying I'm going to do that , I'll leave my reconstruction . Yeah , they ask you what's the likelihood ? Am I going to be in a knee replacement when I'm older ? What's your answer ?
Speaker 3to that . I always tell them there's that possibility . And you know we just talked about evidence . We could start throwing numbers at them . You know we just talked about evidence . We could start throwing numbers at them .
Speaker 3You know , 20-year chance of having an osteoarthritis . You know it's probably going to be around over 50% , depending on their meniscal presence . You know if you can preserve their meniscus , just because you get an osteoarthritis doesn't mean to say you're going to need to be replaced with it . So obviously there's different phenotypes of OA and so we'd have to see how that progresses . And you know , interestingly , most patients don't care about osteoarthritis .
Speaker 3We only did this study not so long ago where we asked our patients what their main goals were following ACL injury and ACL surgery , and we also asked a bunch of surgeons as well . It's kind of interesting because we had complete dip Right Surgeons were all interested in preserving preserving the knee , preserving function , worrying about OA . Patients were want to get back to sport one , I do want another injury very excited , and there's a little bit of this about within that . There's a bit of both for that . But so , yeah , you have that conversation , but ultimately they just want to get back to their function and then , if you take that to the , the higher end of the spec can be elite athletes .
Speaker 2So someone who's like , who's played for Manchester United or played for you know , played hockey for one of the top teams and they same position , the 25 they are . They've ruptured their ACL . What ? And they ask you , what's the lighter ? That I'll get back to playing at this level yeah , I mean , and those .
Speaker 3There's so many nuances to those conversations . You know , at the end of the day , with an elite level athlete there may be a contract involved . It's their employment , you know . So they wonder how quickly they can get back . Do they have a contract pending ? So lots of issues surrounding that , you know . So you may have you have to think that that comes into your conversation Chances of getting back in we always talk about .
Speaker 3Well , you know , with the legal athlete there's very , very high chance of getting back . Actually , when you start looking at the data it's maybe not as good as we would like to think it is . You know , if you look at pages across the board is probably about a 65 percent return to free injury level of sport or off that great um nfl recently showed that within first three years post injury there's only again 55 55 percent of elite level athletes in the nfl were able to get back to the pre-injured level and that was very dependent on their positions as well . So the quarterbacks are getting about , but then quarterback is getting much more money . They have a different contract . You know that . It's a different skill set . Some of the running backers , some of the big guys , maybe , maybe know this , but not as successful this move . There may be a little bit more replaceable , so contracts come into the conversation as well .
Speaker 2Yeah .
Speaker 3And so you know that that , and then the I mean something we probably don't talk about enough that we share with , if you look at your sort of non elite athlete is should they go back to sport ? You know , when you hit always the goal , we think about ACL re-destructions to get them back to their sport . But we know that going back to sport is the biggest risk for them to have another injury , blow out the knee again , and if that happens , their risk of developing a way to help and needing knee replacement for the knee is much higher . So maybe we should be actually talking about going back to at-risk activities . So those are conversations that we have on a daily basis and it's important as physicians to do that .
Speaker 1And we're modifying techniques all the time to try and reduce that re-injury rate further . But it's interesting because when we talk to patients about the risk of developing arthritis they go well , there's a 50% chance you'll get it after a ACL reconstruction . There are some papers that say your risk is a bit lower but , like Al said , it doesn't mean because you've got arthritis you need a knee replacement . And there is an argument . But actually if you've got your ACL reconstructed and you go back to sport , you're more likely to be more active on your knee . If you do nothing again and you stop doing sport , then actually you're not putting volume into your knee . Your risk is possibly lower . So do you want 20 , 30 years of activity and do whatever you want to do ? There's a lot more to it than just you broke me , fix Nothing . Respect for my folly .
Speaker 3Undermining my thinking , the thinking man surgery right yes .
Speaker 2The mindset is different between the acute situation when you've just broken your femur . Usually patients are not mad keen to hear about the high-level evidence around . They do want to know that it's got a high union rate . You put a metal rod down the middle of it but going into the individual likelihoods of infection and non-union as method of work failure and required to remove a harbour etc . I've never found that massively helpful in that acute phase because actually they just want to know they're going to be all right so , but there are areas of contrariety , such as distal tumult , fractures , nail versus absolutely , no , absolutely you do , and also this discussion about frame versus plate .
Speaker 2You've associated framing versus this , versus internal fixation , and then , once you get to the post trauma situation where you're , maybe they've gone to an ornithium or their line it's not absolutely perfect or an off brush has been done somewhere else , it's something's happened that is not ideal , always somewhere else what's up in your own department ?
Speaker 1of course , I never did that or indeed in your own .
Speaker 2Well , it's something a bit else , yeah , at this , where actually that suddenly changes massively and now you really do have to have very , very clear conversations with the patient in that decision .
Speaker 3I think one of the bigger challenges that we'll probably face is that the patient's actually a little bit older , maybe more sedentary , maybe don't need to have an ACL reconstruction . And that's where the average rare effects come in , because a lot of the time an ACL reconstruction may not be the best thing for them . Yeah , and you know . But they often have a mindset that's not . Yeah , I can't have it fixed . Yeah , and so you know . Conversations pros and cons of operative first and operative treatment yeah , uh .
