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Vasireddi N, Vasireddi N, Shah AK, Moyal AJ, Gausden EB, Mclawhorn AS, Poelstra KA, Gould HP, Voos JE, Calcei JG. High Prevalence of Work-related Musculoskeletal Disorders and Limited Evidence-based Ergonomics in Orthopaedic Surgery: A Systematic Review. Clin Orthop Relat Res 2024; 482:659-671. [PMID: 37987688 PMCID: PMC10936985 DOI: 10.1097/corr.0000000000002904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/29/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND The Centers for Disease Control defines work-related musculoskeletal disorders as disorders of the nerves, muscles, tendons, joints, spinal discs, and cartilage that are caused or exacerbated by the environment or nature of work. Previous meta-analyses have characterized work-related musculoskeletal disorders among interventionists, general surgeons, and other surgical subspecialties, but prevalence estimates, prognosis, and ergonomic considerations vary by study and surgical specialty. QUESTIONS/PURPOSES (1) What is the career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons? (2) What is the treatment prevalence associated with work-related musculoskeletal disorders in orthopaedic surgeons? (3) What is the disability burden of work-related musculoskeletal disorders in orthopaedic surgeons? (4) What is the scope of orthopaedic surgical ergonomic assessments and interventions? METHODS A systematic review of English-language studies from PubMed, MEDLINE, Embase, and Scopus was performed in December 2022 and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that presented prevalence estimates of work-related musculoskeletal disorders or assessed surgical ergonomics in orthopaedic surgery were included. Reviews, case reports, gray literature (conference abstracts and preprints), and studies with mixed-surgeon (nonorthopaedic) populations were excluded. The search yielded 5603 abstracts; 24 survey-based studies with 4876 orthopaedic surgeons (mean age 48 years; 79% of surgeons were men) were included for an analysis of work-related musculoskeletal disorders, and 18 articles were included for a descriptive synthesis of ergonomic assessment. Quality assessment using the Joanna Briggs Institute Tool revealed that studies had a low to moderate risk of bias, largely because of self-reporting survey-based methodology. Because of considerable heterogeneity and risk of bias, prevalence outcomes were not pooled and instead are presented as ranges (mean I 2 = 91.3%). RESULTS The career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons ranged from 37% to 97%. By anatomic location, the prevalence of work-related musculoskeletal disorders in the head and neck ranged from 4% to 74%; back ranged from 9% to 77%; forearm, wrist, and hand ranged from 12% to 54%; elbow ranged from 3% to 28%; shoulder ranged from 3% to 34%; hip and thigh ranged from 1% to 10%; knee and lower leg ranged from 1% to 31%; and foot and ankle ranged from 4% to 25%. Of orthopaedic surgeons reporting work-related musculoskeletal disorders, 9% to 33% had a leave of absence, practice restriction or modification, or early retirement, and 27% to 83% received some form of treatment. Orthopaedic surgeons experienced biomechanical, cardiovascular, neuromuscular, and metabolic stress during procedures. Interventions to improve orthopaedic surgical ergonomics have been limited, but have included robotic assistance, proper visualization aids, appropriate use of power tools, and safely minimizing lead apron use. In hip and knee arthroplasty, robotic assistance was the most effective in improving posture and reducing caloric expenditure. In spine surgery, proper use of surgical loupes was the most effective in improving posture. CONCLUSION Although the reported ranges of our main findings were wide, even on the low end of the reported ranges, work-related musculoskeletal disability among orthopaedic surgeons appears to be a substantial concern. We recommend that orthopaedic residency training programs incorporate surgical ergonomics or work injury lectures, workshops, and film review (alongside existing film review of surgical skills) into their curricula. We suggest hospitals engage in shared decision-making with surgeons through anonymous needs assessment surveys to implement wellness programs specific to surgeons' musculoskeletal needs. We urge institutions to assess surgeon ergonomics during routine quality assessment of novel surgical instruments and workflows. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Nikhil Vasireddi
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Drusinsky Sports Medicine Institute, South Euclid, OH, USA
| | | | - Aakash K. Shah
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Andrew J. Moyal
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Drusinsky Sports Medicine Institute, South Euclid, OH, USA
| | | | | | - Kornelis A. Poelstra
- The Robotic Spine Institute of New Jersey, Jersey City, NJ, USA
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | | | - James E. Voos
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Drusinsky Sports Medicine Institute, South Euclid, OH, USA
| | - Jacob G. Calcei
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Drusinsky Sports Medicine Institute, South Euclid, OH, USA
