March 2009 – March 2010 in Massachusetts General Hospital shoulder surgery study, study in the middle of writing something, yesterday in the computer by chance to find, today posted it, welcome to the same way questions and exchanges. Meditation review I arrived in the United States nearly three months of life and learning, I feel very fruitful, the following on some personal experience and harvest to make a brief report. BOSTON is located in the northeastern United States of New England, Boston’s latitude and climate and Beijing is almost the same, four distinct seasons. in May, in Shanghai has been relatively hot, and here is still very cool, the average temperature of about 15 ℃. Massachusetts General Hospital is right next to the MGHCharles subway station on the redline. I rented a room near the North Quincy station on the redline, sharing the kitchen and bathroom with 2 other tenants. It takes about 10 minutes to walk to the redline North Quincy station, plus waiting time, usually it takes about 45 minutes one way, which is quite convenient. I bought a monthly Charlie card, which is good for both subway and bus, and it’s$59 per month. Every night when I came back from work, the first thing I did was to cook dinner for that night and the next day’s lunch (lunch in the hospital cafeteria costs about 6 dollars, so I usually brought my lunch box to the hospital to solve the problem). To save time and give myself as much time as possible to read, I would usually stir-fry once on the weekend, make the food half-finished and make enough for a week’s worth and put it in the fridge for later. This way, I only need to heat it up in the microwave for 4 minutes each time and then I can eat it, which is convenient and saves time, and frees up more study time for myself. In order to save money, I would go to a haymarket (similar to the open-air bazaar in China) once a weekend, where the price of food is cheaper, and I once bought 3 pounds (1 pound = 0.907 kilograms) of green beans in one cut. MGH was founded in 1811, the existing employees of all kinds of nearly 25,000 people, last year the hospital revenue has been more than 2.5 billion U.S. dollars. MGH attaches great importance to scientific research, research staff accounted for half of the total number of employees, the annual budget of nearly 550 million U.S. dollars in scientific research, the whole hospital has a total of 118 research centers and laboratories. The Department of Orthopaedic Surgery is its key department, with seven laboratories (see the following paragraph), including the Bioengineering Laboratory and the Harris Orthopaedic Biomechanics and Biomaterials Laboratory (HOBBL), which are considered to be international-level labs. The Bioengineering Laboratory is a joint venture with MIT, headed by Guoan Li, PhD, from China. This laboratory mainly does 3D dynamic research on various types of joints, with more than 20 research fellows from all over the world and a few PhDs from MIT collaborating in this laboratory, and the main equipments are two C-arm machines. The main equipments are two C-arm machines, and this lab has collaborative projects with Shanghai Nine Hospitals and Beihang Third Hospital in China. HOBBL was founded by Dr. Harris, who has an international reputation in the field of hip joints (he designed the famous Harris Score hip joint), and the research direction is mainly on artificial joints. Arthroscopic Psychomotor Skills Laboratory Bioengineering Laboratory Biomaterials Research Laboratory Cartilage Biology and Orthopaedic Oncology Laboratories Harris Orthopaedic Biomechanics and Biomaterials Laboratory (HOBBL) Laboratory of Orthopaedic Biochemistry and Osteoarthritis Therapy Trauma Research Laboratory My mentor Dr. Warner is the director of harvard should service, here is a brief biography of him. graduated from Rochester medical school with first class honors in 1982, 84-87 Harvard Orthopaedic Residency ’84-’87, Clinical Fellow in Shoulder and Sports Medicine at NewYork HSS ’89-’90, Director of Should Service at the University of Pittsburgh ’90-’98, Director of the Harvard Should Service ’99-present. Dr. Warner is one of the only two full professors of orthopaedics at MGH (2004–). He is a member of 14 professional societies including AAOS, ANNA, AOSSM, ASES. He is a reviewer or editorial board member of 10 journals including Lancet, JBJS, CORR, AJSM, JSES, Arthroscopy, etc. Since I wanted to find a few more topics for myself, I took a closer look at all the articles and monographs Dr. Warner has published. He has published a total of 218 articles and 10 monographs and monographs. Among them, 38 articles on shoulder anatomy and biomechanics, 53 articles on shoulder instability and glenoid labral injury, 13 articles on frozen shoulder, 4 articles on shoulder nerve problems, 23 articles on shoulder impingement and rotator cuff injuries, 2 articles on biceps tendon, 4 articles on shoulder special sports injuries, 17 articles on shoulder OA and arthroplasty, 16 articles on shoulder fracture, 2 articles on AC joints, 5 articles on pterygoid scapulae, 3 articles on shoulder