Has the NHS saved Christmas for the last 75 years?

By Nick Clement
Consultant Orthoaedic Surgeon, Royal Infirmary of Edinburgh, NHS Lothian Trust

There can be no denying it, Santa Claus must have had the occasional polytrauma and several joint replacements during his lifetime. St Nicholas in the 4th Century was the Christian Bishop of Myra and was of course known for his generous gifts to the poor. Multiple descriptions of Santa have since been made, which have gradually evolved into the current version of a portly ruddy faced gentleman in a red suit rimmed with white fur. If it is assumed the latest chap fulfilling the role has been in the post since the turn of the last century, then over the intervening 120 years he will have had a few falls, likely from height, and collisions. He will also likely needed some hip and knee replacements along the way to keep him moving.  

Santa probably has one of the highest risk occupations, traveling at lighting fast speeds in an uncontained sleigh, with no evidence of a seat belt or air bags, clambering on roofs in treacherous weather conditions. There is simply no conceivable way he has not had the odd fall from height. If it is assumed that Santa is immortal and is a good driver, then his injury rate as a result of a crash would be approximately 70 per 100 million miles travelled. It is estimated that he travels around 99 million miles every Christmas Eve, therefore every year poor Santa is going to be stopping off at the Emergency Department at some point. In addition to the risk of scrambling around on frozen roofs, slightly intoxicated, the likelihood of a fall from height is high. All those roofs in one night, even the great man himself is going to put a foot wrong as he does not come across as the nimblest of steeplejacks. Even the odd sceptical physician will have to admit that Santa will have needed the input of an orthopaedic surgeon. Due to his age and his recognised increased alcohol intake his bone quality will have taken quite a hit and will likely have osteoporosis, this combined with his high-risk occupation will have resulted it countless fragility fractures. As he is an active person with higher-than-average functional demands he will have had a large proportion of these fractures managed operatively with internal fixation.  



The rate of total hip arthroplasty is approximately 200 per 100,000 per year and there is a similar prevalence of knee arthroplasty. Furthermore, this rate is increased in steeplejacks and those sustaining periarticular trauma, which is likely in his case, in addition to the fact he is probably morbidly obese which is associated with younger age at time of joint replacement. Therefore, if the current Santa has been in the job for circa 123 years, he must have had bilateral hip and knee replacements to keep him going. Likely he may have had a couple of revisions, the odd dislocation and even a periprosthetic fracture or two in view of his high-risk occupation. Hip and knee replacements last about 25 years so he will have had at least one or two revisions, may be even a re-revision. The rate of dislocation of a total hip is between 0.2% to 10% per year, which will be towards the higher end of this range for Santa due to his higher BMI and occupation. He will therefore have required a few trips to the Emergency Department to 'pop' it back in and get him on his way. Hip and knee arthroplasty has the ability to restore joint specific function and health related quality of life and should be acknowledged for keeping Santa going for a large proportion of his career.  

It simply must be true, there would be no Christmas without the NHS and orthopaedics. As Santa would be suffering with several malunions and nonunions in addition to being physical immobile and living in a health state worse than death from his severe arthritis. He would not be physically capable to continue to travel at 3 million miles an hour and then leap out at each stop, carrying a weighty sack, and then nip down the chimney. Rest ye Merry, the NHS and Orthopaedics will be there for Santa and keep Christmas going for many more years to come. However, the waiting times in the National Health Service are increasing…