Vitamin D Deficiency Leads to Poorer Health Outcomes and Greater Length of Stay After Total Knee Arthroplasty and Supplementation Improves Outcomes: A Systematic Review and Meta-Analysis.

BACKGROUND: Vitamin D deficiency is increasingly identified as a predictor of poorer outcomes in musculoskeletal disease affecting as many as 1 in 4 people. This study aimed to evaluate the effect of vitamin D supplementation on outcomes after primary total knee arthroplasty (TKA). METHODS: A targeted search of terms related to vitamin D and TKA outcomes was performed in PubMed, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, American Academy of Orthopaedic Surgeons, and British Orthopaedic Association databases. The results were analyzed using forest plots with I2 heterogeneity statistics and pooled effects with 95% confidence intervals (CIs) and p values. A p < 0.05 was considered statistically significant. RESULTS: A total of 146,054 patients with 150,107 TKRs were analyzed in 10 studies that complied with the inclusion criteria, of which 3 were suitable for meta-analysis. Of these, 4 of the 10 studies showed that vitamin D deficiency resulted in poorer functional outcome scores (Western Ontario and McMasters Universities Osteoarthritis Index, Knee Society Scoring System, and American Knee Society scores), as well as increased risk of revision surgery, incidence of joint infection, and postoperative stiffness. Meta-analysis of length of hospital stay (LOS) demonstrated a significant increase in LOS in patients with vitamin D deficiency (standardized mean difference, -0.54, 95% CI, -0.69 to -0.38, p < 0.00001). Furthermore, outcomes were improved with vitamin D supplementation in 6 of 10 studies. CONCLUSION: Vitamin D deficiency results in poorer outcomes of primary TKA, with improved outcomes after supplementation. Further studies should examine the role of preoperative vitamin D screening and/or perioperative supplementation in primary TKA and standardize outcome measures to assess their effect. LEVEL OF EVIDENCE: Level I/II. See Instructions for Authors for a complete description of levels of evidence.

Artificial intelligence applied to magnetic resonance imaging reliably detects the presence, but not the location, of meniscus tears: a systematic review and meta-analysis.

OBJECTIVES: To review and compare the accuracy of convolutional neural networks (CNN) for the diagnosis of meniscal tears in the current literature and analyze the decision-making processes utilized by these CNN algorithms. MATERIALS AND METHODS: PubMed, MEDLINE, EMBASE, and Cochrane databases up to December 2022 were searched in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. Risk of analysis was used for all identified articles. Predictive performance values, including sensitivity and specificity, were extracted for quantitative analysis. The meta-analysis was divided between AI prediction models identifying the presence of meniscus tears and the location of meniscus tears. RESULTS: Eleven articles were included in the final review, with a total of 13,467 patients and 57,551 images. Heterogeneity was statistically significantly large for the sensitivity of the tear identification analysis (I2 = 79%). A higher level of accuracy was observed in identifying the presence of a meniscal tear over locating tears in specific regions of the meniscus (AUC, 0.939 vs 0.905). Pooled sensitivity and specificity were 0.87 (95% confidence interval (CI) 0.80-0.91) and 0.89 (95% CI 0.83-0.93) for meniscus tear identification and 0.88 (95% CI 0.82-0.91) and 0.84 (95% CI 0.81-0.85) for locating the tears. CONCLUSIONS: AI prediction models achieved favorable performance in the diagnosis, but not location, of meniscus tears. Further studies on the clinical utilities of deep learning should include standardized reporting, external validation, and full reports of the predictive performances of these models, with a view to localizing tears more accurately. CLINICAL RELEVANCE STATEMENT: Meniscus tears are hard to diagnose in the knee magnetic resonance images. AI prediction models may play an important role in improving the diagnostic accuracy of clinicians and radiologists. KEY POINTS: • Artificial intelligence (AI) provides great potential in improving the diagnosis of meniscus tears. • The pooled diagnostic performance for artificial intelligence (AI) in identifying meniscus tears was better (sensitivity 87%, specificity 89%) than locating the tears (sensitivity 88%, specificity 84%). • AI is good at confirming the diagnosis of meniscus tears, but future work is required to guide the management of the disease.

