Inside The Shoulder

In 1980 everyone wanted to do knees. Des Bokor asked his mentor Merv Cross whether he should too, and Merv said: you and twenty other people just like you. Do something nobody else wants to do, and the world will be your oyster.

What nobody wanted was the shoulder. Colleagues called it difficult, awkward, a joint you could not get good results from. So he went to North America, did a fellowship with Rich Hawkins in London Ontario and spent time with Frank Jobe at the Kerlan Jobe Clinic, and came home to a country where there was effectively no shoulder surgery at all.

He had done exactly one rotator cuff repair in his entire training, with David Sonnabend, in 1980. There were no anchors. Diagnosis was a plain film and an arthrogram, and if the dye leaked out, that was your cuff tear.

What followed was a career that built the specialty in this country. Founding the Shoulder and Elbow Society of Australia with Sonnabend, when barely a dozen surgeons turned up and most of their colleagues did not believe you could make a living in shoulders. More than three and a half thousand stabilisations, and a practice full of Wallabies and league players that led him to the HAGL lesion. Being the first person in the world to implant Regeneten into a human being, a collagen patch that has since gone into a quarter of a million shoulders.

And sitting in a room in New York in the early 1990s, watching Paul Grammont present the reverse shoulder replacement, and thinking the man was completely mad. "We did not see what he could see."

Before any of it, he was hanging off a winch line down the side of a cliff as one of the original CareFlight rescue doctors, putting a chest tube into an unconscious girl.

Inside The Shoulder is hosted by Associate Professor Kenneth Cutbush, a specialist orthopaedic shoulder surgeon in Brisbane, Australia.

IN THIS EPISODE

03:15 Merv Cross: do what nobody else wants to do

05:00 The fellowship with Rich Hawkins

07:00 Frank Jobe, instability, and operating flat

08:49 Deciding at twelve to be a surgeon

11:50 CareFlight, and being winched down a cliff

15:00 Founding the Shoulder and Elbow Society

19:55 Regeneten and the problem of cuff healing

32:26 Reverse arthroplasty arrives

44:22 What shoulder surgery taught him about people

49:11 Proudest moments

In 1981 a rotator cuff repair was regarded as an impossible operation.

When David Sonnabend presented a case at the weekly meeting at Royal North Shore, senior colleagues told him not to bother. It never works. Give them some steroids and send them on their way.

His patient was a little Italian stonemason whose entire cuff had come away. Without a repair the man's trade was finished and his family was in trouble. Sonnabend and his first registrar, Des Bokor, read up an approach that had been described in England, reattached the cuff slowly, and the man went back to work. Every year for the next twenty years, until he died, a dozen bottles of red wine arrived.

Years earlier, a young consultant at a small district hospital had been handed the patient nobody else would touch. The Health Minister's mother, a shattered shoulder, an operation he had never seen performed. He read what literature there was, then picked up the phone and called New York. Charles Neer, the father of shoulder surgery, talked him through it down the line while Sonnabend sat in his lounge room with three textbooks and a notepad.

He never did a fellowship. He did one of the first reverse shoulder replacements in Australia without having seen one. He founded the Shoulder and Elbow Society of Australia with Des Bokor by rewriting the Knee Society constitution. He designed the retractor that carries his name, and an oval glenoid reamer that a major implant company bought and shelved.

Ask him what mattered most and it is not the papers. It is the more than fifty surgeons he trained. I did not have a wife in orthopaedics, he says, but the younger guys became a family.

IN THIS EPISODE

02:13 The phone call to Charles Neer

06:47 Indonesia, and real pathology

08:06 The fellowship that fell through

10:49 Three months with Charles Neer

13:00 One of the first rotator cuff repairs in Australia

15:10 One of Australia's first reverse shoulder replacements

18:17 If in doubt, don't

20:42 Why training surgeons mattered most

24:38 The 1998 congress in Sydney

27:33 The oval reamer that got shelved

32:27 Advice to his younger self

33:40 There's no condition that surgery can't make worse

Watch the full conversation on YouTube: https://youtu.be/dwI7OE5XcNk

Inside The Shoulder is hosted by Associate Professor Kenneth Cutbush, a specialist orthopaedic shoulder surgeon in Brisbane, Australia.

At sixteen, flat on his back in traction with a broken neck, Christian Gerber started collecting quotations. One was Einstein: try not to become a man of success, try to become a man of value.

Fifty eight years later he says that line still governs how he works. Finding out that something doesn't work isn't a success, but it is value.

Professor Christian Gerber is the most decorated shoulder surgeon alive. Four Neer Awards. The Kappa Delta. Twenty two years as chairman of Balgrist in Zurich. Ask him what drives him and the answer is flat: no particular talent, just curiosity.

