Video-Based Microsurgical Education versus Stationary Basic Microsurgical Course: A Noninferiority Randomized Controlled Study.

BACKGROUND: Repetitive training is essential for microsurgical performance. This study aimed to compare the improvement in basic microsurgical skills using two learning methods: stationary microsurgical course with tutor supervision and self-learning based on digital instructional materials. We hypothesized that video-based training provides noninferior improvement in basic microsurgical skills. METHODS: In this prospective study, 80 participants with no prior microsurgical experience were randomly divided into two groups: the control group, trained under the supervision of a microsurgical tutor, and the intervention group, where knowledge was based on commonly available online instructional videos without tutor supervision. Three blinded expert microsurgeons evaluated the improvement in basic microsurgical skills in both groups. The evaluation included an end-to-end anastomosis test using the Ten-Point Microsurgical Anastomosis Rating Scale (MARS10) and a six-stitch test on a latex glove. Statistically significant differences between groups were identified using standard noninferiority analysis, chi-square, and t-tests. RESULTS: Seventy-seven participants completed the course. Baseline test scores did not differ significantly between groups. After the 4-day microsurgical course, both groups showed statistically significant improvement in microsurgical skills measured using the MARS10. The performed tests showed that data for self-learning using digital resources provides noninferior data for course with surpervision on the initial stage of microsurgical training (7.84; standard deviation [SD], 1.92; 95% confidence interval [CI], 7.25-8.44) to (7.72; SD, 2.09; 95% CI, 7.07-8.36). CONCLUSION: Video-based microsurgical training on its initial step provides noninferior improvement in microsurgical skills to training with a dedicated instructor.

Recent Advances in Assessment and Treatment in Kienböck's Disease.

Kienböck's disease is a rare disease described as progressive avascular osteonecrosis of the lunate. The typical manifestations include a unilateral reduction in wrist motion with accompanying pain and swelling. Besides recent advances in treatment options, the etiology and pathophysiology of the disease remain poorly understood. Common risk factors include anatomical features including ulnar variance, differences in blood supply, increased intraosseous pressure along with direct trauma, and environmental influence. The staging of Kienböck's disease depends mainly on radiographic characteristics assessed according to the modified Lichtman scale. The selection of treatment options is often challenging, as radiographic features may not correspond directly to initial clinical symptoms and differ among age groups. At the earliest stages of Kienböck disease, the nonoperative, unloading management is generally preferred. Patients with negative ulnar variance are usually treated with radial shortening osteotomy. For patients with positive or neutral ulnar variance, a capitate shortening osteotomy is a recommended option. One of the most recent surgical techniques used in Stage III Kienböck cases is vascularized bone grafting. One of the most promising procedures is a vascularized, pedicled, scaphoid graft combined with partial radioscaphoid arthrodesis. This technique provides excellent pain management and prevents carpal collapse. In stage IV, salvage procedures including total wrist fusion or total wrist arthroplasty are often required.

Microsurgical Anastomosis Rating Scale (MARS10): A Final Product Scoring System for Initial Microsurgical Training.

BACKGROUND: High cost and ethical controversy of using living models in microsurgical training made non-living models more popular. However, non-living models don't provide appropriate feedback of microsurgical performance. Currently existing Global Rating Scales used for advanced microsurgical skills validation are difficult to apply on non-living model. This study presents a simple instrument for basic assessment of microsurgical anastomosis on non-living model. METHODS: Seventy medical students were divided into 2 groups depending on their prior microsurgical experience. Each participant performed 3 end-to-end anastomoses on chicken femoral artery model. Anastomoses were reviewed by 3 blinded experts and then photographed. Evaluation included a patency tests, longitudinal cut of anastomosis, and the newly proposed tool 10 Point Microsurgical Anastomosis Rating Scale (MARS10). Presented scale consists of 5 factors important for anastomosis closure (anastomosis closure, suture spacing, bites size, knot tying, and cut ends length), graded on 3 point scale (0-2 points). Results were analyzed with analysis of variance, Spearman correlation, and t Student test. RESULTS: Anastomoses evaluated by experts as patent significantly correlated with a high summary score in MARS10 scale (r = 0.73 P < .0001). There was a significant difference in MARS10 score between groups (P < .0001). There were no significant inter-rater differences in scoring among all 3 evaluators (p > .05). CONCLUSIONS: 10 Point Microsurgical Anastomosis Rating Scale is a quick, valid, and reliable tool to assess microsurgical end-to-end arterial anastomoses on non-living model.

