Amiethab Aiyer, MD, FAAOS; William Levine, MD, FAAOS
May 19, 2021
You’ve planned and planned. This is the case you’ve been waiting to do and have felt the most ready for. Then it happens; the joint won’t reduce, the bone splinters, the implant won’t sit correctly….and everyone looks to you; what’s your next move, Doctor?
First, take a deep breath! No matter what, you will come up with a solution (because you have to!) See below for some tips and tricks to handle this inevitable situation:
1Take a Step Back and Dig into Your Knowledge Bank.
Think about similar cases from residency/fellowship and how faculty mentors handled those situations. This can be very helpful to come up with a solution. Don’t hesitate to think that techniques from other subspecialties (i.e. trauma, foot and ankle, shoulder elbow, etc) aren’t helpful. Pearls from those rotations can provide critical insight.
2Scroll Back Through Radiographs and Advanced Imaging.
look for bony deficits, erosive patterns, regions of stress shielding. As you look at the intra-op fluoro shots or at the operative field, think back to the anatomy; what soft tissue imbalances could be contributing to the malalignment?
3Check for Reduction and Malreduction.
Make sure you haven’t malreduced and fixed one bone (i.e. ulna) which is preventing anatomic reduction of the other (i.e. radius).
4Use the Implants to your Advantage.
Use blocking screw or pins to alter your implant trajectory, consider hybrid locking and non-locking fixation, or upsize your components. Use wires or smaller plates/screws for provisional fixation; soft-tissue and osseous balancing are critical in many cases and need to be completed before implants go in.
5Phone a Friend.
Don’t shy away from calling former co-fellows, former faculty from residents or fellowships. Absolutely do not stand on ceremony – call one of your partners or colleagues now – this is not a time to allow ego to interfere with patient care. It is okay to ask for help, even if you are scrubbed in! Sometimes this can be critical to getting through a challenging portion of the case.
6It’s Okay to Not be Perfect.
We all want our x-rays to be perfect, but experience also teaches that sometimes less is more. Strive for clinical improvement and try your best to get the case done as close to plan as possible, but do not perseverate if the x-rays are not perfect.
7Do Not Leave the OR When the Procedure is not Ideal.
That being said, however, do not leave the OR when you know that the procedure is not up to par, will likely fail, and will be presenting back to you where you have to revise the procedure on another OR day. There’s never a better time to get it right (even if it takes a while) than when you’re in the operating room.
No matter what, you will get it through any challenge that comes your way. As you plan your case, think about pitfalls that may cross your way. Embrace the challenges and learn each one of them. We strongly recommend you read Dr. Chris Ahmad’s book, “Skill” in which he discusses mental rehearsal which encourages surgeons to perform the operation in their mind before the actual surgery day – this can be a game changer for many young surgeons.
DISCLOSURE: Dr. Aiyer American Orthopaedic Foot and Ankle Society: Board or committee member, Delee & Drez Orthopaedic Sports Medicine (Elsevier): Publishing royalties, financial or material support, Medline: Paid consultant, Medshape: Paid consultant, Miller’s Review of Orthopaedics (Elsevier): Publishing royalties, financial or material support
Dr. Levine is Editor-in-Chief of the Journal of the American Academy of Orthopaedic Surgeons, Rosemont, IL, and the Frank E. Stinchfield Professor and Chairman, Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY.
Dr. Levine or an immediate family member serves as an unpaid consultant to Zimmer Biomet.
Read the AAOS Discussion Group Terms, Conditions and Disclaimers HERE
Copyright© 2021 by the American Academy of Orthopaedic Surgeons
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