Tips

Coracoid harvest for transfer during Latarjet procedure performed and filmed by Dr. Jobin using GoPro Hero 3.

To read the authors' full article "5 Points on Using Wearable Technology to Record Surgical Videos," click here. 

Coracoid harvest for transfer during Latarjet procedure performed and filmed by Dr. Jobin using GoPro Hero 3.

To read the authors' full article "5 Points on Using Wearable Technology to Record Surgical Videos," click here. 

Coracoid harvest for transfer during Latarjet procedure performed and filmed by Dr. Jobin using GoPro Hero 3.

To read the authors' full article "5 Points on Using Wearable Technology to Record Surgical Videos," click here. 

Safe and efficient advanced surgical skill training is of tremendous importance. With the recent increase in Internet use for medical education, there has been a concomitant increase in video recording of surgical procedures and techniques. Surgical recordings have been used in a variety of ways—as live webcasts for remote participants, as “coaching” opportunities for surgeons evaluating their own performance in the operating room, and even as informational resources for patients about to undergo the same surgery.

Surgical multimedia is being delivered through several different outlets. Many academic conferences and meetings showcase videos of different procedures, and several subspecialty societies (eg, Arthroscopy Association of North America) house archives of technical videos for viewing by members. In addition, the VuMedi website offers videos and allows members to comment on them and interact with the videographers. Surgeons are even posting technique videos on YouTube and other public websites.

A large proportion of surgical multimedia is recorded with conventional high-definition video cameras.¹ Besides being able to experience a case at any time and from outside the operating room, the audience can watch from numerous vantage points, angles, and zoom levels. Also, surgeons’ narration can be valuable in helping the audience follow along with the case.

Recording surgical multimedia historically required tight coordination and precise planning by surgeon and videographer. However, innovations in wearable technology now allow surgeons to literally wear video cameras and record procedures as they perform them, in real time—to act as both surgeon and videographer.

Two such products are Google Glass (Google, Mountain View, California) and GoPro Hero (GoPro, San Mateo, California), both of which allow surgeons to record exactly what they see during procedures (Figure 1). Using a wearable technology for surgical multimedia creation requires a deep familiarity with its capabilities and limitations. In this article, we summarize these products’ similarities and differences and provide a technical overview for using wearable technologies in surgical multimedia creation.

1. Choosing a device

When purchasing either wearable device, several factors must be considered, including budget, possible uses outside the operating room, and possible limitations of the technology (Table 1). At this time, Google Glass is significantly more expensive than GoPro Hero. The Google Glass base unit costs $1500, and the GoPro Hero 3 model costs approximately $200 (higher-priced Hero models are available). Both devices require accessories (eg, portable battery unit, dedicated hard drive).

Device capabilities must also be considered (Table 2). Google Glass consists of both hardware and software. Users can record what is seen and heard through the lens and then use apps to create text and e-mail portals to online gaming, social media, and even golf-course GPS. The app market for Google Glass is nascent but undoubtedly will increase in volume and scope as more users adopt the technology (Google Glass comes with both Bluetooth and Wi-Fi and can function tethered through a smartphone). GoPro is mainly a hardware unit that can record in various settings (it is popular with athletes who want to capture and broadcast their participation in action sports). Newer GoPro Hero versions offer Wi-Fi, which allows streaming of video content to a smartphone or tablet through an app. Having clearly defined goals for a device—‌‌as they pertain to use outside the operating room, such as outdoor activities and underwater recording—‌may help the surgeon decide which product is more suitable. Last, it is important to consider limitations. Google Glass resolution is 720p (1280×720) for video and 5 MP for still images, and GoPro resolution can reach 1080p (1920×1080) for video and 5 MP for stills.

Both devices require purchase of accessories. An external USB battery pack is useful for both devices, as is a password-encrypted hard drive for media storage. Lenswear does not come with the base version of Google Glass and is purchased separately from the company. GoPro users buy micro SD cards (~$50 per 64-GB high-speed transfer card) for storage on the device and may buy lithium-ion batteries as an alternative to the external USB battery pack.

Author Update

In January 2015, Google announced that it was temporarily suspending its “Explorer” program, which allowed individual users to buy and test the device for personal use. However, Google is continuing its development of Glass with health care technology, among other areas of growth and development.^2,3

2. Recording a successful surgical video

Unlike a camcorder, which typically is set on a tripod for conventional video recording of surgery, Google Glass and GoPro are intricately linked to the operator. Surgeons must be constantly aware of where they are during surgery and try not to let anything obstruct the camera’s view.

Before starting a case, the surgeon using either device must ensure that its battery is fully charged, as a full charge typically supports 1 hour of continuous recording (the Google Glass battery is a lithium-ion 670-mAh internal unit). A full charge should be enough to capture a short case. Newer GoPro models, with a battery listed at 1050 mAh, provide 1 to 2 hours of recording. When more than 1 hour is needed, an external USB battery pack can be used. This pack allows the device to remain plugged in throughout the case (the pack is kept in the surgeon’s back pocket). We recommend having an external battery pack that is at least 10,000 mAh (~$30 online retail), which easily provides 3+ hours of recording. Unfortunately, this arrangement can be cumbersome. Alternatively, with GoPro, additional batteries may be purchased, but the user needs to dismount the device in order to swap them in (may be difficult during surgery). With both units, partitioning a video into shorter segments conserves battery power and minimizes the risk of file corruption, which may occur if the battery dies or the device overheats.

Google Glass users can bypass manual operation of the device by giving it voice commands (eg, start video, take still image). The exception is for recording video for more than 10 seconds (current default setting). Unfortunately, the surgeon must touch the device to start this recording, which means using extra gloves to preserve operating field sterility. Still images can be made through a combination of voice and head gestures and without manual intervention (Figure 2). Last, users must ensure that the device is not actively connected through Bluetooth to a mobile phone, as incoming calls, text messages, and e-mails may disrupt active recording and become a distraction. The connection can be deactivated by disabling Bluetooth on the host smartphone or by placing the phone into airplane mode and turning off Wi-Fi.

Google Glass users can see what is being recorded through the viewfinder prism, whereas GoPro requires precise framing of the video before recording. Framing is done by grossly aiming the device in the desired direction. However, there is no way to ensure exact aim during recording. If at any point during a case there is slight repositioning of the GoPro, there is a risk of recording the case out of the center of view. An important advantage to newer GoPro versions is the ability to control the device through a wireless remote that can be placed under the surgeon’s gown. The remote can be used to pause and resume recording, without changing gloves, as is done with Google Glass. Last, because the minimum viewing distance from the surgical field is usually 18 inches or more, typically there is no loss of focus or blurring of the image from short-distance recording on either device.

3. File management and playback

Before using wearable technology in the operating room, surgeons must become aware of its limitations with respect to file storage and playback. Google Glass has a usable memory of about 12 GB (1 hour of video may require 1.5-2.0 GB). Conversely, GoPro’s capacity is defined by the micro SD card used. Therefore, the Google Glass hard drive must be regularly maintained well before being brought into the operating room, whereas recording can be extended (with respect to memory) for the GoPro if the media card is large enough.

Both devices allow for wired file transfer, which may be done with Windows Explorer (PC) or iPhoto (Macintosh). However, Google Glass also allows for wireless transfer, through portable storage supported by Google. Although this type of file transfer may be convenient for short, everyday clips made outside the operating room, it is prohibitive for surgical media, mainly because of patient privacy concerns. With wireless transfer to a nonsecure cloud platform, there is a risk of breach of patient confidentiality. We therefore recommend against using wireless upload when producing surgical multimedia, as patient identifiers are likely to be included in the recorded audio or video contents. Conversely, with GoPro, the micro SD card can be used as a portable hard drive to transfer files to a laptop or media reader, obviating the need for wired or wireless transmission. Last, when using traditional wire transfer or memory card to upload to a hard drive, users must ensure that the drive complies with patient privacy laws and regulations.

 4. Privacy and patient consent

As mentioned, great care must be taken to ensure that patient privacy laws are followed. This is especially relevant with content uploaded to online cloud storage, as with Google Glass. The upload may occur automatically if the unit is connected to a Wi-Fi hotspot. In addition, when using surgical media for a real-time webcast for education or demonstration purposes, surgeons must ensure that no protected health information is broadcast and that the patient and the surgical team are aware of the webcast and its purposes.

Before using wearable technology during patient care, patient consent must be obtained. Surgeons should ask the patient to consent to video recording of surgery or an encounter (eg, clinic visit) for education purposes. Our institution’s consent form includes a section for this particular type of consent. If an institution’s form lacks such a section, surgeons should consult their risk management department to ensure there is a proper avenue for obtaining patient consent to record the procedure or encounter. A separate, dedicated media consent form may be required. Last, whoever operates a wearable device should be careful to use the device only during encounters that have received explicit recording consent—as opposed to wearing the device in the hallways or elsewhere in the hospital, where protected health information might be inadvertently recorded.⁴

 5. Putting it all to use

After successful recording of surgery, an effort should be made to produce a high-quality video for education or demonstration purposes. Unfortunately, there is no built-in optical zooming with Google Glass or GoPro, and recording segments in which surgeons focus on detailed anatomy (with high-quality zoom) may prove difficult. Online descriptions of do-it-yourself modifications to place zoom capability on GoPro devices may be useful in surgical video recording, particularly for small surgical fields (hand or foot surgery). In addition, footage may be zoomed in on during postprocessing (Figure 3), though some resolution will be lost in the editing.

There is no practical way to incorporate Google Glass or GoPro while using surgical loupes or a surgical microscope. As a result, videos recorded with wearable technology may not reach the minimum resolution needed for useful surgical technique videos, as these traditionally are produced on high-definition camcorders with optical zoom, allowing detailed viewing of anatomical structures without resolution loss through digital zoom or postprocessing editing.

There has been tremendous benefit in incorporating wearable technology into our practice. Videos made with Google Glass and GoPro have been successfully used for surgical preparation and training, allowing orthopedic surgical residents to rehearse surgery before participating in it. Alternatively, having used Google Glass or GoPro to record a case, residents have then been able to review each surgical step on video—thereby reinforcing their knowledge of the steps, techniques, pearls, and pitfalls before performing the surgery again. Footage from surgeries recorded with Google Glass and GoPro has also been shown at weekly technique-focused conferences, allowing surgeons to analyze particular steps and highlight applicable learning points. Last, attending surgeons in our practice have used wearable technology in “coaching” mode, either reviewing case footage to identify areas for improvement or sharing footage with senior surgeons in order to elicit feedback and suggestions for possible improvement.

As new iterations of wearable video technology come to market, with advancements in both hardware and software, surgeons may be able to enhance education and teaching through seamless recording of surgical procedures. Use of wearable technology may also begin to extend beyond the operating room—to outpatient settings, such as preoperative and postoperative physical examinations. The latest versions of Google Glass and GoPro Hero allow surgeons to record surgical procedures with relative ease, without the personnel, equipment, and coordination required for traditional surgical videography.

Video 1. Coracoid harvest for transfer during Latarjet procedure performed and filmed by Dr. Jobin using GoPro Hero 3.

Video 2. Distal biceps repair performed by Dr. Makhni and Dr. Jobin, filmed by Dr. Makhni using Google Glass.

Safe and efficient advanced surgical skill training is of tremendous importance. With the recent increase in Internet use for medical education, there has been a concomitant increase in video recording of surgical procedures and techniques. Surgical recordings have been used in a variety of ways—as live webcasts for remote participants, as “coaching” opportunities for surgeons evaluating their own performance in the operating room, and even as informational resources for patients about to undergo the same surgery.

Surgical multimedia is being delivered through several different outlets. Many academic conferences and meetings showcase videos of different procedures, and several subspecialty societies (eg, Arthroscopy Association of North America) house archives of technical videos for viewing by members. In addition, the VuMedi website offers videos and allows members to comment on them and interact with the videographers. Surgeons are even posting technique videos on YouTube and other public websites.

A large proportion of surgical multimedia is recorded with conventional high-definition video cameras.¹ Besides being able to experience a case at any time and from outside the operating room, the audience can watch from numerous vantage points, angles, and zoom levels. Also, surgeons’ narration can be valuable in helping the audience follow along with the case.

Recording surgical multimedia historically required tight coordination and precise planning by surgeon and videographer. However, innovations in wearable technology now allow surgeons to literally wear video cameras and record procedures as they perform them, in real time—to act as both surgeon and videographer.

Two such products are Google Glass (Google, Mountain View, California) and GoPro Hero (GoPro, San Mateo, California), both of which allow surgeons to record exactly what they see during procedures (Figure 1). Using a wearable technology for surgical multimedia creation requires a deep familiarity with its capabilities and limitations. In this article, we summarize these products’ similarities and differences and provide a technical overview for using wearable technologies in surgical multimedia creation.

1. Choosing a device

When purchasing either wearable device, several factors must be considered, including budget, possible uses outside the operating room, and possible limitations of the technology (Table 1). At this time, Google Glass is significantly more expensive than GoPro Hero. The Google Glass base unit costs $1500, and the GoPro Hero 3 model costs approximately $200 (higher-priced Hero models are available). Both devices require accessories (eg, portable battery unit, dedicated hard drive).

Device capabilities must also be considered (Table 2). Google Glass consists of both hardware and software. Users can record what is seen and heard through the lens and then use apps to create text and e-mail portals to online gaming, social media, and even golf-course GPS. The app market for Google Glass is nascent but undoubtedly will increase in volume and scope as more users adopt the technology (Google Glass comes with both Bluetooth and Wi-Fi and can function tethered through a smartphone). GoPro is mainly a hardware unit that can record in various settings (it is popular with athletes who want to capture and broadcast their participation in action sports). Newer GoPro Hero versions offer Wi-Fi, which allows streaming of video content to a smartphone or tablet through an app. Having clearly defined goals for a device—‌‌as they pertain to use outside the operating room, such as outdoor activities and underwater recording—‌may help the surgeon decide which product is more suitable. Last, it is important to consider limitations. Google Glass resolution is 720p (1280×720) for video and 5 MP for still images, and GoPro resolution can reach 1080p (1920×1080) for video and 5 MP for stills.

Both devices require purchase of accessories. An external USB battery pack is useful for both devices, as is a password-encrypted hard drive for media storage. Lenswear does not come with the base version of Google Glass and is purchased separately from the company. GoPro users buy micro SD cards (~$50 per 64-GB high-speed transfer card) for storage on the device and may buy lithium-ion batteries as an alternative to the external USB battery pack.

Author Update

In January 2015, Google announced that it was temporarily suspending its “Explorer” program, which allowed individual users to buy and test the device for personal use. However, Google is continuing its development of Glass with health care technology, among other areas of growth and development.^2,3

2. Recording a successful surgical video

Unlike a camcorder, which typically is set on a tripod for conventional video recording of surgery, Google Glass and GoPro are intricately linked to the operator. Surgeons must be constantly aware of where they are during surgery and try not to let anything obstruct the camera’s view.

Before starting a case, the surgeon using either device must ensure that its battery is fully charged, as a full charge typically supports 1 hour of continuous recording (the Google Glass battery is a lithium-ion 670-mAh internal unit). A full charge should be enough to capture a short case. Newer GoPro models, with a battery listed at 1050 mAh, provide 1 to 2 hours of recording. When more than 1 hour is needed, an external USB battery pack can be used. This pack allows the device to remain plugged in throughout the case (the pack is kept in the surgeon’s back pocket). We recommend having an external battery pack that is at least 10,000 mAh (~$30 online retail), which easily provides 3+ hours of recording. Unfortunately, this arrangement can be cumbersome. Alternatively, with GoPro, additional batteries may be purchased, but the user needs to dismount the device in order to swap them in (may be difficult during surgery). With both units, partitioning a video into shorter segments conserves battery power and minimizes the risk of file corruption, which may occur if the battery dies or the device overheats.

