38th adrian e. flatt residents & fellows conference

All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.

38th Adrian E. Flatt Residents & Fellows

Conference

Co-Chairs: Daniel A. Osei, MD, MSc and Samir K. Trehan, MD

Program Syllabus

September 30, 2020

75TH ANNUAL MEETING OF THE ASSH

OCTOBER 1 – 3, 2020

822 West Washington Blvd

Chicago, IL 60607

Phone: (312) 880-1900

Web: www.assh.org

Email: [email protected]

http://www.assh.org/

mailto:[email protected]


38th Adrian E. Flatt Residents & Fellows

Conference

Sponsored by the American Foundation for Surgery of the Hand, The Adrian E. Flatt Residents

and Fellows Conference in Hand Surgery is specifically geared to hand surgery fellows and

residents in orthopaedic, plastic and general surgery. The conference includes review of common

hand surgical conditions, interactive case discussions with small group faculty, review of

resources/opportunities available through the American Society for Surgery of the Hand, invited

faculty lectures on topics specifically relevant to trainees (such as starting practice, career

planning and burnout), and a scientific program where residents and fellows present original

research. Participants are invited to submit research abstracts relevant to hand and upper

extremity surgery.

CME CREDIT HOURS

The ASSH designates this live activity for a maximum of 5.00 AMA PRA Category 1 Credits TM.

Physicians should claim only the credit commensurate with the extent of their participation in the

activity.

The ASSH is accredited by the Accreditation Council for Continuing Medical Education to

provide continuing medical education for physicians.

DISCLAIMER

The material presented in this continuing medical education program is being made available by

the American Society for Surgery of the Hand for educational purposes only. This material is

not intended to represent the best or only methods or procedures appropriate for the medical

situation discussed; rather the material is intended to present an approach, view, statement or

opinion of the authors or presenters, which may be helpful, or of interest to other practitioners.

The attendees agree to participate in this medical education program, sponsored by ASSH with

full knowledge and awareness that they waive any claim they may have against ASSH for

reliance on any information presented in this educational program. In addition, the attendees

also waive any claim they have against the ASSH for injury or other damage that may result in

any way from their participation in this program.

All of the proceedings of the 75th Annual Meeting, including the presentation of scientific

papers, are intended for limited publication only, and all property rights in the material

presented, including common-law copyright, are expressly reserved to the speaker or the ASSH.

No statement or presentation made is to be regarded as dedicated to the public domain. Any

sound reproduction, transcript or other use of the material presented at this course without the


permission of the speaker or the ASSH is prohibited to the full extent of common-law copyright

in such material.

The ASSH is not responsible for expenses incurred by an individual who is not confirmed and

for whom space is not available at the meeting. Costs incurred by the registrant such as airline or

hotel fees or penalties are the responsibility of the registrant.

The approval of the U.S. Food and Drug Administration is required for procedures and drugs that

are considered experimental. Instrumentation systems discussed and/or demonstrated in or at

ASSH educational programs may not yet have received FDA approval.

Claim your CME hours through www.ASSH.org

• How to Claim: You can claim your CME for attending the live event in the same

way you've claimed CME at previous ASSH Annual Meetings. Simply login to your

ASSH account, choose the 75th Annual Meeting of the ASSH, and indicate which

sessions you attended.

Physicians should claim only the credit commensurate with the extent of their

participation in the activity.

Questions? Problems? Contact the American Society for Surgery of the

Hand at (312) 880-1900 or by email at [email protected].

http://www.assh.org/

https://www.assh.org/myaccount/cmesavailableforclaim

https://www.assh.org/myaccount/cmesavailableforclaim

Conflict of Interest Disclosures for 2020

Program Committee and Course Faculty

Program Faculty & Disclosures

The American Society for Surgery of the Hand gratefully acknowledges those who have

generously volunteered considerable time and effort to plan, organize and present this CME

course. The ASSH appreciates the faculty’s dedication to teaching, their support of the ASSH

mission, and their significant contribution to the educational success of this program.

The following is a list of disclosures for all participating faculty and program staff.

CONFLICT OF INTEREST POLICY

According to the ASSH conflict of interest policy, individuals involved in continuing medical

education activities are required to complete a disclosure statement. The ASSH acknowledges

this fact solely for the information of the listener. Non-conflicted reviewers have examined,

documented and resolved financial relationship disclosures for this course content.

Financial Disclosure – represented by ●

Instructors, planners, content reviewers and managers who affect the content of a CME/CE

activity are required to disclose financial relationships they have with commercial interests (i.e.

any entity producing, marketing, pre-selling, or distribution health care goods or services

consumed by, or used on, patients) associated with this activity.

FDA Disclosure – represented by ▲

Some drugs or medical devices demonstrated at this course may have not been cleared by the

FDA or have been cleared by the FDA for specific purposes only. The FDA has stated that it is

the responsibility of the physician to determine the FDA clearance status of each drug or medical

device he or she wishes to use in clinical practice.

The ASSH policy provides that “off label” uses of a drug or medical device may be described in

the ASSH CME activities so long as the “off label” use of the drug or medical device is also

specifically disclosed (i.e., it must be disclosed that the FDA has not cleared the drug or device

for the described purpose). Any drug or medical device is being used “off label” if the described

use is not set forth on the product’s approval label.

Planners

2020 Annual Meeting Program Chairs

Dawn M. LaPorte, MD

No relevant conflicts of interest to disclose

Ryan P. Calfee, MD, MSc


Session Co-Chairs/Moderators

Daniel A. Osei, MD, MSc


Samir K. Trehan, MD


Faculty

Martin I. Boyer, MD, FRCS(C)

● Intellectual Property: Exsomed, LLC (patent submitted)

● Consulting Fees: Exsomed. LLC; Hand Surgery Medicolegal Consultation; A Gift of Hope

Adoptions

Joseph A. Buckwalter, MD


Kevin Chan, MD


A. B. Chhabra, MD


Rafael J. Diaz-Garcia, MD

● Consulting Fees: Axogen, TelaBio and Smith + Nephew

Christopher J. Dy, MD, MPH, FACS


Felicity Fishman, MD


Paige M. Fox, MD, PhD


Michael J. Franco, MD


Louis Christopher Grandizio, DO


Curtis M. Henn, MD


Nikolas H. Kazmers, MD, MSE


Scott D. Lifchez, MD, FACS

● Ownership Interests: Co-founder and equity holder of EduMD, LLC, an educational

assessment company that makes the Operative Entrustability Assessment surgical assessment

tool.

Mary Claire Manske, MD


Walter B. McClelland, Jr., MD

● Consulting Fees: MicroAire, Acumed

Kenneth R. Means, Jr., MD

● Contracted Research: Axogen

Gregory A. Merrell, MD


Daniel J. Nagle, MD


Sameer Kumar Puri, MD


Peter C. Rhee, DO, MS

● Consulting Fees: TriMed Inc., Integra LifeSciences

Julie B. Samora, MD, PhD

● Consulting Fees: (Spouse) Walter Samora with Globus Medical

Apurva S. Shah, MD, MBA


Steven S. Shin, MD

● Royalty: Arthrex Hely & Weber

● Consulting Fees: Arthrex

● Speakers Bureau: Arthrex

Brandon S. Smetana, MD

● Consulting Fees: Axogen

● Speakers Bureau: Axogen

Eric R. Wagner, MD

● Consulting Fee: Stryker, Wright Medical

● Contracted Research: Arthrex

Lindley B. Wall, MD


38th Adrian E. Flatt Residents & Fellows Conference Co-Chairs: Daniel A. Osei, MD, MSc and Samir K. Trehan, MD

Description

Sponsored by the American Foundation for Surgery of the Hand, The Adrian E. Flatt Residents

and Fellows Conference in Hand Surgery is specifically geared to hand surgery fellows and

residents in orthopaedic, plastic and general surgery. The conference includes review of common

hand surgical conditions, interactive case discussions with small group faculty, review of

resources/opportunities available through the American Society for Surgery of the Hand, invited

faculty lectures on topics specifically relevant to trainees (such as starting practice, career

planning and burnout), and a scientific program where residents and fellows present original

research. Participants are invited to submit research abstracts relevant to hand and upper

extremity surgery.

Program

3:00 PM - 8:00 PM

Daniel A. Osei, MD, MSc | Samir K. Trehan, MD

3:00 PM - 3:05 PM

Welcome


3:05 PM - 3:10 PM

Introduction


3:10 PM - 3:15 PM

Adrian Flatt Memorial

Daniel A. Osei, MD, MSc

3:15 PM - 3:30 PM

Research


3:30 PM - 3:45 PM

Nerve Repair

Kevin Chan, MD

3:45 PM - 3:55 PM

Nerve Case Presentation


3:55 PM - 4:05 PM

Distal Radius Fracture

Sameer Kumar Puri, MD

4:05 PM - 4:15 PM

Wrist Case Presentation

Louis Christopher Grandizio, DO

4:15 PM - 4:20 PM

Private Practice Career


4:20 PM - 4:25 PM

Privademics Career


4:25 PM - 4:30 PM

Academic Career


4:30 PM - 4:45 PM

Panel: PP, Privademics, Academics

Walter B. McClelland, Jr., MD | Kenneth R. Means, Jr., MD | Julie B. Samora, MD, PhD

4:45 PM - 4:50 PM

Break

All Faculty

4:50 PM - 4:55 PM

Boyes Award


4:55 PM - 5:05 PM

Sports Injuries of Hand

Steven S. Shin, MD

5:05 PM - 5:20 PM

Pediatric Fractures

Lindley B. Wall, MD | Apurva S. Shah, MD, MBA

5:20 PM - 5:30 PM

Pediatric & Trauma Case Presentation


5:30 PM - 5:50 PM

Panel: Pearls for Starting Practice

Joseph A. Buckwalter, MD | Peter C. Rhee, DO, MS | Gregory A. Merrell, MD

5:50 PM - 5:55 PM

Fellowship Update

A. B. Chhabra, MD

5:55 PM - 5:56 PM

Introduction to Richard Smith Lecture


5:56 PM - 6:26 PM

Richard Smith Lecture

Christopher J. Dy, MD, MPH, FACS | Paige M. Fox, MD, PhD

6:26 PM - 6:46 PM

Physician Value

Daniel J. Nagle, MD

6:46 PM - 6:56 PM

Hand/Finger Flaps


6:56 PM - 7:09 PM

Arthritis Case Presentation

Eric R. Wagner, MD

7:09 PM - 7:11 PM

Mary S. Stern Scholarship Announcement


7:11 PM - 7:31 PM

Nightmare Cases: Lessons I Learned Early in Practice

Curtis M. Henn, MD | Brandon S. Smetana, MD

7:31 PM - 7:41 PM

Ethics: COI


7:41 PM - 7:55 PM

Ethics: Burnout


7:55 PM - 8:00 PM

Closing remarks


75TH ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

38th Adrian E. Flatt Residents & Fellows Conference

3:15 PM - 3:30 PM

Research

Nikolas H. Kazmers, MD, MSE No relevant conflicts of interest to disclose

9/18/2020

1

DISCLOSURES


Speaker has no relevant financial relationships

with commercial interest to disclose.

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 8

Incorporating Research

Into your New PracticeNikolas H. Kazmers, MD MSE

Department of Orthopaedics

September 30, 2020


DISCLOSURES

• No financial disclosures

• JHS Am Associate Editor

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OUTLINE

• The need for clinical research

• Common barriers

– Balance

• Clinical practice

• Personal / family life

– Resources

• Monetary

• Non-monetary

• Strategies to address barriers


THE NEED FOR CLINICAL RESEARCH

• Often no literature pointing to the “right answer”

• Expand the knowledge base of our subspecialty

– Broad spectrum of pathology

• Complete understanding is lacking for:

– Anatomy

– Diagnosis

– Treatment

– Measurement of outcomes

– Costs and value


THE NEED FOR CLINICAL RESEARCH

Why you?

• You are best equipped, and…

– There’s a lot we don’t know!!!!!

– Consistently work with the patient population

– Observe trends and patterns

– Pros and cons of treatment options

– Recognize when literature is lacking

– Were hired to do it!

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COMMON BARRIERS

• Balancing Clinical Practice:

– 3 A’s:

• Availability, affability, ability

– Growing pains of a new practice:

• Lots of reading for patient care

• How do I do this surgery?

