What makes a great surgeon? Certainly, sound surgical principles are paramount when handling tissues. I feel the most important ability that makes a great surgeon is knowing what to do if your “plan A” is not working out. Being able to assess a situation and make good surgical decisions is what separates a surgeon from a technician.
I am sure we all have the same preoperative ritual. The night before surgery, we do a careful review of X-rays, magnetic resonance images, computed tomography scans, etc., and prior office notes. We confirm our game plan. For example, Mrs. Jones is going to get an Austin bunionectomy or Mrs. Smith is having a second hammertoe operation, which will include a fusion of the proximal interphalangeal joint and release of the extensor tendon and dorsal capsule.
What happens when you do the surgeries as planned (and scheduled) and the result is not exactly what you want? For example, you fix the second hammertoe just like you planned and the toe is still dorsally elevated and leaning toward the big toe. What do you do? The question is rhetorical but I am sure you have been in this position before.
The really talented surgeons know what to do because they are prepared for situations like this. Surgery is easy when it goes off without a hitch. Being able to fine-tune your procedures, add procedures,or completely scrap what you planned to do and do something different may be necessary. To illustrate with the second hammertoe procedure, maybe you did not plan to do a flexor tendon transfer or a plantar plate repair, but that may be what you need to fix the toe appropriately.
I have a recent example to illustrate this situation. I had a patient who needed a revision bunionectomy. She had buried, threaded K-wires in the metatarsal head from a prior distal metaphyseal osteotomy. Her surgery happened about 15 years ago. My plan was to remove the hardware and do an Austin. After fiddling with the buried, threaded K-wire for 15 minutes (it kept breaking off as I would get a pliers on it and twist), I decided to do a Lapidus. I knew she was not going to be happy about being non-weightbearing after surgery but I had to do what I had to do. After surgery, I discussed the situation with the patient and her husband. They understood and were gracious that I did what I had to do to get it done right.
I have another example for you. A 61-year-old female patient got a referral to me from her podiatrist in Maryland. She had just moved to Arizona and had a first metatarsophalangeal joint (MPJ) fusion, six months prior to presenting to my office. The fusion was a revision from a failed implant surgery. She had an interpositional bone graft with a lag screw and a dorsal plate. The patient had evidence of a non-union and was having pain. She surprisingly had minimal appreciable motion of the great toe joint on exam and her toe position was perfect.
The plan was to remove her hardware and redo her fusion with a new interpositional bone graft. In regard to the intraoperative findings, the distal graft host interface was healed and the non-union was only in the proximal interface. After a thorough debridement of the non-union, there was a healed plantar ledge and the toe was very stable. Therefore, rather than doing what I had planned, I decided to obtain an autogenous graft from her calcaneus, pack the non-union site and apply another plate and screws. Since her toe position was perfect and inherently stable, I will hopefully save her at least a month of healing time by not “replacing” her entire graft.
I have a statement in my surgical consent form that says I will do the best to my ability to correct the problem with the outlined planned surgery. However, if I need to add more or different procedures to accomplish this goal, I also have this addressed in my surgical consent form as well. Certainly, you will need to use good judgment when changing procedures. Changing an Austin to a Keller is not reasonable in a 30-year-old but an Austin could become a Reverdin or an Austin may become an Austin with an Akin.
The bottom line is this: anybody can go through the motions to cut skin and bone, and put in hardware. Take the extra time to play out all the potential scenarios in your head of what may not work and have a series of backup plans. Usually it is “plan B” but sometimes it may be “plan C” or “D.”