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One of my early mentors, Dr. Brindley, used to say that orthopedics is just a bag of tricks.
The more I learn, the more I agree with him. However, mastering techniques is easy compared to knowing which one to use. In orthopedics, true skill isn’t just about knowing the ‘tricks’; it’s about the judgment to use them correctly.
Learning the Tricks
To understand what he meant, it helps to start with how surgeons are trained. Orthopedic surgery is full of named moves, learned techniques, and small technical details that get passed from one generation of surgeons to the next. You learn how to make cuts in bone. You learn which ligaments to release. You learn when to transfer a tendon, when to reconstruct a ligament, when to replace a joint, and when to leave something alone. You learn Weston knots, Roeder knots, modified Hardinge approaches, Dega osteotomies, Latarjets, Bankart repairs, and a thousand other maneuvers that become part of your surgical armamentarium.
At first, it can feel like a long list of tricks. But as that list grows, a deeper realization begins to take shape.
The real work is not just learning the tricks. The hard part is knowing when to use them.
When Things Don’t Go as Planned
That distinction becomes especially clear in the operating room. Surgery is humbling because things do not always go the way you imagine they will. A case may take longer than expected. Tissue may not behave the way it looked on the MRI. Bone may be softer than planned. Exposure may be harder. A repair may not hold the way you hoped. Sometimes, despite careful planning and good intentions, things fail.
This unpredictability is not unique to orthopedics. It is part of any craft that involves working with your hands. There is always a gap between the picture in your head and the reality in front of you.
Faced with that gap, young, ambitious surgeons often respond by searching for new tricks. A new approach. A new implant. A new device. A new way to solve an old problem. Sometimes that search is exactly how progress happens. Other times, the search is driven by fear: fear of struggling, fear of looking inadequate, fear that someone else has found a better way.
Fear and Innovation
That tension between progress and fear has been studied more formally in recent years. A recent article in The Journal of Arthroplasty explored this idea in total hip replacement. The authors discussed how fear can drive the adoption of new technology and new techniques in hip arthroplasty. Some innovations endure because they truly solve problems. Highly cross-linked polyethylene, for example, improved one of the major historical problems in hip replacement: wear. Other innovations rise quickly and later fall away, such as metal-on-metal hips. Some techniques, like the direct anterior approach, spread widely as surgeons gained experience, training improved, and the technique found its place.
To better understand these patterns, the authors compared them to adoption curves often used in business and technology. The two frameworks are the Gartner Hype Cycle, which describes the rise and fall of enthusiasm around new technology, and Rogers’ Diffusion of Innovations, which divides adopters into innovators, early adopters, early majority, late majority, and laggards. New ideas usually begin with innovators and early adopters.
If the idea works, it spreads into the early majority and eventually becomes mainstream. If it does not work, it may fade away, sometimes after a painful period where enthusiasm ran ahead of evidence.
Orthopedics has many examples of this.
In shoulder instability, the Putti-Platt procedure was once popular because it was simple and could stabilize a shoulder. Over time, surgeons recognized that overtightening the front of the shoulder could create its own problems, including stiffness and arthritis. The procedure largely disappeared. The Bankart repair, which was described in the 1920s, on the other hand, has endured. It has changed over time, especially with arthroscopy, better implants, and improved understanding of bone loss, but the core idea remains valuable.
Taken together, these examples highlight one of the strange things about surgical progress. Some tricks are abandoned. Some are refined. Some become foundational.
Helping Patients Understand the Process
All of this raises an important question from the patient’s perspective: how do you know what bag of tricks your surgeon has?
Historically, that has been very hard to answer. A patient comes to the office, describes a problem, gets examined, reviews imaging, and hears a recommendation. There is usually some time for questions, but it can be difficult to understand the full decision-making process in one visit. Why this surgery? Why not another? What has to be true before surgery makes sense? What options are available if the first plan does not fit?
