Dr Nikolai Goncharov is Chairman of the Executive Committee of the Association of Traumatologists and Orthopaedists of Russia. He is also a speaker at the Eurasian Orthopedic Forum (EOF) scheduled to take place on June 29-30 in Moscow. In an email interview with India Medical Times, Dr Goncharov talks about the latest advances in traumatology and orthopaedics.
Please, tell us about yourself. What are your professional achievements so far?
At the moment, I am a Doctor of Medical Sciences; Professor, Chairman of Traumatology and Orthopaedics Department at the Russian Medical Academy of Post Graduate Education; Chief of Traumatology and Orthopaedics Department at the Russian Medical Academy of Continuous Professional Training; Head of Medicine and Biology Unit of the Russian Research Centre ‘Kurchatov Institute’. I’m a practising doctor and I also have some extracurricular duties mainly related to my medical specialty: being an orthopaedic traumatologist, I act as the Executive Board Chairman at the Russian Professional Association of Orthopaedic Traumatologists.
Why did you choose orthopaedics as your specialty?
The same as for many other people in medicine, circumstances led me here. I met a great professional and a charismatic person. It was Viktor Obolonkov, the Head of Traumatology Department at a municipal hospital. He was the one who awoke my interest in traumatology and orthopaedics after my fourth year at the medical school. Later in my life, I have always felt that this area drew my attention due to Dr Obolonkov, and it was rather his charisma than professional skills that inspired me, as the methods and techniques used back then cannot stand up to any scrutiny. Nevertheless, this man, using these methods, managed to make them look so good that I was excited to follow his path and use them too. Of course, it’s very human to try to be a little better every day. So we always try.
Could you please touch upon how your professional way took its shape?
Actually, my medical destiny happened to be quite monotone, as I did not have many places to work at. After the medical school I got my specialty training at the professional traumatological unit at the municipal hospital, which had two large departments. Then I had worked as a resident specializing in traumatology and orthopaedics for two years. After that I was close to the area of sports medicine and sports traumatology. I was the head of the medical unit at the Army, Aviation and Navy Support NGO (there was such establishment during the USSR period) based in a town of the Moscow region. During the next eight years, I was an academic specialist. I went through all stages from junior to senior research fellow. Then I got the job as the Chief of Department at the Moscow Tuberculosis Research Centre, where I happened to deal with vertebral conditions. At first, it was surgical treatment, then conservative one, which gave me a wider view of traumatology and orthopaedics challenges.
Since 1994, I have worked at the Traumatology and Orthopaedics Department of the Russian Medical Academy of Post-Graduate Education that I was recently honoured to become the head of. At first, I became an associate professor at the Department. Then, after I received my doctorate degree in 2001, I became a professor at the Department. At the same time, from 1994 to 2002, I was Chief of the Orthopaedics Department. Later at one and the same time, I was the director of the hospital and the medical centre director of the Russian Academy of Sciences, which was a structure with dozens of medical institutions providing services to our scientists, until the Medical Academy merged with the Agricultural Academy of Sciences in 2013. I was offered the office of the head at a special medical unit at the newly established institution, i.e. the Federal Agency for Scientific Organizations, where I worked for one year and then resigned. The reason was that the major arrangement problems had been solved, while solving all the other problems was too much for me.
Now, I continue both clinical and teaching practice, as I have been for all my life. Since 2015, I have been co-working at the Kurchatov Institute keeping in touch with the Department. During 2009-2017, I was the Chairman of Public Health Department at the same Institute. Since 2017, I’m the Chairman of Traumatology and Orthopaedics Department.
Do you agree that competition in orthopaedics is very high? What should one do to succeed?
I wouldn’t call it competition, because in medical sphere patients need to get medical aid and to have enough doctors who are able to provide it professionally. Both on the global and national scale, long and short term predictions state that the number of people in need of medical aid is growing larger than the number of qualified doctors able to provide it. That is why you cannot conclude that there is any tough competition just from the number of doctors of any specialty. Moreover, medicine has traditions and ideas of cooperation that are stronger than anywhere else. Medicine requires the possibility and necessity to discuss challenges jointly to come to a comprehensive unbiased solution, rather than competition to reach personal best. That’s why it’s difficult to say if there is competition in orthopaedics (in simple lexical sense). On the other hand, every sensible person that has ambitions seeks to become the best at his job, I guess. And that is great, if it finds any practical implementation. On top of everything, there are no three-tier podiums in real life, unlike in sports, so there may be many people at the top. The more the better. And the desire of any trained professional to find his or her place among the best (which doesn’t mean pushing all the others out of the way and being the only one) is, in fact, a great driving force for many important discoveries.
Which ones of the recent orthopaedic projects and achievements would you mention?
