AOA Critical Issues Symposium: Leadership and Education During and After COVID-19: Back to the Future or a New Normal

ABSTRACT

The devastating impact of COVID-19 has reshaped how we lead and train our future surgeons in the field of orthopaedics. Overnight, leaders in our field had to dramatically shift their mindset to continue to lead a hospital, department, journal, or residency or fellowship program in the face of an unprecedented level of adversity in the history of the United States. This symposium discusses the role of physician leadership during and after a pandemic, as well as the adoption of technology for training surgeons in the field of orthopaedics.

Methods of imaging the scaphoid

Rapid diagnosis of a scaphoid fracture is important so that proper treatment may be initiated. The high frequencies of nonunion of proximal pole, AVN, and scaphoid fractures warrant the use of special imaging to identify an occult fracture that may cause a long-term disability if not diagnosed. The modalities discussed allow the reader to treat patients in an expeditious and accurate manner.

Arthroscopic subacromial decompression

In this study, we analyzed the results of two series of patients treated for impingement syndrome by undergoing arthroscopic subacromial decompression (ASD). Patients had not responded to nonoperative treatment. Group 1 included 112 consecutive patients (average age, 41 years) with 96 (77%) patients available for 2-year follow-up. Group 2 (28 patients, 29 shoulders; average age, 43 years; range, 22 to 72) had ASD and the subacromial space digitally palpated to determine if adequate decompression was performed. Twenty-two (85%) of 26 shoulders were available for follow-up. At follow-up, pain, function, range of motion, strength, impingement signs, and patient satisfaction were assessed. In group 1, according to the Neer criteria, 48% of the patients were graded as satisfactory and 52% unsatisfactory. Workers' Compensation patients had a satisfactory rate of 32%, whereas non-Workers' Compensation patients had a satisfactory rate of 59%. Twenty patients had open acromioplasty after ASD. Inadequate decompression was noted in 14 of 20 failed patients. In group 2, 86% of the patients were graded as satisfactory according to the Neer criteria, with 14% unsatisfactory, which included the 2 failures. The 2 (9%) of 22 shoulders that failed the ASD went on to further surgical treatment. Average follow-up was 56 months (range, 13 to 78 months). The average American Shoulder and Elbow Society score at follow-up was 90.4. No difference between Workers' Compensation cases and the other cases was seen (P <.7). Finger palpation can help to improve outcomes by allowing the surgeon to assess the adequacy of decompression.

Fracture dislocations of the elbow in athletes

Elbow dislocations can result in extensive injury to the supporting structures of the elbow joint. Principles of treatment include prompt reduction of the dislocation and treatment of associated fractures. The goal is to restore joint stability and to allow for early mobility. Most simple dislocations are stable after closed reduction with early mobility that can lead to anatomic and functional restoration. When stability is compromised, as with many complex dislocations, further stabilization with ligament repair, reconstruction, and fracture fixation also can lead to satisfactory results. The prognosis following complex dislocations is more guarded in the athlete, and depends on anatomic restoration and initiation of early motion.

The relationship of the infrapatellar branches of the saphenous nerve to arthroscopy portals and incisions for anterior cruciate ligament surgery. An anatomic study

The purposes of this study were 1) to carefully define the anatomic distribution of the infrapatellar branches of the saphenous nerve, 2) to provide the surgeon with reliable parameters for where the nerve is most commonly encountered, and 3) to provide specific surgical recommendations to minimize the risk of nerve injury. To accomplish these goals, we dissected 20 cadaveric, fresh-frozen, matched-pair knees. Calipers were used to measure the distance from the nerve to three clinically relevant and easily reproducible landmarks: the inferior pole of the patella, the medial border of the patella at its midpoint, and a point 2 cm medial to the patellar ligament at the level of the joint line. Distances were recorded with the knees in extension and in 90 degrees of flexion to examine the effect of dynamic knee motion on nerve position. We consistently found two main trunks of the nerve that traverse the knee primarily in a medial to lateral but somewhat proximal to distal direction. Because of this, we recommend that incisions for arthroscopy portals be made in a horizontal fashion to decrease the likelihood of nerve injury. Measured from both the inferior pole of the patella and the medial border of the patella, the nerve moved distally with knee flexion. We therefore recommend that incisions across the anterior aspect of the knee be made with the knee in flexion. In 8 of our 20 specimens, the nerve was actually found at the landmark located 2 cm medial to the patellar ligament. This is an extremely high-risk area and should be avoided if possible.

Role of MR imaging in the management of "skier's thumb" injuries

"Skier's thumb" is an acute rupture of the ulnar collateral ligament (UCL) of the metacarpophalangeal (MCP) joint of the thumb. As the method of choice in evaluating soft tissue injuries, MR imaging is useful in evaluating UCL injuries. This article reviews current concepts regarding the rupture of the UCL, including a study of 34 UCL injuries in which MR imaging was used as the main diagnostic tool. When correlated with surgical findings, MR imaging resulted in identifying UCL tears with 96% sensitivity and 95% specificity.

