A Survey of Burnout Among Members of the American Society for Surgery of the Hand.

PURPOSE: Physician burnout affects approximately half of US physicians, significantly higher than the general working population. The aims of this study were to determine the prevalence of burnout specifically among hand surgeons and to identify factors unique to the practice of hand surgery that may contribute to burnout. METHODS: A Web-based survey, developed in conjunction with the American Medical Association, was administered to all active and lifetime members of the American Society for Surgery of the Hand using the Mini Z Burnout assessment tool. Additional data were collected regarding physician demographics and practice characteristics. RESULTS: The final cohort included 595 US hand surgeons (American Society for Surgery of the Hand [ASSH] members) and demonstrated that 77% of respondents were satisfied with their job, although 49% regarded themselves as having burnout. Lower burnout rates were correlated with physicians aged older than 65, those who practice in an outpatient setting, practice hand surgery only, visit one facility per week, having a lower commute time, those who performed 10 or fewer surgeries per month, and being considered grandfathered for Maintenance of Certification. It was shown that sex, the use of physician extenders, compensation level, and travel club involvement had no impact on burnout rates. CONCLUSIONS: The survey demonstrated that nearly half of US hand surgeons experience burnout even though most are satisfied with their jobs. There is a need to increase awareness and promote targeted interventions to reduce burnout, such as creating a strong team culture, improving resiliency, and enhancing leadership. CLINICAL RELEVANCE: Burnout has been shown to affect physicians, their families, patient care, and the health care system as a whole negatively. The findings should promote awareness among hand surgeons and inform future quality improvement efforts targeted at reducing burnout for hand surgeons.

Misdiagnosis and Radial Tunnel Syndrome: Considering the Distal Biceps Tendon.

Radial tunnel syndrome (RTS) has long been a difficult therapeutic and diagnostic entity for upper extremity surgeons. The presentation is vague and the diagnosis is typically one of exclusion. Multiple clinical entities are known to mimic RTS, but little attention has been paid to the distal biceps. Experience suggests that insertional biceps tendonitis is a potential confounding diagnosis in suspected RTS and that magnetic resonance imaging (MRI) may be of diagnostic benefit in chronic cases before surgical intervention is undertaken. This study is a 13-patient case series. The included patients presented with proximal forearm pain and positive provocative maneuvers for RTS. All included patients were found to have distal biceps pathology on MRI evaluation. At final follow-up (average 6.9 years), all patients had resolution of symptoms with therapy aimed specifically at addressing the distal biceps tendon. A diagnosis of insertional biceps tendonitis could explain both the typical success with conservative treatment and the poor results from surgical intervention for RTS. (Journal of Surgical Orthopaedic Advances 28(1):35-40, 2019).

Isolated loss of active external rotation: a distinct entity and results of L'Episcopo tendon transfer.

BACKGROUND: The purpose of this study was to characterize a subgroup of cuff-deficient patients with isolated loss of active external rotation (ILER) but preserved active elevation and to evaluate the outcomes of the L'Episcopo procedure to restore horizontal muscle balance. METHODS: During a 10-year period, 26 patients (14 men, 12 women) were identified with ILER in the setting of massive irreparable posterosuperior cuff tears. A modified L'Episcopo tendon transfer was performed to restore active external rotation and to improve shoulder function. The mean age at surgery was 64.5 years (29-83 years). Patients were evaluated with a mean follow-up of 52 months (range, 24-104 months). RESULTS: Preoperatively, despite maintained active elevation (average of 161°), ILER patients complained about loss of spatial control of the arm and difficulties with activities of daily living. On computed tomography scan or magnetic resonance imaging, there was severe fatty infiltration of infraspinatus and absent or atrophic teres minor. After L'Episcopo transfer, 84% of patients were satisfied. The gain in active external rotation was +26° in arm at the side and +18.5° in 90° abduction. Adjusted Constant score and Simple Shoulder Value increased from 63.6% to 86.9% and from 36.9% to 70.8%, respectively (P < .001). The ADLER score increased from 10 to 24.5 points (P < .002). Two patients with advanced cuff tear arthropathy (Hamada stage 3 and 4) required conversion to a reverse shoulder arthroplasty (RSA) 7 and 9 years after the index surgery. CONCLUSIONS: ILER is a distinct entity that is a cause of severe handicap because of loss of spatial control of the upper limb. This symptom is related to absent or atrophied infraspinatus and teres minor. In properly selected cases (Hamada stage 1 or 2), the modified L'Episcopo transfer is effective at restoring anterior-posterior rotator cuff force balance. In more advanced cuff tear arthropathy (Hamada stage ≥3), the tendon transfer should be performed with an RSA because of possible secondary degeneration of the glenohumeral joint.

