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.

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.

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.

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.

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.

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.

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.

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.

ACL graft compression: a method to allow reduced tunnel sizes in ACL reconstruction.

PURPOSE: A common problem during ACL reconstruction is asymmetry of proximal-distal graft diameter leading to tunnel upsizing and graft-tunnel mismatch. Compression downsizing provides a graft of uniform size, allowing easy passage into a smaller tunnel. The purpose of this study was to quantify the graft compression technique and its effects on graft biomechanics and stability. It was hypothesised that compression downsizing would significantly reduce cross-sectional area (CSA); that no significant changes in graft biomechanics would occur; graft fixation stability would be improved. METHOD: Sixty-eight non-irradiated peroneus longus (PL) tendons were investigated. Twenty were halved and paired into ten four-strand grafts, 20 strands were compressed by 0.5-1 mm diameter and changes in CSA recorded using an alginate mould technique. The following properties were compared with 20 control strands: cyclic strain when loaded 70-220 N for 1000 cycles; stiffness; ultimate tensile load and stress; Young's modulus. 24 PL tendons were quadrupled into grafts, 12 were compressed and all 24 were submerged in Ringer's solution at 37 °C and the CSA recorded over 12 h. Twelve compressed and 12 control quadrupled grafts were mounted in porcine femurs, placed in Ringer's solution for 12 h at 37 °C and graft displacement at the bone tunnel aperture recorded under cyclic loading. RESULTS: Mean decreases in CSA of 31% under a stress of 471 kPa and 21% under a stress of 447 kPa were observed for doubled and quadrupled grafts, respectively. Compressed grafts re-expanded by 19% over 12 h compared to 2% for controls. No significant differences were observed between compressed and control grafts in the biomechanical properties and graft stability; mean cyclic displacements were 0.3 mm for both groups. CONCLUSIONS: No detrimental biomechanical effects of graft compression on allograft PL tendons were observed. Following compression, the grafts significantly increased in size during in vitro joint simulation. No significant difference was observed in graft stability between groups. Graft compression did not cause adverse mechanical effects in vitro. Smaller tunnels for compressed grafts reduce bone loss and ease anatomical placement.

Knee Arthroscopy: A Simulation Demonstrating the Imperial Knee Arthroscopy Cognitive Task Analysis (IKACTA) Tool.

BACKGROUND: Virtual reality and cadaveric simulations are expensive and not readily accessible1. Innovative and accessible training adjuncts are required to help meet training needs. Cognitive task analysis (CTA) has been used extensively to train pilots and surgeons in other surgical specialties2-6. However, the use of CTA tools within orthopaedics is in its infancy. Arthroscopic procedures are minimally invasive and require a different skill set compared with open surgery. Residents often feel poorly prepared to perform this in the operating room because of the steep learning curve associated with acquiring basic arthroscopic skills. We designed the Imperial Knee Arthroscopy Cognitive Task Analysis (IKACTA) tool, which is, to our knowledge, the first CTA tool described in the orthopaedic literature, demonstrating significant objective benefits in training novices to perform diagnostic knee arthroscopy. DESCRIPTION: The IKACTA tool, which is the combination of the written description of the phases below and the videos (with superimposed audio recordings) of each phase, utilizes simultaneous written and audiovisual modalities to teach diagnostic knee arthroscopy. The procedure was divided into 7 phases: (1) operating room and patient setup, (2) preparation and draping, (3) anterolateral portal placement, (4) examination of the patellofemoral joint and the lateral gutter, (5) examination of the medial compartment and anteromedial portal placement, (6) examination of the intercondylar notch and the lateral compartment, and (7) postoperative care and rehabilitation.For each phase, there are sections on the technical steps, cognitive decision-making behind each technical step, and potential errors and solutions. Video clips recorded by an expert surgeon in the operating room specific to each phase and audio voice recordings explaining each phase superimposed on the video clips were combined with the written information to design the IKACTA tool. ALTERNATIVES: Not applicable. RATIONALE: This learning tool allows a trainee to learn each technical step, the cognitive decision-making underpinning each step, and potential errors and solutions relevant to each phase of the procedure. Furthermore, the learner can use written and audiovisual modalities simultaneously to learn this technique by reading the written component of the tool first and then watching the relevant video clips with the audio recordings for each phase of the procedure. Alternative training techniques currently include the traditional apprenticeship model, which is becoming increasingly insufficient in the current environment of reduced training hours7,8. Adjuncts to this model are essential to help meet training needs. The IKACTA tool has demonstrated significant objective benefits for novice trainees to learn diagnostic knee arthroscopy9. The idea behind this learning tool is for the trainee surgeon to use this tool independent of the trainer, prior to attending the operating room. The tool provides trainees with knowledge and cognitive understanding of the procedural steps before they perform this procedure on patients. They are aware of potential errors and methods to avoid or overcome these errors. We believe that this tool will reduce the initial difficult phase of the learning curve for junior residents and, therefore, will improve training efficiency in the operating room.

