Mark Rieger, MD, was trained to operate on clubfoot. At the time, extensive surgery was considered the way to achieve the best correction. But pediatric orthopedists have an unusually long window in which to judge their work. They do not just see what happens five or 10 years later. They can see what happens decades later.
And those surgically corrected feet could become stiff. Then Dr. Rieger saw the long-term results of the Ponseti method, which uses manipulation and casting to treat clubfoot largely without surgery.
He went to Iowa to learn the technique from Ignacio Ponseti, MD. Then he stopped operating.
“I haven’t operated on a clubfoot probably in over two decades now,” Dr. Rieger told Becker’s. “It really has to do with results. You’re always looking for what gives the best outcome.”
Nearly 40 years into pediatric orthopedic practice, the lesson has stayed with him.
Dr. Rieger, founding partner and senior physician at The Pediatric Orthopedic Center in Cedar Knolls, N.J., and an assistant professor at New York City-based NYU Langone Medical Center, has spent his career watching new technologies reshape orthopedics and spine surgery. He became an early adopter of endoscopic spine surgery in New Jersey, embraced technologies that reduced radiation exposure and later moved away from techniques when newer approaches produced similar or better results with fewer tradeoffs.
His standard for innovation has become increasingly simple. “Is this just a new, fancy tool that we should use, or is it something that’s actually improving outcomes?” he said.
When better surgery meant less surgery
Dr. Rieger credits one of his mentors, John Hall, MD, former chief of orthopedic surgery at Boston Children’s Hospital, with giving him the framework he still uses: Look at the results.
Clubfoot was an early test of that principle. Dr. Rieger enjoyed operating. He had also been trained to believe surgery produced the best correction. But once the long-term results of nonoperative treatment became convincing, neither mattered.
“Surgery is not always the answer, and nonoperative is not always the answer,” he said. “You have to look at the techniques.”
That distinction matters especially in pediatric orthopedics. A procedure performed on a young child may have to serve that patient for another 70, 80 or 90 years. Dr. Rieger illustrates the stakes to residents with a calculation.
A person takes roughly 1 million steps each year, he tells them. Treat a 5-year-old child, and the decision made today could affect tens of millions of future steps. “If you pay attention and do the right thing today, they have 90 million good steps,” he said.
That time horizon has shaped how he evaluates nearly every innovation since.
Spine surgery’s pendulum
Few areas have changed more dramatically during Dr. Rieger’s career than scoliosis surgery. He trained with Harrington rods. Neuromonitoring was not available, and neurologic injury was a concern.
Surgeons would sometimes wake children during an operation to verify that they could move before putting them back under anesthesia and completing the case. Then neuromonitoring arrived. Pedicle screws changed deformity correction. Imaging allowed surgeons to place instrumentation with greater precision.
But innovation introduced new tradeoffs. As pedicle screws became more common, Dr. Rieger said surgeons relied heavily on imaging to improve placement. That raised another concern in pediatric care: radiation exposure.
The technology evolved again. Dr. Rieger said low-dose imaging can now be used to help create a model of the spine and guides before surgery, reducing radiation while allowing surgeons to plan screw placement in advance.
Recovery has changed just as dramatically. Patients who once remained hospitalized for considerably longer periods can now leave within days under accelerated recovery pathways, he said.
“Complicated is not always better,” Dr. Rieger said. “Sometimes simple and well thought out is quite nice.” But perhaps the more important lesson is that today’s improvement can become tomorrow’s outdated technique.
Knowing when to leave an innovation behind
Dr. Rieger learned that firsthand with endoscopic spine surgery. When he first encountered the approach, he did not immediately adopt it. He traveled to California to observe a surgeon using the technique and asked to see the results.
At the time, Dr. Rieger said, the approach offered an important advantage: Surgeons could limit the number of fused segments and preserve more motion in the lumbar spine.
He was convinced enough to bring the technique to New Jersey, but asked an experienced surgeon to mentor him through his first cases.
“The results were exceptional at that time,” he said.
Then spine surgery moved again. As pedicle-screw techniques advanced, Dr. Rieger traveled to learn those approaches too. He concluded they could achieve similar goals with fewer complications and without the chest approach required by the endoscopic technique he had adopted.
So he changed. “That’s where you have to pivot when a newer technique comes out and it shows that you can get equal or better results,” he said.
That willingness to leave an innovation behind has become as important to Dr. Rieger as being willing to adopt one.
“You listen, you learn,” he said. “If they can prove it to you, you change. And if they can’t, you just say thank you and move on.”
Most new ideas, he added, fall into the latter category. “You say thank you and move on more than you adapt.”
‘I’m not adamant about anything anymore’
Four decades of watching techniques rise, fall and sometimes return have changed something else: Dr. Rieger’s confidence in his own certainty.
“When you finish residency, you’re a little more dogmatic because your professors teach you, ‘This is the way to do it,’” he said.
Experience taught him to listen differently. He listens more closely to colleagues proposing approaches that conflict with his own. He listens more closely to parents, who understand their children in ways a physician cannot. And he tries to separate what he was taught from what the evidence in front of him is showing.
“I’m not adamant about anything anymore,” he said. That does not mean lowering the threshold for adopting something new. It means lowering the threshold for questioning what he already believes.
“If I was more open to listening to other techniques, I probably would have adapted things a little bit earlier in my career,” he said.
The next test
AI is now confronting Dr. Rieger with the same question. He is exploring how it could be used in his practice, including its potential to support planning, patient education and administrative work.
He sees opportunity, particularly if AI can reduce the administrative burden that increasingly pulls physicians away from patients.
But he also sees another shiny new tool that has to prove what it improves.
“It’s a fancy tool, but it could be a time suck and take you away from what you need to do,” he said. “But it can also be a tremendous tool.”
For younger surgeons, Dr. Rieger wants the lesson to extend beyond any particular technology. Tools will change. The responsibility for deciding when they actually improve care will remain with the surgeon.
“You can have the most knowledge, and you can have all these fancy tools,” he said. “But you have to understand how all that knowledge and all that new technology is working to give better care.”
After nearly 40 years, Dr. Rieger has watched orthopedic surgery become almost unrecognizable from the field he entered. He has also watched ideas once dismissed become standards of care and innovations once considered advances give way to something better.
That has made him less interested in whether a technique is new than whether it deserves to last. The question is the same one his mentors taught him to ask decades ago: What do the results show?
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