Proximal humeral fractures in Sweden-a registry-based study.

Proximal humeral fracture is the third most common osteoporotic fracture. To our knowledge, this is the first nationwide population-based registry study in adults that includes both inpatient and outpatient visits. Thus, we were able to report the true incidence rates and trends in the treatment of proximal humeral fractures. INTRODUCTION: Proximal humeral fractures are among the most common osteoporotic fractures. Valid epidemiologic population-based data, including both inpatient and outpatient visits, however, are lacking. METHODS: To investigate the Swedish national incidence rates and treatment trends of proximal humeral fractures, we obtained data from the Swedish Hospital Discharge Register between 2001 and 2012. All adult patients (≥18 years of age) in the Swedish Hospital Discharge Register were included. Outpatient visits have been included in the register since 2001. RESULTS: We identified 98,770 patients (women n = 72,063; 73 %) with proximal humeral fractures between 2001 and 2012. In 2001, the sex-specific incidence of proximal humeral fractures was 134.5 per 100,000 person-years for women and 49.2 for men. In 2012, the corresponding values were 174.6 for women and 68.1 for men, increasing 30 % in women and 39 % in men. A total of 17,013 surgical procedures were conducted between 2001 and 2012. Open reduction and internal fixation with a plate was the most common procedure (n = 5050, 30 %), followed by endoprosthetic implantation (n = 3962, 23 %) and intramedullary nailing (n = 3376, 20 %). The proportion of surgically treated patients increased from 12.1 % in 2001 to 16.8 % in 2012 for women and from 15.1 % in 2001 to 17.1 % in 2012 for men. CONCLUSION: The Swedish national incidence of proximal humeral fractures has been increasing, although it seems to have peaked in the elderly population during 2008-2010. The rate of surgical treatment has increased substantially, particularly open reduction and internal fixation with a plate. To our knowledge, this is the first nationwide epidemiologic study for Sweden reporting the incidence of proximal humeral fractures and including all inpatient and outpatient visits.

Functional and muscle morphometric effects of ACL reconstruction. A prospective CT study with 1 year follow-up.

Computed tomography (CT) was used to explore if changes in muscle cross-sectional area and quality after anterior cruciate ligament (ACL) injury and reconstruction would be related to knee function. Fourteen females and 23 males (16-54 years) underwent clinical tests, subjective questionnaires, and CT 1 week before and 1 year after ACL surgery with semitendinosus-gracilis (STG) graft and rehabilitation. Postoperatively, knee laxity was decreased and functional knee measures and subjective patient scores improved. The most obvious remaining deficit was the quadriceps atrophy, which was significantly larger if the right leg was injured. Right-leg injury also tended to cause larger compensatory hypertrophy of the combined knee flexor and tibial internal rotator muscles (preoperatively). The quadriceps atrophy was significantly correlated with the scores and functional tests, the latter also being related to the remaining size of the gracilis muscle. Biceps femoris hypertrophy and, in males only, semimembranosus hypertrophy was observed following the ACL reconstruction. The lack of semimembranosus hypertrophy in the women could, via tibial internal rotation torque deficit, contribute to the less favorable functional and subjective outcome recorded for the women. The results indicate that the quadriceps, the combined knee flexor/tibial internal rotator muscles, side of ACL injury, and sex are important to consider in rehabilitation after STG graft.

Mixed virtual reality simulation--taking endoscopic simulation one step further.

This pilot study aimed to assess medical students' appraisals of a "mixed" virtual reality simulation for endoscopic surgery (with a virtual patient case in addition to a virtual colonoscopy) as well as the impact of this simulation set-up on students' performance. Findings indicate that virtual patients can enhance contextualization of simulated endoscopy and thus facilitate an authentic learning environment, which is important in order to increase motivation.

Retention of knowledge after repeated virtual world CPR training in high school students.

We investigated the retention of knowledge and skills after repeated Virtual World MOS (VWMOS) team training of CPR in high school students. An experimental group of 9 students were compared to a control group of 7 students. Both groups initially received traditional CPR training and the experimental group also received 2 VWMOS sessions six months apart. Although we found no significant differences in general basic life support knowledge, the changes that occurred in the CPR guidelines were retained 18 months after the last Virtual World training session in the experimental group. Moreover fewer deviations from the CPR guidelines occurred.

