Smaller incisions do not necessarily make for better surgery.
That distinction matters to Bonnie Chien, MD, as foot and ankle surgery moves toward less-invasive techniques and surgeons encounter a steady stream of new implants and technologies promising to improve care.
Dr. Chien, an orthopedic surgeon at NewYork-Presbyterian/Columbia University Irving Medical Center in New York City, has helped refine an arthroscopic approach to treating ankle instability. The procedure itself is not new. Her innovation is performing the repair arthroscopically through small percutaneous incisions, an approach she said can reduce scarring and infection risk, speed recovery and make the technique more reproducible for other surgeons.
But for Dr. Chien, a smaller incision alone does not make for a better operation.
“If the patient isn’t doing well, it doesn’t really matter how big the scar is or how it looks,” Dr. Chien told Becker’s. “What really matters is the ultimate outcome.”
She evaluates a new surgical technique on three measures: safety, effectiveness and reproducibility.
“Is it just one surgeon who can do it, or can a number of surgeons do it?” she said. “My philosophy has always been that if something is good, I want it to be shared across as many people as possible.”
When the old operation is still the right one
Not every patient with ankle instability is a candidate for the arthroscopic approach.
Anatomy can make the working space too tight for Dr. Chien to safely reach the necessary areas. A patient’s ligament tissue may be too thin to use in the reconstruction. Previous operations, revision cases or other conditions that need to be addressed simultaneously can also make an open procedure more appropriate.
And sometimes, the limits of the arthroscopic approach do not become apparent until surgery is underway.
If the anatomy prevents Dr. Chien from safely reaching what she needs to repair, she converts to an open procedure, a decision she sees as an exercise in surgical judgment rather than a failure of the technique.
“It’s kind of just letting down the ego and just doing it the way it’s been done, open, all these years,” she said.
The same principle applies beyond ankle instability. Dr. Chien recently treated a patient whose joints had been dislocated for months. By the time he underwent surgery, the area had become severely stiff and scarred.
A minimally invasive approach would have required gradually working through significant bone and scar tissue. Instead, Dr. Chien performed an open operation that allowed her to remove the necessary bone, shorten the foot and restore the joints to their proper position.
For Dr. Chien, the choice of technique ultimately comes back to the patient’s anatomy, imaging and pathology, and what can be accomplished safely, efficiently and effectively.
The newest thing in the OR
That same calculus shapes how Dr. Chien evaluates new implants and surgical technologies.
She is interested in whether newer technologies improve outcomes enough to justify their costs. But surgeons face an inherent problem when evaluating innovation: The evidence does not always arrive at the same speed as the technology.
High-level research can take years to develop, and Dr. Chien does not believe surgeons should necessarily wait for perfect data before considering something new. Doing so, she said, can mean missing opportunities to improve care.
Instead, she weighs the available evidence alongside the experience of mentors and colleagues whose judgment she trusts. She also returns to the fundamentals: anatomy, established surgical principles and whether a new technology makes sense for the problem it is supposed to solve.
That does not mean taking claims about new technology at face value. Dr. Chien said she pays attention to how device companies discuss their products, and an unwillingness to acknowledge limitations can make her more skeptical.
“If they’re absolutely defending their product and saying everything is perfect, that doesn’t instill a lot of confidence,” she said.
She prefers conversations that acknowledge both what a technology could improve and what remains uncertain.
“There’s a lot of things we don’t really know,” Dr. Chien said.
What she wants the next generation to keep
That balance between innovation and restraint also shapes how Dr. Chien trains residents.
Her first lesson is decidedly low-tech. “The key thing is always anatomy,” she said. “It’s always, always anatomy.”
Implants and techniques will change. Anatomy, she tells residents, gives them the foundation to evaluate what comes next without becoming wedded to what they learned in training.
“Don’t pigeonhole yourself into thinking, ‘This is the only way I learned, so that’s the only way I’m going to do it,’” she said.
Cost is part of that judgment, too. Academic centers may offer more flexibility to use newer technologies, particularly in complex cases, while surgeons in other practice settings may face tighter constraints, Dr. Chien said.
For Dr. Chien, the goal is not to teach the next generation to embrace every new technique. It is to give them the judgment to know which ones are worth embracing.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
