Comparison of visibility in needle arthroscopy of the ankle according to surgical experience: A cadaveric study.

BACKGROUND: Literature regarding the feasibility of inexperienced surgeons using needle arthroscopy is limited. The present study aimed to clarify the feasibility of performing ankle needle arthroscopy for inexperienced surgeons. METHODS: Diagnostic needle arthroscopy was performed for 10 cadaveric ankles by two surgeons with different levels of experience in ankle arthroscopy (inexperienced and expert surgeons). The visibility of arthroscopy was assessed based on a 15-point checklist and compared between surgeons. In addition, iatrogenic articular cartilage injury created by the inexperienced surgeon was investigated. RESULTS: The number of visible points was significantly larger for the expert surgeon than for the inexperienced surgeon (14.1 ± 1.0 vs. 13.7 ± 1.0, P = 0.035). The location of cartilage injury was greatest on the medial talar dome when viewing from the anteromedial portal at a rate of 30%. CONCLUSION: Ankle needle arthroscopy may be an option for surgeons in the future, however, differences in surgeon experience may impact effective visualization.

Inconsistent radiographic diagnostic criteria for lisfranc injuries: a systematic review.

PURPOSE: To evaluate the radiographic diagnostic criteria and propose standardised radiographic criteria for Lisfranc injuries. METHODS: A systematic review of the PubMed and Embase databases was performed according to the PRISMA guidelines. The various radiographic criteria for the diagnosis of Lisfranc injuries were extracted. Descriptive statistics were presented for all continuous (as mean ± standard deviation) and categorical variables (as frequencies by percentages). RESULTS: The literature search included 29 studies that totalled 1115 Lisfranc injuries. The risk of bias ranged from "Low" to "Moderate" risk according to the ROBINS-I tool. The overall recommendations according to the GRADE assessment ranged from "Very Low" to "High". 1st metatarsal to 2nd metatarsal diastasis was the most common of the 12 various radiographic diagnostic criteria observed, as was employed in 18 studies. This was followed by 2nd cuneiform to 2nd metatarsal subluxation, as was employed in 11 studies. CONCLUSION: The radiographic diagnostic criteria of Lisfranc injuries were heterogeneous. The proposition for homogenous radiographic diagnostic criteria is that the following features must be observed for the diagnosis of Lisfranc injuries: 1st metatarsal to 2nd metatarsal diastasis of ≥ 2 mm on anteroposterior view or 2nd cuneiform to 2nd metatarsal subluxation on anteroposterior or oblique views. Further advanced imaging by CT or MRI may be required in patients with normal radiographs but with continued suspicion for Lisfranc injuries. LEVEL OF EVIDENCE: 4, systematic review.

Validity of a simple footprint assessment board for diagnosing the severity of flatfoot: a prospective cohort study.

BACKGROUND: A simple, non-quantitative, and cost-effective diagnostic tool would enable the diagnosis of flatfoot without need for specialized training. A simple footprint assessment board that investigates which toe the cord passes through from the centre point of the heel to the most lateral point of the medial contour of the footprint has been developed to assess flatfoot. The purpose of this study was to verify the validity of a simple footprint assessment board for flatfoot. METHODS: Thirty-five consecutive patients with foot pain, foot injury, or any associated symptoms who underwent computed tomography (CT) were analysed prospectively. At the time of the CT scan, a footprint analysis using a simple footprint assessment board was performed. The navicular index, tibiocalcaneal angle, and calcaneal inclination angle were evaluated by CT to assess flat feet. These three criteria were compared to those evaluated with the simple footprint assessment board by regression analysis. In addition, the same analysis was conducted separately for young, middle-aged, and older patients in order to investigate each age group. RESULTS: The navicular index and tibiocalcaneal angle generally decreased as the score of the simple footprint assessment board increased. Calcaneal inclination angle generally increased as the score of the simple footprint assessment board increased. As the scores of the simple footprint assessment board decreased by approaching the great toe, the navicular index and tibiocalcaneal angle were higher and calcaneal inclination angle was lower, which is indicative of a higher likelihood of flatfoot. The scores derived from the simple footprint assessment board was correlated with these three criteria measured by CT, not only when the result of simple footprint assessment board was set as a non-continuous variable but also when the result was set as a continuous variable. The results of the age-stratified survey were similar for all groups. CONCLUSIONS: The findings of this study suggest that a simple footprint assessment board can be potentially useful to detect flatfoot. TRIAL REGISTRATION: Retrospectively registered.

