Examiner effect on the objective structured clinical exam - a study at five medical schools.

BACKGROUND: The Objective Structured Clinical Examination (OSCE) is increasingly used at medical schools to assess practical competencies. To compare the outcomes of students at different medical schools, we introduced standardized OSCE stations with identical checklists. METHODS: We investigated examiner bias at standardized OSCE stations for knee- and shoulder-joint examinations, which were implemented into the surgical OSCE at five different medical schools. The checklists for the assessment consisted of part A for knowledge and performance of the skill and part B for communication and interaction with the patient. At each medical faculty, one reference examiner also scored independently to the local examiner. The scores from both examiners were compared and analysed for inter-rater reliability and correlation with the level of clinical experience. Possible gender bias was also evaluated. RESULTS: In part A of the checklist, local examiners graded students higher compared to the reference examiner; in part B of the checklist, there was no trend to the findings. The inter-rater reliability was weak, and the scoring correlated only weakly with the examiner's level of experience. Female examiners rated generally higher, but male examiners scored significantly higher if the examinee was female. CONCLUSIONS: These findings of examiner effects, even in standardized situations, may influence outcome even when students perform equally well. Examiners need to be made aware of these biases prior to examining.

[The Medical Examination - Between Desire and Reality - Analysis of Consensus Between the Second Part of the Medical Licensing Exam (IMPP) and the National Catalogue of Expertise-based Learning Goals in Surgery (NKLC)]. / Medizinische Prüfung zwischen Wunsch und Wirklichkeit ­ Analyse der Übereinstimmung zwischen dem 2. Abschnitt der ärztlichen Prüfung und dem Nationalen Kompetenzbasierten Lernzielkatalog Chirurgie.

Background The working party of the German Society for Surgery (DGCH) on undergraduate surgical education has developed a national expertise-based catalogue of learning goals in surgery (NKLC). This study analyses the extent to which the questions of the German second medical licensing examination compiled by the IMPP are congruent with the NKLC and which thematic focus is emphasised. Materials and Methods Firstly, a guideline and evaluation sheet were developed in order to achieve documentation of the individual examination questions of the second licensing examination with respect to the learning goals of the NKLC. In a retrospective analysis from autumn 2009 to autumn 2014, eleven licensing examinations in human medicine were screened independently by three different reviewers. In accordance with the guideline, the surgical questions were identified and subsequently matched to the learning goals of the NKLC. The analysis included the number of surgical learning goals as well as the number of surgical questions for each examination, learning goal, and different levels of expertise (LE). Results Thirteen reviewers from six surgical disciplines participated in the analysis. On average, reviewers agreed on the differentiation between surgical and non-surgical questions in 79.1% of all 3480 questions from 11 licensing examinations. For each examination (n = 320 questions), 98.8 ± 22.6 questions (min.: 69, max.: 150) were rated as surgical. For each surgical learning goal addressed, 2.2 ± 0.3 questions (min.: 1, max.: 16) were asked. For each examination, 23.5 ± 6.3 questions (min.: 11; max.: 31) referred to learning goals of LE 3, 52.5 ± 16.7 questions (min.: 34; max.: 94) addressed learning goals of LE 2 and 22.8 ± 7.7 questions (min.: 9; max.: 34) were related to learning goals of LE 1. 64 learning goals (27.8% of all learning goals of the NKLC) were not reflected in the examinations. With a total of 70 questions, the most frequently examined surgical topic was "disorders of the rheumatic spectrum". Conclusion The number of surgical examination questions in the German second medical licensing examination seems to be sufficient. However, the questions seem to be unevenly distributed between different surgical areas of undergraduate education. In order to achieve a more homogenous representation of relevant surgical topics, improved alignment is needed between the state examination with existing catalogues of learning goals by the IMPP.

Allogenous bone with collagen for repair of deep osteochondral defects.

