Why Some Orthopedic Surgeries Take Over 10 Hours to Perform

Orthopedic surgery is one of the most physically demanding and technically complex specialties in medicine. From reconstructing shattered bones to replacing worn-out joints and correcting spinal deformities, orthopedic surgeons perform some of the most intricate and high-risk procedures in the medical field.

These surgeries require exceptional precision, strength, and endurance, as well as the ability to handle unexpected complications. Some procedures last over 10 hours, demand millimeter-perfect accuracy, and carry high risks of nerve damage, infection, or implant failure.

This article explores the most difficult orthopedic surgeries, what makes them so challenging, and how surgeons prepare, execute, and recover from these high-stakes procedures.

1. Spinal Deformity Correction (Scoliosis & Kyphosis Surgery)
Why It’s So Challenging:
✔ Operating on the spine carries enormous risks—one wrong move can result in paralysis or permanent nerve damage.
✔ Scoliosis surgeries require placing multiple rods and screws along the spine, which must be positioned with absolute precision.
✔ Patients with severe scoliosis or kyphosis often have twisted, rotated, or unstable vertebrae, making realignment extremely difficult.
✔ The surgery can last 6-12 hours, requiring the surgeon to maintain focus and endurance for extended periods.

How Surgeons Handle It:
✔ Pre-surgical 3D imaging helps map the exact placement of screws and rods.
✔ Intraoperative neuromonitoring (IONM) ensures that no nerves are damaged during correction.
✔ Robotic-assisted surgery enhances precision in screw placement.
✔ Staging the surgery (splitting it into two procedures) can reduce the risk of excessive blood loss and complications.

2. Total Hip Revision Surgery
Why It’s So Challenging:
✔ Unlike a primary hip replacement, revision surgery involves removing and replacing a failed implant, which is often fused to the bone.
✔ Bone loss is a major issue, requiring bone grafting or special implants to restore function.
✔ There is a higher risk of infection, dislocation, and nerve damage compared to a first-time hip replacement.
✔ These procedures require longer operative times and significant force to remove old implants while preserving healthy bone.

How Surgeons Handle It:
✔ Preoperative planning with CT scans helps determine how to remove the old implant safely.
✔ Custom-made implants are sometimes used when standard implants won’t fit.
✔ Intraoperative bone grafting techniques help restore lost bone structure.
✔ Advanced fixation methods (cemented vs. uncemented implants) ensure the new hip is stable and durable.

3. Complex Pelvic Fracture Surgery
Why It’s So Challenging:
✔ The pelvis is one of the most vascular regions of the body, meaning surgery carries a high risk of massive bleeding.
✔ Pelvic fractures often involve multiple breaks in different planes, requiring complex realignment.
✔ Many pelvic injuries involve nerve and organ damage, making surgical access difficult.
✔ These surgeries require large incisions and precise screw and plate placement to restore pelvic stability.

How Surgeons Handle It:
✔ Preoperative angiography helps identify and control major blood vessels before surgery.
✔ External fixation devices are sometimes placed first to stabilize the pelvis before definitive surgery.
✔ Computer navigation and fluoroscopy guide screw placement in challenging angles.
✔ Multidisciplinary teams (trauma surgeons, urologists, vascular surgeons) collaborate to manage associated injuries.

4. Limb Lengthening Surgery (Ilizarov Method or PRECICE Nail System)
Why It’s So Challenging:
✔ Lengthening a limb requires gradual bone growth, meaning the process takes months to complete.
✔ The patient must undergo multiple surgeries and daily adjustments to the lengthening device.
✔ There is a high risk of nonunion, infection, muscle contractures, and nerve damage.
✔ Postoperative rehabilitation is extensive and physically demanding.

How Surgeons Handle It:
✔ The Ilizarov technique uses an external fixator with daily adjustments to gradually lengthen the bone.
✔ The PRECICE nail system is a newer, less invasive technique using an internal lengthening rod controlled by a remote.
✔ Frequent X-ray monitoring ensures the bone is growing at the correct rate.
✔ Physical therapy is mandatory to prevent joint stiffness and muscle weakness.

5. Total Shoulder Replacement in Young Athletes or Manual Laborers
Why It’s So Challenging:
✔ Unlike hip or knee replacements, shoulder replacements endure extreme wear and tear due to rotational forces.
✔ Young, active patients place excessive strain on artificial joints, leading to early implant failure.
✔ The surgery involves removing and replacing the ball-and-socket joint while preserving delicate rotator cuff muscles.
✔ Rehabilitation takes months, and returning to sports or manual labor is not always possible.

How Surgeons Handle It:
✔ Reverse total shoulder replacements are often used in patients with severe rotator cuff damage.
✔ Customized implants may be needed for patients with abnormal joint anatomy.
✔ Postoperative rehab focuses on strengthening the deltoid muscle to compensate for lost rotator cuff function.
✔ Joint-preserving procedures (such as resurfacing or partial replacements) may be considered for younger patients.

6. Complex Knee Ligament Reconstruction (Multi-Ligament Repair)
Why It’s So Challenging:
✔ Most knee surgeries focus on one ligament, but multi-ligament repairs involve reconstructing ACL, PCL, MCL, or LCL tears simultaneously.
✔ Knee instability after severe trauma makes restoring normal joint function incredibly difficult.
✔ Graft selection (autograft vs. allograft) plays a major role in surgical success.
✔ Postoperative rehabilitation is extensive and requires long-term physical therapy.

How Surgeons Handle It:
✔ Multiple grafts (from hamstring, patellar tendon, or cadaver sources) are used to replace torn ligaments.
✔ Intraoperative knee stability tests ensure proper ligament tension.
✔ Bracing and staged rehab protocols prevent stiffness while protecting healing ligaments.

7. Complex Ankle Fusion or Total Ankle Replacement
Why It’s So Challenging:
✔ Unlike hip and knee replacements, ankle replacements have higher failure rates due to the joint’s complex movement.
✔ Severe arthritis or post-traumatic damage may require ankle fusion instead, permanently limiting motion.
✔ Previous injuries, infections, or deformities can make implant placement difficult.

How Surgeons Handle It:
✔ Choosing between fusion and replacement based on the patient’s activity level and expectations.
✔ Using CT-guided templating ensures proper implant alignment.
✔ Careful balancing of soft tissues maintains normal gait mechanics.

Final Thoughts
Orthopedic surgeons perform some of the most difficult and high-risk procedures in medicine. Whether realigning a spine, reconstructing a shattered pelvis, or replacing a failing joint, these procedures demand technical skill, endurance, and the ability to adapt under extreme conditions.

✔ Advanced imaging, robotic assistance, and specialized implants have improved outcomes, but these surgeries remain among the most physically and mentally demanding in medicine.
✔ Surgeons rely on years of experience, meticulous planning, and intraoperative adaptability to handle unexpected complications that inevitably arise in complex orthopedic procedures.
✔ Despite the challenges, these surgeries restore mobility, reduce pain, and dramatically improve patients' quality of life—making them some of the most rewarding in medicine.