The internet has helped, but it has also created noise. Patients can now look up procedures, implants, recovery timelines, and complications, but not all information is equally useful. More recently, large language models and reasoning tools have become increasingly useful for helping patients organize questions and understand medical information, though they are not a substitute for a physician. These tools can help patients arrive more prepared.
Building on that shift, I think the next step is for surgeons to make their own systems more transparent.
A patient should be able to understand what problems a surgeon treats, what options that surgeon commonly considers, what must be tried before surgery is recommended, and how different procedures fit into the decision-making process. That does not replace the clinic visit. It improves it.
That is one of the reasons I started building SurgeonStack. The idea is simple: let patients ask questions, explore what I have to offer, understand the general framework for their problem, and then come to clinic ready for a better conversation. The goal is not to automate the patient-physician relationship. The goal is to make that relationship more informed, more efficient, and more useful.
Better systems should make the clinic visit more informed, not less human.
The Future of Surgery
Looking ahead, these themes naturally extend into the future of the field. The future of surgery will be interesting. Artificial intelligence will give us new tools. Better data will help us understand which techniques last and which ones fade. Surgeons will continue to refine their bag of tricks, and some of those tricks will become better because of the tools around them.
But even as technology evolves, one thing will not change.
Patients will continue to have problems they need help with. Surgeons will continue to learn, adapt, and develop tools to help them. And the best care will still come from the same place it always has: a thoughtful physician, a trusting patient, and the judgment to know which trick fits the problem in front of you.
In the end, orthopedics is not defined by the number of techniques a surgeon knows, but by the ability to apply the right one at the right time for the right patient. Mastery of technique matters, but it is judgment that determines outcomes, guides innovation, and ultimately separates good surgeons from great ones.
References
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Blumenfeld TJ, Fitzsimmons LE, Goodman SB, Amanatullah DF. Fear and the adoption of technology in total hip arthroplasty. The Journal of Arthroplasty. 2026;41(7):1934-1940. doi: 10.1016/j.arth.2026.04.003
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Gartner. Hype Cycle Research Methodology. Gartner. Accessed July 1, 2026. https://www.gartner.com/en/research/methodologies/gartner-hype-cycle
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Rogers EM. Diffusion of Innovations. 5th ed. Free Press; 2003.
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Peters RM, ten Have BLEF, Rykov K, van Steenbergen L, Putter H, Rutgers M, et al. The learning curve of the direct anterior approach is 100 cases: an analysis based on 15,875 total hip arthroplasties in the Dutch Arthroplasty Register. Acta Orthopaedica. 2022;93:775-782. doi: 10.2340/17453674.2022.4802
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Smith AJ, Dieppe P, Vernon K, Porter M, Blom AW; National Joint Registry of England and Wales. Failure rates of stemmed metal-on-metal hip replacements: analysis of data from the National Joint Registry of England and Wales. The Lancet. 2012;379(9822):1199-1204. doi: 10.1016/S0140-6736(12)60353-5
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Kurtz SM, Gawel HA, Patel JD. History and systematic review of wear and osteolysis outcomes for first-generation highly crosslinked polyethylene. Clinical Orthopaedics and Related Research. 2011;469(8):2262-2277. doi: 10.1007/s11999-011-1872-4
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Bankart AS. Recurrent or habitual dislocation of the shoulder-joint. British Medical Journal. 1923;2(3285):1132-1133. doi: 10.1136/bmj.2.3285.1132
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Kiss J, Mersich I, Perlaky GY, Szollas L. The results of the Putti-Platt operation with particular reference to arthritis, pain, and limitation of external rotation. Journal of Shoulder and Elbow Surgery. 1998;7(5):495-500. doi: 10.1016/S1058-2746(98)90201-4
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Salomonsson B, Abbaszadegan H, Revay S, Lillkrona U. The Bankart repair versus the Putti-Platt procedure: a randomized study with WOSI score at 10-year follow-up in 62 patients. Acta Orthopaedica. 2009;80(3):351-356. doi: 10.3109/17453670902988387
