How Arthroscope Orientation Affects Performance: Arthroscopy in the Perspective of the Viewer and Arthroscopy Opposite of the Viewer.

BACKGROUND: Elements of competency-based training are being incorporated into surgical training. The primary objective of this study was to determine how the orientation of the arthroscope and the instruments relative to the standing position of the surgeon affects basic arthroscopic performance. The secondary objective was to determine how arthroscopic level of training affects performance. METHODS: Participants from a single academic institution were recruited and divided by level of training into 2 groups: novice and advanced. The Fundamentals of Arthroscopic Surgery Training (FAST) Workstation (Sawbones) was used in this study. Performance on the ring transfer module was evaluated based on the total number of ring transfers that were completed and the errors that were made in timed sessions. All participants performed the task with the arthroscope facing away from (position A) and facing toward (position B) their standing position. Two trials were completed for each position, followed by a survey. RESULTS: Fifty-seven subjects participated in this study. Overall, position A showed 2.7 times the amount of transfers compared with position B (p < 0.001). The advanced group had 1.6 times more transfers in position A than the novice group (p = 0.007), and there was no significant difference in transfers between training level in position B. The advanced group had 3.6 times more transfers in position A compared with position B (p < 0.001), while the novice group had 2.0 times more transfers in position A than in position B (p < 0.001). CONCLUSIONS: Performing an arthroscopic simulator task with the arthroscope directed toward the operator was found to be more difficult. An understanding of how the orientation of the operator, the arthroscope, and the instruments can strongly influence performance may be important for the primary surgeon, trainees, or assistants who may be standing opposite the arthroscope, and to optimize training to overcome this discrepancy.

Graft use in the treatment of large and massive rotator cuff tears: an overview of techniques and modes of failure with MRI correlation.

Despite technical advances, repair of large or massive rotator cuff tears continues to demonstrate a relatively high rate of failure. Rotator cuff repair or superior capsular reconstruction (SCR) using a variety of commercially available grafts provides a promising option in patients with tears that may be at high risk for failure or otherwise considered irreparable. There are three major graft constructs that exist when utilizing graft in rotator cuff repair or reconstruction: augmentation at the rotator cuff footprint, bridging, and SCR. Each construct has a unique appearance when evaluated using postoperative magnetic resonance imaging (MRI), and each construct has unique sites that are predisposed to failure. Understanding the basic principles of these constructs can help the radiologist better evaluate the postoperative MRI appearance of these increasingly utilized procedures.

Surgical Management of Proximal Tibiofibular Joint Instability Using an Adjustable Loop, Cortical Fixation Device.

A technique for proximal tibiofibular joint stabilization using an adjustable loop, cortical fixation device is presented. A standard diagnostic arthroscopy is performed to exclude intra-articular pathology. After arthroscopy, a 5-cm posterior-based curvilinear incision is made over the fibular head with dissection of the fascia and decompression of the common peroneal nerve ensuring adequate exposure of the fibular head. A guidewire is placed across 4 cortices using fluoroscopic guidance from the fibular head to the anteromedial tibia. A cannulated drill bit is guided through the 4 cortices. A shuttle wire carrying the adjustable loop, cortical fixation device is fed from lateral to medial and through the skin until the medial cortical button is deployed. The device is tightened until the lateral circular cortical button is secured on the fibula. Fluoroscopy is performed to confirm the button position. The device is secured after tensioning by tying the sutures. To confirm joint stabilization, a shuck test can be performed. If a second fixation device is necessary, this procedure can be repeated distally to the first.

Adjustable-Loop Femoral Cortical Suspensory Fixation for Patellar Tendon Anterior Cruciate Ligament Reconstruction: A Time Zero Biomechanical Comparison With Interference Screw Fixation.

