The following case is a 49 y/o female who was treated with AC joint cortizone injections for 6 months (2 injections) prior to treatment of her AC joint arthritis with an arthroscopic Mumford procedure. During a previous post (please click here) it was highlighted that the CA ligament not only provides stability to the cuff deficient and cuff intact shoulder but it also has mechanoreceptors that are important for the proprioception of the shoulder joint.
During the arthroscopic procedure for AC joint arthritis we always preserve the CA ligament by placing our working instruments just medial to the CA ligament as demonstrated below. This technique allows for direct access to the AC joint and resection of 0.5 to 1 cm of distal clavicle which has been proven to prevent AC joint instability and provide adequate relief of symptoms. The posterior superior capsule needs to be preserved as well because it provides stability to the AC joint.
Most rotator cuff tears start at the articular side of the supraspinatus tendon and at the leading fibers near biceps
Love is great, but it’s actually empathy that makes the world go ‘round. Understanding other peoples’ viewpoints is so essential to human functioning that psychologists sometimes refer to empathy as “social glue, binding people together and creating harmonious relationships.”
Narcissists tend to lack this ability. Think of the charismatic co-worker who refuses to cover for a colleague who’s been in a car accident. Or the affable friend who nonetheless seems to delight in back-stabbing.
These types of individuals are what’s known as “sub-clinical” narcissists—the everyday egoists who, though they may not merit psychiatric attention, don’t make very good friends or lovers.
“If people are in a romantic relationship with a narcissist, they tend to cheat on their partners and their relationships break up sooner and end quite messily,” Erica Hepper, a psychologist at the University of Surrey in the U.K., told me. “They tend to be more deviant academically. They take credit for other peoples' work.”
Psychologists have long thought that narcissists were largely incorrigible—that there was nothing we could do to help them be more empathetic. But for a new study in the Personality and Social Psychology Bulletin, Hepper discovered a way to measurably help narcissists feel the pain of others.
First, she gathered up 282 online volunteers who hailed from various countries but were mostly young and female. They took a 41-question personality quiz designed to assess their levels of subclinical narcissism, checking boxes next to statements like “I like to have authority over other people” or “I will be a success.” They then read a story about a person named Chris who had just gone through a breakup, and then took another quiz to determine how bad they felt for Chris. The more narcissistic among them were indeed less likely to feel empathy for the fictional jilted man.
An important note here: The study participants, though they’re described as “narcissists,” were not clinically diagnosed with Narcissistic Personality Disorder, a bona-fide mental illness. Psychologists aren’t sure how much overlap there is between functional people who are very narcissistic and those who suffer from NPD. One rule of thumb, Hepper tells me, is that most ordinary narcissists are happy, while NPD tends to lead its sufferers to extreme dissatisfaction with life.
Personality and Social Psychology BulletinFor her next manipulation, Hepper and her co-authors asked a group of 95 female undergrads to take the same narcissism quiz, and then later to watch a 10-minute documentary about Susan, a victim of spousal abuse. Half were told to try to put themselves in Susan’s shoes (“Imagine how Susan feels. Try to take her perspective in the video...”), while the others were told to imagine they were watching the program on TV one evening.
The subjects who were told to take Susan’s perspective were significantly more likely to score higher on empathy. In fact, the more narcissistic they were, the more the trick seemed to work.
“I think what's going on here is that people who are low on narcissism are already responding to people—telling them what to do it isn't going to increase their empathy any further,” Hepper said. “But the higher on narcissism you get, the less empathy [you feel]. By instructing them to think about it, it activates this empathic response that was previously much weaker.”
And the narcissists weren’t just faking it. In a third experiment, Hepper showed that extreme narcissists had lower-than-average heart rates when listening to a recording of a woman in distress. (That is, “Their lack of empathy is more than skin-deep,” Hepper writes.) But if they were told to take the woman’s perspective, their heart rates leapt back up to a normal level.
Hepper thinks that eventually, this research could help shape therapeutic interventions aimed at narcissists. Teachers or human resources representatives could use such tools to try to get their resident egomaniacs to be more charitable.
Perhaps one day we can banish all the world’s narcissists to a desert island littered with tanning beds and TV cameras. Until that day, this type of compassion training might be the best weapon we have against the self-absorbed. As Hepper said, maybe it can help make the world “a nicer, more prosocial place. ”
The following case is a 50 year old male who presented in a office with a 4 part proximal humerus fracture after a fall. He underwent ORIF of the fracture using a proximal humerus locking plate. His preoperative and postoperative imaging studies as shown below. At 8 weeks post operatively he has active forward elevation to 90 degrees and assistive passive forward elevation to 160 degrees. He has an intact axillary nerve on exam and he complains of minimal pain. The postoperative Xrays demonstrate a shoulder inferior subluxation..
