Key opinion leaders

Mohammed Ali died on June 3 2016. Perhaps one of the most successful sportsmen of all time, Ali was widely regarded as a strong political force and human rights activist. A fearsome fighter, he was also known for his love of poetry (sometimes of dubious quality) and support for the black emancipation movement in the USA, conversion to Islam and continuous presence on the world stage throughout a long and difficult fight with Parkinson’s disease. Despite his reportedly low IQ, having scored 78 on a US army recruitment test, Ali remarked “I said I was the greatest, not the smartest”. An amazing insight into one of the world’s most colourful, successful and inspirational people.

Human beings are not good at separating personality traits and physical characteristics. Just because an individual is able to run 100 m faster than anyone ever before does not make them more insightful in politics or their views on world peace any more worthwhile than the next person’s. However, we do bestow worth to the opinions and thoughts of highly-performing individuals. It is the same in surgery, why should someone who is particularly good at an operation have special insight into the design features of an implant? Why should a professor of orthopaedics with world-leading insight into biphasic models of bone substitutes be any better at fixing an ankle fracture than the next surgeon? However, we do live in a world of celebrity, and this does extend to orthopaedic surgery as well. Our opinion leaders tend to be excellent surgeons, but are they also excellent scientists?

There are a number of papers in this month’s 360 that call into question the status quo – perceived wisdom handed down by orthopaedic greats. In an excellent feature article calling into question the rationale behind total knee arthroplasty, Mr Kos Sehat asks, is there a better way of achieving balance in the knee? Should we still be constrained by the early biomechanical and tribological limitations of implants, or is there a better, more physiological way to implant a total arthroplasty? Sticking with the total knee, the question of all polyethylene tibial components has raised its head again¹ – previously derided based mostly on the success of the AGC knee (BioMet, Warsaw, IN), it turns out that with a modern eye, the modular components may well have the edge, but things are not as straightforward as once thought, and indeed if the metal-backed components do have an edge, it is because of the modularity rather than anything else. A similar difficulty can be seen with a paper on rationing in hip arthroplasty,² although from a well-respected group, the science is poor, and hence the message of the paper that the New Zealand score can be used to ration total hip arthroplasties is far from accurate. In fact the paper does not present any data to support use in rationing, and the rather rudimentary statistics run the risk of giving a damaging message to clinicians and healthcare funders.

The difficulty with a complex specialty like surgery is that it takes more than skill with a knife to make sensible decisions not just on a patient-by-patient basis, but also on a hospital-wide and population-wide basis. Now more than ever, a marriage between clinicians and scientists is needed to move the specialty forwards. The current environment is one of thrift and value; not which option is best, but which is cheapest. Choosing economy over quality, and with an ever-increasing array of interventions, higher expectations than ever before determining which is the best intervention, who will benefit and why is becoming increasingly difficult. I cannot help thinking that we are missing something at the moment – if the days of the all-knowing chief of surgery are numbered, what are they to be replaced with? A myriad of randomised controlled trials all proclaiming ‘no difference’? In an age where we are mature enough to accept that different skills are needed for different approaches, the profession needs to embrace its scientists, and also ensure there is new direction of scientific clarity and leadership to ensure that relevant scientific messages are given as much of a platform as surgical technique. The age of sportsmen like Muhammed Ali who double as civil rights activists and the voice of social conscience are probably gone, so too probably is the day of the single ‘key opinion leader’, hopefully to be replaced with something wholly better.