A computerized bioskills system for surgical skills training in total knee replacement.

Although all agree that the results of total knee replacement (TKR) are primarily determined by surgical skill, there are few satisfactory alternatives to the 'apprenticeship' model of surgical training. A system capable of evaluating errors of instrument alignment in TKR has been developed and demonstrated. This system also makes it possible quantitatively to assess the source of errors in final component position and limb alignment. This study demonstrates the use of a computer-based system to analyse the surgical skills in TKR through detailed quantitative analysis of the technical accuracy of each step of the procedure. Twelve surgeons implanted a posterior-stabilized TKR in 12 fresh cadavers using the same set of surgical instruments. During each procedure, the position and orientation of the femur, tibia, each surgical instrument, and the trial components were measured with an infrared coordinate measurement system. Through analysis of these data, the sources and relative magnitudes of errors in position and alignment of each instrument were determined, as well as its contribution to the final limb alignment, component positioning and ligament balance. Perfect balancing of the flexion and extension gaps was uncommon (0/15). Under standardized loading, the opening of the joint laterally exceeded the opening medially by an average of approximately 4 mm in both extension (4.1 +/- 2.1 mm) and flexion (3.8 +/- 3.4 mm). In addition, the overall separation of the femur and the tibia was greater in flexion than extension by an average of 4.6 mm. The most significant errors occurred in locating the anterior/posterior position of the entry point in the distal femur (SD = 8.4 mm) and the correct rotational alignment of the tibial tray (SD = 13.2 degrees). On a case-by-case basis, the relative contributions of errors in individual instrument alignments to the final limb alignment and soft tissue balancing were identified. The results indicate that discrete steps in the surgical procedure make the largest contributions to the ultimate alignment and laxity of the prosthetic knee. Utilization of this method of analysis and feedback in orthopaedic training is expected rapidly to enhance surgical skills without the risks of patient exposure.

Brief report: validation of a system for automated measurement of knee laxity.

OBJECTIVE: To determine the accuracy and repeatability of an automated quantitative fluoroscopic imaging system for measuring knee laxity. DESIGN: Cadaveric validation study. BACKGROUND: Current methods of measuring anterior-posterior laxity lack sufficient accuracy and repeatability. A commercially developed fluoroscopic software package, capable of measuring laxity, required validation. METHODS: Five human cadaveric knees were used. A constant force of 130 N was applied anteriorly and posteriorly in turn to the tibia of each knee with the femur fixed in 30 degrees and 90 degrees of flexion. Quantitative fluoroscopic measurements of anterior-posterior laxity were determined using image analysis software. Fluoroscopic results were compared to the true anterior-posterior displacements of the tibia, which were simultaneously recorded using linear transducers directly attached to the cadaveric specimens. RESULTS: The quantitative fluoroscopic method underestimated laxity by an average of 0.40 mm with a root mean square error of 0.49 mm. The 95% confidence intervals for anterior and posterior laxity error were calculated to be -0.99 to 0.25 mm and -0.89 to 0.03 mm, respectively, where a negative error represents an underestimation. CONCLUSIONS: The quantitative fluoroscopic method offers a dramatic improvement in accuracy over current laxity measurement techniques and acceptable repeatability for assessing ligament damage. RELEVANCE: The considerably more accurate, validated measurement system of this study could improve ligament assessment and diagnosis, and the recognition of injuries otherwise undetected with current methods.

Central representation of time during motor learning.

This study stemmed from the observation that the brain of human as well as nonhuman primates is capable of forming and memorizing remarkably accurate internal representations of the dynamics of the arm. These dynamics establish a functional relation between applied force and ensuing arm motion, a relation that generally is quite complex and nonlinear. Current evidence shows that the motor control system is capable of adapting to perturbing forces that depend on motion variables such as position, velocity, and acceleration. The experiments we report here were aimed at establishing whether or not the motor system also may adapt to forces that depend explicitly on time rather than on motion variables. Surprisingly, the experiments suggest a negative answer. When asked to compensate for a predictable and repeated time-varying pattern of disturbing forces, subjects learned to counteract the disturbance by producing forces that did not depend on time but on the velocity and the position of the arm. We conclude from this evidence that time and time-dependent dynamics are not explicitly represented within the neural structures that are responsible for motor adaptation. Although our findings are not sufficient to rule out the presence of a timing structure within the central nervous system, they are consistent with other investigations that conspicuously failed to find evidence for such a central clock.

