Mr Abbas Rashid: Giving upper limb injuries the elbow

Mr Abbas Rashid is a pre-eminent orthopaedic consultant specialising in the elbow. He helped set up the London Elbow Specialists Group at St John & St Elizabeth Hospital, the UK’s first private group dealing solely with elbow issues. Prior to that, he joined the University College London Hospitals (UCLH) as a Consultant Elbow and Shoulder Surgeon in 2016. 

His clinical reputation has been bolstered by his international lectures which have raised his profile and caught the attention of elite athletes and sports organisations; most recently, he treated Tottenham Hotspur captain Hugo Lloris for a dislocated elbow and sustained ligament damage.

Here, Mr Rashid talks all things elbow, and the importance of challenging the orthodoxy when it comes to treating a joint that is all-too-often overlooked as an area of study.

The appeal of the elbow

I knew I wanted to be an orthopedic surgeon from quite early on. I was working with some great upper limb specialists who are very, very inspirational. Within that group I found they fell into two categories: shoulder surgeons or hand and wrist surgeons. Although they had a great depth of knowledge in these two areas, I found everyone was a bit lost when it came to the elbow.

Towards the latter half of my training, however, I found that there was a group of people who were very interested in the basic science of the elbow; its anatomy, pathophysiology, its biomechanics. And I started paying attention to that, which is what piqued my interest. 

A growing field of study

Compared to other joints, the medical community is lagging behind when it comes to the elbow. We’re learning new things about it almost every single day – it’s basically a vertical learning curve. It surprises me that I see very simple, common pathologies that still haven’t been worked out. The fact is, when it comes to the elbow we’re very limited in our understanding. My mandate is to try and improve that. 

I’m fortunate enough to be involved in a lot of science and clinical research around the elbow, not only at UCLH, but in collaboration with lots of colleagues around the country and overseas. Through this research we’re able to extrapolate principles and philosophies and apply it to our patients for clinical gain which is what I find particularly enjoyable.

The day-to-day work

My private clinical work is here at the Hospital of St. John and St. Elizabeth, and my NHS clinical work is over at UCLH. I teach at a regional level for other residents and fellows in training as well as nationally and internationally on cadaveric courses and bio skills courses for other consultants. It gives me a great platform to talk about what I’ve learnt. 

The research

The way I’ve structured my working week affords me time to do basic science research and enroll my patients in clinical studies for the elbow. So, for example, we’ve got a cadaveric elbow simulator that we’ve built over at the Royal School of Mines at Imperial College, and we’re currently doing some cadaveric testing on new operative techniques around the elbow to fix fractures.

It’s effectively a machine in which you can place an elbow and it loads the elbow as one would load it in real life, this enables us to try new operative techniques or put in new implants and see how they fare under physiological loading. It’s like stress testing for joints. 

The innovative surgical techniques

There’s a fantastic new technique that we’re using at the moment to fix elbow fractures. There’s a type of elbow fracture called an olecranon fracture, which is very common.

Traditionally, it’s fixed with plates and screws or with stainless steel wires. The issue is that it’s often associated with poor outcomes and elbow stiffness. Quite often, even if the patient makes a good clinical recovery, they need a secondary operation to remove the hardware.

However, a new technique has been developed by my friend and mentor Professor Adam Watts to fix fractures using stitches and sutures without the need for hardware. He designed the technique, wrote it up and published a case series with medium-term follow up.

He’s just managed to get a large grant from the National Institute of Health Research and he’s going to be running a randomized controlled trial as of next year, which my patients will be a part of. We’re using my cadaveric simulator to stress test the suture fixation technique against conventional techniques. As you can see, in the elbow community we are very collaborative!

Questioning the orthodoxy of recovery

Because there is a general lack of understanding around how the elbow works, people have a tendency to treat it like any other hinge joint in the body. Most people – even upper limb surgeons – will spend time doing a beautiful operation to fix a difficult fracture, or treat a chronic degenerative problem about the elbow, and then just immobilize patients in plaster for a lengthy period of time, which leads to significant stiffness. 

The biggest deterrent to stiffness is early active mobilization. So for example, in my practice, we don’t use plaster of paris at all. We don’t use any plasters. We rely on the strength and integrity of our operative fixation, and if you’ve done a good enough job, the patient should be able to ride a horse on that elbow.

We’re trying to move away from these old philosophies which aren’t evidence based, i.e. immobilizing patients for extensive periods of time. I sometimes joke that we’re practicing orthopedics the same way we did in the mid-20th century, because not much has changed since then; people were still fixing fractures with stainless steel wires and immobilising the joint in plaster for three or four weeks. And 60 years on most practitioners are doing the same thing. I’ve found that getting people to change what they’re doing is very difficult – even in the face of robust evidence.

The sporting edge

If you spend a lot of time out there and develop a high profile, people will eventually come to you and I’ve been lucky enough to develop a reputation for working with elite athletes.

Essentially, you treat everyone like they’re a professional athlete in the sense that you want to give them the best possible outcome. In terms of the technical execution of the operation, I fix a fracture in a professional goalkeeper the same way I would in a middle-aged banker. The difference is that the rehabilitation may be more aggressive with a professional athlete, as the team is always very concerned about return to play, return to function, how soon they can compete, how soon they can load the elbow.

The Tottenham Hotspur Captain

From treating Hugo Lloris I noticed that Tottenham Hotspur have a really, really good physiotherapy infrastructure. Of course, in football, the majority of injuries tend to be in the lower limb, so their physiotherapists and their medical team have great expertise in dealing with these problems. Upper limb injuries, however, are few and far between. Aside from doing clinical assessment, diagnostic imaging and technically carrying out the surgery, we’ve been quite focused on the rehabilitation. I’ve been very, very explicit in what I think he should be doing and at what stage.

Essentially, it’s like I’ve been temporarily drafted into their medical team – if there’s an area in which they lack expertise, they’ll go out and source the expertise. So we’ve had a lot of dialogue since the surgery about what Hugo should be doing – very, very specific bits and pieces in the rehab protocol. Whereas, with my non-elite athlete patients, I would instruct the physiotherapist probably once or twice and have regular updates, with Hugo it’s slightly different. I talk to the team physios regularly and we’ll probably see him a little bit more regularly because we’re hoping to get him playing again relatively quickly.

The benefits of St John and St Elizabeth

The most important thing is that the patients really like the hospital. Since I switched exclusively to John and Lizzie’s, the patient feedback has been absolutely phenomenal. It’s not only about my convenience but about how happy my patients are and the overall patient journey. 

From a selfish perspective, it’s operationally a good hospital: I can get things done relatively quickly and smoothly. Having worked in a few other private hospitals before I was very, very disappointed in how long it would take to get things done and the volume of mistakes. But operationally, John and Lizzie’s is an excellent hospital from start to finish. 

If you’re interested in arranging an appointment with one of our elbow specialists at the hospital please call 0207 078 3867