Symptomatic scapulothoracic crepitus and bursitis

Scapulothoracic crepitus and scapulothoracic bursitis are related painful disorders of the scapulothoracic articulation. Scapulothoracic crepitus is the production of a grinding or snapping noise with scapulothoracic motion, which may be accompanied by pain. Scapulothoracic bursitis manifests as pain and swelling of the bursae of the scapulothoracic articulation. Scapulothoracic bursitis is always seen in patients with symptomatic scapulothoracic crepitus, but may exist as an isolated entity. Symptomatic scapulothoracic crepitus may be due to pathologic changes in the bone or soft tissue between the scapula and the chest wall or may be due to changes in congruence of the scapulothoracic articulation, as seen in scoliosis and thoracic kyphosis. Treatment of patients with symptomatic scapulothoracic crepitus begins with nonoperative methods, including postural and scapular strengthening exercises and the application of local modalities. When soft-tissue lesions are the cause of scapulothoracic crepitus, conservative treatment is highly effective. When symptomatic scapulothoracic crepitus is due to osseous lesions, or when conservative treatment has failed, surgical options are available. Partial scapulectomies have produced satisfactory outcomes in selected patients. Recently, open and arthroscopic scapulothoracic bursectomies have been performed with some success and are being used more frequently.

Biomechanics of wrist injuries in sports

Athletic injuries of the wrist are common. Wrist anatomy, biomechanics, and injury mechanisms are outlined for the athletic population. Common injuries are discussed in a biomechanical context for impact sports; racquet, stick, and club sports; and apparatus and external contact sports.

Reconstruction of the anterior cruciate ligament in patients who are at least forty years old. A long-term follow-up and outcome study

The long-term results were reviewed for seventy-two patients (seventy-five knees) who had had a bone-patellar ligament-bone intra-articular reconstruction of the anterior cruciate ligament between August 1984 and May 1992. The mean age of the patients at the time of the operation was forty-five years (range, forty to sixty years). Three patients had a bilateral procedure. The primary mechanisms of injury were accidents that occurred during skiing (thirty-two knees), tennis (fourteen knees), and soccer (five knees). We analyzed the responses to subjective questionnaires, the functional results, and the objective clinical data. The clinical examination included assessment of the range of motion, performance of Lachman and pivot-shift tests, and measurements with use of a KT-1000 arthrometer. All knees were evaluated with use of three common rating scales: that of Lysholm and Gillquist; that of The Hospital for Special Surgery, as modified by Insall et al.; and the International Knee Ligament Standard Evaluation Form. At the latest follow-up evaluation, at a mean of fifty-five months (range, twenty-six to 117 months), three patients reported pain or swelling. No patient reported giving-way or symptoms related to the patellofemoral joint. The mean range of extension was -12 to 6 degrees, compared with -8 to 42 degrees preoperatively, and the mean range of flexion was 112 to 150 degrees, compared with 52 to 154 degrees preoperatively. Flexion was limited to 112 degrees in one patient, but this was 5 degrees greater than that of the uninvolved knee. Sixty knees (80 per cent) had a negative pivot-shift test, and ten knees (13 per cent) had a grade of 1+. On testing with the KT-1000 device at maximum manual pressure, the mean difference between the injured and uninjured knees was found to have improved by 5.1 millimeters, from 6.4 millimeters preoperatively to 1.4 millimeters postoperatively (p < 0.01). The grade on the International Knee Ligament Standard Evaluation Form improved markedly; seventy-two knees (96 per cent) had a grade of C or D preoperatively, whereas seventy knees (93 per cent) had a grade of A or B postoperatively. The Hospital for Special Surgery score improved from a mean of 69 points preoperatively to a mean of 92 points postoperatively (p < 0.01). The mean score according to the scale of Lysholm and Gillquist increased from a mean of 63 points preoperatively to a mean of 94 points postoperatively (p < 0.01). All patients indicated that they were pleased with the result of the procedure. Bicycling was resumed at a mean of four months; jogging, at a mean of nine months; skiing, at a mean of ten months; and tennis, at a mean of twelve months.

Diagnosis and treatment of congenital thumb hypoplasia

The hypoplastic thumb has a variety of presentations, which have been generalized into a formal classification system that has treatment implications. In most cases, the spectrum of hypoplasia has predictable deficits in terms of tendon and bone absence. The ultimate goal is always the same--to enhance usage of the radial digit. In this article, a straightforward, reliable, and reproducible surgical technique is discussed and illustrated. Pitfalls, indications, and treatment regimes also are discussed to help the physician successfully treat the child with a hypoplastic thumb.

