Retired Orthopedic Surgeons' Reflections on Their Lives and Careers: A Cross-Sectional Study.

Background: Retired surgeons often have limited opportunities to disseminate their wisdom and expertise in a structured manner to their younger colleagues. In addition, when asked to reflect on their personal and professional lives, many physicians say they wish they had done something differently. The extent to which this is true of retired orthopedic surgeons is not known. Purpose: We sought to determine the percentage of retired orthopedic surgeons who say that they would like to have changed something in their life/career and delineate the most commonly desired changes. Methods: We conducted a cross-sectional study of retired orthopedic surgeons, by emailing a Qualtrics survey to 5864 emeritus members of the American Academy of Orthopaedic Surgeons (AAOS), with 1 initial email invitation in April 2021 followed by 2 reminders in May 2021. The survey employed a branching logic, with up to 16 questions designed to determine whether they would have done anything differently in their life/career. Results: The survey was completed by 1165 of 5864 emeritus AAOS members, for a response rate of nearly 20%. The 3 most represented surgical subspecialties were general orthopedics, adult reconstruction, and hand and upper extremity surgery. Respondents' average age was 74.9 years and age at retirement was 67.8 years; nearly half worked part-time before retiring. More than 80% of the participants said that they had retired at the appropriate time, and 28.5% said they wished they had done something differently. The wished-for changes most often noted were spending more time with family, spending more time on personal wellness, and selecting better practice partners. Conclusion: The results of our survey of retired orthopedic surgeons show that while most were satisfied with their lives and careers, some had regrets. These findings suggest that there may be factors in the work lives of current surgeons that could be altered to reduce regret. Further study is warranted.

Transfer of the coracoid and conjoined tendon for failed, unstable, short clavicle following excessive outer clavicle resection.

Nineteen patients presented with an unsightly deformity of the shoulder, pain or discomfort at the medial scapular border, pseudo nonparalytic scapular winging, and thoracic outlet symptoms after excessive resection of the clavicle for either complete acromioclavicular separation or displaced fracture of the outer clavicle, which allows the scapula and shoulder to rotate anteriorly and inferiorly on the chest creating traction on the medial scapular muscles and the brachial plexus resulting in pseudo nonparalytic winging and thoracic outlet symptoms. RESULTS: All underwent transfer of the coracoid process with the attached conjoined tendon to the end of the clavicle, restoring length and alignment. Eighteen patients were evaluated at a mean of 13.3 years. Seventeen had resolution of symptoms, restored alignment of the clavicle with the shoulder, improved appearance, healed transfer, and were pleased with the outcome. One patient was lost to follow-up but was considered a failure at his last visit. In a second patient, the transfer healed in a tilted position and the patient was dissatisfied with the appearance but otherwise had resolution of his symptoms. The mean American Shoulder and Elbow Surgeons Outcome Score improved from 53.2 preoperatively to 87.4 postoperatively (P < .02). CONCLUSION: This is the first report of using this transfer to restore length and alignment of an excessively short, unstable clavicle. The transfer succeeded in improving the appearance and symptoms in this complication of an excessively short, unstable clavicle.

The Influence of Exposure in Training to the Open Bankart on the Declining Current Use of the Procedure.

OBJECTIVE: The purpose of this study was to assess the influence of exposure to the open Bankart during residency and fellowship on the trend toward obsolescence of the procedure. Our hypothesis was that the open Bankart would be used with decreasing frequency and that this would be related to lack of exposure to the procedure during training. METHODS: A survey consisting of 10 questions about their experience with the open Bankart procedure in residency, fellowship, and practice, as well as their current usage of it and other operations, was sent to members of the American Shoulder and Elbow Surgeons. Respondents were divided into groups based on the year of completion of training. RESULTS: Statistical analysis of the responses revealed a notable trend of progressively diminished use of the open Bankart by those trained before 2000 compared with those completing training between 2001 and 2017. Ancillary findings included more surgeons using the open Bankart for revision cases than as a primary procedure and many using the Latarjet for patients with less than 15% or even no glenoid bone loss. CONCLUSION: We concluded that a statistically notable trend of the decreasing use of the open Bankart was observed despite excellent reported outcomes and that its current role is most likely as a revision procedure. Lack of exposure to the operation in training is a major factor in its decline, and this decreasing exposure is self-perpetuating. LEVEL OF EVIDENCE: Survey.