Speaker 2So you must be as one of the top dogs in in , uh , in knee sports surgery in in caledon or in globally , sure , but but , but , but uh it , geographically where you are , people must come to you . You must suck in the big sports players , the movie stars that become the big cheeses were around . How do you deal with your own sort of I mean , you call it imposter syndrome , but do you ever find yourself being wowed by the person in front of you ?
Speaker 3Actually , interestingly , I don't see an awful lot of the pro athletes . We don't have a pro sports team in and around London and you know what the majority of pro athletes will do is that they will go to a local guy . You've got great surgeons all across Ontario , all across Canada , and that's the most appropriate thing , and you know so . If you're looking after one of the pro teams , the lady will go and see the local guy or the agent will often send them to one of a handful of people in North America who are dealing the most with the pro athletesics . Um , the patients that tend to come and see me it's usually , unfortunately for me is that they've usually failed surgeries . So it's you know they're looking for a revision or they're coming to the end of their career , and you know they go on a third opinion and , oh , let's go and see , get you to what he can do . Just a thought they should have . It's like that's a real dumb run for me . Thank you very much .
Speaker 1It's not Tom Cruise from Minnesota .
Speaker 3They're challenging , right , you really try to extend their careers by year after year . The interesting thing I was thinking for me in Canada is that , you know , having not been brought up there , having not been brought up in a world of hockey , of ice hockey , I mean , of football , you know , I don't know an awful lot of the players , just to the same extent that maybe some of my colleagues would . You know , I think if I was working in the UK or working in Europe , I'd have a much better idea in terms of a lot of the soccer , a lot of the football players . So it's a different , slightly different . So I don't really I don't really get to have a knockback ball . They're buying these guys coming and seeing me and that's . I think that's one benefit of it . But imposter syndrome is an interesting one because certainly I have for sure faced that throughout 10 years I've been over there as my career has progressed , because sometimes you can't quite believe what you're doing and why you're doing it and I have to pinch myself at times . Are you talking ?
Speaker 1about being gay with us now .
Speaker 3I was just about to say you highlighted some of my career achievements . I can't wait to have this one . So you'll see me . I mean Penn State . It'll be in bold without the letters . Some of my career achievements . I can't wait to have this one . So this evening I'm in Penn State . It'll be in bold without the letters . I sneak a problem . I can strongly resign right now . I'm done it . I'm done it .
Speaker 2Hey , have you ever seen Rocky 3 ? Yes , I have . Yeah , which one was that ? Was that one with Dolph Lundgren ?
Speaker 1No , it's Rocky 4 . Yes , I know . Yeah , which one was that ? Was that one with Dolph Lundgren ? No , it's Rocky IV . Okay , rocky III and Mr T Club of Lang . Oh yeah , the bad man is a physical machine . Yeah , so basically at the beginning of Rocky III , there's this montage where Rocky's basically having these 10 title defences in a row and he's fighting a selection of hand-picked fighters that he can beat number one contender and he can't get a . Can't get a shot , the title right . So he's in the audience looking at all these and he's getting really mad because his bums are being knocked out the first round , yeah , yeah . And he's getting really angry and he's kind of going around , um , as rocky's getting more and more famous . So he's like , why not me ? I should be up there , and that was me around out for many years , because , oh , the difference being that , well , there's a huge difference . But the the thing is , you know , obviously he had the fellowship that I couldn't even get an application for , and then suddenly I'd go to .
Speaker 2Mr T is at Winnie , doesn't ?
Speaker 1he the first time . The first time Because Rocky regains the eye of the tiger . That's right . Yeah , he goes to kind of yeah . So but another time we'll talk about why the Rocky fills the Europe shop . But he's never got the eye of the tiger . So basically I'd go no , but say only in your career . I'd go to American Academy . You'd be on stage doing ICL . I'd go to Isikoff's You're on stage . I'd go to Warwick Sports and the E4 . You're there . To a degree I was trying to think what's this guy got ? He's gone from zero to a hundred . He's on stage with Freddie Theroux , andy Williams , you know these guys and I could have now . I get it . But the thing is , except he's now a guest on my podcast . I've played a long day . But no , I totally get . I get it . Why ?
Speaker 2but two bucks no , I don't it . I get it why , but two bucks , no I don't Two bucks .
Speaker 1I thought you said you'd taken a pounding in the ribs , but anyway , my point is that you basically Go on , cut that out . Yeah , no , but you are basically every orthopedic conference going in the world . You're there , you're on stage , you've got this huge presence , for know what we call soft tissue near now , right , we all know it's much more complications , cartilages , meniscus , it's coming away . Complications , yeah , there's such more to it . But you send a number , a lot of boards , program chairs . What you do is insane . How did that come about ? How did it start ? When did you first get the big advice ? What did you do to ?
Speaker 3Good question . I mean , I guess opportunities and yeah , I think one of my strengths is probably about working . I'm pretty good at meeting people and you know I did , I think probably the ISO rest was huge . So the National College of Parasite , that sort of gave me . That was probably my opportunity when I first started Got to meet
ACL Reconstruction and the Stability Trial
Speaker 3a bunch of different people Past Travelling Fellowship , so that was in 2009 , I think it was .