Editorial Commentary: Postoperative Pain Management After Arthroscopic Rotator Cuff Repair: The Journey to Pain Relief.

Presently, interscalene block is the undisputed gold-standard procedure for postoperative pain management after arthroscopic rotator cuff surgery in patients experiencing considerable pain. However, the challenge is to make this short-term total pain relief long-term.

Simultaneous ossicle resection and lateral ligament repair give excellent clinical results with an early return to physical activity in pediatric and adolescent patients with chronic lateral ankle instability and os subfibulare.

PURPOSE: To elucidate surgical outcomes in pediatric/adolescent patients with chronic lateral ankle instability and os subfibulare. METHODS: A retrospective chart review was conducted of pediatric/adolescent patients with chronic lateral ankle instability and os subfibulare following simultaneous ossicle resection and lateral ligament repair using suture anchors with subsequent immediate full weightbearing and active range of motion exercises for the ankle in our department between 2013 and 2017. Clinical outcomes were evaluated by comparing preoperative and final follow-up American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) and Karlsson-Peterson ankle function scores. Intervals between surgery and return to physical education in school were determined. RESULTS: 31 feet of 15 male and 16 female patients were examined. Mean postoperative follow-up duration was 40.7 ± 12.7 (range 24-66) months. Mean AOFAS score increased significantly from 66.3 ± 2.5 (range 62-77) preoperatively to 96.5 ± 4.9 (range 87-100) at final follow-up (p < 0.001). Mean Karlsson-Peterson score increased significantly from 51.7 ± 4.0 (range 47-70) preoperatively to 95.3 ± 6.7 (range 80-100) at final follow-up (p < 0.001). Mean interval between surgery and return to physical education in school was 11.4 ± 1.6 (range 10-18) weeks. CONCLUSION: Simultaneous ossicle resection and lateral ligament repair using suture anchors with subsequent immediate full weightbearing and active ankle range of motion exercises may give excellent clinical outcomes with early return to physical activity for chronic lateral ankle instability with os subfibulare in pediatric/adolescent patients desiring an early return to physical activity. Level of evidence III.

Periarticular multimodal drug injection does not improves early postoperative analgesia compared with continuous interscalene brachial plexus block after arthroscopic rotator cuff repair: A retrospective single-center comparative study.

BACKGROUND: Although continuous interscalene brachial plexus block (CISBPB) is common method in pain management following arthroscopic rotator cuff repair (ARCR), little is known about the analgesic effects of periarticular multimodal drug injection (PMDI) for ARCR. This retrospective study sought to clarify which technique could provide the best analgesic effect after ARCR. METHODS: We retrospectively reviewed consecutive patients who underwent ARCR performed by the same surgeon at our institution between June 2016 and November 2017. Patients who underwent surgery before January 2017 received CISBPB and those who underwent surgery after February 2017 received PMDI for postoperative pain control. Both treatment groups also received fentanyl by intravenous patient-controlled analgesia (IV-PCA). Postoperative pain was evaluated by visual analog scale (VAS) pain scores at 3, 6, 12, 24, and 48 h and need for IV-PCA at 8, 16, and 24 h. RESULTS: Twenty-eight patients received CISBPB and 21 received PMDI. According to the VAS scores, the postoperative analgesic effect was significantly better in the CISBPB group during the first 6 h (p < 0.05). Total fentanyl consumption by IV-PCA during the first 8 postoperative h was significantly greater in the PMDI group than in the CISBPB group. CONCLUSIONS: PMDI does not improve early postoperative analgesia after ARCR compared with CISBPB. CISBPB had a significantly better analgesic effect in the first 8 h postoperatively. LEVEL OF EVIDENCE: Level III.