Scaffold-associated procedures are superior to microfracture in managing focal cartilage defects in the knee: A systematic review & meta-analysis.

BACKGROUND: Debate continues as to whether surgical treatment with chondral-regeneration devices is superior to microfracture for focal articular cartilage defects in the knee. PURPOSE: To evaluate the superiority of scaffold-associated chondral-regeneration procedures over microfracture by assessing: (1) Patient-reported outcomes; (2) Intervention failure; (3) Histological quality of cartilage repair. STUDY DESIGN: A three-concept keyword search strategy was designed, in accordance with PRISMA guidelines: (i) knee (ii) microfracture (iii) scaffold. Four databases (Ovid Medline, Embase, CINAHL and Scopus) were searched for comparative clinical trials (Level I-III evidence). Critical appraisal used two Cochrane tools: the Risk of Bias tool (RoB2) for randomized control trials and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I). Study heterogeneity permitted qualitative analysis with the exception of three patient-reported scores, for which a meta-analysis was performed. RESULTS: Twenty-one studies were identified (1699 patients, age range 18-66 years): ten randomized control trials and eleven non-randomized study interventions. Meta-analyses of the International Knee Documentation Committee (IKDC), Knee Injury And Osteoarthritis Outcome Score (KOOS) for pain and activities of daily living, and Lysholm score demonstrated statistically significant improvement in outcomes for scaffold procedures compared to microfracture at two years. No statistical difference was seen at five years. CONCLUSION: Despite the limitations of study heterogeneity, scaffold-associated procedures appear to be superior to MF in terms of patient-reported outcomes at two years though similar at five years. Future evaluation would benefit from studies using validated clinical scoring systems, reporting failure, adverse events and long-term clinical follow up to determine technique safety and superiority.

The effect of liquid-liquid extraction on metabolite detection and analysis using NMR spectroscopy in human synovial fluid.

The evaluation of joint disease using synovial fluid is an emerging field of metabolic profiling. The analysis is challenged by multiple macromolecules which can obscure the small molecule chemistry. The use of protein precipitation and extraction has been evaluated previously, but not in synovial fluid. We systematically review the published NMR spectroscopy methods of synovial fluid analysis and investigated the efficacy of three different protein precipitation techniques: methanol, acetonitrile and trichloroacetic acid. The trichloroacetic wash removed the most protein. However, metabolite recoveries were universally very poor. Acetonitrile liquid/liquid extraction gave metabolite gains from four unknown compounds with spectral peaks at δ = 1.91 ppm, 3.64 ppm, 3.95 ppm & 4.05 ppm. The metabolite recoveries for acetonitrile were between 1.5 and 7 times higher than the methanol method, across all classes of metabolite. The methanol method was more effective in removing protein as reported by the free GAG undefined peak (44 % vs 125 %). However, qualitative evaluation showed that acetonitrile and methanol provided good restoration of the spectra to baseline. The methanol extraction has issues of a gelatinous substrate in the samples. All metabolite recoveries had a CV of > 15 %. A recommendation of acetonitrile liquid/liquid extraction was made for human synovial fluid (HSF) analysis. This is due to consistency, effective protein precipitation, recovery of metabolites and additional compounds not previously visible.

Motivators and deterrents for early career female doctors applying to surgical training programmes in the UK National Health Service: a mixed-methods study.