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Awad G, Pohl R, Darius S, Thielmann B, Varghese S, Wacker M, Schmidt H, Wippermann J, Scherner M, Böckelmann I. Activation of the stress response among the cardiac surgical residents: comparison of teaching procedures and other (daily) medical activities. J Cardiothorac Surg 2022; 17:112. [PMID: 35545777 PMCID: PMC9092698 DOI: 10.1186/s13019-022-01873-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this Pilot study was to investigate the cardiac surgical residents' workload during different surgical teaching interventions and to compare their stress levels with other working time spent in the intensive care unit or normal ward. METHODS The objective stress was assessed using two cardiac surgical residents' heart rate variability (HRV) both during surgical activities (32 selected teaching operations (coronary artery bypass graft n = 26 and transcatheter aortic valve implantation n = 6), and during non-surgical periods. Heart rate, time and frequency domains as well as non-linear parameters were analyzed using the Wilcoxon test. RESULTS The parasympathetic activity was significantly reduced during the surgical phase, compared to the non-surgical phase: Mean RR (675.7 ms vs. 777.3 ms), RMSSD (23.1 ms vs. 34.0 ms) and pNN50 (4.7% vs. 10.6%). This indicates that the residents had a higher stress level during surgical activities in comparison to the non-surgical times. The evaluation of the Stress Index during the operations and outside the operating room (8.07 vs. 10.6) and the parasympathetic nervous system index (- 1.75 to - 0.91) as well as the sympathetic nervous system index (1.84 vs. 0.65) confirm the higher stress level during surgery. This can be seen too used the FFT Analysis with higher intraoperative LF/HF ratio (6.7 vs. 3.8). CONCLUSION HRV proved to be a good, objective method of identifying stress among physicians both in and outside the operating room. Our results show that residents are exposed to high psychological workloads during surgical activities, especially as the operating surgeon.
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Affiliation(s)
- George Awad
- Department of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Germany.
| | - Robert Pohl
- Department of Occupational Medicine, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Sabine Darius
- Department of Occupational Medicine, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Beatrice Thielmann
- Department of Occupational Medicine, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Sam Varghese
- Department of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Germany
| | - Max Wacker
- Department of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Germany
| | - Hendrik Schmidt
- Clinic for Cardiology and Diabetology, Magdeburg Clinic, Magdeburg, Germany.,University Clinic for Internal Medicine III, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Jens Wippermann
- Department of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Germany
| | - Maximilian Scherner
- Department of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Germany
| | - Irina Böckelmann
- Department of Occupational Medicine, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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Lorenz M, Pelliccia L, Werner M, Scholze M, Klimant P, Heyde CE, Klima S, Hammer N. Wrist at risk? - Considerations derived from a novel experimental setup to assess torques during hip reaming with potential implications on the orthopedic surgeons' health. J Mech Behav Biomed Mater 2020; 113:104160. [PMID: 33129034 DOI: 10.1016/j.jmbbm.2020.104160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 06/26/2020] [Accepted: 10/23/2020] [Indexed: 11/30/2022]
Abstract
Orthopedic surgeons endure high physical stresses when performing surgery, as large forces and torques are applied commonly. Occupational risks are consequently higher when compared to other surgical disciplines. One example is the reaming of the acetabula during total hip arthroplasty, using customized instruments. This surgery may predispose the surgeon to overuse-related wrist pathology. In this study, torques acting along the reaming tool were measured, and the resulting forces applied to the orthopedic surgeons' wrists were estimated based on the measured torque data from hip reaming. Different reamer sizes and tool velocities were analyzed to determine how both parameters may influence the torques applied at the surgeon's wrist. Using a highly standardized setup, torques were measured while the reamer was pushed into the acetabula to remove cartilage. Maximum torques and stoppage torques at blocking of the reamer were compared between feed rates and reamer sizes. Peak values of the maximum torques along the reamer axis averaged 1.5-1.8 Nm. No significant difference between maximum torques and reamer sizes was found. A significant difference in maximum torques was noted between feed rates with a large effect (p = 0.010; η2 = 0.214) and a large interaction effect (p = 0.017; η2 = 0.186). Based on this experimental setup, it can be hypothesized that the impulsive behavior of the torque when the milling tool reaches the subchondral lamella could potentially contribute to wrist pathology. These preliminary data warrant further study. Consequently, torque limiters should be implemented in reamers to minimize the risk of occupation-related pathology to the wrist.
