Orthopedic Surgery Residents: How Much Do They Know About Occupational Therapy?

Background Orthopedic hand surgeons rely on occupational therapy (OT) as a crucial part of rehabilitation following injury or surgery. Therefore, orthopedic surgeons should understand the full range of OT services. There is limited prior research on orthopedic residents' understanding of OT in the United States. The main goal of this study is to examine how well orthopedic surgery residents grasp and perceive the role of OT, particularly in hand surgery, as integrated into their educational curriculum. Methods The study included all orthopedic surgery residents from a single institution (Columbia University, New York) during 2022-2023. We obtained permission from the Institutional Review Board, Department Chair, and Program Director to recruit participants. Eligible residents who agreed to participate completed questionnaires regarding their understanding of the role of OT in orthopedic surgery. Results Thirty subjects met the inclusion criteria. The total response rate from the residents was 14/30 (47%). The residents reported a mediocre level of familiarity with OT while also rating 4.5/5 the importance of OT in hand surgery without significant difference between postgraduate year groups. 11/14 residents reported no formal training concerning the role of OT in hand surgery. 12/14 residents reported that it would be helpful to spend time with an occupational therapist. Conclusions This study revealed the lack of confidence residents expressed regarding occupational therapists' roles. All residents recognized the importance of OT in hand surgery and expressed interest in shadowing occupational therapists. Residents of all levels acknowledge the crucial partnership between orthopedists and occupational therapists but lack formal education about the therapist's scope and role.

Antecubital Burn Resulting From Antenna Coupling: A Case Report.

CASE: We present the case of a 54-year-old man who underwent elective hip disarticulation complicated by third-degree burn of the left antecubital fossa requiring skin graft. After careful review, it was determined that "antenna coupling" as a result of electrosurgery was the likely cause. We present an experiment demonstrating this phenomenon. CONCLUSION: Antenna coupling is a real but rare cause of intraoperative burns not previously described in the orthopaedic literature. Care should be taken to avoid coiling or running bovie or other electrosurgical device cords with other metallic cords or corded devices.

Extra-Articular Base Fractures of the Proximal Phalanx in Adults: A Systematic Review.

Background: Extra-articular proximal phalanx base fractures are common in adults and can lead to permanent finger stiffness and joint contractures. The purpose of this review is to summarise the evidence for operative and non-operative management of this fracture type. Methods: The MedLine, Embase, PubMed, Scopus and Cochrane Library databases were searched using the following key terms: 'proximal phalanx', 'base', 'fracture', 'repair' and 'fixation'. A total of 2,889 unique records were extracted. All studies with primary data on the management of extra-articular proximal phalangeal base fractures in adults were included for initial review. Results: Eleven studies met inclusion criteria with a total of 441 extra-articular proximal phalanx base fractures. Outcomes were determined by final total active range of motion. 182 extra-articular proximal phalangeal base fractures were treated non-operatively, with excellent or good outcomes attained in 80% of cases. Another 259 extra-articular proximal phalangeal base fractures were treated operatively, including 236 with Kirschner wires (K-wires), 18 with plates, and five with intramedullary screws. Case-level data were available in 186 fractures managed by K-wire fixation, with excellent or good outcomes achieved in 79% of cases. Excellent or good outcomes were achieved in 35% of cases treated by plates, and 80% of five cases treated by intramedullary screw fixation. Three (1.6%) patients managed conservatively required surgery after reduction loss. No patients managed with K-wires required re-operation for reduction loss; tenolysis/capsulotomy was required in 11 (4.5%) cases for stiffness, and pin site infections occurred in eight (3.5%) cases. Complex regional pain syndrome occurred in five cases (28%) of plate fixation. Conclusions: In summary, excellent or good results may be achieved by K-wire pinning or conservative management. Current evidence is limited for plate or intramedullary screw fixation. Prospective trials and outcomes standardisation are needed to improve the evidence base. Level of Evidence: Level III (Therapeutic).