HISTORIQUE: Le coût élevé et la controverse éthique liés à l'utilisation de modèles vivants pendant la formation en microchirurgie ont popularisé l'utilisation des modèles non vivants. Cependant, les modèles non vivants ne donnent pas de commentaires appropriés sur l'exécution de la microchirurgie. Les échelles d'évaluation mondiales actuellement utilisées pour valider les habiletés microchirurgicales avancées sont difficiles à appliquer sur des modèles non vivants. La présente étude propose un simple instrument d'évaluation fondamentale de l'anastomose microchirurgicale sur un modèle non vivant. MÉTHODOLOGIE: Les chercheurs ont divisé 70 étudiants en médecine en deux groupes d'après leur expérience microchirurgicale. Chaque participant a effectué trois anastomoses bout à bout sur un modèle d'artère fémorale de poulet. Trois experts ont examiné les anastomoses en aveugle puis les ont photographiées. L'évaluation incluait un test de perméabilité, la coupe longitudinale de l'anastomose et la nouvelle échelle d'évaluation de l'anastomose microchirurgicale en 10 points (MARS10). Cette échelle est composée de cinq facteurs importants pour fermer l'anastomose (fermeture de l'anastomose, espace entre les sutures, dimension des piqûres d'aiguille, exécution des nœuds et longueur des extrémités de fils), classés sur une échelle de trois points (de 0 à 2). Les chercheurs ont analysé les résultats avec l'analyse de variance, la corrélation de Spearman et le test de Student. RÉSULTATS: Les anastomoses évaluées comme perméables par les experts étaient corrélées par un sommaire de cotation élevé dans l'échelle de MARS10 (r = 0,73 P < 0,0001). Il y avait une différence significative du score MARS10 entre les groupes (p < 0,0001). Il n'y avait pas de différences interévaluateur significatives dans les scores des trois évaluateurs (p > 0,05). CONCLUSIONS: L'échelle de MARS10 est un outil rapide, valide et fiable pour évaluer les anastomoses artérielles microchirurgicales bout à bout sur des modèles non vivants.

Possible causes of failure in treatment of forearm bone shaft fractures - own experience.

BACKGROUND: Non-surgical treatment of forearm shaft fractures in adults is associated with a high incidence of non-union. Operator errors during surgery also often result in bone union complications. We attempted to identify the errors made during the treatment or other factors that might influence the development of forearm shaft union complications. MATERIALS AND METHODS: We have analysed the causes of 67 cases of non-union in 53 patients (17 women and 36 men), aged 18 to 85 years. Thirty-five patients were treated by open repositioning and fixation with plates and screws, 11 patients were treated by closed or open reposition and stabilization with Kirschner wires, and 4 patients had closed reposition and immobilization in a plaster cast. Other methods were used in 3 patients. RESULTS: In the group treated by open reposition and plate fixation, we found the following complications that might impede bone union: plate fracture, technical errors, screw loosening, bone inflammation, and other complications. In the group treated by closed or open repositioning and stabilization with Kirschner wires, we found the following factors that might impede bone union: open fractures, inaccurate fracture repositioning and inappropriately inserted Kirschner wires. CONCLUSIONS: Using rigid fixation, for example with a plate and screws, and avoidance of technical errors seem to be the most appropriate measures helping to decrease the risk of non-union during treatment of a fracture of both forearm shafts.

[The comparison of the use of cages with the use of autogenous bone grafts in the operative treatment of the isthmic spondylolisthesis by the posterior stabilisation and ALIF]. / Porównanie uzycia klatek miedzytrzonowych z uzyciem autogennych przeszczepów kostnych w operacyjnym leczeniu kregozmyku ciesniowego metoda tylnej stabilizacji i przedniego miedzytrzonowego usztywnienia kregoslupa.

In the following study the use of cages and autogenous bone grafts were comparised in the operative treatment of isthmic spondylolisthesis by the posterior stabilization and anterior lumbosacral interbody fusion. 55 patients were divided into two groups. Patients underwent ALIF with the use of autogenous bone grafts in the first group (34) and with the use of titanium interbody implants (cages) in the second group (21). The mean follow up period in the first group was 8.6 years and in the second group was 3.4 years. The objective clinical outcome assessment was based on Oswestry disability questionnaire. Subjective clinical evaluation was conducted with the use of visual analog pain score and two questions concerning the evaluation of success of the operative treatment and a possible agreement to the following operation if necessary. The radiological results were based upon the evaluation of the degree of spondylolisthesis, the angle of the lumbar lordosis, the height of the interbody space and intervertebral foramen and the evaluation of the spinal fusion. The usage of autogenous bone grafts alone in ALIF was related to the significant loss of achieved segmental spine anatomy restoration. The implantation of the cages prevented the loss of slippage correction, permanently reconstructed the anatomical conditions in the area of the operated spinal segment.