BACKGROUND: A scaffold for treatment of deep osteochondral defects should be stable, integrate well, and provide a surface for chondrocytes. To meet these demands, a biphasic scaffold of allogenous sterilized bone with a collagen surface was developed. Integration was tested in the sheep model. MATERIAL AND METHODS: Cartilage chips were taken from the nonweight-bearing area of the left knee of 12 sheep and cultured. After 4 wk a second procedure followed and defects of 9.4-mm diameter at the weight-bearing area of the medial femoral condyle of the right knee were created. The sterilized scaffold was inserted and the cultured autologous chondrocytes were dripped onto the surface. After 6 wk, 3 mo, and 6 mo the animals were sacrificed; the explanted femoral condyles were evaluated macroscopically and using histologic, immunohistochemical, and electronmicroscopic methods. RESULTS: After 6 wk the level of the surface was well preserved, after 3 mo parts of the scaffold were sintered but after 6 mo the surface was continuous. Full integration of the allogenous bone could be observed after 6 mo. The surface of the scaffold after 6 wk consisted of bone, but after 3 mo some chondrocytes and after 6 mo a continuous chondral layer could be detected. CONCLUSIONS: The biphasic scaffold of allogenous bone and collagen proved to be stable and sufficiently integrated in the short- and midterm interval. Whether the chondrocytes on the surface had been derived from implanted chondrocytes or the scaffold with its surface was sufficiently chondroconductive must be answered in further investigations.

Biphasic scaffolds for repair of deep osteochondral defects in a sheep model.

BACKGROUND: To oppose the disadvantages of autologous osteochondral transplantation in the treatment of deep osteochondral defects such as donor site morbidity, size limitation, and insufficient chondral integration, we developed two biphasic scaffolds of either hydroxylapatite/collagen (scaffold A) or allogenous sterilized bone/collagen (scaffold B) and tested their integration in a sheep model. METHODS: We collected chondral biopsies from 12 sheep for the isolation of chondroblasts and cultured them for 4 wk. We created defects at the femoral condyle and implanted either scaffold A or B with chondrocytes or cell free. After 6 wk, animals were euthanized, we explanted the condyles, and evaluated them using histological, immunohistochemical, molecular biological, and histomorphometrical methods. RESULTS: Specimens with scaffold A showed severe lowering of the surface, and the defect size was larger than for scaffold B. We found more immune-competent cells around scaffold A. Chondrocytes were scarcely detected on the surface of both scaffolds. Histomorphometry of the interface between scaffold and recipient showed no significant difference regarding tissue of chondral, osseous, fibrous or implant origin or tartrate-resistant acid phosphatase-positive cells. Real-time reverse transcriptase-polymerase chain reaction analysis revealed significant up-regulation for collagen II and SOX-9 messenger ribonucleic acid expression on the surface of scaffold B compared with scaffold A. CONCLUSIONS: Scaffold B proved to be stable and sufficiently integrated in the short term compared with scaffold A. More extensive evaluations with scaffold B appear to be expedient.

Pyrocarbon spacer as a trapezium replacement for arthritis of the trapeziometacarpal joint; a follow-up study of 60 cases.

Rhizarthrosis is the most common degenerative joint disease of the hand, affecting about 10% of the population. We report our results with trapezium replacement using a pyrocarbon spacer. Between January 2005 and April 2010, 70 patients underwent trapeziectomy with interposition of a pyrocarbon spacer. Sixty patients were examined at an average follow-up of 23.6 (5-64) months after the operation. Six (8.6%) of the 70 implanted pyrocarbon spacers dislocated. Based on the assessment scale devised by Buck-Gramcko, 19 patients achieved a very good outcome (31.6%), 31 patients (51.6%) had a good outcome, six results were satisfactory (10%) and four patients (6.6%) had a poor result. In this study, trapeziectomy and implantation of a pyrocarbon spacer achieved good or very good results in 83.2% of cases. The high cost of the implant and the observed rate of spacer dislocation should however be considered critically. While the short-term results of this method are encouraging, long-term outcomes will show whether this technique can keep up with the good results of suspension arthroplasty.