• Clinic and OR workflow

• Getting to know your team

• Meet & greet referring physicians


COMMON BARRIERS

• Balancing Personal Life / Family:

– Adjustment to a new location

– New living situation

– New friends and social scene


COMMON BARRIERS

• Resources for Research:

– Monetary

– Non-monetary

• Ideas / questions and the

patient population to tackle

them

• Statistics help

• Collaborators

• Chart review

• IRB considerations

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STRATEGIES TO ADDRESS BARRIERS



• Residency and Fellowship Contacts:

– Opportunity to continue projects that may not

be immediately feasible in your new practice

– May have a more developed infrastructure

– Familiarity

– Don’t forget about current trainees

– Caveat: will want to branch out and develop your own program over time



• Things to Consider when On-Boarding:

– Salary vs support

• Research stipend

• Research assistant/coordinator

• Infrastructure for patient follow-up / PRO collection

• Access to statisticians / databases

• Master’s programs

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• Things to Consider when On-Boarding:

– What are your partners working on / interested

in?

• Opportunity to jump-start select projects

– Research assistant/coordinator job search

– Schedule / academic day?



• Help with Pending Projects:

– Opportunity to make progress before your own

ideas take off

– Tackle loose ends and drive it home

• Remaining data collection, analysis, editing, etc



• Get to Know the Residents (and Fellows):

– Smart, eager, and hard-working

– Need at least 1 research project

– If you are approachable and accessible:

• They will ask you interesting clinical questions

• May ask you for mentorship

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• Be a Useful Resource to Medical Students:

– Also are smart, eager, and hard-working

– Orthopaedics / plastics training is competitive

• Advice

• Interest groups

• Opportunity to collaborate on projects

– Approachability and accessibility



• Identify Motivated Collaborators:

– Answer questions you can’t alone

• MSK Radiology

• Rheumatology

• Emergency Medicine

• Health Economics

• Engineering Department

• Laboratory

– Your microsurgery skills are unique

• Ortho / Plastics (esp. if separate programs)

→ Finding the right team is they key



• Miscellaneous:

– What are your non-hand colleagues are working on?• Read CVs

• Skim non-hand journals

– Write down your research ideas

– “Night school” analogy

– Take advantage of unique pathology / unique resources

– Take advantage if ‘not busy’

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SUMMARY

• Barriers exist

• Ways to overcome some of them exist

• Mentorship makes it more fun

• Study what is feasible, yet interesting to you,

and important to the hand community

• Find a niche


THANK YOU

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3:30 PM - 3:45 PM

Nerve Repair

Kevin Chan, MD No relevant conflicts of interest to disclose

9/29/2020

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DISCLOSURES

Kevin Chan, MD



Nerve repairs

Kevin Chan MD

Clinical Assistant Professor

Spectrum Health | Michigan State University

Basic science of nerve regeneration

• Within injured axon, rapid influx of ions (calcium) and disruption of transport protein signalling leads to upregulation of RAG in neurons → promotes axonal outgrowth

• Distally, Wallerian degeneration occurs»Schwann cells dedifferentiate to “repair”

phenotype: clear axon and myelin debris, upregulate neurotrophic factors

»Recruits innate immune cells (neutrophils, macrophages): phagocytic function, promote angiogenesis

»SC migrate down this network, forming cellular cords with fibroblasts, which enables axon growth across nerve defect

Pan et al. Advances in the repair of segmental nerve injuries and trends

in reconstruction. Muscle Nerve. 2020;61:726–739.

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Where is the lesion?

• PIN MCP extension

Thumb IP extension

– Radial wrist extension– Radial nerve

Wrist extension

BR

Triceps

– Sensory loss

• 1st webspace vs posterior aspect of arm & posterolateral arm

• Posterior cordAxillary nerve, thoracodorsal n

• C7 radiculopathyPronator teres, FCR

– Sensory loss middle finger

Radial Nerve Reinnervation

• Reinnervation order can be variable

• Order of innervation of the radial nerve (proximal to distal):

1. brachioradialis

2. extensor carpi radialis longus,

3. supinator

4. extensor carpi radialis brevis

5. extensor digitorum communis

6. extensor carpi ulnaris

7. extensor digiti quinti

8. abductor pollicis longus

9. extensor policis longus

10. extensor policis brevis

11. extensor indicis proprius.

Abrams RA, Ziets RJ, Lieber RL, Botte MJ. Anatomy of the radial nerve motor

branches in the forearm. J Hand Surg Am. 1997 Mar;22(2):232-7.

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Beware of median-ulnar interconnections

• Forearm: Martin-Gruber anastomosis

• Hand: Riché-Cannieu anastomosis

• May account for preservation of muscle function even if median/ulnar

nerves are not intact

– E.g. The MGA between the median and ulnar nerves can account for

intrinsic function despite the presence of a more proximal ulnar lesion

Grades 1, 2, 3 “Favorable, recoverable” vs grades 4, 5 “non-favorable, non-

recoverable”

Non-op vs op

Mackinnon SE. Nerve Surgery. Thieme 2015.

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Distinguishing nerve injury severity

• History and physical exam

- Mechanism of injury: blunt vs penetrating trauma

• EDX

- Presence of fibrillations distinguish a neurapraxia from more severe injuries

- MUAPs are absent in fourth/fifth degree injuries

- MUAPs can signify collateral sprouting as early as 12 weeks postinjury in

second/third degree injuries

Will it make it?

• Nerves regenerate at ~ 1 mm/day or 1 inch/month

• Irreversible motor end plate degeneration by 12-18 months post-injury

• Motor recovery dependent on time to muscle reinnervation and number

of regenerated motor axons

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The value of Tinel’s test

• The progress of nerve regeneration can be followed using the Tinel’s

test

• Reflects axons that have not obtained myelinization

• An advancing Tinel’s test with distal radiation is a promising sign for

regenerating axons across nerve repair site

Principles of nerve repairs

• Timing

• Trim

• Tension

• Technique

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“Timing”

1. Better functional outcomes occur in patients with

spontaneous recovery who do not require a surgical

intervention

2. Surgical intervention is indicated for patients with no hope

for spontaneous recovery or for further recovery

3. Surgical outcome is inversely proportional to the time

interval from injury to surgery (i.e., outcomes are better if

surgery is per- formed earlier)

Timing of nerve repairs

• Sharp, penetrating injuries

• Injuries with high index of suspicion for nerve transection

• Observe blunt injuries, crush, avulsion for signs of spontaneous

recovery:

- EDX around 8-12 weeks postinjury

- EDX may precede clinical evidence of returning muscle function

- MUAPs signify nerve recovery

‘Technique’: Types of Nerve Repair

Mackinnon SE. Nerve Surgery. Thieme 2015.

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“Trim”

• Recognize “zone of injury”: scarring of nerve following injury; inhibits

nerve recovery; not fully present until about 3 weeks after injury

Mackinnon SE. Nerve Surgery. Thieme

2015.

“Bread loaf”

“Tension”

• Excess tension leads to ischemia and scar formation

• When faced with a nerve laceration, how much tension and strain is too

much?

• Smetana et al (JHS 2019) recommended using 9-0 nylons

Treatment of nerve gaps

• Autogeneous nerve graft

• Processed acellular allograft

• Nerve conduits

• Nerve transfers

Moore A. Processed acellular nerve grafts. 2018

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Autografts

• Sural

• MABC

• LABC

• PIN

PART

V

NERV

E

38

1252

Important attributes of nerve transfers are as follows:

1. Closer to the end-organ (increased likelihood of more

rapid or more reliable recovery, or both)

2. Delivery of a large number of “ pure” axons

3. Repair outside the injured and scarred zone

4. Avoidance of nerve graft and their two repair sites

5. Ease of relearning, especially with synergistic transfers

Common intraplexal and extraplexal nerve transfers are

described in the following sections.

Spinal Accessory Nerve Transfer

SURGICAL ANATOMYThe spinal accessory nerve (cranial nerve XI) innervates the

sternocleidomastoid and trapezius muscles. It originates in

the posterior cranial fossa from spinal and cranial nerve

roots, passes through the jugular foramen, and divides into

an internal branch (containing fibers originating from the

“ cranial part” ) that joins the vagus (X) nerve and an external

branch (consisting of fibers from the “ spinal part” ). The

external branch of the spinal accessory nerve supplies the

sternocleidomastoid and trapezius muscles. After its division,

the spinal accessory nerve supplies the sternocleidomastoid

muscle and then descends obliquely in the posterior triangle

of the neck between the superficial and deep layers of the

deep cervical fascia (Figure 38.17). In this area the nerve is

embedded in loose connective tissue and is in contact with

the cervical lymph node chain. This is the most common

location for iatrogenic injuries to the spinal accessory nerve

during lymph node biopsies. The spinal accessory nerve

provides two or three branches to the upper part of the

trapezius muscle before passing under its anterior edge.

Tissue adhesive can be used to approximate multiple strands

of nerve graft and simplify the coaptation with proximal and

distal nerves (Figure 38.16). We generally reinforce the

nerve coaptation sites with the use of a bivalved nerve tube

and tissue adhesive.

Nerve Conduits

Nerve conduits are increasingly being used in nerve surgery

for small-caliber (more commonly sensory) nerves, for short

nerve gaps, or as an adjunct to nerve repair or transfer;

however, in proximal brachial plexus injuries, this technique

is not recommended at this time as a substitute for nerve

grafts.

Nerve TransferThe terms nerve transfer, neurotization, and nerve crossing

are used interchangeably and describe the transfer of a

normal or nearly normal fascicle or nerve branch to a more

important sensory or motor nerve that has sustained irrepa-

rable proximal damage. The term nerve transfer is used most

frequently in the current literature; nerve transfer and neu-

rotization will be used in this text without distinction. It

should be noted that muscular neurotization is different in

that it describes direct implantation of nerve ends into a

denervated muscle for reinnervation.

Indications

1. Irreparable preganglionic injury

2. Selected postganglionic injury

3. Reinnervation of FFMTs

Figure 38.16 Nerve repair with tissue adhesive. The graft strands

are first glued together (A), the graft ends are freshened with a

sharp blade (B) and then coapted with conventional epineurial

sutures (C). (Copyright Elizabeth Martin.)

A

B

C

Sural n. graft

Edgesfreshened

Fibrin glue

Figure 38.17 The course of the spinal accessory nerve. The nerve

can readily be identified in the lateral portion of a supraclavicular

incision on the anterior surface of the trapezius muscle several

centimeters above the clavicle. (By permission of Mayo Foundation

for Medical Education and Research. All rights reserved.)

Green’s Operative Hand Surgery

• Lack supportive

cells

• 3-D scaffold

PNAProcessed nerve allografts

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PNA in the literature

• No cases of tissue rejection

• S3 or M4 achieved in ~86% of procedures

• 89% digital nerves

• 75% median nerves

• 67% ulnar nerves

Moore A. Processed acellular nerve grafts.

2018

Processed nerve allografts

Nerve Transfers

Definition

• Surgical coaptation of a healthy nerve donor to a denervated nerve

• To regain a necessary function by sacrificing another function that is

less essential

Nerve transfers

Indications

• When the proximal nerve end is nonfunctional

• Nerve reconstruction would require an excessively long nerve graft or

exceed the expected viability of motor end plates and muscle

Contraindications

• Excessive time between injury and reinnervation (ie, >18 months)

• Donor nerve motor strength of less than MRC 4

• Superior reconstructive option

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Nomenclature

Lee SK, Wolfe SW. Nerve transfers. JAAOS 2012; 20: 506-517.

Reverse end-to-

side

End-to-sideEnd-to-end

Thank you!

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3:45 PM - 3:55 PM

Nerve Case Presentation

Rafael J. Diaz-Garcia, MD ● Consulting Fees: Axogen, TelaBio and Smith + Nephew

9/29/2020

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DISCLOSURES


Consulting Fees: Axogen, TelaBio and Smith +

Nephew

Rafael J. Diaz-Garcia, MD, FACS

Hand and Upper Extremity SurgeryAllegheny Health Network

Clinical Assoc. Professor of Plastic SurgeryUniversity of Pittsburgh School of Medicine

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24yo RHD male with laceration of the right hand after assault. Exam notable for anesthesia of R thumb radial sensory nerve distribution. After exploration and debridement, 8mm nerve gap of RDN.

Treatment Options?