Giant Cell Reparative Granuloma in the Thumb Distal Phalanx: A Case Report.

Giant cell reparative granulomas (GCRG) often affect the bones of the hands and the feet. Treatment of this lesion depends on the exact location and amount of localized bony destruction. Ours is the first case report to discuss the nuances of treating this lesion in the thumb distal phalanx. A 19-year-old male presented with lytic, destructive expansion of his left thumb distal phalanx; imaging was suggestive of an aneurysmal bone cyst. Open biopsy was interpreted as giant cell reparative granuloma. Curettage and bone grafting resulted in complete healing of the distal phalanx with an excellent range of motion and interphalangeal joint stability. GCRG is a rare, benign entity typically presenting as a lytic bone lesion. Despite the initial massive bony destruction, this lesion nevertheless healed with curettage and bone grafting with maintained flexor pollicis longus and extensor pollicis longus function, permitting excellent active motion postoperatively.

Percutaneous Fixation of Unstable Proximal Phalanx Fractures: A Biomechanical Study.

BACKGROUND: Unstable extra-articular proximal phalanx fractures are common injuries to the hand that are often treated by closed reduction and percutaneous pinning. Fracture-induced shortening of the proximal phalanx leads to an extensor lag at the proximal interphalangeal joint. We describe a biomechanical study in cadaver hands to compare the ability of each of three different pin configurations to resist shortening in unstable fractures. METHODS: Seventeen fresh frozen hands were disarticulated at the proximal ends of the metacarpals. The second, third, and fourth proximal phalanges were tested. A 5-mm section of bone was resected from the mid-shaft of proximal phalanx to simulate an unstable fracture. Three techniques were employed and randomized for each finger: transmetacarpophalangeal joint pinning using 1 or 2 Kirschner wires (K-wires) and periarticular cross pinning using 2 K-wires. Compressive axial loads and energy at 1 mm, 2 mm, 3 mm, 4 mm, and 5 mm of subsidence were examined. RESULTS: The forces and energy required to shorten the finger for each amount of subsidence were similar for all 3 pinning techniques and for all 3 finger types. Greater amounts of shortening were found to require larger forces. CONCLUSION: Closed reduction and percutaneous pinning using any of the presented techniques is an adequate method of treatment for unstable proximal phalanx fractures. All of the techniques were equivalent in their ability to resist axial loading, regardless of the complexity of technique, the number of pins used, or finger that was pinned.

Recurrence Rates of Dorsal Wrist Ganglion Cysts After Arthroscopic Versus Open Surgical Excision: A Retrospective Comparison.

BACKGROUND: This study directly compares the recurrence rates of dorsal wrist ganglion cysts in patients treated via open surgical excision versus arthroscopic surgical excision. We hypothesized that there would be no difference between recurrence rates with these 2 surgical options. METHODS: We retrospectively reviewed the charts of all patients with a dorsal ganglion cyst undergoing either open or arthroscopic surgical excision at a single academic center with 3 fellowship-trained attending hand surgeons from 2012 to 2017. Charts were identified using Current Procedural Terminology codes and were reviewed using postoperative office notes for preoperative and postoperative symptoms, episodes of recurrence, time at which recurrence occurred, subsequent operations, and outcome at final follow-up. RESULTS: The charts of 172 patients undergoing either arthroscopic or open dorsal ganglion excision were reviewed. Nine of 54 (16.7%) arthroscopic excisions resulted in cyst recurrence, while 8 of 118 (6.8%) open excisions resulted in cyst recurrence (P = .044). Two of 9 (22%) recurrences after arthroscopic ganglion excision versus 2 of 8 (25%) recurrences after open ganglion excision underwent repeat surgical intervention. Time to recurrence, as well as final follow-up, was not statistically different between groups. CONCLUSIONS: Dorsal wrist ganglion cysts are the most common benign soft tissue mass of the upper extremity, but it remains unknown whether arthroscopic or open surgical excision leads to lower recurrence rate. Scant literature exists directly comparing these 2 methods of surgical excision. This study suggests that open excision of dorsal wrist ganglia leads to a lower recurrence rate than does arthroscopic excision.