OBJECTIVES: To perform a mixed-methods study identifying motivators and deterrents to female doctors interested in core surgical training (CST). To provide tangible implementations based on the findings. DESIGN: This study used quantitative (questionnaires) and qualitative (semistructured interviews (SSIs)) analyses. Participants completed online questionnaires on Qualtrics and SSIs were conducted remotely on Microsoft Teams. Questions were derived from previous studies and a novel term, the gender impact rating (GIR), was coined to assess the impact of gender on opportunities available during CST application. SETTING: Participants were working in the UK National Health Service and data collected from December 2020 to January 2021. PARTICIPANTS: A total of 100 female surgical trainees in the UK ranging from Foundation Year 2 to Core Training Year 2. MAIN OUTCOME MEASURES: Participants ranked factors by their influence on their CST application. Of the 100 trainees, 21 were randomly selected for an SSI to explore their questionnaire responses. Statistical analyses were performed using MATLAB and SPSS, alongside a thematic analysis of the interviews. RESULTS: A total of 44 out of 100 questionnaire respondents ranked early exposure to surgery as the most influential motivator, while 43% selected work-life balance as the greatest deterrent and 33% suggested mentoring schemes to encourage women to apply to CST. The median GIR was 3 out of 5, indicating a moderate perceived impact of gender on opportunities available during CST application. Qualitative analysis found four overarching themes: institutional factors (including mentorship schemes), organisational culture (including active engagement), social factors and personal factors. CONCLUSION: Thematic analysis suggested that seniors involving women in theatre and a supportive work environment would encourage entry of more female surgeons. Therefore, the proposed implementations are the active engagement of women in theatre and destigmatising less than full-time training. Further research into ethnicity and personality on motivations to enter surgery is advised.

Triple dislocation around the knee joint: a case report.

BACKGROUND: Dislocation of the knee is a serious and potentially limb-threatening injury. There are three types of dislocation around the knee joint: patellofemoral, tibiofemoral, and tibiofibular. Tibiofemoral dislocation is the variant that is deemed the most serious, with a higher risk of compromise to the popliteal artery and common peroneal nerve. Although simultaneous dislocations of two types have been described, there has been no such description of all three types occurring simultaneously. CASE PRESENTATION: We present a case of a 40-year-old hairdresser who suffered a fall off her moped in Spain, and simultaneously dislocated all three articulations around the knee. Diagnosis was achieved with clinical examination, plain films, and computed tomography and magnetic resonance imaging scans. Management consisted of initial surgical debridement and reduction with stabilization of the affected joints. CONCLUSION: Dislocation of the knee is an uncommon but life changing and potentially limb-threatening injury. It should always be suspected in trauma patients who present with multiligamentous knee injuries. The main concern is of neurovascular compromise to the lower leg, namely, the popliteal artery and common peroneal nerve. The treatment of multiligamentous knee injuries for most patients is surgical treatment with physiotherapy and adequate stabilization of the knee joint. Close monitoring of progress of the knee in terms of persistent laxity, range of movement, and functional status is required for at least 1-year post injury. Current evidence suggests that, despite good functional outcomes for knee dislocations in the short term, the prevalence of post-traumatic osteoarthritis is high in the long term.

Training Surgeons to Perform Arthroscopic All-Inside Meniscal Repair: A Randomized Controlled Trial Evaluating the Effectiveness of a Novel Cognitive Task Analysis Teaching Tool, Imperial College London/University College London Meniscus Repair Cognitive Task Analysis (IUMeRCTA).

BACKGROUND: All-inside meniscal repair is an increasingly common technique for the surgical treatment of meniscal tears. There are currently no standardized techniques for training residents in this procedure. Cognitive task analysis (CTA) is a method of analyzing and standardizing key steps in a procedure that allows training to be conducted in a validated and reproducible manner. PURPOSE: (1) To design a digital CTA teaching tool for a standardized all-inside meniscal repair. (2) To evaluate whether CTA-trained residents would perform better in a meniscal repair task compared with a control group who underwent traditional apprenticeship methods of training. STUDY DESIGN: Controlled laboratory study. METHODS: Three expert knee surgeons were interviewed using a modified Delphi method to generate a consensus among the ideal technical steps, cognitive decision points, and common errors and solutions for an all-inside meniscal repair. This written information was then combined with visual and audio components and integrated onto a digital platform to create the Imperial College London/University College London Meniscus Repair Cognitive Task Analysis (IUMeRCTA) tool. Eighteen novice residents were randomized into an intervention group (digital CTA tool) and control group (equipment instruction manual). Both groups performed an all-inside meniscal repair on high-fidelity, phantom knee models and were assessed by expert surgeons, blinded to the interventions, using a validated global rating scale (GRS). After a power calculation, median GRS scores were compared between groups using the Mann-Whitney U test; significance was set at P < .05. RESULTS: For the IUMeRCTA tool design, the procedure was divided into 55 steps across 9 phases: (1) preoperative planning, (2) theater and patient setup, (3) portal placement, (4) meniscal examination, (5) tear reduction, (6) suture planning, (7) suture insertion, (8) repair completion, and (9) postoperative care and rehabilitation. For the trial, the intervention group (mean ± SD GRS, 32 ± 2.9) performed significantly better than did the control group (GRS, 24 ± 3.3; P < .001). CONCLUSION: This is the first CTA tool to demonstrate objective benefits in training novices to perform an arthroscopic all-inside meniscal repair. CLINICAL RELEVANCE: The IUMeRCTA tool is an easily accessible and effective adjunct to traditional teaching that enhances learning the all-inside meniscal repair for novice surgeons.