Massive irreparable rotator cuff tears: how to rebalance the cuff-deficient shoulder.

In its natural state, the shoulder is unbalanced in both the vertical and horizontal planes because the deltoid is stronger than the rotator cuff muscles and the internal rotator muscles are stronger than the external rotator muscles. With aging, this muscle imbalance can become worse, leading to tendon wear, irreversible fatty infiltration of the rotator cuff muscles, and upward migration of the humeral head. Most shoulders with tendon wear are functional and asymptomatic. A traumatic event (such as a fall onto the upper limb) can lead to rotator cuff tearing and a shoulder that becomes symptomatic and nonfunctional. Symptomatic massive irreparable rotator cuff tears present in one of four recognizable patterns depending on the muscular imbalance that occurs and the symptoms that are present: painful loss of active elevation, with conserved muscle balance; isolated loss of active elevation, with loss of vertical muscle balance; isolated loss of external rotation, with loss of horizontal muscle balance; and combined loss of elevation and external rotation, with loss of vertical and horizontal muscle balance. Assessing the plane of shoulder muscle imbalance is a key feature in the decision-making process. Classifying and understanding these tears allows surgeons to select the correct treatment (conservative measures, arthroscopic techniques, reverse shoulder arthroplasty, or tendon transfers) to restore shoulder balance and function.

Proximal interphalangeal joint injection through a volar approach: anatomic feasibility and cadaveric assessment of success.

PURPOSE: The proximal interphalangeal (PIP) joint is a challenging joint to access reliably for corticosteroid injection. Literature has confirmed both a relatively high failure rate for injections performed with the traditional dorsal approach and an improved clinical response rate for confirmed intra-articular injections. We describe a technique for injecting the PIP joint through a volar approach, assess its reliability through cadaveric dissection, and determine its reproducibility by comparing success rates with the dorsal approach in a cadaver model. METHODS: We dissected the PIP joint of 10 cadaveric digits to document necessary anatomic landmarks for this technique. We then used 20 matched pairs of cadaver hands for the remainder of our study. Four PIP joints on each hand (thumb excluded) were injected with a solution of saline and radio-opaque dye using the dorsal approach. We injected each joint on the contralateral matched hand through the volar approach. We obtained standardized fluoroscopic images of each joint immediately after injection, which were reviewed by an independent observer who was blinded to the technique and who rated outcomes as success, failure, or mixed. Success rates were evaluated based on approach used, digit injected, and degree of pre-existing arthritis. RESULTS: We found reproducible anatomic landmarks that justified our injection technique. The rates of absolute failure were similar in the 2 cohorts. The volar approach demonstrated a higher percentage of successful injections with a smaller percentage of mixed results, although results did not reach statistical significance. There was no statistically significant difference in success rates based on digit injected or grade of arthritis in either cohort. CONCLUSIONS: The volar approach to injecting the PIP joint demonstrated success similar to that of the traditional dorsal approach. Reproducible surface landmarks exist to guide practitioners using this technique. Further study is needed to determine the potential complications and clinical outcomes of the volar approach. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The clinical results of arthroscopic transtendinous repair of grade III partial articular-sided supraspinatus tendon tears.