Flexor Tendon Zone II Repair.

Background: Flexor-tendon injury is a historically challenging problem for orthopaedic surgeons. Much research has been dedicated to finding solutions that offer balance in terms of the strength and ease of the repair versus the rate of complications such as adhesions. The number of core sutures, distance from the tendon edge, and use of an epitendinous stitch have been shown to affect repair strength1-4. A number of configurations have been described for the placement of the suture; however, none has been identified as a clear gold standard5. This article will highlight the preferred tendon repair technique of the senior author (R.J.S.), the Strickland repair with a simple running epitendinous stitch. Relevant anatomy, indications, operative technique, and postoperative management will be discussed. Description: The flexor tendon is typically accessed via extension of the laceration that caused the initial injury. After the neurovascular structures and pulleys are assessed, the tendon is cleaned and prepared for repair. A 3-0 braided nylon suture is utilized for the 4-core strand repair and placed in the Strickland fashion. A 5-0 polypropylene suture is then utilized for the simple running epitendinous stitch. Alternatives: Multiple alternative techniques have been described. These vary in the number of core strands, the repair configuration, the suture caliber, and the use of an epitendinous or other suture. Nonoperative treatment is typically reserved for partial flexor-tendon laceration, as complete tendon discontinuity will not heal and requires surgical intervention. Rationale: The 4-core strand configuration has been well established to increase the strength of the repair as compared with 2-core strand configurations, while also being easier to accomplish and with less suture burden than other techniques1. The presently described technique has excellent repair strength and can allow for early active range of motion, which is critical to reduce the risk of postoperative adhesions and stiffness. Expected Outcomes: Excellent outcomes have been demonstrated for primary flexor-tendon repair if performed soon after the injury1,2,6,7. Delayed repair may lead to adhesions and poor tendon healing8. Early postoperative rehabilitation is vital for success9. There are advocates for either active or passive protocols10-12. The protocol at our institution is to begin early active place-and-hold therapy at 3 to 5 days postoperatively, which has been shown in the literature to provide improved finger motion as compared with passive-motion therapy13-16.Important Tips:: The proximal end of the tendon may need to be retrieved via a separate incision if it is not accessible through the flexor-tendon sheath.The proximal end of the tendon may be held in place with a 25-gauge needle in order to best place sutures into both ends of the tendon.The epitendinous suture is run around the back wall before the core sutures are tied down, in order to prevent the tendon and repair from bunching up and becoming overly bulky.The entire A4 pulley and the distal A2 pulley can be divided for exposure if necessary.Up to 2 cm of the flexor-tendon sheath can be divided.If there are concomitant digital nerve injuries, repair these after the tendon, in order to avoid damaging the more delicate nerve repair while manipulating the tendon for repair.The most common major complications following tendon repair are formation of adhesions and rerupture. Acronyms and Abbreviations:: FDS = flexor digitorum superficialisFDP = flexor digitorum profundusMCP = metacarpophalangealPIP = proximal interphalangealDIP = distal interphalangeal.

Anatomic Risks with Overpenetration of the Volar Locking Plates' Proximal Holes.

Background Volar locking plate fixation (VLP) is commonly used to treat distal radius fractures (DRF). Risk of dorsal compartment injury with distal screw hole fixation has been studied; however, the risk with proximal screw hole fixation is not well studied. Purpose The goal of this study was to investigate the risk of dorsal structure injury from the screw holes proximal to the two distal rows. Methods Nine cadaveric forearms were used. After volar distal radius exposure, a long VLP was applied. Kirschner wires were placed through the most proximal holes into the dorsal compartments. The extensor structures penetrated were noted and tagged with hemoclips. The distance from the dorsal cortex to the structures was measured. Results The abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscle bodies were only penetrated; no tendons were penetrated. Proportion of muscle penetration increased with the more proximal screw holes. EPB was more likely to be penetrated distally and APL proximally; both were injured at holes 2 and 3. The extensors were 2 mm from the dorsal cortex of the radius on average; this did not decrease with compression of the forearm. Conclusions This is the first study to examine the anatomic risk of extensor structure injury with VLP proximal screw hole penetration. No extensor tendons were penetrated by these proximal screw holes; first dorsal compartment muscle bellies may be irritated with overpenetration. Our findings suggest that proximal VLP screws do not need to be downsized if they are not over 2 mm prominent.