Mid-term to long-term outcome of the open Bankart repair for recurrent traumatic anterior dislocation of the shoulder.

BACKGROUND: The purpose of this study was to assess the long-term outcome of the open Bankart repair for traumatic, recurrent anterior dislocation of the shoulder by evaluation of recurrence, range of motion, return to sports, arthritis, patient satisfaction, and outcome measures. METHODS: Of 162 patients, 127 patients (mean age, 31 years) were evaluated at a mean follow-up of 17.1 years (5-24) after undergoing an open Bankart repair using suture anchors. An independent orthopedic surgeon obtained a history and examined each for range of motion. Radiographs for arthritis and osteolysis were obtained unless the patient refused. Questionnaires including return to sports and function as well as satisfaction and outcome measures were completed by all patients. RESULTS: There was 1 recurrent dislocation (0.8%) and 1 recurrent subluxation (0.8%) but no pain or apprehension. All remaining shoulders were stable. Compared with the normal shoulder, there was statistical difference in external rotation in abduction and at the side as well as in internal rotation but not in forward elevation or abduction. However, no patient considered any measurable loss functionally significant. Of 107 patients who participated in sports, 98 returned to the sport; 7 of the remaining 9 discontinued for reasons other than the shoulder. There were 91 patients who agreed to radiography; 48 had normal findings, 34 had mild arthrosis, 9 had moderate arthrosis, and none had severe arthrosis. Mean postoperative outcome scores were as follows: American Shoulder and Elbow Surgeons, 93.53; Rowe, 91.41; and Western Ontario Shoulder Instability Index, 327.7. There were 125 patients who were satisfied and would undergo the procedure again. CONCLUSION: The open Bankart procedure remains the standard by which other techniques can be measured for treatment of recurrent, traumatic anterior dislocation of the shoulder.

Identifying the Risk of Swallowing-Related Pulmonary Complications in Older Patients With Hip Fracture.

To identify and potentially modify the risk of pulmonary complications in a group of older patients with hip fracture, the authors obtained speech and language pathology consultations for these patients. Then they performed a retrospective chart review of all patients 65 years and older who were admitted to their institution between June 2011 and July 2013 with acute hip fracture, were treated surgically, and had a speech and language pathology evaluation in the immediate perioperative period. The authors identified 52 patients who met the study criteria. According to the American Society of Anesthesiologists (ASA) classification system, at the time of surgery, 1 patient (2%) was classified as ASA I, 12 patients (23%) were ASA II, 26 (50%) were ASA III, and 12 (23%) were ASA IV. Based on a speech and language pathology evaluation, 22 patients (42%) were diagnosed with dysphagia. Statistical analysis showed that ASA III status and ASA IV status were meaningful predictors of dysphagia and that dysphagia itself was a strong risk factor for pulmonary aspiration, pneumonia, and aspiration pneumonitis. Evaluation by a speech and language pathologist, particularly of patients classified as ASA III or ASA IV, may be an efficient means of averting pulmonary morbidity that is common in older patients with hip fracture.

Classification of proximal humeral fractures based on a pathomorphologic analysis.

