Ethical Challenge Orthopaedic

Ethics in Modern Knee
Osteoarthritis Treatment
dr. Tangkas Sibarani, Sp.OT(K)
Our Privileges
Physicians have been granted the privilege to interact with
individuals in ways that no other citizens can.
On any given day, doctors routinely invade people’s private lives, ask
them decidedly personal questions, touch them, manipulate their
extremities, expose them to radiation, inject them with potential
toxins, prescribe them harmful chemicals, and even cut into their
bodies.
Ironically, when we are done, most people thank us for the incursion.
Capozzi, James & Rhodes, Rosamond. (2015). Ethical challenges in orthopedic surgery. Current reviews in musculoskeletal medicine. 8. 10.1007/s12178-015-9274-y.
Because of our privileges….
We are obligated, as physicians, to use our knowledge of science and

medicine to act for the good of our patients.
We have a fiduciary responsibility, from the Latin fiducia,
meaning trust, to place our patients’ interests above all others,
including our own. It is our obligation as physicians to hold our
patients’ interests and well-being as paramount.
What do we mean by “Ethics”?
Code of professional conduct

◦ Nonmaleficience, “Primum non nocere”
◦ Beneficience
◦ Autonomy
◦ Justice
Holt G, Wheelan K, Gregori A. The ethical implications of recent innovations in knee arthroplasty. J Bone Joint Surg Am. 2006 Jan;88(1):226-9. doi: 10.2106/JBJS.E.8801.eth. PMID: 16391269.
Nonmaleficence
• “Primum non nocere,” first do no harm, is one of the most
fundamental aspects of biomedical ethics.
• Harm in bioethics : physical harm, pain, disability, and death.
Unfortunately, all surgical interventions inevitably cause some harm
and carry some form of risk, and so this principle is impossible to
guarantee in any surgical procedure.
Beneficence
•Beneficence refers to the principle of intervening to benefit the
well-being of an individual what we try to achieve in every
procedure
•The duty of nonmaleficence is more universal than the duty of
beneficence because “it is possible to act nonmaleficently toward all
persons, but it would be impossible to act beneficently toward all
persons.”
Autonomy
•“Personal rule of the self, free from both controlling interferences
by others and from personal limitations that prevent meaningful
choice.”
•Autonomy requires that an individual is independent from a
controlling influence and has the capacity for intentional action.
•The most common way in which a surgeon demonstrates respect for
a patient’s autonomy is by obtaining the patient’s valid consent for a
surgical intervention.
Justice
•Justice in distribution of health care
•Fair, equitable, and appropriate distribution in society of a privilege,
benefit, or service.
•Introduction and application of new techniques that needs
appreciable finding  may divert funding from other areas of
health care provision
• Our conduct must justify our patients’ trust
both in us and in our profession; it is
essential that we are honest about our own
Surgeon experience and qualifications.
Ground rule •Every surgeon should recognise the
limitations of his experience, skill and
surgical expertise and be prepared to refer
to a more experienced colleague when
necessary.
•We must not promise excellent clinical
results when the outcome is often
unpredictable.
Benson, M. (2022). Efort Ethical Orthopaedics. Efort.
Resident Training
CASE ILLUSTRATION
Hip Arthroplasty
•A senior resident was assisting attending
physician to perform hip arthroplasty, as the
resident has assisted the attending physician
on many occasion, the attending allows the
resident to prepare the femur.
•Upon broaching the canal, the proximal femur
is fractured necessitating fixation of the
fracture and conversion to a long stem
prosthesis
•In the above scenario, the patient
required a more extensive surgical
procedure, likely requiring additional
anesthesia, incurring a greater blood
loss, and necessitating a more complex
prosthesis.
•The patient was subjected to greater
risk, discomfort, and potential
complications violating the medical
dictum of “do no harm”
•Respect for a patient’s autonomy requires
that patients be informed of their role in
the teaching process
•It is essential that patients be made aware
of the presence of residents in the
operating room, the extent of resident
involvement in their case, and the level of
experience of the resident.
•Patients must be allowed to make
informed decisions regarding their
participation in the medical education
process.
•Reasonable people understand that continuing
medical education is essential for having
trained physicians available to their
community.
•Everyone would like only the most
experienced surgeon to perform their surgery,
only the most knowledgeable clinician to care
for them.
•At the same time, people realize that
additional physicians must continually be
trained and that patient involvement is an
integral part of that training.
New Technology
ANOTHER CASE
New Technology
•New devices or innovative surgical techniques may fill a void in our
armamentarium of patient care options.
•New technology may address a problem that was previously
unsolvable or may improve upon an existing treatment modality that
had previously been ineffective or incomplete.
•Before embracing new technology, orthopedic surgeons must
carefully examine our reasons for utilizing unproven modes of
treatment with the potential for substantial risks to the patient.
•Many patients, as well as their
physicians, want what is new.
•People often equate new with better,
new with improved, and new with the
latest technological advances.
•Minimally invasive surgery has been
touted as being safer, better, and more
effective than more traditional
modalities, even though much of the
literature has demonstrated uncertain
or conflicting results
Total Knee Arthroplasty
•It is a well validated procedure due to well
established experiments and literature
•It fullfill patient autonomy because we can provide
sufficient evidence regarding predicted benefits and
risks to allow patient to do informed consent.
•During last decade, improved access to the medical
literature has caused a shift in modern patient’s
expectations and knowledge
• This situation posed ethical issue, mainly by recent
innovation in knee arthroplasty -> unrealistic expectation
Minimally Invasive surgery
•Potential advantage :
• early postoperative recovery, reduced length
of stay and rehabilitation, early return to
work, improved cosmetic appearance, and
high patient satisfaction
•Several disadvantage
• Restricted visual field, issue related to learning
a new exposure and technique  implant
malposition, intraoperative fracture or
neurovascular injury
One vital
question that When does a new technique
must always be represent unacceptable
foremost in our experimentation rather than
thoughts is:
innovation?
Minimally Invasive vs Conventional
Technique
Patients often assume that the outcome of a new procedure such as
minimally invasive total knee replacement will be better than the outcome of
a standard technique
Actually, there are several risks of the new procedure
Patients may not grasp the concept that, although a “minimally invasive”
procedure has a smaller skin incision, the complications associated with that
procedure may be equal to or even greater than those associated with a
standard surgical approach.
Take home message
•Our desire to improve the outcome after surgery is what drives us to
develop innovative surgical techniques.
•A new technique may not be better than the standard procedure.
Therefore, true informed consent is absolutely essential
•Therefore, true informed consent is absolutely essential. It is
important for the surgeon to have a frank discussion with the patient
about the potential benefits and risks of a new procedure as well as
the surgeon’s experience with that procedure.

Ethical Challenge Orthopaedic

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Ethical Challenge Orthopaedic

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Ethics in Modern Knee

We are obligated, as physicians, to use our knowledge of science and

Code of professional conduct

Actually, there are several risks of the new procedure

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