Arthroscopic Repair of Medium to Large Rotator Cuff Tears With a Triple-Loaded Medially Based Single-Row Technique Augmented With Marrow Vents.

PURPOSE: The primary purpose of this study was to evaluate the repair integrity on magnetic resonance imaging (MRI), and secondarily, clinical outcomes, of medium to large (2-4 cm) rotator cuff tears treated using an arthroscopic triple-loaded medially based single-row repair technique augmented laterally with bone marrow vents. METHODS: This is a retrospective outcomes study of patients with full-thickness medium to large (2-4 cm) rotator cuff tears repaired by 4 surgeons at a single institution over a 2-year period with a minimum of 24 months' follow-up. A single-row repair with tension-minimizing medially based triple-loaded anchors and laterally placed bone marrow vents was used. Patients completed a satisfaction and pain survey, the Western Ontario Rotator Cuff index questionnaire, and a Short Form-36 version 2 survey to evaluate clinical outcomes. MRI was obtained at a minimum of 24 months follow-up to assess repair integrity. RESULTS: A total of 64 males and 27 females with a mean age of 59.7 (range, 34-82) were included. The mean tear size was 2.6 cm in anteroposterior dimension, treated with a mean of 2.2 anchors. Eighty-three of 91 shoulders (91%) reported being completely satisfied with their result. The median Western Ontario Rotator Cuff score was 95.2% of normal, with a significant difference found between those with an intact repair and those with a full-thickness recurrent defect (median, 95.9% vs. 73.8%; P = .003). Postoperative MRI obtained at a median of 32 months (range, 24-48) demonstrated an intact repair in 84 of 91 shoulders (92%), with failure defined as a full-thickness defect of the tendon. CONCLUSIONS: Arthroscopic repair of medium to large rotator cuff tears using triple-loaded medially based single-row repair augmented with marrow vents resulted in a 92% healing rate by MRI and excellent patient-reported outcomes LEVEL OF EVIDENCE: Level IV, retrospective case series.

A Comparative Study of Traditional Technique Guide versus Virtual Reality in Orthopedic Trauma Training.

Background: Medical and surgical education is an expansive field fraught with many challenges. Technology such as virtual reality could be a new venue that can offer a solution to improve surgical training. Objective: The objective of this prospective, blinded study was to evaluate virtual reality as a training model for orthopedic surgery and surgical training at large. Methods: Fourth-year medical students with novice skills volunteered to participate in this observer-blinded 1:1 randomized controlled trial. They had no prior experience in tibia intramedullary nail (IMN) surgery. They were randomized into traditional technique guide education and virtual reality. The participants were timed on their mock surgery, and a blinded observer was utilized to subjectively grade their performance throughout the procedure using the Global Assessment 5-point Rating Scale and Procedure-Specific Checklist. Results: Thirty-eight participants were recruited and randomized into virtual reality (19) and traditional (19) groups. There were trends in all categories favoring the virtual reality group. The VR group had improved time to completion (9.6 minutes vs 12.2 minutes, P = 0.034) and reduced need for corrections within the mock procedure (2.2 vs 2.5; P = 0.05). Conclusion: Virtual reality training was more effective than traditional training in learning and completing the steps of the tibia IMN surgery for novice medical students. Virtual reality training may be a useful method to augment orthopedic education and surgical training.

Epidural phlegmon and iliopsoas abscess caused by Salmonella enterica bacteremia: A case report.

INTRODUCTION AND IMPORTANCE: Iliopsoas abscesses (IPA) are rare and typically present with a non-specific triad of fever, back pain, and antalgic gait. Staphylococcus aureus is the organism responsible for nearly 90 % of IPA cases. We present a case of primary IPA with progression to osteomyelitis and discitis due to Salmonella enterica bacteremia, an exceedingly rare etiology occurring in an otherwise healthy individual. CASE PRESENTATION: This patient presented with fever, back pain, and hip pain. Initial imaging and laboratory workup did not reveal any source of infection. He became septic within 72 h of admission, and blood cultures were confirmed as Salmonella enterica. However, the etiology of the infection remained unclear. Computed Tomography (CT) imaging revealed a right-sided psoas abscess measuring 7 mm × 7 mm and an epidural phlegmon. He was discharged home with intravenous ceftriaxone and levofloxacin. However, the patient was readmitted due to L2-L3 osteomyelitis and discitis with an eccentric disc bulge causing compression of the right L3 nerve root and neutropenia. CLINICAL DISCUSSION: This case in unique in the fact that this occurred in a healthy patient with no significant risk factors or exposure to this bacteria. Additionally, this case highlights the rapid progression of IPA and the spread to adjacent spinal structures with the potential to cause nerve compression with successful medical management. CONCLUSION: Salmonella enterica is rare cause of iliopsoas abscess. This case emphasizes the importance of including iliopsoas abscesses as a differential diagnosis in patients with a high index of clinical suspicion.

