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My New Magic Recipe

By Constantinos Ketonis, MD, PhD

Surgeons are often called “creatures of habit” and are known to abide by the slogan “if it’s not broken don’t fix it.” We like routine and we like to perform each procedure the exact same way, every time–from the placement of the retractors to the application of the bandages. There is definitely comfort in knowing that something you have done hundreds of times has been successful and can be performed using muscle memory. If it works well, we stick with the magic recipe and resist change. However, it is the novel case that challenges us to change and improve, using creative solutions to address the problem at hand.  

We complete our fellowship training thinking that we have probably seen nearly all the possible scenarios one could encounter. We soon realize that the one year of training is only enough to ground us in the basic principles of hand surgery. We, as hand surgeons, are nevertheless able to navigate through the infinite number of injury patterns or pathologies because of our understanding of anatomy and the application of developed skills. Perhaps, more so than in any other field, creativity is thus required to amalgamate all these elements into the desired outcomes – and this is what I love about hand surgery. 

In my view, the decision to try a new technique or procedure usually stems from one of three motivations:

1.     A not previously encountered injury pattern or pathology that requires a potentially new technique to address it

2.     The current approach is either inefficient, unnecessarily complicated or otherwise yields unpredictable results

3.     The current technique works well, but there is room for improvement, i.e., decreased operative time, use of smaller incision, shorter rehabilitation time, etc. 

Recently, I tried a new technique which falls into the third category, and has changed the way I approach metacarpal fractures. Throughout my training, I have seen operative metacarpal fractures treated with either K-wires or plates and screws. In the summer between fellowship and beginning practice, I traveled to Spain and spent time with Dr. Francisco del Piñal, who I find extremely skilled and innovative, seeking to learn his approach to difficult problems in hand surgery. It was an incredible experience but one of the things that most impressed me was how quickly his patients with phalangeal and metacarpal fractures regained function and range of motion, allowing them to return to work and activities sooner. As it turns out, a large majority of these fractures were fixed with intramedullary headless compression screws through small incisions that allowed for early active motion and minimal immobilization. He has since published further on these techniques, but it was then that I realized that this technique would certainly become an important part of my armamentarium of repairing these types of fractures. Shortly thereafter, I began to notice a relatively new vendor at the ASSH meeting exhibit halls who demonstrated an intramedullary fixation implant specifically made for metacarpal fractures, further corroborating use of the technique I first encountered in Europe. Upon starting practice, I then discovered that one of my partners had been using this implant, had good experience with it, and that the system was available at our institution. This was the last element I needed to change my approach. I observed him using it a few times, studied the technique guide, watched as many videos I could find and then waited for the perfect patient. For me, that patient was a simple transverse ring finger metacarpal fracture with angulation and scissoring. The case went perfectly, and the patient regained full motion and returned to activities much faster than I had anticipated. Since then, I address the vast majority of metacarpal fractures with intramedullary fixation with the exception of highly comminuted patterns where I still use plates and screws. I have made small incremental adjustments to the technique and now I do these under local anesthesia only. It has become my new magic recipe.

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