Learning and retaining simulated arthroscopic meniscal repair skills

BACKGROUND

Previous studies of task-specific skills have suggested that a loss of technical performance occurs if the skill is not practiced for a six-month period. The aims of this study were to objectively demonstrate the learning curve for a complex arthroscopic task (meniscal repair) by means of motion analysis and to determine the impact of task repetition on the retention of this skill.

METHODS

Nineteen orthopaedic residents with experience in routine knee arthroscopy but not in arthroscopic meniscal repair were recruited into a randomized study. During the initial learning phase, all subjects performed twelve meniscal repairs on a knee simulator over a three-week period. A validated motion analysis tracking system was used to objectively record the performance and learning of each subject; the outcomes were the time taken, distance traveled, and number of hand movements. The subjects were then randomized into three groups. Group A performed one meniscal repair each month, Group B performed one meniscal repair at three months, and Group C performed no repairs during this interim phase. All three groups then returned at the six-month point for the final assessment phase, during which they carried out an additional twelve meniscal repairs over three weeks.

RESULTS

All subjects demonstrated a clear learning curve during the initial learning phase, with significant objective improvement in all motion analysis parameters over the initial twelve episodes (p < 0.0001). Although some residents had reached a learning plateau by twelve episodes, others continued to make further improvements for up to another nine episodes. Importantly, Group C did not display any loss of skill between the initial learning phase and final evaluation phase despite a six-month break in task repetition (p > 0.05).

CONCLUSIONS

In contrast to previous studies, residents did not lose any skill over a six-month interruption in task performance, and other residents took longer to produce a more consistent performance.

The use of standard operating procedures in day case anterior cruciate ligament reconstruction

The current rate of day-case anterior cruciate ligament reconstruction (ACLR) in the UK remains low. Although specialised care pathways with standard operating procedures (SOPs) have been effective in reducing length of stay following some surgical procedures, this has not been previously reported for ACLR. We evaluate the effectiveness of SOPs for establishing day-case ACLR in a specialist unit. Fifty patients undergoing ACLR between May and September 2010 were studied prospectively ("study group"). SOPs were designed for pre-operative assessment, anaesthesia, surgical procedure, mobilisation and discharge. We evaluated length of stay, readmission rates, patient satisfaction and compliance to SOPs. A retrospective analysis of 50 patients who underwent ACLR prior to implementation of the day-case pathway was performed ("standard practice group"). Eighty percent of patients in the study group were discharged on the day of surgery (mean length of stay=5.3h) compared to 16% in the standard practice group (mean length of stay=21.6h). This difference was statistically significant (p<0.05, Mann-Whitney U test). All patients were satisfied with the day case pathway. Ninety-two percent of the study group were discharged on the day of surgery when all SOPs were followed and 46% where they were not. High rates of day-case ACLR with excellent patient satisfaction can be achieved with the use of a specialised patient pathway with SOPs.

Simple visual parameters for objective assessment of arthroscopic skill

BACKGROUND

Restrictions placed on the working hours of doctors over the past decade have resulted in substantial changes to the training and assessment of orthopaedic surgical residents. Many who are responsible for training the surgeons of the future have become concerned that this reduced clinical exposure is having a detrimental impact on technical skill acquisition. Consequently, there is a need for surgical educators to develop more objective methods for assessing surgical skill. The primary aim of this study was to determine whether a novel set of visual parameters assessing visuospatial ability, fine motor dexterity, and gaze control could objectively discriminate among various levels of arthroscopic experience. The secondary aim was to evaluate the correlations between these new parameters and previously established technical skill assessment methods.

METHODS

Twenty-seven subjects were divided into a novice group (n = 7), a resident group (n = 15), and an expert group (n = 5) on the basis of arthroscopic experience. All subjects performed a diagnostic knee arthroscopy task on a simulator. Their performance was assessed with use of novel simple visual parameters that included the prevalence of instrument loss, triangulation time, and prevalence of lookdowns. Performance was also evaluated with use of previously validated technical skill assessment methods (a global rating scale and motion analysis).

RESULTS

A significant difference in performance among the groups was demonstrated with use of all three novel visual parameters, the global rating scale, and motion analysis (p < 0.05). There were strong and highly significant correlations (p < 0.0001) between each of the novel parameters and the previously validated skill assessment methods.