He was going to be a professional footballer, and captained Switzerland's national youth side. Then he dove into shallow water and dislocated his cervical spine. It was missed at first, and doctor after doctor said the same thing. Don't touch it. He could end up tetraplegic. Twenty weeks passed in traction.

Then the family were sent to Professor Maurice Müller, because people said he was a magician. This was 1968. When Gerber's father raised the warnings, Müller looked the sixteen year old in the eye and told him that if it were going to happen it would have happened in the accident, not in surgery. "You are not planned to become tetraplegic." The fear left him instantly, and he calls it the first time he understood the power a physician holds. Afterwards Müller charged a thousand Swiss francs and made a different kind of deal with the boy: that he would give back to orthopaedics what orthopaedics had given him.

He trained under Müller, then Reinhold Ganz, then Charles Rockwood in Texas.

There's a question in here that shows how differently he thinks. Roger Federer served a thousand times a day for two decades and never had shoulder pain. We say 40% of rotator cuffs are torn by 60, but nobody asks why the other 60% aren't. Orthopaedic research begins at the moment treatment starts, and by then, he argues, it's already too late.

In 1991 he described the subscapularis tear, which nobody had thought about. The first sixteen cases were so unusual he photographed every one. The American journal wrote back saying it was probably a Swiss disease and didn't occur in the United States. The British journal published it. The lift off test that came out of that work is now performed in every shoulder clinic in the world, and he hates that it carries his name.

He talks about Dominic Meyer, the most brilliant colleague he ever had, who developed motor neurone disease and died at fifty leaving four children, and the award he created in his memory to fund research that actually disrupts something.

And he explains a line that sounds like arrogance until you hear the reasoning. He has never had a bad result in his life, and never a good one. His patients have.

Recorded in Brisbane, the day before he scrubbed in to operate.

Inside The Shoulder is hosted by Associate Professor Kenneth Cutbush, a specialist orthopaedic surgeon practising exclusively in shoulder surgery in Brisbane, Australia.

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If a surgical robot needs to know exactly where your bones are, there are currently two options. Take repeated X ray images and accept the radiation. Or drill metal pins into the bone and track markers mounted on them.

Ahmed Sewify spent his PhD working on a third option. Put an ultrasound probe on the skin and see through to the bone underneath.

A biomedical engineer who has just completed a PhD in 3D ultrasound imaging of the shoulder, Ahmed took a path through five countries and about seven internships before he found the field he wanted. Born in Egypt, the son of an intensive care physician whose work moved the family repeatedly. At sixteen he left for Malaysia alone, and later moved to Brisbane without knowing a single person there.

He is a native Arabic speaker who taught himself English by mimicking Taylor Swift songs, then working up to Eminem when that got too easy. He also speaks Japanese and French, and is about to add Danish.

The internship section is genuinely useful for any engineering student. He went through IT, mechanical, electronics and defence before landing at a biomedical company. He paid $2,000 out of his own pocket for one of them.

The research is remarkable. A cadaver study validating skin mounted ultrasound tracking against endocortical bone pins, the gold standard, and finding it worked.

His father's advice runs through the whole episode. Never say no to an opportunity.

At twenty one, Chris Haseman decided he wanted to be a fighter, and that where he was wasn't serving him. He stopped drinking. He didn't touch alcohol again until he was thirty six.

He is clear that the alcohol itself probably wasn't why he did so well. It was a measure of how badly he wanted it. As he puts it, if you're not assessing, you're guessing.

Chris is Australia's original mixed martial arts fighter. He fought in RINGS in Japan, in the King of Kings tournament, and at UFC 38 against Evan Tanner, who went on to become world champion. He instructed at the Queensland Police Academy, built a training system for the Iraqi police during the war, and ran conditioning for the Brisbane Broncos.

His father gave up a poultry farm to teach jiu jitsu full time and is still teaching at seventy six. To see his dad, Chris had to go to class.

He describes fighting his first no rules bout in Alabama in 1995, being drawn against a Brazilian black belt in his first round in Japan, and sitting alone on the fighters' bus in Tokyo while everyone else had a corner and a country behind them.

He is candid about what it cost. Instinctive training with no measuring and no recovery.

And there is his shoulder: bone on bone, completely worn out, and what happened when he tried to move it after Ken replaced it.

Most doctors finish their intern year with no publications. Brandon Ziegenfuss has ten peer reviewed papers on the shoulder, and he wrote most of them while he was still a medical student.

Now a resident medical officer in Toowoomba, Brandon took a route into medicine that needed considerably more than one attempt. He spent his first thirteen years in Johannesburg before the family moved to Brisbane, where he swam and played cricket, coaching at his old school after he finished.

He is open about the fact that his biomedical science GPA was good but not competitive, so he did an honours year and then a Master of Public Health to lift it to 6.8. He still needed several applications and several interviews to get a place.