- Primary repair after mobilization- Repair with nerve conduit for gap- Repair with vein conduit for gap- Repair with allograft for gap- Repair with autograft for gap- Nerve transfer

Trade-offs- Primary repair after mobilization

cheap, easy, but possible tension- Repair with nerve conduit for gap

additional cost, but fast & tension free- Repair with vein conduit for gap

cheap, but additional time and donor site- Repair with allograft for gap

expensive, but fast and tension free- Repair with autograft for gap

additional time and donor site- Nerve transfer

additional time and donor site

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64yo RHD female with R open olecranon fracture and ulnar nerve laceration. Exam notable for anesthesia of R small and ½ ring finger, intrinsic paralysis. After exploration and debridement, 8cm nerve gap of ulnar nerve at elbow.

Treatment Options?

- Primary repair after mobilization- Repair with nerve conduit for gap- Repair with vein conduit for gap- Repair with allograft for gap- Repair with autograft for gap- Nerve transfer

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Trade-offs- Primary repair after mobilization

even with ulnar nerve transposition, too large a gap- Repair with nerve conduit for gap

no commercial conduits at length > 4cm, outside FDA indication- Repair with vein conduit for gap

cheap, but unlikely to bridge a gap this long- Repair with allograft for gap

expensive, but fast ; unclear data for long gap mixed nerves- Repair with autograft for gap

additional time and donor site, traditional gold standard- Nerve transfer

additional time and donor site, shorter distance

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3:55 PM - 4:05 PM

Distal Radius Fracture

Sameer Kumar Puri, MD No relevant conflicts of interest to disclose

9/21/2020

1

DISCLOSURES

Sameer K. Puri, MD



Distal Radius Fractures

Sameer Puri, MDLoyola University Medical Center (until Oct 2020)/Indiana Hand to Shoulder Center (as of Nov 2020)

Outline

• Epidemiology/Incidence

• Pertinent Anatomy

• Imaging

• Fracture Characteristics

• Indications

• Surgical Options

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Epidemiology

• Very common– 3% of all upper extremity injuries

• ~640,000 annually in US (2001)

• Bimodal distribution– Early peak (5-24)

• Young, male, sports and high energy

– Late peak• Old, female, low energy and fragility fractures

Pertinent Anatomy

• 3 articular facets– Scaphoid

– Lunate

– Sigmoid notch

• Bony landmarks– Styloid

– Lister’s tubercle

– Volar lip

Pertinent Anatomy• Volar wrist ligaments

– Radioscaphocapitate• Role in position of

scaphoid

• Role in controlling midcarpal position

– Short radiolunate

• Keeps lunate in lunate fossa

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Pertinent Anatomy

• Dorsal wrist ligaments

– Dorsal radiotriquetral

• Lister’s to triquetrum

– Dorsal intercarpal

• Triquetrum to STT

From Green’s Operative Hand Surgery, 7th Ed.

Pertinent Anatomy

• TFCC– Forms the ulnar

articular surface– Attaches to

styloid• Deep limb of

radioulnarligaments

• Multiple parts– Articular disc– Meniscus

homologue– Radioulnar

ligaments– Volar ulnocarpal

ligaments– ECU subsheath

Imaging/Alignment

• Good X-rays

– PA

– Fossa lateral

– Oblique

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Imaging and Alignment – PA

• Looking down the DRUJ

✓ ✖

Imaging and Alignment - PA

• Wrist neutral– Pronation shortens the radius

Neutral Pronation

Imaging and Alignment - Lateral

• Rotation

– SPC

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Imaging and Alignment - Lateral• Fossa lateral


• Radial height

• Radial Inclination

• Ulnar Variance

• Coronal alignment


• Volar and dorsal rim

– Distal line usually dorsal rim

– Depends on volar tilt

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Imaging and Alignment - Lateral

• Volar tilt

Classification / Common Patterns

• Many flavors

– Young, high energy probably not same as old, fragility fracture

• Eponymous fractures may be just as useful to understand these…

Classification / Common Patterns• Colles Fracture

– Dorsal bending mechanism

– Apex volar angulation

– Dorsal comminution

– Shortening

– With or without

ulnar styloid

16

17

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• Smith

– Palmar angulation

– Type 1 - Extra-articular

– Shortened

– DRUJ incongruity


• Smith

– Type 2 Smith / Volar Barton’s

– Partial articular volar shear

– Carpus goes with the volar

piece

Classification / Common Patterns• Dorsal Barton’s

– Rare, ~ 2%

– Partial articular dorsal shear

– Radiocarpaldislocation• Short radiolunate

injury

• Lunate loses association with the radius

19

20

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• Chauffeur Fracture

– Styloid fracture

– Often with associated SL

dissociation

– Probably part of perilunate injury spectrum


• Die punch

– Intraarticularimpaction

– CT can be helpful

Who to treat?

• Articular surface– Intraarticular stepoff < 2mm– Maybe can accept more in older

patients

• Length– Ulnar variance– Ulnar-sided pain in some series

>40% non-op Colles– Associated with loss of grip and

pinch strength

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Who to treat?

• Carpal Malalignment

– Loss of volar tilt

– “Adaptive DISI”

– “Nondissociative Carpal Instability”

– Is the center of the capitate over the radius?

Who to treat?

• Carpal Malalignment

– McQueen et al JBJS 1996

– Single most predictive for loss of strength and functional outcomes

Who to treat?

• Coronal shift

– Related to radial height

– Distal IOL

– DRUJ

Trehan et al JHS 2015

25

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Who to treat?

• Associated carpal tunnel syndrome– Approximately 5%

• Occasionally with nondisplaced, especially if baseline symptoms

– First attempt reduction

• Associated ligament injuries– Some have ligament injuries by definition

• Radiocarpal dislocation

– Some have high suspicion• Chauffeur’s fracture

– Arthroscopic studies show as high as 30% SL, 15% LT injuries• Geissler JBJS 1996

Nonoperative Management

• Functional goals

• Previously discussed alignment criteria

• Fracture stability


• Elderly patients may accept more deformity

– Metanalysis Chen et al JHS 2016

• 2 RCTs, 6 high quality retrospective studies

– Operative treatment

» Better radiographic outcomes

» Earlier return of grip strength

» Slightly higher complication

» No significant difference in endpoint ROM

» No significant difference in DASH or PRWE

» No significant difference in endpoint VAS

– Cast

» Potential delay in return to function and grip

» Lower complication rate overall, but maybe higher CRPS

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• Functional goals are paramount

– Early return to function, even if endpoint the same, is not meaningless

– Neither is a complication

• Final outcome related to fingers

– Watch your splints!!

– Keep them short and thin in the

palm



– Some fractures tend to fall back to injury films

– Risk factors for loss of reduction

Nonoperative Management• Fracture stability

– Lafontaine’s criteria

• Dorsal angulation > 20

degrees

• Dorsal comminution

• Intraarticular extension

• Associated ulnar fracture

• Age > 60

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– Other factors have been shown

• Mackenney, McQueen et al JBJS 2006– Age

– Dorsal comminution

– Ulnar variance increase >3 mm



– Other factors have been shown

• Lamartina, Tornetta et al JHS 2015– “volar hook”

•✔✔✔

✔ ✖

Operative Treatment

• Open

• Poor alignment

• Unstable– Shear

– Comminuted

– Impacted

– Fracture-dislocation• Associated ligament injury

– Metadiaphyseal extension

– Concomitant nerve injury

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Operative Treatment Options

• Fixed angle volar plate





Operative Treatment Options

• Closed reduction percutaneous pinning

• External fixation

• Augmented external fixation

• Dorsal bridge plating

• Open reduction internal fixation– Dorsal plate

– Nail

– Fragment specific fixation

– Volar locked plating

Fixed Angle Volar Plate

• Internal buttress for articular surface

• Previous plates placed dorsally had high rates of tendon complications

• Designed to tuck under volar rim

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Fixed Angle Volar Plate - Prominence

• Plate position is key– Soong grade (JBJS 2011)

• 0 – dorsal to critical line and proximal to volar rim

• 1 – volar to critical line• 2 – at or distal to volar

rim

– Kitay et al JHS 2013• At risk for tendon

ruptures– 2mm volar to critical line– Within 3 mm of volar rim

Fixed Angle Volar Plate – Volar Rim

• Volar rim fragment

– Attachments of volar ligaments

– Can escape over or around the plate

Fixed Angle Volar Plate – Volar Rim

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A Nascent Malunion

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Fixed Angle Volar Plate - Not Quite Enough

Dorsal Plates

• Improved designs

– Dorsal shear fractures

– Articular impaction

Dorsal Plates

• Improved designs

– Dorsal shear fractures

– Articular impaction

46

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Dorsal Bridge Plating

• Favorable reported outcomes– Elderly patients with highly

comminuted fractures

– High energy injuries with proximal extension

– Control of hand to radius connection (volar rim or short radiolunate ligament)

– Polytrauma with need for load-bearing through wrist

• Requires a second surgery

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Summary

• Different fractures with different characteristics

• Identify the deformity

• Identify the stability

• Get the fingers moving

• Customize your fixation

– Not all volar plates!

55



4:05 PM - 4:15 PM

Wrist Case Presentation

Louis Christopher Grandizio, DO No relevant conflicts of interest to disclose

9/29/2020

1

DISCLOSURES

Louis Christopher Grandizio, MD



WRIST CASEASSH 2020

L. Christopher Grandizio, DO

Hand and Upper-Extremity Surgery

Geisinger Commonwealth School of Medicine

Disclosures

None

| 3

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CASE

HPI: 15yo RHD healthy male was tackled during football and fell onto outstretched left hand.

Presented to ED.

EXAM: closed, NVI w/o evidence of acute CTS.

| 4

Diagnosis?

Great arc vs Lesser arc

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Initial Management?

Trans-styloid, trans-scaphoid, perilunate fracture dislocation

s/p closed reduction in ED with sedation

Definitive management?

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ScaphoidORIF

Radial styloid fixation, L-T stabilization, L-C stabilization

Returned to sports around 4 months

10

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12



4:15 PM - 4:20 PM

Private Practice Career

Walter B. McClelland, Jr., MD ● Consulting Fees: MicroAire, Acumed

9/29/2020

1

DISCLOSURES


Consulting Fees: MicroAire, Acumed

Career in Private Practice


Peachtree Orthopedics; Atlanta, GA

2018 AAOS Census Data

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4

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Workforce Trends 2012-2018

• Relative decline in private practice, increase

in hospital employment

• Academic practice has remained relatively

stable

Comparing Practice Models

How to Evaluate a Private Practice

• Must have a well organized governance structure

• Our Practice: 35 physicians, 29 partners

• Full C-suite (CEO, COO, CFO), Physician President

• Executive Committee (C-suite, Clinical Mgr, President, 5 Elected MDs)

• Committees (Relevant Mgrs, Physicians)

• Quarterly business meetings, twice yearly retreats

7

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How To Decide

• Determine what is your most important variable:

• Location

• Financial Compensation

• Work/Life Balance

• Practice Autonomy

• Practice Scope

• Research Production

• Quality of Partners

No Such Thing As A Perfect Job

• Maximize what’s most important to

you

• Accept that there may be some

things you don’t love, but these will

be less impactful

• Everything is a trade-off, try to think

long-term

“You can’t always get what you want”

Thank You


Hand, Shoulder & Elbow Surgery

Peachtree Orthopedics; Atlanta, GA

[email protected]

Cell: 404-550-3025

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mailto:[email protected]



4:20 PM - 4:25 PM

Privademics Career

Kenneth R. Means, Jr., MD ● Contracted Research: Axogen

8/28/2020

1

DISCLOSURES


Contracted Research: Axogen


Privademic Hand Surgery Practice


The Curtis National Hand Center

MedStar Union Memorial Hospital

P a n

1

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= mt2h

Academic Privademic Private

More Less

Research OptionsGrant OpportunitiesTeaching/Academia

Protected TimePrestige

Breadth of Pathology

Research OptionsGrant OpportunitiesTeaching/Academia

Protected TimePrestige

Breadth of Pathology

Less More

EfficiencyFreedom

CompensationBusiness Opportunities

EfficiencyFreedom

CompensationBusiness Opportunities

Curtis National Hand Center Privademic Practice

•1 vs. 2 practices

4

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List Them!!

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10



4:25 PM - 4:30 PM

Academic Career

Julie B. Samora, MD, PhD ● Consulting Fees: (Spouse) Walter Samora with Globus Medical

9/29/2020

1

DISCLOSURES


Consulting Fees: (Spouse) Walter Samora

with Globus Medical

Julie Balch Samora, MD/PhD/MPH

Academic Medicine-

Is it for me?