Stress fracture of the posterior talar process in a female long-distance runner treated by osteosynthesis with screw fixation via two-portal hindfoot endoscopy: a case report.

BACKGROUND: Stress fracture of the lateral tubercle of the posterior talar process in runners is extremely rare. Here, we describe a case of a female long-distance runner who sustained a stress fracture of the lateral tubercle of the posterior talar process. Osteosynthesis with screw fixation via two-portal hindfoot endoscopy achieved a good surgical outcome with a less invasive procedure. CASE PRESENTATION: An 18-year-old female long-distance runner who belonged to her university's road running club presented to our institution with a half-year history of persistent left hindfoot pain when running. Radiographs revealed a stress fracture of the lateral tubercle of the posterior talar process. Because the fracture showed no signs of healing 3 months after starting conservative therapy, osteosynthesis with screw fixation was performed via two-portal hindfoot endoscopy. Non-contrast computed tomography at 10 weeks postoperatively revealed consolidation of the stress fracture. At 15 weeks postoperatively, the patient was permitted to jog and return to athletic activity while wearing an orthosis. As of this writing 2 years postoperatively, she remains an active competitive runner. CONCLUSIONS: Osteosynthesis with screw fixation via two-portal hindfoot endoscopy was a less invasive procedure that successfully treated stress fracture of the lateral tubercle of the posterior talar process in this female long-distance runner.

Endoscopic plantar fascia release via a suprafascial approach is effective for intractable plantar fasciitis.

PURPOSE: To evaluate the medium-term clinical results of endoscopic plantar fascia release (EPFR) using a suprafascial approach for recalcitrant plantar fasciitis. METHODS: Twenty-four feet of twenty-three patients who underwent EPFR using a suprafascial approach were followed up for more than 2 years using the American Orthopedic Foot and Ankle Society (AOFAS) score. The AOFAS score at final follow-up was compared between patients who participated in athletic activity (group A) and those who were sedentary (group S) and between those with and those without calcaneal spur (group with CS and group without CS, respectively). The ability of patients to return to athletic activity, and if so, the time interval between surgery and return to athletic activity, were investigated in group A. Complications were recorded. RESULTS: The median follow-up duration was 48 months. The mean AOFAS score in all patients increased significantly between before surgery and final follow-up (P < 0.001). The mean score in group A at final follow-up was significantly higher than that in group S (P < 0.05). However, there was no significant difference in the mean score at final follow-up between the groups with and without CS. In group A, all patients could return to athletic activity after a median 8 weeks. Injury to the first branch of the lateral plantar nerve occurred in three feet. CONCLUSION: EPFR using a suprafascial approach was effective for recalcitrant plantar fasciitis. However, the prognosis of sedentary patients was inferior to that of patients engaged in athletic activity. LEVEL OF EVIDENCE: IV.

Induced membrane technique using beta-tricalcium phosphate for reconstruction of femoral and tibial segmental bone loss due to infection: technical tips and preliminary clinical results.

PURPOSE: This study aimed to provide preliminary evidence regarding effectiveness of grafting beta-tricalcium phosphate (ß-TCP) combined with a cancellous autograft for treating nonunion of long bones in the lower extremity due to infection by evaluating clinical and radiological outcomes. METHODS: We retrospectively reviewed the clinical and radiological results in seven patients (six men, one woman; median age 39 years) treated by the induced membrane technique for nonunion of the femur or tibia due to infection. In the second stage of the procedure, the bony defect was filled with a combination of autologous cancellous bone and ß-TCP, which were mixed in approximately the same proportions. The time interval between the second stage of the procedure and bone healing was investigated. Radiographic characteristics including maximum bone gap and radiographic apparent bone gap were evaluated. RESULTS: The median follow-up period was 14 months. Bone healing was achieved in a median of six months after the second procedure. The median maximum bone gap and radiographic apparent bone gap were 55 mm and 34 mm, respectively. DISCUSSION: Use of ß-TCP, which has osteoconductive ability, with an autograft provided good clinical and radiological outcomes. The findings of this preliminary study suggest the potential of ß-TCP as a useful bone substitute for autografts in the induced membrane technique. CONCLUSIONS: Our findings suggest that ß-TCP may be an effective extender when using the induced membrane technique.