A comparison of the effect of autogenous vs. frozen homogenous grafts on the healing of non-union of forearm bones.

BACKGROUND: A large percentage of autogenous and homogenous grafts are resorbed and replaced by the recipient's own tissue. It is generally believed that autogenous grafts are superior to homogenous ones. The aim of our study was to compare the effectiveness of autografts and allografts in achieving the healing of a non-union of forearm bones. MATERIAL AND METHODS: Between 1976 and 2005, 56 patients with 68 non-unions of forearm bone shafts were operated on. The study group consisted of 45 male and 11 female patients aged 8 to 85. The patients were operated on using methods requiring autogenous cancellous bone chips or homogenous frozen grafts. Autografts were used in 47 patients, and allografts were applied in the treatment of 21 non-unions. The effectiveness and speed of achieving a bone union with both types of grafts were subsequently compared. RESULTS: The percentage and time of bone union were similar between autogenous and homogenous grafts. The differences are not statistically significant. CONCLUSION: No statistically significant differences in the effectiveness and time to bone union were found between recipients of autogenous vs. homogenous grafts. The use of homogenous frozen grafts seems justified when the mechanical advantages of the graft are not essential. It also allows for avoiding additional mutilation to healthy parts of the body.

[The influence of segmental lumbosacral anatomy restoration on clinical outomes in the operative treatment of the isthmic spondylolisthesis]. / Wplyw odtworzenia segmentarnej anatomii kregoslupa ledzwiowo-krzyzowego na wynik operacyjnego leczenia kregozmyku ciesniowego.

The influence of lumbosacral spine segmental anatomy restoration on the outcome of the operative treatment of isthmic spondylolisthesis was taken into evaluation. A series of 55 patients (29 males and 26 females) was examined. The long-term follow up period exceeded 3 years. The Oswestry Disability Questionaire was used to evaluate the objective clinical condition of the patients, while for the subjective assessment an analog pain score and the two questions survey concerning the evaluation of success of the operative treatment and a possible agreement to a following operation if necessary were used. The presence of neurological radical symptoms was evaluated. The radiological assessment was consisted of the evaluation of the degree of spondylolisthesis, the angle of lumbosacral lordosis, the height of the interbody space and intervertebral foramen. In conclusions, the proper spine anatomy restoration had the influence on the improvement of the outcome of operative treatment of isthmic spondylolisthesis. A metal cage usage for the anterior interbody fusion of lumbar spine in the operative treatment of isthmic spondylolisthesis enables long-lasting proper anatomical relations of the fused segment.

[The results of decompression and anterior lumbar interbody fusion with the use of interbody cages for the treatment of degenerative lumbar spondylolisthesis]. / Zastosowanie przedniego usztywnienia kregoslupa z uzyciem czopów miedzytrzonowych w leczeniu kregozmyku zwyrodnieniowego.

In this paper we reviewed 28 patients who had been treated surgically for lumbar degenerative spondylolisthesis. They were operated between 1998-2003. The decompression and anterior lumbar interbody fusion with the use of interbody cages, was performed in all of them. The outcome was assessed using rating system of Prolo and VAPS. The disc height, degree of slippage and segmental lordosis were measured, on the radiographs, before surgery, after 6 weeks and at the time of final follow-up. In all cases spinal fusion was achieved. The disc height, degree of slipage and segmental lordosis were improved and these results were stable in time. A significant decrease in radicular pain and low back pain were seen but the relation between clinical and radiological autcomes was not observed.

[Anterior and posterior stabilization of the lumbosacral spine with the usage of interbody cages in the operational treatment of the isthmic spondylolisthesis]. / Przednia i tylna stabilizacja kregoslupa ledzwiowo-krzyiowego z uzyciem klatek miedzytrzonowych w operacyjnym leczeniu kregozmyku ciesniowego.