Disclosures

Acknowledgement: Thank you to

Dawn LaPorte for sharing some of

these slides

Board or Committee member:

RJOS, AAOS, POSNA, ASSH, AOA

Spouse: Consultant for Globus Medical

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Background

• 70% change jobs after 5 years

– Beatty, AAOS Now 2014

• Medical Group Management Association (MGMA):

compensation in academic practices continues to trail

that of private practices

• Academic surgeons earn an average of 10% or $1.3

million less in gross income across their lifetime than

surgeons in private practice

https://www.mdedge.com/obgyn/article/96879/practice-

management/private-academic-surgeon-salary-gap-would-you-pick-academia/page/0/1

“CARTSQ”

• Clinical practice

• Administrative obligations

• Research

• Teaching/ education

• Service

• Quality Improvement

Research Options

• Bench/laboratory science research,

translational research, clinical

research, outcomes research,

epidemiological, multi-center studies,

trial involvement

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Pros• Surrounded by like-minded colleagues, intellectually

stimulating

• Intelligent trainees with curious minds

– med students, residents, fellows

• Staying up to date with research and surgical trends

– Journal clubs, GR, lectures

• Increased complexity of patients

– Ability to discuss odd/unusual case

• Opportunity to present at conferences regionally, nationally

and internationally

Pros

• Clinical, Research and Administrative support

• Call can potentially be less burdensome than in private

practice

• Surgeons may have a more ‘consistent’ salary that is not

completely dependent on being ‘maximally productive’ at all

times

– This allows you more time to explore other avenues including

education and research

Cons

• Less dedicated time for patient care

– potentially less revenue/ fewer RVUs

• Increased responsibilities (CARTSQ)

• Pressure to publish while still producing

clinically

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Cons

• These benefits aren’t consistent across every

academic institution

• Academic surgeons (generally speaking)

are employees, and don’t really have the opportunity

to be “their own boss”

– Academic clinicians may feel constrained by the fact that they often

cannot make all of their own decisions

– Scheduling, medical staff, what types of patients they see

Compensation

• Collections

• wRVU

• Hybrid

• Bonus structure (admin, research, QI,

service)

• Chair’s discretionary ‘bonus’

Academic Rank

• Instructor - <5 publications

• Assistant Professor

– Many start at this level (>5 publications)

• Associate Professor

– National reputation

– >15 publications (not case reports)

• Professor

– International reputation

– >15 publications (not case reports)

– Extramural funding

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Tracks

Research Clinical Care Education

CLINICIAN

Physician with clinical distinction for outstanding clinical skills

Clinical Program Builder – developed a broad-reaching clinical program

Physician-Innovator – developed a diagnostic tool, assay, or clinical procedure

Clinician /Educator- patient care and local educational leadership

EDUCATOREducational Scholars

Clinician/Educator

RESEARCHER

Physician-Basic Scientist

Physician-Clinical Investigator/Translational Researcher

Basic Scientist/Educator

Research Innovator – developed novel research assay

Promotional pathways Major Categories

Specific areas of career focus

P&T

• Extramural funding

• Invited talks (national, international)

• Editorial Boards

• National leadership roles/awards

– National committees

• Teaching awards

• National teaching courses

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P&T

• Journal peer reviewer

• Local/regional talks/teaching

• Videos/ chapters

• Citizenship/service

• Travelling fellowships

Professor

• H-index > 15 (Mean/Median– 25/23)

• Extramural funding – sustained record

• NIH Study Sections

• National Leadership

• Invited talks (national, international)

• National/international awards/selective fellowships

• Board examiner

• Book – author/editor

Conclusion

• Academic medicine does include administrative

obligations, research, teaching, service, and

quality improvement involvement -above and

beyond clinical duties

• Exposure to trainees/didactics, and complex case

mix

• Multiple pathways for P&T

• There is potentially less earning potential and less

control in academic medicine compared to private

practice

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Julie Balch Samora, MD,PhD,MPH

[email protected] You

19



4:55 PM - 5:05 PM

Sports Injuries of Hand

Steven S. Shin, MD ● Royalty: Arthrex Hely & Weber

● Consulting Fees: Arthrex

● Speakers Bureau: Arthrex

1

Steven S. Shin, MD, MMScDirector, Orthopaedic Center

Associate Professor & Executive Vice ChairmanDepartment of Orthopaedic Surgery

Cedars-Sinai Health SystemLos Angeles, California

38th ASSH Residents/Fellows Conference: Sports Injuries of the Hand

DISCLOSURES: Steven Shin, MD

Royalties: Arthrex, Hely & WeberConsulting Fees: ArthrexSpeakers Bureau: ArthrexEditorial Boards: JBJS, Orthopedics TodayCommittees: ASSH, AAOS

Things to Think About

• Level of Play (high school, college, professional, weekend warrior)

• Timing • Which sport? Which position? Which hand?

Metacarpal and Phalanx Fractures

When do we operate?Rotational deformity

Articular step-offOpen fracture

Multiple fractures

EARLIER RETURN TO PLAY (?)

Return to Play

• My experience:– NBA: 3-5 weeks (after

ORIF)– NFL: 1-4 weeks (after

ORIF)– MLB: 4-8 weeks (with or

without ORIF)

1 2

3 4

5 6

2

Risk of Re-Injury (IMO)Without Plate and Screws• 3 weeks: 50%• 4 weeks: 25% • 5 weeks: 10%• 6 weeks: ”near” 0%

With Plate and Screws• 3 weeks: “near” 0%

19 yo RHD D-1 wide receiver

• 19 yo RHD D-1 wide receiver

• Injured right hand while throwing a block during game

Injury X-rays Surgery 2 days later (Monday)

• 2 and 3 days after surgery (Wednesday and Thursday)

5 days after surgery

• Padded metacarpal brace• 8 catches, inc 72-yard TD• 138 yards• One of his best games of

the season

7 8

9 10

11 12

3

RHD NHL player: Left MF P1 Fx

RTP 3.5 weeks

Pro Boxer, Left IF: P1 fx

Hook of Hamate FractureHistory• Felt sharp pain in left hand

(bottom hand) after a swing• X-rays: “negative”• CT: hook of hamate fx• Exam

– Tender at hook– Check ulnar nerve, RF/SF

flexor tendons, ulnar artery

Surgery

• 2012-2017• 41 baseball players

• Single surgeon• 12 professional, 17 collegiate, 12 high school• Median RTP: 5 weeks (range: 3-7 weeks)• HITS study: 51.5 days missed (7+ weeks)

Acute Thumb UCL Tears• Common sports injury, “skier’s thumb”• UCL: 90%; RCL: 10%• Usually distal• When to operate

– Complete tear WITH INSTABILITY (compared to opposite thumb)

– Avulsion fracture that is DISPLACED

• Earlier Return to Play/Activity?

13 14

15 16

17 18

4

Repair (suture anchor)• Post-op immob x 4 weeks,

then start ROM• RTP 8-12 weeks +/- splint

Repair + Internal Brace• Immediate ROM• RTP when comfortable,

usually 5-6 weeks

Thumb UCL Tear: Surgical Options CASE: UCL Tear, QB Throwing Hand

POD #2

IntraOp

Conclusion

• Different hand requirements in different sports

• Both NON-OPERATIVE and OPERATIVE treatments should be discussed (pros and cons of both)

• Sometimes OPERATIVE is preferred for RTP

• Player should always make the final decision

THANK YOU

19 20

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23



5:05 PM - 5:20 PM

Pediatric Fractures

Lindley B. Wall, MD | Apurva S. Shah, MD, MBA

Lindley B. Wall, MD




9/21/2020

1

DISCLOSURES


Speaker has no relevant financial relationship

to disclose.

Pediatric Wrist & Forearm FracturesOperative vs. Nonoperative Management & Remodeling Potential

Apurva S. Shah, MD MBA

Assistant Professor of Orthopaedic Surgery

Director of Orthopaedic ResearchDirector of the Brachial Plexus Program

2020 ASSH Annual Meeting

Disclosures

I have no relevant financial disclosures

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9/21/2020

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Epidemiology

Distal radius & forearm fractures represent 24% fractures in children (most common long bone fracture)Christoffersen et al Arch Osteoporos 2016

Distal radius fractures incidence 5.7/1,000 children per yearHofer et al Gesundheitswesen 2019

Forearm fractures incidence of 0.7/1,000 children per yearLyman et al JPO B 2016

Clinical Presentation Distal Radius Fx

Fracture PatternsTorus

Bicortical metaphyseal

Physeal

Greenstick (rare)

Associated ulnar fracture rarely places role during initial treatmentStyloid

Physeal

Metaphyseal

Diaphyseal

Basic Principles of Distal Radius Fx Care

Closed reduction and castingShort arm or long arm cast acceptable

Bivalving does not increase risk of loss of reduction or surgeryBae et al JPO 2015

Goal cast index < 0.7Webb et al JBJS 2006

Poor casting often due to excess padding & lack of three-point mold

Management influenced by remodeling potential of the distal radius in growing children

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6

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=1toL8H1vREDlBM&tbnid=tkS-6w0CQnVG2M:&ved=0CAUQjRw&url=http://www.toledoblade.com/gallery/Perrysburg-defeats-Medina&ei=06FMUtbvAeOIiAKskoGoAQ&bvm=bv.53537100,d.cGE&psig=AFQjCNEoVCy9IhuGnc6bCjRnIbthw49JQQ&ust=1380840245093316

9/21/2020

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Remodeling Potential – Distal Radius Fxs

Distal radial physis provides 75% of radial growth

~5.25 mm longitudinal growth/year

Injury

Reduction

After 10 Days

After 6 Months

Overriding Distal Radius Fxs

Prospective evaluation of overriding distal radius fractures (Hawaii)Crawford et al JBJS 2012

51 consecutive children, average 5 mm shortening on presentation

No formal reduction, SAC x 6 weeks

Final sagittal angulation 2.2° and final coronal angulation 0.8°

All children achieved radiographic union with full wrist motion

Cost of closed reduction or surgery ~5-6x and ~9x higher, respectively

Overriding Distal Radius Fxs

Injury

After 6 Weeks

After 2 Years

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Operative Indications – Distal Radius Fxs

Open fracture

Floating elbow

Displaced intra-articular fractures (Salter-Harris type III or IV)

Irreducible fracture or loss of reductionNeeds careful monitoring over first 2 weeksFriberg Acta Orthop Scand 1979, Houshian et al JPO 2004, Zimmermann Arch Orthop Trauma Surg 2004

Children 5-10 YearsAngulation > 20-25°Translation > 50%

Children > 10 YearsAngulation > 10°

Translation > 25%

Children < 5 YearsAngulation > 30-35°Translation > 50%

Operative Intervention

Only 2.7% of distal radius fractures undergo surgery at tertiary care children’s hospitalsMahan et al POSNA 2016

Considerations in Physeal Injuries

4.4-7.0% risk of physeal arrest following distal radius physeal fracturesCannata et al JOT 2003, Lee et al CORR 1984

43% risk of physeal arrest following SHIII and IV fracturesKallini JPO 2020

Does late or repeat attempt at reduction increase risk of physeal arrest? ProbablyLee et al CORR 1984

6/22 pts with ≥ 2 reduction or late attempts developed physeal arrest

1/78 pts with ≤ 1 reduction attempt developed physeal arrest

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Distal Radius Fx – Case 1 12 yo M

Injury

After 10 Days

Distal Radius Fx – Case 2 6 yo F

Injury

Reduction

After 3 Weeks

Distal Radius Fx – Case 2 6 yo F

After 6 Months

After 6 Weeks

After 3 Weeks

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Clinical Personation in Forearm Fxs

Fracture PatternsPlastic deformation

Greenstick

Complete

Comminuted

Fracture LocationDistal 1/3

Middle 1/3

*Proximal 1/3

Basic Principles of Forearm Fracture Care

“True” orthogonal radiographs

Closed reduction and castingFactor the mechanism into the primary reduction strategy

Long arm cast

Poor casting often due to excess padding & lack of three-point mold

Management influenced by remodeling potential of radius & ulna

Since 80% of radial growth occurs at the wrist, remodeling in proximal and middle third considerably less than distal third

Operative Indications – Forearm Fxs

Open fracture

Floating elbow

Unstable Monteggia fracture-dislocations

Failure of closed reduction or loss of reduction (careful monitoring over first 2-3 weeks)

F 8-12 & M 8-14 YearsAngulation > 10-15°Translation > 50%

F > 12 & M > 14 YearsMinimal Angulation or

Translation

Children < 8 YearsAngulation > 20°

Bayonet apposition ok

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Operative Indications – Forearm Fxs