Knee Arthroscopy Simulation: A Randomized Controlled Trial Evaluating the Effectiveness of the Imperial Knee Arthroscopy Cognitive Task Analysis (IKACTA) Tool.

BACKGROUND: Virtual-reality and cadaveric simulations are expensive and not readily accessible. Innovative and accessible training adjuncts are required to help to meet training needs. Cognitive task analysis has been used extensively to train pilots and in other surgical specialties. However, the use of cognitive task analyses within orthopaedics is in its infancy. The purpose of this study was to evaluate the effectiveness of a novel cognitive task analysis tool to train novice surgeons in diagnostic knee arthroscopy in high-fidelity, phantom-limb simulation. METHODS: Three expert knee surgeons were interviewed independently to generate a list of technical steps, decision points, and errors for diagnostic knee arthroscopy. A modified Delphi technique was used to generate the final cognitive task analysis. A video and a voiceover were recorded for each phase of this procedure. These were combined to produce the Imperial Knee Arthroscopy Cognitive Task Analysis (IKACTA) tool that utilizes written and audiovisual stimuli to describe each phase of a diagnostic knee arthroscopy. In this double-blinded, randomized controlled trial, a power calculation was performed prior to recruitment. Sixteen novice orthopaedic trainees who performed ≤10 diagnostic knee arthroscopies were randomized into 2 equal groups. The intervention group (IKACTA group) was given the IKACTA tool and the control group had no additional learning material. They were assessed objectively (validated Arthroscopic Surgical Skill Evaluation Tool [ASSET] global rating scale) on a high-fidelity, phantom-knee simulator. All participants, using the Likert rating scale, subjectively rated the tool. RESULTS: The mean ASSET score (and standard deviation) was 19.5 ± 3.7 points in the IKACTA group and 10.6 ± 2.3 points in the control group, resulting in an improvement of 8.9 points (95% confidence interval, 7.6 to 10.1 points; p = 0.002); the score was determined as 51.3% (19.5 of 38) for the IKACTA group, 27.9% (10.6 of 38) for the control group, and 23.4% (8.9 of 38) for the improvement. All participants agreed that the cognitive task analysis learning tool was a useful training adjunct to learning in the operating room. CONCLUSIONS: To our knowledge, this is the first cognitive task analysis in diagnostic knee arthroscopy that is user-friendly and inexpensive and has demonstrated significant benefits in training. CLINICAL RELEVANCE: The IKACTA will provide trainees with a demonstrably strong foundation in diagnostic knee arthroscopy that will flatten learning curves in both technical skills and decision-making.

Biomechanical comparison of graft structures in anterior cruciate ligament reconstruction.

