Fatal failures from failing to learn from failure

 

Soon after Anne and I arrived in Seattle, we became hooked on alpine climbing.

Three of our favorite climbs were:

The Inspiration Glacier Route on El Dorado

The Kautz Glacier Route on Mt. Rainier

and 

The West Ridge of Mt. Stuart

It occured to me that alpine climbing was similar to surgery in many ways: it is rewarding, it is technical, and it turns out well most of the time.

 

Also, like climbers, surgeons often do not learn from past failures.

My friend, Colton Bramson, loaned me a book last night called Accidents in North American Climbing 2023. What stuck me as I paged through this book was that a substantial number of fatalities occurred during rappelling. For the non-climbers among you, rappelling is a standard method of descending from a climb in which the climber slides down a rope that is fixed to an anchor.

In contrast to climbing up (where the climber is supported by his/her hands and feet), in rappelling the climber is completely dependent on (1) the anchor fixed to the rock or snow, (2) the link between the anchor and the rope (usually a combination of a carabiner and webbing or cord sling), (3) the rope (passed through  the anchor system so that the ends are of equal length with large knots at the end of each one), (4) the climber's harness, and (5) the link between the harness and the rope (such as a jumar). The technique of getting it right is shown in this link.  

As can easily be seen (as is the case in surgery) there are many points of potential failure:  anchor, carabiner, sling, harness, jumar and the rope (e.g. sliding off the end of the rope). 

Causes of fatal rappel falls have been well documented:

2004 Devils Tower — Fatal rappel error - no knots at the end of the rope 

2006: Sinks Canyon — Fatal fall while rappelling - no knots at the end of the rope

2016: Indian Creek — Uneven rope ends, no knots at the end of the rope

2017: Shelf Road — Fatal rappel error - improper set up of rappel system

2020: 6 rappel-anchor failures, 3 of them fatal 

2022: Joshua Tree (broken sling) - fatality

          Tahquitz (broken sling) - fatality

          Mt. Evans (fell while pulling rope after rappel) - fatality 

In spite of these examples of fatal errors from which climbers could learn, there were 8 known rappelling fatalities in 2023.

Accidents in North American Climbing sought to determine the cause of each failure, even when complete information was not available, and to suggest what could have been done to prevent the failure

45 yo female, Auburn Quarry-only one end of the rope passed through her belay device=>make sure both ends of the rappel rope are passed through the device

51 yo female, Joshua Tree-failure of old anchor and weathered sling=>avoid using anchor systems placed by prior climbers unless they are solid and in mint condition, take time to place new anchor system

22 yo female, Mt. Evans-fall while retrieving rappel rope=>make sure footing is secure and/or that the retrieving climber is anchored so that the act of rope retrieval does not cause a fall

58 yo female, El Dorado Canyon-one end of rope pulled through anchor=>tie knots in the end of each rope strand

two 67 yo males, Glacier National Park-hastily placed anchor pulled from rock=>take time to assure that anchor is solid and redundant

44 yo male, Leavenworth-poor anchor placement leading to anchor failure=>take time to assure that anchor is solid and redundant

33 yo female, Tahquitz Rock-failure of old anchor and weathered sling=>avoid using anchor systems placed by prior climbers unless they are solid and in mint condition, take time to place new anchor system

It is apparent that the American Alpine Club provides a great example of causal modeling. In each case, they sought to determine the counterfactual - what could have been done differently to prevent the rappelling accident - even in cases where complete information was not available.  In addition to the analyses of individual fatalities, they publish their results in their annual publication, Accidents in North American Climbing, so that all climbers have access to the results.

This a perfect example of learning from a relative small number of failures in a space - like orthopaedic surgery - where the great majority of cases are successful (see this link)

For more learning from failure in the mountains, see When Everest Climbers Die Because of Poor Decisions.

Surgery, like climbing, is usually wonderful, 

but past failures contain lessons for preventing future failures 

Mt. Rainier

August 2025

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link)
The total shoulder arthroplasty (see this link)
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).