Rotation > 45°Bicipital tuberosity and radial styloid should be opposite on the AP radiograph

Coronoid process and ulnar styloid should be 180° with limited cut CT

Isolated middle third radius fractures with ulnar displacement that significantly narrows the interosseous space

Proximal third fractures

Impact of Malunion on Forearm Rotation

Degree of AngulationMatthews et al JBJS 1982

10° angulation of a single bone does not compromise forearm rotation

10° angulation of both forearm bones results in a 10-20° loss of supination and pronation

20° angulation of a single or both bones results in a 40° loss of supination and pronation

Fracture LocationTarr et al JBJS 1984

Angular deformity in distal third fractures result in greater pronation losses

Angular deformity in middle third fractures result in greater supination losses

Both Bone Forearm Fx – Case 1

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Both Bone Forearm Fx – Case 2

Take Home Points

1. Management influenced by remodeling potential of radius & ulna

2. Overriding fracture of the distal radius generally acceptable

3. Surgery may be indicated in distal radius fractures with > 20-25°angulation in children < 10 years

4. 10° angular deformity in forearm fractures only concerning when both bones angulated

5. Beware of malrotation and collapse of the interosseous space

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1

DISCLOSURES

Lindley B. Wall, MD



Pediatric Hand Fractures:

Management and Remodeling

Lindley B. Wall, MD MSc

Washington University

Background

• Hand Injuries in Children

• 56% Nondisplaced

• 64% Nonphyseal

• Approx 75% are quite benign

• Key is to recognize problem injuries

• Phalangeal Neck

• Condylar Fractures

• Displaced Fractures

* Know what you can accept

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General Treatment

• Large soft tissue envelope

• Thick periosteum

• Healing is reliable in all cases*

• Physeal fractures rarely lead to growth arrest

• Angulation and displacement within the plane of

motion can remodel over time before skeletal

maturity

• Malrotation cannot

Examination

• Malrotation

• Flexion/Extension

• Deviation

• *If initial exam difficult, see back in

one week to reassess

Scaphoid Fracture

• Fall, higher energy

• Peak at 15 years old

• Very rare under 10 years old

• Physical Exam:

Snuffbox tenderness

Distal pole tenderness

Radial wrist pain with radial deviation

• (confirm with MRI)

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Scaphoid Fracture

• Usually nondisplaced

• Cast for 8-12 weeks

Scaphoid Fracture

• Displaced or proximal pole

• Open reduction, screw fixation

• Low threshold for CT to allow return to

activities

Metacarpal Fractures

• Thumb metacarpal base

• “Pediatric Bennett”

• Across growth plate and joint

• Needs anatomic reduction

• CRPP/ORPP/ORIF

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Metacarpal Fractures

• Thumb metacarpal base

• Extraarticular

• Excellent remodeling

• Multiple planes of motion

• Can be treated non-op…30o

• Significant displacement –

CRPP/ORPP

Metacarpal Shaft Fractures

• Check rotation

• Extensor lag due to shortening

• ORIF if unstable

• CRPP if transverse

• *Multiple metacarpals, do NOT

always need fixation

Metacarpal Neck Fractures

• Debate regarding acceptable

angulation

• Usually extraphyseal

• Check rotation*

• Assess digit extension

• Frequent recurrence

10

11

12

9/21/2020

5

Phalanx Fractures

• Phalangeal base

• SF “extra octave”

• Adduct to RF?

• Central digits

Cross-over, overlap

• Minimal/no angulation

• See back one week**

Phalanx Fractures

• Phalangeal base

• Cast/brace treatment

• Reduce under local anesthesia

If significantly angulated or malrotated

Buddy tape + cast

• CRPP

Unstable or unable to hold

Not amenable to local reduction

Phalanx Fractures

Thumb

• Skier’s thumb

• Collateral ligament avulsion

• Osteochondral injury

• Palmar and larger*

13

14

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9/21/2020

6

Phalanx Fractures

• Reduction and

fixation

• CRPP/ORPP

• ORIF

• Need 2 points of

fixation

Phalanx Fractures

• Phalangeal shaft

• Check rotation!

• CRPP/ORIF if rotated, shortened

Phalangeal Neck Fractures

• Usually displaced

• Frequently malrotated

• Adjacent to joint

• Minimal Intrinsic Stability

16

17

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9/21/2020

7


• Phalangeal neck

Remodeling?

Only occurs in the

plane of motion

Cannot be relied

upon


• Rotation and coronal plane angulation do

not remodel


• Pinning needed

• Closed reduction with osteoclasis

if necessary

• Must be done early (1-2 weeks)

• Avascular necrosis if reduction

done late or open

19

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8

Phalanx Condyle Fractures

• Intra-articular

• Unstable Injuries

• Fragment larger

• Not uniplanar

• Typically oblique fx line


• Need anatomic reduction

• Open dorsal approach

• Visualize in joint

• Clamp/pin

• Screw or K-wire fixation

• Need 2 to control rotation


• Malunion problematic

• Osteotomy for correction

• *Preserve vascularity

• Will NOT remodel

22

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9

Phalanx Fractures

• Beware of the Seymour fracture!

• Physeal fracture

• Open (Nail avulsed)

• Torn nailbed or periosteum

interposed

Phalanx Fractures

• Seymour fracture

• Needs operative treatment to

avoid osteomyelitis*, deformity,

growth arrest

Key Points

• Angulation and malrotation does NOT remodel

• Remodeling occurs in the plane of motion

• ? Age….do not rely in phalangeal necks

• Assess extension with metacarpal shortening

• Articular alignment matters in kids too

25

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10

Thank you

28



5:20 PM - 5:30 PM

Pediatric & Trauma Case Presentation

Mary Claire Manske, MD No relevant conflicts of interest to disclose

9/29/2020

1

DISCLOSURES




M. Claire Manske, MD

Shriners Hospital for Children Northern CaliforniaUniversity of California Davis, Orthopedic Surgery

Sacramento CA

• 23 month old female with a left thumb difference

• L thumb smaller than right

• Doesn’t use L thumb

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9/29/2020

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Left Right

4

5

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9/29/2020

3

• Diagnosis?

• Clinical Exam?

• Work up?

• Treatment plan?

• Spectrum of deficiency of the radial side of the upper extremity

• 5-15% of congenital hand anomalies

• 50% bilaterally affected, usually asymmetric

• 5 key features

• small, short, narrow thumb

• underdeveloped thenar muscles

• narrow first web space

• joint instability (MCP, CMC)

• extrinsic muscle deficiency

James MA, JHS, 1999 24A; 6: 1145-1155

7

8

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9/29/2020

4

• 5 key features

• small, short, narrow thumb

• underdeveloped thenar muscles

• narrow first web space

• joint instability (MCP, CMC)

• extrinsic muscle deficiency

Modified Blauth Classification

•Modified Blauth Classification

Type 2

•Modified Blauth Classification

Type 3A Type 3B

10

11

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9/29/2020

5

•Modified Blauth ClassificationType 4

•Modified Blauth ClassificationType 5

Reconstruction

• Type 2 and 3A thumbs (stable CMC)

• Webspace deepening (Z-plasty)

• Opponensplasty

• MCP stabilization

Ablation and Pollicization

• Type 3B, 4, 5 thumbs (unstable CMC)

13

14

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9/29/2020

6

• Assess thumb size, webspace, thenar eminence, finger creases (extrinsics), MCP stability

• Does child use thumb or bypass thumb for index finger (CMC status)

• Position of wrist, forearm

• Look at contralateral upper extremity (>60% bilateral, asymmetric)

• Full physical exam

• 67% with associated anomaly

• Severity of RLD predictive of associated anomaly

• Associated conditions

•Cardiac (20%)

•VACTERL (13%)

•Holt-Oram syndrome (4%)

•Fanconi anemia (1%)

•Scoliosis (23%)

•May take priority over upper extremity treatment Goldfarb CA, JHS 2006, 31A; 7: 1176-1182.

Wall LB, PRS 2013, 132; 1: 122-128.

•Complete physical exam

•CBC

•Echocardiogram

•Renal ultrasound

• Spine xrays

•Chromosomal challenge test

•Referral to genetics

• Associated conditions

•Cardiac (20%)

•VACTERL (13%)

•Holt-Oram syndrome (4%)

•Fanconi anemia (1%)

•Scoliosis (23%)

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9/29/2020

7

• Radiographs bilateral hands and forearms

• 3B thumb

– CMC unstable (x-ray, bypass)

– Pollicization

• 3A thumb

– CMC stable

– Reconstruction

19

20

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9/29/2020

8

• Skin incisions

• Ablate hypoplastic thumb, allow rotation of index finger into thumb position

• Elevate 1st dorsal interosseous→ ABP

• Exposed index metacarpal shaft

• Excise metacarpal shaft to shorten index finger

22

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9/29/2020

9

• Elevate 1st VIO→Adductor pollicis

• Release intermetacarpal ligament and RDA to long finger

• Secure metacarpal head in hyperextension

• Position index finger in thumb position

– 90-120° rotation & 40° palmar & radial abduction

• Attach intrinsic muscles

– 1stDIO→APB, 1st VIO→adductor pollicis

• Secure intrinsic muscles

• Close skin

25

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10

• Thumb hypoplasia is on the spectrum of RLD

– Bone, soft tissue, neurovascular structures

• Work-up for internal organ systems anomalies

• Modified Blauth classification/CMC stability is key to treatment

– 2, 3A thumbs: reconstruction

– 3B, 4, 5 thumbs: pollicization

28

29



6:26 PM - 6:46 PM

Physician Value

Daniel J. Nagle, MD No relevant conflicts of interest to disclose

9/2/2020

1

DISCLOSURES

Daniel J. Nagle, MD



Physician Value

RVUs

1

2

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9/2/2020

2

Pre World War II

No one cared Health Care CheapHealth Insurance

4

5

6

9/2/2020

3

InsurersHealth Insurance

Only sick people want insurance!!

7

8

9

9/2/2020

4

Adverse Selection!!

WWII

President Roosevelt

Inflation

10

11

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9/2/2020

5

October 4, 1942

Stabilization Act

Health Insurance

13

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6

Young Healthy

Adverse Selection

16

17

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9/2/2020

7

McCarran-Ferguson Act (1945)

Sen. Homer Ferguson (R-Mich)Sen. Pat McCarran (D-Nev)

Sherman Anti Trust Act

1940

10% 70%

1955

19

20

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9/2/2020

8

Major Medical

• Hospitalization

Office visit $5

Cheap Drugs

22

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9/2/2020

9

Low Tech

Pay the doctor

Insurance reimbursed the patient

25

26

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10

Usual and Customary

July 30, 1965

President Lyndon Baines Johnson

28

29

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11

Life expectancy 6615 % > 65 Yrs. uninsured <$500M

“…look like the worst kind of damn fool.”

LBJ 1965

31

32

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12

1970

$13,000,000,000

Costs

Advanced Technology

• CABG

• Transplantation

• CT (1972)

• MRI (1977)

34

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13

1986

•Life expectancy 75

•Medicare budget $106B

Too many peopleLiving too longUsing too much expensive technologyWith no skin the game

37

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14

Adverse Selection

40

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15

William Hsiao PhDWilliam Hsiao PhD

• Actuary Connecticut General Insurance

• Head Actuary of Medicare

• Professor of Economics Harvard

• Consultant to Carter, Nixon, Ted Kennedy on

National Health Insurance

RBRVS

ResourceBasedRelative ValueScale

43

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9/2/2020

16

RELATIVE

VALUE

UNITRVU

Objective method to value

physician services

46

47

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17

Quantify the real cost

of physician services

quantify the relative cost

of physician services

Magnitude Estimation

49

50

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18

52

53

54

9/2/2020

19

Relative Value

•Physician Work

•Practice Expense

•Professional Liability Insurance

55

56

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20

PHYSICIAN WORK

Technical skill and physical effort

Mental effort and

judgmentTime

Stress due to

the potential

risk

Work

Practice Expense

Liability Insurance

Opportunity cost& debt

Education debt$200,000

58

59

60

9/2/2020

21

$800,000 $300,000

33 years old

Opportunity cost v a v plumber = $500,000

$700,000

61

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22

“Practice Expense” / Overhead

PRACTICE EXPENSE

19 Step Calculation

Imbedded Budget Neutrality Adjustment

Discount Direct Expense

40%!

DiscountIndirect Expense

61%!

64

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23

Should

Attorney RBRVS

67

68

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24

?

Relative Value?