Femoral neck and ipsilateral neck and shaft fractures in the young adult

Femoral neck and ipsilateral neck and shaft fractures in the young adult represent a significant source of morbidity and mortality. This article reviews the anatomy, pathophysiology, radiographic evaluation, timing of surgery, and complications in an attempt to increase recognition of these injuries and provide better patient care.

Management of osteonecrosis of the femoral head

Osteonecrosis of the femoral head continues to pose a therapeutic challenge to orthopedic surgeons. This pathologic process results from the death of living components of bone from mechanical and biologic factors. Diagnosis, clinical symptoms, and classification systems are discussed. Several treatment regimens and their controversies are explored in this article.

The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome

The hypothenar fat pad flap interposes adipose tissue from the hypothenar eminence between the median nerve and overlying transverse carpal ligament and surgical scar. This retrospective study reviews 62 hands in 58 patients (46 non-workers' compensation and 16 workers' compensation) with recurrent symptoms after failed open carpal tunnel release who underwent revision carpal tunnel decompression and in whom a hypothenar fat pad flap was used. The follow-up period averaged 33 months. Patient satisfaction was 6 in the non-workers' compensation group and 4 in the workers' compensation group. Average time to return to work for the non-workers' compensation group was 12 weeks, compared to 37 weeks for the workers' compensation group. Study results indicate that the hypothenar fat pad flap produces excellent results in procedures designed to alleviate recalcitrant idiopathic carpal tunnel syndrome.

Recalcitrant carpal tunnel. The hypothenar fat pad flap

Open decompression of the median nerve generally is so effective that little is mentioned of the surgical treatment options for recalcitrant or unrelieved carpal tunnel syndrome. The hypothenar fat pad flap has been shown to be a reliable local source of well-vascularized adipose tissue that can be used for coverage of the median nerve during re-exploration of recurrent or persistent idiopathic carpal tunnel syndrome. The hypothenar fat pad flap is a technically simple procedure that allows the fat pad to be mobilized easily and placed across the palm as a barrier between the nerve and the radial leaf of the transverse carpal ligament, effectively preventing median nerve readherence. This flap hopefully will improve the tissue environment for the median nerve, permitting it to have normal excursion during wrist motion. Our results to date have been better than previously described for other techniques. We believe the hypothenar fat pad flap should be considered in the hand surgeon's armamentarium for recalcitrant idiopathic carpal tunnel syndrome.

Anterior intramuscular transposition of the ulnar nerve

The surgical management of cubital tunnel syndrome is well documented in the literature. Anterior intramuscular transposition of the ulnar nerve is indicated for chronic cubital tunnel syndrome with symptoms refractory to conservative therapy. Prompt diagnosis is essential to yield excellent results. Extreme care must be exercised in the performance of anterior intramuscular transposition. The surgeon must know the details of medial epicondylar anatomy and pathophysiology, as well as all possible sites of potential nerve compression. The placement of the transposed nerve in an intramuscular bed requires that all fibrous septae are resected from the shallow trough created for the nerve to avoid scar formation. Postoperatively, the arm is immobilized for 3 weeks, after which range-of-motion exercises are begun. By the eighth postoperative week, most patients are able to resume their regular activities, including manual labor. Recurrence or persistence of symptoms postoperatively typically is traced to an inadequate decompression of the nerve. Common sites of persistent ulnar nerve compression include (1) the medial intermuscular septum, (2) the arcade of Struthers, (3) fibrous bands immediately proximal or distal to the cubital tunnel, (4) persistence or kinking at the arcuate ligament of Osborne, (5) Spinner's ligament or other fascial slings, and (6) incomplete anterior transposition. Anterior intramuscular transposition of the ulnar nerve is attractive for its relative ease of dissection, simplicity, reliability, and low morbidity. Transposition of the nerve into a shallow muscular trough deep only to the flexor-pronator fascia is a logical, effective, and consistently reliable method of treating cubital tunnel syndrome refractory to conservative management.

Vitamin B6 (pyridoxine) therapy for carpal tunnel syndrome

The literature at this time does not give convincing evidence for use of pyridoxine as the sole treatment when confronted with a patient with idiopathic CTS. It may be of value as an adjunct in conservative therapy through altered perception of pain and increased pain threshold. For patients not responsive to conservative therapy, surgical decompression of the carpal canal is the treatment of choice.

Carpal tunnel release with a small palmar incision

The use of carpal tunnel tome with a small palmar incision to release the transverse carpal ligament is discussed. The technique is fully illustrated, and the authors early clinical experience is reviewed.

Medial and lateral epicondylitis in the athlete

An appropriate diagnosis must be made after carefully excluding all other options in treating the patient with lateral epicondylitis. The majority of these patients will do well with nonsurgical treatment; however, if unresponsive to this regimen, a carefully selected patient will have a successful result with surgical reconstruction (85%-95% of patients). Attention to detail both pre- and postoperatively will help to create a successful result in a disease entity that plagues a large proportion of our athletic population.

