Broken bones, healing hands: fixing the pro peloton in Herentals

On the Saturday, he climbed the Ventoux. Not once, not twice, not thrice. Nine times in one day. That’s five days after breaking the collarbone. “The clavicle was the least of my worries,” he says now. “Everything was hurting.” For good measure, he did it ten times in one day the following year. Oh, and he was in his early fifties at the time.

His name is Claes, Toon Claes, and he’s an orthopaedic surgeon. The orthopaedic surgeon. In Flemish, Toon rhymes with bone. He is the reason why, every time a pro breaks a bone, the press release states they are undergoing treatment at Herentals – Boonen, Van Avermaet, Alberts, Van der Poel, Van Aert… It’s difficult, near impossible, to find a Belgian rider who hasn’t been to the orthopaedics department at Herentals. 

Toon is waiting for us at reception. He bears an uncanny resemblance to Robert De Niro. It’s not just the look, it’s the blend of gentleness and firmness. Something in the mannerisms; the expectant, gauging eyes; the slight slant in the corners of the mouth. Toon doesn’t dwell – a solid handshake and we’re told to follow, clinging on to his athletic step through a maze of tunnels and stairways. 

His physique looks more rouleur than grimpeur, but he promptly wrong-foots first impressions. “You can take the lift if you want,” he says, bounding up the umpteenth flight of steps. “I always take the stairs.” I can’t help feeling it’s a character test and promptly trip over, nearly falling flat on my face. He pretends not to notice.

Finally in his consultation room, Toon serves up a series of X-rays to outline the two main collarbone scenarios: “One is natural healing, which can shorten the shoulder and the bone may have to be broken again if it doesn’t grow back properly. The second involves surgery and applies when the fracture is misaligned, or if we’re bang in the racing season. In that case, we pin it in and the rider can be back on the turbo in three to four days and back racing in a fortnight. 

“In 2011, Cadel Evans came to me with a broken collarbone, five weeks before the Tour. I suggested conservative treatment. It may seem strange so close to a main race objective, but it was a pretty well-aligned fracture, so we looked at the pros and cons with Cadel and agreed on conservative treatment. The main advantage was not messing with his muscles and vascular tissues. Disturbing blood circulation is one of the main risks when putting a bridge in.” 

After applying some tape over the shoulder, he advised Evans to get on the turbo in three days’ time and on the bike in ten. “I knew Cadel was a seasoned pro who would follow the treatment to the letter. If he’d been a young, reckless rider, it would have been a different story.”

Five weeks after first meeting Toon, Evans triumphed on the Champs-Elysées. “But,” Toon warns, “when there is a major goal around the corner and a rider is determined to achieve it, Cadel-style treatment is not an option.” Like when the doctor climbed Ventoux nine times in one day?

He ignores the rhetorical question and continues: “We believe that everyone should be able to get the right treatment at the right time. Too much waiting before surgery means that things start to stiffen up, which delays the healing afterwards. If we operate, we do it ASAP. That’s why we always have surgeons on call. Accidents happen all the time, especially at weekends…” 

Toon’s sons, Tom and Steven, have followed in the family tradition and are surgeons too. The younger brother, Tom, joins us to recall a Sunday in April, 2016: “I was sitting at home watching De Ronde when Van Avermaet crashed and broke his collarbone. I thought, hey, that one’s on me! In that moment, I went from spectator to surgeon. I was on call and had to drag myself from the screen.”

“When Van Avermaet arrived and saw that it wasn’t Toon, he just said: ‘You’re a Claes, you can do it,’” Tom says. “No pressure…”

Having finished in the adjacent consultation room, Toon jumps straight into the conversation about teams: “Big name riders are often accompanied by a DS, coach, psychologist or manager. Everyone wants a say. Sometimes I have to tell them to step out. In the end, it’s about what the rider wants. Doesn’t matter what fancy machines or training algorithms you have, if you don’t start by listening to the rider, it’s all pointless. Understanding the person is key to getting the full picture.

“An important part of our work is about informing the riders and their teams, then developing working relationships – the more the riders know, the better injuries can be prevented, and handled.” 

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Toon’s father Dries Claes was the doctor and confidant of local legend Rik Van Looy, so following the medical path was a natural development. The surgeon knows most people in cycling, but name-dropping is something they are careful about at Herentals. “We don’t publicise the names of patients, the public relations are left to the teams. I’ll sit in on a press conference if asked to clarify something, but generally we prefer to focus on treating patients.”

