Abstract
Objective
Approximately 68% of orthopaedic surgeons report occupational related musculoskeletal pain, with back pain being the most common. Poor posture while operating has been proven to contribute to these high rates of musculoskeletal pain. There is little research regarding intraoperative surgeon posture within the field of hand and upper extremity surgery. This prospective study aims to investigate and analyze hand surgeon posture in the operating room.
Methods
Posture of three hand surgeons was recorded using the UPRIGHT GO posture tracking device while performing a prospective series of 223 hand and upper extremity surgeries. This device reports posture in terms of overall percentage of time spent slouched versus upright. For this cohort of 223 cases, data were collected including surgical procedure, whether the surgery was performed in a seated or standing position, whether or not loupes were worn during the procedure, and if the surgeon was the primary or assistant surgeon. These data were then analyzed to look for any contributing factors to poor posture.
Results
The three hand surgeons in this study spent an average of 40.3% of their time slouched while operating. The average percentage of time slouched was significantly greater with the use of loupes versus no loupes. Additionally, mean time slouching was slightly increased when the surgeon was seated and also when the surgeon was acting as the assistant surgeon.
Conclusion
The three orthopaedic hand surgeons in our study spent a significant portion of their operative time slouched. The main variable associated with a significant risk of poor surgical posture was wearing loupes. Slight increases in slouching were seen with operating while seated and as the assistant surgeon. Surgeon awareness of these variables, as well as techniques to improve surgeon posture, should be developed in order to help contribute to better surgeon posture within the field of hand surgery.
Keywords: back pain, hand surgery, neck pain, orthopaedics, posture
Introduction
It is well known that the field of hand surgery is quite demanding with regard to the physical challenges placed on surgeons. This subspecialty requires both mental and physical strength and endurance. Patient positioning, handling of power instruments, and the possibility of spending long hours in the operating room (OR) are all tasks that occur on a daily basis. Job requirements such as these make a hand surgeon’s occupation not only physically demanding but also can pose potential threats to the surgeon’s health and wellness. While these physical stressors are well known within the surgical community, one occupational hazard commonly overlooked that can affect all surgeons is work-related musculoskeletal injuries and pain. One meta-analysis of 5,152 surgeons found that 68% of these surgeons reported some type of occupational related muscular pain of the back, neck, and shoulders.1 Additionally, 71% of those surgeons reported job-related physical and mental fatigue.
One source of work-associated musculoskeletal pain in surgeons is related to posture in the operating suite. Hand surgeons commonly sit or stand in one static position while performing surgery, sometimes for hours, and often while they are leaning over the OR table. Several studies have shown that poor physician posture and constant neck flexion during surgery can contribute to high rates of musculoskeletal disorders in orthopaedic surgeons.2,3 The field of hand surgery is a surgical subspecialty where the surgeon is often positioned with their neck and back in a flexed position looking down toward the surgical field. This, combined with the fact that hand surgeons often perform a high volume of surgical cases, can often lead to posture-related musculoskeletal pain.
While the occupational hazard of poor surgeon posture has been recognized for quite some time,2,3 there have been few reported successful methods to objectively measure and analyze surgeon posture. In the past, photography, radiology, and three-dimensional motion analysis have all been attempted in order to examine surgeon posture; however, these modalities have had minimal efficacy.2 More recently, the UPRIGHT GO (UG) posture training device was invented to measure, record, and also help correct an individual’s posture.
To the best of our knowledge, there have been no studies that utilize and analyze data from a real-time posture tracking device such as the UG in the field of hand surgery. The purpose of this study was to evaluate posture-related data in a prospective cohort of upper extremity surgical cases and to use these data to investigate any potential risk factors that could lead to poor posture among hand surgeons. We hypothesized that the UG would demonstrate that hand surgeons would have poor posture for a significant time while operating as they are often seated with their heads flexed toward the operative field.
Materials and Methods
For a 6-month period between April and September 2020, 223 prospective surgical procedures were performed by three fellowship trained hand surgeons while wearing the UG posture training device. The level of expertise of these three hand surgeons is experienced specialists according to Tang and Giddins.4 The UG is a rechargeable device that is connected to a lanyard that is worn around the neck and uses Bluetooth technology to record and send posture-related measurements to any smart device it is synced with (Fig. 1). It can be used in the seated or standing position and can be used to either record data or correct posture if it is set to “correct mode” where it sends a warning vibration if the individual wearing it begins to slouch.
Fig. 1.
Photograph of the UPRIGHT GO posture device demonstrating device dimensions and associated magnetic lanyard.