Innovation gone bad. A sad beginning and happy ending: return to rock climbing after a ream and run plus an informative story of chondrolysis

In the early 2000s the innovation of using intra-articular pain pumps (devices for administering local anesthetics) were being marketed to manage post arthroscopic pain see The effectiveness of an anesthetic continuous-infusion device on postoperative pain control and The pain control infusion pump for postoperative pain control in shoulder surgery. It was not until a decade later that it was conclusively demonstrated that intra-articular pain pumps caused a devastating type of arthritis in young patients known as chondrolysis: Published evidence demonstrating the causation of glenohumeral chondrolysis by postoperative infusion of local anesthetic via a pain pump

=>

This is a poignant example of a technological innovation gone bad. We use the term "future shock" to refer to devastating complications from new technologies that are only discovered years after these devices are sold in the marketplace and used in patients. Chondrolysis remains one of the principal indications for shoulder arthroplasty in young individuals.

Consider a 21 year old active male who had a labral repair followed by the implantation of a pain pump. Ten years later he presented to us with progressive pain and stiffness of his shoulder; however he was still able to perform all 12 of the Simple Shoulder Test Functions. His x-rays at that time are shown below.

We advised him that he need not consider arthroplasty until his symptoms progressed.

Another decade later when he was in his early 40s, his symptoms had progressed as indicated by his Simple Shoulder Test

The radiographic appearance of his shoulder had substantially progressed as well.

To avoid the risks and limitations associated with a polyethylene glenoid component he elected to have a ream and run procedure. This was performed without preoperative CT scan, preoperative 3D planning, a nerve block, or an ingrowth humeral component. The long head tendon of the biceps was preserved, the glenoid was reamed conservatively to a single concavity, the thin humeral stem was fixed with impaction autografting.

Shown below are his follow-up x-rays.

 

As a part of his one year report he indicated, "I can do all my sports, and handle the kids with little and only temporary pain, and am even climbing at around the highest level I've ever climbed."  He kindly gave us permission to show some videos of his climbing.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/


Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link). 

Rock climbing, swimming and the ream and run

Impact of 30 years’ high-level rock climbing on the shoulder: an magnetic resonance imaging study of 31 climbers

These authors sought to analyze the prevalence of pain and degenerative changes in the shoulder joints after highlevel rock climbing over at least 25 years in 31 adult male high-level rock climbers in comparison to controls.

On MRI examination, the rock climbers had significantly more abnormalities in the labrum (82% vs. 52%), long biceps tendon (53% vs. 23%), and cartilage (28% vs. 3%).  There were no significant differences between the 2 groups with respect to rotator cuff tendon pathology (68% vs. 58%) and acromioclavicular joint degeneration (88% vs. 90%). 

Despite the increased degenerative changes in the rock climbers, their Constant scores were still better than that of the nonclimbers.

The authors concluded that prolonged high-level rock climbing leads to a high prevalence of shoulder pain and increased degenerative changes to the labrum, long biceps tendon, and cartilage on shoulder imaging, but that these changes were not related to any restriction in shoulder function.

Comment: Serious rock climbers are very committed to their sport - a sport that requires both range of motion and strength. As a result, abnormalities on shoulder imaging may be less symptomatic in climbers than in a control group because the former continue to optimize their rehabilitation.

Serious climbers can develop advanced glenohumeral arthritis and are often concerned about the risks and limitations associated with the polyethylene glenoid component used in total shoulder arthroplasty. As a result, they may consider the ream and run arthroplasty which avoids a glenoid prosthesis.

Here is an example:

An active technical climber presented with a painful stiff left shoulder than was limiting his ability to pursue challenging international routes. Here is a photo of him climbing in Laos.

Below are his x-rays at presentation showing osteoarthritis and a biconcave glenoid with posterior decentering.

He had a left ream and run using an anteriorly eccentric humeral component. At one year after surgery is postoperative films show good alignment of his humeral head with his reamed glenoid in both views.

Note the anteriorly eccentric humeral head.

Here is a video of him climbing at 12 months after his left ream and run. Note the stretches!

He returned for a ream and run on the right shoulder.

His postoperative films are shown here.

Note the anteriorly eccentric humeral head.

Three months after his right shoulder arthroplasty, he sent this video of him "dry tooling" in his gym, stating that his shoulders are getting stronger everyday.