Google Glass users can bypass manual operation of the device by giving it voice commands (eg, start video, take still image). The exception is for recording video for more than 10 seconds (current default setting). Unfortunately, the surgeon must touch the device to start this recording, which means using extra gloves to preserve operating field sterility. Still images can be made through a combination of voice and head gestures and without manual intervention (Figure 2). Last, users must ensure that the device is not actively connected through Bluetooth to a mobile phone, as incoming calls, text messages, and e-mails may disrupt active recording and become a distraction. The connection can be deactivated by disabling Bluetooth on the host smartphone or by placing the phone into airplane mode and turning off Wi-Fi.

Google Glass users can see what is being recorded through the viewfinder prism, whereas GoPro requires precise framing of the video before recording. Framing is done by grossly aiming the device in the desired direction. However, there is no way to ensure exact aim during recording. If at any point during a case there is slight repositioning of the GoPro, there is a risk of recording the case out of the center of view. An important advantage to newer GoPro versions is the ability to control the device through a wireless remote that can be placed under the surgeon’s gown. The remote can be used to pause and resume recording, without changing gloves, as is done with Google Glass. Last, because the minimum viewing distance from the surgical field is usually 18 inches or more, typically there is no loss of focus or blurring of the image from short-distance recording on either device.

3. File management and playback

Before using wearable technology in the operating room, surgeons must become aware of its limitations with respect to file storage and playback. Google Glass has a usable memory of about 12 GB (1 hour of video may require 1.5-2.0 GB). Conversely, GoPro’s capacity is defined by the micro SD card used. Therefore, the Google Glass hard drive must be regularly maintained well before being brought into the operating room, whereas recording can be extended (with respect to memory) for the GoPro if the media card is large enough.

Both devices allow for wired file transfer, which may be done with Windows Explorer (PC) or iPhoto (Macintosh). However, Google Glass also allows for wireless transfer, through portable storage supported by Google. Although this type of file transfer may be convenient for short, everyday clips made outside the operating room, it is prohibitive for surgical media, mainly because of patient privacy concerns. With wireless transfer to a nonsecure cloud platform, there is a risk of breach of patient confidentiality. We therefore recommend against using wireless upload when producing surgical multimedia, as patient identifiers are likely to be included in the recorded audio or video contents. Conversely, with GoPro, the micro SD card can be used as a portable hard drive to transfer files to a laptop or media reader, obviating the need for wired or wireless transmission. Last, when using traditional wire transfer or memory card to upload to a hard drive, users must ensure that the drive complies with patient privacy laws and regulations.

 4. Privacy and patient consent

As mentioned, great care must be taken to ensure that patient privacy laws are followed. This is especially relevant with content uploaded to online cloud storage, as with Google Glass. The upload may occur automatically if the unit is connected to a Wi-Fi hotspot. In addition, when using surgical media for a real-time webcast for education or demonstration purposes, surgeons must ensure that no protected health information is broadcast and that the patient and the surgical team are aware of the webcast and its purposes.

Before using wearable technology during patient care, patient consent must be obtained. Surgeons should ask the patient to consent to video recording of surgery or an encounter (eg, clinic visit) for education purposes. Our institution’s consent form includes a section for this particular type of consent. If an institution’s form lacks such a section, surgeons should consult their risk management department to ensure there is a proper avenue for obtaining patient consent to record the procedure or encounter. A separate, dedicated media consent form may be required. Last, whoever operates a wearable device should be careful to use the device only during encounters that have received explicit recording consent—as opposed to wearing the device in the hallways or elsewhere in the hospital, where protected health information might be inadvertently recorded.⁴

 5. Putting it all to use

After successful recording of surgery, an effort should be made to produce a high-quality video for education or demonstration purposes. Unfortunately, there is no built-in optical zooming with Google Glass or GoPro, and recording segments in which surgeons focus on detailed anatomy (with high-quality zoom) may prove difficult. Online descriptions of do-it-yourself modifications to place zoom capability on GoPro devices may be useful in surgical video recording, particularly for small surgical fields (hand or foot surgery). In addition, footage may be zoomed in on during postprocessing (Figure 3), though some resolution will be lost in the editing.

There is no practical way to incorporate Google Glass or GoPro while using surgical loupes or a surgical microscope. As a result, videos recorded with wearable technology may not reach the minimum resolution needed for useful surgical technique videos, as these traditionally are produced on high-definition camcorders with optical zoom, allowing detailed viewing of anatomical structures without resolution loss through digital zoom or postprocessing editing.

There has been tremendous benefit in incorporating wearable technology into our practice. Videos made with Google Glass and GoPro have been successfully used for surgical preparation and training, allowing orthopedic surgical residents to rehearse surgery before participating in it. Alternatively, having used Google Glass or GoPro to record a case, residents have then been able to review each surgical step on video—thereby reinforcing their knowledge of the steps, techniques, pearls, and pitfalls before performing the surgery again. Footage from surgeries recorded with Google Glass and GoPro has also been shown at weekly technique-focused conferences, allowing surgeons to analyze particular steps and highlight applicable learning points. Last, attending surgeons in our practice have used wearable technology in “coaching” mode, either reviewing case footage to identify areas for improvement or sharing footage with senior surgeons in order to elicit feedback and suggestions for possible improvement.

As new iterations of wearable video technology come to market, with advancements in both hardware and software, surgeons may be able to enhance education and teaching through seamless recording of surgical procedures. Use of wearable technology may also begin to extend beyond the operating room—to outpatient settings, such as preoperative and postoperative physical examinations. The latest versions of Google Glass and GoPro Hero allow surgeons to record surgical procedures with relative ease, without the personnel, equipment, and coordination required for traditional surgical videography.

Video 1. Coracoid harvest for transfer during Latarjet procedure performed and filmed by Dr. Jobin using GoPro Hero 3.

Video 2. Distal biceps repair performed by Dr. Makhni and Dr. Jobin, filmed by Dr. Makhni using Google Glass.

Safe and efficient advanced surgical skill training is of tremendous importance. With the recent increase in Internet use for medical education, there has been a concomitant increase in video recording of surgical procedures and techniques. Surgical recordings have been used in a variety of ways—as live webcasts for remote participants, as “coaching” opportunities for surgeons evaluating their own performance in the operating room, and even as informational resources for patients about to undergo the same surgery.

Surgical multimedia is being delivered through several different outlets. Many academic conferences and meetings showcase videos of different procedures, and several subspecialty societies (eg, Arthroscopy Association of North America) house archives of technical videos for viewing by members. In addition, the VuMedi website offers videos and allows members to comment on them and interact with the videographers. Surgeons are even posting technique videos on YouTube and other public websites.

A large proportion of surgical multimedia is recorded with conventional high-definition video cameras.¹ Besides being able to experience a case at any time and from outside the operating room, the audience can watch from numerous vantage points, angles, and zoom levels. Also, surgeons’ narration can be valuable in helping the audience follow along with the case.

Recording surgical multimedia historically required tight coordination and precise planning by surgeon and videographer. However, innovations in wearable technology now allow surgeons to literally wear video cameras and record procedures as they perform them, in real time—to act as both surgeon and videographer.

Two such products are Google Glass (Google, Mountain View, California) and GoPro Hero (GoPro, San Mateo, California), both of which allow surgeons to record exactly what they see during procedures (Figure 1). Using a wearable technology for surgical multimedia creation requires a deep familiarity with its capabilities and limitations. In this article, we summarize these products’ similarities and differences and provide a technical overview for using wearable technologies in surgical multimedia creation.

1. Choosing a device

When purchasing either wearable device, several factors must be considered, including budget, possible uses outside the operating room, and possible limitations of the technology (Table 1). At this time, Google Glass is significantly more expensive than GoPro Hero. The Google Glass base unit costs $1500, and the GoPro Hero 3 model costs approximately $200 (higher-priced Hero models are available). Both devices require accessories (eg, portable battery unit, dedicated hard drive).

Device capabilities must also be considered (Table 2). Google Glass consists of both hardware and software. Users can record what is seen and heard through the lens and then use apps to create text and e-mail portals to online gaming, social media, and even golf-course GPS. The app market for Google Glass is nascent but undoubtedly will increase in volume and scope as more users adopt the technology (Google Glass comes with both Bluetooth and Wi-Fi and can function tethered through a smartphone). GoPro is mainly a hardware unit that can record in various settings (it is popular with athletes who want to capture and broadcast their participation in action sports). Newer GoPro Hero versions offer Wi-Fi, which allows streaming of video content to a smartphone or tablet through an app. Having clearly defined goals for a device—‌‌as they pertain to use outside the operating room, such as outdoor activities and underwater recording—‌may help the surgeon decide which product is more suitable. Last, it is important to consider limitations. Google Glass resolution is 720p (1280×720) for video and 5 MP for still images, and GoPro resolution can reach 1080p (1920×1080) for video and 5 MP for stills.

Both devices require purchase of accessories. An external USB battery pack is useful for both devices, as is a password-encrypted hard drive for media storage. Lenswear does not come with the base version of Google Glass and is purchased separately from the company. GoPro users buy micro SD cards (~$50 per 64-GB high-speed transfer card) for storage on the device and may buy lithium-ion batteries as an alternative to the external USB battery pack.

Author Update

In January 2015, Google announced that it was temporarily suspending its “Explorer” program, which allowed individual users to buy and test the device for personal use. However, Google is continuing its development of Glass with health care technology, among other areas of growth and development.^2,3

2. Recording a successful surgical video

Unlike a camcorder, which typically is set on a tripod for conventional video recording of surgery, Google Glass and GoPro are intricately linked to the operator. Surgeons must be constantly aware of where they are during surgery and try not to let anything obstruct the camera’s view.

Before starting a case, the surgeon using either device must ensure that its battery is fully charged, as a full charge typically supports 1 hour of continuous recording (the Google Glass battery is a lithium-ion 670-mAh internal unit). A full charge should be enough to capture a short case. Newer GoPro models, with a battery listed at 1050 mAh, provide 1 to 2 hours of recording. When more than 1 hour is needed, an external USB battery pack can be used. This pack allows the device to remain plugged in throughout the case (the pack is kept in the surgeon’s back pocket). We recommend having an external battery pack that is at least 10,000 mAh (~$30 online retail), which easily provides 3+ hours of recording. Unfortunately, this arrangement can be cumbersome. Alternatively, with GoPro, additional batteries may be purchased, but the user needs to dismount the device in order to swap them in (may be difficult during surgery). With both units, partitioning a video into shorter segments conserves battery power and minimizes the risk of file corruption, which may occur if the battery dies or the device overheats.

Google Glass users can bypass manual operation of the device by giving it voice commands (eg, start video, take still image). The exception is for recording video for more than 10 seconds (current default setting). Unfortunately, the surgeon must touch the device to start this recording, which means using extra gloves to preserve operating field sterility. Still images can be made through a combination of voice and head gestures and without manual intervention (Figure 2). Last, users must ensure that the device is not actively connected through Bluetooth to a mobile phone, as incoming calls, text messages, and e-mails may disrupt active recording and become a distraction. The connection can be deactivated by disabling Bluetooth on the host smartphone or by placing the phone into airplane mode and turning off Wi-Fi.

Google Glass users can see what is being recorded through the viewfinder prism, whereas GoPro requires precise framing of the video before recording. Framing is done by grossly aiming the device in the desired direction. However, there is no way to ensure exact aim during recording. If at any point during a case there is slight repositioning of the GoPro, there is a risk of recording the case out of the center of view. An important advantage to newer GoPro versions is the ability to control the device through a wireless remote that can be placed under the surgeon’s gown. The remote can be used to pause and resume recording, without changing gloves, as is done with Google Glass. Last, because the minimum viewing distance from the surgical field is usually 18 inches or more, typically there is no loss of focus or blurring of the image from short-distance recording on either device.

3. File management and playback

Before using wearable technology in the operating room, surgeons must become aware of its limitations with respect to file storage and playback. Google Glass has a usable memory of about 12 GB (1 hour of video may require 1.5-2.0 GB). Conversely, GoPro’s capacity is defined by the micro SD card used. Therefore, the Google Glass hard drive must be regularly maintained well before being brought into the operating room, whereas recording can be extended (with respect to memory) for the GoPro if the media card is large enough.

Both devices allow for wired file transfer, which may be done with Windows Explorer (PC) or iPhoto (Macintosh). However, Google Glass also allows for wireless transfer, through portable storage supported by Google. Although this type of file transfer may be convenient for short, everyday clips made outside the operating room, it is prohibitive for surgical media, mainly because of patient privacy concerns. With wireless transfer to a nonsecure cloud platform, there is a risk of breach of patient confidentiality. We therefore recommend against using wireless upload when producing surgical multimedia, as patient identifiers are likely to be included in the recorded audio or video contents. Conversely, with GoPro, the micro SD card can be used as a portable hard drive to transfer files to a laptop or media reader, obviating the need for wired or wireless transmission. Last, when using traditional wire transfer or memory card to upload to a hard drive, users must ensure that the drive complies with patient privacy laws and regulations.

 4. Privacy and patient consent

As mentioned, great care must be taken to ensure that patient privacy laws are followed. This is especially relevant with content uploaded to online cloud storage, as with Google Glass. The upload may occur automatically if the unit is connected to a Wi-Fi hotspot. In addition, when using surgical media for a real-time webcast for education or demonstration purposes, surgeons must ensure that no protected health information is broadcast and that the patient and the surgical team are aware of the webcast and its purposes.

Before using wearable technology during patient care, patient consent must be obtained. Surgeons should ask the patient to consent to video recording of surgery or an encounter (eg, clinic visit) for education purposes. Our institution’s consent form includes a section for this particular type of consent. If an institution’s form lacks such a section, surgeons should consult their risk management department to ensure there is a proper avenue for obtaining patient consent to record the procedure or encounter. A separate, dedicated media consent form may be required. Last, whoever operates a wearable device should be careful to use the device only during encounters that have received explicit recording consent—as opposed to wearing the device in the hallways or elsewhere in the hospital, where protected health information might be inadvertently recorded.⁴

 5. Putting it all to use

After successful recording of surgery, an effort should be made to produce a high-quality video for education or demonstration purposes. Unfortunately, there is no built-in optical zooming with Google Glass or GoPro, and recording segments in which surgeons focus on detailed anatomy (with high-quality zoom) may prove difficult. Online descriptions of do-it-yourself modifications to place zoom capability on GoPro devices may be useful in surgical video recording, particularly for small surgical fields (hand or foot surgery). In addition, footage may be zoomed in on during postprocessing (Figure 3), though some resolution will be lost in the editing.

There is no practical way to incorporate Google Glass or GoPro while using surgical loupes or a surgical microscope. As a result, videos recorded with wearable technology may not reach the minimum resolution needed for useful surgical technique videos, as these traditionally are produced on high-definition camcorders with optical zoom, allowing detailed viewing of anatomical structures without resolution loss through digital zoom or postprocessing editing.