Effects of repeated CPR training in virtual worlds on medical students' performance.

We report on a study that investigates the relationship between repeated training of teams managing a medical emergency (CPR) in a Virtual World and performance outcome measures in a group of 12 medical students. The focus of the training was on individual actions, but also on interaction and behavior in the team. Current CPR training seems to lack important team training aspects which this type of training is addressing. Although a pilot study, we found clear indications of improved performance related to reduced number of errors and an increased CPR efficiency. This type of educational technology could be expanded to other groups for a similar purpose because of its easiness to use, adaptability and interactivity.

Visual working memory influences the performance in virtual image-guided surgical intervention.

BACKGROUND: This study addresses for the first time the relationship between working memory and performance measures in image-guided instrument navigation with Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) and GI Mentor II (a simulator for gastroendoscopy). In light of recent research on simulator training, it is now prime time to ask why in a search for mechanisms rather than show repeatedly that conventional curriculum for simulation training has effect. METHODS: The participants in this study were 28 Swedish medical students taking their course in basic surgery. Visual and verbal working memory span scores were assessed by a validated computer program (RoboMemo) and correlated with visual-spatial ability (MRT-A test), total flow experience (flow scale), mental strain (Borg scale), and performance scores in manipulation and diathermy (MD) using Procedicus MIST-VR and GI Mentor 11 (exercises 1 and 3). RESULTS: Significant Pearson's r correlations were obtained between visual working memory span scores for visual data link (a RoboMemo exercise) and movement economy (r = -0.417; p < 0.05), total time (r = -0.495; p < 0.01), and total score (r = -0.390; p < 0.05) using MIST-MD, as well as total time (r = -0.493; p < 0.05) and efficiency of screening (r = 0.469; p < 0.05) using GI Mentor 11 (exercise 1). Correlations also were found between visual working memory span scores in rotating data link (another RoboMemo exercise) and both total time (r = -0.467; p < 0.05) and efficiency of screening (r = -0.436; p < 0.05) using GI Mentor 11 (exercise 3). Significant Pearson's r correlations also were found between visual-spatial ability scores and several performance scores for the MIST and GI Mentor II exercises. CONCLUSIONS: Findings for the first time demonstrate that visual working memory for surgical novices may be important for performance in virtual simulator training with two well-known and validated simulators.

Implementing virtual worlds for systematic training of prehospital CPR in medical school.

We report on a study that investigates the relationship between repeated training of teams managing medical emergencies in the Virtual World and affective learning outcomes in a group of 12 medical students. The focus of the training was on individual actions, but also on interaction and behaviour in the team. Current CPR training seems to lack important team training aspects which this type of training is addressing. We found an increase in flow experience and in self efficacy. This type of training could probably be expanded to other groups for a similar purpose because of its easiness to use, adaptability and interactivity.

Early exposure to haptic feedback enhances performance in surgical simulator training: a prospective randomized crossover study in surgical residents.

BACKGROUND: In the literature of skill acquisition and transfer of skills, it often is assumed that the rate of skill acquisition depends on what has been learned in a similar context (i.e., surgical simulators providing haptic feedback). This study aimed to analyze whether the addition of haptic feedback early in the training phase for image-guided surgical simulation improves performance. METHODS: A randomized crossover study design was used, in which 38 surgical residents were randomized to begin a 2-h simulator training session with either haptic or nonhaptic training followed by crossover after 1 h. The graphic context was a virtual upper abdomen. The residents performed two diathermy tasks. Two validated tests were used to control for differences in visual-spatial ability: the BasIQ general cognitive ability test and Mental Rotation Test A (MRT-A). RESULTS: After 2 h of training, the group that had started with haptic feedback performed the two diathermy tasks significantly better (p < 0.05, unpaired t-test). Only the group that had started with haptic training significantly improved during the last 1-h session (p < 0.01, paired t-test). CONCLUSION: The findings indicate that haptic feedback could be important in the early training phase of skill acquisition in image-guided surgical simulator training.

Objective assessment of visuospatial and psychomotor ability and flow of residents and senior endoscopists in simulated gastroscopy.

