Thanks for putting this amazing ICL together. Sorry, I can't be with you guys in person, but we're going to talk about some very interesting features of Complications that happen in the operating room and how to minimize the chances of them happening and if they do happen How do we deal with them and still get a great? Here are my disclosures. I do have a book that's called skill that I receive LTS from the goals are to manage hard skills the hard skills of the elbow surgery but really I want to get into the weeds of soft skills that are related to Performance the things that make us better as surgeons and we're going to use distal biceps to get Just to go over distal biceps. You make an incision from a technical standpoint. You'll find the lateral end to be cutaneous nerve Get the biceps out you prepare the biceps by trimming some of the Devitalized tissue suture it together in preparation for repair. You get a good strong suture construct You size it and then you get exposure. Maybe you got to ligate some vessels as you see here You get retractors in place you place a pin This is an anterior approach and then you drill We get a button you pass the sutures from the biceps around the button Then you pass the button to the far cortex of the radius You tension it you tie it and you got a beautiful repair Simple easy love this operation But here's the thing. It has a massive complication rate I mean, it's just high this little biceps has high complication rate The most common are related to nerves and in our field nerve injury is very hard to manage But the thing re-ruptures we put it back if something happens we deal with it, but nerve injury is hard So we're going to get into nerve injuries as an especially as it relates to elbow. How do you minimize nerve injury? The first thing is you have to have a great exposure and a great set Setup retractor placement arm position sets you up to see and do this is what it looks like during a Exploration I use a funny incision funny because I never see anybody else using it and I like it because you can move it extensile up north and South and you can get to exactly where you want to be And the first thing about this setup that I appreciate is it's not hard. You got a non-sterile tourniquet They're on an armboard really what I care about for this setup is light in the wound. I Operate a place where light is not grace that the Light it shifts it drifts it does all kind of stuff But at least we start with the light in the wound that starts over the patient's shoulder going into this hole Now if we can see and we got exposure Things become easy. The first thing we look for is this love asking residents this question. What is that? It's the first thing we want to find it's the lateral end to be a cutaneous nerve It hangs over the brachioradialis usually find it and the thing about lateral end to be a cutaneous Taneous nerve is that it often is compromised after the surgery We got numbness over there for if you discuss it ahead of time and explain that to him It actually is not even a complication to me It's just a post-operative feature and yeah You can minimize retraction and pulling on it. The consequence is smaller comes back. There's no more Let's talk about the more Challenging issue. That's the posterior interosseous nerve There may be some things about retractor points that are important. I want to take you on a journey in chess. I bet some of you play chess if you don't I don't play a lot of chess But I am fascinated by it. I'm gonna tell you why this is my son. He's playing in New York City Scholastic chess tournament and when he goes into the ballroom, they kick you out. He gets his table assignment He has his opponent and they start playing against the clock They are instructed to write down every move in a book. Look he's writing four backwards E4 is the notation of his first move and the reason why Is when the game is over they meet with their chess coach and they go over the game Immediately and they compare move by move on whether it was a good move or a bad move Is it a move that a master would make or is it a blunder where you lost your Queen because you left it hanging? That's not that much different than when we do in residency training we ask residents to go and evaluate and do physical exams and then present to us and then we Critique them on whether it was a good move a good exam a good thought process and then they go and do it How on Fridays we have a technique conference at our institution It is an incredible conference where we take a surgery and we go from the beginning of the surgery to the end and throughout We stop and we are critical of every move of the surgery just like in a chess match it's a Humongous workout for the resident or Fellow who's presenting? Let me give you an example. Is it this the biceps or in the middle of a distal biceps? They show this slide here and they say, okay, we're getting exposure like whoa exposure doesn't look that good Tell us more about how you can enhance exposure But I say we'll ligate some vessels fabulous and then we're gonna put retractors and we're gonna put the retractor I'm gonna put a retractor on the radial neck what retractor and where on the reading that I'm gonna put a home I'm not gonna put it over the radial neck on the radial side and Then we say we got a problem Because that type of retractable put pressure on the posterior neurostatis nerve and cause an injury So in conference, we've already gone through a feature of eliminate complications It's not why did you do that? It's what would you do if this situation arose? So