8 weeks postop
8 weeks postop
This finding is of limited clinical importance as most of the time within a year or two from the surgery it resolves without any functional limitations. Below please see reference:
Inferior subluxation of the humeral head can occur after shoulder trauma or surgery. One hundred consecutive patients were evaluated prospectively after shoulder surgery or injury. The radiographic incidence of inferior subluxation of the humeral head 2 weeks after rotator cuff repair was 10%. The radiographic incidence of inferior subluxation after fracture of the proximal humerus was 42%, and the incidence 2 weeks after prosthetic humeral head replacement was 60%. The immediate postoperative radiograph showed an inferior subluxation of the humeral head in 4% of patients after prosthesis insertion, but no subluxations were seen immediately after rotator cuff repair. Radiographs made immediately after fracture of the humerus showed a 16% incidence of inferior subluxation. The inferior subluxation resolved by 6 weeks in 92% of patients with humeral fractures, 96% of patients with humeral head prostheses, and all patients who had undergone rotator cuff repair. No subluxations were seen 2 years after injury or surgery. The treatment used--early active exercises and a sling when not exercising--was effective.
Hospitals are buying up medical practices at a feverish pace. According to data from the American Hospital Association, the number of physicians employed by hospitals grew by 34 percent between 2000 and 2010, and the pace shows no signs of slackening. In reviewing its data for the past decade, a large physician recruiting firm found that in 2004 only 11 percent of physician searches were conducted by hospitals, but by 2013 that figure had risen to 63 percent.
There are a number of reasons hospitals want to employ physicians. A major aim is to funnel patients to the hospital’s facilities. By law, it is illegal for hospitals to offer physicians inducements to refer patients to their facilities unless the physicians are hospital employees. A term that some hospitals use to describe the referral of patients to providers and facilities outside their system is “leakage.” Such leakage represents lost revenue, and by employing physicians hospitals hope to plug up the holes.
Of course, there are other factors. One is the ability to hospitals to charge more for a variety of procedures than independent physicians, by tacking on “facility fees.” By buying a physician practice, a hospital can charge more for the same test or procedure, even though it is performed in the same place by the same physician. In some cases, such facility fees can raise prices to Medicare by as much as 70 percent compared to what would be paid to an independent physician.
Another factor is negotiating clout with healthcare payers. When a hospital employs a greater proportion of physicians in a healthcare market, it can often negotiate more favorable payment rates with health insurers. The Federal Trade Commission has taken an interest in this trend, lodging complaints against hospitals for employing too high a percentage of local physicians. In some cases, the FTC has even filed lawsuits against such hospitals.
Hospitals also argue that by employing physicians, hospitals can achieve greater integration of care. For example, they say they can reduce needless variations in practice, including the use of different medical devices for the same procedure, such as knee joint replacement. They also argue that they can ensure better coordination of care between different medical specialties, as well as between physicians and other hospital-employed health professionals such as nurses.
This is not the first time that hospitals have gone on a medical practice buying spree. Something similar took place in the 1990s when the rise of managed care made it appear that hospitals needed to exert more control over patient referral patterns. But widespread public revolt against managed care quickly led to the opening up of such network restrictions. Moreover, as physicians became employees, their productivity fell. Before long, hospitals began divesting themselves of physician employees.
Hospitals hope that this time will be different. For one thing, more sophisticated information systems enable hospitals to do a better job of tracking physician behavior. Even if hospitals lose money on a per-physician basis, they hope that more favorable payment rates and control of referrals will enable them to make up the difference. If successful, they would both get more patients and generate more revenue per patient.
But there is another pitfall in physician employment. Compared to the independent physicians of 20 years ago, today’s employed physicians often exhibit poor morale. It is easy to see why. When physicians become employees, they forfeit a substantial degree of professional autonomy. They are subjected to more institutional rules and regulations, feel increasing pressure to practice according to prescribed patterns, and often labor under escalating productivity quotas.
A related danger is a loss of autonomy on the part of the entire profession of medicine. Increasingly, physicians find themselves working for non-physicians, individuals who never trained in the health professions or cared for the sick. As the trend toward physician employment continues, the people in charge of medical practices are less likely to sport white coats and stethoscopes and more likely to be in business suits. Many physicians feel they are losing control of their profession.
A sense of control can exert a profound effect on morale, energy, and even health. One of the best-known social psychology experiments of the 1970s compared residents of different floors of a nursing home. On one floor, residents were encouraged to make decisions for themselves. For example, they were allowed to choose where to receive visitors, what movies to watch, and how to care for a houseplant they had been given.
On another floor, residents were told that the nursing staff would take care of them. They were not allowed to make choices about where to receive visitors or what movies to watch. They were given houseplants, but were not allowed to determine where to position them or how to care for them. Instead they were told that the staff would take care of things. In contrast to the first group, they were encouraged to see themselves as dependent on the nursing staff.
The two groups were followed for 18 months. At the end of this period, striking differences emerged. The members of the first group were more alert, active, and cheerful than the second group. They were also significantly healthier. In fact, less than half as many members of the first group had died as in the second group. The findings strongly suggest that our ability to choose for ourselves plays an important role in our psychological and physical well-being.