Follow up of complete subtalar release for clubfoot--Evolution of different scores.

BACKGROUND: Even today there are still some cases of clubfoot that require a more extensive form of treatment. Thus, it is still essential to ascertain the development of the clubfoot after extensive release operations. METHOD: 70 children presenting 99 cases of primary clubfoot (age 8 months-10 years) were followed up after 4.5 and 9 years following complete subtalar release. Function, clinical and radiological results as well as 3 scores were assessed at both dates. RESULTS: Function and pain worsened between the two follow-up periods, whereas objective clinical and radiological results remained equivalent. 44-79% were rated good or excellent depending on the scoring system applied.Older children with primary clubfoot had comparable results to children operated on at a younger age; also pre-operated feet achieved similar results. CONCLUSION: In our opinion the results justify keeping complete release in mind as an alternative method in cases of severe residual and recurrent clubfoot.

Minimal-invasive posterior approach for total hip arthroplasty versus standard lateral approach.

In this prospective study we compared clinical and radiological results and rehabilitation progress of 64 patients who underwent total hip arthroplasty using the standard lateral approach with 64 patients operated with a minimal-invasive (MIS) posterior approach. The outcome of our study did not show any significant differences with regard to patient's safety such as complication rate and radiological assessment of the cup position. There was no difference in the duration of surgery, blood loss, hospital stay and postoperative leg length discrepancy. Rehabilitation milestones were achieved earlier by MIS patients and three and six months postoperatively, the Harris Hip Score of the MIS group was significantly higher.

Training of physical examination techniques in video conferences.

Objective: The COVID-19 pandemic also called for the teaching of practical skills to develop teaching formats outside of classroom teaching. Methods: Selected physical examination techniques (musculoskeletal system, neurological system) were taught via video conference using a modified Peyton method. The core element was the mutual, real demonstration of the respective skill by student tutor and student with immediate possible correction. Results: The IT requirements turned out to be sufficient, direct feedback from tutors and students was positive. Conclusion: Whether this method can be a substitute for classroom courses must be evaluated in more extensive studies.

[Weighting of Orthopaedics & Trauma Surgery in the Medical State Examination - Comparison of the Written Examination with the National Catalogue of Learning Objectives in Surgery]. / Die Wertigkeit des gemeinsamen Faches Orthopädie-Unfallchirurgie im 2. Staatsexamen ­ Vergleich der schriftlichen 2. Staatsexamina mit dem Nationalen Kompetenzbasierten Lernzielkatalog Chirurgie.

BACKGROUND: The national competence-based catalogue of learning-goals in surgery (NKLC) defines competence levels for each of its 230 goals, including "competence level in 1: factual knowledge" up to "competence level 3: independent action". Aside from the cumulative examinations influencing the learning behaviour of students, those teaching targets do not affect the second state examination. This study analyses the extent to which the questions of the German second medical licensing examination compiled by the IMPP (central German institute for medical and pharmaceutical examinations) are congruent with the trauma-surgical and orthopaedic learning goals in the NKLC, in which this thematic focus is emphasised. MATERIAL AND METHODS: Exam questions from autumn 2009 to autumn 2014 (n = 11) were retrospectively analysed. Orthopaedic and trauma-surgical teaching targets defined in NKLC were identified by five senior orthopaedic physicians and trauma surgery experts. All questions addressing one of these learning goals were identified and analysed (re: the number of learning goals, the number of questions addressing a trauma-surgical, or orthopaedic goal, as well as different competency levels). RESULTS: We found 113 learning goals of NKLC (49.1% of the overall NKLC learning goals) identified as orthopaedic or trauma surgery subjects. During the study period, 543 questions included teaching targets referring to orthopaedic or trauma surgery subjects (15.6% of the total of 3480 questions). Per exam, a mean of 49.36 ± 14.1 questions (minimum 30; maximum 80) was identified that addressed a learning goal referring to these issues. For each exam, 13.45 ± 6.39 (minimum 6; maximum 24) questions referred to learning goals of competence level 3a and b, 21.45 ± 9.94 (minimum 9; maximum 39) questions referred to learning goals of competence level 2, and 14.45 ± 6.36 (minimum 6; maximum 25) questions referred to learning goals of competence level 1. Most questions addressed the topic: "disorders of the rheumatic spectrum" (n = 16 questions in autumn 2009). CONCLUSION: Questions focusing on orthopaedic and trauma surgery appeared sufficiently often during the second state examination. There is a thematic imbalance, and important clinical learning goals tagged with high competence levels were not addressed in a satisfactory manner. This indicates that a clear adjustment between the state examination and NKLC is necessary.

