The Limits of Orthopaedic Surgery: A Critique of Heroic Salvage Measures

In this episode of the AAOS Now Podcast, host Ahmed Emara, MD, speaks with Nathan Mesko, MD, FAAOS, to explore the limits of orthopaedic surgery and the difficult decisions surrounding “heroic” measures.

Dr. Mesko draws on 13 years of experience in orthopaedic oncology and joint reconstruction to unpack what "heroic" really means in surgery. He argues that heroism has less to do with technical difficulty – ”can I perform this procedure” – and more to do with what a patient is being asked to endure to reach a surgeon's envisioned outcome.

Throughout the conversation, Dr. Mesko returns to a central idea: Surgical capability should always be outpaced by wisdom. He walks through how to recognize when the push toward a heroic operation is being driven by the surgeon rather than the patient, and he offers concrete techniques for having honest, humane conversations with patients around amputation, cancer diagnoses, and end of life. He also discusses the emotional toll of these decisions, including guilt, escalation of commitment, and how surgeons can build the humility and self-forgiveness needed for a sustainable career.

The episode closes with a personal story that illustrates why staying present with a patient and not turning away from them, even after a frustrating conversation, can matter even more than the surgery itself.

Key topics covered:

• Defining "heroic" measures in orthopaedic surgery and how that threshold shifts over a surgeon's career as the surgeon matures, including the evolution from saying "yes" to every procedure to knowing when to say "no”

• The challenges of actually getting informed consent for maiming or life-altering procedures, such as sacral resections and proximal femoral replacements, given the challenge of explaining to patients how much the procedure will impact their daily life

• Recognizing when surgical momentum is being driven by the surgeon rather than the patient, including escalation of commitment and the sunken cost fallacy in surgical decision-making

• The value of physically equalizing the conversation, such as pulling up a chair and sitting down rather than towering over the patient, to build trust and openness

• The importance of listening to patients before recommending treatment options to ensure that the treatment aligns with the patient’s goals and personal wishes

• Strategies for guarding against unnecessary repeat interventions, including peer consultation and pausing after setbacks

• Rethinking success in orthopaedics beyond X-rays and implant longevity, including patient-reported outcomes

• Managing surgeon guilt, self-forgiveness, and separating outcomes from the integrity of the decision-making process

• The importance of never leaving a patient without a clear next step or follow-up plan

Listeners are encouraged to reflect not only on how they operate, but on how and why they decide to operate at all.

Host: Ahmed Emara, MD, member, AAOS Now Editorial BoardGuest: Nathan Mesko, MD, FAAOS, Vice Chair of Global Clinical Operations, Center Director for Orthopaedic Oncology, and Associate Professor, departments of Orthopaedics (Integrated Surgical Institute) and Hematology/Oncology, Cleveland Clinic