Paediatric anterior cruciate ligament injury.

The number of paediatric anterior cruciate ligament injuries is rising at a greater rate than in the adult population, as a result of the increased participation of children and adolescents in sports. This review explores the key presentations, diagnostic and management plans, and prevention methods associated with paediatric anterior cruciate ligament injuries. This injury presents as an acute pop and effusion, with limitations in gait, and can be extremely debilitating. Clinical examination and magnetic resonance imaging are used to diagnose the injury. The pivot shift and Lachman test remain the most valid exams when suspecting an anterior cruciate ligament tear. Management of the injury can be surgical or non-surgical depending on the severity of the tear and associated injuries. The surgical approach chosen is determined by the patient's Tanner classification, considering potential damage to the physes of the bone. Management plans should include rehabilitation consisting of strength, proprioception and neuromuscular training, to maximise the patient's recovery. Injury prevention programmes, consisting of strength training and neuromuscular training, should be followed by young athletes to reduce anterior cruciate ligament injuries. Compliance and earlier implementation coupled with an understanding of the biomechanics of anterior cruciate ligament injuries and verbal feedback maximise the benefit of neuromuscular training.

Evaluating the effectiveness of the Imperial Femoral Intramedullary Nailing Cognitive Task Analysis (IFINCTA) tool in a real-time simulation setting (Distributed Interactive Simulation): a randomized controlled trial.

INTRODUCTION: Working time regulations, senior led service delivery and increasing complexity of surgical technology has led to significant strains in surgical training. Additionally, the current COVID-19 pandemic has placed substantial limitations on surgical training worldwide. Contact free, remote, web-based, validated learning tools which are easily accessible and allows repeated, sustained practice are the need of the hour. Cognitive Task Analysis (CTA) have been used extensively to train pilots and military personnel and has shown excellent early results within orthopaedic training. We designed a femoral nailing CTA tool which showed objective benefits in the enhancement of cognitive knowledge in medical students. The aim of this study was to evaluate the effectiveness of this CTA tool to enhance practical skills in orthopaedic trainees in a real time interactive simulation setting (Distributed Interactive Simulation (DIS)). METHODS: This was a double blinded, randomized controlled trial. 14 junior orthopaedic residents who met the inclusion criteria were recruited in the study. They were randomized into two equal groups. The intervention group were given the CTA learning tool, the control group were given a standard operative technique manual used for antegrade femoral intramedullary nailing. The participants were assessed on a high-fidelity phantom femur model with actual femoral nailing instruments in a simulation mobile operating theatre where the candidate had a simulation patient, an acting anesthetist and a scrub nurse (DIS). They were assessed using the modified Objective Structured Assessment of Technical Skills (OSATS) rating scale which has been validated for orthopaedic trauma. RESULTS: The median OSATS score in the intervention group was 49 (±4.93, range 39-55) compared to 17 in the control group (±14.98, range 12-51). The median improvement was by 32 points (p = 0.02). The ICC between the two raters was 0.977. CONCLUSIONS: This study has demonstrated objective benefits of a novel femoral nailing CTA tool in the enhancement of practical skills for junior trainees in the DIS setting. This adds to the growing evidence supporting the use of CTA in orthopaedic training. This tool can be accessed remotely, is contact free and allows repeated sustained practice which is key in simulation training.