Orthopaedics and traumatology are usually considered among the most technology-intensive areas. On the other hand, almost all medical areas nowadays have extensive technical background. Quite complex diagnostic and monitoring technologies are crucial for both cardiology and nephrology, not to mention surgical disciplines, where we have long put scalpels and threads aside to make use of more complex devices and equipment. I think it is wrong to mention only recent achievements, as the development is continuous. Past and present, present and future are inseparable from each other now and, I hope, will remain so. Nevertheless, it isn’t about steps, either. They may appear when we reach such level of perfection that we can activate body’s natural defence (I don’t know how) and stop using surgical procedures at all. However, as of now, this is just a dream.
As far as orthopaedics and traumatology are concerned, such techniques are implants that can restore support and moving ability in damaged or diseased joints and limbs. These are the same technologies that, if applied to the vertebral column, give a person relief in case of disk related diseases or make it possible to replace destructed segments in both anterior and posterior vertebral columns even now. Previously, a specialist had to dedicate his life to master such a utilitarian procedure as anterior vertebral column restoration. Now it is definitely a qualification-intensive, but simple surgery. I mean all types of orthopaedic arthroscopy making possible all the manipulations that seemed absolutely fantastic not so long ago. Manipulations that comprise more than just cutting off a damaged section or meniscus to avoid discomfort, that enable getting to intermuscular sheathes rather than just joints. Manipulations that enable endoscopic osteoplastic operations on muscles and skeleton, such as the Latarjet endoscopic procedure for shoulder instability, arthroscopic exposition of muscles from anterior to posterior tendon surface. Naturally, it involves improvement of technologies, but also other aspects, such as material studies: we improve materials used for osteosynthesis or bone defect replacement. We increasingly use different kinds of biocompatible and biodegradable plastic materials, as well as cellular technologies that are currently undergoing an intensive development in the world. Orthopaedics and traumatology is a driver and end-user of these products: intra-articular cartilage transplantation, bone growing, not to mention composite polymer material experiments, anything related to improving and accelerating activation of osteogenesis, fracture healing, prevention of dystrophic processes in muscles and bones.
Arthroscopic procedures are getting more and more popular. What pros and cons of these procedures would you name, as compared to the traditional ones?
I have already mentioned endoscopy and arthroscopy. Twenty-five years ago, my colleagues from the Priorov Central Scientific Research Institute of Traumatology and Orthopaedics, the Peoples’ Friendship University, the Second Medical Institute, other institutions and I had to compensate for the poverty and insufficient technical equipment of the Soviet health care during the Perestroika and early 1990s. We were actively assimilating the Western practices in endoscopic orthopaedics, which made us a team of people who had both open surgery and endoscopic experience. Thus, I tell with all responsibility: these technologies are not interchangeable; they are to add to each other. It is the same as in any other medical area: there is no drug to cure everything and every method is as good as it is appropriate for the given individual and reasonable for the indications. Without doubt, this method has the advantage of low damage to the surrounding structures, muscles and skeleton, other organs and tissues. Which makes it highly attractive. Although arthroscopy has its limitations, it surely has economic and social benefits, if it is indicated.
Many young doctors believe that orthopaedics lack creativity and require everything to be precise as in machine building. Do you agree?
Preciseness is what we always need. However, I’d like to remind you one historical maxim that is as meaningful today as it was back then: medicine is the trade combining science and art. Any medical manipulation or assessment combines these two aspects, to a various extent. You surely cannot separate trade from medicine: we have standard combinations and formulas every doctor must know. However, every doctor must use the knowledge with understanding and creativity. Always: when performing manual procedures, prescribing drugs or diagnosing a patient. Understanding involves science, while creativity means a case-by-case approach, which is called personalized medicine in popular terms. Abandoning standardization of procedures (that is essential for our profession) can lead to national catastrophe. On the other hand, every procedure should take all personal factors into account, which requires understanding, science-based approach and creativity all combined. That is why our young colleagues are right in one thing: medicine, as a trade, must be mastered. However, after that, everyone actualizes self-growth in this trade differently.
Tell us about the Eurasian Orthopedic Forum. What are its aims? How is it useful?
The Eurasian Orthopedic Forum is the first large-scale professional meeting of our European and Asian colleagues. As far as we know, guests from Latin America and Africa consider it interesting, too. So, we may have visitors from countries other than the European ones. Of course, the majority of guests will be from the South and South-Eastern Asia, the CIS and the vast Russian territories. Our colleagues from the Eastern and Western Europe are expected to come as well. Gathering such an impressive, highly educated company is a highly appreciated and unique experience, as the people will be able to exchange their views on the latest development of their specialties in person. It is obvious that nowadays we can get any information without gathering a meeting, but it is still impossible to reflect all nuances even in a detailed journal article or a book, that’s why any reading gives rise to many questions. In this sense, face-to-face communication is irreplaceable. We all know that it takes many months or even years to write a book, and quite a big number of changes may appear during this period making the information less topical, as it wouldn’t reflect the latest achievements.