Does quantity ensure quality? Standardized OSCE-stations for outcome-oriented evaluation of practical skills at different medical faculties.

BACKGROUND: Practical skills are often assessed using Objective Structured Clinical Skill Exams (OSCE). Nevertheless, in Germany, interchange and agreement between different medical faculties or a general agreement on the minimum standard for passing is lacking. METHODS: We developed standardized OSCE-stations for assessing structured clinical examination of knee and shoulder joint with identical checklists and evaluation standards. These were implemented into the OSCE-course at five different medical faculties. Learning objectives for passing the stations were agreed beforehand. At each faculty, one reference examiner scored independently of the local examiner. Outcome of the students at the standardized station was compared between faculties and correlated to their total outcome at the OSCE, to their results at the Part One of the National Medical Licensing Examination as a reference test during medical studies and to their previous amount of lessons in examining joints. RESULTS: Comparing the results of the reference examiner, outcome at the station differed significantly between some of the participating medical faculties. Depending on the faculty, mean total results at the knee-examination-station differed from 64.4% to 77.9% and at the shoulder-examination-station from 62.6% to 79.2%. Differences were seen in knowledge-based items and also in competencies like communication and professional manner. There was a weak correlation between outcome at the joint-examination-OSCE-station and Part One of the National Medical Licensing Examination, and a modest correlation between outcome at the joint-examination-station and total OSCE-result. Correlation to the previous amount of lessons in examining joint was also weak. CONCLUSION: Although addressing approved learning objectives, different outcomes were achieved when testing a clinical skill at different medical faculties with a standardized OSCE-station. Results can be used as a tool for evaluating lessons, training and curricula at the different sites. Nevertheless, this study shows the importance of information exchange and agreement upon certain benchmarks and evaluation standards when assessing practical skills.

Surface modification by complexes of vitronectin and growth factors for serum-free culture of human osteoblasts.

Cell attachment, expansion, and migration in three-dimensional biomaterials are crucial steps for effective delivery of osteogenic cells into bone defects. Complexes composed of vitronectin (VN), insulin-like growth factors (IGFs), and insulin growth factor-binding proteins (IGFBPs) have been reported to enhance cell attachment, proliferation, and migration in a variety of cell lines in vitro. The aim of this study was to examine whether prebound complexes of VN and IGFs +/- IGFBPs could facilitate human osteoblast serum-free expansion in vitro and enhance cell attachment, proliferation, and migration in three-dimensional biomaterial constructs. Human osteoblasts derived from alveolar bone chips and the established human osteoblast cell line Saos-2 were used. These cells were seeded on tissue culture plates and porous scaffolds of type I collagen sponges and polyglycolic acid (PGA), which had been coated with VN +/- IGFBP-5 +/- IGF-I. Cell attachment, proliferation, and migration were evaluated by cell counting, confocal microscopy, and scanning electron microscopy. The number of attached human osteoblasts was significantly higher in VN-coated polystyrene culture dishes. Furthermore, significant increases in cell proliferation were observed when growth factors were bound to these surfaces in the presence of VN. In the two scaffold materials examined, greater cell attachment was found in type I collagen sponges compared with PGA scaffolds. However, coating the scaffolds with complexes composed of VN + IGF-I or VN + IGFBP-5 + IGF-I enhanced cell attachment on PGA. Moreover, the presence of VN + IGFBP-5 + IGF-I resulted in significantly greater osteoblast migration into deep pore areas as compared with untreated scaffolds or scaffolds treated with fetal calf serum. These results demonstrated that complexes of VN + IGFBP-5 + IGF-I can be used to expand osteoblasts in vitro under serum-free conditions and enhance the attachment and migration of human osteoblasts in three-dimensional culture. This in turn suggests a potential application in surface modification of biomaterials for tissue reconstruction.

