Virtual Reality and Surgical Simulation Training for Orthopaedic Surgery Residents: A Qualitative Assessment of Trainee Perspectives.

Background: The demonstrated benefits of virtual reality (VR) in orthopaedic surgical training are numerous. However, it is relatively unknown how best to implement VR into an already established orthopaedic resident education curriculum and how trainees will engage and use these technologies longitudinally. Methods: This was an exploratory, qualitative research study performed in accordance with Consolidated Criteria for Reporting Qualitative Research guidelines. Orthopaedic surgery residents at a single institution were recruited during the 2022 to 2023 academic year. Semistructured interviews were conducted. Data were analyzed through grounded theory methodology, beginning with open coding, followed by axial coding, and concluding with selective coding that describes orthopaedic surgery residents' current perceptions of VR as a training tool. Results: Six residents participated in interviews before thematic saturation was achieved. Average interview length was 13:27 (±2:59) minutes. Residents felt that currently, VR is most useful for interns and junior residents as an educational adjunct for learning anatomy, surgical exposures, and the steps of a procedure in a risk- and judgment-free arena. There seems to be a "ceiling effect" with VR given current technological limitations, and residents remarked that there is an associated "opportunity cost" with using VR technology. Some residents may find it more time-efficient to study texts, videos, or surgical guides rather than use VR. Cost (limited number of headsets) and technological barriers (i.e., hardware, software, and Wi-Fi issues) were some of the described barriers to VR utilization. Residents felt that there needs to be dedicated technological support to help with these issues. At this time, given these limitations of VR, many preferred VR as an optional educational adjunct rather than as a required curricular tool or assessment of surgical competency. Conclusions: There is current utility for VR in orthopaedic surgical training. Future technological advances may make VR more central to resident education. This study describes resident perceptions about the technology and best use practices for the technology. Level of Evidence: Qualitative Study, Level V Evidence.

Orthopaedic Surgery Training and Education During COVID-19: A Systematic Review.

COVID-19 forced surgical resident training programs to adapt to meet educational requirements within the constraints of various guidelines. Some of the changes implemented during the pandemic have imparted a lasting effect on orthopaedic education. As such, the purpose of this article was to review how orthopaedic training and education were affected during the COVID-19 pandemic. Methods: The published literature was queried using search strategies devised by a medical librarian, according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Studies eligible for inclusion were studies related to COVID-19, orthopaedic surgical training, and medical education. Studies were excluded if they (1) were abstracts, conference proceedings, letters, perspective pieces, reviews, or editorials; (2) evaluated medical student education; (3) included other specialties; or (4) were unrelated to COVID-19 and/or orthopaedic training. Results: Eighty-three (n = 83) studies were included. Five themes emerged including (I) Fellowship Application, Interview, and Match Processes; (II) Social Media and Websites for Program Information; (III) Changes in Trainee Surgical Volume; (IV) Trainee Mental Health and Well-being; and (V) Innovations in Education. The pandemic decreased opportunities for medical students to gain exposure to orthopaedic surgery. Social media use, particularly Instagram, among orthopaedic residencies increased during the pandemic. Between the cancellation of away rotations and in-person interviews, applicants saved over $6,000; however, both residency applicants and interviewers preferred in-person interviews. The pandemic led to decreased surgical volume and in-person didactics for trainees, thus relying more on virtual learning. Orthopaedic trainees had mixed feelings regarding online virtual education. Although some respondents reported that they preferred the convenience of online learning, others expressed dissatisfaction with the quality of virtual education. Conclusions: The shift to virtual learning affected how applicants learned about residency programs, with many relying on virtual away rotations and social media to compare different programs. The pandemic also highlighted issues of diversity and accessibility within orthopaedic surgery, with cost savings from virtual interviews and canceled away rotations potentially benefiting applicants from lower socioeconomic backgrounds. Although some innovative approaches and adaptations to orthopaedic education and training have shown promise and may continue to be used in the future after the COVID-19 pandemic, the role of others, such as virtual interviews, is less clear.

American Academy of Orthopaedic Surgeons Clinical Practice Guideline Case Study: Management of Anterior Cruciate Ligament Injuries.

Considering the frequency of anterior cruciate ligament (ACL) tears, optimal management of these injuries was the subject of a 2022 clinical practice guideline update from The American Academy of Orthopaedic Surgeons (AAOS) with input from representatives from the American Orthopaedic Society for Sports Medicine, the Pediatric Orthopaedic Society of North America, the American Orthopaedic Society for Sports Medicine, the American Medical Society for Sports Medicine, the American Academy of Physical Medicine and Rehabilitation, and the American College of Emergency Physicians. The eight recommendations and seven options to guide orthopaedic surgeons and other physicians managing patients with these anterior cruciate ligament injuries are based on the best current available evidence. The cases presented in this article are examples designed to demonstrate the clinical application of these guidelines.

Editorial Commentary: Preoperative Patient-Reported Outcomes Measurement Information System Scores Predict Which Patients Will Benefit From Arthroscopic Meniscectomy: To Scope or Not to Scope?

Despite its widespread use and low complication rates, arthroscopic meniscectomy has not been uniformly successful in all patients, especially in those with concurrent osteoarthritis. The Patient-Reported Outcomes Measurement Information System (PROMIS) is an initiative funded by the National Institutes of Health to develop and validate patient-reported outcomes for clinical research and practice. PROMIS has shown the ability to enhance and standardize measurement of a variety of health domains affecting musculoskeletal function and in discriminating between various orthopaedic procedures through the use of computer adaptive testing. Preoperative PROMIS scores are valid predictors of postoperative minimal clinically important difference in patients undergoing arthroscopic meniscectomy based on preoperative decreased physical function and increased pain interference. PROMIS score cutoffs may be used by arthroscopic surgeons to counsel patients considering arthroscopic meniscectomy.