Speaker 3I visited the States and spent a bit of time with a few guys there and it's actually part of my story . I went to an ICRS surgical skills meeting and that was the start of the Travelling Fellowship and Brian Cole was there . Cole was there building jack for at least you know guys who didn't know at the time . But you know legends and legends in in the field and , um , it was , it was Halloween and we went out . We had a night out and , uh , I managed to blab myself and Bill and a couple other guys into the uh , the Versace , actually on Halloween night . That is a good party , and so that was the chat . The next day , Of course , we managed to get into the Versace match and then I went and did these different tours , so you know , going to the Jack Farsawar and the Russian staff were like , oh , I knew the guy that got into the Versace match and they just kind of went around the turf with you . I think it sounds silly thing , but it was just . It was an opening talking point .
Speaker 3Yeah , I got to meet these people and I got on very well with them and , you know , thankfully , with the research I'd done in Cambridge , you know , I had a bit of substance to go with . You know , having a bit of a laugh , and I got to know them . I think they've been friends and measures ever since and you know those are the guys that started opening doors for me and then when they got those opportunities , they took the opportunities and yeah , I think that the easiest thing is it's difficult to be on a podium and talking about other people's research . It's much , much easier if you have your own research to fulfill and at the early stage of your career .
Speaker 3You know , I recognized already that I couldn't talk about technical practice . I don't have the experience . How can I go and talk about my last 10 years of HCL research and just don't have that data Plus ? I didn't want to talk about other people's work . So , you know , we did some volcanic studies , like I talked about animal studies . Those are things that you can do in a very quick turnaround and that had then subsisted . They got me an opportunity to and that had then subsisted and they got the opportunity and took talk on stage and once you get those opportunities , then they began to start to sell and they have been very fortunate , I mean .
Speaker 1I think you've been modest in terms of your network . Clearly that's a strength of yours , but you've taken their impetus with your research and the research has really accelerated . It's all clinically relevant , it is huge stuff and it's developed in its complexity and significance , and so was that an active decision of yours .
Speaker 3But yes , I mean , you know I knew I wanted to do some research and you know , when I was a resident registrar I was really not that very close to computer research . But you know , but maybe because I wasn't really interested in doing research for research sake , right , I want you know , as soon as I got an opportunity to do some research on knees , that were clinically translatable things that actually might be interesting for me unless we're getting australian questions to you that , yeah , so wow , talk about light bulb moment . And that was just huge . And so you really did snowball after that . And again , you know the whole atrium lateral ligament , glafotene thesis thing . That was very topical when I first started in canada . So we started researching that . Anatomy studies , biomechanic studies got into clinical studies . We have a great group of people around us and you know so . Therefore those were really important clinical questions that we were able to answer .
Speaker 1So it's actually real relatively straightforward first , could you just explain to my ignorant friend what elatrotinidesis is , what stability trial was , why it's so impactful . Wow , we have had them .
Speaker 2You've got to keep this as simple , simple , agonist , like monosyllabic .
Speaker 3I mean , I guess the most simple thing we talked about already . You know our young patients are at high risk of re-injury . I mean , yeah , and this is the conversation I have on a daily basis my risk of re-injuring . In my mid-40s I've had an ACL reconstruction 3% to 5% by two years . Take someone who's under the age of 20 , 15% to 20% , maybe even 100% , so big difference .
Speaker 3So throughout my fellowships I've worked with a lot of really great surgeons and I saw a lot of variability in outcome . I was like , wow , this is pretty disappointing . As a surgeon , you want to try and make it go for the same amount of Nardos possible and there's huge variability . So what can we do ? Surgically Recognizing there's lots of other things going on for rehabilitation pod of food as well , but anyway .
Speaker 3So I got interested in the actual left side of the knee and so , 2012 , there's a Belgian study that looked like developed after . You know this here marked the lateral ligament been around for years , decades . Number of people have talked about it kaplan talked about it , glenn , terry talked about it and it's just essentially a structure in the lateral side of the knee to reduce your risk of having a temperature , and so we did some studies in that area , did a clinical study looking at the addition of a lateral tenodesis . A lateral tenodesis is really just a check grain on the lateral side and they could prevent anterolateral translation , which is essentially a pit of chip . We did a large randomized trial , so this was a multi-center study by Hisokovs and Biedadik . It was kind of interesting . I wouldn't say only it was a huge amount of money for their point of view , but $200,000 for a nine-cent or randomized trial , the one I recruited , 600 patients , wow , that's cheap .
Speaker 1So that's nothing . I mean , peter , what three million for your trial , didn't ?
Speaker 3you . I mean it was . I said I mean I won't frame this the right way . It was a huge amount of money for a mesocost , to put it as you . But the thing that was special about it was that the sites that were involved in the study they essentially did it . It was like charity . They had infrastructure already . We all got together . I was in my first two years of practice and I had all these giants of orthopedics in Canada that got behind me and helped me on this study orthopedics in Canada that were behind me and helped me with this study . And , yeah , we knocked off . As everyone said , we never recruited 600 plus patients for a round-mestlin trial , nasal reconstruction never been done but we achieved these numbers and we showed with the lab protein adhesives that we could reduce failure rates by over 50% . So you know , it was a big impact in time and continues to be a big impact , if they give me that .
Speaker 2And that is now your standard practices in young people who have a 20 , 15 , 20% failure rate or are definitely going back to sport , to pivoting sport .