PURPOSE: The purpose of this study was to evaluate the clinical results of arthroscopic transtendinous repair of deep partial articular-sided rotator cuff tears. METHODS: We retrospectively evaluated the results of 53 patients who underwent arthroscopic transtendinous repair for Ellman grade III articular-sided rotator cuff tears (>50% of the thickness of the rotator cuff). The intact bursal side of the cuff was not detached, and all associated pathology was treated. Fifty patients available for follow-up were evaluated with the American Shoulder and Elbow Surgeons (ASES) questionnaire. RESULTS: American Shoulder and Elbow Surgeons scores improved from a mean of 48.0 to 89.4 (+41.4) (P < .0001). Pain scores on a visual analog scale improved from 5.7 to 1.0 (P < .0001). Ninety-eight percent of patients were satisfied with the results of surgery. Results for the 50 patients available for follow-up were excellent in 32 (64%), good in 6 (12%), fair in 6 (12%), and poor in 6 (12%). Articular-sided rotator cuff tears rarely occurred in isolation but were typically found in association with coexisting pathology suggestive of the tears' etiology. Most common were impingement lesions, seen in 94% of patients, and instability lesions such as labral tears, seen in 30% of patients. Associated procedures included acromioplasty in 47, distal clavicle resection in 29, treatment of biceps pathology in 7, and instability repair in 15. One patient sustained a postoperative pulmonary embolism, which represented the only complication. Tears varied in size from 50% to 90% of the thickness of the cuff insertion. Significant differences were identified in the results of Workers' Compensation patients. Preoperative magnetic resonance imaging and magnetic resonance arthrography were accurate in identifying a partial-thickness rotator cuff tear in less than 40% of cases. CONCLUSIONS: Arthroscopic transtendinous repair of partial articular-sided rotator cuff tears is a safe and effective treatment that allows identification of commonly associated pathology and reliable improvement in pain and function. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Palmaris profundus tendon prohibiting endoscopic carpal tunnel release: case report.

Palmaris profundus is an aberrant muscle of forearm and wrist anatomy. It has no discernible function, but its tendon has been implicated as a cause of carpal tunnel syndrome. Previously, all cases of palmaris profundus in the literature have been encountered during either open surgery or cadaveric dissection. We report a case of palmaris profundus encountered during attempted single-portal endoscopic carpal tunnel release, necessitating conversion to an open approach. There was a unique point of tendon insertion onto the undersurface of the transverse carpal ligament, more proximal than what has been previously described in the literature. There were other anomalies present as well, including a persistent median artery and bifid median nerve. Given the volar position of the structure, its proximal point of insertion, and its minimal bulk, we did not feel that this was the cause of our patient's carpal tunnel syndrome.

Minimally invasive proximal biceps tenodesis: an anatomical study for optimal placement and safe surgical technique.

BACKGROUND: An anatomic study specifically investigating the optimal location for proximal biceps tenodesis and detailing the topographic relationship to neurovascular structures has not been conducted. METHODS: Twelve cadaveric upper extremities were dissected to identify the proximal biceps musculotendinous junction and topographic relationships to neighboring neurovascular structures. RESULTS: The musculotendinous junction of the long head of the biceps tendon was on average 2.2 cm distal to the superior border and 3.1 cm proximal from the inferior border of the pectoralis major tendon. The musculocutaneous nerve was on average 2.6 cm medial to the long head of the biceps at the musculotendinous junction. The distance from the lesser tuberosity to the musculotendinous junction of the long head of the biceps averaged 5.4 cm. The distance from the anterior humeral circumflex vessels to the musculotendinous junction of the long head of the biceps was 4.6 cm on average. The distance from the musculotendinous junction of the long head of the biceps to the musculocutaneous nerve as it pierces the coracobrachialis was 4.6 cm. CONCLUSION: In order to restore the appropriate length-tension relationship of the biceps muscle, proximal biceps tenodesis should possibly be placed closer to the superior border of the pectoralis major tendon than previously thought. The lesser tuberosity can be used as a tactile landmark for appropriate intraoperative placement. Although there is a relatively safe "buffer zone" between the location of the tenodesis and adjacent neurovascular structures, extreme caution must be used.

Impact of the Current United States Health Care Environment on Practice: A Private Practice Viewpoint.