rehabilitation, and 23 articles on others. Knee 15 articles. The articles were mainly published in JBJS(Am), CORR, Arthroscopy, AJSOM and JSES, the first 4 journals are familiar to domestic professionals, and the last one, JOURNAL OF SHOULDER AND ELBOW, is a very good journal, which publishes articles on shoulder joints of a high standard. Since HARVARD SHOULDER SERVICE has a good international reputation, it receives TRAVEL FELLOWs from the US, Europe and Asia almost every month, and in the three months I have been here, WARNER has received 4 groups of TRAVEL FELLOWs from ANNA (Arthroscopy Association of North America), ENGLAND, GERMANY, and KOREA. There are two groups in the MGH SHOULDER SERVICE, and DR. WARNER himself is in charge of one group, with the following staff structure: KAREN, the academic secretary, is responsible for all academic-related matters in the department, and she is specifically responsible for handling the matter of me coming to MGH for study; MISSY, the clinical secretary (also called the head of the office), coordinates and arranges all clinical work; a NURSE, who is responsible for the coordination and organization of the department; and a NURSE, who is the head of the MGH SHOULDER SERVICE. MISSY Clinical Secretary (also called Office Director), all clinical work is coordinated by her; one NURSE PRACTIONER; one MEDICAL ASSISTANT; two FRONT DESK; five FELLOW and one RESEARCH ASSISTANT. WARNER to make his own money (outpatient visits and surgeries) to take care of it. But this is a piece of cake for WARNER, the outpatient registration fee is$438 a head, and the regular shoulder arthroscopy fee (surgery) is around$30,000 dollars. WARNER’s weekly working arrangement: Tuesdays 7AM-8AM is INDICATION CONFERENCE, or discuss some difficult cases, or on a hot topic for learning, such as last week’s learning is glenoid resurfacing. 9AM start clinic, generally see 25 in the morning, 25 in the afternoon. FELLOW, RESIDENT or NURSE PRACTIONER will first see the patient, ask for history and physical examination, then report to WARNER, who will finally see the patient in person and give his opinion. There are 6 consultation rooms and WARNER sees them in turn. This side of the medical history is not recorded on the spot, but WARNER or FELLOW after seeing each patient, through the phone to DICTATION, written by a professional record keeper and then passed back to the patient’s file, so that it can be more efficient, the doctor has more time to check the patient and communicate with them. My impression is that the patients here have a high level of professionalism, and often ask some very specific questions, such as a certain literature says that the results of a certain surgical method is not good, how do you think ah, and that is the arthroscopy or arthroplasty that you do, what is the ratio of primary and revision ah, and so on (a lot of the patients who come to the patient have been outside of the surgery, but the results are not good). I have been here for almost 3 months. I have been here for almost 3 months, and the most tiring thing is the outpatient clinic, because I have to stand all the time, and there is no customary lunch here. A lot of times, because there are a lot of surgeries in the first couple weeks, by the time the first follow up visit is 2 weeks post op, it’s not 50, it’s 70, and you usually have to see them until 7PM. if we end up seeing them only at 5PM one day, everyone is happy. Although it is very tiring to see the clinic, but in my case, it is the most rewarding, because on the one hand, I can see all kinds of difficult and complicated cases (often see a patient with 9 or 10 incisions in the shoulder joint), so my professional progress is very fast, and on the other hand, listening to Warner and the patients talk about English for a whole day, so my English has grown a lot as well. Wednesday was arthroscopic surgery at MGH WEST (in another city in Massachusetts, WALTHAM), and just a little bit of a rant here, HARVARD’s shoulder arthroscopy is an outpatient procedure whether it’s done at the MGH main office or at MGH WEST. Even the LATARJET procedure (an incisional procedure to treat anterior dislocation of the shoulder) is an outpatient procedure. Immediately after one is done, the WARNER goes to the DICTATION surgery record, which is very detailed and 2-3 pages long. The surgeries are usually scheduled for 6-7, starting at 7:15AM, done in two ORs jumping from table to table, and can usually be finished by 2PM. Because it is almost 2 hours drive from where I live to WALTHAM, I have to wake up at 5:15AM that day. The rest of the 3 days in MGH surgery, because DR.WARNER has to go out for a meeting once a month (usually about a week), Tuesday’s clinic will cancel, so MISSY will often arrange for a varying number of outpatient clinics to fill in the gaps on these 3 days. The main OR has 50 rooms and the SDSU has 10 rooms. Interestingly, all surgical patients are admitted on the day of surgery and discharged the day after surgery (except for arthroscopy). All of the patient’s information (medical records, various