Speaker 3Yes and no in that that was the surgery that we did was a hamstring tendon , autograft ACL reconstruction . I pivoted away from that and moved to using either patella tendon or quadricep tendon and so probably some patients don't necessarily need to have a lateral tendinitis with those graft types . But that's our second trial where I did STAIRY2 , which , off the paper now that's a Canadian Institute of Health Research and NIH funded study . I I was her colleague at the University of Pittsburgh and that's 28 sites , 1,200 patients .
Speaker 2And you're comparing what ?
Speaker 3BTB and COD , with or without tinnitus . So it's now taking it to the next level , doubling the number of patients , and that's going to be a huge study , if we ever manage to get a complaint of its sister . Yeah , it's a bit of a monster .
Speaker 1So I can comment on this stability trial because that's a hamstring ACL . So the re-ruption in that went from 11% down to 4% by adagalactinodesis . Yeah , and predominantly in the UK . We're still hamstring growth ACLs . The US is evidence of late-sevenths was just 50-50 . Yeah , Parachuting a BTB or other it depends on the patient population .
Speaker 3Certainly you know athletes mostly going up to BTB .
Speaker 1But yeah . But the thing that's revolutionary is my practice , certainly over the last three or four years , and , to be fair , andy Williams has done a lot of work over here , and Andy and Alex Dodds did it . So basically , these Belgian guys described this anterolateral ligament and it went viral in the Times newspaper .
Speaker 2These guys were giving interviews all over the world about a ligament that's been discovered 100 years later , and there was a lot of mockery at the same time , wasn't there from the non-knee surgeons ? The non-knee surgeons , the knee guys , had found another ligament to replace it .
Speaker 1But the irony is that Andy Williams and Alex Dodds were doing that work with Andrew Amos at the exact same time . It got beat to the publication by about a day , but like by about a day . But they've done a lot of work in that , and so I use Andy's technique the Hero of the Blood and so for the last three or four years I do that synthesis for every single revision ACL . I will do it for any elite athlete , I'll do it for anyone who's hypermobile , I will do it for anyone who's got significant pre-surgical laxity , and so that's a procedure that's gone from zero to 100 in as much that , and I'd say 99% of knee surgeons will use a lateral shingles at some point in their practice .
Speaker 3It's kind of the same . When I first started talking about the academy , and maybe six years or so before we had the results of the study , it was kind of frantic . It know , it was just getting practically . It felt like I was getting booed off . Yeah .
Speaker 1That was me , berkey . It was like Mr T , it was that joke , what was it ? Yeah ?
Speaker 3But yeah , it was crazy and you know , now it's actually . It's really cool . I can sit back and watch other people talking , yeah , it's really cool , I can sit back and watch other people talking , yeah . And so it's been huge and it's been an enjoyable journey for sure , why don't you go without asking about the quartz tendon ?
Speaker 1So , pete , we've essentially used the hamstring ACL or epithelial tendon as being the graph for an ADL retraction since the last 20 years , right , yeah . And now , increasingly , you hear about the court's tendon . Um , and whenever there's a meeting or a panel discussion and you'll there'll be like five people on the panel , there'll be a complex case come up , they go roughly quiet , quiet , quiet , quiet , and you're kind of like this thing's got from zero into a thousand . Yeah , so , um , because now you can basically the court's tendon and use that instead . Yeah , and that's kind of come out of nowhere . Over the last well , not over the last few years it's increased massively in popularity , yep . So how's your practice changed in that time ?
Speaker 3I mean the study is pushing an awful lot . I do an awful lot more quads just because of the study . I mean I was using quads for PCLs a lot . I was using quads for patients who were mixed martial arts or wrestlers , you know , or anybody going to see advantage of a quad .
Speaker 2Is it that much stronger ?
Speaker 3Well , no , I guess the perceived potential benefit would be that you don't get as much anterior knee pain . That's a battel tendon and so it's a comparator to a battel tendon . But at the end of the day the data isn't there . There's some studies that are showing equivalence to a hamstring tendon . I would argue that a cruzlet with a hamstring tendon is not a great comparator . So I think the quad we don't know enough about it , and head stability too . We know if we will know something about it soon enough , but there's no question there's a big industry push . One of the major advantages of a quad tendon for industry was that they could develop instrumentation for quad harness . They could look at new fixation directions . So yeah , it really transformed the industry side of things . That's over and above compared to lateral tendinitis . I used a staple , you probably used a C-driver or something . Yeah , exactly . So it's a massive difference from that point of view . So if you're a quad surgeon , you're in a district green , if you're a Lafayette team , it's non-summit .
Speaker 2We do often find ourselves being swept along by industry . As orthopedics in general , because industry is so knitted into all the operations we do , into , or assuming , the operations we do , we often find ourselves being driven by them rather than by evidence or by our own ideas .
Speaker 3Yeah , no , 100% . It's a symbiotic relationship . You can't get away from it and nor should we try and get away from it . I think that was one of the real strengths of the society . For example , icrs is that very early they brought industry in and industry were part of the meeting , they were part of the board and so we're doing things together because , ultimately , trying to develop technologies that would improve our patient outcomes , they're an integral part of that development process , so you have to be on board with that . Equally , you go as a physician , you physician , you better understand the potential damage sides of that and you're going to be able to start looking at the , the evidence .
Speaker 1I think so I would push it a little bit more on the quad , because the hamstring but anapetal tender have been a gold standard since aso retraction began . The challenge I have the quad is the evidence is still not out there . So , given that your practice so evidence-based , I'm just trying to understand what's made you conceptually come to terms with the use of the quad tendon . Well , that's it .