There has been tremendous benefit in incorporating wearable technology into our practice. Videos made with Google Glass and GoPro have been successfully used for surgical preparation and training, allowing orthopedic surgical residents to rehearse surgery before participating in it. Alternatively, having used Google Glass or GoPro to record a case, residents have then been able to review each surgical step on video—thereby reinforcing their knowledge of the steps, techniques, pearls, and pitfalls before performing the surgery again. Footage from surgeries recorded with Google Glass and GoPro has also been shown at weekly technique-focused conferences, allowing surgeons to analyze particular steps and highlight applicable learning points. Last, attending surgeons in our practice have used wearable technology in “coaching” mode, either reviewing case footage to identify areas for improvement or sharing footage with senior surgeons in order to elicit feedback and suggestions for possible improvement.

As new iterations of wearable video technology come to market, with advancements in both hardware and software, surgeons may be able to enhance education and teaching through seamless recording of surgical procedures. Use of wearable technology may also begin to extend beyond the operating room—to outpatient settings, such as preoperative and postoperative physical examinations. The latest versions of Google Glass and GoPro Hero allow surgeons to record surgical procedures with relative ease, without the personnel, equipment, and coordination required for traditional surgical videography.

Video 1. Coracoid harvest for transfer during Latarjet procedure performed and filmed by Dr. Jobin using GoPro Hero 3.

Video 2. Distal biceps repair performed by Dr. Makhni and Dr. Jobin, filmed by Dr. Makhni using Google Glass.

Distal radius fractures are among the most common upper extremity injuries. A Swedish study noted that 75% of forearm fractures involve the distal radius.¹ Extensor pollicis longus (EPL) ruptures are a well-documented complication (0.3% incidence²) of distal radius fractures.

The first description of EPL ruptures is attributed to Duplay in 1876 and was termed drummer boy’s palsy.³ Spontaneous EPL ruptures are often described in the setting of acute or chronic tenosynovitis.^4,5 Beginning in the early 1930s, multiple case reports began to connect distal radius fractures with EPL ruptures.⁶ Although EPL ruptures are rare, their consequences are substantial and typically necessitate reconstructive procedures. Extensor indicis proprius (EIP)-to-EPL tendon transfer has become a common surgical treatment for this complication. Increasing our knowledge of several characteristics associated with this complication may help clinically in preventing EPL ruptures.

Multiple studies have indicated that EPL ruptures occur more often in nondisplaced fractures and often occur between 6 and 8 weeks after injury.^2,5,7,8 Several factors are implicated in the etiology of EPL ruptures in distal radius fractures. The classic 1979 study by Engkvist and Lundborg⁹ showed that the EPL tendon has an area of poor vascularity around the Lister tubercle. Explorations of nondisplaced distal radius fractures have shown an intact extensor retinaculum that allows the tendon to continue to travel through an enclosed space.^4,5,7 In the setting of distal radius fracture, hematoma may contribute to tendon ruptures secondary to increased pressure within an intact third dorsal compartment, which further compromises vascularity in this region of the EPL tendon.

Recognition and prevention of an impending EPL rupture may help avoid the significant consequences of this complication. Decompression and release of the third dorsal compartment have been described as constituting a prophylactic surgical option.^10,11 Early thumb range of motion is also advocated to help prevent EPL rupture.⁹ However, results reported in the literature are inconclusive as to the effectiveness of these or indeed any preventive procedures. Dr. Lourie uses a novel technique that involves aspiration of the third dorsal compartment in patients with clinical symptoms associated with impending EPL rupture. Needle decompression, a less invasive option, can be quickly performed in an office, and it is hypothesized that removal of the hematoma may prevent EPL ruptures.

In the present study, we retrospectively reviewed Dr. Lourie’s records of patients with EPL ruptures in association with distal radius fractures to help delineate which radiographic and clinical characteristics identify patients at risk for these ruptures. A cadaveric model of a nondisplaced distal radius fracture was then created in order to simulate a change in third compartment pressures before and after needle decompression. We present preliminary outcomes on a case series of 4 patients who underwent aspiration of the third compartment and who were thought to be at risk for EPL rupture.

Materials and Methods

Institutional review board approval was obtained for this study. From Dr. Lourie’s records, 19 patients treated between 1998 and 2009 were identified as having confirmed or clinically impending EPL ruptures in association with nonoperative treatment of distal radius fractures. Prodromal symptoms that were used to diagnose impending EPL ruptures included pain with resisted active EPL extension, pain with passive flexion of the thumb interphalangeal joint, and localized swelling over the third dorsal compartment of the wrist.^5,7,10,12 Eleven patients had complete radiographs, which were reviewed for radiographic characteristics. Posteroanterior (PA) and lateral radiographs of the injured wrist were reviewed. On the PA radiographs, fraction location was measured from the tip of the radial styloid using a line perpendicular to the radial shaft. Fractures were also evaluated for displacement and intra-articular involvement.

A cadaveric model was developed to evaluate compartment pressures in the EPL sheath in a simulated distal radius fracture. Six fresh-frozen cadaveric forearms were used after being thawed at room temperature. The cadavers were radiographically evaluated to determine that there was no evidence of prior fracture. A Stryker compartment pressure monitoring system (Stryker, Kalamazoo, Michigan) was used to take initial pressure readings in the third dorsal compartment slightly ulnar to the Lister tubercle (preinjection readings). A limited volar approach was then created. Under fluoroscopy, a half-inch osteotome was used to make an extra-articular fracture line in the distal radius, in the region of the Lister tubercle. The osteotomy was a mean of 1.2 cm from the distal aspect of the radius. The osteotomy site was then injected from the volar aspect with 5 mL of radiopaque (Hypaque) dye (Figure 1). Fluid extravasation into the third dorsal compartment was visualized under fluoroscopy (Figures 2–4). The monitor was then reinserted into the EPL sheath, and once again pressures were measured (postinjection readings). An 18-gauge needle was then used to aspirate the compartment just ulnar to the Lister tubercle. Compartment pressures were measured a final time (postaspiration readings). For all readings, 3 pressure measurements were recorded and then averaged. Pressure measurements were compared using t test.

In the office, the third dorsal compartment was aspirated after skin preparation with povidone-iodine. The Lister tubercle is typically palpable along the dorsal distal radius and is aligned with the cleft between the index and long fingers. Aspiration with an 18-gauge needle is performed just ulnar to the Lister tubercle in the EPL sheath, and hematoma is evacuated. The patient is then placed back into a long-arm cast or splint per the clinical situation.

Results

Patient age ranged from 17 to 81 years. Eight (1 male, 7 female) patients sustained an EPL rupture a mean of 46 days after initial trauma (range, 21-118 days). Two patients were treated with a prophylactic EPL transposition secondary to clinically apparent impending rupture, and 4 were treated with prophylactic needle decompression of the third compartment. Ruptures were treated with EIP-to-EPL transfers.

As in other studies, each patient’s radiographs showed a nondisplaced fracture and a transverse fracture line. Six patients also had a longitudinal, intra-articular fracture line that exited in a common spot between the scaphoid and the lunate facet.

Results in our cadaveric model were consistent with those in in vitro decompression of the third dorsal compartment (Table 1). In the cadaver model, mean (SD) initial third dorsal compartment pressure was 0.77 (0.88) mm Hg. Mean (SD) pressure after osteotomy and Hypaque injection was 25.5 (11.11) mm Hg. After simulated therapeutic aspiration, mean (SD) pressure decreased to 1.61 (1.40) mm Hg. Mean change in pressure from after injection to after aspiration was 23.89 mm Hg (P = .000388) (Table 2).

Information from other studies and from Dr. Lourie’s experience was used to identify patients at significant risk for EPL ruptures in association with distal radius fractures. Four patients in Dr. Lourie’s practice between 2004 and 2009 had characteristic findings, including a nondisplaced distal radius fracture, localized swelling over the third dorsal compartment, and pain with resisted active EPL extension. Prophylactic aspiration and hematoma evacuation were performed in this series, yielding a mean hematoma amount of 2 mL (Table 3).

For all 4 patients, aspirations were performed within 2 weeks of injury. Subjectively, these patients described almost immediate pain relief and less discomfort with EPL motion after aspiration. Three of the 4 reported sustained pain relief on close follow-up 7 and 14 days after aspiration. The fourth patient continued to have pain over the third dorsal compartment, though she described it as significantly improved. Her initial fracture contained about 50% dorsal comminution, and she began to have a significant callus response. After 2 months of continued symptoms, and out of concern about consequences of an impending rupture, open decompression and transposition of the EPL were performed. In follow-up over 29 months, this patient continued to do well and had full EPL function. The 3 patients treated with aspiration alone have not had an EPL rupture (range of follow-up, 29-89 months).

Discussion

Distal radius fractures are very common injuries, and treating physicians must attempt to prevent possible complications. EPL tendon ruptures continue to be rare events (incidence, <1%) in association with distal radius fractures. Although statistics vary, studies have found a higher incidence in nondisplaced (vs displaced) distal radius fractures.^5,7,10 Ruptures in nondisplaced fractures occur within 2 weeks to 3 years after injury but typically an average of 6 weeks after injury.^2,4,7-9 Prodromal symptoms often include tenderness and swelling around the dorsal distal radius region around the Lister tubercle.^7,11,12 Patients may complain of pain with active thumb extension or passive thumb range of motion.¹¹ Rupture is indicated by an inability to actively extend the thumb.

Studies have shown that the tendon rupture site is around the Lister tubercle.⁷ No single cause for EPL ruptures has been confirmed, and the etiology is likely a mix of factors in relation to the clinical situation. Two theories have been espoused for the relation between EPL ruptures and distal radius fractures. The mechanical theory involves a prominent spicule of bone abrading the tendon and subsequently causing rupture.^5,9 This seems less likely for nondisplaced fractures. The vascular theory centers on a watershed region of the EPL tendon around the Lister tubercle. Studies have found microangiographic evidence of a 5-mm portion of tendon around the Lister tubercle that has no mesotenon and poor vascularity.^7,9 The tendon in this section may be reliant on synovial diffusion for nutrition,⁷ but hematoma may displace synovial fluid, interfering with tendon nutrition.

Researchers have studied the third dorsal compartment in patients with impending or established ruptures. In a series by Hirasawa and colleagues,⁷ 11 patients with a nondisplaced fracture and a tendon rupture had an intact retinaculum and smooth bony surfaces on the dorsal radius. Periosteal hypertrophy and narrowing of the third compartment were noted. In another series, Helal and colleagues⁵ reported on 16 patients (nondisplaced and displaced fractures) who had possible EPL ruptures over a 4-year period. In all cases, the extensor retinaculum was intact. Likewise, the 7 patients with EPL ruptures in a series by Bonatz and colleagues⁴ had an intact extensor retinaculum. On exploration, Bunata¹⁰ noted fluid collections, including hematomas, within the sheath, as well as a lack of bony prominences. Simpson¹² explored 2 cases of blunt trauma, no fracture, and subsequent EPL rupture. Clinically these 2 patients had swelling in the region of the Lister tubercle, and surgically they were found to have a distended, blood-filled sheath. These ruptures may correlate with nondisplaced distal radius fractures and provide further evidence supporting the vascular theory of ruptures. The combination of intact compartment and volume overload presents a situation akin to compartment syndrome. Acute compartment decompression with needle evacuation would theoretically relieve the vascular insult.

In the study by Helal and colleagues,⁵ Hypaque injections were given to patients with nondisplaced distal radius fractures. The dye remained in the third dorsal compartment, which implies an intact closed space. That study used a cadaveric model as well, with distal radius osteotomies performed to simulate a nondisplaced distal radius fracture. The authors noted an intact extensor retinaculum in their model. Our cadaver model is similar, except we measured pressures in the third compartment; our model indicated increased compartment pressures within the EPL sheath. Subsequent aspiration in our cadaveric study led to lower pressures in the third dorsal compartment. This cadaveric model implies that needle decompression of the third dorsal compartment may be beneficial in the setting of nondisplaced distal radius fractures and symptoms indicating a compromised EPL.

Splinting is an important factor that may help prevent EPL tendon ruptures after distal radius fractures. Synovial diffusion may be the primary mechanism for delivering nutrition to the EPL tendon.⁷ A splint that allows thumb metacarpophalangeal and interphalangeal flexion may provide the EPL motion needed for effective synovial nutritional pathways.⁹ Prodromal symptoms of tendon rupture should then be carefully monitored.

Conclusion

Results of our retrospective review are consistent with previous results elucidating the risk factors for EPL ruptures in association with distal radius fractures. In our patients who sustained EPL ruptures, findings included nondisplaced fractures, about 50% with an intra-articular component. Clinical findings included localized swelling over the third dorsal compartment, pain with resisted active EPL extension, and pain with passive flexion of the thumb interphalangeal joint. The cadaveric portion of this study indicated a significant change in pressure in the third dorsal compartment after aspiration. Preliminary outcomes in this 4-patient series are no EPL ruptures after prophylactic aspiration. Hematoma evacuation after nondisplaced distal radius fractures may become a useful addition to the surgeon’s armamentarium. Studies are needed to determine if needle aspiration of the third dorsal compartment can become an office-based procedure with value in preventing EPL ruptures in the appropriate clinical situation.

Distal radius fractures are among the most common upper extremity injuries. A Swedish study noted that 75% of forearm fractures involve the distal radius.¹ Extensor pollicis longus (EPL) ruptures are a well-documented complication (0.3% incidence²) of distal radius fractures.

The first description of EPL ruptures is attributed to Duplay in 1876 and was termed drummer boy’s palsy.³ Spontaneous EPL ruptures are often described in the setting of acute or chronic tenosynovitis.^4,5 Beginning in the early 1930s, multiple case reports began to connect distal radius fractures with EPL ruptures.⁶ Although EPL ruptures are rare, their consequences are substantial and typically necessitate reconstructive procedures. Extensor indicis proprius (EIP)-to-EPL tendon transfer has become a common surgical treatment for this complication. Increasing our knowledge of several characteristics associated with this complication may help clinically in preventing EPL ruptures.

Multiple studies have indicated that EPL ruptures occur more often in nondisplaced fractures and often occur between 6 and 8 weeks after injury.^2,5,7,8 Several factors are implicated in the etiology of EPL ruptures in distal radius fractures. The classic 1979 study by Engkvist and Lundborg⁹ showed that the EPL tendon has an area of poor vascularity around the Lister tubercle. Explorations of nondisplaced distal radius fractures have shown an intact extensor retinaculum that allows the tendon to continue to travel through an enclosed space.^4,5,7 In the setting of distal radius fracture, hematoma may contribute to tendon ruptures secondary to increased pressure within an intact third dorsal compartment, which further compromises vascularity in this region of the EPL tendon.

Recognition and prevention of an impending EPL rupture may help avoid the significant consequences of this complication. Decompression and release of the third dorsal compartment have been described as constituting a prophylactic surgical option.^10,11 Early thumb range of motion is also advocated to help prevent EPL rupture.⁹ However, results reported in the literature are inconclusive as to the effectiveness of these or indeed any preventive procedures. Dr. Lourie uses a novel technique that involves aspiration of the third dorsal compartment in patients with clinical symptoms associated with impending EPL rupture. Needle decompression, a less invasive option, can be quickly performed in an office, and it is hypothesized that removal of the hematoma may prevent EPL ruptures.

In the present study, we retrospectively reviewed Dr. Lourie’s records of patients with EPL ruptures in association with distal radius fractures to help delineate which radiographic and clinical characteristics identify patients at risk for these ruptures. A cadaveric model of a nondisplaced distal radius fracture was then created in order to simulate a change in third compartment pressures before and after needle decompression. We present preliminary outcomes on a case series of 4 patients who underwent aspiration of the third compartment and who were thought to be at risk for EPL rupture.

