Finesse in Ortho?

[Deekle]

First off, let me say that I don't want to offend anyone with this question. It truly is ignorance of what ortho does that makes me ask.

Over the summer before I start med school, I've been considering where my interests lie, and I keep coming back to surgery. I've watched as many procedures as I can find online and they are all very interesting to me.

When I watch an ortho procedure, it often seems to be a sort of brute force methodology. I say often because among the procedures I have seen, I can distinguish a degree of difference between the surgeons. While some do appear to my untrained eye to be precise and efficient with their procedures, most seemed to me to simply cut, saw, drill as if they were in shop class. Again, to my untrained eye it seemed "messy", not in the sense that it was surgery, which is a messy business, but perhaps sloppy or less precise than many of the other types of surgery procedures I have seen.

My question is, does this come with the territory or am I just imagining things? Is ortho by nature less of a precision surgical specialty and more of a brute force, mechanical "don't have to look pretty, just has to work" type of a surgical specialty? Or does it depend on the surgeon and I've just been seeing more of the "hack'n slash" types?

Again, no offense intended, I'm curious how the ortho's see things.

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[Makaio]

im not ortho, but have scrubbed in on both gen surg and ortho cases and from what i can surmise--you simply need to apply more force to manipulate bone than you do soft tissue.

 

[Deekle]

That's logical, but I'm not so much talking about manipulating the bones as I am about access to the bones. The methods of release of the muscles and tendons often seemed like more of an afterthought. (Just get me to the bone dagummit).

I did see some surgeons who were very clean and precise in their access. I'm wondering if this is due to anatomical differences or if they're just the anal ones who like to keep things neat.

I'm guessing that perhaps there are divisions among the ortho's and that some are more precision oriented than others. (Hands requiring more precision than say....a shoulder replacement.)

 

[naus]

You are not alone in noticing that, especially with implants. I think that aspect of ortho also appeals to a lot of guys.

 

[Deekle]

Yeah. It's way too early to make these kinds of decisions, but I have some MD friends (including a surgeon) who "just know" that I'd love ortho. I never really considered it. To be honest I am very, very interested in surgery, but I'm more of a precision guy in my mind-set (see o.c.d.). The ortho procedures are interesting, and I'd like to consider everything. It seems to me just starting out that there isn't much room for change once you set your path in medicine. I want to make sure I get on the right road the first time.

 

[cbtk18]

Too early

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[Deekle]

Acknowledged and understood. I'm less concerned about making decisions and more concerned about asking questions at this point.

 

[DHT]

First off, let me say that I don't want to offend anyone with this question. It truly is ignorance of what ortho does that makes me ask.

Over the summer before I start med school, I've been considering where my interests lie, and I keep coming back to surgery. I've watched as many procedures as I can find online and they are all very interesting to me.

When I watch an ortho procedure, it often seems to be a sort of brute force methodology. I say often because among the procedures I have seen, I can distinguish a degree of difference between the surgeons. While some do appear to my untrained eye to be precise and efficient with their procedures, most seemed to me to simply cut, saw, drill as if they were in shop class. Again, to my untrained eye it seemed "messy", not in the sense that it was surgery, which is a messy business, but perhaps sloppy or less precise than many of the other types of surgery procedures I have seen.

My question is, does this come with the territory or am I just imagining things? Is ortho by nature less of a precision surgical specialty and more of a brute force, mechanical "don't have to look pretty, just has to work" type of a surgical specialty? Or does it depend on the surgeon and I've just been seeing more of the "hack'n slash" types?

Again, no offense intended, I'm curious how the ortho's see things.

Ortho requires a high degree of precision, but I think its difficult to appreciate at your level because you don't realize what you're looking for. Every saw cut and drill hole needs to be lined up in all 3 planes, which is harder than you may think. Just notice how often attendings and residents will readjust your hands when they let you do this as a med student or intern.

Certain approaches to bones and joints are more straight forward than others. In general, you try to go through internervous-intermuscular planes to minimize denervation and muscle damage as you approach the bone. So even if it may not seem like it, the approach is generally a well thought out plan with excellent anatomy. (Read up on Volar approach to the radius (Henry) or the anterior approach to the hip (smith-peterson) for decent examples of this).