CONCLUSIONS

This study demonstrates the construct validity of three novel visual parameters for objectively assessing arthroscopic performance. These parameters are simple, can be used easily in the operating room, and are strongly correlated with current validated methods of technical skill assessment.

Seasonal changes in plasma steroid levels in relation to ovarian steroidogenic ultrastructural features and progesterone receptors in the house gecko, Hemidactylus flaviviridis, in Oman

A comprehensive study of the annual ovarian cycle in the house gecko, Hemidactylus flaviviridis, was conducted in Oman. Circulating estradiol (E(2)), progesterone (P), and testosterone (T) were measured during the active and inactive phases of the cycle. The steroid levels were related to the steroidogenic ultrastructural features such as the abundance of smooth endoplasmic reticulum (SER), the presence of cisternal whorls, and close association of lipid droplets with swollen vesiculated mitochondria and SER. The steroids were measured using a sensitive detection technique HPLC-MS/MS. E(2) levels began to rise in January at the onset of vitellogenesis and continued to rise between February and May relative to ovulation, postovulation, gravidity and oviposition. Afterwards, E(2) remained low during the inactive phase (June-December). P levels increased significantly in March and peaked in April, which coincided with luteinization. P levels began to decline relative to luteolysis (May-June). Afterwards, it remained low throughout the inactive phase. T levels rose significantly in March-April coinciding with vitellogenesis, but decreased rapidly and significantly in May and remained low during the inactive phase. Progesterone receptors (PR), identified using immunohistochemistry, were strongly expressed during the breeding period, but were absent during the non-breeding period. The appearance of the steroidogenic ultrastructural features in the preovulatory and lutein granulosa cells was correlated with the significant rise in the three steroid levels and the PR. As the steroid levels declined, the granulosa cells underwent a general degeneration and disruption of the associated steroidogenic features.

Spontaneous bilateral compartment syndrome of the legs: A case report and review of the literature

INTRODUCTION

Bilateral acute compartment syndrome of the legs is a rare presentation requiring emergent surgical intervention.

PRESENTATION OF CASE

We report the case of 41-year-old woman who presented with acute bilateral compartment syndrome of the legs, complicated by rhabdomyolysis and acute renal failure.

DISCUSSION

There are very few previously reported cases of bilateral compartment syndrome of the legs. In the present case, despite any clear causative factor, we suggest that the aetiology is related to inadvertent posture during sleep.

CONCLUSION

The diagnosis of acute bilateral compartment syndrome of the legs requires a high index of suspicion, particularly in the absence of obvious aetiology. A successful outcome can be achieved with early diagnosis, prompt surgical intervention and a multidisciplinary approach.

Identifying orthopaedic surgeons of the future

The aim of this study was to investigate the effect of training on the arthroscopic performance of a group of medical students and to determine whether all students could be trained to competence. Thirty-three medical students with no previous experience of arthroscopy were randomised to a ‘Trained’ or an ‘Untrained’ cohort. They were required to carry out 30 episodes of two simulated arthroscopic tasks (one shoulder and one knee). The primary outcome variable was task success at each episode. Individuals achieved competence when their learning curve stabilised. The secondary outcome was technical dexterity, assessed objectively using a validated motion analysis system. Six subjects in the ‘Untrained’ cohort failed to achieve competence in the shoulder task, compared with one in the ‘Trained’ cohort. During the knee task, two subjects in each cohort failed to achieve competence. Based on the objective motion analysis parameters, the ‘Trained’ cohort performed better on the shoulder task (p < 0.05) but there was no significant difference for the knee task (p > 0.05).

Although specific training improved the arthroscopic performance of novices, there were individuals who could not achieve competence despite focused training.These findings may have an impact on the selection process for trainees and influence individual career choices.

Fc24-01 - Ego defense mechanisms in pakistani medical students: a cross sectional analysis

Background

Ego defense mechanisms, defined by Freud as unconscious resources used by the ego to reduce conflict between the id and superego, are a reflection of how an individual deals with conflict and stress. Vaillants’ proposed Hierarchy of Defenses states that mature defenses are associated with better adaptive functioning and health, as opposed to immature defense which are correlated negatively with measures of adaptive adult functioning.

Objectives

This study assesses the prevalence of various ego defense mechanisms employed by medical students of Karachi, which is a group with higher stress levels than the general population.