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Affiliation(s)
- Mario Lorenz
- Chemnitz University of Technology, Professorship Machine Tool Design and Forming Technology, Professorship Factory Planning and Factory Operation, Institute of Materials Science and Engineering, Straße der Nationen 62, 09111, Chemnitz, Germany; University Hospital Leipzig, Department of Orthopedics, Trauma and Plastic Surgery, Liebigstraße 20, 04103, Leipzig, Germany; Medical University of Graz, Department of Macroscopic and Clinical Anatomy, Harrachgasse 21, 8010, Graz, Austria.
| | - Luigi Pelliccia
- Chemnitz University of Technology, Professorship Machine Tool Design and Forming Technology, Professorship Factory Planning and Factory Operation, Institute of Materials Science and Engineering, Straße der Nationen 62, 09111, Chemnitz, Germany.
| | - Michael Werner
- Fraunhofer Institute for Machine Tools and Forming Technology IWU, Nöthnitzer Straße 44, 01187, Dresden, Germany; Orthopaedicus Clinics, Lortzingstraße 15, 04105, Leipzig, Germany.
| | - Mario Scholze
- Chemnitz University of Technology, Professorship Machine Tool Design and Forming Technology, Professorship Factory Planning and Factory Operation, Institute of Materials Science and Engineering, Straße der Nationen 62, 09111, Chemnitz, Germany; Medical University of Graz, Department of Macroscopic and Clinical Anatomy, Harrachgasse 21, 8010, Graz, Austria.
| | - Philipp Klimant
- Chemnitz University of Technology, Professorship Machine Tool Design and Forming Technology, Professorship Factory Planning and Factory Operation, Institute of Materials Science and Engineering, Straße der Nationen 62, 09111, Chemnitz, Germany; Fraunhofer Institute for Machine Tools and Forming Technology IWU, Nöthnitzer Straße 44, 01187, Dresden, Germany.
| | - Christoph-E Heyde
- University Hospital Leipzig, Department of Orthopedics, Trauma and Plastic Surgery, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Stefan Klima
- University Hospital Leipzig, Department of Orthopedics, Trauma and Plastic Surgery, Liebigstraße 20, 04103, Leipzig, Germany; Orthopaedicus Clinics, Lortzingstraße 15, 04105, Leipzig, Germany.
| | - Niels Hammer
- University Hospital Leipzig, Department of Orthopedics, Trauma and Plastic Surgery, Liebigstraße 20, 04103, Leipzig, Germany; Fraunhofer Institute for Machine Tools and Forming Technology IWU, Nöthnitzer Straße 44, 01187, Dresden, Germany; Medical University of Graz, Department of Macroscopic and Clinical Anatomy, Harrachgasse 21, 8010, Graz, Austria.