BACKGROUND: Advanced medical simulators have predominantly been used to shorten the learning curve of endoscopy for medical students and young residents. Rarely have the effects of visuospatial ability and attitudes of intermediately experienced and experienced specialists been studied with regard to simulator training. The aim of this study was to assess the effects of visuospatial ability and attitude on performance in simulator training. METHODS: Eighteen surgical residents were included in the study. Prior to the simulated gastroscopy task, they performed a visuospatial test (the card rotation test). After the simulated gastroscopy task, they completed a questionnaire regarding flow experiences. Their results were compared with those of 11 expert endoscopists who performed the same tests. RESULTS: Total gastroscopy time was significantly shorter for the expert endoscopists compared to residents (2 min 11 sec, p = 0.003). There was also a trend of more mucosa inspected (p = 0.088) and higher efficiency of screening (p = 0.069) by the experts. The residents made fewer errors in the card rotation test than the expert endoscopists (2.5 +/- 0.8 vs 5.5 +/- 1.2, respectively; p = 0.034), and their visuospatial card rotation test results correlated better with their performance in the simulated gastroscopy. CONCLUSIONS: A virtual gastroscopy task presents more of an emotional as well as a psychomotoric challenge to intermediately experienced endoscopists than to senior experts. Our study demonstrates that these differences can be objectively assessed by the use of visuospatial ability tests, flowsheets, and an endoscopic simulator.

High-level visual-spatial ability for novices correlates with performance in a visual-spatial complex surgical simulator task.

BACKGROUND: This study addresses how high-level visual-spatial ability of surgical novices is related to performance of two simulator tasks with (KSA) and without (MIST) anatomic graphics and haptic feedback, differing in visual-spatial complexity. METHODS: Visual-spatial test scores assessed by Mental Rotation Test (MRT) and BasIQ and performance scores for Instrument Navigation (IN) in Key Surgical Activities (Procedicus KSA) and Manipulate and Diathermy (MD) in Minimally Invasive Surgical Trainer (Procedicus MIST) were correlated for 54 Swedish surgical novices. RESULTS: Significant Pearson's r correlations were obtained between visual-spatial scores measured by MRT-C and total score from the last trial for IN (r = 0.278, p < 0.05). Visual-spatial scores (measured by BasIQ) also correlated with total score from the first trial (r = 0.443, p < 0.05) and from the last trial (r = 0.489, p < 0.05). CONCLUSION: High-level visual-spatial ability is important for surgical novices to possess in the early training phase of a visual-spatial complex task in KSA.

Training in tasks with different visual-spatial components does not improve virtual arthroscopy performance.

BACKGROUND: We earlier showed that training in the Procedicus KSA Simulator improves the performance of tasks done later in the same simulator. However, it is still unclear how performance in a specific visual-spatial simulator context may change after training in other simulators with different visual-spatial components. In particular, the aim of this study was to test whether performance in the Procedicus Virtual Arthroscopy (VA) Knee Simulator would remain unchanged after a training session in three other simulators with different visual-spatial components. METHODS: Twenty-eight medical students participated in a quasi-transfer study. They were randomly allocated to an experimental group ( n = 14) and a control group ( n = 14). RESULTS: Performance in the Procedicus VA Knee Simulator did not improve after training in other simulators with different visual-spatial components ( t-test p = NS). No significant correlation was found between the Procedicus VA Knee and the Minimally Invasive Surgical Trainer (MIST) simulators. CONCLUSION: One hour of training in different visual-spatial contexts was not enough to improve the performance in virtual arthroscopy tasks. It cannot be excluded, however, that experienced trainees could improve their performance, because perceived similarity between different situations is influenced by many psychological factors, such as the knowledge or expertise of the person performing the transfer task.

Validation and learning in the Procedicus KSA virtual reality surgical simulator.