Resorbable Nerve Wraps: Can They Be Overtightened?

BACKGROUND: Nerve wrapping has been advocated to minimize scarring and adhesion following neurorrhaphy or neurolysis. A wrap should provide an enclosure that is snug enough to protect and support the affected nerve without strangulating the nerve. The degree to which resorbable wraps should be ": tightened" around the nerve is largely subjective with scant literature on the subject. The purpose of this study was to evaluate the effects of tightly fitting resorbable nerve wraps around intact rat sciatic nerves. METHODS: Twenty-four Sprague-Dawley rats underwent exposure and circumferential measurement of the right sciatic nerve. Porcine-derived extracellular matrix (ECM) wraps were trimmed and sutured to enclose the nerve with a tight (same as that of the nerve, n = 8) or loose (2.5x that of the nerve, n = 8) circumference. Sham-surgery control animals (n = 8) had no wrap treatment. Functional outcome was recorded biweekly by sciatic functional index (SFI) with walking track analysis and electrical stimulation. Animals were sacrificed at 12 weeks for histologic analyses. RESULTS: No withdrawal response could be evoked in the tight-wrap group until week 9, while significant improvement in SFI first occurred between weeks 5 and 7. By week 12, the tight-wrap group required 60% more current compared with baseline stimulation to produce a withdrawal response. They recovered 81% of SFI baseline values but also demonstrated significantly greater intraneural collagen content (p < 0.001) and lower axon density (p < 0.05) than in the loose-wrap and sham groups. The loose-wrap group had comparable functional and histologic outcomes to the sham control group. CONCLUSION: Resorbable ECM nerve wraps applied tightly around intact rat sciatic nerves caused significant functional impairment and histological changes characteristic of acute nerve compression. Significant but incomplete functional recovery was achieved by the tight-wrap group after 12 weeks, but such recovery may not apply in humans.

Extensor Tendon Injury After Volar Locking Plating for Distal Radius Fractures: A Systematic Review.

Distal radius fractures are common orthopedic injuries. Treatment has varied historically, but volar locking plating currently predominates. Although flexor tendon injury is a well-studied complication of this operation, extensor tendon injury is less well studied. The purpose of this review is to search the literature and present the epidemiology, presentation, and treatment of this complication. The Cochrane, EMBASE, PubMed, and SCOPUS databases were searched for the terms "volar" + "radius" + ("plate" OR "plating") + "extensor." Ninety final studies were included for analysis in this review. The incidence of extensor tendon rupture varies from 0% to 12.5%; the extensor pollicis longus is most commonly ruptured. The presentation and management of extensor tendon injury after injury, intraoperatively, and postoperatively are summarized. Radiographic views are described to detect screw prominence and minimize intraoperative risk. Extensor tendon injury after volar locking plate for distal radius fractures is an uncommon injury with several risk factors including dorsal screw prominence and fracture fragments. Removal of hardware and tendon transfers or reconstruction may be necessary to prevent loss of extensor mechanism.

Ring finger metacarpal fracture iatrogenic rotation using an ulnar gutter splint: A cadaveric study.