Materials and Methods

Institutional review board approval was obtained for this study. From Dr. Lourie’s records, 19 patients treated between 1998 and 2009 were identified as having confirmed or clinically impending EPL ruptures in association with nonoperative treatment of distal radius fractures. Prodromal symptoms that were used to diagnose impending EPL ruptures included pain with resisted active EPL extension, pain with passive flexion of the thumb interphalangeal joint, and localized swelling over the third dorsal compartment of the wrist.^5,7,10,12 Eleven patients had complete radiographs, which were reviewed for radiographic characteristics. Posteroanterior (PA) and lateral radiographs of the injured wrist were reviewed. On the PA radiographs, fraction location was measured from the tip of the radial styloid using a line perpendicular to the radial shaft. Fractures were also evaluated for displacement and intra-articular involvement.

A cadaveric model was developed to evaluate compartment pressures in the EPL sheath in a simulated distal radius fracture. Six fresh-frozen cadaveric forearms were used after being thawed at room temperature. The cadavers were radiographically evaluated to determine that there was no evidence of prior fracture. A Stryker compartment pressure monitoring system (Stryker, Kalamazoo, Michigan) was used to take initial pressure readings in the third dorsal compartment slightly ulnar to the Lister tubercle (preinjection readings). A limited volar approach was then created. Under fluoroscopy, a half-inch osteotome was used to make an extra-articular fracture line in the distal radius, in the region of the Lister tubercle. The osteotomy was a mean of 1.2 cm from the distal aspect of the radius. The osteotomy site was then injected from the volar aspect with 5 mL of radiopaque (Hypaque) dye (Figure 1). Fluid extravasation into the third dorsal compartment was visualized under fluoroscopy (Figures 2–4). The monitor was then reinserted into the EPL sheath, and once again pressures were measured (postinjection readings). An 18-gauge needle was then used to aspirate the compartment just ulnar to the Lister tubercle. Compartment pressures were measured a final time (postaspiration readings). For all readings, 3 pressure measurements were recorded and then averaged. Pressure measurements were compared using t test.

In the office, the third dorsal compartment was aspirated after skin preparation with povidone-iodine. The Lister tubercle is typically palpable along the dorsal distal radius and is aligned with the cleft between the index and long fingers. Aspiration with an 18-gauge needle is performed just ulnar to the Lister tubercle in the EPL sheath, and hematoma is evacuated. The patient is then placed back into a long-arm cast or splint per the clinical situation.

Results

Patient age ranged from 17 to 81 years. Eight (1 male, 7 female) patients sustained an EPL rupture a mean of 46 days after initial trauma (range, 21-118 days). Two patients were treated with a prophylactic EPL transposition secondary to clinically apparent impending rupture, and 4 were treated with prophylactic needle decompression of the third compartment. Ruptures were treated with EIP-to-EPL transfers.

As in other studies, each patient’s radiographs showed a nondisplaced fracture and a transverse fracture line. Six patients also had a longitudinal, intra-articular fracture line that exited in a common spot between the scaphoid and the lunate facet.

Results in our cadaveric model were consistent with those in in vitro decompression of the third dorsal compartment (Table 1). In the cadaver model, mean (SD) initial third dorsal compartment pressure was 0.77 (0.88) mm Hg. Mean (SD) pressure after osteotomy and Hypaque injection was 25.5 (11.11) mm Hg. After simulated therapeutic aspiration, mean (SD) pressure decreased to 1.61 (1.40) mm Hg. Mean change in pressure from after injection to after aspiration was 23.89 mm Hg (P = .000388) (Table 2).

Information from other studies and from Dr. Lourie’s experience was used to identify patients at significant risk for EPL ruptures in association with distal radius fractures. Four patients in Dr. Lourie’s practice between 2004 and 2009 had characteristic findings, including a nondisplaced distal radius fracture, localized swelling over the third dorsal compartment, and pain with resisted active EPL extension. Prophylactic aspiration and hematoma evacuation were performed in this series, yielding a mean hematoma amount of 2 mL (Table 3).

For all 4 patients, aspirations were performed within 2 weeks of injury. Subjectively, these patients described almost immediate pain relief and less discomfort with EPL motion after aspiration. Three of the 4 reported sustained pain relief on close follow-up 7 and 14 days after aspiration. The fourth patient continued to have pain over the third dorsal compartment, though she described it as significantly improved. Her initial fracture contained about 50% dorsal comminution, and she began to have a significant callus response. After 2 months of continued symptoms, and out of concern about consequences of an impending rupture, open decompression and transposition of the EPL were performed. In follow-up over 29 months, this patient continued to do well and had full EPL function. The 3 patients treated with aspiration alone have not had an EPL rupture (range of follow-up, 29-89 months).

Discussion

Distal radius fractures are very common injuries, and treating physicians must attempt to prevent possible complications. EPL tendon ruptures continue to be rare events (incidence, <1%) in association with distal radius fractures. Although statistics vary, studies have found a higher incidence in nondisplaced (vs displaced) distal radius fractures.^5,7,10 Ruptures in nondisplaced fractures occur within 2 weeks to 3 years after injury but typically an average of 6 weeks after injury.^2,4,7-9 Prodromal symptoms often include tenderness and swelling around the dorsal distal radius region around the Lister tubercle.^7,11,12 Patients may complain of pain with active thumb extension or passive thumb range of motion.¹¹ Rupture is indicated by an inability to actively extend the thumb.

Studies have shown that the tendon rupture site is around the Lister tubercle.⁷ No single cause for EPL ruptures has been confirmed, and the etiology is likely a mix of factors in relation to the clinical situation. Two theories have been espoused for the relation between EPL ruptures and distal radius fractures. The mechanical theory involves a prominent spicule of bone abrading the tendon and subsequently causing rupture.^5,9 This seems less likely for nondisplaced fractures. The vascular theory centers on a watershed region of the EPL tendon around the Lister tubercle. Studies have found microangiographic evidence of a 5-mm portion of tendon around the Lister tubercle that has no mesotenon and poor vascularity.^7,9 The tendon in this section may be reliant on synovial diffusion for nutrition,⁷ but hematoma may displace synovial fluid, interfering with tendon nutrition.

Researchers have studied the third dorsal compartment in patients with impending or established ruptures. In a series by Hirasawa and colleagues,⁷ 11 patients with a nondisplaced fracture and a tendon rupture had an intact retinaculum and smooth bony surfaces on the dorsal radius. Periosteal hypertrophy and narrowing of the third compartment were noted. In another series, Helal and colleagues⁵ reported on 16 patients (nondisplaced and displaced fractures) who had possible EPL ruptures over a 4-year period. In all cases, the extensor retinaculum was intact. Likewise, the 7 patients with EPL ruptures in a series by Bonatz and colleagues⁴ had an intact extensor retinaculum. On exploration, Bunata¹⁰ noted fluid collections, including hematomas, within the sheath, as well as a lack of bony prominences. Simpson¹² explored 2 cases of blunt trauma, no fracture, and subsequent EPL rupture. Clinically these 2 patients had swelling in the region of the Lister tubercle, and surgically they were found to have a distended, blood-filled sheath. These ruptures may correlate with nondisplaced distal radius fractures and provide further evidence supporting the vascular theory of ruptures. The combination of intact compartment and volume overload presents a situation akin to compartment syndrome. Acute compartment decompression with needle evacuation would theoretically relieve the vascular insult.

In the study by Helal and colleagues,⁵ Hypaque injections were given to patients with nondisplaced distal radius fractures. The dye remained in the third dorsal compartment, which implies an intact closed space. That study used a cadaveric model as well, with distal radius osteotomies performed to simulate a nondisplaced distal radius fracture. The authors noted an intact extensor retinaculum in their model. Our cadaver model is similar, except we measured pressures in the third compartment; our model indicated increased compartment pressures within the EPL sheath. Subsequent aspiration in our cadaveric study led to lower pressures in the third dorsal compartment. This cadaveric model implies that needle decompression of the third dorsal compartment may be beneficial in the setting of nondisplaced distal radius fractures and symptoms indicating a compromised EPL.

Splinting is an important factor that may help prevent EPL tendon ruptures after distal radius fractures. Synovial diffusion may be the primary mechanism for delivering nutrition to the EPL tendon.⁷ A splint that allows thumb metacarpophalangeal and interphalangeal flexion may provide the EPL motion needed for effective synovial nutritional pathways.⁹ Prodromal symptoms of tendon rupture should then be carefully monitored.

Conclusion

Results of our retrospective review are consistent with previous results elucidating the risk factors for EPL ruptures in association with distal radius fractures. In our patients who sustained EPL ruptures, findings included nondisplaced fractures, about 50% with an intra-articular component. Clinical findings included localized swelling over the third dorsal compartment, pain with resisted active EPL extension, and pain with passive flexion of the thumb interphalangeal joint. The cadaveric portion of this study indicated a significant change in pressure in the third dorsal compartment after aspiration. Preliminary outcomes in this 4-patient series are no EPL ruptures after prophylactic aspiration. Hematoma evacuation after nondisplaced distal radius fractures may become a useful addition to the surgeon’s armamentarium. Studies are needed to determine if needle aspiration of the third dorsal compartment can become an office-based procedure with value in preventing EPL ruptures in the appropriate clinical situation.

Distal radius fractures are among the most common upper extremity injuries. A Swedish study noted that 75% of forearm fractures involve the distal radius.¹ Extensor pollicis longus (EPL) ruptures are a well-documented complication (0.3% incidence²) of distal radius fractures.

The first description of EPL ruptures is attributed to Duplay in 1876 and was termed drummer boy’s palsy.³ Spontaneous EPL ruptures are often described in the setting of acute or chronic tenosynovitis.^4,5 Beginning in the early 1930s, multiple case reports began to connect distal radius fractures with EPL ruptures.⁶ Although EPL ruptures are rare, their consequences are substantial and typically necessitate reconstructive procedures. Extensor indicis proprius (EIP)-to-EPL tendon transfer has become a common surgical treatment for this complication. Increasing our knowledge of several characteristics associated with this complication may help clinically in preventing EPL ruptures.

Multiple studies have indicated that EPL ruptures occur more often in nondisplaced fractures and often occur between 6 and 8 weeks after injury.^2,5,7,8 Several factors are implicated in the etiology of EPL ruptures in distal radius fractures. The classic 1979 study by Engkvist and Lundborg⁹ showed that the EPL tendon has an area of poor vascularity around the Lister tubercle. Explorations of nondisplaced distal radius fractures have shown an intact extensor retinaculum that allows the tendon to continue to travel through an enclosed space.^4,5,7 In the setting of distal radius fracture, hematoma may contribute to tendon ruptures secondary to increased pressure within an intact third dorsal compartment, which further compromises vascularity in this region of the EPL tendon.

Recognition and prevention of an impending EPL rupture may help avoid the significant consequences of this complication. Decompression and release of the third dorsal compartment have been described as constituting a prophylactic surgical option.^10,11 Early thumb range of motion is also advocated to help prevent EPL rupture.⁹ However, results reported in the literature are inconclusive as to the effectiveness of these or indeed any preventive procedures. Dr. Lourie uses a novel technique that involves aspiration of the third dorsal compartment in patients with clinical symptoms associated with impending EPL rupture. Needle decompression, a less invasive option, can be quickly performed in an office, and it is hypothesized that removal of the hematoma may prevent EPL ruptures.

In the present study, we retrospectively reviewed Dr. Lourie’s records of patients with EPL ruptures in association with distal radius fractures to help delineate which radiographic and clinical characteristics identify patients at risk for these ruptures. A cadaveric model of a nondisplaced distal radius fracture was then created in order to simulate a change in third compartment pressures before and after needle decompression. We present preliminary outcomes on a case series of 4 patients who underwent aspiration of the third compartment and who were thought to be at risk for EPL rupture.

Materials and Methods

Institutional review board approval was obtained for this study. From Dr. Lourie’s records, 19 patients treated between 1998 and 2009 were identified as having confirmed or clinically impending EPL ruptures in association with nonoperative treatment of distal radius fractures. Prodromal symptoms that were used to diagnose impending EPL ruptures included pain with resisted active EPL extension, pain with passive flexion of the thumb interphalangeal joint, and localized swelling over the third dorsal compartment of the wrist.^5,7,10,12 Eleven patients had complete radiographs, which were reviewed for radiographic characteristics. Posteroanterior (PA) and lateral radiographs of the injured wrist were reviewed. On the PA radiographs, fraction location was measured from the tip of the radial styloid using a line perpendicular to the radial shaft. Fractures were also evaluated for displacement and intra-articular involvement.

A cadaveric model was developed to evaluate compartment pressures in the EPL sheath in a simulated distal radius fracture. Six fresh-frozen cadaveric forearms were used after being thawed at room temperature. The cadavers were radiographically evaluated to determine that there was no evidence of prior fracture. A Stryker compartment pressure monitoring system (Stryker, Kalamazoo, Michigan) was used to take initial pressure readings in the third dorsal compartment slightly ulnar to the Lister tubercle (preinjection readings). A limited volar approach was then created. Under fluoroscopy, a half-inch osteotome was used to make an extra-articular fracture line in the distal radius, in the region of the Lister tubercle. The osteotomy was a mean of 1.2 cm from the distal aspect of the radius. The osteotomy site was then injected from the volar aspect with 5 mL of radiopaque (Hypaque) dye (Figure 1). Fluid extravasation into the third dorsal compartment was visualized under fluoroscopy (Figures 2–4). The monitor was then reinserted into the EPL sheath, and once again pressures were measured (postinjection readings). An 18-gauge needle was then used to aspirate the compartment just ulnar to the Lister tubercle. Compartment pressures were measured a final time (postaspiration readings). For all readings, 3 pressure measurements were recorded and then averaged. Pressure measurements were compared using t test.

In the office, the third dorsal compartment was aspirated after skin preparation with povidone-iodine. The Lister tubercle is typically palpable along the dorsal distal radius and is aligned with the cleft between the index and long fingers. Aspiration with an 18-gauge needle is performed just ulnar to the Lister tubercle in the EPL sheath, and hematoma is evacuated. The patient is then placed back into a long-arm cast or splint per the clinical situation.

Results

Patient age ranged from 17 to 81 years. Eight (1 male, 7 female) patients sustained an EPL rupture a mean of 46 days after initial trauma (range, 21-118 days). Two patients were treated with a prophylactic EPL transposition secondary to clinically apparent impending rupture, and 4 were treated with prophylactic needle decompression of the third compartment. Ruptures were treated with EIP-to-EPL transfers.

As in other studies, each patient’s radiographs showed a nondisplaced fracture and a transverse fracture line. Six patients also had a longitudinal, intra-articular fracture line that exited in a common spot between the scaphoid and the lunate facet.

Results in our cadaveric model were consistent with those in in vitro decompression of the third dorsal compartment (Table 1). In the cadaver model, mean (SD) initial third dorsal compartment pressure was 0.77 (0.88) mm Hg. Mean (SD) pressure after osteotomy and Hypaque injection was 25.5 (11.11) mm Hg. After simulated therapeutic aspiration, mean (SD) pressure decreased to 1.61 (1.40) mm Hg. Mean change in pressure from after injection to after aspiration was 23.89 mm Hg (P = .000388) (Table 2).

Information from other studies and from Dr. Lourie’s experience was used to identify patients at significant risk for EPL ruptures in association with distal radius fractures. Four patients in Dr. Lourie’s practice between 2004 and 2009 had characteristic findings, including a nondisplaced distal radius fracture, localized swelling over the third dorsal compartment, and pain with resisted active EPL extension. Prophylactic aspiration and hematoma evacuation were performed in this series, yielding a mean hematoma amount of 2 mL (Table 3).