The UG device was positioned at the same level for all three surgeons, which was at the cervicothoracic junction just below the seventh vertebral spinous process as recommended by the manufacturer (Fig. 2). Reusable adhesive backing on the device held it in place during surgery. The device was turned on by pushing a button on the UG by the circulating nurse after the time out for the surgical procedure was performed. The device was connected to a phone application via Bluetooth that recorded posture in terms of time slouched and time upright to the nearest minute. The UG was only used in record mode rather than correct mode and device settings were standardized for all surgeons and surgical cases. The threshold for slouching was set at 30 degrees of flexion from a neutral cervicothoracic spinal axis (setting “3” on the device) as recommended by the manufacturer as a midrange value. Posture data were recorded and analyzed to compare the average amount of time slouched versus time in the upright position during surgery.
Fig. 2.
Intraoperative photograph of a surgeon wearing the UPRIGHT GO posture device during surgery.
Three hand surgeons participated in this study, surgeons A, B, and C. Demographic data for these surgeons can be seen in Table 1. Surgeons A and B are hospital employed hand surgeons within the same group located in the same facility, and both of these surgeons perform procedures of the hand, elbow, and shoulder. Surgeon C is a hand surgeon in private practice at a separate facility and performs surgical procedures distal to the elbow.
Table 1.
Surgeon and case demographics
| Surgeon A |
Surgeon B |
Surgeon C |
|
|---|---|---|---|
| Total cases = 69 | Total cases = 104 | Total cases = 50 | |
| Surgical cases | Standing, n = 10 | Standing, n = 9 | Standing, n = 1 |
| Seated, n = 59 | Seated, n = 95 | Seated, n = 49 | |
| Primary, n = 63 | Primary surgeon, n = 93 | Primary surgeon, n = 50 | |
| Assistant, n = 6 | Assistant surgeon, n = 11 | Assistant surgeon, n = 0 | |
| Loupes, n = 61 | Loupes, n = 98 | Loupes, n = 48 | |
| No loupes, n = 8 | No loupes, n = 6 | No loupes, n = 2 | |
| Surgeon demographics | Age = 49 y | Age = 37 y | Age = 51 y |
| Height = 6.6 ft | Height = 6.1 ft | Height = 6.2 ft | |
| Weight = 209 lb | Weight = 165 lb | Weight = 245 lb | |
| BMI = 24.1 | BMI = 21.8 | BMI = 31.5 | |
| 9 y in practice | 5 y in practice | 16 y in practice |
Abbreviation: BMI, body mass index.
Institutional review board approval was obtained through our institution’s orthopaedics department and inclusion criteria included all hand and upper extremity surgical procedures, including shoulder and elbow surgeries, in patients over the age of 18 years. No patients in our consecutive, prospective cohort were excluded.
Univariate within-group means of the proportion of time in either the upright or slouched position were assessed for each surgeon. Independent variables such as whether the surgeon was seated or standing, the primary or assistant surgeon, or wearing loupes versus wearing a shield were recorded and analyzed. The averages were compared using independent t-tests, where applicable, and adjusted for heterogeneity of variance. Significance was set at an alpha level of p equal to 0.05 for all comparisons.
Results
Surgeon A performed a total of 69 cases. Surgeon A’s mean percentage time upright was 76% versus slouching 24%. On average, he spent less time slouched while seated versus standing (22 vs. 38%). Additionally, Surgeon A spent more time slouched when operating as the primary surgeon (25%) as opposed to the assistant surgeon (20%), and also in surgical cases where loupes were worn compared to cases when loupes were not worn (25 vs. 22%; Table 2).
Table 2.
Surgeon A
| Variable | Average % of time | p-Value |
|---|---|---|
| Time upright: all cases | 75.5 | < 0.0001 |
| Time slouched: all cases | 24.5 | |
| Time slouched: standing cases (n = 10) | 38.2 | 0.068 |
| Time slouched: seated cases (n = 59) | 22.2 | |
| Time slouched: primary surgeon (n = 63) | 25.0 | 0.65 |
| Time slouched: assistant surgeon (n = 6) | 20.0 | |
| Time slouched: loupes worn (n = 61) | 24.9 | 0.80 |
| Time slouched: loupes not worn (n = 8) | 22.4 |
Surgeon B performed 104 total cases. Surgeon B’s average percentage time upright was 41%, while his average time slouching was 59%. He slouched significantly less when seated versus standing (33 vs. 62%). His mean time slouched while operating as the primary surgeon was only slightly increased when compared to being the assistant surgeon (60 vs. 57%). Surgeon B also spent significantly more time slouched when wearing loupes (63%) versus not wearing loupes (8%; Table 3).
Table 3.