BACKGROUND: Adjustable-loop cortical buttons for femoral fixation of bone-tendon-bone grafts have potential advantages over interference screw fixation; however, these devices have not been benchmarked biomechanically against interference screws. Purpose/Hypothesis: The purpose was to compare the time zero biomechanical properties of commercially available, adjustable-loop cortical button and metallic interference screws for femoral fixation of bone-tendon-bone grafts. It was hypothesized that no significant differences would be found in biomechanical properties between fixation techniques. STUDY DESIGN: Controlled laboratory study. METHODS: Adjustable-loop cortical buttons (n = 8) and metallic interference screws (n = 8) were used to fix matched pairs of human bone-tendon-bone allografts in porcine distal femurs. These constructs were preconditioned (10 N to 50 N at 1 Hz, 10 cycles), subjected to cyclic loading (50 N to 250 N at 1 Hz, 500 cycles), and then pulled to failure at 20 mm/min. RESULTS: The loads to failure (mean ± SD, 700 ± 256 N vs 688 ± 215 N, P = .92) and linear stiffnesses (219 ± 48 N/mm vs 218 ± 49 N/mm, P = .97) for the adjustable-loop cortical button and metallic interference screws, respectively, were not significantly different. Cyclic displacement was higher in the adjustable-loop cortical button group (2.1 ± 0.6 mm vs 1.3 ± 0.4 mm, P = .01). The mechanism of failure was different between groups, with bone block slippage occurring most commonly in the interference screw group (n = 5) and fracture of the bone block through the suture hole occurring most commonly in the adjustable-loop cortical button group (n = 6). CONCLUSION: Adjustable-loop cortical buttons and interference screws have similar time zero failure loads, although cyclic displacement was higher with the adjustable-loop cortical buttons. The mean difference in displacement was less than 1 mm compared with the interference screw. CLINICAL RELEVANCE: Adjustable-loop cortical buttons may be an acceptable alternative to an interference screw for femoral fixation of bone-tendon-bone grafts in anterior cruciate ligament reconstruction. The clinical relevance of the observed differences in cyclic displacement is unknown and should be evaluated in future studies.

Increasing medical student exposure to musculoskeletal medicine: the initial impact of the Orthopaedic Surgery and Sports Medicine Interest Group.

PURPOSE: To investigate the impact of the Orthopaedic Surgery and Sports Medicine Interest Group (OSSMIG) on medical student interest and confidence in core musculoskeletal (MSK) concepts through supplemental education and experiences at a single tertiary, academic institution. METHODS: Medical student OSSMIG members at various levels of training were anonymously surveyed at the beginning and end of the 2014-2015 academic year. RESULTS: Eighteen (N=18) medical student interest group members completed the survey. Significant improvement in their level of training was observed with regard to respondents' self-assessed competence and confidence in MSK medicine (p<0.05). Additionally, respondents' attitudes toward exposure and support from the interest group were significantly higher than those provided by the institution (p<0.05). Members believed OSSMIG increased interest in MSK medicine, improved confidence in their ability to perform orthopedics-related physical exams, strengthened mentorship with residents and attendings, and developed a connection with the Department of Orthopedic Surgery and its residents (median "Strongly Agree", interquartile range one and two scale items). CONCLUSION: Since its inception 8 years ago, OSSMIG has been well received and has positively impacted University of Washington School of Medicine students through various interventions. Surgical interest groups should target both the students interested in primary care and surgery. Medical schools can provide additional exposure to MSK medicine by leveraging interest groups that provide early clinical experiences and supplementary instruction.

Rapid Web-Based Platform for Assessment of Orthopedic Surgery Patient Care Milestones: A 2-Year Validation.

OBJECTIVE: To determine the validity, feasibility, and responsiveness of a new web-based platform for rapid milestone-based evaluations of orthopedic surgery residents. SETTING: Single academic medical center, including a trauma center and pediatrics tertiary hospital. PARTICIPANTS: Forty residents (PG1-5) in an orthopedic residency program and their faculty evaluators. METHODS: Residents and faculty were trained and supported in the use of a novel trainee-initiated web-based evaluation system. Residents were encouraged to use the system to track progress on patient care subcompetencies. Two years of prospectively collected data were reviewed from residents at an academic program. The primary outcome was Spearman's rank correlation between postgraduate year (PGY) and competency level achieved as a measure of validity. Secondary outcomes assessed feasibility, resident self-evaluation versus faculty evaluation, the distributions among subcompetencies, and responsiveness over time. RESULTS: Between February 2014 and February 2016, 856 orthopedic surgery patient care subcompetency evaluations were completed (1.2 evaluations per day). Residents promptly requested feedback after a procedure (median = 0 days, interquartile range: 0-2), and faculty responded within 2 days in 51% (median = 2 days, interquartile range: 0-13). Primary outcome showed a correlation between PGY and competency level (r = 0.78, p < 0.001), with significant differences in competency among PGYs (p < 0.001 by Kruskal-Wallis rank sum test). Self-evaluations by residents substantially agreed with faculty-assigned competency level (weighted Cohen's κ = 0.72, p < 0.001). Resident classes beginning the study as PGY1, 2, and 3 separately demonstrated gains in competency over time (Spearman's rank correlation 0.39, 0.60, 0.59, respectively, each p < 0.001). There was significant variance in the number of evaluations submitted per subcompetency (median = 43, range: 6-113) and competency level assigned (p < 0.01). CONCLUSIONS: Rapid tracking of trainee competency with milestone-based evaluations in a learner-centered mobile platform demonstrated validity, feasibility, and responsiveness. Next Accreditation System-mandated data may be efficiently collected and used for trainee and program self-study.