Hand is extremely technical and needs little explanation
Arthroscopy is much harder than it looks and certainly requires a ton of practice and finesse.

Trust me, orthopaedic surgery is a very technical field and I would not let that issue factor in your decision making.

 

[GAdoc]

I think part of the problem is that you're considering the "vehicle" too much and not the destination. Surgery is part of the treatment process that should lead to a better outcome for the patient than if they didn't have the surgery.

If you watched an otolaryngologist perform a neck dissection for metastatic laryngeal cancer you would probably be amazed at the "precision" of the surgery - would you still be as awed when the patient ends up dying anyway in a few months?

Now consider an orthopaedic trauma surgeon dealing with an otherwise healthy 30 year old male involved in an MVA with a femoral neck fracture. It's a gory surgery because that's the only way to get adequate exposure to the hip and adequately reduce and fix it. However, when the guy wakes up, he doesn't know what took place in surgery. All he cares about is that his hip is fixed.

You'd be surprised at just HOW much respect an orthopod has for the soft tissues. Ironically, it's the trauma surgeons who are MOST aware. Pilons, plateaus, calcaneus fx, etc...all are likely to be treated in an ex fix for a time in order to allow the soft tissues to heal before definitive fixation. As we're taught in AO - these injuries are best thought of as soft tissue injuries that just so happen to involve a bone. Any good orthopod knows that excessive soft tissue injury (whether iatrogenic or from the trauma) is the best way to cause wound complications

 

[Deekle]

Outstanding. Thanks, both of you. I was hoping that things were more involved than they seemed. I'll definitely pay close attention to opportunities that could give me some insight into ortho. Part of my concern was that I trust the folks who think I would be interested by ortho, and I wanted to give it a fair shake in my mind.

 

[GAdoc]

Outstanding. Thanks, both of you. I was hoping that things were more involved than they seemed. I'll definitely pay close attention to opportunities that could give me some insight into ortho. Part of my concern was that I trust the folks who think I would be interested by ortho, and I wanted to give it a fair shake in my mind.

I'd be careful about letting anybody paint you into a corner based on what they "think you'd like". There are definitely some stereotypes in ortho that hold true, but there are also more and more excpetions.

I'm a guy, but other than that most other stereotypes don't hold for me - I didn't play college sports and I spend what free time I have with my wife and two kids; not in the weight room. I do like big surgeries but as I mentioned yesterday I like them not because they are big and bloody but because I like the end result and what it means for the patient. Sure you'll see some brute force for many of the trauma cases and total joints. But I'd challenge you to find procedures more delicate or requiring more finesse than finger replants and certain spine procedures. Also, arthroscopy is exceptionally difficult. It requires you to work in 3D while what you see is in 2D.

 

[Deekle]

I'm definitely not planning on being painted in. I was not at all interested in ortho, thinking that it was for the stereotypical type "that guy" who could brute force his way through things. I'm a precision guy, an ex-Navy micro-miniature electronics repair guy. Yeah, I work on my own cars, own lots of guns and sport a wicked long goatee, but I'd also rather spend time with my wife and kids than pumping iron. I like precision. I like things that fit perfectly into place, make sense and work. I was seeing ortho as sloppy and because of that I wasn't really even considering it. I wanted to get some perspective though, because though I won't let my friends decide how I live my life, I do respect and trust them enough to value their opinions and research their thoughts for myself.

 

[Buckeye(OH)]

As was said previously, there is plenty of precision in every field of ortho. Certainly, some require more finesse than others, but all are very precise. Take a total knee for example, it may look like we are hacking and sawing. Just put the jig on and cut right? As was pointed out, alignment has to be perfect in 3d...if it isnt then midflexion instability, inability to fully straighten the leg, inability to flex > 90 can result. All can be considered, subjectively, catastrophic. While I don't enjoy joints, I appreciate the precision that is required. I prefer a much more delicate approach, hence, I think I am going into peds....but don't let that fool you, rotating spinal rods to get coronal correction from sagittal deformity is about as barbaric as it comes.


All in all, ortho, specifically trauma and joints DO require brute force, but each and every subspecialty requires a certain amount of finesse. No one wants a bull in a china shop doing their total joint.