PURPOSE: Double-bundle (DB) anterior cruciate ligament (ACL) reconstruction may offer kinematic restoration superior to anatomic single bundle (SB), but it remains technically challenging. The femoral attachment site has the most effect on ACL graft isometry, so a simplified three-socket (3S) construct which still uses two sockets to cover the femoral ACL attachment is attractive. It was hypothesised that ACL reconstruction using three- and four-socket techniques would more closely restore native knee kinematics compared to anatomic two-socket (SB) surgery. METHODS: Nine cadaveric knees were used to evaluate the kinematics of ACL-intact, ACL-deficient, anatomic SB, three-socket, and DB arthroscopic ACL reconstructions. Suspensory fixation was used, and grafts were tensioned to match the anterior draw of the intact knee at 20°. A six-degree-of-freedom robotic system measured knee laxity under 90 N anterior tibial force and rotational laxity under 5 N-m torque. Combined moments were applied to simulate the pivot-shift subluxation: 4 N-m internal rotation and 8 N-m valgus. RESULTS: Significant differences between reconstructions were not found during anterior tibial loading, apart from SB being more lax than DB at 60° flexion. All reconstructions produced comparable laxity to the intact state, apart from SB at 60°. Significant differences between reconstructions were not found at any flexion angle during tibial internal/external applied torques. Under combined loading, DB produced significantly less laxity than SB constructs apart from anterior tibial translation at 0° and internal rotation at 45°. 3S and DB were comparable to the native knee throughout. CONCLUSION: Although 3S restored laxities to a similar extent to DB, significant superiority over SB surgery was not observed. Although statistically significant differences were found between SB and DB surgery during anterior tibial and simulated pivot-shift loading, both remained similar to the native knee. The clinical relevance is that this study did not support an ACL graft construct more complex than an anatomic single bundle.

The Role of the Anterolateral Structures and the ACL in Controlling Laxity of the Intact and ACL-Deficient Knee.

BACKGROUND: Anterolateral rotatory instability (ALRI) may result from combined anterior cruciate ligament (ACL) and lateral extra-articular lesions, but the roles of the anterolateral structures remain controversial. PURPOSE: To determine the contribution of each anterolateral structure and the ACL in restraining simulated clinical laxity in both the intact and ACL-deficient knee. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 16 knees were tested using a 6 degrees of freedom robot with a universal force-moment sensor. The system automatically defined the path of unloaded flexion/extension. At different flexion angles, anterior-posterior, internal-external, and internal rotational laxity in response to a simulated pivot shift were tested. Eight ACL-intact and 8 ACL-deficient knees were tested. The kinematics of the intact/deficient knee was replayed after transecting/resecting each structure of interest; therefore, the decrease in force/torque reflected the contribution of the transected/resected structure in restraining laxity. Data were analyzed using repeated-measures analyses of variance and paired t tests. RESULTS: For anterior translation, the intact ACL was clearly the primary restraint. The iliotibial tract (ITT) resisted 31% ± 6% of the drawer force with the ACL cut at 30° of flexion; the anterolateral ligament (ALL) and anterolateral capsule resisted 4%. For internal rotation, the superficial layer of the ITT significantly restrained internal rotation at higher flexion angles: 56% ± 20% and 56% ± 16% at 90° for the ACL-intact and ACL-deficient groups, respectively. The deep layer of the ITT restrained internal rotation at lower flexion angles, with 26% ± 9% and 33% ± 12% at 30° for the ACL-intact and ACL-deficient groups, respectively. The other anterolateral structures provided no significant contribution. During the pivot-shift test, the ITT provided 72% ± 14% of the restraint at 45° for the ACL-deficient group. The ACL and other anterolateral structures made only a small contribution in restraining the pivot shift. CONCLUSION: The ALL and anterolateral capsule had a minor role in restraining internal rotation; the ITT was the primary restraint at 30° to 90° of flexion. CLINICAL RELEVANCE: The ITT showed large contributions in restraining anterior subluxation of the lateral tibial plateau and tibial internal rotation, which constitute pathological laxity in ALRI. In cases with ALRI, an ITT injury should be suspected and kept in mind if an extra-articular procedure is performed.