Validation of an oncoplastic breast simulator for assessment of technical skills in wide local excision.

BACKGROUND: Simulation enables safe practice and facilitates objective assessment of technical skills. However, simulation training in breast surgery is rare and assessment remains subjective. The primary aim was to evaluate the construct validity of technical skills assessments in wide local excision (WLE). METHODS: Surgeons of different grades performed a WLE of a 25-mm palpable tumour on an in-house synthetic breast simulator. Procedures were videotaped (blinded), reviewed retrospectively, and independently rated against a procedure-specific global rating scale by two consultant breast surgeons. Specimen radiographs were obtained and the macroscopic distance from the 'tumour' edge to the resection margin was recorded in four cardinal directions. Expert consensus was used to construct an Oncoplastic Deviation Score (ODS), assigning points for excessively wide (more than 10 mm) and, conversely, close (less than 5 mm) macroscopic margins. RESULTS: Thirty-four surgeons (12 consultant surgeons, 12 specialty trainees and 10 core trainees) participated in the study. Video-based rating scores varied hierarchically with operator expertise (P < 0.050). Inter-rater reliability was excellent (α ≥ 0.80, P < 0.050 for all scales), and inter-rater agreement was moderate (κ = 0.132-0.361, P < 0.050 for all scales). Statistically significant differences were observed on pairwise comparisons between each grade of surgeon in scores for 'exposure', 'skin flap development', 'glandular remodelling', 'skin closure' and 'final product review' (P < 0.050). Consultants received significantly fewer ODS points than specialty trainees (P = 0.012) and core trainees (P = 0.028). Compared with experts (median 9.0 mm), wider margins were observed amongst specialty trainees (median 12.0 mm) and narrower margins amongst core trainees (median 7.1 mm) (P = 0.001). CONCLUSION: Video ratings of performance and a proposed ODS differentiate surgeons based on technical skills in WLE and may be useful for objective assessment of breast surgery trainees.

Reconstruction of the anterior cruciate ligament using the polyester ABC ligament scaffold: a minimum follow-up of four years.

We carried out a prospective study of 71 patients who had undergone reconstruction of the anterior cruciate ligament with the ABC scaffold. Their mean age was 28 years (18 to 50). All had either sub-acute or chronic traumatic deficiency of the ligament. The mean period of follow-up was five years (four to seven). Assessment included the use of the International Knee Documentation Committee score, the modified Lysholm score, the Tegner Activity score, the Knee Injury and Osteoarthritis Outcome score and measurement with the KT-1000 arthrometer. Two patients had mild recurrent synovitis. There were no infections and no failures of the ligament. During the period of study, two patients sustained a traumatic fracture of a femoral condyle. The implants retained their integrity in both cases. All patients returned to their previous or enhanced levels of daily activity by three months after operation and 56 (79%) achieved their pre-injury level of sporting activity by six months. The patients who were competing in National level sports returned to play at one level less after operation than before. The Lysholm score showed that 58% of the patients (41) were excellent, 34% (24) good, and 8% (6) fair, with a mean post-operative score of 93. According to the International Knee Documentation Committee score, 35% of knees (25) were 'normal', 52% (37) 'nearly normal' and 13% (9) 'abnormal'. Complete satisfaction was noted in 90% of patients (64). The development of osteoarthritis and the management of anterior cruciate deficiency associated with laxity of the medial collateral ligament remains uncertain. Our results indicate that in the medium-term, the ABC ligament scaffold is suitable and effective when early and safe return to unrestricted activities is demanded. We acknowledge the current general hostility towards reconstruction of the anterior cruciate ligament with artificial materials following reports of early failure and chronic synovitis associatiated with the production of particulate debris. We did not encounter these problems.

Medium-term results with a primary cemented rotating-hinge total knee replacement. A 7- to 15-year follow-up.

We reviewed 100 cemented Endo-model rotating-hinge (Waldemar Link GMBH & Co, Hamburg, Germany) total knee replacements in 80 patients with a mean age of 70 years (56 to 85) at a mean post-operative follow-up of 11 years (7 to 15). Good or excellent results were seen in 91% of knees and survival at 15 years was 96.1%. There were two deep infections, one dislocation and one supracondylar fracture. There were no peri-operative deaths and there was no loosening, malalignment, migration or wear. We consider this prosthesis to be ideally suited for the replacement of the deformed knee when the use of an unconstrained design may be questionable.

Uncemented total hip replacements and thigh pain.

We reviewed 51 uncemented total hip replacements (THRs) in 44 patients (mean age 62 years) and average postoperative follow-up period of 4 years. The evaluation system used was based on that of D'Aubigne-Postel-Charnley, and the excellent and very good results totalled over 90%. There were no revisions or aseptic loosenings, and only one late infection and one death due to cardiac infarction. Special attention was paid to the so-called thigh pain phenomenon which, despite current views, was found to be unexpectedly low (only one case) and also gone within 2 years. We feel that the design of the prosthesis used, its kind of alloy, the anatomic shape of the stem and the low modulus of the elasticity as well as the avoidance of the press fitting technique at the distal part of the stem are important factors in avoiding the stress shielding phenomenon and thigh pain.

Histological alterations in mice induced by Pseudomonas aeruginosa slime glycolipoprotein.

The time course of lesion development in mice induced by a single intraperitoneal (ip) LD50 dose of Pseudomonas aeruginosa slime glycolipoprotein (GLP) was studied. Slime GLP exerted a marked effect on the lungs, liver and kidneys without any microscopic changes in other organs. The first histological lesions were observed in the lungs 7h after ip injection and were characterized by thickening and pleomorphic inflammatory infiltration of the intraalveolar septae leading to focal atelectasis by 28 h. The initial morphological alterations in the liver were observed at 14 h and consisted of balloon degeneration of the hepatocytes, especially around the central veins, leading to fatty change within 21 h and confluent hepatocellular necrosis at 28 h. The kidneys showed hydropic degeneration of the renal tubular epithelial cells at 14 h and frank necrosis by 28 h post ip injection. The kidney and liver lesions were accompanied by a parallel rise in serum levels of blood urea nitrogen and aspartate and alanine aminotransferases.