BACKGROUND: The purpose of this study was to analyze the pathomorphology of proximal humeral fractures to determine relevant and reliable parameters for fracture classification. METHODS: A total of 100 consecutive acute proximal humeral fractures in adult patients were analyzed by 2 non-independent observers from a single shoulder department using a standardized protocol based on biplane radiographs and 3-dimensional computed tomography scans. A fracture classification system based on the most reliable key features of the pathomorphologic analysis was created, and its reliability was tested by 6 independent shoulder experts analyzing another 100 consecutive proximal humeral fractures. RESULTS: The head position in relation to the shaft (varus, valgus, sagittal deformity) and the presence of tuberosity fractures showed a higher interobserver reliability (κ > 0.8) than measurements for medial hinge, shaft, and tuberosity displacement, metaphyseal extension, fracture impaction, as well as head-split component identification (κ < 0.7). These findings were used to classify nondisplaced proximal humeral fractures as type 1, fractures with normal coronal head position but sagittal deformity as type 2, valgus fractures as type 3, varus fractures as type 4, and fracture dislocations as type 5. The fracture type was further combined with the fractured main fragments (G for greater tuberosity, L for lesser). Interobserver and intraobserver reliability analysis for the fracture classification revealed a κ value (95% confidence interval) of 0.700 (0.631-0.767) and 0.917 (0.879-0.943), respectively. CONCLUSION: The new classification system with emphasis on the qualitative aspects of proximal humeral fractures showed high reliability when based on a standardized imaging protocol including computed tomography scans.

Proximal humeral fractures: pin, plate, or replace.

Proximal humeral fractures are becoming increasingly common in individuals older than 60 years, with only fractures of the hip and distal radius occurring with a higher frequency. Most proximal humeral fractures can be managed without surgery; however, if a fracture is displaced or angulated, surgical treatment may be required. There are four main options for the surgical management of proximal humeral fractures: minimally invasive percutaneous reduction and fixation, open reduction and periarticular plating, hemiarthroplasty, and reverse total shoulder arthroplasty.

Open Bankart repair for revision of failed prior stabilization: outcome analysis at a mean of more than 10 years.

BACKGROUND: The purpose of this study was to analyze the outcome of open Bankart repair for failed stabilization surgery at a mean follow-up of >10 years. MATERIALS AND METHODS: Thirty patients underwent revision open Bankart repair by a single surgeon for failed prior stabilization surgery, with a standard technique and postoperative rehabilitation. All patients were referred by other surgeons. Evaluation was by an independent examiner, at a mean follow-up of 10.2 years. Evaluation included a history, physical examination for range of motion, outcome scores, recurrence, return to athletics, and radiographic examination. RESULTS: All cases had persistent Bankart and Hill-Sachs lesions. Failures included 14 patients with a failed single arthroscopic Bankart repair; 1 patient with 2 failed arthroscopic Bankart repairs; 1 patient with an arthroscopic failure and an open Bankart repair; 7 patients with failed open Bankart repairs; and 1 patient with a failed open Bankart repair, then a failed arthroscopic attempt. Two patients had had thermal capsulorrhaphy; 2 others had staple capsulorrhaphy, 1 with an open capsular shift and 1 after a failed arthroscopic Bankart repair, an open Bankart repair, and then a coracoid transfer. All arthroscopic Bankart repairs had anchors placed medial and superior on the glenoid neck. Mean motion loss compared with the normal contralateral side was as follows: elevation 1.15°, abduction 4.2°, external rotation at the side 3.2°, external rotation in abduction 5.1°, and internal rotation 0.6 vertebral levels (NS). No patient had an apprehension sign, pain, or instability. Of 23 who played sports, 22 resumed after. Outcomes scores were as follows: American Shoulder and Elbow Surgeons, 89.44; Rowe, 86.67; Western Ontario Shoulder Instability Index, 476.26. On radiographic examination, there were 13 normal radiographs and 7 with mild, 2 with moderate, and 0 with severe arthritic changes. CONCLUSION: The open Bankart repair offers a reliable, consistently successful option for revision of failed stabilizations.

Management of adult diaphyseal both-bone forearm fractures.