Speaker 3It's for a very specific patient population , but I'm pretty happy that the evidence is equivalent to a hamstring and so if I don't , so therefore , if I get the question for me , is it better or does it provide equivalent outcomes or better than a patella tendon ? So a patella tendon would still be my grafted choice for an elite level athlete . But if there's a reason why we want to use a patella tendon they tell length , kneeling , sports such as wrestling , mixed martial arts then I'd use a quadricep tendon . But you know , again , you have that conversation and the conversation at the moment with stability to patients is really interesting because so many of them want to have a TNZ-ses and you know we have to . We have to say well , there's potential negatives without this concept that they randomized either patella tendon or quadriceps tendon . You know the evidence does not point more what our other is superior . So we have complete echo points and being able to have that conversation . So you know it's a , it's a really interesting . Uh , it's an interesting study because I have to be very confident to say I'm doing well at the answer and I can speak to .
Speaker 3Not everybody is comfortable with that sort of concept . I think , as knee surgeons , though you have to be in a position where you should be able to offer different grants . I think ACL reconstruction whether it's tenodesis or whatever we're doing is moving towards a sort of risk assessment , a la carte surgery for patient-specific surgery . I think it's not a key cutter anymore , it's not one size fits all . I'm talking about a lot of clichés here , I know you do .
Speaker 1I heard that .
Speaker 3And so we have to be able to do what's the best option for a patient , and eventually we will have that data field to support those decisions .
Speaker 1but based on what you're saying , then it sounds as though the quad tendon is one that using more so for revisionist , um , that probably is me maybe at the moment .
Speaker 3Yeah , it was probably probably 50 . 50 again , it's difficult to know because the study is really skewing practice , you know , yeah , as much as my sort of at risk athlete .
Evidence-Based Approaches to Knee Surgery
Speaker 3Those are the patients that are trying to study , in which case they're excused , the different our phenograph study is .
Speaker 1I mean , this study is going to be the one that gives us the evidence . This is the study we've been waiting for , which is costanomous of teletendent plus minus teodesis . Any early indications nothing . You know you take your early full echo boys and tell the results for me . Just wink in this bit of time .
Speaker 2Tell us about life in Canada . How did your wife make the transition ? How did she find it sorry ? How was this taking your family to Canada ? I would say it's pretty transition . How did she find it Sorry ? How did she ? Was you know ? How was this sort of taking your family to Canada ?
Speaker 3Yeah , I would say pretty well . I would say it's pretty seamless , as you may say differently . No , I think we settled in very , very easily . Both of our kids were very so . One was born . As I said , my eldest , jasper , was born in Canada when we were there in fellowship , and then my youngest , freddine , was born in the UK . So when we moved back there they were both from the UK too . So very straightforward . It's kind of interesting because Jasper had an English accent and he knew it was different by the Gubb's Fulon community . Yeah , it's kind of cool . Can you tell it on there ? Oh , totally . They were here with me this week and I arrived late . I got in yesterday . They'd been here for the weekend and as soon as I arrived to the hotel they were both speaking and they just that was pretty awesome .
Speaker 3So they're all over the place and then they can do the Northern Irish taxes . So they're all over it . It's pretty focused . I think the transition was pretty easy for us and it took a while . Like any big move , yes , getting set in society , building and getting your friend base , and now we're very well set up there and life is good , but you've got to enjoy it . We enjoy the outdoors . We run along , bike a lot and the kids enjoy the sports . We enjoy skiing . They enjoy being outdoors . It makes a lot of sense , yeah .
Speaker 1Are you a big ?
Speaker 3ice hockey fan now , no , no , I'm sorry , oh geez , sorry .
Speaker 1I was like , yeah , tandor's National Sport , I just can't follow the puck . Yeah , it's quite hard . When I hit it , I don't know where it is until the buzzer goes . All right , let's go at this bill well , that's what .
Speaker 3Yeah , it's one of those sports and I'm sure most canadians are the same about . You just don't get rugby and you know , not unless you play the sport , cricket's probably insane . Unless you play this sport and really understand there's little nuances which we really enjoy . Yeah , it's the same for hockey . For that I don't say I don't really ask a lot , what's going on ? Yeah , I don't know the light changes , it's just , yeah , what's going on . But it's like they've told you . They told you what to watch .
Speaker 1I wanted to watch yeah , which we don't know , talking a cricket , pete's only found a naked cricket , but that's a story for another day . Um , can I ask you about running ? It's one thing , pete , we didn't . I don't he picked on this . He's a huge runner . Yeah , a whole bunch of ultra marathons . So , as the music huge runner you do so .
Speaker 1Running your is a passion for you . Yeah , and you've done a few ultra marathons , correct , and do you know the Marathon des Sables ? No , it's the marathon in the sands . It's six marathons in six days in the middle of the Sahara Desert . Right , and Al did that .
Speaker 3Why ? How was it ? It was pretty not . It was pretty not . That was fun , that was 2004 .
Speaker 1Yeah , that's called the toughest race in the world , so running's a big thing of yours . I see you on Twitter posting pictures of you running quite a bit , yeah that's probably the only personal stuff I ever tweet .
