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Treatment Comfort Zone

By Michael B. Lilyquist, MD

We have likely all heard the phrase, “don’t be the first, but don’t be the last” to adopt a new surgical technique or device.  This is seemingly wise counsel and was often repeated during my orthopaedic residency training. It was almost always stated when an x-ray was reviewed in morning rounds of someone who came into the ER the night before with complications from a new surgical technique or implant. It was a warning to prove you should never be an early adopter of new things in the world of orthopaedics, almost as if the old techniques were flawless and never had complications.  The reality is, the complications of old techniques are well known. When a patient presents with a complication, we can quickly point to a journal article that proves a certain percentage of patients have that complication.  This can make us feel the complication isn’t a result of our technique or implant, but rather just par for the course. However, if a complication occurs with a new technique or implant, we can quickly conclude that this new approach is a failure or not worth trying again. 

It wasn’t until my fellowship that I realized I could and should do more for my patients.  I had a very influential mentor who always told me, “you owe it to your patients to always strive to give them the most advanced techniques possible.” He taught me that it is my duty as a surgeon to continually evolve and progress in order to provide my patients with the most up to date surgical treatments.  Not in a reckless, thoughtless way, but rather in a well-studied, focused and progressive way.  This means reading journal articles, studying new techniques that would improve, replace or add value to the status quo approach and then mastering the technique.  This will inevitably lead to discovering new complications, having failures and getting out of our comfort zone.  Most importantly, this means seeing patients recover more quickly, achieving better outcomes, regaining better function and having less pain during their recovery.  This reminds me of another phrase I often heard from my fellowship mentor: “If you are doing surgery the same way you did in residency then you have failed your patients.”

My approach to implementing a new technique or implant is to search for those that solve a problem, improve patient recovery or improve outcomes such as strength or range of motion.  At times I have found myself searching for a better implant because I am unhappy with the results I’ve been seeing in my patients.  For example, nearly three months ago I decided to try a new wrist fusion device.  The wrist fusion plates I had tried in the past seemed to be prominent, especially in thinner patients and they are limited in the ability to adjust dorsal tilt and radial and ulnar deviation.  In my search to find something different I found the Skeletal Dynamics Implate. It is an intramedullary device which allows the surgeon to easily adjust the dorsal tilt along with radial and ulnar deviation to match the patients’ anatomy.  I have used this new implant twice and thus far it appears to resolve the problems I was seeing with the previous devices.  My hope is this will continue to provide my patients with better results and less complications postoperatively than I was seeing with the previous plates; close follow up will tell the tale.

In summary, it is imperative to get outside of our treatment comfort zone.  We must seek out new techniques and devices that can solve problems we are seeing in our current treatments.  We must keep our minds open to new methodologies that may help provide our patients with improved recovery and outcomes.  It is unfair to rely on stale techniques that have since been proven less effective than current approaches or treatment plans.  We owe it to ourselves, our profession and most of all to our patients to constantly be evolving and improving our practices with the most up-to-date surgical techniques and implants available.

Comment (1)
October 16, 2020 2:00 am

How many times have you had to abandon one of your new techniques and go back to the ” stale” technique that in retrospect looks pretty good? The Implate is not that new and all I can say is, wait until you try to take one out!! It is an excellent implant when things go well. There are also low profile wrist fusion plates out there. All I can tell you is that I have had to abandon new techniques several times in my career, and go back to the tried and true techniques, which worked better for my patients. I have come to realize that I have occasionally done a disservice to those upon whom I tried techniques that did not have long follow up in the literature.


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