Such meetings also attract the business community. It gives my colleagues an opportunity to find out new state-of-the-art surgical techniques and methods of treatment and diagnosing, learn them first-hand, get a look at the exhibitions of the meeting, even touch the products they could or would use. It may even give an opportunity to make a change in or complement the routine application of equipment. Frankly speaking, it gives the suppliers of medical devices and equipment a great opportunity to show their newest projects, tell the global orthopaedic community about their products.
The Eurasian Orthopedic Forum is the venue for establishing international ties, including cooperation between Russia and India that is undergoing an active development now. For instance, Meril, India, has entered the Russian market of hi-tech implants for traumatology and orthopaedics recently, and it is the first Indian company in this area. Meril is going to supply primary knee joint arthroplasty systems. Indian traumatologists and orthopaedists will talk at the Eurasian Orthopedic Forum in Moscow about their experience of using such systems, including complicated cases. One more area of cooperation is developing robots for orthopaedics and traumatology. It is a joint project of the Moscow and Indian governments that was presented in the Moscow Commerce and Industry Chamber. The details are currently under discussion, but we have already received product prototypes. We have a joint computer project for navigation during surgeries in orthopaedics and traumatology. The Eurasian Orthopedic Forum will become an additional incentive for all these projects.
What is the development vector in orthopaedics? What innovations are likely in the future?
We have already touched upon this topic during our talk. Without doubt, technology will continue evolving; new better treatment techniques for orthopaedic disorders and injuries will be developed. The main issues in traumatology are finding the most reliable and functional way to connect damaged segments of extremities, restoring them as soon as possible, fracture healing, minimizing all harm to the patient: of physical, emotional, social and economic kind. We should strive to heal the fractures and ensure the recovery of the injured as soon as possible. The patient should be able to do whatever he usually does without any hurdles before the fracture is fully healed. In addition to the traditional approaches, i.e. replacement or union of fractured bones, we have the biological bone repair technique now. It consists in developing standard equivalents from the patient’s tissues and then developing and growing equivalents to replace the patient’s muscles and bones to replace the defective ones, cartilage tissues, in particular. It also concerns all products for stimulation of osteogenesis, active healing in case of injury, or just the opposite, delaying tear and destruction of muscle and bone structures, especially, vertebral ligaments and joints.
In ancient times, orthopaedics mainly had to deal with congenital defects. Nowadays, the majority of orthopaedic patients are elderly people with acquired disorders. Your comment?
There is a joke: where a bad traumatologist’s job ends, a good orthopaedist’s job begins. Traditionally, our specialty deals with a number of congenital defects in human development: scoliosis, defects in lower and upper extremities. Unfortunately, they are quite rare. Injuries are much more common. You can try to separate traumatology from orthopaedics, probably, but it is very difficult from the methodological and technical point of view, as these areas are much blended. If the fracture treatment was inadequate or, for some other reasons, its healing went wrong or it is malunited, the patient will need osteoplastic or orthopaedic surgery, in spite of the fact that the fracture is actually the traumatologist’s area of expertise. Furthermore, arthroplasty may be used in degenerative and dystrophic changes, as well as the first-stage fracture treatment. For example, a prosthetic implant is the first step for the elderly to avoid other osteosynthesis methods that are long and not always reliable. For example, the prosthetic implants, which are widely applied worldwide, may be used in case of subcapital femoral neck fracture. It saves an elderly patient the pain and ensures resuming normal activity in two weeks.
In your opinion, why do so few women choose to specialize in orthopaedics?
I find it quite difficult to explain, as I am not a woman. However, I guess, it is because we still have a physical work component to our surgeries and outpatient care, such as forcible reduction of dislocations, etc. In addition, the work may involve conservative treatment of fractures. Currently, plaster is often replaced by polymer materials, and to put such polymer bandages you need to make a tangible physical effort. Another possible reason is the fact that we have a large amount of surgical procedures that are quite difficult and must be performed fast to be as safe and minimally invasive as possible, and it requires not just skill and ability, but real physical strength.
What would you wish to young specialists?
As plainly as it sounds, I wish them to love the people they treat, keep striving to become better and remember that the one who’s interested will find many opportunities and the one who isn’t – many excuses. If something doesn’t work out, it is probably nobody’s fault, and the reason is you’re being not eager enough or not painstaking enough. And what you need to make it work is more effort and more patience. Then, you’ll do it right.
by Usha Nandini