The influence of sample collection, handling and low temperature storage upon NMR metabolic profiling analysis in human synovial fluid.

The impact of metabolism upon the altered pathology of joint disease is rapidly becoming recognized as an important area of study. Synovial joint fluid is an attractive and representative biofluid of joint disease. A systemic review revealed little evidence of the metabolic stability of synovial joint fluid collection, handling or storage, despite recent reports characterizing the metabolic phenotype in joint disease. We aim to report the changes in small molecule detection within human synovial fluid (HSF) using nuclear magnetic resonance (NMR) spectroscopy at varying storage temperatures, durations and conditions. HSF was harvested by arthrocentesis from patients with isolated monoarthropathy or undergoing joint replacement (n = 30). Short-term storage (0-12 h, 4°C & 18°C) and the effect of repeated freeze-thaw cycles (-80°C to 18°C) was assessed. Long-term storage was evaluated by early (-80°C, <21days) and late analysis (-80°C, 10-12 months). 1D NMR spectroscopy experiments, NOESYGPPR1D and CPMG identified metabolites and semi-quantification was performed. Samples demonstrated broad stability to freeze-thaw cycling and refrigeration of <4 h. Short-term room temperature or refrigerated storage showed significant variation in 2-ketoisovalerate, valine, dimethylamine, succinate, 2-hydroxybutyrate, and acetaminophen glucuronide. Lipid and macromolecule detection was variable. Long-term storage demonstrated significant changes in: acetate, acetoacetate, creatine, N,N-dimethylglycine, dimethylsulfone, 3-hydroxybutyrate and succinate. Changeable metabolites during short-term storage appeared to be energy-synthesis intermediates. Most metabolites were stable for the first four hours at room temperature or refrigeration, with notable exceptions. We therefore recommend that HSF samples should be kept refrigerated for no more than 4 hours prior to freezing at -80°C. Furthermore, storage of HSF samples for 10-12 months before analysis can affect the detection of selected metabolites.

Predictors of Pediatric Anterior Cruciate Ligament Injury: The Influence of Steep Lateral Posterior Tibial Slope and Its Relationship to the Lateral Meniscus.

PURPOSE: To examine the relationship between posterior tibial slope and lateral meniscal bone angle (LMBA) on anterior cruciate ligament (ACL) tear risk in a pediatric population. METHODS: In this case-control study, non-contact ACL-injured pediatric patients with no significant lateral meniscal lesions were matched by age and sex in a 1:1 ratio to a group of radiologically normal controls. Knee magnetic resonance imaging (MRI) studies were analyzed by 3 independent, blinded observers measuring the medial posterior tibial slope (MTS), lateral posterior tibial slope (LTS), and LMBA. Sagittal slope asymmetry was calculated as the absolute difference in degrees between slopes, and the relationship between LMBA and LTS was calculated as a ratio. Binary logistic regressions identified independent predictors of ACL injury. Receiver operator characteristics were performed to determine predictive accuracy. RESULTS: 20 study patients were compared with 20 sex- and age-matched controls (age 14.8 ± 2.42, mean ± standard deviation). LTS was significantly higher in the ACL-injured group (11.30° ± 3.52° versus 7.00° ± 2.63°, P = .0001), as were the absolute slope difference (7.10 ± 2.92° versus 3.14 ± 3.25°, P = .0002) and LTS:LMBA ratio (0.46 ± 0.17 versus 0.26 ± 0.12, P = .0001). No significant differences were observed for MTS or LMBA. Independent predictors were LTS (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.18 to 2.13, P = .002), LTS:LMBA ratio (OR 3.13, 95% CI 1.48 to 6.62, P = .003), and absolute slope difference (OR 1.65, 95% CI 1.17 to 2.32, P = .005). LTS:LMBA ratio was the strongest predictor variable (area under the curve 0.86). CONCLUSION: This study suggests that LTS, absolute slope difference, and LTS:LMBA ratio are significant pediatric ACL-injury risk factors. All 3 demonstrate good predictive accuracy; however, the relationship between steep LTS and shallow LMBA was the strongest predictor. LEVEL OF EVIDENCE: III, case-control study.