STUDY DESIGN: Cohort cadaveric study. INTRODUCTION: Ring finger metacarpal fractures are often treated with ulnar gutter orthoses incorporating the ring and small fingers. Iatrogenic pronation of the distal metacarpal fragment may occur from overzealous orthotic "molding", resulting in a crossover deformity of the ring finger over the small finger. PURPOSE OF THE STUDY: The goal of this cadaveric study is to determine whether including the middle finger in an ulnar gutter orthotic could lessen the chances of iatrogenic ring finger metacarpal fracture rotation. METHODS: Transverse ring finger metacarpal shaft fractures were created in 24 cadaver hands. The ring and small fingers were then placed into an intrinsic plus position, simulating the application of an ulnar gutter orthotic. Weights of 2.5, 5, and 10 pounds were applied to the ring and small fingers to simulate iatrogenic-induced fracture pronation. The amount of rotational displacement at the fracture was measured, and the protocol was repeated, including the middle finger in the intrinsic plus position. Mann-Whitney-Wilcoxon test was used for statistical analysis. RESULTS: There was an increase in distal fragment rotation with increasing weight. Fracture displacement was greater with the 2-finger position than the 3-finger at all weight levels; this reached statistical significance at 10 lbs (2.8 vs 1.8 mm). CONCLUSIONS: Application of an ulnar gutter orthotic including only ring and small fingers can rotate the distal fragment of a ring finger metacarpal shaft fracture such that overlap could occur with the small finger. Including the middle finger in ulnar gutter splints will mitigate against the rotation of the ring finger metacarpal shaft fracture.

How Close Are the Volar Wrist Ligaments to the Distal Edge of the Pronator Quadratus? An Anatomical Study.

Background: This cadaveric study defines the interval distance between the proximal insertion of the volar wrist ligaments and the distal edge of the pronator quadratus on the distal radius. It is important to be aware of this distance during surgical dissection for placement of volar locking plates for wrist fractures. Disruption of the volar wrist ligament insertion may have adverse biomechanical consequences such as carpal instability, which can lead to pain and eventually wrist arthritis. Methods: Thirteen cadaveric wrists were dissected using the trans-flexor carpi radialis volar approach to identify relevant anatomy. The distance between the distal border of the pronator quadratus and the most proximal insertion of the volar wrist ligaments was measured. Results: The average distance between the pronator quadratus and the proximal insertion of the volar wrist ligaments was 5 mm, with a standard deviation of 2 mm. Conclusions: The volar wrist ligaments insert quite near the distal end of the pronator quadratus. Surgeons should be cognizant of the proximity of the volar wrist ligaments and be judicious with subperiosteal stripping of the distal fragment during volar plating procedures.

Flexor tenosynovectomy in carpal tunnel syndrome as a screening tool for early diagnosis of amyloidosis.

INTRODUCTION: Amyloidosis is a heterogeneous group of diseases that most often presents with advanced cardiac pathology. Another presentation of the disease can include symptoms consistent with carpal tunnel syndrome; however, the true incidence of amyloidosis in patients with carpal tunnel syndrome remains unclear. METHODS: We performed a retrospective chart review on all patients who underwent an open carpal tunnel release, with tenosynovium biopsy by a single surgeon between 01/2000 and 12/2018. Samples were stored in formalin following hematoxylin-eosin or congo red staining. A total of 199 patients were excluded for incomplete records, and carpal tunnel release performed for traumatic or infectious etiologies. Histologic findings of the attending pathologist were examined and categorized as follows: amyloidosis, fibrous tissue, tenosynovitis/inflammation edematous, benign tenosynovium, and gout. RESULTS: Exactly 898 open carpal tunnel releases were performed, and 699 patients were included for final analysis. In all patients, biopsies for histology with hematoxylin-eosin (HE) staining were taken; in those HE stains where amylogenic proteins were suspected (73 or 10.4%), a subsequent congo red staining was additionally performed which confirmed the diagnosis of amyloidosis in 10 patients (1.4% of the carpal tunnel procedures). Overall, 10 patients were identified and constituted 1.4% of all HE stains (n = 10/699) and 13.7% of all congo red stains (n = 10/73). CONCLUSION: Our results suggest that the incidence of amyloidosis in the general CTS patient population may be as high as 1.4% with routine screening by synovial biopsy and the diagnosis should be considered as a potential cause. Level of Evidence: III, retrospective study.