Adipose-Derived Stem Cell Transplant Technique for Degenerative Joint Disease.

The treatment of mild to moderate osteoarthritis can be a challenging problem for orthopaedic surgeons. As new research and treatment strategies have emerged, stem cell therapy has risen in popularity for the management of degenerative joint conditions. In this article, we describe a stepwise technical approach with tips and pearls to performing adipose-derived stem cell transplantation for degenerative joint disease of the knee.

Reflections in a time of transition: orthopaedic faculty and resident understanding of accreditation schemes and opinions on surgical skills feedback.

INTRODUCTION: Orthopaedic surgery is one of the first seven specialties that began collecting Milestone data as part of the Accreditation Council for Graduate Medical Education's Next Accreditation System (NAS) rollout. This transition from process-based advancement to outcome-based education is an opportunity to assess resident and faculty understanding of changing paradigms, and opinions about technical skill evaluation. METHODS: In a large academic orthopaedic surgery residency program, residents and faculty were anonymously surveyed. A total of 31/32 (97%) residents and 29/53 (55%) faculty responded to Likert scale assessments and provided open-ended responses. An internal end-of-rotation audit was conducted to assess timeliness of evaluations. A mixed-method analysis was utilized, with nonparametric statistical testing and a constant-comparative qualitative method. RESULTS: There was greater familiarity with the six core competencies than with Milestones or the NAS (p<0.05). A majority of faculty and residents felt that end-of-rotation evaluations were not adequate for surgical skills feedback. Fifty-eight per cent of residents reported that end-of-rotation evaluations were rarely or never filled out in a timely fashion. An internal audit demonstrated that more than 30% of evaluations were completed over a month after rotation end. Qualitative analysis included themes of resident desire for more face-to-face feedback on technical skills after operative cases, and several barriers to more frequent feedback. DISCUSSION: The NAS and outcome-based education have arrived. Residents and faculty need to be educated on this changing paradigm. This transition period is also a window of opportunity to address methods of evaluation and feedback. In our orthopaedic residency, trainees were significantly less satisfied than faculty with the amount of technical and surgical skills feedback being provided to trainees. The quantitative and qualitative analyses converge on one theme: a desire for frequent, explicit, timely feedback after operative cases. To overcome the time-limited clinical environment, feedback tools need to be easily integrated and efficient. Creative solutions may be needed to truly achieve outcome-based graduate medical education.

Prospective randomized controlled trial comparing 1- versus 7-day manipulation following collagenase injection for dupuytren contracture.

PURPOSE: To compare the efficacy, tolerance, and safety of manual manipulation at day 7 to day 1 following collagenase Clostridium histolyticum (CCH) injection for Dupuytren contracture. METHODS: Eligible patients were randomized to manipulation at day 1 versus day 7 following CCH injection. Preinjection, premanipulation, postmanipulation, and 30-day follow-up metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint contractures were measured. Pain scores were recorded at each time point. Data were stratified per cohort based on primary joint treated (MCP vs PIP). Means were compared using paired and unpaired t-tests. RESULTS: Forty-three patients with 46 digits were eligible and were randomized to 1-day (22 digits) and 7-day (24 digits) manipulation. For MCP joints, there were no significant differences in flexion contractures between 1- and 7-day cohorts for initial (47° vs 46°), postmanipulation (0° vs 2°), or 30-day follow-up (1° vs 2°) measurements. Premanipulation, the residual contracture was significantly lower in the 7-day group (23° vs 40°). For PIP joints, there were no significant differences between 1- and 7-day cohorts for initial (63° vs 62°), premanipulation (56° vs 52°), postmanipulation (13° vs 15°), or 30-day (14° vs 16°) measurements. There were no significant differences in pain or skin tears between the 2 groups. No flexor tendon ruptures were observed. CONCLUSIONS: The effectiveness of CCH in achieving correction of Dupuytren contractures was preserved when manipulation was performed on day 7, with no differences in correction, pain, or skin tears. These data suggest that manipulation can be scheduled at the convenience of the patient and surgeon within the first 7 days after injection. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Clinical trade-offs in cross-linked ultrahigh-molecular-weight polyethylene used in total joint arthroplasty.

