“You don’t operate on images”

Both – but rather in the positive sense. Courage always requires a degree of trust, because you can never fully oversee all the risks. What appealed to us was preserving something that is becoming rarer in everyday practice: an established, owner-run practice with two orthopaedists, a familiar team, and real relationships with the people who come to us. We don’t want to see patients only sporadically, but to accompany them over years – from the first pain through therapy and back into everyday life and sport. On our own, we probably wouldn’t have taken this step. What was decisive was that we both shared the same idea of good orthopaedics.

Above all, the reliability. It was important to us that patients don’t sit across from a new face every time, but know who is treating them. That includes a team that is reachable, listens, and knows the people. Especially with long-standing patients of the practice we took over, I like to say: My name is Trach, I’m new here – you are not. That often takes away the initial uncertainty

For me, the person in front of me decides first, not the image. Pain is individual, and findings don’t always reliably explain how limited someone is in everyday life. You see X-rays where you would expect a massive impairment – and then someone walks into the consultation relatively mobile. Conversely, minor findings can cause considerable complaints. That’s why I explain openly: yes, there is osteoarthritis, and it can explain your symptoms. But it is your body, and in the end it is your decision. Anyone who wants to continue conservatively gets that option. We talk about surgery when quality of life in everyday activities suffers significantly – for instance when simple walks, standing up, or climbing stairs become increasingly difficult.

The biggest fallacy is the idea that there are only two options: either a great deal of sport and discipline – or an artificial joint right away. In between, however, lies a large conservative spectrum. We can often influence complaints through movement, targeted strength training, weight reduction, injections, acupuncture, or good physiotherapy. The prerequisite is that patients are willing to participate actively. Conservative orthopaedics is not a passive treatment – it works as a joint process.

That is a very complex question. Numbers are an important signal, but they don’t yet explain the causes. If comparatively many endoprostheses are implanted in Germany, you have to look closely: is it the age structure, patients’ expectations, care structures, waiting times in other countries, or the economic framework? I would be cautious about deriving simple accusations from that. Joint replacement is a major procedure with real risks, and most colleagues make such decisions responsibly. Nevertheless, it is right to look at the system critically and to ask whether conservative options are being sufficiently exhausted everywhere.

That is also possible. Healthcare systems are organised differently, and they set different incentives. Doctors always operate within these structures. That’s why one shouldn’t look only at individual decisions, but also at which care the system makes easier – and which it makes harder. In any case, the high numbers remain a reason to look more closely.

What’s missing most in everyday practice is planning certainty. You want to prescribe in a medically sensible way, but you don’t always know how your own prescribing practice will be assessed later. Recourse proceedings can arrive after long delays, and this uncertainty naturally influences daily decisions. That is unsatisfying for doctors – and hard for patients to understand.

Guidelines are important, but they don’t always fully reflect everyday practice. With knee and hip osteoarthritis, it isn’t just about painkillers on one side and a prosthesis on the other. Many patients benefit from a structured conservative concept – movement, strengthening, weight management, physiotherapy, sometimes also acupuncture or injections. If a measure is well tolerated, reduces complaints, and can delay a major procedure, that is a relevant gain in my view – as long as we talk honestly about the evidence.

I particularly like working with practices that activate: training, functional exercises, home exercises, and a clear goal for everyday life. Physiotherapy has an enormous strength, because far more time is spent with patients there than in the doctor’s consultation. My benchmark is therefore not the method on paper, but what someone can do better themselves afterwards. Good physiotherapy makes people more independent – it conveys understanding, confidence, and concrete tools for their own body.

The choice of physiotherapy practice is free, and rightly so. Anyone who has had a therapist for years whom they trust and with whom they have had good experiences should stay with them. Our aim is not to steer anyone anywhere, but to find a therapy that fits the person, the problem, and the goal.

What I sometimes wish for is even clearer feedback on the therapy goal. Not every treatment has to be extended automatically. Sometimes the most valuable information would be: we have reached the goal, the patient can continue working independently. Or: we are not making progress and need a fresh medical assessment. Such honest feedback helps us enormously, because it makes treatment more targeted.

For a long time I very much enjoyed clinical and surgical work – almost ten years at the trauma hospital and many years as an emergency physician. That was an intense and formative time, professionally and personally. At the same time, I notice that I don’t miss this form of medicine in everyday life. Today I’m drawn more to long-term care: assessing complaints, exhausting conservative options, making decisions together, and seeing people again over the years. Acute, full-throttle medicine had its time; now a different chapter is underway.