In the footprints of Cook

I have been slightly distracted of late, having some nine months ago clicked ‘go’ on entry for an unusual race. A face-to-face interview and a few long late-night discussions at home and I sent off my cheque to enter the ‘hardest foot race on the planet’. Consequently, evenings and weekends have become overnight sled pulls and a range of other slightly unusual activities as I prepare to attempt the 6633 Ultra, a self-sufficient foot race across the Canadian Arctic. I am perhaps not an obvious candidate for Arctic racing; nonetheless I hope to achieve what only seven people have managed to do in the history of the race. First conquered by Frederick Cook (although the claim is disputed) in 1908, very little of the mystery and romanticism surrounding the Antarctic explorers is shared with the early days of Arctic exploration - probably because there is very little there, just polar bears. Although running has taken on a new urgency this is only part of the story. I have become an expert (I hope) in sleeping at temperatures well below -40°C, building bearings, sled harnesses, nutrition, arctic cooking and amongst other things, planning a self-sufficient expedition. Should any of this planning be incorrect I stand to lose a lot, maybe a digit or even more.

On one of many long sledge runs down by the side of the River Trent at 2am this week I was thinking how like orthopaedic surgery my preparation for this expedition has been. Meticulous step-by-step planning is essential to both. The analogy between surgery and the airline industry is often made, and the emphasis in recent years has been on the ‘WHO Checklist’, now implemented in most developed countries in the world. But surgical safety is so much more than simply a checklist; it’s thinking through every eventuality, and having a plan B. Although not included in this issue of 360, I would recommend readers read David Ring’s heartfelt case report in the New England Journal of Medicine.¹ Describing a case of ‘wrong site surgery’, Dr Ring describes how sometimes a series of small mistakes can result in complete failure. I do wonder if the WHO surgical checklist as described would ever have enough scope to prevent all of the small things that contributed to his mistake. I would commend him for having the courage to publicly discuss this case, from which we can all learn a lot. There but for the grace of God go many of us. We must all be fostering a culture of safety; I wouldn’t trust my life in the Arctic to a checklist designed for general running. I believe quite strongly that surgery is more akin to Arctic exploration than the airline industry. A checklist covers all the potential parts of an aircraft but you can never have such an exhaustive checklist for an operation. A checklist is only a small part of surgical safety, and adjunct to, rather than substitute for a vigilant surgeon.

This month in 360 we have a thought-provoking article from Professor Chris Colton, describing some of the earliest records of orthopaedic and trauma surgery in Ancient Egypt. Professor Colton makes a journey through some of the evidence describing orthopaedic and trauma surgery in the Kingdoms of the Pharaohs, even unearthing probably the earliest records of internal fixation and prosthesis use. Also this month, we have an interesting report from the IPOS meeting and a new feature, Cochrane Corner, which rounds up recent Cochrane reviews. 360 is continuing to develop and I would welcome letters, contributions or feature article submissions as 360 continues to wind its way to becoming (hopefully) an ever more useful adjunct to daily orthopaedic practice.

Some of the most important orthopaedic research comes from the most unlikely of places, and a fascinating paper included in this issue informs our understanding not only of limb development but also adding to evolutionary biology.² We report on important research in the world of ACL surgery,³ and there is finally a scientific answer to: can I drive in my plaster, Doctor?⁴ Finally, I would draw your attention to a paper relevant to all orthopaedic surgeons, whatever their specialist interest, that examines the ‘designer effect’ in reporting surgical outcomes.⁵ These and 80 more papers are discussed in this new issue.

I hope you will enjoy reading this issue of 360 as much as I have enjoyed editing it. My very best wishes to you all.

Ben Ollivere

Editor-in-Chief