Ortho & Physio in dialogue • Issue 02
"You don’t operate on images"
Berlin orthopaedists Simon Trach and Niclas Lutz on why it isn’t the X-ray that decides whether to operate, but the person in front of you — and when accompanying a patient turns into surgery.
A conversation by Somana
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6 min
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June 2026
Dr. Simon Trach & Niclas Lutz
Specialists in Orthopaedics & Trauma Surgery, Berlin
Anyone who goes to an orthopaedist with knee or hip pain often gets a diagnosis quickly — arthrosis, wear and tear — and the question of an artificial joint is on the table. But what if it isn’t the X-ray that decides on surgery, but the person in front of you? Simon Trach and Niclas Lutz have, against the trend of their generation, taken over their own practice — and in daily work almost always decide against the scalpel. Not out of convenience, but out of conviction.
01
Courage or naivety?
Somana
The death of the private practice is talked about everywhere, investors are buying up statutory-health-insurance licences, and many of your generation are fleeing into salaried employment. You two did the opposite and saddled yourselves with your own practice — brave or naive?
Trach
Both — but more in the positive sense. Courage always requires a bit of trust, because you can never fully survey all the risks. What appealed to us was preserving something that is becoming rarer in everyday practice: a permanent, 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 at isolated moments, but to accompany them over years — from the first pain, through therapy, back into everyday life and sport. On our own we probably wouldn’t have taken this step. What was decisive was that we both had the same idea of what good orthopaedics is.
Lutz
I’d keep the naivety part small. An owner-run practice can make a great deal of sense, both clinically and commercially. What is brave above all is the up-front commitment: you take on responsibility for the patients, for the team, for your own family, and for economic decisions in a politically turbulent healthcare environment. At the same time, that is precisely the appeal: we can shape ourselves how our consultations work, which areas we focus on, and how committedly we care for people over years.
Trach
And of course idealism is part of it too — without it you wouldn’t take a step like this.
„Having your own practice means responsibility — but also the freedom to practise medicine the way you believe is right.“
02
Why your own practice?
Somana
You took over a practice that had grown over fifteen years, along with its team and long-standing patients. What was so important to you that you deliberately left it untouched — and what appeals to you about this continuity that a large medical centre can’t offer?
Trach
Above all, reliability. It was important to us that patients don’t sit in front of a new face every time, but know who is treating them. Part of that is a team that is reachable, listens, and knows the people. Especially with long-standing patients from the practice we took over, I like to say: My name is Trach, I’m new here — you’re not. That often takes away the initial uncertainty. We deliberately wanted to preserve this established bond and continue it in our own way.
Lutz
This doctor-patient relationship was the founding principle for us. We didn’t want to create a hard break or give anyone the feeling: from today everything here is different. Everyone who wanted to stay was welcome — and we kept the entire team. Much of the basic idea remained; we’re only adding modern workflows, clear communication, and our conservative-orthopaedic focus.
„My name is Trach, I’m new here — you’re not.“
03
"You don’t operate on images“
Somana
You are surgically trained, yet in daily work you almost always decide against surgery. Where is the threshold for you — when is it still physiotherapy and training, and when the scalpel?
Trach
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 daily life. You see X-rays where you’d expect a massive restriction — and then someone walks into the consultation relatively mobile. Conversely, small findings can cause considerable complaints. So I explain openly: yes, there is arthrosis, and it can explain your symptoms. But it’s your body and, in the end, your decision. Anyone who wants to continue conservatively gets that option. We talk about an operation when quality of life in everyday activities is clearly suffering — for example when simple walks, standing up, or climbing stairs become increasingly difficult.
Lutz
see it exactly the same way: you operate on the person, not the MRI or X-ray. There are pronounced findings without major complaints, and conversely minor changes with a high level of suffering. Sometimes it’s even a relief to say: formally, you can’t damage anything more. The option of surgery isn’t going to run away from you. If someone gets along well with training, weight management, injections, acupuncture, or physiotherapy, that is completely legitimate. The only important thing is to keep an eye on the point at which conservative measures no longer secure enough quality of life.
„We talk about an operation when quality of life in everyday activities is clearly suffering.“
04
What patients misunderstand
Somana
Many patients arrive with the feeling that something in them is broken — and that only a new joint can help. What is the biggest error in thinking there? And how much of this fear have doctors bred themselves?
Lutz
The biggest error in thinking is the idea that there are only two options: either a great deal of sport and discipline — or straight to an artificial joint. But in between lies a large conservative field. We can often influence symptoms through movement, targeted strength training, weight reduction, injections, acupuncture, or good physiotherapy. The prerequisite is that patients are willing to actively participate. Conservative orthopaedics is not a passive treatment — it works as a joint process.
Trach
And a finding is not a verdict. A conspicuous image doesn’t automatically mean someone is seriously ill or may no longer be put under strain. Conversely, we take complaints seriously even when the imaging shows little. Often it’s a relief to hear: yes, there is a change — but you may move, try things out, and make your everyday life more active again. Fear of your own X-ray shouldn’t cost more quality of life than the condition itself.
„Between daily training and surgery lies a large conservative field.“
05
Why so many joints are replaced
Somana
Germany is among the world leaders in knee and hip prostheses. Are these too many operations — and if so: is it down to the incentives in the system, or to the doctors?
Trach
That is a very complex question. Numbers are an important indicator, 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 economic conditions? I would be cautious about drawing simple accusations from that. A joint replacement is a major operation with real risks, and most colleagues make such decisions responsibly. Nevertheless, it is right to look critically at the system and ask whether conservative options are being sufficiently exhausted everywhere.
