Stabilization of Recurrent Elbow Instability in the Presence of Hyperlaxity in Children Using a Nonanatomic Soft Tissue Reconstruction.

Despite growing concordance of opinion in the adult setting, pediatric elbow instability and its management are poorly represented in the literature due to its low prevalence and often unique circumstances. The authors present a case of posttraumatic recurrent posterior pediatric elbow instability in a patient with joint hypermobility. Our patient, a 9-year-old girl, sustained a right-sided supracondylar fracture of the humerus in April 2019. Having been managed operatively, the elbow remained unstable and dislocated posteriorly in extension. Definitive surgical management was designed to provide a stable functional elbow. The principle of the surgery was to create a checkrein of tissue, not changing in length in extension and flexion, and to prevent further posterior elbow instability. A 3 mm slip of the central triceps tendon was dissected, leaving its attachment to the olecranon tip. Gracilis allograft was sutured to the strip of the triceps tendon to increase the tensile properties of the native tendon graft using a braided nonabsorbable suture. The tendon construct was then passed through a window made in the olecranon fossa and a transosseous tunnel in the ulna from the coronoid tip to the dorsal cortex. The tendon was tensioned and secured to the radial-dorsal aspect of the ulna with a nonabsorbable suture anchor in 90 degrees of flexion. At one year follow-up, the patient has a stable and pain-free elbow joint with no functional limitations.

Is the Virtual Reality Fundamentals of Arthroscopic Surgery Training Program a Valid Platform for Resident Arthroscopy Training?

BACKGROUND: Training in arthroscopy is associated with a steep learning curve for trainees and bears risks for patients. Virtual reality (VR) arthroscopy simulation platforms seek to overcome this and to provide a safe environment for surgical learners. The Fundamentals of Arthroscopic Surgery Training (FAST) program is one such platform. It is currently not known whether the VR FAST program can be employed as a useful teaching or examination tool to assess the basic arthroscopic skills of surgical trainees. QUESTIONS/PURPOSES: (1) Does the VR FAST program differentiate among novice, intermediate, and expert arthroscopists? (2) Does ambidextrous performance in the VR FAST program correlate with arthroscopic experience? METHODS: We prospectively recruited orthopaedic interns (novices), residents (intermediates), and fellows and attendings (experts) to complete the VR FAST program over a 1-year period from four major orthopaedic training programs on a voluntary basis. Sixty-six of 156 invited orthopaedic surgeons participated: 26 of 50 novices (16 men and 10 women), 27 of 65 intermediates (20 men and seven women), and 13 of 41 experts (10 men and three women). Surgeons of any arthroscopic experience were included, with only those with prior experience on the VR FAST program being excluded. The program consists of eight modules: three basic camera modules (Image Centering, Horizon Control, and Telescoping), three advanced camera modules (Periscoping, Trace the Line, and Trace the Curve), and two instrumented bimanual-dexterity modules (Probe Triangulation and Gather the Stars). Time taken to complete each task and measures of economy of movement (camera and instrument path length, camera alignment) were used as measures of arthroscopic experience. Every participant completed the modules using their dominant and nondominant hands. Equality in proficiency in completing the tasks using the dominant and nondominant hands were determined to be measures of arthroscopic experience. Due to the large number of outcome variables, only p values < 0.01 were considered to be statistically significant. RESULTS: Six of eight VR FAST modules did not discriminate among novice, intermediate, and expert arthroscopy participants. However, two did, and the ones that were most effective at distinguishing participants by level of experience were the Periscoping and Gather the Stars modules. For the Periscoping module using the dominant hand, novices required longer to complete the task with a median time of 231 seconds (IQR 149 to 358) and longer camera path length median of 191 cm (IQR 128 to 273) compared with intermediates who needed 127 seconds (IQR 106 to 233) and 125 cm (IQR 92 to 159) and experts who needed 121 seconds (IQR 93 to 157) and 119 cm (IQR 90 to 134) (p = 0.001 and p = 0.003, respectively). When using the nondominant hand, novices took longer to complete the task with a median time of 231 seconds (IQR 170 to 350) and longer camera path length 204 cm (IQR 169 to 273) compared with intermediates who required 132 seconds (IQR 97 to 162) and 111 cm (IQR 88 to 143) and experts who needed 119 seconds (IQR 104 to 183) and 120 cm (IQR 108 to 166) (p < 0.001 and p < 0.001, respectively). For the Gather the Stars module using the nondominant hand, only the novices needed longer to complete the task at a median of 131 seconds (IQR 112 to 157) and needed a longer grasper path length of 290 cm (IQR 254 to 332) compared with intermediates who needed 84 seconds (IQR 72 to 119) and 232 cm (IQR 195 to 254) and experts who needed 98 seconds (IQR 87 to 107) and 244 cm (IQR 215 to 287) (p < 0.001 and p = 0.001, respectively). CONCLUSION: Six of eight VR FAST modules did not demonstrate construct validity, and we found no correlation between arthroscopic experience and ambidextrous performance. Two modules demonstrated construct validity; however, refinement and expansion of the modules is needed with further validation in large prospective trials so that pass-fail thresholds can be set for use in high-stakes examinations. CLINICAL RELEVANCE: Most VR FAST modules were not discriminatory; however, they can form essential conceptual and procedural building blocks in an arthroscopic curriculum that are beneficial for novices when developing key psychomotor skills. In their present format, however, they are unsuitable for assessing arthroscopic proficiency.

