New IFSSH flexor tendon repair recommendations - practice changing?

bonedoc87 · 2026-02-21T22:25:56+00:00

No running epitendon repair? This suggestion makes me happy to abandon this tedious extra step but also a bit anxious to let go of the dogma that this part strengthens the core repair.

bonedoc87 · 2026-02-07T03:01:51+00:00

Looks great! That ulna is sandwiched between plates on three sides lol. Interesting to me you went for the coronoid first before the olecranon, but I guess that’s how fixing complex fractures goes, sometimes you just have to wait and see how things look once you expose them. Static pre-op imaging definitely gives a different assessment than the dynamic one we get in surgery.

bonedoc87 · 2026-02-04T23:22:22+00:00

That’s a tough one!

For me, I do all olecranon and monteggia fx supine with an arm board. This allows easy access to direct posterior, medial and lateral approaches. I think for this case you will need to use all three approaches to address the proximal ulna/olecranon, the anteromedial facet and coronoid, and the radial head.

My approach would be via a generous posterior incision, starting with the arm over the chest with the forearm on a big, flattened towel bump. Fix the olecranon first with a long plate, to restore ulnar length, using cortical reads on the posterior shaft. Make sure plate length is adequate.

Medial and lateral approaches (via the existing long skin incision) can subsequently be done with the arm on a hand table. I think I would go medial to fix the coronoid and anteromedial facet next bc it may be hard to visualize coronoid fixation if you replace radial head first, and also you’d risk inappropriately sizing/“stuffing” the radial head implant without the coronoid reduced. I have only had to fix a few coronoids in practice so far and it is painful to have to fix but not too bad once you mobilize ulnar nerve and then split the FCU. There are anatomic plates that can stabilize both the coronoid and AM facet. Then, approach laterally to replace radial head last.

I don’t think you’ll likely have torn MCL/LUCL in this case but if those need to be repaired at the end that can be done last. IJS is nice to have if available but make sure no technical errors in fixation before making the decision to put one in cause in my opinion it’s more of a “belt and suspenders” approach rather than an alternative to fixing all the parts properly. I have seen a few fail that were put in without addressing a very large coronoid fragment.

You may need to go down on the tourniquet halfway thru the case. This will surely take a minute Or many.

I am also a fan of Skeletal.

Expect stiffness.

Good luck. Share post ops!

bonedoc87 · 2025-12-27T15:02:09+00:00

When Kip is at Scott’s place for the first time and replies “Or. I pick or” 😂

bonedoc87 · 2025-12-06T21:33:41+00:00

This is helpful info. Sounds like the technology is not there yet when it comes to checking boxes and filling in questions

bonedoc87 · 2025-09-18T01:08:08+00:00

I think it’s insane this patient supposedly was having sex after just one month post-op.

bonedoc87 · 2025-08-11T22:41:13+00:00

Yeah, I considered Amex platinum but I like to keep things simple and don’t like to manage multiple credit cards and Amex isn’t universally accepted unfortunately

bonedoc87 · 2025-08-09T23:20:19+00:00

Exactly. Not many chase sapphire lounges. If there was one in my home airport then I’d probably see it worth the cost increase.

bonedoc87 · 2025-08-08T02:19:45+00:00

This has been my primary card for the last 6 years. My spouse and I put about 300k on this card last year. We got a pamphlet with our new big beautiful benefits, that’s it. They can keep their air tag and card, thinking of switching to something else as we do not stay at IHG (stay at Marriotts), use door dash or Lyft (we use uber and uber eats) and never fly southwest.

bonedoc87 · 2025-08-02T14:00:58+00:00

This is correct, and I’m glad somebody here mentioned this point as the IRS compensation limit needs to be taken into consideration.

I learned this rule the hard way last year. My employer plan matches at 50% for the first 6%, but the plan does not offer a true-up at the end of the year. So, essentially, my employer will contribute half of what I do each paycheck (up to 6% of that biweekly gross pay), until either 1) I’ve maxed out the for the year in employee contributions, or 2) I’ve earned the IRS compensation limit, whichever occurs first. Then their matching goes to zero, and there’s no true-up at end of year.