Highly cross-linked formulations of ultrahigh-molecular-weight polyethylene (XLPE) offer exceptional wear resistance for total joint arthroplasty but are offset with a reduction in postyield and fatigue fracture properties in comparison to conventional ultrahigh-molecular-weight polyethylene (UHMWPE). Oxidation resistance is also an important property for the longevity of total joint replacements (TJRs) as formulations of UHMWPE or XLPE utilizing radiation methods are susceptible to free radical generation and subsequent embrittlement. The balance of oxidation, wear, and fracture properties is an enduring concern for orthopedic polymers used as the bearing surface in total joint arthroplasty. Optimization of material properties is further challenged in designs that make use of locking mechanisms, notches, or other stress concentrations that can render the polymer susceptible to fracture due to elevated local stresses. Clinical complications involving impingements, dislocations, or other biomechanical overloads can exacerbate stresses and negate benefits of improved wear resistance provided by XLPE. This work examines trade-offs that factor into the use of XLPE in TJR implants.

Open reduction and intramedullary nail fixation of closed tibial fractures.

Some tibial shaft fractures cannot be accurately reduced using closed or percutaneous techniques during an intramedullary nailing procedure. Under these circumstances, a formal open reduction can be performed. Direct exposure of the fracture facilitates accurate reduction but does violate the soft tissue envelope. The purpose of this study was to evaluate the safety and efficacy of open reduction prior to intramedullary nailing. Using the trauma database at a Level I trauma center, 11 uncomplicated closed displaced tibia fractures treated with formal open reduction prior to intramedullary nailing were identified and matched with a cohort of 21 fractures treated with closed reduction and nailing. The authors attempted to match 2 controls to each patient to improve the power of the study. Clinical and radiographic outcomes were compared. All fractures ultimately healed within 5° of anatomic alignment. No infections or non-unions occurred in the open reduction group, and 1 deep infection and 1 nonunion occurred in the closed reduction group. No significant differences existed between the study groups. Although closed reduction and intramedullary nailing remains the treatment of choice for most significantly displaced tibial shaft fractures, open reduction with respectful handling of the soft tissue envelope can be safe and effective and should be considered when less invasive techniques are unsuccessful.

All-epiphyseal semitendinosus PCL reconstruction in a 10-year-old child.

BACKGROUND: Tears of the posterior cruciate ligament (PCL) in pediatric patients, especially avulsions from its tibial insertion, are not frequently encountered by physicians. However, with an increasing incidence of ligamentous injuries to the knee in skeletally immature patients, orthopaedic surgeons will more frequently need to decide how best to manage a PCL injury in children with open physes. METHODS: A 10-year-old boy sustained an avulsion of the PCL from its tibial insertion site after a bicycle motocross racing accident. He required a PCL reconstruction after failed conservative treatment and an unsuccessful attempt at primary repair. This successful physeal sparing reconstruction was accomplished using a modified method of femoral tunnel placement in combination with the tibial inlay technique. RESULTS: A magnetic resonance imaging was acquired 2 years postoperatively when physical examination demonstrated both legs of equal length, no varus or valgus deformity, and a normal posterior drawer examination. Four years after the reconstruction, he continues to bicycle motocross race while experiencing no further symptoms and complete restoration to his prior quality of life. CONCLUSIONS: The use of the tibial inlay technique together with the modified femoral tunnel location prevented transphyseal drilling while attaining a favorable anatomic placement of the graft while avoiding the "killer" turn associated with the transtibial approach. LEVEL OF EVIDENCE: Level IV (Therapeutic Study).