Is Grit Associated with Burnout and Well-being in Orthopaedic Resident and Faculty Physicians? A Multi-institution Longitudinal Study Across Training Levels.

BACKGROUND: Grit has been defined as "perseverance and passion for long-term goals" and is characterized by maintaining focus and motivation toward a challenging ambition despite setbacks. There are limited data on the impact of grit on burnout and psychologic well-being in orthopaedic surgery, as well as on which factors may be associated with these variables. QUESTIONS/PURPOSES: (1) Is grit inversely correlated with burnout in orthopaedic resident and faculty physicians? (2) Is grit positively correlated with psychologic well-being in orthopaedic resident and faculty physicians? (3) Which demographic characteristics are associated with grit in orthopaedic resident and faculty physicians? (4) Which demographic characteristics are associated with burnout and psychologic well-being in orthopaedic resident and faculty physicians? METHODS: This study was an institutional review board-approved interim analysis from the first year of a 5-year longitudinal study of grit, burnout, and psychologic well-being in order to assess baseline relationships between these variables before analyzing how they may change over time. Orthopaedic residents, fellows, and faculty from 14 academic medical centers were enrolled, and 30% (335 of 1129) responded. We analyzed for the potential of response bias and found no important differences between sites in low versus high response rates, nor between early and late responders. Participants completed an email-based survey consisting of the Duckworth Short Grit Scale, Maslach Burnout Inventory-Human Services (Medical Personnel) Survey, and Dupuy Psychological Well-being Index. The Short Grit Scale has been validated with regard to internal consistency, consensual and predictive validity, and test-retest stability. The Psychological Well-being Index has similarly been validated with regard to reliability, test-retest stability, and internal consistency, and the Maslach Burnout Inventory has been validated with regard to internal consistency, reliability, test-retest stability, and convergent validity. The survey also obtained basic demographic information such as survey participants' age, gender, race, ethnicity, marital status, current year of training or year in practice (as applicable), and region of practice. The studied population consisted of 166 faculty, 150 residents, and 19 fellows. Beyond the expected age differences between sub-populations, the fellow population had a higher proportion of women than the faculty and resident populations did. Pearson correlations and standardized ß coefficients were used to assess the relationships of grit, burnout, psychologic well-being, and continuous participant characteristics. RESULTS: We found moderate, negative relationships between grit and emotional exhaustion (r = -0.30; 95% CI -0.38 to -0.21; p < 0.001), depersonalization (r = -0.34; 95% CI -0.44 to -0.23; p < 0.001), and the overall burnout score (r = -0.39; 95% CI -0.48 to -0.31; p < 0.001). The results also showed a positive correlation between grit and personal accomplishment (r = 0.39; 95% CI 0.29 to 0.48; p < 0.001). We also found a moderate, positive relationship between grit and psychologic well-being (r = 0.39; 95% CI 0.30 to 0.49; p < 0.001). Orthopaedic surgeons with 21 years or more of practice had higher grit scores than physicians with 10 to 20 years of practice. Orthopaedic surgeons in practice for 21 years or more also had lower burnout scores than those in practice for 10 to 20 years. Married physicians had higher psychologic well-being than unmarried physicians did. CONCLUSION: Among orthopaedic residents, fellows, and faculty, grit is inversely related to burnout, with lower scores for emotional exhaustion and depersonalization and higher scores for personal accomplishment as grit increases. CLINICAL RELEVANCE: The results suggest that grit could be targeted as an intervention for reducing burnout and promoting psychologic well-being among orthopaedic surgeons. Other research has suggested that grit is influenced by internal characteristics, life experiences, and the external environment, suggesting that there is potential to increase one's grit. Residency programs and faculty development initiatives might consider measuring grit to assess for the risk of burnout, as well as offering curricula or training to promote this psychologic characteristic.

Top Tips for an Orthopaedic Surgeon's Practice.