Distinct metabolic programs induced by TGF-ß1 and BMP2 in human articular chondrocytes with osteoarthritis.

OBJECTIVES: Cellular energy metabolism is important for the function of all tissues, including cartilage. Recent studies indicate that superficial and deep subpopulations of articular chondrocytes (ACs) have distinct metabolic profiles. At the cellular and molecular level, osteoarthritis (OA) is characterised by alteration from a healthy homoeostatic state towards a catabolic state. Several molecular pathways, including transforming growth factor beta (TGF-ß) and bone morphogenetic protein (BMP) signalling, have been identified as critical players in the pathogenesis and progression of OA. However, the manner in which these factors influence cellular energy metabolism in ACs is not well understood. This study investigates the effect of TGF-ß or BMP signalling on energy metabolism in human articular chondrocytes (hACs). METHODS: ACs were isolated from residual macroscopically full thickness and intact cartilage from the femoral condyle of human samples obtained from patients with OA. ACs were treated with Vehicle (control), TGF-ß1 or BMP2 for 48-72 hours. Metabolic assays were performed to determine glucose consumption, lactate production and adenosine triphosphate (ATP) production, whereas the mitochondrial stress test was performed to determine oxygen consumption rate. Protein was isolated to assess translational activity and was evaluated using Western blot. RESULTS: We showed that TGF-ß1, known to maintain chondrocyte homoeostasis, stimulated glycolysis by upregulating key glycolytic factors, such as glucose transporter 1 (Glut1) and hexokinase II, while reducing oxidative phosphorylation in hACs. In contrast, BMP2 enhanced mitochondrial metabolism and oxidative phosphorylation and had a minimal effect on key glycolytic regulators. CONCLUSIONS: Our data revealed distinct metabolic programs induced by TGF-ß1 and BMP2 in hACs, suggesting that the regulation of cellular metabolism may represent a new mechanism underlying the pathogenesis of OA. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: The findings define the regulation of energy metabolism as a potential novel therapeutic approach for the treatment of OA.

Deficient and Null Variants of SERPINA1 Are Proteotoxic in a Caenorhabditis elegans Model of α1-Antitrypsin Deficiency.

α1-antitrypsin deficiency (ATD) predisposes patients to both loss-of-function (emphysema) and gain-of-function (liver cirrhosis) phenotypes depending on the type of mutation. Although the Z mutation (ATZ) is the most prevalent cause of ATD, >120 mutant alleles have been identified. In general, these mutations are classified as deficient (<20% normal plasma levels) or null (<1% normal levels) alleles. The deficient alleles, like ATZ, misfold in the ER where they accumulate as toxic monomers, oligomers and aggregates. Thus, deficient alleles may predispose to both gain- and loss-of-function phenotypes. Null variants, if translated, typically yield truncated proteins that are efficiently degraded after being transiently retained in the ER. Clinically, null alleles are only associated with the loss-of-function phenotype. We recently developed a C. elegans model of ATD in order to further elucidate the mechanisms of proteotoxicity (gain-of-function phenotype) induced by the aggregation-prone deficient allele, ATZ. The goal of this study was to use this C. elegans model to determine whether different types of deficient and null alleles, which differentially affect polymerization and secretion rates, correlated to any extent with proteotoxicity. Animals expressing the deficient alleles, Mmalton, Siiyama and S (ATS), showed overall toxicity comparable to that observed in patients. Interestingly, Siiyama expressing animals had smaller intracellular inclusions than ATZ yet appeared to have a greater negative effect on animal fitness. Surprisingly, the null mutants, although efficiently degraded, showed a relatively mild gain-of-function proteotoxic phenotype. However, since null variant proteins are degraded differently and do not appear to accumulate, their mechanism of proteotoxicity is likely to be different to that of polymerizing, deficient mutants. Taken together, these studies showed that C. elegans is an inexpensive tool to assess the proteotoxicity of different AT variants using a transgenic approach.

The aggregation-prone intracellular serpin SRP-2 fails to transit the ER in Caenorhabditis elegans.

Familial encephalopathy with neuroserpin inclusions bodies (FENIB) is a serpinopathy that induces a rare form of presenile dementia. Neuroserpin contains a classical signal peptide and like all extracellular serine proteinase inhibitors (serpins) is secreted via the endoplasmic reticulum (ER)-Golgi pathway. The disease phenotype is due to gain-of-function missense mutations that cause neuroserpin to misfold and aggregate within the ER. In a previous study, nematodes expressing a homologous mutation in the endogenous Caenorhabditis elegans serpin, srp-2, were reported to model the ER proteotoxicity induced by an allele of mutant neuroserpin. Our results suggest that SRP-2 lacks a classical N-terminal signal peptide and is a member of the intracellular serpin family. Using confocal imaging and an ER colocalization marker, we confirmed that GFP-tagged wild-type SRP-2 localized to the cytosol and not the ER. Similarly, the aggregation-prone SRP-2 mutant formed intracellular inclusions that localized to the cytosol. Interestingly, wild-type SRP-2, targeted to the ER by fusion to a cleavable N-terminal signal peptide, failed to be secreted and accumulated within the ER lumen. This ER retention phenotype is typical of other obligate intracellular serpins forced to translocate across the ER membrane. Neuroserpin is a secreted protein that inhibits trypsin-like proteinase. SRP-2 is a cytosolic serpin that inhibits lysosomal cysteine peptidases. We concluded that SRP-2 is neither an ortholog nor a functional homolog of neuroserpin. Furthermore, animals expressing an aggregation-prone mutation in SRP-2 do not model the ER proteotoxicity associated with FENIB.