Simultaneous diaphyseal fractures of the radius and ulna, often referred to as both-bone forearm fractures, are frequently encountered by orthopaedic surgeons. Adults with this injury are typically treated with open reduction and internal fixation because of the propensity for malunion of the radius and ulna and the resulting loss of forearm rotation. Large case series support the use of plate and screw fixation for simple fractures. More complex fractures are managed according to strain theory, with the intention of controlling rather than eliminating motion at the fracture site. This can be achieved with flexible plate and screw constructs or intramedullary nails. In general, results of surgical fixation have been good, with only modest losses of forearm strength and rotation. Notable complications include nonunion, malunion, and refracture after device removal.

Adhesive capsulitis of the shoulder.

Adhesive capsulitis is characterized by painful, gradual loss of active and passive shoulder motion resulting from fibrosis and contracture of the joint capsule. Other shoulder pathology can produce a similar clinical picture, however, and must be considered. Management is based on the underlying cause of pain and stiffness, and determination of the etiology is essential. Subtle clues in the history and physical examination can help differentiate adhesive capsulitis from other conditions that cause a stiff, painful shoulder. The natural history of adhesive capsulitis is a matter of controversy. Management of true capsular restriction of motion (ie, true adhesive capsulitis) begins with gentle, progressive stretching exercises. Most patients improve with nonsurgical treatment. Indications for surgery should be individualized. Failure to obtain symptomatic improvement and continued functional disability following ≥6 months of physical therapy is a general guideline for surgical intervention. Diligent postoperative therapy to maintain motion is required to minimize recurrence of adhesive capsulitis.

Proximal periarticular locking plates in proximal humeral fractures: functional outcomes.

BACKGROUND: Some recent studies have asserted that locking plates do not provide adequate fixation of proximal humeral fractures. The purpose of this study is to review our experience with proximal humeral locking plates, including complications, functional outcomes, and predictors of successful treatment. MATERIALS AND METHODS: At our institution, 45 patients (46 shoulders) with displaced proximal humeral fractures were treated with a proximal humeral locking plate over a 6-year period. Patients underwent standard surgical and rehabilitation protocols and were evaluated clinically with Disabilities of the Arm, Shoulder and Hand and American Shoulder and Elbow Surgeons standardized outcome measurements and range of motion at last follow-up. Radiographs obtained preoperatively, immediately postoperatively, and at final follow-up were evaluated for fracture type, union, and change in alignment. RESULTS: There were 43 patients (44 shoulders) available for range-of-motion and functional outcome measures with an average follow-up of 34 months. Fracture types included 19 two-part, 21 three-part, 3 four-part, and 1 head-splitting fracture. The mean Disabilities of the Arm, Shoulder and Hand score was 11. The average American Shoulder and Elbow Surgeons score was 85. The average visual analog pain score was 0.8. The average range of motion was as follows: elevation, 140°; external rotation at side, 49°; external rotation in abduction, 77°; and internal rotation, T11. No patient had evidence of screw cutout, varus collapse, or avascular necrosis. One patient required hardware removal. CONCLUSIONS: Displaced proximal humeral fractures can be successfully fixed with locking plates when attention is paid to anatomic reduction, proper plate placement below to the greater tuberosity to allow abduction, screws in the head with subchondral bone purchase, calcar screws from inferior-lateral to superior-medial and delaying shoulder motion until at least 2 weeks.

Mini-open rotator cuff repair does not result in intractable stiffness.

We conducted a study to determine whether intractable postoperative stiffness or deltoid damage results from primary arthroscopic anterior acromioplasty and mini-open repair of full-thickness tears of the superior rotator cuff. Eighty-three repairs (80 patients) were available for follow-up at a mean (range) of 57.2 (12-98) months. Range of motion at presentation and motion in contralateral shoulder at final follow-up were used for comparison. Significant improvements were seen in active forward elevation, passive forward elevation, and active external rotation at 90° abduction. Final motion in the operative and contralateral shoulders was similar. American Shoulder and Elbow Surgeons shoulder index improved significantly (P<.0001) from 50.0 before surgery to 88.3 after surgery. Although 1 patient had a symptomatic retear that required revision surgery, there were no cases of intractable stiffness, and there were no cases of deltoid damage.