In the following work results of the operational treatment of the isthmic spondylolisthesis by the posterior stabilization and anterior lumbosacral interbody fusion with the use of interbody implants--cages was taken under evaluation. The test group consisted of 21 patients (13 male and 8 male). The follow up period exceeded 2 years. The objective clinical outcome assessment was based on Oswestry disability questionnaire. Subjective clinical evaluation was done by the visual analog pain score and two questions concerning the evaluation of success of the operative treatment and a possible agreement to a following operation if necessary. The radiological results were done upon evaluation of the degree of the spondylolisthesis, the angle of the lumbosacral lordosis, the height of the interbody space and intervertebral foramen and the evaluation of the spinal fusion. The conclusion was that the usage of the distraction of the lumbosacral spine in the operational treatment of the isthmic spondylolisthesis result in the reduction of the slippage and the dynamic decompression of the compressed neural roots. The usage of the interbody cages prevented the loss of slippage correction, permanently reconstructed the anatomical conditions in the area of the operated spinal segment and helped to achieve good and very good clinical results in over 95% of patients. The fusion rate was 100%. The restoration of the correct height of the intervertebral foramen in the slip segment caused an improvement of the neurologic state. The usage of two level stabilization in the operative treatment of the isthmic spondylolisthesis prevented the initiation of the secondary degenerative changes adjacent to the fusion.

[Metacarpal fractures--treatment results]. / Zlamania kosci sródreccza--wyniki leczenia.

In the study we presented the results of treatment of 126 fractures in patients hospitalized between 1994-2003 in the Department of Orthopeadics. The assesment was based on 87 patients that presented for the study, including 62 male and 25 female patients in the 14-57 age. The treatment consisted of stationary reduction combined with cast fixation and stabilization with Kirschner wire. The results were dividet into 5 groups based on the fractured metacarpal bone. The best results have observed the couse of treatment of 2nd, 3rd, 4th metacarpal fracturs and not so good in the 1st and 5th metacarpal fractures.

[Application of block of corticocancellous graft in the treatment of forearm shaft nonunions]. / Zastosowanie litego przeszczepu korowo-gabczastego w leczeniu stawów rzekomych trzonu kosci przedramienia.

The paper presents a method for tratment of nonunions of the forearm, using a perforated corticocancellous graft from the iliac crest. After excising the sclerotic ands of the pseudoarthrosis, the bone graft from the iliac crest is inserted into the obtained free space and then fixed to the forearm bone by means of a plate. Satisfactory results using this method were achieved in 18 patients (age ranging from 3 to 61 years; 6 female and 12 male).

Dependency between treatment outcome in pseudarthrosis of the humeral shaft and the surgical technique applied.

Background. Treatment of non-union has always been one of the most difficult problems in bone pathology. In the present study we compare outcomes using 9 different methods of non-union treatment. Material and methods. From 1976 to 2003, 70 patients with 85 cases of pseudoarthrosis in the humeral shaft were operated. During that period, 103 operations using 9 different methods were performed. The study group consisted of 17 females, 36 males and 17 children, ranging in age from 3 to 85 years. The operation techniques were compared based on the achievement of bone union and recovery of limb functional efficiency. Nonunion type was also taken into account. Results. A high percentage of bone union was obtained by using a perforated block of corticocancellous graft taken from the iliac crest. The most complete limb function recovery was achieved using this method, as well as Judet's decortication with cancellous grafting and firm osteosynthesis. Conclusions. In oligotrophic and non-viable humeral shaft non-union, the most effective method is pseudarthrosis excision, using a perforated block of corticocancellous graft from the iliac crest to fill the gap, and firm osteosynthesis. Judet's decortication with cancellous grafting and firm osteosynthesis secured good outcome in hypertrophic pseudarthrosis.

[The long-term results of decompression and anterior lumbar interbody fusion for the treatment of degenerative lumbar spondylolisthesis]. / Odlegle wyniki leczenia kregozmyków zwyrodnieniowych metoda odbarczenia z tylna stabilizacja, i przednim miedzytrzonowym usztywnieniem.

In this paper we reviewed 31 patients who had been treated surgically for lumbar degenerative spondylolisthesis. They were operated between 1990-1996. The decompression and anterior lumbar interbody fusion with use of autologous bone graft,was performed in all of them. The duration of follow-up ranged from 12 to 6 years. The outcome was assessed using rating system of Prolo and VAPS. The disc high, degree of slippage, segmental lordosis, before surgery, after 6 weeks and at the time of final follow-up were measured on the radiographs. In all cases spinal fusion were achieved. A significant decrease in radicular pain and low back pain was seen but the relation between clinical and radiological outcomes was not observed.