For all 4 patients, aspirations were performed within 2 weeks of injury. Subjectively, these patients described almost immediate pain relief and less discomfort with EPL motion after aspiration. Three of the 4 reported sustained pain relief on close follow-up 7 and 14 days after aspiration. The fourth patient continued to have pain over the third dorsal compartment, though she described it as significantly improved. Her initial fracture contained about 50% dorsal comminution, and she began to have a significant callus response. After 2 months of continued symptoms, and out of concern about consequences of an impending rupture, open decompression and transposition of the EPL were performed. In follow-up over 29 months, this patient continued to do well and had full EPL function. The 3 patients treated with aspiration alone have not had an EPL rupture (range of follow-up, 29-89 months).

Discussion

Distal radius fractures are very common injuries, and treating physicians must attempt to prevent possible complications. EPL tendon ruptures continue to be rare events (incidence, <1%) in association with distal radius fractures. Although statistics vary, studies have found a higher incidence in nondisplaced (vs displaced) distal radius fractures.^5,7,10 Ruptures in nondisplaced fractures occur within 2 weeks to 3 years after injury but typically an average of 6 weeks after injury.^2,4,7-9 Prodromal symptoms often include tenderness and swelling around the dorsal distal radius region around the Lister tubercle.^7,11,12 Patients may complain of pain with active thumb extension or passive thumb range of motion.¹¹ Rupture is indicated by an inability to actively extend the thumb.

Studies have shown that the tendon rupture site is around the Lister tubercle.⁷ No single cause for EPL ruptures has been confirmed, and the etiology is likely a mix of factors in relation to the clinical situation. Two theories have been espoused for the relation between EPL ruptures and distal radius fractures. The mechanical theory involves a prominent spicule of bone abrading the tendon and subsequently causing rupture.^5,9 This seems less likely for nondisplaced fractures. The vascular theory centers on a watershed region of the EPL tendon around the Lister tubercle. Studies have found microangiographic evidence of a 5-mm portion of tendon around the Lister tubercle that has no mesotenon and poor vascularity.^7,9 The tendon in this section may be reliant on synovial diffusion for nutrition,⁷ but hematoma may displace synovial fluid, interfering with tendon nutrition.

Researchers have studied the third dorsal compartment in patients with impending or established ruptures. In a series by Hirasawa and colleagues,⁷ 11 patients with a nondisplaced fracture and a tendon rupture had an intact retinaculum and smooth bony surfaces on the dorsal radius. Periosteal hypertrophy and narrowing of the third compartment were noted. In another series, Helal and colleagues⁵ reported on 16 patients (nondisplaced and displaced fractures) who had possible EPL ruptures over a 4-year period. In all cases, the extensor retinaculum was intact. Likewise, the 7 patients with EPL ruptures in a series by Bonatz and colleagues⁴ had an intact extensor retinaculum. On exploration, Bunata¹⁰ noted fluid collections, including hematomas, within the sheath, as well as a lack of bony prominences. Simpson¹² explored 2 cases of blunt trauma, no fracture, and subsequent EPL rupture. Clinically these 2 patients had swelling in the region of the Lister tubercle, and surgically they were found to have a distended, blood-filled sheath. These ruptures may correlate with nondisplaced distal radius fractures and provide further evidence supporting the vascular theory of ruptures. The combination of intact compartment and volume overload presents a situation akin to compartment syndrome. Acute compartment decompression with needle evacuation would theoretically relieve the vascular insult.

In the study by Helal and colleagues,⁵ Hypaque injections were given to patients with nondisplaced distal radius fractures. The dye remained in the third dorsal compartment, which implies an intact closed space. That study used a cadaveric model as well, with distal radius osteotomies performed to simulate a nondisplaced distal radius fracture. The authors noted an intact extensor retinaculum in their model. Our cadaver model is similar, except we measured pressures in the third compartment; our model indicated increased compartment pressures within the EPL sheath. Subsequent aspiration in our cadaveric study led to lower pressures in the third dorsal compartment. This cadaveric model implies that needle decompression of the third dorsal compartment may be beneficial in the setting of nondisplaced distal radius fractures and symptoms indicating a compromised EPL.

Splinting is an important factor that may help prevent EPL tendon ruptures after distal radius fractures. Synovial diffusion may be the primary mechanism for delivering nutrition to the EPL tendon.⁷ A splint that allows thumb metacarpophalangeal and interphalangeal flexion may provide the EPL motion needed for effective synovial nutritional pathways.⁹ Prodromal symptoms of tendon rupture should then be carefully monitored.

Conclusion

Results of our retrospective review are consistent with previous results elucidating the risk factors for EPL ruptures in association with distal radius fractures. In our patients who sustained EPL ruptures, findings included nondisplaced fractures, about 50% with an intra-articular component. Clinical findings included localized swelling over the third dorsal compartment, pain with resisted active EPL extension, and pain with passive flexion of the thumb interphalangeal joint. The cadaveric portion of this study indicated a significant change in pressure in the third dorsal compartment after aspiration. Preliminary outcomes in this 4-patient series are no EPL ruptures after prophylactic aspiration. Hematoma evacuation after nondisplaced distal radius fractures may become a useful addition to the surgeon’s armamentarium. Studies are needed to determine if needle aspiration of the third dorsal compartment can become an office-based procedure with value in preventing EPL ruptures in the appropriate clinical situation.

Rosacea patients experience symptoms ranging from flushing to persistent acnelike rashes that can cause low self-esteem and anxiety, leading to social and professional isolation.¹ Although it is estimated that 16 million individuals in the United States have rosacea, only 10% seek treatment.^2,3 The motivation for patients to seek and adhere to treatment is not well characterized.

A patient journey is a map of the steps a patient takes as he/she progresses through different segments of the disease from diagnosis to management, including all the influences that can push him/her toward or away from certain decisions. The patient journey model provides a structure for understanding key issues in rosacea management, including barriers to successful treatment outcomes.

The patient journey model progresses from development of disease and diagnosis to treatment and disease management (Figure). We sought to examine each step of the rosacea patient journey to better understand key patient care boundaries faced by rosacea patients. We assessed the current literature regarding each step of the patient experience and identified areas of the patient journey with limited research.

Click here to view the figure as a PDF to print for future reference.

Researching the Patient Experience

A PubMed search of articles indexed for MEDLINE as well as a search of the National Rosacea Society Web site (http://www.rosacea.org) were conducted to identify articles and materials that quantitatively or qualitatively described rosacea patient experiences. Search terms included rosacea, rosacea patient experience, rosacea treatment, rosacea adherence, and rosacea quality of life. A Google search also was conducted using the same terms to obtain current news articles online. Current literature pertaining to the patient journey was summarized.

To create a model for the rosacea patient journey, we refined a rheumatoid arthritis patient journey map⁴ and included the critical components of the journey for rosacea patients. We organized the journey into stages, including prediagnosis, diagnosis, treatment, adherence, and management. We first explored what occurs prior to diagnosis, which includes the patient’s symptoms before visiting a physician. We then examined the process of diagnosis and the implementation of a treatment plan. Treatment adherence was then explored, ending with the ways patients self-manage their disease beyond the physician’s office.

Rosacea Patient Journey

Prediagnosis: What Motivates Patients to Seek Treatment

Rosacea can present with many symptoms that may lead patients to see a physician, including facial erythema and telangiectases, papules and pustules, phymatous changes, and ocular manifestations.⁵ The most common concern is temporary facial flushing, followed by persistent redness, then bumps and pimples.⁶ Many patients seek treatment after persistent facial flushing and an intolerable burning sensation. Some middle-aged patients decide to see a dermatologist for the first time when they break out in acne lesions after a history of clear skin. Others seek treatment because they can no longer tolerate the pain and embarrassment associated with their symptoms. However, patients who seek treatment only account for a small proportion of patients with rosacea, as only 10% of patients seek conventional medical treatment.⁷ Furthermore, symptomatic patients on average wait 7 months to 5 years before receiving a diagnosis.^8,9

Care often is delayed or not pursued because many rosacea symptoms are mild when they first appear and may not initially bother the patient. Patients may not think anything of their symptoms and dismiss them as either acne vulgaris or sunburn. Due to the relapsing and remitting nature of the disease course, patients may feel their symptoms will resolve. Of patients diagnosed with rosacea, only one-half have heard of the condition prior to diagnosis,⁸ which can largely be attributed to lack of patient education on the signs and symptoms of rosacea, a concern that prompted the National Rosacea Society to designate the month of April as rosacea awareness month.⁵

With sales of antiredness facial care products growing 35% from 2002 to 2007, accounting for an increase of $300 million in revenue, patients also may be turning to over-the-counter products first.¹⁰ Men with rosacea tend to present with more severe symptoms such as rhinophyma, which may be due to their desire to wait until their symptoms reached more advanced stages of disease before seeking medical help.⁵

Diagnosis of Rosacea

After the patient decides that his/her symptoms are unusual, severe, or intolerable enough to seek treatment, the issues of access to dermatologic care and receiving the correct diagnosis come into play. Accessing dermatologic care can be difficult, as appointments may be hard to obtain, and even if the patient is able to get an appointment, it could be many weeks later.¹¹ For some rosacea patients, the anxiety of waiting for their appointment prompts them to seek support and advice from online message boards (eg, http://www.rosacea-support.org). The long wait for appointments may be attributed to the increased demand for dermatologists for cosmetic procedures.¹² Additionally, disparities according to insurance type can contribute to difficulties procuring an appointment. In one study, privately insured dermatology patients demonstrated a 91% acceptance rate and shorter wait times for appointments compared to publicly insured patients who were limited to a 29.8% acceptance rate and longer wait times.¹¹ Many patients then are left to wait for an appointment with a dermatologist or instead turn to a primary care physician. Of patients diagnosed with rosacea in one study (N=2847), the majority of patients were seen by a dermatologist (79%), while the other patients were diagnosed by a family physician (14%) or other types of physicians such as internists and ophthalmologists (7%).⁶

The diagnosis of rosacea usually is not a major hurdle for dermatologists, but misdiagnoses can sometimes occur. The Rosacea Research & Development Institute compiled multiple patient anecdotes describing the struggles of finally reaching the correct diagnosis of rosacea; however, no estimates as to the frequency of misdiagnoses was estimated.¹³ Even with an accurate diagnosis of rosacea, correct classification of the 4 types of rosacea (ie, erythematotelangiectatic, papulopustular, phymatous, ocular) is necessary to avoid incorrect treatment recommendations. For example, patients with flushing often cannot tolerate topical medications in contrast to patients with the papulopustular subtype who benefit from them.¹⁴ In the meantime, the patients who are misdiagnosed may be met with frustration, as treatment was either delayed or incorrectly prescribed.

Although there are limited data regarding patient reactions after receiving a diagnosis of rosacea, it can be assumed that patients would be hopeful that diagnosis would lead to correct treatment. In a 2008 article in The New York Times, a rosacea patient was described as feeling relieved to be diagnosed with rosacea because it was an explanation for the development of pimples on the cheeks in her late 40s.¹⁰

Implementation of a Treatment Plan

After recognizing the symptoms and receiving a correct diagnosis, the next step in the patient journey is treatment. Long-term management of incurable conditions such as rosacea is difficult. The main goals of treatment are to relieve symptoms, improve appearance, delay progression to advanced stages, and maintain remission.¹⁵ There are only a few reliable clinical trials regarding therapies for rosacea, so treatment has mostly relied on clinical experience (Table). The efficacy and safety of many older treatments has not been assessed.¹⁵ Mainstays of treatment include both topical agents and oral medications. The use of topical metronidazole, oral tetracycline, and oral isotretinoin have been found to improve both skin lesions and quality of life.¹⁸ Initially, a combination of a topical and an oral medication may be used for at least the first 12 weeks, and improvement is usually gradual, taking many weeks to become evident.¹⁵ Long-term treatment with topical medications often is required for maintenance, which can last another 6 months or more.^19,20

Besides using pharmacologic therapies, some patients also may choose to undergo various procedures. The most common procedure is laser therapy, followed by dermabrasion, chemical peels, hot loop electrocoagulation, and surgical sculpting or plastic surgery.⁶ The use of these adjunct therapies may suggest impatience from the patient for improvement; it also indicates the lengths patients will go to and willingness to pay for improvement of symptoms.

Along with medication, patients are recommended to make changes to their skin care regimen and lifestyle. Rosacea patients typically have sensitive skin that may include symptoms such as dryness, scaling, stinging, burning, and pruritus.¹⁶ Skin care recommendations for rosacea patients include using a gentle cleanser and regularly applying sunscreen.⁵ Issues with physical appearance can be addressed with the use of cosmetic products such as green-tinted makeup to conceal skin lesions.²¹ Remission can be maintained by identifying certain triggers (eg, red wine, spicy foods, extreme temperatures, prolonged sun exposure, vigorous exercise) that can cause flare-ups.¹⁵ The most common trigger is sun exposure, making photoprotection an important component of the rosacea patient’s skin care regimen.⁶

Adherence

With a diagnosis and treatment plan in effect, the patient journey reaches the stage of treatment adherence, which should include ongoing education about the condition. Self-reported statistics from rosacea patients indicated that 28% of patients took time off from their treatment regimen,⁶ but actual nonadherence rates likely are higher. The most commonly reported reason for poor treatment adherence among rosacea patients was the impression that the symptoms had resolved or were adequately controlled.⁶ Treatment also must be affordable. In a national survey of rosacea patients, 24% of 427 patients receiving pharmacologic therapy planned on switching medications because of cost, and 17% of 769 patients discontinued medications due to co-pay/insurance issues.⁶ Other reasons cited for discontinuation of treatment included patient perception that symptoms were not that serious, co-pay/insurance issues, ineffectiveness of the medication, and side effects.⁶ Adherence to topical medications is lower than oral medications due to the time and inconvenience required for application.²² For some patients, topical medications may be too messy, have a strange odor, or stain clothing.

It is promising that most rosacea patients have reported the intent to continue using pharmacologic agents because the medication prevented worsening of their symptoms.⁶ However, there are still patients who switch or discontinue therapies without physician direction. These patients often cite that they desire more information at the time of diagnosis, particularly related to causes of flare-ups, physical symptoms to expect, drug treatment options, makeup to cover up visible symptoms, surgical or laser treatment options, psychological symptoms, patient support groups, and counseling options.⁶

Management

The last part of the journey is disease management, which occurs when the patient learns how to control his/her symptoms long-term. Important factors contributing to long-term control of rosacea flares are medication adherence and avoiding lifestyle triggers.^23,24 Through the other stages of the journey, the patient has learned which treatments work and which factors may lead to exacerbation of symptoms.

Educating Patients on the Journey

The patient journey is a concept that can be applied to any disease state and brings to light roadblocks that patients may face from the initial diagnosis to successful disease management. Rosacea patients are faced with confusing and aggravating symptoms that can cause anxiety and may lead them to seek treatment from a physician. Facial flushing and phymatous changes of the nose can be mistaken for alcohol abuse, leading rosacea to be a socially stigmatizing disease.¹⁵ Because rosacea involves mostly the facial skin, it can disrupt social and professional interactions, leading to quality-of-life effects such as difficulty functioning on a day-to-day basis, which can be detrimental because patients usually are aged 30 to 50 years and may be perceived based on their appearance in the workforce.³ A lack of confidence, low self-esteem, embarrassment, and anxiety can even lead to serious psychiatric conditions such as depression and body dysmorphic disorder.²⁵ Because the severity of rosacea increases over time, it is important to educate patients about seeking early treatment; therefore, understanding and awareness of rosacea symptoms are necessary to prompt patients to see a medical professional to either confirm or refute the diagnosis.