Methods

A questionnaire based cross-sectional study was conducted on 682 students from five major medical colleges of Karachi in November 2006. Ego defense mechanisms were assessed using the Defense Style Questionnaire(DSQ-40) individually and as grouped under Mature, Immature, and Neurotic factors.

Results

Neurotic defenses had a higher mean score(5.62) than Mature(5.60) and Immature(4.78) mechanisms. Immature mechanisms were more commonly employed by males whereas females employed more Neurotic mechanisms than males. Neurotic and Immature defenses were significantly more prevalent in first and second year students. Mature mechanisms were significantly higher in students enrolled in Government colleges than Private institutions (p< 0.05).

Conclusions

Neurotic mechanisms are more commonly encountered than Mature or Immature mechanisms among medical students of Karachi, and this could reflect greater stress levels than the general population. Employment of these mechanisms was associated with female gender, enrollment in a private medical college, and students enrolled in the first 2 years of medical school.

Interventions for treating wrist fractures in children

BACKGROUND

Approximately a third of all fractures in children occur at the wrist, usually from falling onto an outstretched hand.

OBJECTIVES

We aimed to evaluate removable splintage versus plaster casts (requiring removal by a specialist) for undisplaced compression (buckle) fractures; cast length and position; and the role of surgical fixation for displaced wrist fractures in children.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (October 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 4), MEDLINE (from 1966), EMBASE (from 1988), CINAHL (from 1982) and reference lists of articles. Date of last search October 2007.

SELECTION CRITERIA

Any randomised or quasi-randomised controlled trials comparing types and position of casts and the use of surgical fixation for distal radius fractures in children.

DATA COLLECTION AND ANALYSIS

Two authors performed trial selection. All three authors independently assessed methodological quality and extracted data.

MAIN RESULTS

The 10 included trials, involving 827 children, were of variable quality.Four trials compared removable splintage versus the traditional below-elbow cast in children with buckle fractures. There was no short-term deformity recorded in all four trials and, in one trial, no refracture at six months. The Futura splint was cheaper to use; a removable plaster splint was less restrictive to wear enabling more children to bathe and participate in other activities, and the option preferred by children and parents; the soft bandage was more comfortable, convenient and less painful to wear; home-removable plaster casts removed by parents did not result in significant differences in outcome but were strongly favoured by parents. Two trials found below-elbow versus above-elbow casts did not increase redisplacement of reduced fractures or cast-related complications, were less restrictive during use and avoided elbow stiffness. One trial evaluating the effect of arm position in above-elbow casts found no effect on deformity. Three trials found that percutaneous wiring significantly reduced redisplacement and remanipulation but one of these found no advantage in function at three months.

AUTHORS' CONCLUSIONS

Limited evidence supports the use of removable splintage for buckle fractures and challenges the traditional use of above-elbow casts after reduction of displaced fractures. Although percutaneous wire fixation prevents redisplacement, the effects on longer term outcomes including function are not established. Further research is warranted on the optimum approach, including splintage, for buckle fractures; and on the use of below-elbow casts and indications for surgery for displaced wrist fractures in children.

In vivo gastrocnemius muscle fascicle length in children with and without diplegic cerebral palsy

The effect of spastic cerebral palsy on in vivo gastrocnemius muscle fascicle length is not clear. Similarity of fascicle lengths in children with diplegia and typically developing children, but shortening of fascicle lengths in the paretic legs of children with hemiplegia compared with the non-paretic legs, are both reported. In the former case, comparisons were made between fascicle lengths normalized to leg length, whereas in the latter case, absolute fascicle lengths were compared. The inherent assumptions when normalizing fascicle length (measured via ultrasonography) were not validated, raising the possibility that inappropriate normalization contributed to the controversy. We used statistical methods to control the potential confounding effect of leg length on fascicle length, and tested the feasibility of the normalization method for a group of 18 children with diplegia (nine males, nine females; mean age 8y 7mo [SD 3y 11mo], range 2-15y; Gross Motor Function Classification System levels II and III) and 50 typically developing children (20 males, 30 females; mean age 9y 1mo [SD 2y 4mo], range 4-14y). Children with diplegia, as a group, had shorter absolute and normalized fascicle lengths (p<0.05) but we could not refute the appropriateness of the normalization method. Other methodological issues (such as sample characteristics) might have contributed to the apparent controversy between the studies.