The Herentals reputation developed over the years by word of mouth. “When I started working here, my father’s connection to Van Looy and the cycling world helped, but I had to prove myself.” Since then, Toon and his team have developed rider treatment to another level.

Toon is replacing the knee ligament on a footballer this afternoon, but there is also the chance to follow a cycling-specific clavicle operation by Tom. He did his residency as a foot specialist, but changed to shoulders and knees, the same as his father. “I like big bones. Feet are too fiddly, everyone can do collarbones,” he says.

Joining Tom’s clavicle operation, the first thing I see is the anaesthesist using ultrasound for precise administration of anaesthetics. Before surgery can commence, the nurse goes through a checklist: patient name, body part to be operated, type of surgery.

Once the collarbone patient has been cut open, there is a gaping wound with a tube propped into it, gargling away like at the dentist’s. That’s from the complete layman’s perspective. Tuning into the room after the initial sensory overload caused by staring into the interior of the patient’s shoulder, I hear a radio playing and the life monitoring machine beeping away. 

Tom escapes into the cleaning of the collarbone. A nurse holds the patient’s sheet-covered head in a vice grip, while her hand keeps the wound open with a metal instrument to maintain Tom’s access. 

A rack of titanium clavicular plates in a range of flashy colours is displayed on a metal trolley at the foot of the patient. They look like derailleur hangers manufactured by Chris King. Tom eyes up a few before picking one from the dozens of different angles and lengths.

Using a caliper-like instrument, he measures the thickness of the plate, as well as the depth of the hole drilled in the bone, to make sure they get the right length screw. “The last thing we want is play between the bone and the plate, or an overtightened screw,” Tom warns. Everything is triple-checked down to the last detail. 

He chucks blood-soaked tissues and other remains onto a green paper sheet spread on the floor behind him. As he is drilling into the collarbone, he pauses briefly to explain: “When you do this, you have to be careful not to drill into the lung. It’s right below.” As he said earlier, collarbones are easy…

After cleaning and preparing the collarbone for the next step, Tom and the nurse cover it up. He then sticks on a fresh pair of latex gloves on top of the dirty ones before suddenly starting to cut into the left side of the patient. 

Did he say the patient had broken ribs, or did I imagine that? It still doesn’t make sense. Don’t ribs usually heal with conservative treatment? Once he is in and things get less frantic – he’s gone from digging in to pulling out small bits of… I’m not sure what – Tom looks up to explain: “I’m harvesting bone from the hip to use on the collarbone.”

He will use that fresh bone to bridge the gap left after cleaning up the weak, non-healing bone. I imagine a bone chunk, but he chips away for a while, only pulling out mixtures of tissue and bone, none of which look very solid, more like a fibrous mash with a blood-red glow.

Tom says the ‘live tissues’ thrown into the mix are good. He stuffs them in just like that. I’m concerned it’s going to fall out, but he says it’s supported by other tissues underneath and the collarbone is held in place by the new bridge, which offers support too. Plus, the body is full of other tissues around the collarbone that will help keep things in position. There is no empty void for the ‘filler’ to fall into. The blood circulation and soft tissues will enable healing.

Tom says the bone taken from the hip has to be packed as tightly as possible between the realigned collarbone ends. The plate holds the collarbone ‘ends’ together. He pushes in the last bone bits with a tweezer-type instrument.

 “The bridge will require seven or eight screws,” says Tom as he is packing away. He goes on to tighten the screws really hard. As far as I can tell, his technique is no different from when hanging up a shelf, except he’s not dealing with a lifeless wall. He is screwing into a human body. 

As Tom finally stitches up the shoulder, he says that plates can’t fight bacteria so it’s essential they are thoroughly disinfected and then covered properly with subcutaneous tissues and muscles. “Now we must pray and hope that Mother Nature does the job.” I ask if he’s religious. “Not religious,” he replies, “but when I do this kind of work, I often end up appealing to something higher. It’s humbling.”

The sheer physicality of the surgery is mind-blowing. These guys have sharp brains and delicate hands, but they also need serious muscle. The kind of brawn that gets you up and down the Géant de Provence ten times in one day. 

Edited extract from  Rouleur 17.1.