Surgical outcome of posterior ankle impingement syndrome with concomitant ankle disorders treated simultaneously in patient engaged in athletic activity.

BACKGROUND: It is unclear whether simultaneous surgery for posterior ankle impingement syndrome (PAIS) and concomitant ankle disorders, such as anterior ankle impingement syndrome (AAIS), lateral ankle instability (LAI), and osteochondral lesion of the talus (OLT), allows for early return to athletic activity. METHODS: Ninety-seven patients who engaged in athletic activity (mean age 27 [range 18-43] years) and were treated by a hindfoot endoscopic approach for PAIS alone or simultaneously for PAIS and concomitant ankle disorders were included in this study. The patients were divided into four groups: PAIS alone (group A, n = 61), PAIS with AAIS (group B, n = 8), PAIS with LAI with or without AAIS (group C, n = 20), and PAIS with OLT with or without AAIS/LAI (group D, n = 8). In all patients, the concomitant ankle disorder was treated simultaneously by arthroscopic debridement for AAIS, bone marrow stimulation or autologous cancellous bone transplantation for OLT, and anterior talofibular ligament repair or reconstruction for LAI. American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale scores before and 2 years after surgery and times from surgery to resuming training and athletic activity were compared between the groups. RESULTS: Mean AOFAS score improved significantly after surgery in all groups (groups A and C, P < .0001; groups B and D: P < .05). The time taken to return to training was significantly longer in group D than in groups A, B, and C (all P < .01) as was the time taken to return to athletic activity in groups C and D when compared with group A (P < .01); however, there were no significant differences in this regard between groups B and C. CONCLUSION: Concomitant surgery for AAIS and LAI with PAIS did not delay the postoperative start of training, however, concomitant surgery for LAI and OLT delayed the return to athletic activity when compared with PAIS surgery alone. STUDY DESIGN: Clinical Retrospective Comparative Study.

Chipping and lengthening over nailing technique for femoral shaft nonunion with shortening.

PURPOSE: Chipping and lengthening over nailing (CLON) technique was developed to treat femoral shaft nonunion with shortening more than 10 mm. The purpose of the current retrospective case series was to clarify the effectiveness of the CLON technique on the femoral shaft nonunion following intramedullary nailing. METHODS: Clinical and radiological outcomes in the patients receiving operative treatment for femoral shaft nonunion between August 2012 and December 2016 were retrospectively reviewed using the Refractory Fracture Data Registry at the authors' institution. The CLON technique was indicated for patients with the femoral shaft nonunion with shortening more than 10 mm. RESULTS: Five patients with median follow-up of 32 months (range, 14 to 50 months) were included in this study. All patients achieved bone union at the median of 8 months after the CLON technique. The median limb length discrepancy was 2.0 mm at the most recent follow-up. CONCLUSIONS: The present study demonstrated that the CLON technique for femoral shaft nonunion may be the first choice as operative treatment for femoral shaft nonunion with shortening more than 10 mm.

Midterm clinical results of osteochondral autograft transplantation for advanced stage Freiberg disease.

PURPOSE: We aimed to evaluate the midterm clinical results of osteochondral autograft transplantation (OAT) for advanced stage Freiberg disease. METHODS: This study included consecutive patients who underwent OAT for advanced stage Freiberg disease and were followed postoperatively for more than five years. In all cases, the autograft was harvested from the ipsilateral knee joint. Clinical evaluation was performed based on the American Orthopaedic Foot and Ankle Society Lesser Metatarsophalangeal-Interphalangeal Scale (AOFAS) score and visual analogue scale (VAS) score, which were done pre-operatively and at the most recent follow-up. Radiological evaluation was performed at two years after the operation. Furthermore, the most recent six patients underwent magnetic resonance imaging (MRI) five years after the operation to assess the configuration of the articular surface. RESULTS: A total of 13 patients (all female; mean age 16.7 years; range 10-38 years) were included and followed up for a mean duration of 67.2 months (range 60-100 months). The mean AOFAS significantly improved from a score of 66.9 ± 5.3 (range 59-77) to 93.0 ± 7.6 (range 82-100) (p < 0.0001). Likewise, the mean VAS significantly improved from a score of 72.7 ± 10.3 (range 60-90) to 7.8 ± 7.2 (range 0-20) (p < 0.0001). Radiographs at two years after the operation revealed no osteoarthritic change in all cases. MRI at five years after the operation showed consolidation of the transplanted autograft and smooth configuration of the articular surface in the six cases. CONCLUSIONS: OAT may be effective for advanced stage Freiberg disease. Further studies are necessary before this technique can become the standard operative treatment.