Ludwig von Mises

70

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25

Economic Calculations in the Socialist Commonwealth 1920

There is no way to calculate the Relative Value of services and products outside of a free market.

There is no “intrinsic universal” valueof a service or product.

There is only the perceived valueas defined by the individual consumer.

The market is the most efficient at determining the “natural

price.”

1776

73

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26

“Results, Potential Effects and

Implementation Issues of the

Resource-Based Relative Value Scale”Wm Hsiao, Ph.D., Peter Braun, M.D.

JAMA, Oct. 28, 1988, Vol. 260, No. 16

• “Standardize Payments, Rationalize Incentives and Influence Physician Decisions.”

• “Provide a Neutral Incentive Structure”

• “Enhance Cost Effectiveness and Ameliorate Manpower Shortage in Primary Care.”

Translation

Physician Fees

76

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27

Proceduralists Primary Care

RBRVS

Calculate Intrinsic Value

79

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28

Intrinsic Value

Ignores the value perceived by the patient.

« Interchange » 1955 Willem de Kooning

$300,000,000

82

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29

Market based physician fees

R.I.P.

OBRA 1989

2019 CV $36.05/RVUPE

$193.08/HR

Code DescTotal time Total Fac $ Fac $/hr vs PPIS PE

Total Non Fac $ Non Fac $/hr vs PPIS PE

P&L / Hr P&L / Hr

25600Closed Rx

DR 108 $319.68 $177.60 -$15.48 $339.12 $188.40 -$4.68

25607 Orif Fx DR 275 $760.31 $165.89 -$27.19

25608 Orif Fx DR 305 $853.55 $167.91 -$25.17

25609 Orif Fx DR 358 $1,085.03 $181.85 -$11.23

64721 OCTR 171 $441.72 $154.99 -$38.09 $444.24 $155.87 -$37.21

25000 DeQ 135 $348.12 $154.72 -$38.36

26055 Trigger 154 $320.40 $124.83 -$68.25 $574.91 $223.99 $30.91

25447 CMC 278 $857.87 $185.15 -$7.93

26123 Dup 308 $863.63 $168.24 -$24.84

99203 OV New 29 $109.80 $227.17 $34.09

99213 OV Est 23 $74.16 $193.46 $0.38

And Then

85

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30

Value Based Payment

Fee for service is Evil

88

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31

Advanced AlternativePayment Models

ACA

MACRA

Reauthorization

Medicare

Access

CHIP (Children’s Health Insurance Program)

Act

April 16, 2015

91

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32

SGRQUALITY

PAYMENT PROGRAMQPP

PQRS EHR

VBM

MIPSMerit-Based Incentive Payment System

By implementing MACRA to promote participation in certain APMs, …., we support the nation’s progress toward achieving a patient-centered health care system …we are while finalizing a program that emphasizes high-quality care and patient outcomes minimizing burden on eligible clinicians and that is flexible, highly transparent, and improves over time with input from clinical practices.

94

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33

16 17 18 19 20 21 22 23 24 2526 & on

Fee

Schedul

e

97

+0.5% each year

No change

+0.25%or

0.75%

MIPS

AAPM

4 5 7 9 9 9Max Adjustment

(+/-)

+5% bonus(excluded from MIPS)

MIPSZero sum game

97

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99

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34

16 17 18 19 20 21 22 23 24 2526 & on

Fee

Schedul

e

100

+0.5% each year

No change

+0.25%or

0.75%

MIPS

AAPM

4 5 7 9 9 9Max Adjustment

(+/-)

+5% bonus(excluded from MIPS)

OFFICE OF THE ACTUARY

DATE: April 9, 2015

FROM: Paul Spitalnic Chief Actuary CMS

SUBJECT: Estimated Financial

Effects of the Medicare Access and

CHIP Reauthorization Act of 2015

(H.R. 2)

Paul Spitalnic

MACRA Impact

“…. physician payment updates are not expected to keep

pace with the average rate of physician cost increases…we

expect access to Medicare-participating physicians to

become a significant issue in the long term…”

100

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35

Reauthorization

Medicare

Access


Act

“MIPS cannot be saved.”

Medicare Payment Advisory Commission

MedPAC

• Burdensome and Complex

• Information is not meaningful

• Will not Improve value

• Will not reward value based care

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36

Almost closing thoughts

The Resource Based Relative Value Scale

Practice Expense

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Reauthorization

Medicare

Access


Act

DOUBLETHINK

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38

Physician ValueLess

0.04 RVU / Minute$86.40 / Hour

Job hourly rate annual rate Barista $ 10.35 $ 21,528.00

Plumber $ 26.35 $ 54,808.00 Electrician $ 26.87 $ 55,889.60

Elementary school teacher (181 d/yr) $ 34.53 $ 50,000.00

Fireman $ 37.02 $ 77,000.00 Police officer $ 38.46 $ 80,000.00

Chef $ 58.70 $ 85,000.00 Pharmacist $ 65.00 $ 135,200.00

Lawyer (50hr / wk) $ 72.12 $ 150,000.00

Medicare MD payment $ 86.40 Golf (median) $ 302.88 $ 630,000.00 NFL (median) $ 413.46 $ 860,000.00

MLB (median) $ 721.15 $ 1,500,000.00

NHL (Ave) $ 1,153.85 $ 2,400,000.00

NBA $ 1,201.92 $ 2,500,000.00

CEO hospital largest $ 3,125.00 $ 6,500,000.00

CEO fortune 500 $ 4,807.69 $ 10,000,000.00 CEO Aetna Mark

Bertolini $28,221.15 $ 58,700,000.00

112

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39

Sen. Homer Ferguson (R-Mich)Sen. Pat McCarran (D-Nev)

Repeal

McCarran-Ferguson Act (1945)

115

116

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40

Executive Order 10-17 (Business Association Insurance - Rules Released 1-18)

• Small business groups to form

Intra and Inter-state health

insurance plans

Allow physician owned hospitalsEliminate Certificate of Need

Just a few more thoughts

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41

We are NOT the problem

Physician and Clinical Services 20%

(8% MC Budget)

Uncontrollable cost driversSenescence (63% healthcare expenditure last years of life)Obesity (10% of healthcare costs)

Life style

121

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42

We are the good guys

Honesty and Ethics

In Professions

2018

124

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43

#1#2

Thank you

127

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129



6:46 PM - 6:56 PM

Hand/Finger Flaps

Michael J. Franco, MD No relevant conflicts of interest to disclose

9/21/2020

1

DISCLOSURES




Finger and Hand Flaps

Michael J Franco MD

Cooper University Hospital, Camden NJ


• Overview

- V-Y flap

- Cross finger flap

- Thenar flap

- Homo-digital Island flap (anterograde and retrograde)

- First Dorsal Metacarpal Artery Flap (FDMA flap)

1

2

3

9/21/2020

2


• Indications

- Injuries of the finger or thumb not amenable to healing by primary

closure, secondary intention, skin graft or skin graft substitute

- exposure of critical structures (bone, tendon denuded of

paratenon, blood vessels, nerves

- a flap may be needed to expedite healing or allow for earlier range

of motion therapy

V-Y flap

• V-Y Flap is indicated for finger-tip amputations with exposed bone

• Amputation origin needs to be transverse of slight dorsal oblique

• The proximal part of the “V” is at the DIPJ flexion crease

• Dissection goes down to periosteum and flexor sheath. The blood supply is maintained through septi

• The flap is advanced several millimeters and can be anchored to the nail plate if intact

• The proximal part is closed in a line


• 21 yo M s/p avulsion crush injury to R ring finger with open distal phalanx fracture

• Exposed bone and flexor tendon• Wound size 2x2 cm

4

5

6

9/21/2020

3

Cross Finger Flap - markings

• This is a random pattern fasciocutaneous flap

• The blood supply is left intact on the side adjacent to the injured finger

• The flap is raised subfascial in a loose areolar plane, leaving the paratenon intact

Cross Finger Flap – flap inset

• The inset is done along 3 sides being careful to protect the ”hinge”

• The donor site gets a full thickness skin graft harvested from the forearm or groin area

• A bolster is applied to the skin graft and the flap is dressed withnon-stick gauze and a splint is applied

• I do not typically pin or suture the fingers together

• Plan for division at 2-3 weeks

Cross Finger Flap – 2 weeks post inset

7

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9/21/2020

4

Cross Finger Flap – 1 week post division

Cross Finger Flap – 3 months post op


10

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9/21/2020

5


Cross Finger Flap – 6 month post op


• 20 yo F, RHD, cashier• 2x2 cm defect L LF with

exposed distal phalanx

13

14

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9/21/2020

6

Thenar Flap

• The flap can be designed proximally or distally based

• I chose the ”H” type design for maximum freedom

Thenar Flap

• The flap is elevated about the neurovascular bundles

• In this case, a portion of the flap was re-inset though both limbs were used

• A non-stick dressing is applied and bulky gauze with a dorsal blocking splint (though this is not critical.

• Again, I do not ”protect” the flap by placing any other sutures

• Plan to divide the flap at 2-3 weeks

Thenar Flap

16

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9/21/2020

7

Thenar Flap – post division

Thenar Flap – 6 weeks post op


19

20

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9/21/2020

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- 25 yo M, manual laborer

- Crush avulsion injury R LF

- Exposed distal phalanx and tendon

- Nail matrix partially intact



22

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9/21/2020

9

Homodigital Flap - midlateral design

• This is a neurovascular island flap• This should be a sensate flap to the

finger tip (as opposed to the thenar and cross finger flap)

• Approximately 2x2 cm flap is designed centered on the pedicle

• This could have a more volar skin paddle or be designed as a “reverse” flap based on retrograde flow. Though the nerve is not included in the reverse flap typically.

Homodigital Flap – midlateral design


• A midlateral incision is made with a zig-zag component into the palm to allow for pedicle dissection and distal excursion of the flap

• Bipolar cautery and or micro clips are used for hemostasis as many small vessel branches or sacrificed

• This flap can be raised a more of an extended V-Y with less direct pedicle dissection

25

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28

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Homodigital Flap

Homodigital Flap

Homodigital Flap – 3 months post op

31

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9/21/2020

12


Photo from Aravind Pothula, MD

• 30 yo M, mechanic• Thumb avulsion/degloving• Treated with bilayer dermal

matrix and skin graft• Erosion of bone at distal

aspect


Photo from Aravind Pothula, MD

• The First dorsal metacarpal artery can often be dopplered out pre op (note: the radial artery is near by in the snuff box, so this signal can be confused)

• Approximately 3x2 flap is designed over the dorsal proximal phalanx with the PIPJ as the distal point.

• The ulnar proximal aspect of the skin paddle is curved to keep it out of the 2nd

web space• A curvilinear incision is designed over

the pedicle

FDMA Flap

• The flap is raised above the paratenon distally and can include the fascia above the dorsal interosseus muscle

• This skin flaps are raised maintaining the fat and soft tissue about a wide vascular leash

• The pedicle is not skeletonized• Dissection stops proximally

before the artery is encountered or until the reach is obtained

34

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FDMA Flap

FDMA Flap

• The flap can be placed through a wide tunnel

• The donor defect is skin grafted• A non stick guaze is applied and

a bulky dressing and splint

FDMA Flap

`

37

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FDMA Flap - complication

`

FDMA Flap

`

FDMA Flap

`

40

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15

FDMA Flap

`

FDMA Flap

`

Alternative Finger Flap

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16



Thank You

46

47



6:56 PM - 7:09 PM

Arthritis Case Presentation

Eric R. Wagner, MD ● Consulting Fee: Stryker, Wright Medical

● Contracted Research: Arthrex

9/21/2020

1

Wrist Arthritis Case Presentation

Eric R. Wagner, MD MSDivision of Upper Extremity Surgery

Department of Orthopaedic Surgery

Director of Upper Extremity Research

Emory University, Atlanta GA

[email protected]

773-203-5400

Product of My Mentors

1

2

3

9/21/2020

2

Case: 40 y/o M c Advanced Wrist OA

▪ HPI: Progressively worsening pain

▪ No prior wrist surgeries, 2 prior injections, 6 months PT/OT

▪ WSV 20%, VAS 8/10

• SH: home remodeler, enjoys golfing and lifting weights

• 20 pack year smoker, “quit 3 months ago”

• Exam: TTP at radioscaphoid articulation

• Pain with any motion

• +Watson Shift Test


Work-up

Treatment Options

Considerations

Wrist Arthritis

Etiologies

4

5

6

9/21/2020

3

Wrist Arthritis

Etiologies

Work-up

Treatment Options

Considerations

Wrist Arthritis: Etiologies

SLAC SNAC Inflammatory

Kienbocks Preissers

SLAC

Etiologies

SNAC

Kienbocks

Preissers

Rheumatoid

Arthritis

1972

What direction does lunate rotate after SLIL injury?