As orthopaedic surgeons become more specialized, it is important that they remain up to date in the diagnosis and management of common orthopaedic problems. These can include conditions encountered in the clinic and/or on call. It is important that practicing surgeons stay abreast of recognition and management of problems, not only for the patients, but also to avoid commonly missed conditions or less-than-optimal treatment. The orthopaedic surgeon should be aware of the top tips in multiple disciplines, including orthopaedic oncology, hand, and trauma.

Prospective Analysis of Hand Infection Rates in Elective Soft Tissue Procedures of the Hand: The Role of Preoperative Antibiotics.

Background: The purpose of this study was to evaluate the efficacy of prophylactic antimicrobial prophylaxis in elective hand surgery in preventing postoperative infection. Methods: Between 2009 and 2012, we performed a multicenter trial in which patients undergoing elective hand surgeries were categorized into an antibiotic or control group depending on the center they were enrolled in. Surgical site infections were defined according to the Centers for Diseases Control and Prevention. Results: In total, 434 patients were included: 257 did not receive antibiotics (control) and 177 received antibiotics at a mean age of 61.0 years. In the control group, comorbidities were more common with 23.7% (61/257) in comparison to the antibiotics group with 14.1% (25/177). Only one surgical site infection in each group was identified. One wound was opened surgically, and an antimicrobial treatment was indicated in both cases. In addition, we observed four complications in the control group and three complications in the antibiotics group which required conservative management. No significant differences in the two cohorts in infection rate (0.006% vs 0.003%, χ2 = 0.07, P > .05) and complication rate (2.8% vs 1.6%, χ2 = 0.01, P > .05) were found. Conclusions: Our prospective multicenter trial showed no significant difference in infection rate in elective hand surgery whether antibiotics were administered preoperatively or not.

The Benefits of Expert Instruction in Microsurgery Courses.

BACKGROUND: Microsurgery requires repeated practice and training to achieve proficiency, and there are a variety of curriculums available. This study aims to determine the importance of an expert instructor to guide students through procedures. We compared student proficiency across two microsurgery courses: one with (Columbia University, United States [CU] cohort) and one without a dedicated microsurgery instructor (University of Thessaloniki, Greece [UT] cohort). METHODS: Students were divided into two cohorts of 22 students (UT cohort) and 25 students (CU cohort). Student progress was evaluated by examining patency (lift-up and milking tests), anastomotic timing, and quality (Anastomosis Lapse Index [ALI]) of end-to-end arterial and venous anastomoses on day 1 and again on day 5. Chi-squared tests evaluated patency immediately and 30 minutes postoperation. t-Tests evaluated anastomotic timing and ALI scores. p-Values < 0.05 were considered significant. RESULTS: We evaluated progress within and between each cohort. Within the CU cohort, the quality of the arterial and venous anastomosis improved, respectively (by 54%, p = 0.0059 and by 43%, p = 0.0027), the patency of both the arterial and venous anastomosis improved, respectively (by 44%, p = 0.0002 and by 40%, p = 0.0019), and timing of arterial and venous anastomosis reduced respectively (by 36%, p = 0.0002 and by 33%, p = 0.0010). The UT cohort improved the quality of their arterial anastomoses (by 29%, p = 0.0312). The UT cohort did not demonstrate significant improvement in the other above-mentioned parameters. The CU cohort improved materially over the UT cohort across categories of quality, patency, and timing. CONCLUSION: There are clear benefits of an expert instructor when examining the rate of progress and proficiency level attained at the conclusion of the course. We suggest students who are seeking to maximize proficiency in microsurgical procedures enroll in courses with an expert instructor.

Isolated Radial Nerve Palsy After Glenohumeral Dislocation in a Collegiate Athlete: A Review of the Literature.