Early recovery after arthroscopic repair compared to open repair of the anterior talofibular ligament for lateral instability of the ankle.

INTRODUCTION: To compare the early result between arthroscopic and traditional open repair of the anterior talofibular ligament (ATFL) with inferior extensor retinaculum (IER) reinforcement for lateral instability of the ankle (LIA). MATERIALS AND METHODS: We retrospectively reviewed cases that had been surgically treated for LIA and compared two treatment groups: those treated with an open procedure (Group O) vs those treated with an arthroscopic procedure (Group A). The parameters compared between the groups were visual analog scale (VAS) score at 3 days and 2 weeks after surgery, duration of surgery, time to return to daily activities and sports activities, postoperative complications, recurrence of the instability, and Japanese Society for Surgery of the foot ankle-hindfoot (JSSF) scale score before and at 1 year after surgery. RESULTS: Significant differences were seen in the mean duration of surgery, mean VAS score at 3 days, and mean time to return to daily activities between the groups. Two patients had temporary numbness in Group A, while 3 patients had wound irritation and 1 patient had temporary numbness in Group O. Ankle instability did not recur in either group. There was no significant difference in either preoperative or postoperative JSSF scale score between the groups. CONCLUSIONS: Compared with the open procedure, arthroscopic ATFL repair with IER reinforcement for LIA had an equivalent clinical result at the 1-year follow-up and allowed early recovery after surgery.

Simultaneous ankle arthroscopy and hindfoot endoscopy for combined anterior and posterior ankle impingement syndrome in professional athletes.

INTRODUCTION: This study aimed to evaluate the clinical outcome of simultaneous less-invasive ankle arthroscopy and hindfoot endoscopy for combined anterior ankle impingement syndrome (AAIS) and posterior ankle impingement syndrome (PAIS) in professional athletes. MATERIALS AND METHODS: Between October 2009 and October 2011, 12 feet of 9 professional athletes (8 men, 1 woman; mean age 25 years; range 19-34 years) with combined AAIS and PAIS underwent simultaneous ankle arthroscopy and hindfoot endoscopy. Radiography, computed tomography, and magnetic resonance imaging were performed in all patients. Ultrasound-guided anesthetic injection was administered for the diagnosis of PAIS. Active plantar and dorsal flexion angles of the ankle before and after surgery, occurrence of complications, and time to return to competitive sports were evaluated. RESULTS: All feet had osteophytes in the anterior ankle joint. Ostrigonum and a large posterior talar process were found in 8 and 4 feet, respectively. Combined disorders that were noted were lateral ankle instability in 6 feet and an osteochondral lesion of the talus in 4 feet. Median JSSF and VAS scores improved significantly from 63 (range 55-69) points preoperatively to 82 (range 77-100) points postoperatively (p < 0.01), and from 85 (range 70-95) points preoperatively to 8 (range 3-15) points postoperatively (p < 0.01), respectively. Median active plantar and dorsal flexion angles improved significantly from 40° (range, 30°-50°) and 10° (range 5°-20°) preoperatively to 50° (range 40°-55°) and 15° (range 10°-20°) postoperatively, respectively (p < 0.01 and p < 0.05, respectively). One patient complained of numbness in the vicinity of the sural nerve, which resolved spontaneously by the 4th week after surgery. Median time to return to competitive sports was 12 (range 12-15) weeks. CONCLUSION: Simultaneous ankle arthroscopy and hindfoot endoscopy for combined AAIS and PAIS enables professional athletes to return to athletic activity.