7

8

9

9/21/2020

4

SLAC

Etiologies

SNAC

Kienbocks

Preissers

Rheumatoid

Arthritis

1972

SL → DISI LT → VISI

SLAC

Etiologies

SNAC

Kienbocks

Preissers

Rheumatoid

Arthritis

What are the stages of SLAC Arthritis??

SLAC

Etiologies

SNAC

Kienbocks

Preissers

Rheumatoid

Arthritis

10

11

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5

SLAC

Etiologies

SNAC

Kienbocks

Preissers

Rheumatoid

ArthritisGiuffre et al. Hand Clin 31 (2015) 267–275

SLAC

Etiologies

SNAC

Kienbocks

Preissers

Rheumatoid

Arthritis

What are the stages of SNAC Arthritis??

SLAC

Etiologies

SNAC

Kienbocks

Preissers

Rheumatoid

ArthritisWhite et al. J Am Acad Orthop Surg 2015;23:691-703

13

14

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6

What is the likely Diagnosis???

SLAC

Etiologies

SNAC

Kienbocks

Preissers

Rheumatoid

Arthritis

1910

SLAC

Etiologies

SNAC

Kienbocks

Preissers

Rheumatoid

Arthritishttps://www.orthobullets.com/hand/6050/kienbocks-disease?expandLeftMenu=true

What are the risk factors for Kienbocks?

16

17

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9/21/2020

7

SLAC

Etiologies

SNAC

Kienbocks

Preissers

Rheumatoid

Arthritis

➢Risk Factors

➢Ulnar negative, decreased radial inclination

➢Variable vascularity to lunate (Y, X, I)

➢Disruption of venous outflow → AVN???

https://www.orthobullets.com/hand/6050/kienbocks-disease?expandLeftMenu=true

SLAC

Etiologies

SNAC

Kienbocks

Preissers

Rheumatoid

Arthritis

What are the stages of Kienbocks?

SLAC

Etiologies

SNAC

Kienbocks

Preissers

Rheumatoid


Stage 1 Stage 2

Stage 3 Stage 4

19

20

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8

What is the Diagnosis???

SLAC

Etiologies

SNAC

Kienbocks

Preissers

Rheumatoid


What about these???

22

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9

Etiologies

SLAC

SNAC

Kienbocks

Preissers

Rheumatoid

Arthritis

Ankylotic

Secondary OA

Erosive

Courtesy of Marco Rizzo

Zig Zag

➢Carpus: Supination, volar displacement + ulnar translocation, radial deviation

➢MCP: Ulnar deviation

What is classic deformity in Rheumatoid Wrist???

Etiologies

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Work-up

Treatment Options

Considerations

Wrist Arthritis

Etiologies

Work-up

Wrist Arthritis

Etiologies Treatment Options

Considerations

Wrist Arthritis: Evaluation

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Scapholunate Injury

White et al. J Am Acad Orthop Surg 2015;23:691-703

SL Angle >70oLunate Extension >10o


What advanced imaging is indicated for patients with wrist arthritis?

What examination findings???

Wrist Arthritis: Examination

Watson Shift Test

Gelberman et al. J Bone Joint Surg Am. 2000;82:578.

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Wrist Arthritis: Examination

Wrist Arthritis: First Step???

➢Activity Modification +/- Splints

➢NSAIDS

➢Injections: corticosteroids, “biologics”

Nonoperative

Work-up

Treatment Options

Considerations

Wrist Arthritis

Etiologies

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Work-up

Wrist Arthritis

Etiologies Treatment Options

Considerations

What are the Surgical Options???

Strauch J Hand Surg 2011;36A:729–735Total Wrist Fusion

PRC

PIN/AIN

4CF CL

TWA

PIN/AIN

Wrist Arthritis: Treatments

PRC

4CA

CL

TWA

TWF

1998

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38

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PIN/AIN


PRC

4CA

CL

TWA

TWFPartial denervation of the wrist: a new approach, Berger, Tech Hand UE Surg, 1998

PIN/AIN


PRC

4CA

CL

TWA

TWFPartial denervation of the wrist: a new approach, Berger, Tech Hand UE Surg, 1998

PIN/AIN


PRC

4CA

CL

TWA

TWF

1944

40

41

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PIN/AIN


PRC

4CA

CL

TWA

TWF

PIN/AIN


PRC

4CA

CL

TWA

TWF

1985

PIN/AIN


PRC

4CA

CL

TWA

TWFAmotz and Sammer, Hand Clin 31 (2015) 495–504

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PIN/AIN


PRC

4CA

CL

TWA

TWF

1966

PIN/AIN


PRC

4CA

CL

TWA

TWFAmotz and Sammer, Hand Clin 31 (2015) 495–504

PIN/AIN


PRC

4CA

CL

TWA

TWF 1973

1977

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47

48

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1st Generation

Swanson

2nd Generation

Meuli Volz


3rd Generation

Biaxial Universal

4th Generation

Remotion Maestro

PIN/AIN


PRC

4CA

CL

TWA

TWF

1942

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50

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PIN/AIN


PRC

4CA

CL

TWA

TWF

PIN/AIN


PRC

4CA

CL

TWA

TWF

Weiss et al. (J Hand Surg 2007;32A:725–746

Work-up

Treatment Options

Considerations

Wrist Arthritis

Etiologies

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Treatment Options

Work-up

Wrist Arthritis

Etiologies

Considerations


▪ HPI: Progressively worsening pain

▪ No prior wrist surgeries, 2 prior injections, 6 months PT/OT

▪ WSV 20%, VAS 8/10

• SH: home remodeler, enjoys golfing and lifting weights

• 20 pack year smoker, “quit 3 months ago”

• Exam: TTP at radioscaphoid articulation

• Pain with any motion

• +Watson Shift Test


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Case: 40 y/o M Laborer c Wrist OA

▪ Plan?➢Selective Neurectomy (AIN/PIN)

➢Proximal Row Carpectomy (PRC)

➢ Three or Four Corner Arthrodesis (3CF or

4CF) + Scaphoidectomy

➢Capitolunate Arthrodesis (CLA) +

Scaphoidectomy

➢ Total Wrist Arthroplasty (TWA)

➢ Total Wrist Fusion (TWF)


6 months postopWSV 75%VAS 2/10

Wrist Arthritis: Considerations

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Considerations

➢<45 years old

➢4CA (n=51): 11 years follow-up

➢PRC (n=38): 16 years follow-up

Considerations

Thank you for your time!

[email protected]

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7:11 PM - 7:31 PM

Nightmare Cases: Lessons I Learned Early

in Practice

Curtis M. Henn, MD | Brandon S. Smetana, MD

Curtis M. Henn, MD



● Consulting Fees: Axogen

● Speakers Bureau: Axogen

Lessons I Learned Early in Practice Curtis M. Henn, MD


1. Lesson #1: You Don’t Know What You Don’t Know a. Pay attention to Details b. Debrief c. Take Notes

2. Lesson #2: Be Wary of the “Home Run” cases

a. Look for the snakes in the grass b. Make your life easier always, but especially earlier on c. Extra help (partners), imaging, larger exposures d. Diminish variables e. Keep it simple

3. Lesson #3: Do not be afraid to ask for help

a. Use your lifelines i. Mentors

ii. Residents iii. Co-fellows iv. Partners v. Communities (ASSH)

4. Lesson #4: The best made plan does not always pan out

a. Have bail outs available b. Mental or physical walk through preop

9/21/2020

1

DISCLOSURES

Curtis M. Henn, MD



Nightmare Cases: Lessons Learned in

the First Years of PracticeCurtis M. Henn, MD

MedStar Georgetown University Hospital

Case 1: 2nd opinion

• 41M 3.5 months s/p distal humerus ORIF through olecranon osteotomy

• Referred by the therapist for a second opinion after she saw his X rays

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H&P

• Doing specialized pull up and fractured humerus

• 3 days later underwent ORIF

• Immobilized 2 weeks then initiated therapy

• Revision surgery discussed at most recent follow up

• Some mild pain, no improvement in ROM in about a month

• Wound healed, tender over olecranon

• 45-90 elbow ROM, NVI

What do you tell the patient?

Key Points

• You were not there

• Avoid throwing others under the bus

• Lay out options going forward

• Get more information

• Consider contacting the previous surgeon

(with patient’s permission)

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More Information:

More Information (cont)

Plan?

• More therapy?

• Revise the olecranon?

• Revise both?

• Revise with contracture release, excision HO?

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1 week s/p revision of humerus and olecranon, excision HO

6 weeks postop

• No pain

• NVI

• Wound healed

• 40-120 degrees of elbow motion

6 weeks postop

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Now what?

• BE HONEST

• Take your time

• Do not be afraid of second opinions

(within your group or community)

• Recruit your mentors, partners, colleagues

• Keep the patient close

(phone or frequent visits)

Plan:

• Discussed with partner and fellowship mentor

• Agreed with plan for revision with small plates, ICBG, no contracture

release

• Obtained labs – metabolic bone disease

• Send cultures

6 days s/p revision #2- ORIF with ICBG

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6 weeks s/p revision #2

• 45-80 ROM

• No pain

• Some clicking with ROM

• Start passive ROM?

Good News / Bad News

Now what?

• BE HONEST

• Keep the patient close

• Joint decision-making

• Enlist assistance – mentors/colleagues

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Intraop

• Removed the screw but the plate was still impinging

• Diamond-tip burr to remove proximal part of plate

• Unable to achieve last 30 degrees of extension despite removing

olecranon fossa HO

• Called partner who came to the OR and ultimately scrubbed in to help

achieve full ROM

Take Photos

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• Full normal elbow use

• Deadlifts 390 pounds

• ROM 30-125

Final Follow up

Take Homes

• Be humble when seeing second opinions – you were not there… and you

could always make the patient worse

• Be honest with yourself and with your patients

• Enlist the help of others – mentors (formal and informal), partners,

classmates, community colleagues

• Keep your complications close

Thank You

Curtis M. Henn, MD

[email protected]

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7:31 PM - 7:41 PM

Ethics: COI

Felicity Fishman, MD No relevant conflicts of interest to disclose

9/21/2020

1

DISCLOSURES




Conflicts of Interest

Residents & Fellows ConferenceASSH 2020


Associate Professor, Loyola University Medical Center

Shriners Hospital for Children- Chicago

COI Overview

• I have nothing to disclose

• No consulting arrangements with industry

• Academic practice → no shares in MRI,

OT, DME, surgery center

• No research funding with industry

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What is a Conflict of Interest?

• A set of conditions in which professional judgement

concerning a patient’s welfare or validity of research

can be influenced by financial gain:

• Examples: paid speaking engagements, gifts, travel, owning

of company shares (Dennis Thompson NEJM 1993)

• A conflict of interest may promote bias that distracts

from primary goal → patient care

What is a Conflict of Interest?

• COI have the potential to skew decision making that

might possibly impact patient care adversely

• COI can arise in professional setting when secondary

interest can distract from primary interest (financial

gain distracts from patient centered care)

Bias Stemming from COI

• Deliberate → surgeon intentionally chooses particular

device/implant due to a financial relationship with

manufacturer

• Unconscious influence → choose device due to a

favorable relationship with manufacturer

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Categories of Conflict of Interest• Industry Relationships:

• Medical devices/Implants, consulting

arrangements

• Research Funding

• Educational courses → teaching, resident

education

• Provider Self-Referral

• MRI, OT, DME, Surgical Centers, Specialty

Hospitals

Why do we have to disclose COI?

• Disclosing COI is an attempt at transparency

• Allows “learner” or patient to be informed as to

possible conflicts/biases and make their own

determinations

Official COI Statements

• Majority of professional medical societies

have adopted a formal statement

regarding COI

• Many healthcare corporations and

academic institutions have also created

formal statements

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ASSH

• The Hand Care Professional shall regard responsibility to the patient as

paramount.

• The practice of medicine inherently presents potential conflicts of interest.

Hand Care Professionals must be aware of the potential negative

implications of professional-industry relationships, and other areas of

potential conflict, and not allow conflicts to compromise patient care.