Somana
Or the other countries are under-provided.
Trach
That is also possible. Healthcare systems are organised differently, and they set different incentives. Doctors always operate within these structures. So one shouldn’t look only at individual decisions, but also at which type of care the system makes easier — and which it makes harder. The high numbers remain, in any case, a reason to look more closely.
Lutz
I would also see this in a differentiated way. It may be that patients in Germany tend to expect a problem to be solved technically — especially when the level of suffering is high. At the same time, conservative therapy requires time, guidance, and personal initiative. Not everyone has the same conditions for that in daily life. That’s why it’s important for us to advise realistically: what can be achieved conservatively, what must the patient contribute themselves, and when is a joint replacement genuinely the better option?
06
What makes every prescription uncertain
Somana
Let’s talk about money and risk. The budgeting of physiotherapy is biting ever harder, and the threat of recourse claims hangs over every prescription. Where does that chafe most in everyday practice?
Trach
In everyday practice, what’s missing above all is planning security. You want to prescribe in a medically sensible way, but you don’t always know how your own prescribing practice will later be assessed. Recourse proceedings can come with a long delay, and this uncertainty naturally influences the daily decision. That is unsatisfactory for doctors — and hard for patients to understand.
Lutz
What would help are clear, robust, diagnosis-related guardrails: what amount of physiotherapy is typically justifiable for which condition, and when does it need special justification? Blanket limits often don’t reflect reality — an uncomplicated course is something different from a complex post-operative situation or a chronic limitation. More transparency would help both sides: those prescribing and those being treated.
Somana
: And the guidelines — do they reflect what really helps in everyday practice?
Trach
Guidelines are important, but they don’t always fully reflect everyday practice. With knee and hip arthrosis, it isn’t only about painkillers on one side and a prosthesis on the other. Many patients benefit from a structured conservative approach — movement, strengthening, weight management, physiotherapy, sometimes also acupuncture or injections. If a measure is well tolerated, reduces symptoms, and can postpone a bigger operation, that is, in my view, a relevant gain — as long as we speak honestly about the evidence.
„Between painkillers and a prosthesis, you need a structured conservative approach.“
07
How to recognise good physiotherapy
Somana
After a few patients, how can you tell whether a physio practice really moves something — or just passes the time?
Lutz
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 much more time is spent with patients there than in the medical consultation. So my benchmark isn’t 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.
Trach
On top of that comes the relationship. The bond of trust between therapist and patient is very important for success. If it doesn’t fit on a human level, it often becomes difficult — even with clinically good therapy. And physiotherapists bring a perspective that we in orthopaedics, within the narrow consultation window, sometimes have too little of: they think more in terms of functional chains and see how hip, back, knee, and gait pattern are connected.
Somana
Patients constantly ask you: where should I even go for therapy?
Trach
The choice of physio practice is free, and that’s how it should be. Anyone who has had a therapist for years whom they trust and with whom they’ve had good experiences should stick with them. It’s not about steering someone somewhere, but about finding a therapy that fits the person, the problem, and the goal.
Somana
And what annoys you most about the collaboration today?
Lutz
What I sometimes wish for is even clearer feedback on the therapy goal. Not every treatment has to be automatically extended. Sometimes the most valuable information would be: we’ve reached the goal, the patient can carry on independently. Or: we’re not making progress and need a fresh medical assessment. Such honest feedback helps us enormously, because it makes the treatment more targeted.
„Good physiotherapy makes people more independent — it conveys understanding, confidence, and concrete tools.“
08
Do you miss operating?
Somana
You are both surgically trained and could operate — but hardly do any more. Do you unlearn the cutting, or unlearn the appetite for it? Do you miss it?
Trach
For a long time I very much enjoyed working clinically and surgically — almost ten years at the trauma hospital and many years as an emergency physician. That was an intense and formative time, both professionally and personally. At the same time, I notice that I don’t miss this form of medicine in everyday work. What appeals to me more today is the long-term accompaniment: classifying complaints, exhausting conservative paths, making decisions together, and seeing people again over years. Acute, full-throttle medicine had its time; now a different chapter is due.
„Emergency medicine was a formative time. What appeals to me today is the long-term accompaniment.“
4 quick questions
A sentence from a colleague you never want to hear again?
The most underrated exercise?
One thing physios do better than orthopaedists?
If you were Health Minister — which service would you newly reimburse?
Ortho & Physio in Dialogue
About
Dr. Simon Trach & Niclas Lutz
Dr Simon Trach — Specialist in orthopaedics and trauma surgery Around ten years at the trauma hospital in Berlin, long-standing emergency physician with the Berlin Fire Service and ATLS instructor. Focus on trauma and foot surgery. Studied in Heidelberg, with international placements in Madrid, Porto Alegre, and Wake Forest.
Niclas Lutz — Specialist in orthopaedics and trauma surgery Placements at Vivantes, the Bundeswehr, and Med 360°, among others. MBA, studied in Leipzig. Focus on conservative and outpatient orthopaedics. Since April 2026 the two have jointly run the owner-operated practice orthemos am Schiffbauerdamm (Albrechtstraße 12, Berlin-Mitte).
Stay tuned for more interviews
This interview is part of the "Ortho & Physio in Dialogue" series by Somana – a series in which both sides have their say. None of the voices speaks for everyone. But each contributes to a better understanding of the interface. Further interviews will follow.