The evolving healthcare landscape creates unique challenges for private practitioners. They experience the same issues that face physicians in general - including increased regulatory/documentation burdens and downward financial pressures - but without the safety nets that exist in larger healthcare systems. Costs are born more directly, as there are fewer providers over which to spread expenditures. Financial reserves are less robust, making margins thinner to maintain profitability. Guaranteed referral streams are absent, requiring additional effort and creative solutions to maintain patient volume. As hospital systems expand, private practitioners must remain nimble, while maintaining excellent service and outcomes, in order to stay ahead.

Arthroscopic Hill-Sachs Remplissage with Bankart Repair: Strategy and Technique.

INTRODUCTION: Arthroscopic Hill-Sachs remplissage describes the fixation of the posterior aspect of the capsule and the infraspinatus tendon into a posterosuperior humeral head impaction fracture in cases of recurrent anteroinferior glenohumeral instability. STEP 1 ANTERIOR CAPSULOLABRAL MOBILIZATION AND GLENOID PREPARATION: Perform diagnostic arthroscopy through a standard posterior portal to rule out additional pathology and document the "engaging" nature of the Hill-Sachs defect. STEP 2 PREPARATION OF THE HILL-SACHS DEFECT: With the camera remaining in the posterior portal, the assistant provides visualization of the Hill-Sachs defect by translating the humeral head anteriorly over the glenoid rim with direct pressure on the proximal part of the humerus. STEP 3 REMPLISSAGE WITH THE POSTERIOR ASPECT OF THE CAPSULE AND INFRASPINATUS TENDON: Transfer the camera to the anterior portal and leave a switching stick in the posterior portal; under direct visualization, withdraw the posterolateral cannula from the posterior aspect of the capsule and the infraspinatus tendon until it rests in the subdeltoid space (∼1 cm). STEP 4 ANTERIOR BANKART REPAIR: Transition the camera back to the standard posterior portal over a switching stick in order to perform the Bankart repair. STEP 5 POSTOPERATIVE REHABILITATION PROTOCOL: Patients wear a brace and perform pendulum exercises for four weeks, and then initiate range-of-motion exercises; they avoid strengthening for eight weeks and sports for three to six months. RESULTS: In our recently published series of forty-seven patients (forty-two male and five female; average age, twenty-nine years), the use of Bankart repair combined with Hill-Sachs remplissage performed according to the above algorithm resulted in 98% of the patients being satisfied or very satisfied with their surgical result and a recurrent instability rate of only 2% at a mean of twenty-four months postoperatively.IndicationsContraindicationsPitfalls & Challenges.

Arthroscopic posterior bone block procedure: a new technique using suture anchor fixation.

We present a novel all-arthroscopic technique of posterior shoulder stabilization that uses suture anchors for both bone block fixation and capsulolabral repair. The bone graft, introduced inside the glenohumeral joint through a cannula, is fixed with 2 suture anchors. The associated posteroinferior capsulolabral repair places the bone block in an extra-articular position. In this article we present the detailed arthroscopic technique performed in a consecutive series of 15 patients and report the early results. We also report the positioning, healing, and remodeling of the bone block using postoperative 3-dimensional computed tomography. The benefits of this new technique are as follows: (1) it is all arthroscopic, preserving the posterior deltoid and posterior rotator cuff muscles; (2) it is accurate, resulting in appropriate bone block positioning; (3) it is efficient, allowing for consistent bone graft healing; (4) it is anatomic, both restoring the glenoid bone stock and repairing the injured posterior labrum; and (5) it is safe, limiting hardware-related complications and eliminating the risk of injury to vital structures associated with drilling or screw insertion from posterior to anterior. We believe that this technique is advantageous because it does not use screws for fixation and may be safer for the patient.

Prognostic factors and limitations of anatomic shoulder arthroplasty for the treatment of posttraumatic cephalic collapse or necrosis (type-1 proximal humeral fracture sequelae).

