ACTA CHIRURGIAE ORTHOPAEDICAE ET TRAUMATOLOGIAE ČECHOSL.,
83, 2016, p. 9 - 15
Immediate post-operative rating of surgical performance can be a valuable source of learning when trying to analyze the reasons for the difference between "work as planned" and "work as done".
There are many reasons for the difference, but they can only be found if complete documentation of the surgical steps allows retrospective scrutiny. Documentation like ICUC provides this opportunity for scrutiny and may allow better understanding of some unexpected post-operative evolutions.
Manuals, textbooks, guidelines, electronic learning tools and scientific publications describe the options available to treat a given trauma situation. Advice and tricks are offered, hopefully, on how to realize optimal results after careful planning. The literature about how things should be done is extensive (13, 14, 16, 18). The goal is to have a perfect match between the preoperative plan and the postoperative outcome (6). However, there is often a difference between work as planned and work as done (12). Computer-assisted tools help to implement preoperative plans (5, 17). However, the majority of all surgical procedures are still done conventionally. There are a variety of reasons for the afore-mentioned differences, like suboptimal planning, special patient situations, unforeseeable events during the operation, suboptimal technical equipment, and lack of experience of the surgical team, but systematic analyses are missing.
It is very instructive to search for the reasons for the differences between plan and performance. Suboptimal surgical technique can be a cause of such differences. Available ratings of surgical performance are usually based on complication and death rates and functional outcomes (20). These data are important as they are an overall result of the quality of the indication, surgical act and post-operative care. Adjustments based on the general patient status increase the relevance of the results. It is however difficult to find literature about an "immediate postoperative rating of the surgical act", thus excluding an essential factor, the technical performance. Except for trainees, the quality of the surgical act alone is seldom rated. Furthermore, the rating requires complete documentation, allowing objective retrospective analysis (4).
In certain situations in surgery a decision must be taken intraoperatively on whether the result obtained is acceptable or not. The risks and advantages of an attempt to improve the reconstruction must be weighed up on the spot.
Post-operatively, it would be important to know the acceptability of a deviation from the planned optimum, which is generally as close as possible to normal anatomy (8). Unfortunately, clear and precise data about such tolerances are not often available and the idea of collecting this data is not universally accepted (2, 3, 11). The situation is complicated further by the fact that it is often impossible to predict the consequences of a deviation from the desired intraoperative result, i.e. its consequences and relevance for the patient.
Usually cases are analyzed at the end of the course and it is easy to find reasons to explain the unexpected outcome. The ex-post analysis of a false prediction might be a useful learning source. Concepts with insufficient evidence for prediction have to be questioned. When sequelae only occur after ten or more years, for example, deviations from perfect results are perhaps more easily accepted, especially in elderly patients. Only a minority of outcome studies show data for individual patients and none of them offer the possibility of tracing back to the individual surgical steps. This is however offered by the complete, detailed and continuous recording of ICUC® (9, 19) by specially trained docu-mentalists who are surgeons certified in Surgicorder® technology.
Table 1 shows an overview of the workflow in fracture treatment with the required decisions and their effects. For the surgeon treating a defined patient an important issue is to know when to accept a technical and functional result and when to take the risk of trying to improve it.
The following examples (cases) illustrate the relationship between immediate post-operative result and function and its predictability.
Volar approach, a congruent radio-ulnar joint is easily realized using a special clamp, despite literature statements that fractures with displaced dorso-ulnar fragments are particularly challenging when a volar approach is used (1).
Full functional pain free recovery (Fig. 1b) illustrating that reconstruction with only 0° palmar tilt is within tolerance.
The distal radio-ulnar joint (DRUJ) and the distal ulna were not reconstructed. The functional loss (Fig. 2b) is predictable from the immediate postoperative X-ray. A second surgery was necessary because of a poorly placed screw protruding into the joint.
Functional limitations have to be expected for both cases, after any type of treatment. Congruous joint reconstruction extremely difficult if not impossible. For this case one could consider reconstruction of the gross anatomy of the hindfoot and a secondary fusion or, as alternatives, a difficult primary fusion or a primary conservative treatment and secondary fusion (15).
In a case series it is interesting to see the deviations of every single case from clearly predefined goals (18), as it allows both an understanding of acceptable tolerances and an evaluation of the quality of the surgical act. It is general experience that some cases with shortcomings may go on to produce exceptionally good results. Contrariwise, exaggerated efforts to obtain the planned result may lead to complications, this is a ridge walk between sound accepting "good" and risky insisting in "better". This is a constant balancing act between sound procedure, accepted as good, and calculated risks to achieve better.
A high quality surgical act is characterized by little difference between work-as-planned and work-as-done if we exclude deviations due to unforeseen events. (12) As stated in the DOE Handbook, Accident and Operational Safety Analysis (12): "The key is that one cannot fix problems one does not see. Seeing the gaps between work-as-done and work as planned provide the required eye-opening moment to recognize a need for change".
Complete documentation of the surgical act (Surgicorder®) as offered by the ICUC® app might allow the intra-operative technical errors to be pinpointed by secondary analysis, like a flight recorder in aviation. As transparent information is a fundamental right of patients the surgeons have to remind them preoperatively that predictions are difficult and that certain pathologies do not allow a "restitutio ad integrum" when the trauma is too extensive (cases 3 and 4). Furthermore, it is not realistic to expect surgeons to perform optimally on every occasion (case 5).
Faced with a given problem surgeons usually plan and try to follow guidelines, textbooks and reference publications (14, 16, 18). Sometimes implementation does not conform. The consequence of such a deviation can be a complication, e.g. implant fatigue failure or an unexpectedly acceptable result. Based on previous experiences with implant fatigue after treatment with single plates a complex femur shaft fracture with segmental comminution (shown in Figs 6a and 6b) was treated with a primary double plating. At 0 and 28 weeks the fracture is far from consolidated, knee function is limited in both flexion and extension but the patient has no pain and is putting full weight on the leg. In such a situation the majority of surgeons would suggest further surgical actions (bone graft or growth factors) , but - in contrast to cases treated with a single lateral plate - no fatigue occurred in case 6 and the fracture did consolidate without any further surgery. Does such a construct illustrate a "fatigue resistant internal fixation"? (13).
Experience tells us that, in other cases not illustrated here, despite good surgery according to guidelines, we do sometimes see unpredictable limited function or an inexplicable pain. Many different reasons have then to be considered, sometimes without conclusion: among others
Suboptimal surgical performance can be one of the reasons for a difference between planning and performance. The analysis of the difference is a valuable source for learning. Its prerequisite is complete documentation of the surgical act allowing retrospective analysis and recognition of deviations from the defined goals and acceptable tolerances. Intra- or post-operatively the surgeon can be faced with the dilemma of sound acceptance of a given suboptimal result or risky insistence on striving for better. Unpredicted evolutions might help towards a better understanding of certain biomechanical phenomena Complete documentation of the surgical steps as offered by ICUC® is helpful.
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