Surgeon B
| Variable | Average % of time | p-Value |
|---|---|---|
| Time upright: all cases | 40.5 | < 0.0001 |
| Time slouched: all cases | 59.5 | |
| Time slouched: standing cases (n = 9) | 33.4 | 0.015 |
| Time slouched: seated cases (n = 95) | 62.0 | |
| Time slouched: primary surgeon (n = 93) | 59.9 | 0.75 |
| Time slouched: assistant surgeon (n = 11) | 56.5 | |
| Time slouched: loupes worn (n = 98) | 62.7 | < 0.0001 |
| Time slouched: loupes not worn (n = 6) | 7.7 |
Surgeon C performed a total of 50 cases, and he was the primary surgeon for all 50 cases. Surgeon C’s overall mean percentage time upright was 78% versus slouching 22%. His average time slouched while standing or as an assistant surgeon was not analyzed as he performed only one case while standing and was the primary surgeon in all cases. Finally, although posture was analyzed for loupe usage, it was found to be insignificant because surgeon C performed all but two cases of his cases wearing loupes (Table 4).
Table 4.
Surgeon C
| Variable | Average % of time | p-Value |
|---|---|---|
| Time upright: all cases | 78.1 | < 0.0001 |
| Time slouched: all cases | 21.9 | |
| Time slouched: standing cases (n = 1) | 51.0 | – |
| Time slouched: seated cases (n = 49) | 21.3 | |
| Time slouched: primary surgeon (n = 50) | 21.9 | – |
| Time slouched: assistant surgeon (n = 0) | – | |
| Time slouched: loupes worn (n = 48) | 21.4 | 0.54 |
| Time slouched: loupes not worn (n = 2) | 34.0 |
Table 5 represents the pooled analysis of the 223 cases performed by surgeons A, B, and C. The surgeons were the primary surgeon for 206 cases and assistant surgeon for 17 cases. The majority of cases were performed seated compared to standing (203 vs. 20). Finally, these surgeons wore loupes for 207 cases and did not wear loupes for 16 cases. The average time spent upright for the three surgeons was 59.7 versus 40.3% slouched (p < 0.0001). The mean percentage time slouched while wearing loupes (42%) was significantly more when compared to cases where no loupes were worn (18%; p = 0.01). Between the three surgeons, they did spend more time slouched while seated compared to standing (41 vs. 37%) and also while operating as the assistant rather than the primary surgeon (44 vs. 40%), but neither of these comparisons reached statistical significance. A strong, negative correlation was noted between years in practice for the surgeons and average percent of time spent slouched (r = –0.82). However, correlation between the percentage of time spent slouched and the length of the surgical procedure was not appreciated (r = 0.03).
Table 5.
Pooled data of surgeons A, B, and C
| Variable | Average % of time | p-Value |
|---|---|---|
| Time upright: all cases | 59.7 | < 0.0001 |
| Time slouched: all cases | 40.3 | |
| Time slouched: standing cases (n = 20) | 36.7 | 0.63 |
| Time slouched: seated cases (n = 203) | 40.6 | |
| Time slouched: primary surgeon (n = 206) | 40.0 | 0.69 |
| Time slouched: assistant surgeon (n = 17) | 43.6 | |
| Time slouched: loupes worn (n = 207) | 42.0 | 0.01 |
| Time slouched: loupes not worn (n = 16) | 18.3 |
Discussion
Surgical specialties such as hand surgery can be physically demanding as there are several occupational hazards that exist for these surgeons including physical injury from instrumentation, fatigue, psychosocial stressors, and musculoskeletal injury from poor body mechanics and posture. The American Academy of Orthopaedic Surgeons (AAOS) has long recognized the importance of correct surgical posture for surgeons. In 1947, the AAOS formed a posture committee to define correct and incorrect posture in order to help educate its society members on posture mechanics.5 Although the importance of correct surgeon posture has been known for many years, there is a dearth of evidence-based publications related to the topic of measuring and analyzing surgeon posture. This study’s primary purpose was to utilize a real-time posture tracking device to obtain objective data on three different fellowship trained hand surgeons in order to analyze posture in the operating environment and to determine the risk factors that can negatively affect it.
As a group, we found that the three hand surgeons in our study spent a large amount of time operating in a slouched position (40.3%) rather than upright (59.7%), thus proving our hypothesis. Individually, surgeons A and C spent more time upright (74 and 78%, respectively) when compared to surgeon B (40%). It should be noted that surgeon B performed more total cases (104) when compared to surgeons A and C (69 and 50, respectively). This could represent surgeon fatigue for surgeon B as it is plausible that a surgeon’s upright posture throughout the day may suffer if they were to operate for longer periods of time. Interestingly, our study found no correlation between time slouched and the length of individual surgical cases; however, there may be some type of “additive” effect where fatigue and risk of poor posture increases as the total number of cases a surgeon performs in a day increases.
Another possible explanation for the difference in mean time upright between the three surgeons may be the variability that exists among hand surgeons and their posture. Some hand surgeons may be predisposed to poor posture and slouching, whereas others have established good posture habits with proper posture mechanics over the course of their training and career. Of note, the surgeons in the current study completed their residencies and hand fellowship training at different institutions, which may have contributed to these differences in operating habits and posture as different institutions and mentors may have had different influences on correct posture while operating. Interestingly, a strong, negative correlation was found between the number of years in practice and the average percent of time spent slouched while operating. This could indicate that correct posture and the importance of posture education may be more commonly appreciated and/or applied as a surgeon matures in their surgical practice.