Speaker 3Yeah , I mean it's , I enjoy it . I mean I travel a lot , as you know , and one of the things I like to do is bring my trainers , and anywhere I go , my trainers will go for a run , see the sights on the road and then get on with the meeting . So I find that a great way of being able to introduce a city to me . And , yeah , I love running . I started running when I was about 25 , 26 years old , after I stopped playing rugby . A few years of not doing very much travel , a bit of weight , thought that it is could stop because and uh , yeah , got into running . But why should I run together ? Um and the dog and the dog , and um , yeah , we started doing some mountain marathons and uh , it's on the swiss alpine march and he's like , and , um , and then slowly started to get into , uh , ultra martians and the one who just caught that , yeah , so , but Martin Sarp is blessed . But , uh , it's actually funny . It's funny story .
Speaker 3This is this is my , my claim to fame with this one is that one of my Ted mates . So I called Bill Coles and he was a uh , uh , he used an X , uh , columnist for the sun , and so he was there on the on the race basically doing um , uh , taking notes , because he wanted to write a novel . And he wrote a couple of other novels before about his time with people that I was quite in quite a bit to get , yeah , so he ended up after the race writing a romantic novel set in morocco during the marathons of the south , and we were all characters in it . So I can't all right , so I'm a character in this book . Yeah , I was so far . I was carlo , right , carlo , and I think I was .
Speaker 1I was , I was described as a bit of a rascal so , uh , some great stories from that , and is that right ?
Speaker 3yeah , we had some bits of pretty interesting stuff going there so you , you run , you stop sleeping your tents .
Speaker 3Yeah , yeah , so you run , you sleep your tent , so you . So you run , you sleep in your tent , so you have like a backpack . You get a car while you're in the food . You're rushing water , so everyone gets to see him out of the water . So I had to see him out of the water . It is the Moroccan Gafians that winning the race .
Speaker 3And so for me , you know , whilst I was probably the fittest I've ever been in my life and I was running an awful lot before that leading up to that time put me in the desert and try and run , it was into a bit of a nightmare . So I had to ranch for the first two days and then after that it was a lot of speed walking and just trying to amount to the end physiology and , yeah , trying not to get too dehydrated . If you ended up on an ivy , you lost an hour a few times . So right , and and plus was really just , it was a matter of looking after your body . I saw other people who were in absolute pieces and really suffered and totally didn't enjoy the week , whereas I can just well went through the yeah and really just thought about what I was doing . I had a lot of fun , met some really cool people came somewhere in the middle of the park . Was that a wind on fit ? So yeah , there were days where it was just really probably the worst experience of my life .
Speaker 3Remember , there's one stage . The fourth stage is a double marathon . It's this 81-kilometer . So we have to cross these sun engines in the middle of the night and they have this huge big laser light going up in the air in the sky and that was your way marker . So you just following this laser but thinking I was just across the next tip , like just doing the next tip . I think it was about eight hours of just heading towards this green laser light that was just so destroyed . And then , you know , the last few hours I think that stage took me about 22 hours to the main was just insane . And , and it was just insane and all I wanted to do was get back to the tent . I had to get back and I had these type of temperamies and that was you can get back to the tent that could have a temperamie and I was dying and I just wanted to get back . And by the time I got back to the tent there was a solid storm blowing . I was sitting in the middle of the tent , pretty much in tears , just totally broken . She was absolutely all the time low and then the sun came out and we had a day off . You know those little cans of cookies to get on the flight . You know how you do that . We each got a cap cook and that was a sort of well done .
Speaker 3Finished the long stage . And once you've finished the long stage , you've pretty much done this . You've still got another two or three miles to do , but now it's time to leave . So sitting in the sun , drying off , having my coat and just taking a while , this is the best . This is the best . I'm eating my pepperoni . So you go from the absolute lowest to high , and I think that's some of the things you get from pushing yourself a little bit . Do you feel suffering is good from time to time ? Yes , we all live in friend and privilege lives . It was a great privilege to be there and do that . Yeah , it's a cheap thing to do , but at the same time , just to suffer , that's never a bad thing . You learn enough . You have all your resources .
Speaker 1Usually you push yourself to the absolute limit . It's probably as humanly possible , probably doing that right ?
Speaker 3Well , it's humanly possible probably doing that right ? Well , certainly it's humanly possible for me anyway . I'm sure there's a lot of other people who could push themselves a little bit further . Pete , I think we should sign up for that . You guys would have a laugh , you could do a podcast . You could do Ortho Hub in the desert yeah , we'd be dead .
Speaker 1It'd . The funny thing is you've got that Fabio Marpe carrying the gear for you . I'm not Russian and the wheeling is long . No , so I treat a lot of older distance runners by chance . I think I treated a few I don't quite know , I think it on some for a running form . Somewhere Someone gave my name and so I treat a lot of people who do Marathon du Sable . There's another one um , it's called the name marathon du medoc , which is basically a marathon in france but it's but you drink cheese and wine as you go around .
Speaker 1Whatever you need , there's something there , and I'm that's important . Yeah , so I think it's around my students yeah , there's another one where it's basically the five days of the tour de france . So you're in the . I don't know if it's the , the or the alps , or the himalayas . I don't mean this . I know they hate this .
Speaker 3I'm looking back and I think I hate it . I don't want to educate you to this problem .