BACKGROUND: Advanced simulator training within medicine is a rapidly growing field. Virtual reality simulators are being introduced as cost-saving educational tools, which also lead to increased patient safety. METHODS: Fifteen medical students were included in the study. For 10 medical students performance was monitored, before and after 1 h of training, in two endoscopic simulators (the Procedicus KSA with haptic feedback and anatomical graphics and the established MIST simulator without this haptic feedback and graphics). Five medical students performed 50 tests in the Procedicus KSA in order to analyze learning curves. One of these five medical students performed multiple training sessions during 2 weeks and performed more than 300 tests. RESULTS: There was a significant improvement after 1 h of training regarding time, movement economy, and total score. The results in the two simulators were highly correlated. CONCLUSION: Our results show that the use of surgical simulators as a pedagogical tool in medical student training is encouraging. It shows rapid learning curves and our suggestion is to introduce endoscopic simulator training in undergraduate medical education during the course in surgery when motivation is high and before the development of "negative stereotypes" and incorrect practices.

In vivo physiological changes in the synovial membrane of the knee during reperfusion after arthroscopy. A study using the microdialysis technique.

We have used in vivo microdialysis to monitor postoperative physiological events in the synovial membrane after arthroscopy. The levels of lactate were significantly higher in the synovial membrane than in the reference tissue (subcutaneous fat) and there was a significant increase in lactate after operation. Blood flow, measured as the ethanol ratio, was stable in both tissues. Our findings show that there was an increase in the local production of lactate since the levels of lactate in blood and the reference tissue were comparable and did not show a significant increase. There was also a consumption of glucose in the synovial membrane which was not observed in the reference tissue. The levels of pyruvate were higher in the synovial membrane. A state of reperfusion occurs in the synovial membrane after moderate trauma such as standard arthroscopy of the knee. Microdialysis should be further evaluated in studies of the in vivo physiology of the synovial membrane.

Local bone deformation at two predominant sites for stress fractures of the tibia: an in vivo study.

Local bone deformation was registered at two predominant injury sites for tibial stress fractures in a healthy female volunteer. Two instrumented strain gauge staples were inserted under local anesthesia to the anterior middiaphysis (AM) and to the posteromedial part of the distal tibia (PD). Calibration and reliability of the instrumented staple system have previously been demonstrated in vitro. Concomitant ground reaction forces were registered with a Kistler force plate. Studying peak values, it was shown that during a voluntary 30-cm forward jump, PD deformation was greater during forefoot landing (2700-4200 microstrain) than during a heel strike landing (1200-1900 microstrain) and also compared with the concomitant AM deformation under both above testing conditions (1300-1900 microstrain). The stance phase during walking resulted in PD deformation of 950 microstrain, whereas the concomitant AM deformation was 334 microstrain. The greatest AM deformation (mean, 2128 microstrain) was registered during ground contact after a voluntary vertical drop from a height of 45 cm, concomitant with a PD deformation of 436 microstrain. These data are the first to show different local deformations at various sites of the tibia in vivo. The PD deformation was larger than previously noted from other parts of the tibia, whereas the middiaphysis data are consistent with other reports. The results may support the clinical assumption of different etiologies for stress fractures at these predominant sites.

[Simulator training in medicine and health care. A new pedagogic model for good patient safety]. / Simulatorträning inom medicinsk verksamhet. Ny pedagogisk modell för god patientsäkerhet.

Advanced simulation within medicine and health care is a rapidly growing field. Simulator based training can be applied in minimal invasive surgery, in endoscopic procedures as well as in anaesthesia and critical care management. At Huddinge University Hospital a center for advanced simulation of both endoscopic surgery and anaesthesia/critical care management is currently being set up. The objective is to focus on improved medical and health care training and thus improving patient safety by reducing medical errors.

Hybrid simulation: bringing motivation to the art of teamwork training in the operating room.