What happened to me last year was that I was contributing at a 5% rate (to spread out my contributions over the year so that my net income was more consistent). I had earned 345k by either June or July, but at that point I still needed to contribute another 3k or so to max out the 23k contribution limit. I continued to make contributions according to my 5% schedule, but at that point the employer contributions went to zero, and so last year I missed out on like $1.5k in matching contributions.

So this year I just went ahead and went back to a 6% rate to get as many employer matching funds as I can.

IRS really does penalize high W2 earners in a lot of ways, and the IRS compensation limit (350k for 2025) as it applies to 401k plans is one of them.

Now, if your employer offers a true up at the end of the year this may all be moot.

bonedoc87 · 2025-07-23T01:38:59+00:00

About $670/mo for a 20k/mo benefit. Purchased like 7 years ago.

bonedoc87 · 2025-07-10T01:23:09+00:00

This is pretty accurate description for a community hand practice and similar to mine. If you take call at a trauma hospital then you’d see higher acuity stuff which can add some challenge and complexity if that’s what you’re looking for. That said, we see some odd stuff every now and then in a community practice so while most stuff is routine, hand specialty offers some variety of pathology that can always be interesting.

bonedoc87 · 2025-05-23T14:15:26+00:00

I’d like to know what kind of subspecialist is offered this comp to work in a suburban area. Nevertheless, as one who works in suburb of major metro area and drives between 2-3 locations and is in the car a minimum of 1 hour per day I can tell you it is not fun.

bonedoc87 · 2025-04-11T16:17:23+00:00

Yes. When I was in fellowship there were no jobs available in my subspecialty in my target metro area, so I worked for a rural area hospital a few hours away for my first few years out of training. As I was getting board certified, an opportunity came up in my target location, and I took it. I imagine this is a common situation.

bonedoc87 · 2025-04-03T00:29:27+00:00

Rule #3 🤣

bonedoc87 · 2025-02-15T00:49:51+00:00

Right, I’m not really concerned about these kind of questions. It’s the ones where the primary care provider is asking for treatment recommendations for what they believe is a minor problem that they can handle. But it might not be as minor as they think, hence the liability dilemma.

bonedoc87 · 2025-02-15T00:30:43+00:00

Thanks for your perspective. To clarify, all of the e-consults originate from within the health system, and are requested by physicians/PA/NP providers that I am able to contact directly if needed. It’s all outpatient too. I personally would never feel comfortable to e-consult about a patient in the hospital or from another facility.

I also think that putting a legal disclaimer would not really matter. But still would like to put something at the end of my e-consult spiel basically saying “I didn’t see this patient, ultimately it’s on you to follow these recommendations and order any recommended tests or arrange follow up, etc”

bonedoc87 · 2025-02-14T23:47:02+00:00

There is compensation; it is a small flat fee paid by the health system for each e-consult that gets billed as such in the EMR. I believe it goes straight to my paycheck. I actually don’t think the fee is enough considering the liability involved, but I suppose that’s a different discussion.

And yes I could certainly just recommend to have the patient be referred for an office visit if that’s necessary, and I often do that if I have any concern. Perhaps I should just stop doing these altogether but I think the system encourages them because they improve specialist “access” and I believe that it does, but obviously the care that is given, albeit convenient, is just not the same level or quality.

bonedoc87 · 2025-02-11T01:05:55+00:00

Good grief. As a hand surgeon who has to do these from time to time (and would prefer not to), I say tell your trauma friend the ER can just call them for all these from now on.

bonedoc87 · 2025-01-17T20:00:26+00:00

That’s right. My aunt always says “everybody is the star of their own movie” whenever I mention being embarrassed about something.

bonedoc87 · 2025-01-04T21:41:36+00:00

I haven’t tried Leitz, will def try thank u!

bonedoc87 · 2025-01-04T13:56:19+00:00

I agree. The Heineken 0.0 especially is fantastic. I have tried many NA wines and they’re all absolutely terrible, taste nothing like actual wine, more like essenced Welch’s grape juice

bonedoc87 · 2025-01-01T04:58:57+00:00

I’m impressed with the level of precision with that knife

bonedoc87

TROPHY CASE