Virtual Reality Training in Unicompartmental Knee Arthroplasty: A Randomized, Blinded Trial.

OBJECTIVE: The objective of this study was to evaluate the effectiveness of immersive virtual reality training in orthopedic surgery education in comparison to the standard technique guide for fixed-bearing medial unicompartmental knee arthroplasty DESIGN: Participants included 22 orthopedic surgery residents who were randomized to undergo fixed-bearing medial unicompartmental knee arthroplasty (UKA) surgical training with either an immersive virtual reality technology or by studying the traditional technique guide. Participants were randomized within their training year via block randomization. Participants then performed a medial UKA on a SawBone model using standard industry system surgical trays and equipment. Proficiency, timing, number of errors made, and subjective data were obtained during and after the SawBone procedure. A blinded observer was utilized to obtain objective data. SETTING: Community Memorial Health System, a primary clinical care institution in Ventura, California. PARTICIPANTS: Twenty-two orthopedic surgery residents were randomly selected. There were 7 PGY-1 residents (3 TG, 4 VR), 7 PGY-2s (4 TG, 3 VR), 3 PGY-3s (1 TG, 2 VR), 3 PGY-4s (2 TG, 1 VR), and 2 PGY-5s (1 TG, 1 VR) in total. Eligibility criteria were 1) an active orthopedic surgery resident, 2) no prior immersive VR surgical training, and 3) no prior experience with the Zimmer PPK implants or its technique guide. All participants completed the study. RESULTS: Residents were randomized evenly in the virtual reality (n = 11) and technique guide groups (n = 11). Analysis showed that residents who trained with the immersive VR executed significantly more steps correctly (33 vs. 27, p < 0.01) and completed their procedure in significantly faster time (26.7 vs. 35.4 minutes, p < 0.01). They also scored higher in all global assessment categories reaching significance in 4 of 5 categories. Subjective questionnaire responses demonstrated positive feedback within both groups with a trend toward virtual reality. No adverse events were recorded. CONCLUSIONS: Immersive virtual reality was more effective than traditional training for the participants of this study. There are numerous potential applications of this technology and it provides an alternative learning modality to accommodate different learning styles.

Septic gonococcal arthritis in a pediatric patient: Rare case report.

INTRODUCTION: Septic arthritis is an orthopedic emergency that requires rapid diagnosis and treatment due to the rapid destruction to cartilage. The responsible organism and etiology differs depending on patient age, especially in children. Gonococcal Arthritis in toddlers is a rare occurrence with few documented cases in the literature. An orthopedic surgeon is likely not to come across this either in training or through their careers. Consequently, its presentation and subsequent treatment algorithms leave several gray areas. PRESENTATION OF CASE: In this case report, we present a rare and not so straightforward presentation of a toddler with septic gonococcal arthritis along with a summary of treatment considerations described in the current literature and the course of treatment for this patient. Our patient is a toddler who originally presented to the emergency department with shoulder and knee pain for several days after an unwitnessed fall. He was subsequently discharged and presented again the next day with a knee effusion and elevated inflammatory markers. An MRI showed a large joint effusion without any underlying abscess or osteomyelitis to explain his elevated inflammatory markers. A knee aspiration was subsequently preformed which eventually grew out Neisseria Gonorrhea on hospital day 3 after the patient had been on antibiotics. He was taken back for an arthroscopic irrigation and debridement for definitive treatment. CLINICAL DISCUSSION/CONCLUSION: Disseminated gonococcal infection in toddlers is a rare occurrence without much information in the literature and should not be dismissed as a differential. We recommend a high index of suspicion with thorough work up. We also recommend surgical management of a septic joint due to DGI diagnosed via arthrocentesis (gross purulence, symptoms not improving on medical therapy, positive aspiration cultures, elevated synovial cell counts, and medically unstable patients) given the sequelae of medical management alone. The importance of interdisciplinary team collaboration that include pediatrician, infectious disease specialist, social worker, and government child safety associations is pivotal.