Speaker 1I think it goes on through every once in a while , but basically you often know the mountains but it's a five day foot race on the thing . You know . You sit a little on the bike but you don't get in the foot . But sleep counts as part of your time . So if you sleep , when people come in , absolutely trash the number of people I see . You go , my knee hurts , I go okay , when does that hurt ? They go . Whenever I'm running about mile 52 , my knee hurts . Where does it hurt ? They go right there and point their knee out and I just sigh and it's kind of like but the problem is you can't just say , well , why don't you stop running at mile 51 ? Because if you start to run and not to run , they're challenging people to 3L , now 400% , and you know they want to keep going and yeah , he's got to recognize that .
Speaker 3Then , you know , as you said , they're not going to stall Saying it's just a matter of , you know , trying to trying to help them out . And , yeah , sometimes you just need to get them to , you just need to reduce the training , and they're tortured . And they don't get that because they think , right , yeah , you know , and this is always for me , it's always do as I say , you know as I do . You know , because I've got all sorts of problems in my days but never get three at the scale you should do and um , but you know you have to sort of take them back a stage there . But now you need this , this is this , because you're helping frog and , uh , as long as you're getting by it about that , they never want to see a physio and they never do basic rehab , and yet they're like well , I run 50 marathons .
Speaker 1I don't just want to tell me how to do some squats , and yeah , 90 times at a time , that's so if that's not putain , putain , putain , is it putain ?
Speaker 2I was like what I was like I saw my face and I was like wow ,
Running Ultras and the Marathon des Sables
Speaker 2I'm so good .
Speaker 1Okay , we should get cancer out of that . Poutine is the delicacy .
Speaker 3I feel like I'm speaking what .
Speaker 1I'm sweating . I'm sorry , I'm sweating poutine .
Speaker 2Yeah , poutine , great snack , so can we talk about poutine ?
Speaker 3I'm sweating , I'm sorry , is this right ? Poutine , yeah , poutine , great snack . So can I just have a Poutine , some fries or chips , fries , gravy and cheese curds , cheese curds , cheese curds , it's a very it's nice , it's a . You know what it's a it's . It's variable depending where you get it from . It's a big Quebec thing , but the best bit to bear , best I've ever had , is in Big White in British Columbia Ski resort . Fabulous . Threw some bacon in there , some onions and peas Amazing . A lot of gravy on them as well . Yeah , my kids love it . They love poutine . Right , that's the thing .
Speaker 2So you're brought up with it as a kid , the kids just want to .
Speaker 3you know they ski and then they want to have poutine Play hockey .
Speaker 1Aren't common fast food restaurants that just serve poutine over there Probably .
Speaker 3I think I've had some ice on the serve of poutine . You probably haven't , yeah that's right .
Speaker 1When I make thunder , I make this for my time at Food Cops . I think I've seen it quite a bit . See , just let us pronounce okay , all right , um ask you , we're gonna just to kind of as we draw things too close . Who has ?
Speaker 3mentored you and who are your mentors and key influences ? Uh , you'd have to name us anyone else so , apart from you ?
Speaker 1kind of sitting down there in the audience . I know , yeah , uh , back to your instance .
Speaker 3I don't know if you ever noticed anytime you time you were down there . I always give you a little thought .
Speaker 2You'll see me at you wouldn't you ?
Speaker 3Yeah , yeah , yeah , Just a little . I didn't see you there , but I tell the difference that you're there . Stop worrying me . No , yeah , so many . And I always find the conversation about mentorship always interesting , right , Because I think there are many managers in different parts of my life , in different parts of both professional and private life and personal life , and I think that's really important . I can name a few . I've got Tony Buller . Tony is a surgeon in Taterberg and it was my second year of my residency training in Cambridge . Registered training always get the impetus that there's that Canadian coming in we're international what he has to say so .
Speaker 3Right , that's right . So Tony was the guy who was an e-surgeon and he really introduced me to Cardiac Surgery as well , actually , and was a very tough tax minister in terms of surgical technique . He's one of those guys that you never work with who's always saying you know , that's not good enough , this should be better , just driving you to be always reaching that level of excellence that he he expected and um subsequently became great friends . You know , to the point now I think he's like a granddad to my kids . I mean just just an incredible person . Um , you know other people , the number I miss , miss him .
Speaker 3I mean , uh , bob lissfield , who's my partner in london , huge influence on one of the london turks and , uh , and one of the main reasons I went back there , um mark her just can't speak highly enough of that guy . I mean again that you know the experience in the OR , what he taught me , mark , but also just outside of the OR and trying to get that work-life balance thing , yeah , tim Spalding continues to be huge in terms of the influence he's had on me . We still do a lot of work together . And then there are just so so many others that have had the opportunity to work with , you know Lex , brian Cole , jack Farr . Those are guys that just you know I said before , really opened up many doors and have remained great friends ever since . So , yeah , I'm probably missing a ton and anybody have missed them again , so apologies , but yeah , I'm just you know I've been very , very fortunate to have a lot of really great people . I've had an influence on my career , so , yeah , lucky .
Speaker 1That's awesome . We should get Brian Cole on . Actually you would love Brian Cole . Oh he's there .
Speaker 3He's social , he's not only .
Speaker 1Yeah , he does put a shoulder as well . Yeah , yeah , we can spread it out . He is a fascinating man and he's just a million miles an hour . He's the most manly person I think I've probably ever met .