Isolated mononeuropathies are uncommon complications after shoulder dislocations. Of these, injuries to the radial nerve are the rarest. Here, we present a case of an isolated radial nerve palsy after a collegiate athlete was hit during a football game and sustained a glenohumeral dislocation. After reduction of the shoulder, he went on to full recovery of motor and sensory function of the radial nerve 1 year after the injury. This case report is further unique given the long-term follow-up in a young, active patient. We review the sparse literature behind the epidemiology and management of these complications.

Thumb Disability Examination (TDX) as a New Reliable Tool for Basal Joint Arthritis.

Background The general assessment of basal joint arthritis (BJA) is limited using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. This has been shown to be insensitive to pain and disability levels, leading to the development and validation of the thumb disability examination (TDX) as a specific tool for BJA in 2014. Objective The goal of this study was to evaluate the reliability, sensitivity, and specificity of the TDX score for BJA. Methods A multicenter BJA database was established in 2007 to collect prospective data. We evaluated the correlation between the TDX score, visual analog pain scale with activity (A-VAS), Eaton-Littler score, and grip strength using a Pearson test. Additionally, we evaluated the pre- and postintervention scores to assess their predictive values. Results A total of 109 thumbs of 74 patients with TDX scores were evaluated. Females were more commonly affected (75.2%), and the mean age was 65.39 years (standard deviation: 10.04). The majority of participants were white (90.8%). A high correlation between TDX and A-VAS score (Pearson's correlation = 0.520; p < 0.001) and between grip strength (Pearson's correlation = -0.336; p < 0.005) and Eaton-Littler score (Pearson's correlation = 0.353' p < 0.01) was identified. Additionally, when comparing pre- and post-intervention for all treatment groups and for operative intervention, significant differences in TDX scores were observed (both p ≤ 0.01). No significant differences could be identified for DASH score or A-VAS when assessing these same groups. Conclusion The TDX score correlates to high Pearson's correlation values and p -values, especially in grip strength, Eaton-Littler score, A-VAS score, and pre-/postintervention for all treatment groups combined and when specifically assessing the surgical intervention group. As a result, it can be concluded that the TDX score is a specific tool for the assessment of BJA. Level of Evidence This is a Level II, prospective comparative study.

Torsion is Tolerated in Arterial End to Venous Side Anastomoses in the Rat Model.

BACKGROUND: End-to-side (ETS) anastomoses are necessary for many procedures in microvascular surgery, such as free flap transfers. In training courses that use the rat model, the arterial end to venous side (AEVS) anastomosis is a common training exercise for ETS anastomoses. Surgeons-in-training often inadvertently twist the artery when completing the AEVS anastomosis; however, in the clinical setting, torsion is a reported risk factor for ETS anastomosis failure. The purpose of this study was to determine if torsion in an AEVS anastomosis would have a negative effect on patency in the rat model, accurately simulating the clinical scenario. METHODS: All AEVS anastomoses were completed in 15 Sprague-Dawley rats divided into three torsion cohorts: 0, 90, and 180 degrees. Torsion was created in the AEVS anastomosis by mismatching the first two sutures placed between the free femoral artery end and the venotomy. Patency was verified at 0, 2, and 4 hours postoperation via the oxygenated-deoxygenated test and transit-time ultrasound blood flow measurements. RESULTS: All AEVS anastomoses were patent 0, 2, and 4 hours postoperation according to both the oxygenated-deoxygenated test and transit-time ultrasound blood flow measurements. For the average blood flow measurements at 4 hours postoperation, the proximal measurements for 0, 90, and 180 degrees were -34.3, -18.7, and -13.8 mL/min respectively, and the distal measurements were 4.48, 3.46, and 2.90 mL/min, respectively. CONCLUSION: Torsion of 180 degrees does not affect early AEVS anastomosis patency in the rat model. This contrasts with the clinical setting, where torsion is reported to cause ETS anastomosis failure. Since AEVS anastomosis torsion is often difficult to appreciate visually, we suggested that microvascular surgery training instructors include a method to both detect and prevent AEVS anastomosis torsion, such as by marking the free femoral artery end with a marking pen or suture before beginning the anastomosis.