He refused to buy any of the GAMSAT preparation courses that cost thousands of dollars, and worked out his own approach with a study partner instead. It worked.

The conversation covers his research, including an anatomical dissection project involving up to thirty contributors, and a latarjet paper he has now presented internationally. It also covers the practical machinery of getting onto an orthopaedic training program in Australia.

The line that stays with you is about the first weeks on the ward, being the first doctor to arrive at a MET call. In medicine you have to get comfortable being uncomfortable.

His closing advice comes from cricket. You can fumble one ball. It is the next one that matters.

Violet Sattari arrived in Malaysia from Iran at eight years old speaking Persian and not one word of English. The first word she learned was hello. The second was sorry.

She was so proud of knowing it that she would go into the supermarket and deliberately bump into strangers, just so she had a reason to use it.

Within a year she was fluent. Within a decade and a half she had an undergraduate degree, an honours year in biomedicine and a medical degree from the University of Melbourne.

Violet talks about growing up between languages and countries and never quite belonging to any of them. She has an accent in Farsi, an accent in English, and Americans think she sounds foreign too. She describes it not as a loss but as an identity bespoke to her.

She is unusually honest about the parts of medicine that are rarely said aloud. Eight years of study while friends outside the bubble were living. The first time she was the only doctor on site. And a mistake, a post operative patient who should not have had a blood thinner, and who she gave one to because she was overwhelmed and did not take the time to double check.

She has coached around thirty eight students into medical school, and helped create an intern support officer role in Victoria for the skill nobody teaches: how to say no.

There is also a Roman coin, given to her by a patient on the spinal cord unit. She still carries it.

An overbooked public clinic. A waiting room full of people who had been on the list for months. One man at the desk, aggressive, loud, telling Terri-Lyn Bailey she was just a receptionist.

A doctor who had been at the hospital a long time walked over and stood beside her. He said she was not just a receptionist, and that he himself could not do her job. Then he slid a complaints form across the desk and told the man he was welcome to use it, welcome to sit down and wait, or welcome to leave.

The man sat down.

This episode is different from the rest of the series. Terri-Lyn is not a surgeon or a researcher. She started at sixteen behind a pharmacy counter in Bundaberg, and twenty years later she is the person patients speak to before and after the worst days of their lives.

She talks about what that work actually involves. Being disbelieved as a teenager and then watching the pharmacist say the identical thing and be accepted. Why she thinks you can hear a smile down a phone line. Why the person in front of you is the priority and everything else in the room is not.

There is a very funny story about a woman denied cold and flu tablets who put thousands of individual dressings on the floor.

Her advice: be nice to people regardless of who they are, because we all go in the ground the same way.

Saulo Martelli was 23, working in a factory outside Bologna, with no university education and no intention of getting one. Then he came off a motorbike on the way to work.

He woke fifteen days later. He had broken his clavicle and avulsed the brachial plexus, the nerves torn from the spine. Two years of surgery followed, four half days of therapy a week, and a shoulder fusion that left him able to move his arm only by moving his scapula.

Then, waiting in the operating room before another procedure, he looked at his own X ray and understood what the surgeons had been doing. Bending a straight plate by hand to fit a highly complex three dimensional bone. He decided he could do better.

He went to university. He designed his own plate as a final year project in 2003. He did a PhD in an orthopaedic institute in Bologna, helped design a hip implant, moved to Melbourne on an Australian Research Council funded position, then Adelaide for seven years, and is now Associate Professor of Biomechanics at QUT, working on the shoulder.

He explains the work that has followed. Using computational models to predict the outcomes of joint replacement clinical trials years before they run, and to assess fracture risk in osteoporosis from imaging.

There is also a detail worth waiting for. He married in Bologna on a Saturday. On the Sunday morning, he and his wife flew to Australia.

Peter Pivonka's PhD was on concrete failure. Earthquake engineering, and how the foundations of large bridges give way. Then a supervisor asked him what he thought about doing biomechanics in bone.

His first reaction was that it sounded strange. His second was more interesting. Concrete is already well understood, and there is only so much more to be gained. Bone was wide open.

Thirty years on he is Professor and Chair of Biomechanics at Queensland University of Technology and co director of the ARC Industrial Transformation Training Centre in Joint Biomechanics. He looks at what his old colleagues are still doing in concrete and finds it boring.

He covers the path from Vienna to Newcastle on a Schrödinger Fellowship, a planned six months of surfing that never happened, and the reality of supervising twenty five PhD candidates with wildly different skill sets.

The most valuable section is on failure. He describes a major grant application that took two months of full time work and fell just below the funding line, in the top five per cent of unfunded applications. He reapplied. The panel had changed, there was no institutional memory of the first round, and he lost again. There was no third attempt.

He is also thoughtful on PhD students who do not finish, and pushes back on a society obsessed with winners.