• Whenever an actual or potential conflict of interest arises, it must be

disclosed and resolved in the best interest of the patient

AAOS: Physician-Industry Relations

• Generally acceptable for industry to provide financial

and other support to physicians if support has

substantial educational value and contributes to

improving patient care

• Anything received that could be perceived as

influencing the physician’s obligation to act in the best

interest of the patient is considered a conflict of

interest

AAOS: Physician-Industry Relations

• It is unacceptable for physicians to receive subsidies

from industry to defray the cost of attending a meeting

or for third party CME courses

• Industry can support CME meetings by offering grants,

hosting hospitality receptions and providing support for

residents in training

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AAOS SOP Regarding COI

• If anything of significant value is received from industry → a potential

conflict exists which should be disclosed

• Must disclose financial interest in procedure/device/implant if the surgeon

is connected with or has received anything of value from inventor

• Must disclose if surgeon is reporting on research involving device/procedure/implant

• Reimbursement of administrative costs in conducting or participating in

scientifically sound research clinical trial is acceptable

ASPS

• Each leadership year, all Officers, Directors, Trustees, Judicial

Council members, ASPS / PSF / PSPS Committee,

Subcommittee, Work Group and Task Force leaders and

members, and the Editorial Boards of PRS and PRS-Global

Open (“Volunteer Leaders”) must submit an online COI form

• Cannot use affiliation with ASPS to promote anything that may

fall within a COI

• COI statement also provides a framework to resolve conflicts

The Physician –Industry Relationship is Complex…

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OIG of the Dept of Health & Human Services

• Reimbursement for valid research expenses is appropriate

• Appropriate to have salary support for research staff and

equipment needs

• Must disclose support from industry and financial relationships

• Must avoid bias favorable to company funding research

Physician Self-Referral

• 5 major fraud and abuse laws

that apply to physicians

• False Claims Act

• Anti Kickback Statue

• Physician Self Referral Law

(Stark law)

• Exclusion Authorities

• Civil Monetary Penalties Law


• Many realms in which the physician can “self-refer”

• As the practice of medicine became less lucrative,

physicians sought alternative ways in which to improve

income

• MRI, OT, DME, Surgical centers, specialty hospitals

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• # of ASCs ↑ 35% between 2000-2004 with 83% of

existing centers partly or wholly owned by physicians

• Ownership of a facility in which you refer a patient is a

COI

• Secondary interest (income from increased service) has

potential to bias physician's primary interests in patients

welfare

Physician Self-Referral• Stark Laws – federal law prohibits physicians from referring

Medicare or Medicaid beneficiaries for “designated health

services” if the physician or their immediate family have

ownership or investment interests in the entities or comp

arrangements

• Need to disclose ownership in specialty hospitals

• “In-office” or “within practice” exceptions

How do you disclose COI?

• Industry Relationships:

• Most organizations, health care corporations and academic

medical centers have a policy on COI

• Many require annual updating of COI statement/agreement online

• Journals require COI with each submission of a manuscript

• COI slide typically required for all presentations at meetings

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How do you disclose COI?

• Financial Interests/Self Referral-

• Infrequently disclosed directly between surgeon and patient

• Typically a handout either within surgical packet or

initial paperwork when first entering the practice

Sunshine Act (2010)• “Open Payments Program”

• Intention was to ↑ transparency in the financial relationships

between the pharmaceutical and medical device industry and

certain types of health care providers

• Manufacturers of devices, medical supplies, biologics and

group purchasing organizations have to annually submit info

about payments and transfers of value made to “covered

recipients” in the preceding calendar year

“Open Payments Program”

• Originally, only physicians and teaching hospitals were

included

• “Covered recipients” expanded in 2019

• includes PAs, NPs, Clinical Nurse specialists, CRNAs, Certified

nurse midwives

• After 2013, all Payments to physicians and institutions

of > $10 must be reported and info must be retrievable

on searchable databases

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CMS Open Payments Data (2014)

• https://openpaymentsdata.cms.gov/

Is Simple Disclosure Enough?

• Are COI declarations at CME events largely perfunctory?

• By simply making a declaration, has the speaker provided adequate proof of

COI?

• 71% of surgeons, 39% of learners, 35 % of internist felt COI slide was adequate

• 68% felt that amount of money should be declared

• Halo effect →declaration of possible conflict makes presenter more

believable (roughly 50% of all groups)

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https://openpaymentsdata.cms.gov/

9/21/2020

10

How do Patients view Conflicts of

Interest?

• Patients given a form with financial disclosures when

they arrive for informed consent appointment (preop)

• Patients were concerned if physician was paid by a

company that made a product for the surgery

• 50% of patients said they would still have surgery with

a surgeon who developed the prosthesis

• Only 47% were aware of FCOI and only 55% wanted to

learn of the FCOI

• Patients have a poor understanding of FCOI

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Summary• Consider your own relationships with industry carefully

• Evaluate your own potential for bias due to interactions with industry

• Always disclose any financial or other relationships with

industry in appropriate fashion (hospital, journal, meetings)

• Disclose physician involvement in ancillary services when

recommending to patient

• Honesty and transparency is the best policy

Thank you!

• Any questions?

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7:41 PM - 7:55 PM

Ethics: Burnout

Scott D. Lifchez, MD, FACS ● Ownership Interests: Co-founder and equity holder of EduMD, LLC, an educational

assessment company that makes the Operative Entrustability Assessment surgical assessment

tool.

9/21/2020

1

DISCLOSURES


Ownership Interests: Co-founder and equity

holder of EduMD, LLC, an educational

assessment company that makes the

Operative Entrustability Assessment surgical

assessment tool.

Burnout: Maintaining the Joy

of Hand Surgery PracticeScott D Lifchez, MD, FACS

38th Annual Adrian Flatt Resident & Fellows’ Conference

September 30, 2020

Disclosures

• Scientific advisory board of EduMD, LLC

– MileMarker, OEA surgical assessment tools

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Burnout Is

• Emotional exhaustion,

depersonalization

• Decreased sense of personal

accomplishment due to work-

related stress

• Consequences:

– Fatigue

– Inefficiency

– Errors

– Suicide

Burnout Among Physicians

• 2014 Shanafelt (6880

physicians):

– 54.4% met criteria for burnout

(10% from 2011)

– Much higher than general

population

• 2009 ACS (7905 surgeons)

– >40% met criteria

• 2000 Physician Work Life Study

– Burnout symptoms 60% more

frequent among women physicians http://www.newdiaspora.com/dr-burnout/

Burnout Among Hand Surgeons

• No data specific to hand surgeons

• Plastic Surgeons

– ASPS members (Faculty): about 30%

– Residents up to 33%

• Orthopedics (Sargent 2011- 384 residents, 264 faculty):

– Faculty: 15% depersonalization, 28% emotional exhaustion

– Residents: 55% depersonalization, 32% emotional exhaustion

• Worse for residents in larger programs

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http://www.newdiaspora.com/dr-burnout/

9/21/2020

3

Maslach Burnout Inventory

• Burnout (section A)

– <17: Low-level

burnout

– 18-29: Moderate

burnout

– >30: High-level

burnout


• Depersonalization

– <5: Low-level burnout

– 6-11: Moderate

burnout

– >12: High-level

burnout


• Personal Achievement

– <33: High-level burnout

– 34-39: Moderate burnout

– >40: Low-level burnout

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Reminders of How Hard We

are Working are Everywhere

June 8, 2019

What Can We Do

About It?

The Rest of the Story

• What I won’t cover (but is still important)

– Systems issues

– Practice/Health system

• Contracts

• Billing/Reimbursement

• EMR

– Pressures outside of work

– Double binds/Moral Injury

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Self-Care is Part of Our Job

• Resources available in health system/hospital

– Readily available

• Including after hours if needed

– Often free

• Avoid stigmatizing

• Modeling self-care promotes other team

members doing this as well• Johns Hopkins: mySupport

Aspects of Wellness

• Nutrition

– Healthful food options, scheduled time to eat

• Fitness

• Emotional health

• Mindset and behavior adaptability

• Preventive care

– Dental care, provisions to see a primary care physician

• Financial health

– Debt management, retirement planning emergency fund support

Mindfulness-Based Stress

Reduction• Focus on being present in current

moment

• Practice at home and in work environment– Mental exercises

• Meditation

• Gratitude journal

– Physical exercises• Yoga

• Sports

https://www.magzter.com/articles/6166/151600/56c4e157dae11

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https://www.magzter.com/articles/6166/151600/56c4e157dae11

9/21/2020

6

Mindfulness-Based Stress

Reduction• Focus on being present in current moment

• Practice at home and in work

environment

– Mental exercises

• Meditation

• Gratitude journal

– Physical exercises

• Yoga

• Sports

– Prospective studies show this actually workshttps://www.mindful.org/10-

ways-to-define-mindfulness/

Promoting Resilience

• Resilience:

– Ability to “bounce back” from negative event

– Grow from situation

• Need to recognize self when stressed

– Fatigue, irritability, feeling outside “comfort zone”

• Use resources

– Peer support

– Mindfulness

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https://www.mindful.org/10-ways-to-define-mindfulness/

9/21/2020

7

Takeaways

• Control the things you can control

– Mental state, mindfulness

– Nutrition & overall wellness

– Approach to how you interact with colleagues/others around

you

• Be aware of system issues

– Participate to improve these if you have opportunity

Acknowledgements

• ASSH Burnout Task Force (2019)

– Sanj Kakar (MBBS) chair

• Erin Gillard, LCSW

– Hopkins mySupport

Resources Available

• American College of Surgeons

– https://www.facs.org/member-services/surgeon-wellbeing/ps328

• American Medical Association

– https://edhub.ama-assn.org/steps-forward/pages/professional-well-being

• American Orthopedic Association

– https://journals.lww.com/jaaos/Fulltext/2016/04000/Orthopaedic_Surgeon_B

urnout___Diagnosis,.1.aspx

• American Society of Plastic Surgeons

– https://journals.lww.com/plasreconsurg/Fulltext/2019/08000/A_Growing_Epi

demic__Plastic_Surgeons_and_Burnout_A.46.aspx

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https://www.facs.org/member-services/surgeon-wellbeing/ps328

https://edhub.ama-assn.org/steps-forward/pages/professional-well-being

https://journals.lww.com/jaaos/Fulltext/2016/04000/Orthopaedic_Surgeon_Burnout___Diagnosis,.1.aspx

https://journals.lww.com/plasreconsurg/Fulltext/2019/08000/A_Growing_Epidemic__Plastic_Surgeons_and_Burnout_A.46.aspx

9/21/2020

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Additional Reading:

• Ames SE, Cowan JB, Kenter K, Emery S, Halsey D. Burnout in Orthopaedic Surgeons: A Challenge for Leaders, Learners,

and Colleagues: AOA Critical Issues. J Bone Joint Surg Am. 2017 Jul 19;99(14):e78.

• Campbell DA Jr, Sonnad SS, Eckhauser FE, et al. Burnout among American surgeons. Surgery 2001;130:696e-702.

• Chaput B, Bertheuil N, Jacques J, et al. Professional burnout among plastic surgery residents: Can it be prevented?

Outcomes of a national survey. Ann Plast Surg. 2015;75:2–8.

• de Vibe M, Solhaug I, Tyssen R, Friborg O, Rosenvinge JH, Sørlie T, Bjørndal A. Mindfulness training for stress

management: a randomised controlled study of medical and psychology students. BMC Med Educ. 2013; 13: 107.

• Dimou FM, Eckelbarger D, Riall TS. Surgeon Burnout: A Systematic Review. J Am Coll Surg. 2016 Jun;222(6):1230-1239.

• Epstein RM, Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med. 2013

Mar;88(3):301-3.

• Khansa I, Janis JE. A Growing Epidemic: Plastic Surgeons and Burnout-A Literature Review. Plast Reconstr Surg. 2019

Aug;144(2):298e-305e.

• Maslach C, Jackson SE, Leiter MP (Eds.), Maslach Burnout Inventory manual (3rd ed.), Consulting Psychologists Press

(1996).– http://www.uapd.com/wp-content/uploads/Maslach-Burnout-Inventory-MBI.pdf

• Sargent MC, Sotile W, Sotile MO, et al. Managing stress in the orthopaedic family: avoiding burnout, achieving resilience.

J Bone Joint Surg Am 2011;93:e40.

• Streu R, Hansen J, Abrahamse P, Alderman AK. Professional burnout among US plastic surgeons: Results of a national

survey. Ann Plast Surg. 2014;72:346–350.

THANK YOU

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http://www.uapd.com/wp-content/uploads/Maslach-Burnout-Inventory-MBI.pdf

38th adrian e. flatt residents & fellows conference

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