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Lin JS, Lattanza LL, Weber KL, Balch Samora J. Improving Sexual, Racial, and Ethnic Diversity in Orthopedics: An Imperative. Orthopedics 2020; 43:e134-e140. [PMID: 32003842 DOI: 10.3928/01477447-20200129-04] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 02/07/2019] [Indexed: 02/03/2023]
Abstract
Orthopedics is the least diverse medical specialty. From residents to faculty, the representation of women and underrepresented minorities lags behind that of all other specialties. The crux of the disparity stems from the pipeline, as medical students who are female and are underrepresented minorities are simply not applying to orthopedic surgery. Grassroots efforts providing early exposure to orthopedics have led to a considerable proportion of alumnae pursuing science majors and eventually medical school. Institutions with a stated commitment to diversity have successfully produced residency classes with greater diversity. The culture should be one that combats biases, dispels misconceptions about orthopedics, and prioritizes recruiting/retaining diverse providers. [Orthopedics. 2020;43(3):e134-e140.].
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Abstract
INTRODUCTION Orthopaedic surgery can be a physically demanding occupation with high rates of fatigue and burnout. Fatigue has been shown to affect surgeon performance with higher rates of errors in fatigued surgeons. The metabolic cost of performing surgery has yet to be quantified. A better understanding of these costs may provide insights into surgeon fatigue and its effect on patient safety. METHODS Eight subjects performed a one-level lumbar laminectomy and fusion on cadavers. Oxygen consumption (VO2) was measured via indirect calorimetry and used to calculate energy expenditure (EE). Substrate utilization was estimated from measurements of inspired and expired gases (ie, O2 and CO2, respectively). EE was also measured with the use of triaxial accelerometers. RESULTS The peak VO2 was 11.3 ± 0.4 mL/kg/min. The EEtotal was 132 ± 6 kcal corresponding to the EEtotal/hr of 142 ± 7 kcal/hr. Upper arm accelerometers (154.8 ± 9.8 kcal; r = 0.54) accurately estimated total EE. Subjects used, on average, 53% ± 4% CHO versus 47% ± 7% fat, with peak utilization of 65% ± 5% CHO versus 35% ± 15% fat. DISCUSSION Simulated orthopaedic spine surgery elicited modest but significant increases in EE over resting. Surgeons used a higher percentage of carbohydrate than would be expected for the intensity of the activity.
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Kremer J, Reinhold M. [Intraoperative stress in orthopaedic spine surgery : Attending surgeon versus resident]. DER ORTHOPADE 2016; 45:1039-1044. [PMID: 27393555 DOI: 10.1007/s00132-016-3293-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Requirements for orthopaedic spine surgeons include occupational skills, concentration, physical fitness and psychological stress resistance, depending on the attending surgeon's or the resident's position. MATERIAL AND METHODS This study measured and evaluated stress-relevant cardiovascular parameters during 101 spinal surgical procedures of a 40-year old fellowship-trained spine surgeon with 12 years of practice. A training computer, personal scales and a thermometer were used to record the duration of surgery, heart rate, weight loss and calorie burning. RESULTS The average maximum heart rate as an attending surgeon (124 bpm) was significantly higher than the resident's heart rate (99 bmp). A higher stress level resulted in an increasingly higher average maximum heart rate according to the duration of surgery. The mean loss of body fluids at an average room temperature of 20.4 C after surgery was 0.82 kg (0 to 2.3 kg). The mean loss of body weight was calculated as 1.12% of the attending surgeon versus 0.59% of the resident. DISCUSSION Increasing complexity, longer duration and a higher potential of intraoperative complications arouse a strong response from the attending surgeon. The observed cardiovascular parameters are similar to those of a moderate to intense workout such as cycling. Long lasting surgeries result in a weight loss equivalent to a mild dehydration ranging from 2 to 5% of body fluids. Increasing dehydration will eventually worsen cognitive, visual and motor skills. Results of this study suggest early rehydration and utilization of mental relaxation techniques to minimize risks during prolonged, complex spine surgeries.
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Affiliation(s)
- J Kremer
- Univ.-Klinik für Orthopädie, Medizinische Universität Innsbruck, Christoph-Probst-Platz Innrain 52, 6020, Innsbruck, Österreich. .,, Freiherr-vom-Stein Str. 37, 65604, Elz, Deutschland.
| | - M Reinhold
- Univ.-Klinik für Orthopädie, Medizinische Universität Innsbruck, Christoph-Probst-Platz Innrain 52, 6020, Innsbruck, Österreich
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