records, various lab tests, and various imaging films and reports) are in the CAS system, which can be easily accessed through the hospital’s intranet, making it extremely convenient to follow up with the patient. There are so many computers and telephones here that it can be described as “one computer and telephone per step”, with computers and telephones in every consultation room of the outpatient clinic. The operating room is even more exaggerated, each OR has 3 computers and 3 telephones, and the doctors, nurses, and anesthesiologists each use their own, and all medical instructions and records are entered via intranet. In addition to X-RAY, CT and MRI, shoulder imaging is similar to that in Europe and ultrasound is also used here. X-RAY is used to take ture AP (true anteroposterior view) and axillary view (axillary view), which I knew from the literature before, but did not know much about their practical application. It is only after contacting many cases here that I realized their real clinical value. In ture AP, the distance between the apex of the humeral head and the acromion can be measured, and if it is less than 3 mm, it indicates that the rotator cuff injury is irreparable. axillary view can clarify the relationship of the humeral glenoid joint in the axial position, for example, whether there is an anteroposterior subluxation or dislocation (so that posterior dislocations will not be missed), and when diagnosing the acromioclavicular joint subluxation ROCKWOOD In the diagnosis of acromioclavicular joint dislocation ROCKWOOD type 4 (Fig. 1), an axillary view is also required, as the clavicle is displaced posteriorly by the trapezius muscle. The arthro-CT is widely used here, especially in juvenile shoulder instability, because the humeral head or glenoid often has a bone defect in this condition, and even arthro-MRI is not as direct as arthro-CT.MRI is routinely used as a direct imaging study, and is valuable in humeral-glenoid ligament and especially glenoid labral injuries.Coronal and axial scans are not well differentiated from domestic scans. Coronal and axial scans are not very different from domestic scans, but sagittal scans are fundamentally different. I have looked at the films brought by MGH and patients from other hospitals, and all of them are scanned to the root of the rostral process to check the nature of the rotator cuff muscle, and if the signals are high, it indicates that the muscle is fat infiltrated, which is irreparable, and it is not considered as a direct repair. Of course, doing arthrography requires X-ray monitoring, which requires a lot of assistance from the radiologist, which is not a problem at MGH, but at the Sixth Hospital, you need to communicate with the radiology department properly. X-ray monitoring is very common in MGH radiology department. In addition to arthrography, WARNER often requires AC joint closure and SSN (suprascapular nerve) closure under X-ray monitoring. It is difficult to post high quality English articles without good films! In the operating room to see a lot of useful things: 1, arm holder it can be fixed in any position of the upper limb, three LEVER connected by two universal joints (Figure 2 and Figure 5), in doing shoulder surgery especially when the latissimus dorsi tendon displacement and shoulder fusion can come in handy; 2, 79 blade and handle, hand and foot surgery with a very convenient (Figure 3); 3, the square automatic pulling hook, the surgical assistant is very useful when less (Figure 4) The square automatic pulling hook is very useful when there are few assistants (Figure 4); 4. Bean bag, which can be folded into a shape that matches the individual’s body, is very useful (Figure 5). DR.WARNER was very nice to me and gave me a book he edited-complex and revision problems in shoulder surgery (sold at the bookstore for 170 dollars). He asked me to work with his clinical fellow on the chapter Management of the unstable shoulder: arthroscopy and open repair. I have been given three research subjects, the first one is AC joint reconstruction, and two case reports, one is SSN compression after inverse shoulder arthroplasty, and the other one is customized shoulder prosthesis for midget shoulder OA, but I think it is not enough. , I am checking the literature to find three or four more. The HARVARD library has an amazingly large collection of books and magazines, and there is basically no book or magazine that I can’t find, but the originals are frighteningly expensive, so I’m just going to use my digital camera to take pictures of the books in question and come back to research them slowly. If I don’t utilize this opportunity to write more articles this time, I will be really sorry for the leaders to give me this once-in-a-lifetime opportunity. When I was in China, I didn’t know much about the shoulder joint and thought that shoulder service means bankart lesion, shoulder impingement and so on, but when I came here, I realized how ignorant I was. I remember the first day I saw the surgery, an irreparable posterosuperior rotator cuff to do the latissimus dorsi tendon