Rosacea is a clinical diagnosis that relies on patterns of primary and secondary features, as outlined in a 2002 report by the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea.⁵ Even with this consensus grading system, it appears that additional fine-tuning of the criteria is needed in the disease definition. Importantly, because much of the pathogenesis and progression of rosacea is still not completely understood, there is no laboratory benchmark test that can be utilized for correct diagnosis.¹⁴ Moreover, many of the clinical manifestations of rosacea are shared with other conditions, and patients may present with different symptoms or varying combinations.²⁶

Treatment of rosacea is multifactorial and behavioral, as patients must not only be able to obtain and adhere to oral and topical regimens and possible procedures but also avoid various lifestyle and environmental triggers and learn to cope with emotional distress caused by their symptoms. Although patients who discontinue use of medications appear to be in the minority, education is still needed to stress the chronic nature of rosacea and the importance of the continuation of treatment. Collaboration between the physician and patient is needed to determine why a certain medication may not be effective and explore other treatment options. Treatment ineffectiveness could be due to incorrect use of the product, failure to use an adjunct skin care regimen, or inability to control rosacea triggers. Adequate early follow-up also is needed to maximize patient adherence to treatment.²⁷ Working together with the patient to develop a treatment plan that can be followed is necessary for long-term control of rosacea symptoms.

There is little information on how to address the psychological needs of patients, but patients can find support from various avenues. For instance, the National Rosacea Society, a large advocacy group, produces newsletters and educational materials for both physicians and patients.^28,29 There also are online support groups for rosacea patients that have thousands of members who exchange stories and provide words of encouragement. Although there are not many face-to-face support groups, physicians may consider developing live support groups for their rosacea patients. As patients achieve the later stages of the rosacea patient journey, they hopefully will have controlled their symptoms by following a treatment regimen and learning to adapt to a new life of successful disease management.

Many aspects of the rosacea patient journey have yet to be explored. It is uncertain how long patients with symptoms of rosacea wait before seeking treatment, what methods they use to control their rosacea before they receive a prescribed treatment or physician recommendations, and how they react to their diagnosis. It also is unknown how many rosacea patients receive an initial misdiagnosis of another condition and which physicians typically make the misdiagnosis. We also need to know more about the role of psychological issues in addressing patient adherence to treatment. Similarly, what role do support groups such as online forums play on adherence? There is a need for more patient education and awareness of rosacea.

Conclusion

Patients may be relieved that rosacea is not a life-threatening condition, but they may be disappointed that there is no cure for rosacea. As the patient and dermatologist work together to find an appropriate treatment plan, identify certain triggers, and modify the skin care routine, the patient can become disciplined in controlling rosacea symptoms. Ultimately, with the alleviation of visible symptoms, the patient’s quality of life also can improve. Better understanding of the rosacea patient perspective can lead to a more efficient health care system, improved patient care, and better patient satisfaction.

Rosacea patients experience symptoms ranging from flushing to persistent acnelike rashes that can cause low self-esteem and anxiety, leading to social and professional isolation.¹ Although it is estimated that 16 million individuals in the United States have rosacea, only 10% seek treatment.^2,3 The motivation for patients to seek and adhere to treatment is not well characterized.

A patient journey is a map of the steps a patient takes as he/she progresses through different segments of the disease from diagnosis to management, including all the influences that can push him/her toward or away from certain decisions. The patient journey model provides a structure for understanding key issues in rosacea management, including barriers to successful treatment outcomes.

The patient journey model progresses from development of disease and diagnosis to treatment and disease management (Figure). We sought to examine each step of the rosacea patient journey to better understand key patient care boundaries faced by rosacea patients. We assessed the current literature regarding each step of the patient experience and identified areas of the patient journey with limited research.

Click here to view the figure as a PDF to print for future reference.

Researching the Patient Experience

A PubMed search of articles indexed for MEDLINE as well as a search of the National Rosacea Society Web site (http://www.rosacea.org) were conducted to identify articles and materials that quantitatively or qualitatively described rosacea patient experiences. Search terms included rosacea, rosacea patient experience, rosacea treatment, rosacea adherence, and rosacea quality of life. A Google search also was conducted using the same terms to obtain current news articles online. Current literature pertaining to the patient journey was summarized.

To create a model for the rosacea patient journey, we refined a rheumatoid arthritis patient journey map⁴ and included the critical components of the journey for rosacea patients. We organized the journey into stages, including prediagnosis, diagnosis, treatment, adherence, and management. We first explored what occurs prior to diagnosis, which includes the patient’s symptoms before visiting a physician. We then examined the process of diagnosis and the implementation of a treatment plan. Treatment adherence was then explored, ending with the ways patients self-manage their disease beyond the physician’s office.

Rosacea Patient Journey

Prediagnosis: What Motivates Patients to Seek Treatment

Rosacea can present with many symptoms that may lead patients to see a physician, including facial erythema and telangiectases, papules and pustules, phymatous changes, and ocular manifestations.⁵ The most common concern is temporary facial flushing, followed by persistent redness, then bumps and pimples.⁶ Many patients seek treatment after persistent facial flushing and an intolerable burning sensation. Some middle-aged patients decide to see a dermatologist for the first time when they break out in acne lesions after a history of clear skin. Others seek treatment because they can no longer tolerate the pain and embarrassment associated with their symptoms. However, patients who seek treatment only account for a small proportion of patients with rosacea, as only 10% of patients seek conventional medical treatment.⁷ Furthermore, symptomatic patients on average wait 7 months to 5 years before receiving a diagnosis.^8,9

Care often is delayed or not pursued because many rosacea symptoms are mild when they first appear and may not initially bother the patient. Patients may not think anything of their symptoms and dismiss them as either acne vulgaris or sunburn. Due to the relapsing and remitting nature of the disease course, patients may feel their symptoms will resolve. Of patients diagnosed with rosacea, only one-half have heard of the condition prior to diagnosis,⁸ which can largely be attributed to lack of patient education on the signs and symptoms of rosacea, a concern that prompted the National Rosacea Society to designate the month of April as rosacea awareness month.⁵

With sales of antiredness facial care products growing 35% from 2002 to 2007, accounting for an increase of $300 million in revenue, patients also may be turning to over-the-counter products first.¹⁰ Men with rosacea tend to present with more severe symptoms such as rhinophyma, which may be due to their desire to wait until their symptoms reached more advanced stages of disease before seeking medical help.⁵

Diagnosis of Rosacea

After the patient decides that his/her symptoms are unusual, severe, or intolerable enough to seek treatment, the issues of access to dermatologic care and receiving the correct diagnosis come into play. Accessing dermatologic care can be difficult, as appointments may be hard to obtain, and even if the patient is able to get an appointment, it could be many weeks later.¹¹ For some rosacea patients, the anxiety of waiting for their appointment prompts them to seek support and advice from online message boards (eg, http://www.rosacea-support.org). The long wait for appointments may be attributed to the increased demand for dermatologists for cosmetic procedures.¹² Additionally, disparities according to insurance type can contribute to difficulties procuring an appointment. In one study, privately insured dermatology patients demonstrated a 91% acceptance rate and shorter wait times for appointments compared to publicly insured patients who were limited to a 29.8% acceptance rate and longer wait times.¹¹ Many patients then are left to wait for an appointment with a dermatologist or instead turn to a primary care physician. Of patients diagnosed with rosacea in one study (N=2847), the majority of patients were seen by a dermatologist (79%), while the other patients were diagnosed by a family physician (14%) or other types of physicians such as internists and ophthalmologists (7%).⁶

The diagnosis of rosacea usually is not a major hurdle for dermatologists, but misdiagnoses can sometimes occur. The Rosacea Research & Development Institute compiled multiple patient anecdotes describing the struggles of finally reaching the correct diagnosis of rosacea; however, no estimates as to the frequency of misdiagnoses was estimated.¹³ Even with an accurate diagnosis of rosacea, correct classification of the 4 types of rosacea (ie, erythematotelangiectatic, papulopustular, phymatous, ocular) is necessary to avoid incorrect treatment recommendations. For example, patients with flushing often cannot tolerate topical medications in contrast to patients with the papulopustular subtype who benefit from them.¹⁴ In the meantime, the patients who are misdiagnosed may be met with frustration, as treatment was either delayed or incorrectly prescribed.

Although there are limited data regarding patient reactions after receiving a diagnosis of rosacea, it can be assumed that patients would be hopeful that diagnosis would lead to correct treatment. In a 2008 article in The New York Times, a rosacea patient was described as feeling relieved to be diagnosed with rosacea because it was an explanation for the development of pimples on the cheeks in her late 40s.¹⁰

Implementation of a Treatment Plan

After recognizing the symptoms and receiving a correct diagnosis, the next step in the patient journey is treatment. Long-term management of incurable conditions such as rosacea is difficult. The main goals of treatment are to relieve symptoms, improve appearance, delay progression to advanced stages, and maintain remission.¹⁵ There are only a few reliable clinical trials regarding therapies for rosacea, so treatment has mostly relied on clinical experience (Table). The efficacy and safety of many older treatments has not been assessed.¹⁵ Mainstays of treatment include both topical agents and oral medications. The use of topical metronidazole, oral tetracycline, and oral isotretinoin have been found to improve both skin lesions and quality of life.¹⁸ Initially, a combination of a topical and an oral medication may be used for at least the first 12 weeks, and improvement is usually gradual, taking many weeks to become evident.¹⁵ Long-term treatment with topical medications often is required for maintenance, which can last another 6 months or more.^19,20

Besides using pharmacologic therapies, some patients also may choose to undergo various procedures. The most common procedure is laser therapy, followed by dermabrasion, chemical peels, hot loop electrocoagulation, and surgical sculpting or plastic surgery.⁶ The use of these adjunct therapies may suggest impatience from the patient for improvement; it also indicates the lengths patients will go to and willingness to pay for improvement of symptoms.

Along with medication, patients are recommended to make changes to their skin care regimen and lifestyle. Rosacea patients typically have sensitive skin that may include symptoms such as dryness, scaling, stinging, burning, and pruritus.¹⁶ Skin care recommendations for rosacea patients include using a gentle cleanser and regularly applying sunscreen.⁵ Issues with physical appearance can be addressed with the use of cosmetic products such as green-tinted makeup to conceal skin lesions.²¹ Remission can be maintained by identifying certain triggers (eg, red wine, spicy foods, extreme temperatures, prolonged sun exposure, vigorous exercise) that can cause flare-ups.¹⁵ The most common trigger is sun exposure, making photoprotection an important component of the rosacea patient’s skin care regimen.⁶

Adherence

With a diagnosis and treatment plan in effect, the patient journey reaches the stage of treatment adherence, which should include ongoing education about the condition. Self-reported statistics from rosacea patients indicated that 28% of patients took time off from their treatment regimen,⁶ but actual nonadherence rates likely are higher. The most commonly reported reason for poor treatment adherence among rosacea patients was the impression that the symptoms had resolved or were adequately controlled.⁶ Treatment also must be affordable. In a national survey of rosacea patients, 24% of 427 patients receiving pharmacologic therapy planned on switching medications because of cost, and 17% of 769 patients discontinued medications due to co-pay/insurance issues.⁶ Other reasons cited for discontinuation of treatment included patient perception that symptoms were not that serious, co-pay/insurance issues, ineffectiveness of the medication, and side effects.⁶ Adherence to topical medications is lower than oral medications due to the time and inconvenience required for application.²² For some patients, topical medications may be too messy, have a strange odor, or stain clothing.

It is promising that most rosacea patients have reported the intent to continue using pharmacologic agents because the medication prevented worsening of their symptoms.⁶ However, there are still patients who switch or discontinue therapies without physician direction. These patients often cite that they desire more information at the time of diagnosis, particularly related to causes of flare-ups, physical symptoms to expect, drug treatment options, makeup to cover up visible symptoms, surgical or laser treatment options, psychological symptoms, patient support groups, and counseling options.⁶

Management

The last part of the journey is disease management, which occurs when the patient learns how to control his/her symptoms long-term. Important factors contributing to long-term control of rosacea flares are medication adherence and avoiding lifestyle triggers.^23,24 Through the other stages of the journey, the patient has learned which treatments work and which factors may lead to exacerbation of symptoms.

Educating Patients on the Journey

The patient journey is a concept that can be applied to any disease state and brings to light roadblocks that patients may face from the initial diagnosis to successful disease management. Rosacea patients are faced with confusing and aggravating symptoms that can cause anxiety and may lead them to seek treatment from a physician. Facial flushing and phymatous changes of the nose can be mistaken for alcohol abuse, leading rosacea to be a socially stigmatizing disease.¹⁵ Because rosacea involves mostly the facial skin, it can disrupt social and professional interactions, leading to quality-of-life effects such as difficulty functioning on a day-to-day basis, which can be detrimental because patients usually are aged 30 to 50 years and may be perceived based on their appearance in the workforce.³ A lack of confidence, low self-esteem, embarrassment, and anxiety can even lead to serious psychiatric conditions such as depression and body dysmorphic disorder.²⁵ Because the severity of rosacea increases over time, it is important to educate patients about seeking early treatment; therefore, understanding and awareness of rosacea symptoms are necessary to prompt patients to see a medical professional to either confirm or refute the diagnosis.

Rosacea is a clinical diagnosis that relies on patterns of primary and secondary features, as outlined in a 2002 report by the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea.⁵ Even with this consensus grading system, it appears that additional fine-tuning of the criteria is needed in the disease definition. Importantly, because much of the pathogenesis and progression of rosacea is still not completely understood, there is no laboratory benchmark test that can be utilized for correct diagnosis.¹⁴ Moreover, many of the clinical manifestations of rosacea are shared with other conditions, and patients may present with different symptoms or varying combinations.²⁶

Treatment of rosacea is multifactorial and behavioral, as patients must not only be able to obtain and adhere to oral and topical regimens and possible procedures but also avoid various lifestyle and environmental triggers and learn to cope with emotional distress caused by their symptoms. Although patients who discontinue use of medications appear to be in the minority, education is still needed to stress the chronic nature of rosacea and the importance of the continuation of treatment. Collaboration between the physician and patient is needed to determine why a certain medication may not be effective and explore other treatment options. Treatment ineffectiveness could be due to incorrect use of the product, failure to use an adjunct skin care regimen, or inability to control rosacea triggers. Adequate early follow-up also is needed to maximize patient adherence to treatment.²⁷ Working together with the patient to develop a treatment plan that can be followed is necessary for long-term control of rosacea symptoms.

There is little information on how to address the psychological needs of patients, but patients can find support from various avenues. For instance, the National Rosacea Society, a large advocacy group, produces newsletters and educational materials for both physicians and patients.^28,29 There also are online support groups for rosacea patients that have thousands of members who exchange stories and provide words of encouragement. Although there are not many face-to-face support groups, physicians may consider developing live support groups for their rosacea patients. As patients achieve the later stages of the rosacea patient journey, they hopefully will have controlled their symptoms by following a treatment regimen and learning to adapt to a new life of successful disease management.