Reliability and accuracy of templating the proximal humeral component for shoulder arthroplasty.

BACKGROUND: The purpose of this paper is to examine the intra-observer and inter-observer reliability of preoperative templating to help determine its usefulness for approximating proximal humeral stem and head size in shoulder arthroplasty. METHODS: Thirty-one nonconsecutive patients underwent uncemented total shoulder arthroplasty using 1 of 2 commonly used prostheses. Templating was performed by 4 independent observers (2 experienced shoulder surgeons and 2 PGY-3 residents). Two readings were performed with a minimum 2-week interval between templating sessions. Templating was performed in a blinded manner using appropriately magnified templates provided by the prosthesis manufacturer. Postoperative radiographs were analyzed in the same fashion and each observer graded qualitative stem and head size radiographically. Pre-operative templated sizes were compared to actual implant sizes obtained from dictated operative reports. RESULTS: There was substantial (kappa > 0.7) intraobserver reliability for stem and head size selection for both prostheses. Interobserver reliability was moderate for stem size (kappa = 0.53) and substantial (kappa = 0.66) for head size. Preoperative templating accurately predicted stem (84-95%) and head (44-66%) size within 1 size variation (stem width, head thickness, or diameter) for shoulder replacement surgery. There was no significant difference in accuracy between attendings and residents when templating for stem or head size. CONCLUSION: Preoperative templating is a reliable and reasonably accurate step when planning shoulder replacement surgery. Templating for stem size is more accurate than for head size.

Subscapularis function after primary tendon to tendon repair in patients after replacement arthroplasty of the shoulder.

HYPOTHESIS: We studied the results of tendon-to-tendon repair of the subscapularis during total shoulder arthroplasty (TSA) to compare its clinical results relative to more recent studies looking at osteotomy of the lesser tuberosity. MATERIALS AND METHODS: This study analyzed the postoperative integrity of the subscapularis by a tendon-to-tendon repair in 45 arthroplasties in 43 patients. RESULTS: Preoperatively, 23 patients had a negative lift-off test; 22 could not perform the test. Postoperatively, 41 patients had a negative lift-off test; four could not reach behind themselves to do the test. All 45 shoulders had a negative belly-press test pre-operatively and post-operatively. DISCUSSION: Tendon-to-tendon repair is simpler, quicker, and avoids the possibility of an osteotomy nonunion. Tendon-to-tendon repair of the subscapularis tenotomy in shoulder arthroplasty remains an option in the presence of reasonable quality tendon, utilizing relaxing sutures (partial closure of the lateral rotator interval), and limiting early postoperative passive external rotation. LEVEL OF EVIDENCE: Level 4; Retrospective case series, no control group.

Outcome of latissimus dorsi transfer as a salvage procedure for failed rotator cuff repair with loss of elevation.

Eighteen patients, referred from an outside institution with massive, irreparable rotator cuff tears and loss of elevation, were treated with a latissimus dorsi tendon transfer as a salvage procedure for failed, prior, attempted rotator cuff repair. Clinical outcomes were measured by the American Shoulder and Elbow Surgeon's (ASES) score, pain level, and active range of motion. The average postoperative ASES score was 61, an increase from 43 pre-operatively (P = .05). Active elevation improved to an average of 137 degrees compared to 56 degrees pre-operatively (P < .001). The average post-operative pain level was 22 mm, down from 59 (P = .001), and the average post-operative active external rotation at the side was 45 degrees, improved from 31 degrees (P < .001). We conclude that latissimus transfer, as a salvage procedure for failed rotator cuff repair with loss of elevation, allows for significant return of active elevation and function with minimal post-operative pain.