Differences between infected and noninfected synovial fluid.

AIMS: The diagnosis of joint infections is an inexact science using combinations of blood inflammatory markers and microscopy, culture, and sensitivity of synovial fluid (SF). There is potential for small molecule metabolites in infected SF to act as infection markers that could improve accuracy and speed of detection. The objective of this study was to use nuclear magnetic resonance (NMR) spectroscopy to identify small molecule differences between infected and noninfected human SF. METHODS: In all, 16 SF samples (eight infected native and prosthetic joints plus eight noninfected joints requiring arthroplasty for end-stage osteoarthritis) were collected from patients. NMR spectroscopy was used to analyze the metabolites present in each sample. Principal component analysis and univariate statistical analysis were undertaken to investigate metabolic differences between the two groups. RESULTS: A total of 16 metabolites were found in significantly different concentrations between the groups. Three were in higher relative concentrations (lipids, cholesterol, and N-acetylated molecules) and 13 in lower relative concentrations in the infected group (citrate, glycine, glycosaminoglycans, creatinine, histidine, lysine, formate, glucose, proline, valine, dimethylsulfone, mannose, and glutamine). CONCLUSION: Metabolites found in significantly greater concentrations in the infected cohort are markers of inflammation and infection. They play a role in lipid metabolism and the inflammatory response. Those found in significantly reduced concentrations were involved in carbohydrate metabolism, nucleoside metabolism, the glutamate metabolic pathway, increased oxidative stress in the diseased state, and reduced articular cartilage breakdown. This is the first study to demonstrate differences in the metabolic profile of infected and noninfected human SF, using a noninfected matched cohort, and may represent putative biomarkers that form the basis of new diagnostic tests for infected SF. Cite this article: Bone Joint Res 2021;10(1):85-95.

Development of a Virtual Three-Dimensional Assessment Scenario for Anatomical Education.

In anatomical education three-dimensional (3D) visualization technology allows for active and stereoscopic exploration of anatomy and can easily be adopted into medical curricula along with traditional 3D teaching methods. However, most often knowledge is still assessed with two-dimensional (2D) paper-and-pencil tests. To address the growing misalignment between learning and assessment, this viewpoint commentary highlights the development of a virtual 3D assessment scenario and perspectives from students and teachers on the use of this assessment tool: a 10-minute session of anatomical knowledge assessment with real-time interaction between assessor and examinee, both wearing a HoloLens and sharing the same stereoscopic 3D augmented reality model. Additionally, recommendations for future directions, including implementation, validation, logistic challenges, and cost-effectiveness, are provided. Continued collaboration between developers, researchers, teachers, and students is critical to advancing these processes.

Exploring elderly patients' experiences of recovery following complex proximal humerus fracture: A qualitative study.

This study explores the experiences and perceptions of recovery in elderly patients who had sustained a proximal humerus fracture. In-depth semi-structured interviews were conducted with 15 patients over the age of 65. Thematic analysis identified aspects of care that impacted upon patient experience and quality of life. Seven main patient-reported themes were identified, including pain, sleep, shoulder function, emotional state, social support, relationship with their professional and experience of healthcare institution. These themes offer insight into the experiences of adults receiving care for proximal humerus fracture and highlight that existing quantitative measures of quality of life do not measure domains that are important to patients.

Using Cognitive Task Analysis to train Orthopaedic Surgeons - Is it time to think differently? A systematic review.