The motor system does not learn the dynamics of the arm by rote memorization of past experience.

The purpose of this study was to investigate the learning mechanisms underlying motor adaptation of arm movements to externally applied perturbing forces. We considered two alternative hypotheses. According to one, adaptation occurs through the learning of a mapping between the states (positions and velocities) visited by the arm and the forces experienced at those states. The alternative hypothesis is that adaptation occurs through the memorization of the temporal sequence of forces experienced along specific trajectories. The first mechanism corresponds to developing a model of the dynamics of the environment, whereas the second is a form of "rote learning." Both types of learning would lead to the recovery of the unperturbed performance. We have tested these hypotheses by examining how adaptation is transferred across different types of movements. Our results indicate that 1) adaptation to an externally applied force field occurs with different classes of movements including but not limited to reaching movements and 2) adaptation generalizes across different movements that visit the same regions of the external field. These findings are not compatible with the hypothesis of rote learning. Instead, they are consistent with the hypothesis that adaptation to changes in movement dynamics is achieved by a module that learns to reproduce the structure of the environmental field as an association between visited states and experienced forces, independent of the kinematics of the movements made during adaptation.

Interactive effects of tunnel dilation on the mechanical properties of hamstring grafts fixed in the tibia with interference screws.

The effect of dilation of the tibial tunnel on the strength of hamstring graft fixation using interference screws was evaluated. In all, 28 RCI screws were tested in male human tibia-hamstring constructs with tibial tunnels reamed or dilated to the respective size of the graft diameter. Dilation of the tibial tunnel failed to significantly enhance hamstring fixation. Grafts secured in dilated tunnels displayed an 11% greater resistance to the initiation of graft slippage (174+/-112 N) compared to their undilated controls (156+/-77 N, P=0.63). Dilation of the tibial tunnel increased the failure load by an average of 4%, independent of screw diameter (dilated specimens: 360+/-120 N, controls: 345+/-88 N, P=0.74). Biomechanical research on the effect of tibial tunnel dilation in hamstring fixation has not provided satisfactory evidence as to the benefits of this additional surgical step during anterior cruciate ligament (ACL) reconstruction.

Persistence of motor adaptation during constrained, multi-joint, arm movements.

We studied the stability of changes in motor performance associated with adaptation to a novel dynamic environment during goal-directed movements of the dominant arm. Eleven normal, human subjects made targeted reaching movements in the horizontal plane while holding the handle of a two-joint robotic manipulator. This robot was programmed to generate a novel viscous force field that perturbed the limb perpendicular to the desired direction of movement. Following adaptation to this force field, we sought to determine the relative role of kinematic errors and dynamic criteria in promoting recovery from the adapted state. In particular, we compared kinematic and dynamic measures of performance when kinematic errors were allowed to occur after removal of the viscous fields, or prevented by imposing a simulated, mechanical "channel" on movements. Hand forces recorded at the handle revealed that when kinematic errors were prevented from occurring by the application of the channel, recovery from adaptation to the novel field was much slower compared with when kinematic aftereffects were allowed to take place. In particular, when kinematic errors were prevented, subjects persisted in generating large forces that were unnecessary to generate an accurate reach. The magnitude of these forces decreased slowly over time, at a much slower rate than when subjects were allowed to make kinematic errors. This finding provides strong experimental evidence that both kinematic and dynamic criteria influence motor adaptation, and that kinematic-dependent factors play a dominant role in the rapid loss of adaptation after restoring the original dynamics.