Compressive neuropathies and tendinopathies in the athletic elbow and wrist

Overuse syndromes of the upper extremity in the athletic population are a common and often difficult problem for physician and patient alike. Optimal function of the upper extremity is tied intimately to success in many sporting activities. Correct diagnosis and proper care require a thorough knowledge of the pertinent anatomy, pathophysiology, and pathomechanics involved in each disorder. Conservative care with rest, activity modification, and medication is adequate for most athletic injuries. Surgical intervention may be indicated for continuing pain, decreased performance, or to prevent chronic changes. Surgery must be followed by thoughtfully prepared training and rehabilitation programs to optimize the chances of a successful outcome.

Sports-specific injuries

Injuries to the upper extremities can happen in any sport. Injury patterns are common to specific sports. Understanding which injuries occur with these sports allows the examiner to diagnose and treat the athlete easily. This article reviews some of the injuries common in sports such as bicycling, golf, gymnastics, martial arts, racquet sports, and weightlifting.

Elbow injuries to the throwing athlete

Elbow injuries in the throwing athlete are common. Because of the tremendous medial tensile forces and lateral compressive forces borne by the elbow, there is a wide array of injuries that occur. A detailed history and physical examination are necessary for an accurate diagnosis. Many of the injuries discussed can be treated successfully with conservative measures followed by aggressive physical therapy. Prompt recognition and early treatment is mandatory. In those conditions in which conservative treatment tends to fail, the detailed surgical options have been discussed. It is important to select highly motivated patients for those procedures that require extensive rehabilitation postoperatively. The keys to success in elbow surgery are a compliant patient and a well-regimented rehabilitation program.

Arthroscopic removal of loose bodies of the elbow

Arthroscopy of the elbow has proven to have a diagnostic and therapeutic benefit. Removal of loose bodies and a thorough evaluation of associated intra-articular pathologies are possible without arthrotomy. The authors have found this procedure to be safe and effective in the treatment of loose bodies of the elbow and other associated pathologies.

Prevention and rehabilitation of overuse injuries of the elbow

Rehabilitation from injury and prevention of injury are terms that describe differing aspects of the same challenge. The clinician must be continually aware of the principles of rehabilitation and their order of priority (prevent further damage, restore motion, restore strength, reestablish coordination) while supervising patients' progress toward their goals. If patients are made aware of these principles at an early stage, and taught to take as much responsibility as possible for their own rehabilitative course, they will be more likely to reach their own ideal compromise of safety and speed of progress. In addition to helping with rehabilitation from injury, knowledge and self-awareness that patients obtain during this process may help in the prevention of future injuries.

Clinical anatomy of the wrist and elbow

For the orthopedist, the design and execution of surgical procedures requires a thorough understanding of anatomy. The goal of this article is to provide an overview of the pertinent surgical anatomy of the wrist and elbow. Operative techniques improve with advancing technologic breakthroughs and greater understanding of anatomy. Today's orthopedic surgeon is required to remain current on this expanding information base; this information will allow for a better understanding of common and overuse injuries of the wrist, forearm, and elbow.

Percutaneous Kirschner wire fixation through the snuff box: an anatomic study

We undertook this study to better define the anatomy of the radial aspect of the wrist and to establish a zone of safety for the placement of Kirschner wires, cannulated screws, and arthroscopes within the anatomic snuff box. Twenty fresh frozen cadaver upper extremities underwent placement of three percutaneous Kirschner wires under fluoroscopic guidance through the anatomic snuff box. In each extremity, one Kirschner wire was placed into the radial styloid, one across the scaphocapitate joint, and one across the scapholunate joint. A safe zone of mean 0.68 sq cm was found deep to the subcutaneous tissue bordered by the radial styloid, the first dorsal compartment, the radial artery, and the superficial radial nerve. Kirschner wires placed distal, dorsal, or palmar to the borders of the safe zone were at great risk of injuring neurovascular structures. To minimize the risk of injury to adjacent structures, we advise a limited incision in the safe zone with blunt dissection to the wrist capsule. Though improved anatomic understanding, we established a new location for the arthroscopic 1,2 portal within the snuff box.

Rehabilitation of the shoulder in tennis players

The tennis player places unique demands on the shoulder by creating a high risk for overuse and overloading of the soft tissues. Tennis requires concentric work to position and move the arm, eccentric work to stabilize the shoulder, effective depression of the humeral head to avoid impingement in the overhead position, and normal stability to prevent secondary impingement. The tennis serve produces enormous angular velocities about the shoulder joint. A comprehensive rehabilitation program has been described in which the therapist, trainer, player, and physician alike need to have an understanding of the basic biomechanics of this sport. This program can be used to treat the painful shoulder, prevent injury, and enhance performance.