Risk factors for increased slouching were not related to whether the surgeon was seated or standing, or if the surgeon was operating as the primary or assistant surgeon. The most significant factor associated with poor posture seen in this study was the use of surgical loupes. Pooled data seen in Table 5 show that of the 207 cases done while wearing loupes, these 3 surgeons slouched 42% of the times compared to an average of 18% of the time for all surgeries performed without wearing loupes. This can be explained by the flexed position of the neck and shoulders that commonly occurs while wearing loupes in order to maintain an optimal focal length and working distance to the surgical field while operating. Previous studies have shown that the use of surgical loupes increases the mean cervical load by 40% in all postures across all cervical levels.6,7 This problem is not unique to the field of hand surgery, and can be seen in other subspecialties that perform surgery with loupes. A survey of ophthalmic and plastic surgeons found that 73% reported neck and back pain with operating and 61% believed that the use of loupes during surgery can lead to spine problems.8 Similarly, a study of vascular surgeons found that the use of loupes significantly increased their ergonomic postural risk and was associated with higher levels of back pain during procedures.9
Because of the common knowledge among surgical specialties that poor surgical posture can lead to neck and back pain, there have been several attempts to address this occupational hazard. Resistance-based exercise programs and postural education videos have been developed to help surgeons strengthen their spine in order to understand proper posture.3,10,11 In addition, taking regular breaks while operating for long periods of time can also be helpful in relieving symptoms of neck or back pain.2,12 Surgical residency and fellowship programs represent potential opportunities to educate and promote healthier operative habits including better posture among surgeons. For example, one survey of orthopaedic surgery residents found that 59% reported neck pain and 55% reported low back pain at some point during their training.13 This same study showed that adopting ergonomic techniques and body positions at an early stage in a surgeon’s career may reduce future rates of musculoskeletal injury and improve career longevity.
This study showed that the UG, a real-time posture measuring device, can be utilized to collect and analyze the posture of hand surgeons. Implications of this study include not only analyzing real-time posture data by hand surgeons but also possibly using a posture measuring device to correct poor posture. The ease of use with the UG with regard to applying and wearing the device, and its integration with Bluetooth technology for recording data, makes it quite user friendly and can be worn with minimal disruption to a surgeon while operating. Also, because of its ease of us, we believe that this type of study could easily be replicable to other surgical specialties. Similarly, we believe this study can act as a guide for subsequent studies that critically assess posture improving interventions such as posture education training during medical school, residency, and surgical fellowships.
Limitations
One limitation of the current study is that the hand surgeons were required to knowingly apply and activate the device. This may have made them more aware of their posture and caused them to sit and stand more upright, thus instituting bias. Future studies can resolve this by having surgeons wear the device and then blind them as to whether or not the circulating nurse actually powered on their device prior to surgery.
Another limitation is the specific patient population that was utilized in our study. The majority of the surgeries performed were done on elective surgical patients. Trauma patients often will require more time to position and complete surgical procedures, which would increase the overall surgical time. Longer times could lead to fatigue and poor posture mechanics; however, it should be noted that within our cohort, we did not see a correlation between poor posture and length of surgical time per case.
Finally, while this study is successful in demonstrating the utility of this novel method for analyzing hand surgeon posture in the OR, the small sample size of three hand surgeons prevents the data from being generalized to the hand surgeon population. Future, larger-scale studies are warranted to obtain data from a greater population of surgeons across multiple specialties in order to assess applicability. Finally, although poor posture was analyzed, we did not evaluate the pain of each individual surgeon and how it relates to poor posture. This could have been measured by incorporating visual analog scales before and after surgeries while wearing the UG to look for a correlation between poor posture and pain for the surgeon wearing the device.
In conclusion, this is the first study to our knowledge to measure and analyze hand surgeon posture using an objective measuring device such as the UG. In our prospective series of 223 surgical procedures performed by three fellowship trained hand surgeons, we found that these surgeons exhibited poor posture for significant portions of their operative time. On average, they spent 40% of their time slouched and displayed poor posture mechanics. The main risk factor for poor posture was wearing loupes. While not statistically significant, slight increases in slouching were also seen with standing while operating, and operating as the primary surgeon. This study demonstrates the high potential of poor posture while operating as a hand surgeon and highlights the importance of education with regard to proper posture and ergonomic operating practices.
Acknowledgment
We thank Krista J. Howard, PhD, for assistance with statistical analysis.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Ethical Approval
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed consent was obtained from all patients for being included in the study.
Funding
None.
Conflict of Interest
None declared.
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