Arthroscopic versus conservative treatment of osteochondritis dissecans of the knee: value of magnetic resonance imaging in therapy planning and follow-up.

PURPOSE: Magnetic resonance imaging (MRI) was used to control the short-term outcome of osteochondritis dissecans (OCD) of the femoral condyle depending on conservative or surgical treatment at the beginning of therapy. TYPE OF STUDY: Case series. METHODS: Treatment planning for OCD depended on the stage on MRI when analyzing the appearance of the interface between parent bone and fragment on T1- and T2-weighted images. Twenty-seven patients received conservative treatment and 46 patients underwent arthroscopic surgery. After 20 to 24 months, patients were re-evaluated by MRI to assess the condition of bony fragment, parent bone, and interface so as to determine partial or complete remission, no change, or progression of OCD. RESULTS: After conservative treatment, MRI showed partial or complete remission in 30% of patients and no change in 63%. Arthroscopic treatment led to remission in 37% and to no change in 57%. Progressive disintegration of OCD was found on MRI in 7% of conservatively treated patients and in 7% of the surgery patients. In 33.3% of the patients initially treated conservatively, it was decided to treat them arthroscopically because of ongoing, unacceptable clinical symptoms. CONCLUSIONS: The rates of remission and progression were not significantly different between the groups. The patients' age was significantly correlated to the rate of consolidation. OCD in juveniles under 16 years of age followed a milder course than in adults.

Primary bone lymphomas thought to be osteomyelitis urgently demand a rapid diagnosis in bone pathology.

We describe in detail three cases of primary bone lymphoma (PBL), initially treated as osteomyelitis of unknown etiology. These cases show which difficulties can occur with diagnosing this entity and highlight the urgent need for rapid diagnostic results in the field of bone pathology. Case 1: A 22-year-old man with the very rare diagnosis of precursor B-lymphoblastic lymphoma in the tibia (previously published). Case 2: A 13-year-old boy with an anaplastic large cell lymphoma of the "os pubis". With initial diagnosis pointing to multifocal osteomyelitis, histology of the left iliac crest revealed a florid/chronic osteomyelitis. During clinical regression with a new osteolytic lesion, he received treatment for chronic recurrent multifocal osteomyelitis. Case 3: A 60-year-old man with an anaplastic large cell lymphoma of the right sacrum, accompanied by a putrid, florid/chronic osteomyelitis. At first, an incisional biopsy revealed a florid/chronic osteomyelitis-only.

Accuracy of navigation in hip resurfacing with different surgeons and varying anatomy.

The accuracy of a commercial imageless navigation system for hip resurfacing and its reproducibility among different surgeons and for varying femoral anatomy was tested by comparing conventional and navigated implantation of the femoral component on different sawbones in a hip simulator. The position of the component was measured on postoperative radiographs. Variance for varus/valgus alignment and anteversion was higher for conventional implantation. Among the three surgeons, operation time, chosen implant size and anteversion were significantly different for conventional implantation but not for the navigated method. Using navigation, no difference was found for normal and abnormal anatomy. Values obtained with the navigation system were consistent with those measured on radiographs. Navigation appeared to be accurate and helped to reduce outliers. This was true for the three different surgeons and in varying anatomical situations.