Ligament reconstruction with single bone tunnel technique for chronic symptomatic subtle injury of the Lisfranc joint in athletes.

INTRODUCTION: Only few procedures for Lisfranc ligaments reconstruction to treat subtle injury of the Lisfranc joint have been reported. We have developed a novel technique for Lisfranc ligaments reconstruction, which was applied to treat chronic symptomatic subtle injuries that had failed to respond to initial treatment or were misdiagnosed. This article describes the technique and its operative outcome in a small case series. METHODS: Between April 2011 and October 2013, 5 (4 male and 1 female) athletes with a mean age of 19.4 (range 17-21) years were diagnosed with chronic subtle injury of the Lisfranc joint and underwent our novel reconstructive operation. In this technique, only a bone tunnel between the medial cuneiform and the second metatarsal bone is needed for near-anatomical reconstruction of the dorsal and interosseous ligaments. All patients were evaluated before and at 1 year after surgery using the American Orthopaedic Foot and Ankle Society (AOFAS) scale for the ankle-midfoot. In addition, the interval between surgery and return to athletic activity, defined as return to near pre-injury performance level, was investigated. RESULTS: Mean duration of postoperative follow-up was 18.8 (range 12-26) months. Mean AOFAS score improved significantly from 74.6 ± 2.5 (range 71-77) preoperatively to 96.0 ± 5.5 (range 90-100) at 1 year after the operation (p < 0.01). All patients were able to return to their previous athletic activities and the interval between surgery and return to athletic activity was 16.8 ± 1.1 (range 15-18) weeks. There was no complication related to the operation. CONCLUSION: The results of this study suggest that our technique of Lisfranc ligaments reconstruction using autologous graft is effective for athletes with chronic subtle injury. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Simultaneous surgery for chronic lateral ankle instability accompanied by only subchondral bone lesion of talus.

INTRODUCTION: Osteochondral lesion of the talus (OCT) frequently accompanies chronic lateral ankle instability (CLAI). However, it remains unclear whether concomitant OCT and CLAI should be treated surgically at the same time. The purpose was to evaluate the clinical outcome of simultaneous surgery involving stabilization of CLAI and retrograde drilling for only subchondral bone lesion of the talus. STUDY DESIGN: The study was a case series; level of evidence, 4. MATERIALS AND METHODS: Between January 2006 and February 2010, 16 feet of 16 patients (5 men, 11 women; mean age 25 years; age range 14-49 years) with CLAI accompanied by only subchondral bone lesion of talus underwent surgical repair or reconstruction of the anterior talofibular ligament and retrograde drilling. Subchondral bone lesion of talus was diagnosed by preoperative magnetic resonance imaging (MRI) and intraoperative arthroscopic investigation. Clinical outcome was measured using the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) and a visual analog scale (VAS). Improvement in lesion area was evaluated by assessing the change between preoperative and postoperative MRI findings. RESULTS: Preoperative to postoperative changes in all patients were as follows: mean AOFAS score improved from 73.4 points (range 62-87) to 91.2 points (range 85-100) (p < 0.001); mean VAS score improved from 55.0 points (range 40-80) to 6.5 points (range 0-20) (p < 0.001); and mean lesion area improved from 33.9 mm(2) (range 14.2-59.6) to 11.8 mm(2) (range 4.3-22.1) (p < 0.001). CONCLUSIONS: Simultaneous surgery involving lateral ankle stabilization and retrograde drilling under arthroscopic and fluoroscopic guidance is a promising method for treating CLAI accompanied by only subchondral bone lesion of talus.

Arthroscopic Broström repair with Gould augmentation via an accessory anterolateral port for lateral instability of the ankle.

Although several arthroscopic surgical techniques for the treatment of lateral instability of the ankle have been introduced recently, some concern remains over their procedural complexity, complications, and unclear clinical outcomes. We have simplified the arthroscopic technique of Broström repair with Gould augmentation. This technique requires only two small skin incisions for two ports (medial midline and accessory anterolateral ports), without needing a percutaneous procedure or extension of the skin incisions. The anterior talofibular ligament is reattached to its anatomical footprint on the fibula with suture anchor, under arthroscopic view. The inferior extensor retinaculum is directly visualized through the accessory anterolateral port and is attached to the fibula with another suture anchor under arthroscopic view via the anterolateral port. The use of two small ports offers a procedure that is simple to perform and less morbid for patients.