if it happens in real life, you know what to do, it's called counterfactual simulation it is hard It's powerful. It is taxing the person who's doing it, but it makes you a better This is Magnus Carlson, he's visiting the Marshall Chess Club. I used to live by the In the West Village of Manhattan. I visited the Marshall Chess Club with a grandmaster. I used to watch games there. It's fascinating This is Washington Square Park, this is my son in Washington Square Park He's playing a chess game for 10 bucks. They actually lost this game. He's young Okay Here's the question Do elite chess players have amazing IQs? Can they see things that other people can't see with calculation? The research shows they have average IQs. Let me prove it to you. You do an experiment It was done in the 1970s. You take expert chess players and novices You give them a board with a bunch of pieces you show it to them And then you take the board away and you say recreate what you just saw The novices are weak. They have a few pieces they can get accurately Masters they get them all right every time. All right, show me a chess board. I'll do it again You do Another phase of the experiment where you put the pieces random. They don't represent a chess game What has happened what happens after that the experts equal the novices the experts equal the novices if it doesn't resemble a chess game and The reason is elite chess players have libraries and themes of positions in their head. So they're not Remembering all the pieces they're remembering a chunk piece of information Inexperienced chess players are calculating constantly Elite chess players see patterns and they know what to do This is true of surgeons We see a collection of chunked information that are linked together That's what the grandmaster see they see the board differently That's what we see in the operating room and we assess problems weaknesses advantages opportunities There's an eight-year-old he's playing simultaneous chess he's going around the board he's beating everybody this poor guy lost his Queen this is Bobby Fisher, he's gonna play 50 games Simultaneously, he actually knows that this guy cheated. He knows he remembers every position of all this and you may say it's Impossible for your brain to continue to manage all that information. It is not impossible How do I relate that? Let's just say Some of the experienced people who are attending today or even the less who have been involved in some of these teaching courses If I was to walk around the room or one of you guys or Matt and you we were doing ACLs or something And you saw a portal was off here The drill was broken here as you walked around and came back you would remember because you know the operation so well And you know what the deviations are and you know how to make those improvements you see Let's get to that for this PIN we're gonna drill a pin Place a pin drill a hole over here. The PIN goes around the back. We do not want it Terrible if it happened Is what the literature tells us if you put the pin in you can PIN palsy on the far side In fact, if you direct the pin in the wrong direction that's radially and distally you get close to the pin within one millimeter and I believe this study, you know why? I went to the lab and I put a pin across to see if this was true and the pin was close if you drove distally and radially in a radial direction What do we do to get better? We avoid poor pin placement XC arm we can do things like that Here's the thing the best chess players Gary Kasparov said this he was the highest ranked chess player in the history of chess He says the best players recognize pitiful moments in chess. They know when it matters and That's where they succeed and take time The best surfers do the same so We drill far from the cortex. We aim the pin maybe at the PIN and then we drill away from it I do this They say let's say we're going to go with the PIN and then let's get away from it Place the pin as an exercise Check this out. This is the pin going in we got good light. Thank goodness We place the pin and the technique guide would say place the pin across the far cortex We don't place it across the far cortex Just the near cortex that pins only designed to stop the reamer from walking We make sure we're not going to blow out the radius like we could happen with an ACL and then when we're done We put the pin in and now we orient it away from the PIN. We translate it Away from the PIN. We translate it and we orient it away from the PIN Why because we're thinking PIN safety during the whole procedure What's the best predictor of chess ability if somebody asks? What's the best predictor of? Surgeons ability patients will say well, it's the amount of surgeries you've done. How many distal biceps have you done? It's Not the amount of chess playing that predicts chess ability It's the amount of time you analyze chess games. They don't even have to be your own games. They can be master games. I Think that's true of surgery. We should be analyzing surgery more This is a blunder it's a patient brought into our institution at a distal biceps repair Anchors are not in the right spot. These are suture anchors placing Okay, let's talk about practice practice is actually not a difficult concept It's just a loop you try it you get feedback you correct and then you keep doing it and you keep doing it You keep doing it. I want to talk to you about Feedback

complications during surgery

exposure and setup in surgery

nerve injuries in surgery

counterfactual simulation in surgical skills

continuous practice in surgical skills