Many aspects of the rosacea patient journey have yet to be explored. It is uncertain how long patients with symptoms of rosacea wait before seeking treatment, what methods they use to control their rosacea before they receive a prescribed treatment or physician recommendations, and how they react to their diagnosis. It also is unknown how many rosacea patients receive an initial misdiagnosis of another condition and which physicians typically make the misdiagnosis. We also need to know more about the role of psychological issues in addressing patient adherence to treatment. Similarly, what role do support groups such as online forums play on adherence? There is a need for more patient education and awareness of rosacea.

Conclusion

Patients may be relieved that rosacea is not a life-threatening condition, but they may be disappointed that there is no cure for rosacea. As the patient and dermatologist work together to find an appropriate treatment plan, identify certain triggers, and modify the skin care routine, the patient can become disciplined in controlling rosacea symptoms. Ultimately, with the alleviation of visible symptoms, the patient’s quality of life also can improve. Better understanding of the rosacea patient perspective can lead to a more efficient health care system, improved patient care, and better patient satisfaction.

Rosacea patients experience symptoms ranging from flushing to persistent acnelike rashes that can cause low self-esteem and anxiety, leading to social and professional isolation.¹ Although it is estimated that 16 million individuals in the United States have rosacea, only 10% seek treatment.^2,3 The motivation for patients to seek and adhere to treatment is not well characterized.

A patient journey is a map of the steps a patient takes as he/she progresses through different segments of the disease from diagnosis to management, including all the influences that can push him/her toward or away from certain decisions. The patient journey model provides a structure for understanding key issues in rosacea management, including barriers to successful treatment outcomes.

The patient journey model progresses from development of disease and diagnosis to treatment and disease management (Figure). We sought to examine each step of the rosacea patient journey to better understand key patient care boundaries faced by rosacea patients. We assessed the current literature regarding each step of the patient experience and identified areas of the patient journey with limited research.

Click here to view the figure as a PDF to print for future reference.

Researching the Patient Experience

A PubMed search of articles indexed for MEDLINE as well as a search of the National Rosacea Society Web site (http://www.rosacea.org) were conducted to identify articles and materials that quantitatively or qualitatively described rosacea patient experiences. Search terms included rosacea, rosacea patient experience, rosacea treatment, rosacea adherence, and rosacea quality of life. A Google search also was conducted using the same terms to obtain current news articles online. Current literature pertaining to the patient journey was summarized.

To create a model for the rosacea patient journey, we refined a rheumatoid arthritis patient journey map⁴ and included the critical components of the journey for rosacea patients. We organized the journey into stages, including prediagnosis, diagnosis, treatment, adherence, and management. We first explored what occurs prior to diagnosis, which includes the patient’s symptoms before visiting a physician. We then examined the process of diagnosis and the implementation of a treatment plan. Treatment adherence was then explored, ending with the ways patients self-manage their disease beyond the physician’s office.

Rosacea Patient Journey

Prediagnosis: What Motivates Patients to Seek Treatment

Rosacea can present with many symptoms that may lead patients to see a physician, including facial erythema and telangiectases, papules and pustules, phymatous changes, and ocular manifestations.⁵ The most common concern is temporary facial flushing, followed by persistent redness, then bumps and pimples.⁶ Many patients seek treatment after persistent facial flushing and an intolerable burning sensation. Some middle-aged patients decide to see a dermatologist for the first time when they break out in acne lesions after a history of clear skin. Others seek treatment because they can no longer tolerate the pain and embarrassment associated with their symptoms. However, patients who seek treatment only account for a small proportion of patients with rosacea, as only 10% of patients seek conventional medical treatment.⁷ Furthermore, symptomatic patients on average wait 7 months to 5 years before receiving a diagnosis.^8,9

Care often is delayed or not pursued because many rosacea symptoms are mild when they first appear and may not initially bother the patient. Patients may not think anything of their symptoms and dismiss them as either acne vulgaris or sunburn. Due to the relapsing and remitting nature of the disease course, patients may feel their symptoms will resolve. Of patients diagnosed with rosacea, only one-half have heard of the condition prior to diagnosis,⁸ which can largely be attributed to lack of patient education on the signs and symptoms of rosacea, a concern that prompted the National Rosacea Society to designate the month of April as rosacea awareness month.⁵

With sales of antiredness facial care products growing 35% from 2002 to 2007, accounting for an increase of $300 million in revenue, patients also may be turning to over-the-counter products first.¹⁰ Men with rosacea tend to present with more severe symptoms such as rhinophyma, which may be due to their desire to wait until their symptoms reached more advanced stages of disease before seeking medical help.⁵

Diagnosis of Rosacea

After the patient decides that his/her symptoms are unusual, severe, or intolerable enough to seek treatment, the issues of access to dermatologic care and receiving the correct diagnosis come into play. Accessing dermatologic care can be difficult, as appointments may be hard to obtain, and even if the patient is able to get an appointment, it could be many weeks later.¹¹ For some rosacea patients, the anxiety of waiting for their appointment prompts them to seek support and advice from online message boards (eg, http://www.rosacea-support.org). The long wait for appointments may be attributed to the increased demand for dermatologists for cosmetic procedures.¹² Additionally, disparities according to insurance type can contribute to difficulties procuring an appointment. In one study, privately insured dermatology patients demonstrated a 91% acceptance rate and shorter wait times for appointments compared to publicly insured patients who were limited to a 29.8% acceptance rate and longer wait times.¹¹ Many patients then are left to wait for an appointment with a dermatologist or instead turn to a primary care physician. Of patients diagnosed with rosacea in one study (N=2847), the majority of patients were seen by a dermatologist (79%), while the other patients were diagnosed by a family physician (14%) or other types of physicians such as internists and ophthalmologists (7%).⁶

The diagnosis of rosacea usually is not a major hurdle for dermatologists, but misdiagnoses can sometimes occur. The Rosacea Research & Development Institute compiled multiple patient anecdotes describing the struggles of finally reaching the correct diagnosis of rosacea; however, no estimates as to the frequency of misdiagnoses was estimated.¹³ Even with an accurate diagnosis of rosacea, correct classification of the 4 types of rosacea (ie, erythematotelangiectatic, papulopustular, phymatous, ocular) is necessary to avoid incorrect treatment recommendations. For example, patients with flushing often cannot tolerate topical medications in contrast to patients with the papulopustular subtype who benefit from them.¹⁴ In the meantime, the patients who are misdiagnosed may be met with frustration, as treatment was either delayed or incorrectly prescribed.

Although there are limited data regarding patient reactions after receiving a diagnosis of rosacea, it can be assumed that patients would be hopeful that diagnosis would lead to correct treatment. In a 2008 article in The New York Times, a rosacea patient was described as feeling relieved to be diagnosed with rosacea because it was an explanation for the development of pimples on the cheeks in her late 40s.¹⁰

Implementation of a Treatment Plan

After recognizing the symptoms and receiving a correct diagnosis, the next step in the patient journey is treatment. Long-term management of incurable conditions such as rosacea is difficult. The main goals of treatment are to relieve symptoms, improve appearance, delay progression to advanced stages, and maintain remission.¹⁵ There are only a few reliable clinical trials regarding therapies for rosacea, so treatment has mostly relied on clinical experience (Table). The efficacy and safety of many older treatments has not been assessed.¹⁵ Mainstays of treatment include both topical agents and oral medications. The use of topical metronidazole, oral tetracycline, and oral isotretinoin have been found to improve both skin lesions and quality of life.¹⁸ Initially, a combination of a topical and an oral medication may be used for at least the first 12 weeks, and improvement is usually gradual, taking many weeks to become evident.¹⁵ Long-term treatment with topical medications often is required for maintenance, which can last another 6 months or more.^19,20

Besides using pharmacologic therapies, some patients also may choose to undergo various procedures. The most common procedure is laser therapy, followed by dermabrasion, chemical peels, hot loop electrocoagulation, and surgical sculpting or plastic surgery.⁶ The use of these adjunct therapies may suggest impatience from the patient for improvement; it also indicates the lengths patients will go to and willingness to pay for improvement of symptoms.

Along with medication, patients are recommended to make changes to their skin care regimen and lifestyle. Rosacea patients typically have sensitive skin that may include symptoms such as dryness, scaling, stinging, burning, and pruritus.¹⁶ Skin care recommendations for rosacea patients include using a gentle cleanser and regularly applying sunscreen.⁵ Issues with physical appearance can be addressed with the use of cosmetic products such as green-tinted makeup to conceal skin lesions.²¹ Remission can be maintained by identifying certain triggers (eg, red wine, spicy foods, extreme temperatures, prolonged sun exposure, vigorous exercise) that can cause flare-ups.¹⁵ The most common trigger is sun exposure, making photoprotection an important component of the rosacea patient’s skin care regimen.⁶

Adherence

With a diagnosis and treatment plan in effect, the patient journey reaches the stage of treatment adherence, which should include ongoing education about the condition. Self-reported statistics from rosacea patients indicated that 28% of patients took time off from their treatment regimen,⁶ but actual nonadherence rates likely are higher. The most commonly reported reason for poor treatment adherence among rosacea patients was the impression that the symptoms had resolved or were adequately controlled.⁶ Treatment also must be affordable. In a national survey of rosacea patients, 24% of 427 patients receiving pharmacologic therapy planned on switching medications because of cost, and 17% of 769 patients discontinued medications due to co-pay/insurance issues.⁶ Other reasons cited for discontinuation of treatment included patient perception that symptoms were not that serious, co-pay/insurance issues, ineffectiveness of the medication, and side effects.⁶ Adherence to topical medications is lower than oral medications due to the time and inconvenience required for application.²² For some patients, topical medications may be too messy, have a strange odor, or stain clothing.

It is promising that most rosacea patients have reported the intent to continue using pharmacologic agents because the medication prevented worsening of their symptoms.⁶ However, there are still patients who switch or discontinue therapies without physician direction. These patients often cite that they desire more information at the time of diagnosis, particularly related to causes of flare-ups, physical symptoms to expect, drug treatment options, makeup to cover up visible symptoms, surgical or laser treatment options, psychological symptoms, patient support groups, and counseling options.⁶

Management

The last part of the journey is disease management, which occurs when the patient learns how to control his/her symptoms long-term. Important factors contributing to long-term control of rosacea flares are medication adherence and avoiding lifestyle triggers.^23,24 Through the other stages of the journey, the patient has learned which treatments work and which factors may lead to exacerbation of symptoms.

Educating Patients on the Journey

The patient journey is a concept that can be applied to any disease state and brings to light roadblocks that patients may face from the initial diagnosis to successful disease management. Rosacea patients are faced with confusing and aggravating symptoms that can cause anxiety and may lead them to seek treatment from a physician. Facial flushing and phymatous changes of the nose can be mistaken for alcohol abuse, leading rosacea to be a socially stigmatizing disease.¹⁵ Because rosacea involves mostly the facial skin, it can disrupt social and professional interactions, leading to quality-of-life effects such as difficulty functioning on a day-to-day basis, which can be detrimental because patients usually are aged 30 to 50 years and may be perceived based on their appearance in the workforce.³ A lack of confidence, low self-esteem, embarrassment, and anxiety can even lead to serious psychiatric conditions such as depression and body dysmorphic disorder.²⁵ Because the severity of rosacea increases over time, it is important to educate patients about seeking early treatment; therefore, understanding and awareness of rosacea symptoms are necessary to prompt patients to see a medical professional to either confirm or refute the diagnosis.

Rosacea is a clinical diagnosis that relies on patterns of primary and secondary features, as outlined in a 2002 report by the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea.⁵ Even with this consensus grading system, it appears that additional fine-tuning of the criteria is needed in the disease definition. Importantly, because much of the pathogenesis and progression of rosacea is still not completely understood, there is no laboratory benchmark test that can be utilized for correct diagnosis.¹⁴ Moreover, many of the clinical manifestations of rosacea are shared with other conditions, and patients may present with different symptoms or varying combinations.²⁶

Treatment of rosacea is multifactorial and behavioral, as patients must not only be able to obtain and adhere to oral and topical regimens and possible procedures but also avoid various lifestyle and environmental triggers and learn to cope with emotional distress caused by their symptoms. Although patients who discontinue use of medications appear to be in the minority, education is still needed to stress the chronic nature of rosacea and the importance of the continuation of treatment. Collaboration between the physician and patient is needed to determine why a certain medication may not be effective and explore other treatment options. Treatment ineffectiveness could be due to incorrect use of the product, failure to use an adjunct skin care regimen, or inability to control rosacea triggers. Adequate early follow-up also is needed to maximize patient adherence to treatment.²⁷ Working together with the patient to develop a treatment plan that can be followed is necessary for long-term control of rosacea symptoms.

There is little information on how to address the psychological needs of patients, but patients can find support from various avenues. For instance, the National Rosacea Society, a large advocacy group, produces newsletters and educational materials for both physicians and patients.^28,29 There also are online support groups for rosacea patients that have thousands of members who exchange stories and provide words of encouragement. Although there are not many face-to-face support groups, physicians may consider developing live support groups for their rosacea patients. As patients achieve the later stages of the rosacea patient journey, they hopefully will have controlled their symptoms by following a treatment regimen and learning to adapt to a new life of successful disease management.

Many aspects of the rosacea patient journey have yet to be explored. It is uncertain how long patients with symptoms of rosacea wait before seeking treatment, what methods they use to control their rosacea before they receive a prescribed treatment or physician recommendations, and how they react to their diagnosis. It also is unknown how many rosacea patients receive an initial misdiagnosis of another condition and which physicians typically make the misdiagnosis. We also need to know more about the role of psychological issues in addressing patient adherence to treatment. Similarly, what role do support groups such as online forums play on adherence? There is a need for more patient education and awareness of rosacea.

Conclusion

Patients may be relieved that rosacea is not a life-threatening condition, but they may be disappointed that there is no cure for rosacea. As the patient and dermatologist work together to find an appropriate treatment plan, identify certain triggers, and modify the skin care routine, the patient can become disciplined in controlling rosacea symptoms. Ultimately, with the alleviation of visible symptoms, the patient’s quality of life also can improve. Better understanding of the rosacea patient perspective can lead to a more efficient health care system, improved patient care, and better patient satisfaction.

The development of acute compartment syndrome in lower legs placed in the lithotomy position is a rare complication reported within various surgical subspecialties, including general surgery, gynecology, and urology.^1-5 Although it is reported in arthroscopic knee cases, the more frequent occurrence in orthopedics, based on available case reports, appears to involve the well (uninjured or contralateral) leg placed in the hemilithotomy position on the fracture table.^6-9

Prior studies have found significantly elevated lower leg compartment pressures in legs placed in the lithotomy position. Chase and colleagues¹⁰ measured the anterior compartment pressures in 16 limbs placed in the lithotomy position. They found minor elevations after initial lithotomy positioning, but gradual increases over time, with an average elevation to 30 mm Hg and maximum of 70 mm Hg. Similarly, Meyer and colleagues¹¹ recorded the lower leg pressures in 8 healthy volunteers positioned on a fracture table. Changing from the supine position to the lithotomy position significantly increased the intramuscular pressure in the anterior compartment (from 11.6 to 19.4 mm Hg) and in the lateral compartment (from 13.0 to 25.8 mm Hg).