Finger abduction as a novel function of the extensor digitorum brevis manus muscle.

A 25-year-old female presented with a chronic scapho-lunate ligament injury with development of carpal instability requiring reconstruction. During a standard dorsal longitudinal mid-line approach to the carpus, an extensor digitorum brevis manus (EDBM) muscle was found taking its origin from the dorsal wrist capsule overlying the lunate with innervation from the posterior interosseous nerve (PIN). Electrical stimulation of the muscle belly demonstrated abduction of the middle finger. The EDBM is a rare anatomical variant of the extensor compartment of the wrist and may be encountered during surgical approaches. Where possible these variant muscles should be carefully dissected off underlying structures, preserved and repaired at the conclusion of a procedure to ensure no perceived functional deficit to the patient. We present a case of a previously undescribed EDBM muscle function of pure finger abduction with no extension and a surgical technique of preserving its origin. We propose that the middle finger variant of the EDBM should be re-named the extensor digitorum brevis medius to reflect our findings.

Transferable Global Rating Scales in the Validation of the ArthroSim™ Virtual Reality Arthroscopy Simulator.

INTRODUCTION: Virtual reality arthroscopic simulators are becoming increasingly prevalent in the orthopaedic training environment. The construct validity of the ArthroSim virtual reality simulator (TolTech Touch of Life Technologies, Aurora, Colorado) has been established based on time to completion comparison between candidates of differing levels of surgical experience. This study aims to establish the construct validity of the ArthroSim virtual reality simulator using validated global rating scales that allow direct comparison with intraoperative performance. MATERIALS AND METHODS: Eight novices (medical students), eight intermediates (registrars), and seven experts (consultants) were assessed using the Imperial Global Arthroscopy Rating Scale (IGARS) and the Arthroscopic Surgical Skills Evaluation Tool (ASSET) scoring systems while carrying out a standardised basic diagnostic knee arthroscopy using linked and anonymised recordings of both the arthroscopy video output and candidate's hand posture and position. Time to completion was recorded and the expert group also filled out questionnaires assessing the face and content validity of the simulator. RESULTS: The mean IGARS/ASSET scores for the novice, intermediate and expert groups were 14/11, 29/22, and 46/36 respectively. The difference in score between each of the groups was statistically significant (p<0.05). The average time to completion was 257 seconds, 305 seconds, and 204 seconds respectively. The time to completion was not significantly different between the groups (p=0.6). CONCLUSIONS: The ArthroSim virtual reality simulator could effectively distinguish between candidates of differing experience levels using validated global rating scales and therefore demonstrated construct validity.

Global Rating Scales for the Assessment of Arthroscopic Surgical Skills: A Systematic Review.

