Evaluating the Impact of Supervision on Surgical Trainees Stress Response During Simulated Surgical Procedures; A Crossover Randomized Trial.

OBJECTIVE: The aim of this study was to evaluate the cumulative impact of supervision on technical skills and surrogate stress markers in surgical trainees. DESIGN: This was a quasi-experimental crossover study to evaluate the impact of attending supervision on orthopedic trainee stress response during a simulated surgical procedure. Enrolled residents performed a proximal femoral nail module with the Precision OS system twice; once independently, and once under direct attending supervision, whilst wearing a heart rate monitor. Mean and maximum heart rates were recorded. Simulated performance was assessed using validated simulator-based metrics. Student's t-test was used to evaluate the impact of supervision on trainee heart rate, and performance ranking. SETTING: Tertiary trauma center in a Regional Orthopedic Unit PARTICIPANTS: Orthopedic interns and residents within our institution were invited to participate, with 20 participants included for analysis. RESULTS: Both supervised and unsupervised mean heart rate was significantly higher (p = 0.001) than baseline recorded heart rates. Supervised mean and maximum HR were significantly higher than unsupervised HR during module completion (p = 0.015; p = 0.001). Calories burned demonstrated correlation to surrogate stress markers, significantly higher in supervised sessions (p = 0.004). Performance metrics demonstrated superior performance in senior-level participants, with a decrement in performance during supervision, failing to reach significance. CONCLUSION: The development of accretion of technical and non-technical skills required in surgical training pathways may derive benefit from the use of simulation-based training in surgical residents with both supervised and unsupervised sessions.

Recurrent anterior dislocation after the Latarjet procedure: outcome after revision using a modified Eden-Hybinette operation.

We assessed the results of the modified Eden-Hybinette operation as a salvage procedure after failure of an index Latarjet. Outcomes, complications, and evidence of arthritis of the glenohumeral joint were evaluated in 46 patients. Thirty-four (74%) were clinically and radiologically assessed at a mean of 6.8 years (range, 2-17 years). Good or excellent results were recorded in 27 of the 34 patients (79%). Four patients had another dislocation, and 2 became recurrent dislocators. One required an arthrodesis. Thirteen complained of a sensation of persistent apprehension. Twenty-three (68%) returned to their predislocation level of sport. Two gave up sports entirely. Radiographic evidence of arthritis was present in 6 (18%) before revision surgery. At final review, 10 (29%) had glenohumeral arthritis, graded as moderate or severe in 6 patients. Recurrence after an initial Latarjet procedure may be successfully treated by the modified Eden-Hybinette procedure. Patients may still experience a sensation of apprehension, but this does not appear to be clinically significant.

A novel lesion of the infraspinatus characterized by musculotendinous disruption, edema, and late fatty infiltration.

Isolated, atraumatic rupture of the infraspinatus (IS) with associated edema of its muscle is a previously undescribed lesion. We retrospectively identified 19 patients with MRI detected, isolated lesions of the IS tendon or musculotendinous junction with associated muscle edema. The average age at the time of presentation was 47.7 years (range, 30-66). There were 15 females and 4 males. Fourteen patients were treated nonoperatively; 5 underwent an open repair. All patients underwent clinical and MRI follow-up at an average of 50.3 months (range, 24-79) after the initial MRI. Constant scores were recorded as was a detailed physical examination. Two patients had a clear history of trauma with no preceeding shoulder problems; 17 had a history of chronic shoulder pain. We identified disruption occurring within the IS tendon in 9 patients and at the level of the musculotendinous junction in 8, while the level of disruption was inconclusive in 2. No patient had other full thickness tears. Electromyographic studies were normal, as were nerve conduction velocities in the suprascapular nerve in the 15 patients tested. There was a significant improvement in the Constant score comparing the score at presentation (53 points; range, 24-69) with the score at final follow-up (67.2 points; range, 28-95; P = .009). There was no significant benefit seen comparing the gain in the Constant score between those treated operatively and nonoperatively (P = .61). All 19 patients had progressed to stage 4 fatty infiltration of the IS muscle at latest follow-up.

Impaction allografting and the Kerboull acetabular reinforcement device: 35 hips followed for 3-7 years.

BACKGROUND: The incidence of acetabular loosening with segmental and cavitatory bone loss increases as the number of total hips implanted increases. Revision hip arthroplasty using impacted bone graft and an acetabular reinforcement device is one solution to this problem. PATIENTS AND METHODS: Clinically and radiographically, we assessed 35 hips in 33 patients who had undergone revision hip arthroplasty using impaction grafting and the Kerboull acetabular reinforcement device. Mean follow-up was 5 (3-7) years. RESULTS: The mean Mayo score preoperatively was 30, which improved to a mean score of 85. Good to excellent clinical results were seen in 25 patients. The 8 individuals scoring below 80 had significantly more co-morbid conditions than the others. No acetabular reconstruction required re-revision. Aseptic loosening occurred in 6 patients. Graft resorption occurred in 5 cases, resulting in inferior hook fracture of the Kerboull device. This was noted at a mean of 13 months after surgery. Further follow-up showed this to be non-progressive, with incorporation of the remaining graft to the host bone. These patients all had good to excellent Mayo hip scores. INTERPRETATION: Early results of revision acetabular surgery using impaction grafting and the Kerboull shell in patients with severe osteolysis have shown good functional outcome. However, 6 of 35 patients had radiographic evidence of aseptic loosening without progression for 4 years. Long-term follow-up is required to ensure that this loosening does not result in failure.