transposition, and came back to read the book to realize that rotator cuff injuries can be divided into reparable and irreparable, and the irreparable can be done according to the different conditions of tendon transposition or prosthesis replacement or joint fusion. Depending on the condition, tendon transposition, prosthesis replacement or joint fusion can be done. The following is some of my shallow understanding of shoulder joint diseases after studying here for nearly 3 months; 1, supraspinatus rotator cuff injury, the most common, if it is reparable, in arthroscopic repair, we have to put the lens on the lateral approach to observe whether it is layered. Many patients seen here are delaminated, and both layers are sutured on during repair. If it is IRREPARABLE, then either tendon displacement or prosthetic replacement or joint fusion can be done depending on the situation. The indications for latissimus dorsi tendon transposition should be strictly controlled; if the force of the assisted forward elevation is more than one finger, the result will not be good. 2. Anterior inferior rotator cuff, also known as subscapularis injury, is basically unheard of in China. When looking at MRI, pay attention to whether the biceps tendon is in position, such as dislocation to the medial side, which is most likely to be accompanied by subscapularis injury. If REPARABLE, it can also be extremely challenging to repair microscopically because the subscapularis muscle is in front of the brachial plexus and subclavian artery. If reparable, consider transposition of the sternal head tendon of the pectoralis major muscle. 3, Freezing shoulder, anterior joint capsule ligaments including rotator cuff INTERVAL contracture predominates, and shoulder external rotation (ER) is significantly reduced on physical examination. In microscopic release, it is necessary to release the anterior and posterior bundles of SGHL, MGHL and IGHL. SGHL and MGHL are not a big problem, but there is a problem with IGHL, because the axillary nerve passes less than 1CM below it. I saw WARNER did a patient, he used MITEK an electric knife with Hook to do close to 210 degrees of the whole loosening, very thorough, see the TRAVEL FELLOW from Germany to come over the dumbfounded, he said he never dared to loosen the IGHL. 4, the shoulder joint OA, this kind of problem is very rare in the country, this side of the a lot of Europe is also a lot of, may be related to the human race and the way of life and sports. WARNER with artificial joints is his own design ZIMMER ANATOMIC SHOULDER SYSTEM, this prosthesis is characterized by the head and handle is a combination of the head can be placed in the handle to do a 360 rotation, to be rotated to the optimal position and then fixed links, very convenient. If you want to change to inverse after a while, the shank can still be retained. The concept of INVERSE comes from Europe and has only been approved for use by the FDA in North America for 3 years. But its indications should be strictly mastered, because even the big-name GERBER reported 30% of complications. 5, Biceps tendonitis, often complicates with other shoulder joint problems. Diagnosis is primarily based on the presence of tenderness at the biceps tendon groove. Treatment depends on whether the patient is ACTIVE, such as more ACTIVE, in the pectoralis major muscle distal to do tenodesis, if it is nonactive, WARNER only do tenotomy. I saw a lot of postoperative follow-up patients, the effect is quite good. 6, popping scapula (snapping scapula), this concept has never heard of in the country, let alone talk about treatment. It is mainly the scapula nonjuris cavity “still striders Ying sunshine spoon stand Jia Lu Min feed choking tor blade flattering Σ cool boo scandium find owl Min good offices HanBa posthumous lotus curtain trailing (13) ZiLong V plague PuTaoCheChip Min vortex enjoin tanshey謇硗鼻谐 Min feed riparian nonjuris hold (bro bro worry rhomb minus in the scapular endpoints. 7, winged scapula (scapular winging), seen in the country, but will not deal with. In this regard, WARNER is one of the few specialists in the United States, I saw a lot of patients sitting on the morning flight from all the way over to him to see, and take the evening flight back to the patient. The causes are thoracic long nerve entrapment, trapezius muscle insufficiency or shoulder muscle hypoplasia, with thoracic long nerve entrapment being the most common. There are two modes of treatment, one is transposition of the sternocleidomastoid tendon of the pectoralis major muscle and the other is fusion of the scapula with the chest wall. Have not seen the scapular chest wall fusion before, always feel very scary, follow up see WARNER do patients realize how good the effect, a patient said that when playing golf can play a ball 70 yards. 8, backward bankart lesion, WARNER used by the rotator cuff lens approach, only see a patient, experience is not very deep. 9, AC arthritis, WARNER used by the AC joint operation approach, plus 70 degrees with the lens, the clavicle of the superior and posterior can easily cut clean.