Evidence-Based Update on the Surgical Technique and Clinical Outcomes of Retrograde Drilling: A Systematic Review.

BACKGROUND: Retrograde drilling is an established surgical technique to treat osteochondral lesions of the talus (OLT). It involves non-trans-articular drilling to induce subchondral bone revascularization and bone formation without damaging the overlying articular cartilage. The present study aimed to elucidate the heterogeneity of clinical studies on retrograde drilling for OLT. DESIGN: A systematic search of the MEDLINE, Web of Science, EMBASE, and Cochrane Library databases for studies published between January 1996 and August 27, 2022, was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by two independent reviewers. The included studies were evaluated for their level of evidence (LoE) and quality of evidence (QoE) using the Modified Coleman Methodology Score. Variables reporting surgical and clinical outcomes and complications were evaluated. RESULTS: Eleven studies with 207 ankles were included (mean follow-up period = 31.1 months). The mean LoE was 3.8 (LoE 3: two studies, LoE 4: nine studies), and the mean QoE was 50.8 (fair: three studies, poor: eight studies). Ten studies used the American Orthopedic Foot and Ankle Society (AOFAS) score, which improved from 57.9 preoperatively to 86.1 postoperatively. The period and protocol of conservative treatment, lesion character, surgical technique, and postoperative protocol were inconsistent or underreported. CONCLUSIONS: This systematic review revealed that low LoE and poor QoE, coupled with heterogeneity among the included studies, impede definitive conclusions regarding the effectiveness of this technique. Consequently, well-designed clinical trials are essential to develop standardized clinical guidelines for using retrograde drilling in OLT.

Effectiveness of Virtual Reality Training in Teaching Personal Protective Equipment Skills: A Randomized Clinical Trial.

Importance: Training on the proper use of personal protective equipment (PPE) is critical for infection prevention among health care workers. Traditional methods, such as face-to-face and video-based training, can strain resources and present challenges. Objective: To determine the effectiveness of 360° virtual reality (VR) training for PPE donning and doffing compared with face-to-face and video training in enhancing the PPE use skills of prospective health care practitioners. Design, Setting, and Participants: A blinded, prospective, and randomized noninferiority clinical trial was conducted from August to December 2021 at Teikyo University School of Medicine in Tokyo, Japan, with a mixed population of medical students. Participants were second- to fourth-year medicine, medical technology, or pharmacy students aged 20 years or older with no prior PPE training. Participants were randomized into 1 of 3 training groups (VR, face-to-face, or video) based on their enrollment order. An intention-to-treat analysis was conducted. Intervention: A 30-minute lecture on PPE procedures was delivered to all participants before the training. After the lecture, the VR group trained with an immersive 360° VR tool, the face-to-face group trained with actual PPE, and the video group trained by watching video footage on a computer and a projector. After 3 days, a standardized practical skills test was administered. Main Outcomes and Measures: The primary outcome was the mean score on a 20-point practical skills test, and the secondary outcome was the percentage of correct execution. Results: A total of 91 participants were recruited and randomized into 3 groups: VR (n = 30), face-to-face (n = 30), and video (n = 31) training. After excluding 1 participant due to illness, 90 participants (mean [SD] age, 24.2 [3.15] years; 54 males [60.0%]) completed the assessment. The mean (SD) scores were 17.70 (2.10) points for the VR group, 17.57 (2.45) points for the face-to-face group, and 15.87 (2.90) points for the video group. The VR group demonstrated no significant difference in performance from the face-to-face group. However, the VR group had significantly higher effectiveness than the video group (17.70 vs 15.87 points; P = .02). Conclusions and Relevance: Results of this trial indicate that VR training was as effective as face-to-face training in enhancing PPE donning and doffing skills and was superior to video training. The findings suggest that VR training is a viable resource-conserving training option. Trial Registration: Japan Registry of Clinical Trials Identifier: jRCT103021029.