Even If It Ain’t Broke, We Can Still Make It Better

Editor’s note: This letter is in response to the article “How Should Orthopaedic Surgeons Responsibly Introduce Innovation?” by Robert M. Orfaly, MD, MBA, FAAOS, which was published in the December 2023 issue of AAOS Now.

In his recent editorial, Dr. Orfaly asks, “How should orthopaedic surgeons responsibly introduce innovation?” The answer is that, as orthopaedic surgeons, we need to take the lead and to innovate. Dr. Orfaly argues, “Don’t be the first one to pick up the sword.” I disagree.

We should be the leaders who develop new techniques and put them into practice. Often there is no evidence for a new procedure, but we do innovative things that are sensible and will benefit patients.

We can’t wait, because it may take years to accumulate the evidence. The key, however, as Dr. Orfaly notes, is that we have to “responsibly introduce innovation.” It is up to each of us as practicing orthopaedic surgeons to guide our patients safely through the world of orthopaedic advances. Nevertheless, as orthopaedic surgeons, we have to move forward.

Innovation doesn’t come easy, and sometimes it reflects a newer technique or practice as opposed to new technology. Often technology is new, but we should use it where it is logical. New procedures may be slow and difficult at the beginning, but they can be refined and ultimately provide our patients with better outcomes.

In 1980, arthroscopy had just come on the horizon. It was totally new and primitive compared to where it is today. The scopes were sterilized but not covered. There were no cameras, and you put your eye directly up to the scope so that your face was 9 inches away from the knee. There was saline flow but no pumps. To increase the pressure, you raised the bag on a pole. Instruments were poor and limited. At first, arthroscopy was purely diagnostic. Then, slowly, surgeons began to do arthroscopic partial meniscectomies and loose-body removal.

The first arthroscopies were long and difficult, and there was no evidence that the results were any better than open procedures. Many established surgeons took a cynical view of this upstart technology. Still, it became clear that patients would rather have an arthroscopic meniscectomy through three small portals, even if it took an hour and a half, than have the shorter but more painful open procedure. As we gained experience and techniques improved, it was clear that arthroscopy was superior. Tools and equipment got better; surgeons got faster. It took several years to accumulate enough data showing that outcomes were better. Moreover, results of partial meniscectomy performed arthroscopically were better than the long-term results of open procedures where the entire meniscus was removed.

A similar pattern has held true for many new orthopaedic procedures and practices. One can look at noncemented total joint replacements, arthroscopic rotator cuff repair, mini-incision surgery, tranexamic acid, arthroscopic meniscal repair, grafts for anterior cruciate ligament reconstruction, and other new techniques. Years ago, the idea of doing a same-day total joint replacement was unheard of, but surgeons did it because it made sense to do, and, with newer protocols, patients did well. Now it has become the gold standard. As procedures evolve, techniques and instruments become refined. Consider the evolution of suture passers, anatomic implants, suture anchors, allografts, and biologics to see how far we have come.

On the other side, some procedures seemed beneficial at first but then failed the test of time.

One need only look at the Wagner double-cup arthroplasty of the late 1970s or the more recent difficulty with metal-on-metal total hips to see examples of good ideas that have failed. But we wouldn’t have known about the problems if we hadn’t gone and tried the newer techniques. To put it in perspective, Sir John Charnley’s first generation of total hips used a Teflon socket with a high failure rate. That led him to try ultra-high-molecular-weight polyethylene, which gave rise to the standard metal-on-polyethylene arthroplasty.

When new things appear, orthopaedic surgeons should be the ones to design the evolution. As surgeons, we should take the lead and do new things rather than saying, “Wait and see.” Our patients will be happier.

Apple founder Steve Jobs once said, “Some people say, ‘Give the customers what they want,’ but that’s not my approach. Our job is to figure out what they’re going to want before they do.”

Introducing innovation
Of course, we still have to be cautious and make sure there are “guardrails.” When you are doing something new, there are several things to remember:

1. Be honest and tell your patients that this is the first time you are doing the procedure. I have always done new things with patients I know and who have a relationship with me. That way, they trust my judgment and will give consent.
2. Make sure you have informed consent that covers all the possibilities. After more than 400 endoscopic carpal tunnels, I still put “endoscopic or open” on my consent forms. I only had to open one case—my second one—but I keep it on the form.
3. Have a backup plan. It might be converting from an arthroscopic to an open procedure or having different hardware in the room in case you need it.
4. If available, do the procedure on a model or cadaver first. Cadavers don’t bleed and don’t distend with fluid, but you do get a chance to try out new technology before you go to the OR.
5. Identify and have a plan to manage all the possible complications, particularly the operative ones.
6. Keep your eyes open for short-term complications in the literature. Also, talk to your colleagues who have done the same procedure for the first time. Because there will be no long-term published results, anecdotal information may be useful.
7. Lastly, be careful about being led by industry. Company representatives will often push new techniques because they profit from the tools, instruments, and disposables they sell. They don’t have to answer to our patients. We do.

Stuart J. Fischer, MD, FAAOS, is an orthopaedic surgeon in private practice in Watchung, New Jersey. He also serves on the AAOS Membership Council, Board of Councilors, and Evidence-Based Quality and Value Committee.