There is a lesson here for physicians and hospitals. A recent nationwide surveyshowed that the single most important factor in promoting professional fulfillment among physicians is providing high-quality care to patients. Where the health of medicine is concerned, infringing on physicians’ ability to care for patients as they think best can prove toxic. By contrast, one of the best tonics is ensuring that physicians can continue to care for patients as they see fit.
In the short term, hospitals may reap financial rewards by employing large numbers of physicians. Over the longer term, however, the vitality of both individual physicians and the entire profession of medicine seems likely to decline, with deleterious consequences for patient care. To protect and promote the future health of the medical profession, it is important that physicians continue to base their decisions primarily on what is best for the patient, not what is best for the hospital.
In a shoulder and elbow blog the post of a distal radius fracture is without a doubt not relevant. The following case is a female in her 40s who presented in the office complaining of pain to the wrist after a fall on an outstretched hand while playing volleyball. I have always been amazed by the incredible design of the plates that have been introduced in the treatment of distal radius fractures and I have to admit that it is one of the injuries that is interesting in treating and studying due to the "many personalities" of this fracture. In addition, I prefer to offer operative treatment for these fractures in the young and active patients always in accordance with the criteria that have been developed by the AAOS (please see following link). I would strongly encourage surgeons who encounter patients with fractures of the distal radius to refer them in a timely fashion to experienced surgeons for assessment and treatment. The reason lies that based on this study (click here) it is the number one reason for malpractice lawsuits. Watching a fracture collapse with serial XRs is the most common mistake made in the treatment of these fractures. (J Bone Joint Surg Am.2013 Feb 20;95(4):e201-8. Lessons regarding the safety of orthopaedic patient care: an analysis of four hundred and sixty-four closed malpractice claims. Matsen FA 3rd1,Stephens L,Jette JL,Warme WJ,Posner KL).
We elected to use a volar locking plate for this fracture, restore the smoothness of the articular surface and reduce the displaced lunate facet fragment.
Lateral view
10 degree tilted lateral view
immediate postop AP Xray
immediate postop oblique Xray
The following drawing is taken from the Textbook Rockwood and Wilkins Fractures in Adults. It indicates that dorsal plates may result in hardware prominence due to the Lister's tubercle on the dorsum of the wrist. On the contrary, volar plates can be manufactured in a way that they follow the contour of the bone, can be low profile and have less chances of prominence. It seems that most surgeons use volar plates for the treatment of these fractures.
In the recent years there has been discussion about the indications and contra-indications of repair of degenerative tears of the rotator cuff. Cost analysis studies have been published in major orthopaedic journals (JBJS) and the treatment algorithms continue to evolve. A recent study demonstrated that postoperative aggressive physical therapy is equally effective to conservative or slow rehab treatment with no negative impact on shoulder function, patient satisfaction and re tear rate. A few years ago studies demonstrated that rotator cuff repair without or with acromioplasty have the same outcome.
Although there is a debate on the treatment of degenerative rotator cuff tears and while the indications for treatment continue to be explored, there is general agreement among orthopaedic surgeons that traumatic rotator cuff tears that result in loss of motion or strength to the rotator cuff need to be addressed surgically if the patient has no contra-indications to surgery. Timing is important as scarring, retraction and atrophy develop with time. Generally, the sooner are repaired the better the chances for successful healing and treatment.
The following case is a patient who is in his 30s and presented in the office 2 months after a traumatic dislocation of his shoulder which resulted in weakness in shoulder abduction, forward elevation of the shoulder to 90 degrees with pain and no instability. He already had an MRI by another orthopaedic provider that indicated a ruptured biceps, Hill Sachs lesion and a torn retracted rotator cuff. The XRs after the dislocation and MRI after reduction of the dislocation are shown below:
Scapular Y XR demonstrates anterior dislocation of the shoulder
AP Xray shows the dislocation
MRI without contrast shows the retracted tear of the rotator cuff
MRI of the shoulder shows on the axial views Hill Sachs lesion and "empty" bicipital groove indicative of torn biceps tendon.
Due to his young age and his active lifestyle we elected to proceed with an attempt for arthroscopic repair with a backup plan of partial repair or just debridement in case of significant retraction, loss of tendon elasticity or atrophy. Arthroscopic images are shown below. A total of 4 anchor were used for repair of his rotator cuff in a double row configuration as it has been demonstrated that a double row repair is biomechanically more stable compared to a single row repair.
Prior to repair the entire footprint of the rotator cuff is seen exposed. The glenoid is seen from the subacromial space through the lateral portal. The picture above demonstrates what is left after debridement of the tear to stable margins
Double row repair completed with four anchors. Each anchor has 4 sutures thus a total of 16 sutures were passed through the rotator cuff.
For more information about the treatment of massive rotator cuff tears please refer to the American Academy of Orthopaedic Surgeons website by clicking on the link below.