BACKGROUND: Working time restraints; senior led care; and a reduction in 'out of hours' operating has resulted in less operating time for orthopaedic trainees in the United Kingdom. Therefore, there has been an attempt to overcome these challenges by implementing novel techniques. Cognitive Task Analysis (CTA) focuses on the mental steps required to complete complex procedures. It has been used in training athletes and in general surgery but is new to orthopaedic training. AIM: To undertake a systematic review to analyse if CTA is beneficial to train novice surgeons in common orthopaedic and trauma procedures. MATERIALS AND METHODS: A systematic review was performed evaluating CTA in trauma and orthopaedic surgery on MEDLINE and EMBASE. Search terms used were: 'Cognitive task', 'mental rehearsal' and 'Orthop*'']. 33 studies were originally identified. Duplicate studies were excluded (11). Articles not relating to Orthopaedic surgery were excluded (15). The CTA research ranking scale was used to evaluate the impact of the studies included. RESULTS: 7 studies were identified as appropriate for inclusion. 264 participants. 178 M, 86F. All studies showed objective or subjective benefits from CTA in orthopaedic training when compared to traditional methods. The majority of the participants highlighted high subjective satisfaction with the use of the CTA tools and reported that they proved to be excellent adjuncts to the traditional apprenticeship model. CONCLUSION: CTA learning tools have demonstrated significant objective and subjective benefits in trauma and orthopaedic training. It is cost effective, easily accessible and allows repeated practice which is key in simulation training.

Can joint fluid metabolic profiling (or "metabonomics") reveal biomarkers for osteoarthritis and inflammatory joint disease?: A systematic review.

AIMS: Metabolic profiling is a top-down method of analysis looking at metabolites, which are the intermediate or end products of various cellular pathways. Our primary objective was to perform a systematic review of the published literature to identify metabolites in human synovial fluid (HSF), which have been categorized by metabolic profiling techniques. A secondary objective was to identify any metabolites that may represent potential biomarkers of orthopaedic disease processes. METHODS: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines using the MEDLINE, Embase, PubMed, and Cochrane databases. Studies included were case series, case control series, and cohort studies looking specifically at HSF. RESULTS: The primary analysis, which pooled the results from 17 published studies and four meeting abstracts, identified over 200 metabolites. Seven of these studies (six published studies, one meeting abstract) had asymptomatic control groups and collectively suggested 26 putative biomarkers in osteoarthritis, inflammatory arthropathies, and trauma. These can broadly be categorized into amino acids plus related metabolites, fatty acids, ketones, and sugars. CONCLUSION: The role of metabolic profiling in orthopaedics is fast evolving with many metabolites already identified in a variety of pathologies. However, these results need to be interpreted with caution due to the presence of multiple confounding factors in many of the studies. Future research should include largescale epidemiological metabolic profiling studies incorporating various confounding factors with appropriate statistical analysis to account for multiple testing of the data.Cite this article: Bone Joint Res. 2020;9(3):108-119.

A Multicenter Randomized Controlled Trial Evaluating the Effectiveness of Cognitive Training for Anterior Approach Total Hip Arthroplasty.

BACKGROUND: For total hip arthroplasty (THA), cognitive training prior to performing real surgery may be an effective adjunct alongside simulation to shorten the learning curve. This study sought to create a cognitive training tool (CTT) to perform anterior approach (AA)-THA, which was validated by expert surgeons, and test its use as a training tool compared with conventional material. METHODS: We employed a modified Delphi method with 4 expert surgeons from 3 international centers of excellence. Surgeons were independently observed performing THA before undergoing semistructured cognitive task analysis (CTA) and before completing successive rounds of surveys until a consensus was reached. Thirty-six surgical residents (postgraduate year [PGY]-1 through PGY-4) were randomized to cognitive training or training with a standard operation manual with surgical videos before performing a simulated AA-THA. RESULTS: The consensus CTA defined THA in 11 phases, in which were embedded 46 basic steps, 36 decision points, and 42 critical errors and linked strategies. This CTA was mapped onto an open-access web-based CTT. Surgeons who prepared with the CTT performed a simulated THA 35% more quickly (time, mean 28 versus 38 minutes) with 69% fewer errors in instrument selection (mean 29 versus 49 instances), and required 92% fewer prompts (mean 13 versus 25 instances). They were more accurate in acetabular cup orientation (inclination error, mean 8° versus 10°; anteversion error, mean 14° versus 22°). CONCLUSIONS: This validated CTT for arthroplasty provides structure for competency-based learning. It is more effective at preparing orthopaedic trainees for a complex procedure than conventional materials, as well as for learning sequence, instrumentation utilization, and motor skills. CLINICAL RELEVANCE: Cognitive training combines education on decision-making, knowledge, and technical skill. It is an inexpensive technique to teach surgeons to perform hip arthroplasty and is more effective than current preparation methods.