BACKGROUND AND AIMS: Crew resource management-based operating room team training will be an evident part of future surgical training. Hybrid simulation in the operating room enables the opportunity for trainees to perform higher fidelity training of technical and non-technical skills in a realistic context. We focus on situational motivation and self-efficacy, two important factors for optimal learning in light of a prototype course for teams of residents in surgery and anesthesiology and nurses. MATERIAL AND METHODS: Authentic operating room teams consisting of residents in anesthesia (n = 2), anesthesia nurses (n = 3), residents in surgery (n = 2), and scrub nurses (n = 6) were, during a one-day course, exposed to four different scenarios. Their situational motivation was self-assessed (ranging from 1 = does not correspond at all to 7 = corresponds exactly) immediately after training, and their self-efficacy (graded from 1 to 7) before and after training. Training was performed in a mock-up operating theater equipped with a hybrid patient simulator (SimMan 3G; Laerdal) and a laparoscopic simulator (Lap Mentor Express; Simbionix). The functionality of the systematic hybrid procedure simulation scenario was evaluated by an exit questionnaire (graded from 1 = disagree entirely to 5 = agree completely). RESULTS AND CONCLUSIONS: The trainees were mostly intrinsically motivated, engaged for their own sake, and had a rather great degree of self-determination toward the training situation. Self-efficacy among the team members improved significantly from 4 to 6 (median). Overall evaluation showed very good result with a median grading of 5. We conclude that hybrid simulation is feasible and has the possibility to train an authentic operating team in order to improve individual motivation and confidence.

Reliability of radiological and cosmetic measurements in hallux valgus.

PURPOSE: To evaluate the reliability of angular, linear, and sesamoid position measurements on preoperative and postoperative radiographs in hallux valgus (HV), as well as cosmetic foot appearance. MATERIAL AND METHODS: Radiographs and photographs from 100 patients undergoing HV surgery were evaluated by two independent observers. RESULTS: Interobserver and intraobserver agreements for HV angle using coefficient of repeatability measures were 4.4 degrees and 3.7 degrees, respectively. Intraclass correlation coefficient measures within and between agreements were 0.97 for HV angle. For intermetatarsal distance, interobserver and intraobserver values were 0.90 and 0.94 when measuring from the midline of each metatarsal and 0.75 and 0.92 when measuring between cortices. Using the visual analog scale to evaluate esthetic appearance, interobserver and intraobserver agreements were 0.59 and 0.79, respectively. Sesamoid position values were also measured. Interobserver and intraobserver kappa values for preoperative and postoperative evaluations with two established methods (Mann or Smith) were 0.47 and 0.70 or 0.65 and 0.75, respectively. CONCLUSION: Intraobserver reliability was higher than interobserver for intermetatarsal distance, cosmetics, and sesamoid position. Angular measurements were more accurate than linear. Esthetic evaluation was less reliable than radiographic, except in the case of sesamoid position measurements.

Injury incidence and cause in elite gymnasts.

This report describes the incidence, localization, and cause of injuries in Swedish male and female elite gymnasts during 18 active months (three seasons). Thirty-one elite gymnast clubs with all together 437 gymnasts were included in the study, which consisted of a written questionnaire reporting morphometric facts as well as data concerning the injury. There were in total 82 injury reports. The injury incidence was 6.25 per 100 elite gymnasts and season. A majority of the injuries occurred in the lower extremities. The right leg was injured more often than the left. Most of the severe injuries occurred during mounting and dismounting which advocates the need for preventive measures in association with these particular events. Male gymnasts were more prone to sustain severer injuries such as dislocations and fractures. Severe injuries affected the upper extremity in 83%, and the right side was injured more often than the left.

Complications with infection and foreign body reaction after silicon implant arthroplasty in the second metatarsophalangeal joint in an adolescent: a case report.

A 21-year-old otherwise healthy male was referred to our clinic due to severe pain, deformation, development of fistules, and swelling of the second metatarsophalangeal joint of the right foot. He presented a history of two previous operations. At the age of 13, a 2-cm. resection of the distal part of the proximal phalanx was performed due to severe hammertoe deformity. At the age of 19, a partial phalanx resection and implantation of a silicon elastomer ball-shaped joint spacer was performed due to second metatarsophalangeal joint instability. After this operation, the patient suffered from fistules that appeared in the second metatarsophalangeal region. Following referral to our clinic, the patient was operated on. The proximal phalanx was removed along with the prosthesis which had slipped from the metatarsophalangeal joint into the proximal phalanx with the ends of the prosthesis perforating the skin. Debridement of infected tissue and implantation of gentamicin containing beads were performed. Bacterial specimens revealed growth of coagulase-negative staphylococci. Microscopic examination of the debrided tissue showed signs of acute and chronic inflammation. Postoperatively, the patient was treated with antibiotics and healing was uneventful. This case advocates the need for proper selection criteria and strict indications in patients with joint disease needing an arthroplasty.