Here's a second example

A man in his late 50s from a couple of states South of here presented able to perform only half of the functions of the Simple Shoulder Test and with these radiographs of his arthritic left shoulder.

Here's his standardized axillary view. No CT scan or 3-D reconstruction was necessary.

His goal was to return to rock climbing after shoulder arthroplasty without having to worry about wearing out a plastic glenoid component. He elected to have a ream and run procedure. Here are his immediate postoperative x-rays showing prosthesis fixation with impaction grafting and the use of an anteriorly eccentric humeral head component that helped center his head on the glenoid. He also had a rotator interval plication.

At three months after surgery he had returned to sport climbing as shown here and on this youtube

https://www.youtube.com/watch?v=tnGZPwDbY34&t=9s

In our experience, rock climbers and swimmers tend to be excellent candidates for ream and run arthroplasty because of their commitment to flexibility.

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

Follow on twitter: Frederick Matsen (@shoulderarth)

64 year old active man with glenohumeral arthritis.

 An active climber and surgeon in his mid 60s presented with these x-rays showing moderately severe arthritis.

How should this be treated?

Interestingly he had no shoulder pain and his principal issues were a mild loss of range of motion, Obviously he's not at the tipping point (see this link) for surgery and is starting on a range of motion program.

Comment: This case illustrates that one cannot determine functional loss from radiographs.

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How you can support research in shoulder surgery Click on this link.

To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link. Also see the essentials of the ream and run.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages   arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery 

Ream and Run: climbing as therapy: dry tooling

An active technical climber presented with a painful stiff left shoulder than was limiting his ability to pursue challenging international routes. Here is a photo of him climbing in Laos.

Below are his x-rays at presentation showing osteoarthritis and a biconcave glenoid with posterior decentering.

One year ago he had a left ream and run using an anteriorly eccentric humeral component. His postoperative films show good alignment of his humeral head with his reamed glenoid in both views.

Four months ago he returned for a ream and run on the right shoulder.

His postoperative films are shown here.

This week he sent this video of him "dry tooling" in his gym, stating that his shoulders are getting stronger everyday.

This man has obviously put forth a terrific rehabilitation effort and it is paying off. 

We've noted that climbing is an excellent form of therapy after the ream and run procedure.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Ream and run - climbing, a great rehabilitation exerise

Rock climbing is a great rehabilitation exercise after the ream and run procedure. It applies a gentle stretch to the shoulder while strengthening the core muscles. Here are the preoperative and postoperative x-rays of an active man in his 50s.

Here is a video of him climbing at 9 months after his left ream and run. Note the stretches!

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Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages   arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Returning to rock climbing after a ream and run for a B2 glenoid - repost

With apologies.

Apparently the video on the original post did not play, so here it is fixed up.

A man in his late 50ies from a couple of states South of here presented able to perform only half of the functions of the Simple Shoulder Test and with these radiographs of his arthritic left shoulder.

Here's his standardized axillary view. No CT scan or 3-D reconstruction was necessary.

His goal was to return to rock climbing after shoulder arthroplasty without having to worry about wearing out a plastic glenoid component. He elected to have a ream and run procedure. Here are his immediate postoperative x-rays showing prosthesis fixation with impaction grafting and the use of an anteriorly eccentric humeral head component that helped center his head on the glenoid. He also had a rotator interval plication.

At three months after surgery he had returned to sport climbing as shown here.

For fun see this link.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Ream and run for shoulder arthritis with a posteriorly subluxated humeral head - will I be able to return to sport climbing?

A man in his late 50ies from a couple of states South of here presented able to perform only half of the functions of the Simple Shoulder Test and with these radiographs of his arthritic left shoulder.

Here's his standardized axillary view. No CT scan or 3-D reconstruction was necessary.

His goal was to return to rock climbing after shoulder arthroplasty without having to worry about wearing out a plastic glenoid component. He elected to have a ream and run procedure. Here are his immediate postoperative x-rays showing prosthesis fixation with impaction grafting and the use of an anteriorly eccentric humeral head component that helped center his head on the glenoid. He also had a rotator interval plication.

At three months after surgery he had returned to sport climbing as shown here.

For fun see this link.

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link.

===

Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.