The 'sentinel' vessel: an anatomical landmark to identify the pes anserinus during hamstrings harvest for ACL reconstruction.

Hamstrings identification and subsequent graft harvest can be made difficult by body habitus and variability in tendon anatomy. We describe a 'sentinel' blood vessel near the insertions of gracilis and semitendinosus to facilitate identification. A prospective study of 100 patients (100 knees) undergoing primary arthroscopic ACL reconstruction (via the anterior approach) with hamstrings graft was conducted. We searched for a 'sentinel' vessel and studied its position, orientation and perpendicular distance from the pes tendons. The 'sentinel' vessel was present in 98/100 knees. It passed from the superficial fascia to the periosteum at the pes insertion at a mean perpendicular distance of 8 mm from the upper border of the pes tendons. The 'sentinel' vessel was a consistent anatomical finding and served as a reliable guide in determining the pes insertion. Identifying this anatomical landmark allowed a small skin incision with limited wound dissection minimising risk of injury to the infra-patellar branch of the saphenous nerve.

Current concepts in the techniques, indications and outcomes of meniscal repairs.

Knee arthroscopy for meniscal tears is one of the most commonly performed orthopaedic procedures. In recent years, there has been an increasing incidence of meniscal repairs, as there are concerns that meniscectomy predisposes patients to early osteoarthritis. Indications for meniscal repair are increasing and can now be performed in older patients who are active, even if the tear is in the avascular zone. Options for meniscal tear management broadly fall into three categories: non-operative management, meniscal repair or meniscectomy. With limited evidence directly comparing each of these options optimal management strategies can be difficult. Decision making requires thorough assessment of patient factors (e.g. age and comorbidities) and tear characteristics (e.g. location and reducibility). The purpose of this paper is, therefore, to review the management options of meniscal tears and summarize the evidence for meniscal tear repair.

Trauma simulation training: a randomized controlled trial -evaluating the effectiveness of the Imperial Femoral Intramedullary Nailing Cognitive Task Analysis (IFINCTA) tool.

Background and purpose - Cognitive task analysis (CTA) has been used extensively to train pilots and in other surgical specialties. However, the use of CTA within orthopedics is in its infancy. We evaluated the effectiveness of a novel CTA tool to improve understanding of the procedural steps in antegrade femoral intramedullary nailing. Material and methods - Design: A modified Delphi technique was used to generate a CTA from 3 expert orthopedic trauma surgeons for antegrade femoral intramedullary nailing. The written and audiovisual information was combined to describe the technical steps, decision points, and errors for each phase of this procedure Validation: A randomized double-blind controlled trial was undertaken with 22 medical students (novices) randomized into 2 equal groups. The intervention group were given the CTA tool and the control group were given a standard operative technique manual. They were assessed using the validated "Touch Surgery™" application assessment tool on femoral intramedullary nailing. Results - The pre-test scores between the two groups were similar. However, the post-test scores were statistically significantly better in the intervention group compared with the control group. The improvement (post-test median scores) in the intervention group compared with the control group was 20% for patient positioning and preparation, 21% for femoral preparation, 10% for proximal locking, and 19% for distal locking respectively (p < 0.001 for all comparisons). Interpretation - This is the first multimedia CTA tool in femoral intramedullary nailing that is easily accessible, user-friendly, and has demonstrated significant benefits in training novices over the traditional use of operative technique manuals.