Speaker 3Yeah , I mean , I think certainly , I would say probably in his earlier career he was probably I mean to the degree and there's no question that he's I wouldn't say he's slowing down , but he's definitely much , just much more chill and just so much more thoughtful about what he does and needs . This and you know his , he's had huge influence on on what I do and what I do and I , you know , we climbed the mountain together a few years ago , mike Baker , in Washington State . So again , in that whole concept of doing things outside of work , I mean you know that I'm really trying to focus on you know things , you know healthy , and I can't keep me actors and doing things with a bunch of friends .
Speaker 2Just this huge , oh what do you press the future ?
Speaker 3um well , you know , I think the big thing at the moment is focusing on getting stability to fetish . That's that's . I can't see much panacea at the moment . You know that that's . And then post , you know , post that that's and then post , you know , post that study . I mean it is keeping doing the things that I enjoy doing . You know , coming up to the next research question that it was to to ours , um , keeping evolve as societies , um , you know I've enjoyed really enjoying my time at Walton little East , but that's , you know , that's been really fascinating . Can I get there and working at either out there about four times a year ? I don't , you do it .
Speaker 3I'm still working two different centers , so both in Dill and and um in Abu Dhabi . So again , just doing complex day surgery and um , you know that that offers a different type of patient . He had a really complex surgery that in very , very , very challenging patients , um and uh , it , uh , it takes , just takes , takes the skill level to . You know it's a , it's a challenge , yeah and um , and that's been , that's been really fascinating . So continue to do that and uh , and then also focus on the family .
Speaker 3You know , trent , it's I , I think probably , um , I have to keep saying I'm lucky , I have very lucky , but I'm also , you know , I'm fortunate that I can maybe pick and choose a little bit more . I don't feel that I have to do every single meeting . Yeah , um , and so you know , the future brings , hopefully , being a bit more selective . So I try and try and get a maybe a slightly better balance of work . I always find that conversation a little bit challenging because it's very difficult to get through equal librarians right yeah but um , yeah , but again spend more time in the family .
Speaker 3It's just , it's a huge part and I think that's what kovid also really had told us to fully . I really enjoyed that . Having that time go and already , you know , engaging with , with uh , with the kids , it's just fantastic and that still , you know , really just want to continue doing , yeah a lot of our guests .
Speaker 2Uh , you come on this podcast of tool trap reinventing themselves . Uh , when you get into your like late 40s , 50s , uh , into the , the , the back end of your career , reinventing yourself into something you know totally different , like a you know big oyster of a germ or a uh fortician or somebody's driving , driving change , writing new guidelines . Have you got any ambitions for that kind of thing ?
Speaker 3No , I mean , I'm still thinking pretty early in my career . I mean , I guess I'm now officially mid-career and I want to carry on doing the things that I'm doing . I still love cloud board work . I still like answering or trying to answer big research questions . You know , at some point in time like everything gets a little bit but it's a bit of a monotonous at some point , in that I mean , so you do maybe need to reinvent uh yourself . I don't feel I've reached that yet . I think there's a long way to go before that .
Speaker 3I don't necessarily have great aspirations to be an administrator , for example . You know . Yeah , I think one of the things certainly North America is eventually coming to , you know , leadership roles . It's always going to be , yeah , yeah , the ultimate transition and , you know , scaling back a little bit on example , we're taking on more administrative responsibility and ultimately going for , you know , a chair for the department or something . That's never been my real goal . You know , I still see myself as a clinician like . But you know , whilst I do get to do a lot of research , I still think my strongest asset is the surgery and I really enjoy the surgery and I continue . I enjoy training as well as the residents , although I still find that probably the most stressful part of my jobs
Mentorship and Future Directions
Speaker 3. But you know , I did . Certainly I don't feel at any stake that I need to change that at the moment .
Speaker 1Fantastic . I'll thank you very much for coming all the way over here and it's been fascinating . It's been great talk to you . Finally , it's been well worth your wait . I'm off to Trademaster ability three . Sorry , mate , sorry .
Speaker 3Look , maybe you're in dress . Yeah , yeah , subtract .
Speaker 1All right , let's see Fabio . Can we go buy him some pepperoni ? Okay , thank you Awesome . Thanks a lot , pete . Who's our next guest ?
Speaker 2Oh , next guest is Chip Rout . Is Chip Rout ? He's not Chip Rout , he's the Chip Rout . He's a pelvic and acetabular texas . He is , I'd say at the outset , he's probably within my specialty . He's one of the most impressive people . I've met him quite a few times . He's one of the most impressive people I think I've ever met . Uh , and don't say that might , um , he's he , but he's , he's not he's , he's a little bit more white . You know , he's a proper old school harness . He's uh , he's , he's not , he's . He's totally uncompromising . He loves his guns , he loves hunting , he's an amazing trainer and he's proper old school Texan , always carries a weapon with him wherever he goes . He's the real deal . But above all , he is someone who is doing a very challenging breed of surgery fixing pelvic fractures . He is unbelievably good at this .
Speaker 1And is it fair to say he intimidates you a little , he totally does .
Speaker 2I think he intimidates most people in most rooms . He carries that kind of that sort of persona of someone who is very difficult to fuck with in a group situation and having gun belts Actually , I've never seen him wield a weapon , I have never seen that happen but he carries a presence that is unmatched Fantastic .
Speaker 1Well , I'm really looking forward to watching you squirm With that . Thank you very much everyone . Goodbye . Thanks very much , guys . See you next time .