BACKGROUND: The aim of this study was to evaluate the prognostic factors and limitations of anatomic unconstrained shoulder arthroplasty, performed without tuberosity osteotomy, for the treatment of secondary glenohumeral arthritis following posttraumatic cephalic collapse or necrosis of the humeral head, defined as type-1 fracture sequelae. METHODS: Fifty-five patients with type-1 fracture sequelae treated with anatomic shoulder arthroplasty were included in this retrospective single-center cohort study. All anatomic humeral prostheses were implanted without performing a greater tuberosity osteotomy. Glenoid resurfacing was performed in forty-four patients (80%). Clinical and radiographic analysis was performed at a mean of fifty-two months (range, twenty-four to 180 months) postoperatively. RESULTS: Four reoperations (7%) were performed, including two revisions in patients who required glenoid resurfacing because of glenoid erosion after hemiarthroplasty. At the time of the latest follow-up, 93% of patients were satisfied or very satisfied, and the mean Subjective Shoulder Value (SSV) was 81%. There were significant improvements in the mean Constant score (from 32 to 69 points), active anterior elevation (from 88° to 141°), external rotation (from 6° to 34°), and internal rotation (from the buttock to L3). Significantly poorer results were associated with proximal humeral deformity in varus and with fatty infiltration of the rotator cuff muscles. Patients with proximal humeral deformity, specifically varus or valgus malunion of the greater tuberosity, had a mean Constant score that was 10 points lower and active elevation that was almost 20° less than patients with no such deformity. The poorest results were observed in patients with varus malunion. CONCLUSIONS: Our study confirmed that the outcomes of anatomic shoulder arthroplasty for the treatment of type-1 fracture sequelae are good and predictable when deformation of the proximal humerus is acceptable(i.e., when no greater tuberosity osteotomy is necessary). The results were negatively affected by proximal humeral varus deformity and by fatty infiltration of the rotator cuff on imaging studies. In such cases, reverse shoulder arthroplasty may be more appropriate, especially in elderly patients.

Blunt vascular trauma in the extremity: diagnosis, management, and outcome.

BACKGROUND: Blunt vascular trauma in an extremity is an uncommon diagnosis. Considering the complexity of these injuries, it is worthwhile to determine how select factors affect the outcome of the limb and the patient. The objectives of this study were to review the diagnosis, management, and outcomes of patients who sustained blunt vascular injuries in the extremities and relate factors in their treatment to the outcome of the injured extremity. METHODS: A retrospective review of data on adult and pediatric patients who had a diagnosis of blunt vascular injury in an extremity and underwent some attempt at restoration of vascular flow was conducted. RESULTS: From January 1995 to December 2002, 62 patients (80.3% male; mean age, 33.2 +/- 15.8 years) sustained blunt trauma (mean Injury Severity Score, 14.6 +/- 8.4), with 93 vascular injuries in 65 extremities (16 upper and 49 lower). Hard signs of vascular injury occurred in 41 (66%) patients. An associated fracture and/or dislocation was present in 59 patients (95%). Preoperative arteriograms were obtained in 20 patients (17 occlusions, 2 embolizations, and 1 untreated). Vessel injuries were as follows: 16 upper (brachial artery, 50%) and 63 lower (tibial/peroneal/popliteal, 84%), with ligation being the most common treatment in the latter. Intravascular shunts were used to restore blood flow in 18 vessels (13 arteries and 5 veins) in 13 patients. Delays in diagnosis or treatment occurred in six patients, mostly because of errors in management/judgment. Delayed or late fasciotomies were performed in six patients, and five developed rhabdomyolysis. Six patients died. The age (p = 0.0006), Injury Severity Score (p = 0.0007), and Mangled Extremity Severity Score (p = 0.0009) were significantly different for the survivors compared with the nonsurvivors. CONCLUSION: Blunt vascular injuries in the lower extremities occur most commonly in the anteroposterior tibial arteries; injured arteries in the proximal upper and lower extremity require resection with interposition grafting, whereas those in the forearm or calf are usually ligated; the amputation rate in 65 injured extremities with blunt vascular trauma was 18.%, which is at least three times that for those who sustain penetrating injury; and delays in diagnosis and treatment are uncommon in these patients with multiple injuries.