Emphasizing The Value Of Redundancy In Podiatric Surgery

Redundancy is great in almost every discipline and profession. Perhaps the only time it is probably not good is in the domestic arena. For example, you may be engrossed by the important playoff game on your large flat panel HD screen and your spouse keeps reminding/asking you to do something that you really do not want to do — in fact you can’t — because you are hypnotized.

In education, redundancy is an excellent model for training a future surgeon. We know that superstars in any field — guys like Bill Gates, Tiger Woods and Usher — got to where they are by purposeful, focused practice (redundancy so to speak). Authors like Malcolm Gladwell, author of Outliers, and Matthew Syed, author of Bounce, say it takes on average 10,000 hours to get to a world-class level in any discipline and it really has little to do with just talent. There must be passion and there must be a deep understanding of the discipline.

Redundancy is also good when it comes to surgical equipment. For example, after a recent perfect positioning and placement of the small joint obturator/cannula in an ankle arthroscopy for treatment of a complex post-traumatic degenerative arthritis, the scope would not fit into the cannula after removal of the obturator after perfect intra-articular placement. Fortunately, a little scrambling by the OR staff produced another cannula, which was already sterilized, and the case proceeded exceedingly well.

A cannula is a small instrument (both physically and in the pecking order of surgical equipment) and seemingly unimportant in the whole scope of surgical instrumentation. However, this small item, had we not had redundancy, could have snagged the whole procedure and been a total surgical disaster.

My first blog introduced my highly non-mathematical and incalculable, but probably accurate equation for the Ultimate Podiatric Surgical Equation (UPSE):

Surgical Outcome = ∑[(AD + PE) * (SCλ +POM)]*Pt.E

Again, here are the variables:

1. AD= accurate diagnosis
2. PE= patient education
3. SCλ= surgical competence times lambda, which is a coefficient of experience and training
4. POM= postoperative management
5. Pt.E= patient expectations

I guess the cannula would fall into the SCλ variable of the equation. Regardless of the competency of the surgeon, how can one place a 2.3-mm scope into a damaged cannula when one discovers it is slightly bent, even though the obturator was able to pass through it? I could not see any bend in the cannula even though the entire OR staff assured me they could. However, they gave me their redundant backup and the scope slid in perfectly. How could this be?

Close inspection of the original “damaged” cannula and obturator showed that it was a 1.9-mm, not a 2.3-mm diameter system. Are your eyes good enough to pick up a 0.4-mm difference when glancing at the back table while drying your hands prior to donning your gown and gloves? Mine were not.

I can tell you I was not pleased when I removed that obturator, after having a very difficult placement due to all of the exophytic bone that was surrounding this very degenerative ankle joint, and the scope would not fit. This meant I had to replace the proper cannula. This sounds really easy writing about it but in surgical reality, it is a whole different realm. Remember the times when you are showing your colleague at the bar how easy your new surgical technique is to perform, one that you have never performed but have drawn on the cocktail napkin in great detail. It rarely works in the 3-D world of the OR.

Redundancy is good. Redundancy is really good. As with flying, every effort made in the preflight planning stage always makes the mission go better and it is no different in surgery. “Fly the mission in your head,” my residency director would tell me before going into the OR. It is very similar to athletes “seeing” what is going to happen just before it does. Think about Larry Bird, Wayne Gretzky and Ted Williams, just three greats who could “see” what was going to happen.



Anonymoussays: July 22, 2010 at 1:10 pm

I had this exact conversation with Larry Harkless, DPM, at the APMA ASM meeting in Seattle this past weekend.

Excellent article Dr. Barrett!

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