Along with increased intramuscular pressures, local hypotension occurs in lower legs placed in the lithotomy position. Mean diastolic blood pressure in the ankle was 63.9 mm Hg in the leg placed in the supine position as opposed to 34.6 mm Hg in the same leg placed in the lithotomy position.¹⁰ This finding is not unexpected, given that local arteriolar pressure decreases by 0.78 mm Hg for every 1.0 cm of elevation.^12-14 Furthermore, some “kinking” of either femoral vessels at the hip or popliteal vessels at the knee may also occur.¹⁵

For prevention of these problems, the well leg can be placed in a position of slight hip extension and full knee extension on the fracture table—the so-called scissored position. This position is commonly achieved with an additional traction boot and support bar connected to the well leg. However, this additional setup can make positioning the C-arm machine difficult; there is obstruction by the additional support bars and the leg itself. In addition, the uninjured extremity may be placed into positions that cause unnecessarily high stresses across the joints and can potentially lead to iatrogenic injury and pain.

Risk of fracture in the well leg results from the C-arm machine abutting the well leg when swinging through to obtain a lateral image. This problem is overcome by securing the well leg to the fracture table’s longitudinal support bar using a pillow sling, thereby reducing the risks of compartment syndrome, allowing the uninjured limb to be in a relaxed position, and allowing good fluoroscopic images to easily be obtained. This brief report is an introduction to this positioning method.

Surgical Technique

The patient is intubated and anesthetized on the hospital bed before being transferred to the fracture table. On the fracture table, the operative leg is placed in a boot traction device in the standard fashion. The perineal post is then inserted, and the patient is pulled caudally on the bed so that the post is appropriately positioned for countertraction.

With an assistant holding the well leg, the distal flat-top table extension is removed. With a calf or foot sequential compression device still in place, a pillow enclosed in a pillowcase is wrapped around the lower leg and ankle in a U-shaped fashion using the longitudinal length of the pillow (Figure 1). The pillow-wrapped leg is then placed against the side (not the top) of the table’s support bar and secured in place using a 6-in self-adherent compression bandage (eg, Coban; 3M, St. Paul, Minnesota), wrapped circumferentially around both the pillow and the support post (Figures 2A, 2B). Although an Ace wrap may be more readily accessible, we have found it to slowly loosen and/or migrate, thus potentially changing the leg position throughout the case.

As shown in Figure 3, the C-arm machine can then be positioned in an oblique fashion relative to the bed with an unobstructed view of the hip. The C-arm can also be repositioned perpendicular to the injured limb, and unobstructed images can be obtained of the entire length of the femur. This quick and efficient setup of the well leg allows for an optimal amount of relaxed hip and knee extension, and limb adduction to midline along the table’s support bar, to permit lateral fluoroscopic imaging of the injured limb without overlap of the well leg or interference with C-arm positioning.

Results

For more than 2 years, Dr. Mir has used the pillow-sling technique for placement of the well leg in the scissored position on the fracture table in all patients. Between September 2010 and January 2013, he applied the technique 93 times, with the procedures listed as follows with their Current Procedural Terminology (CPT) codes: 14 cases of percutaneous fixation of femoral neck fracture (CPT 27235), 8 cases of treatment of intertrochanteric or subtrochanteric fracture with plate/screw type implant (CPT 27244), 34 cases of treatment of intertrochanteric or subtrochanteric fracture with intramedullary implant (CPT 27245), and 37 cases of treatment of femoral shaft fracture with intramedullary implant (CPT 27506).

With respect to compartment syndrome, there were no intraoperative or postoperative complications. Furthermore, no patients complained of pain in the well leg immediately after surgery or at subsequent follow-ups. No difficulty was encountered with intraoperative C-arm imaging of the injured limb at the hip or along the length of the femur in the lateral or anteroposterior planes. The well leg did not have to be repositioned in any cases to achieve adequate imaging of the hip and femur.

Discussion

Although rare, acute compartment syndrome remains a potential yet avoidable complication of the lithotomy position. Some surgeons avoid this setup of the well leg on the fracture table and instead use a scissored position for the uninjured limb.

In this report, we presented a safe and efficient technique for placing the well leg in a scissored position on the fracture table using a pillow and a self-adherent compression bandage. We did not compare the pillow-sling with other well-leg positioning techniques but instead described a reproducible technique that we have used effectively and successfully, even with multiple morbidly obese patients who met the weight limits for the fracture table.

In addition, even with consistent use of this pillow-sling technique at our high-volume trauma center, there have been no complications, such as compartment syndrome, well-leg pain, or difficulty in intraoperative imaging of the injured limb. The pillow-sling is a safe and expedient alternative technique for well-leg positioning on the fracture table, and it can be easily reproduced by other surgeons.

The development of acute compartment syndrome in lower legs placed in the lithotomy position is a rare complication reported within various surgical subspecialties, including general surgery, gynecology, and urology.^1-5 Although it is reported in arthroscopic knee cases, the more frequent occurrence in orthopedics, based on available case reports, appears to involve the well (uninjured or contralateral) leg placed in the hemilithotomy position on the fracture table.^6-9

Prior studies have found significantly elevated lower leg compartment pressures in legs placed in the lithotomy position. Chase and colleagues¹⁰ measured the anterior compartment pressures in 16 limbs placed in the lithotomy position. They found minor elevations after initial lithotomy positioning, but gradual increases over time, with an average elevation to 30 mm Hg and maximum of 70 mm Hg. Similarly, Meyer and colleagues¹¹ recorded the lower leg pressures in 8 healthy volunteers positioned on a fracture table. Changing from the supine position to the lithotomy position significantly increased the intramuscular pressure in the anterior compartment (from 11.6 to 19.4 mm Hg) and in the lateral compartment (from 13.0 to 25.8 mm Hg).

Along with increased intramuscular pressures, local hypotension occurs in lower legs placed in the lithotomy position. Mean diastolic blood pressure in the ankle was 63.9 mm Hg in the leg placed in the supine position as opposed to 34.6 mm Hg in the same leg placed in the lithotomy position.¹⁰ This finding is not unexpected, given that local arteriolar pressure decreases by 0.78 mm Hg for every 1.0 cm of elevation.^12-14 Furthermore, some “kinking” of either femoral vessels at the hip or popliteal vessels at the knee may also occur.¹⁵

For prevention of these problems, the well leg can be placed in a position of slight hip extension and full knee extension on the fracture table—the so-called scissored position. This position is commonly achieved with an additional traction boot and support bar connected to the well leg. However, this additional setup can make positioning the C-arm machine difficult; there is obstruction by the additional support bars and the leg itself. In addition, the uninjured extremity may be placed into positions that cause unnecessarily high stresses across the joints and can potentially lead to iatrogenic injury and pain.

Risk of fracture in the well leg results from the C-arm machine abutting the well leg when swinging through to obtain a lateral image. This problem is overcome by securing the well leg to the fracture table’s longitudinal support bar using a pillow sling, thereby reducing the risks of compartment syndrome, allowing the uninjured limb to be in a relaxed position, and allowing good fluoroscopic images to easily be obtained. This brief report is an introduction to this positioning method.

Surgical Technique

The patient is intubated and anesthetized on the hospital bed before being transferred to the fracture table. On the fracture table, the operative leg is placed in a boot traction device in the standard fashion. The perineal post is then inserted, and the patient is pulled caudally on the bed so that the post is appropriately positioned for countertraction.

With an assistant holding the well leg, the distal flat-top table extension is removed. With a calf or foot sequential compression device still in place, a pillow enclosed in a pillowcase is wrapped around the lower leg and ankle in a U-shaped fashion using the longitudinal length of the pillow (Figure 1). The pillow-wrapped leg is then placed against the side (not the top) of the table’s support bar and secured in place using a 6-in self-adherent compression bandage (eg, Coban; 3M, St. Paul, Minnesota), wrapped circumferentially around both the pillow and the support post (Figures 2A, 2B). Although an Ace wrap may be more readily accessible, we have found it to slowly loosen and/or migrate, thus potentially changing the leg position throughout the case.

As shown in Figure 3, the C-arm machine can then be positioned in an oblique fashion relative to the bed with an unobstructed view of the hip. The C-arm can also be repositioned perpendicular to the injured limb, and unobstructed images can be obtained of the entire length of the femur. This quick and efficient setup of the well leg allows for an optimal amount of relaxed hip and knee extension, and limb adduction to midline along the table’s support bar, to permit lateral fluoroscopic imaging of the injured limb without overlap of the well leg or interference with C-arm positioning.

Results

For more than 2 years, Dr. Mir has used the pillow-sling technique for placement of the well leg in the scissored position on the fracture table in all patients. Between September 2010 and January 2013, he applied the technique 93 times, with the procedures listed as follows with their Current Procedural Terminology (CPT) codes: 14 cases of percutaneous fixation of femoral neck fracture (CPT 27235), 8 cases of treatment of intertrochanteric or subtrochanteric fracture with plate/screw type implant (CPT 27244), 34 cases of treatment of intertrochanteric or subtrochanteric fracture with intramedullary implant (CPT 27245), and 37 cases of treatment of femoral shaft fracture with intramedullary implant (CPT 27506).

With respect to compartment syndrome, there were no intraoperative or postoperative complications. Furthermore, no patients complained of pain in the well leg immediately after surgery or at subsequent follow-ups. No difficulty was encountered with intraoperative C-arm imaging of the injured limb at the hip or along the length of the femur in the lateral or anteroposterior planes. The well leg did not have to be repositioned in any cases to achieve adequate imaging of the hip and femur.

Discussion

Although rare, acute compartment syndrome remains a potential yet avoidable complication of the lithotomy position. Some surgeons avoid this setup of the well leg on the fracture table and instead use a scissored position for the uninjured limb.

In this report, we presented a safe and efficient technique for placing the well leg in a scissored position on the fracture table using a pillow and a self-adherent compression bandage. We did not compare the pillow-sling with other well-leg positioning techniques but instead described a reproducible technique that we have used effectively and successfully, even with multiple morbidly obese patients who met the weight limits for the fracture table.

In addition, even with consistent use of this pillow-sling technique at our high-volume trauma center, there have been no complications, such as compartment syndrome, well-leg pain, or difficulty in intraoperative imaging of the injured limb. The pillow-sling is a safe and expedient alternative technique for well-leg positioning on the fracture table, and it can be easily reproduced by other surgeons.

The development of acute compartment syndrome in lower legs placed in the lithotomy position is a rare complication reported within various surgical subspecialties, including general surgery, gynecology, and urology.^1-5 Although it is reported in arthroscopic knee cases, the more frequent occurrence in orthopedics, based on available case reports, appears to involve the well (uninjured or contralateral) leg placed in the hemilithotomy position on the fracture table.^6-9

Prior studies have found significantly elevated lower leg compartment pressures in legs placed in the lithotomy position. Chase and colleagues¹⁰ measured the anterior compartment pressures in 16 limbs placed in the lithotomy position. They found minor elevations after initial lithotomy positioning, but gradual increases over time, with an average elevation to 30 mm Hg and maximum of 70 mm Hg. Similarly, Meyer and colleagues¹¹ recorded the lower leg pressures in 8 healthy volunteers positioned on a fracture table. Changing from the supine position to the lithotomy position significantly increased the intramuscular pressure in the anterior compartment (from 11.6 to 19.4 mm Hg) and in the lateral compartment (from 13.0 to 25.8 mm Hg).

Along with increased intramuscular pressures, local hypotension occurs in lower legs placed in the lithotomy position. Mean diastolic blood pressure in the ankle was 63.9 mm Hg in the leg placed in the supine position as opposed to 34.6 mm Hg in the same leg placed in the lithotomy position.¹⁰ This finding is not unexpected, given that local arteriolar pressure decreases by 0.78 mm Hg for every 1.0 cm of elevation.^12-14 Furthermore, some “kinking” of either femoral vessels at the hip or popliteal vessels at the knee may also occur.¹⁵

For prevention of these problems, the well leg can be placed in a position of slight hip extension and full knee extension on the fracture table—the so-called scissored position. This position is commonly achieved with an additional traction boot and support bar connected to the well leg. However, this additional setup can make positioning the C-arm machine difficult; there is obstruction by the additional support bars and the leg itself. In addition, the uninjured extremity may be placed into positions that cause unnecessarily high stresses across the joints and can potentially lead to iatrogenic injury and pain.

Risk of fracture in the well leg results from the C-arm machine abutting the well leg when swinging through to obtain a lateral image. This problem is overcome by securing the well leg to the fracture table’s longitudinal support bar using a pillow sling, thereby reducing the risks of compartment syndrome, allowing the uninjured limb to be in a relaxed position, and allowing good fluoroscopic images to easily be obtained. This brief report is an introduction to this positioning method.

Surgical Technique

The patient is intubated and anesthetized on the hospital bed before being transferred to the fracture table. On the fracture table, the operative leg is placed in a boot traction device in the standard fashion. The perineal post is then inserted, and the patient is pulled caudally on the bed so that the post is appropriately positioned for countertraction.

With an assistant holding the well leg, the distal flat-top table extension is removed. With a calf or foot sequential compression device still in place, a pillow enclosed in a pillowcase is wrapped around the lower leg and ankle in a U-shaped fashion using the longitudinal length of the pillow (Figure 1). The pillow-wrapped leg is then placed against the side (not the top) of the table’s support bar and secured in place using a 6-in self-adherent compression bandage (eg, Coban; 3M, St. Paul, Minnesota), wrapped circumferentially around both the pillow and the support post (Figures 2A, 2B). Although an Ace wrap may be more readily accessible, we have found it to slowly loosen and/or migrate, thus potentially changing the leg position throughout the case.

As shown in Figure 3, the C-arm machine can then be positioned in an oblique fashion relative to the bed with an unobstructed view of the hip. The C-arm can also be repositioned perpendicular to the injured limb, and unobstructed images can be obtained of the entire length of the femur. This quick and efficient setup of the well leg allows for an optimal amount of relaxed hip and knee extension, and limb adduction to midline along the table’s support bar, to permit lateral fluoroscopic imaging of the injured limb without overlap of the well leg or interference with C-arm positioning.

Results

For more than 2 years, Dr. Mir has used the pillow-sling technique for placement of the well leg in the scissored position on the fracture table in all patients. Between September 2010 and January 2013, he applied the technique 93 times, with the procedures listed as follows with their Current Procedural Terminology (CPT) codes: 14 cases of percutaneous fixation of femoral neck fracture (CPT 27235), 8 cases of treatment of intertrochanteric or subtrochanteric fracture with plate/screw type implant (CPT 27244), 34 cases of treatment of intertrochanteric or subtrochanteric fracture with intramedullary implant (CPT 27245), and 37 cases of treatment of femoral shaft fracture with intramedullary implant (CPT 27506).

With respect to compartment syndrome, there were no intraoperative or postoperative complications. Furthermore, no patients complained of pain in the well leg immediately after surgery or at subsequent follow-ups. No difficulty was encountered with intraoperative C-arm imaging of the injured limb at the hip or along the length of the femur in the lateral or anteroposterior planes. The well leg did not have to be repositioned in any cases to achieve adequate imaging of the hip and femur.

Discussion

Although rare, acute compartment syndrome remains a potential yet avoidable complication of the lithotomy position. Some surgeons avoid this setup of the well leg on the fracture table and instead use a scissored position for the uninjured limb.

In this report, we presented a safe and efficient technique for placing the well leg in a scissored position on the fracture table using a pillow and a self-adherent compression bandage. We did not compare the pillow-sling with other well-leg positioning techniques but instead described a reproducible technique that we have used effectively and successfully, even with multiple morbidly obese patients who met the weight limits for the fracture table.

In addition, even with consistent use of this pillow-sling technique at our high-volume trauma center, there have been no complications, such as compartment syndrome, well-leg pain, or difficulty in intraoperative imaging of the injured limb. The pillow-sling is a safe and expedient alternative technique for well-leg positioning on the fracture table, and it can be easily reproduced by other surgeons.