PURPOSE: To evaluate whether sufficient validity and reliability evidence exists to support the use of global rating scales (GRS) as evaluation tools in both formative assessment and competency assessment of arthroscopic procedures. METHODS: A search of PubMed, Embase, and Scopus was conducted for articles published between 1990 and 2018. Studies reporting measures of validity and reliability of GRS relating to arthroscopic skills were included. Procedural checklists and other assessment tools were excluded. RESULTS: A total of 39 articles met the inclusion criteria. In total, 7 de novo GRS specific for arthroscopic education and 3 pre-existing GRS repurposed 4 times for arthroscopic education were identified in the literature. The 11 GRS were used to assess 1175 surgeons 3890 times. Three GRS tools explicitly defined an arbitrary minimum competency threshold, 6 of 11 tools demonstrated construct validity-the ability to significantly discriminate between groups of differing experience-and 5 of 11 tools assessed inter-rater reliability, but only the Arthroscopic Surgical Skills Evaluation Tool demonstrated excellent inter-rater reliability. The Arthroscopic Surgical Skills Evaluation Tool was validated by 16 articles for a total of 537 surgeons for hip, knee, shoulder, and ankle arthroscopy in both simulated and clinical environments but was found to be invalid in wrist arthroscopy. The Basic Arthroscopic Knee Skill Scoring System was validated by 15 articles for a total of 497 surgeons for knee, hip, and shoulder in both clinical and simulated environments. The remaining 9 GRS were validated by 2 or fewer studies. CONCLUSIONS: Overall, GRS have contributed to training, feedback, and formative assessment practices. The GRS reviewed demonstrate both construct and concurrent validity as well as reliability in multiple arthroscopic procedures in multiple joints. Currently, there is sufficient evidence to use GRS as a feedback tool. However, there is insufficient evidence for its use in high-stakes examinations or as a minimum competency assessment. LEVEL OF EVIDENCE: Level III, systematic review of level I to III studies.

Biomechanical Study Comparing Cut-out Resistance of the X-Bolt® and Dynamic Hip Screw at Various Tip-Apex Distances.

BACKGROUND: Bone quality in hip fractures is poor and there is a need to not only correctly position metalwork within the femoral head, but also for implants to resist cut-out. New implant designs may help to reduce metalwork cut-out, leading to fewer failures of fixation. This study compared the cut-out strength of a Dynamic Hip Screw (DHS) to that of an X-Bolt® (X-Bolt Orthopaedics, Dublin, Ireland) implant in an osteoporotic Sawbones® (Sawbones, Vashon Island, WA) model. METHODS: An unstable fracture model (AO 31-A2) was created using low-density 5 pound per cubic foot (pcf) Sawbones®. The DHS and X-Bolts® were inserted into the Sawbones® femoral head at Tip-Apex Distances (TAD) of 10mm, 15mm, 20mm, 25mm, 30mm and 40mm. A cyclic-loading Instron® machine (Instron Corp., Norwood, MA) pushed the bone at a compression rate of 5mm per minute at a 20-degree angle to the axis of the implant with an upper force limit of 4000N. Maximum force reached and load to failure, defined as movement of the implant by 5mm, were recorded. Four implants were used per group to give a total of 48 tests between the two groups. RESULTS: The X-Bolt® demonstrated a superior average maximum total load push-out force compared to the DHS group for all of the TAD configurations tested. The maximum force reached in the X-Bolt® group was significantly higher than that in the DHS group at a TAD of 10mm (X-Bolt® 3299.25N vs. DHS 2843.75N, P<0.029) and 30mm (X-Bolt® 2908.25N vs. DHS 2030N, P<0.029). The X-Bolt® also had a higher load to failure than the DHS group at all of the TAD values tested. CONCLUSIONS: The X-Bolt® implant gave superior performance compared to the standard DHS, as reflected by a greater push-out force in an osteoporotic Sawbones® model.

Hemi-Hamate Autograft Arthroplasty for the Proximal Interphalangeal Joint Revisited: A New Surgical Approach.

The hemi-hamate arthroplasty for proximal interphalangeal joint (PIPJ) dorsal fracture dislocations relies on complete dislocation of the joint using the 'shotgun' approach which provides excellent exposure but damages the delicate intrinsic joint stabilisers. We present a new approach to the PIPJ when performing the hemi-hamate arthroplasty. The volar surgical approach involves freeing up the whole tendon sheath-periosteal unit as a single layer, and retracting this to one side. The articular surface of the joint can then be accessed with a little distraction and hyperextension. The method does not breach the tendon sheath, nor does it damage the collateral ligaments or volar plate. It is akin to the radical total anterior teno-arthrolysis (TATA) technique used for contracted joints, with some crucial differences. We postulate that the new approach causes far less iatrogenic damage and reduces the risk of contractures developing, and in chronic cases, allows concurrent joint release.

Syndesmosis preserving osteotomy of the fibula for access to the lateral talar dome.

BACKGROUND: Open surgical access to the postero-lateral talar dome for the treatment of osteochondral lesions is challenging, often requiring a segmental osteotomy of the fibula (fibular window) and division of the anterior inferior tibiofibular ligament (AITFL) or a fibular osteotomy with division of the AITFL and the anterior talofibular ligament (ATFL) (fibular door). Alternatively, to preserve the tibiofibular syndesmosis both the fibula and the lateral tibial plafond can be osteotomised to expose the entire lateral talar dome. All of these techniques involve extensive surgical exposures and a significant amount of internal fixation of the osteotomy to achieve surgical access. METHODS: A trapezoidal fibular osteotomy which hinges on the AITFL thus preserving the syndesmotic and lateral ligamentous complex was developed to permit perpendicular access to the lateral talar dome. The remaining posterior column of fibula allows keying in of the osteotomy requiring minimal internal fixation. RESULTS: A 43 year old male with a displaced osteochondral fracture of the superolateral talar dome underwent the osteotomy to provide perpendicular fixation with two Herbert's screws. The osteotomy was reduced and fixed with a single 3.5mm lag screw. At 3 month follow up the osteotomy had healed both clinically and radiographically. CONCLUSIONS: Our technique utilizes a novel trapezoidal fibular osteotomy with preservation of key syndesmotic and ligamentous structures and requires minimal internal fixation.

Severe destructive arthritis of the carpometacarpal joint: a diagnosis of exclusion case report.

We present a case of severe destruction of the thumb carpometacarpal joint (CMCJ) and surrounding structures on a background of osteoarthritis and Seronegative Rheumatoid arthritis. Imaging studies suggested a soft tissue lesion consistent with Pigmented Villonodular Synovitis (PVNS), Synovial Osteochondromatosis or Giant Cell Tumour (GCT). Due to the possibility of malignant transformation and deteriorating symptoms the mass was excised. Histological analysis of the lesion revealed severe degenerative disease with no evidence of malignancy or infection. This represents an atypical presentation of thumb carpometacarpal joint arthritis, which should be diagnosed once more sinister pathology has been excluded.

Plastic surgery and burns disasters. What impact do major civilian disasters have upon medicine? Bradford City Football Club stadium fire, 1985, King's Cross Underground fire, 1987, Piper Alpha offshore oil rig disaster, 1988.

Major disasters involving multiple casualties are neither new nor infrequent. Such events have important implications for medicine and can provide crucial lessons for the future. However, while the medical aspects of war have received considerable attention, rather less is known about civilian disasters. To redress this imbalance, this article reviews three major British disasters of the 1980s where serious burns injury was a significant feature of the human casualty: the Bradford City Football Club fire of 1985, the King's Cross Underground fire of 1987 and the Piper Alpha oil rig disaster of 1988. Four related themes are used to examine in detail the ways in which these events impacted on medicine: plastics and reconstructive surgery, clinical psychology, disaster management and long-term structural change. Drawing on articles in specialist burns and psychiatric journals, together with the personal communications and recollections of surgeons and psychiatrists involved, it is revealed that while ground-breaking advances are a relative rarity in medicine, numerous small but significant lessons did emerge from these events, although often in subtle and highly specialised fields of medicine.