Reliability, Surgeon Preferences, and Eye-Tracking Assessment of the Stress Examination of the Ankle Syndesmosis

Eye Tracking Use in Surgical Research: A Systematic Review

INTRODUCTION

Eye tracking (ET) is a popular tool to study what factors affect the visual behaviour of surgical team members. To our knowledge, there have been no reviews to date that evaluate the broad use of ET in surgical research. This review aims to identify and assess the quality of this evidence, to synthesize how ET can be used to inform surgical practice, and to provide recommendations to improve future ET surgical studies.

METHODS

In line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic literature review was conducted. An electronic search was performed in MEDLINE, Cochrane Central, Embase, and Web of Science databases up to September 2020. Included studies used ET to measure the visual behaviour of members of the surgical team during surgery or surgical tasks. The included studies were assessed by two independent reviewers.

RESULTS

A total of 7614 studies were identified, and 111 were included for data extraction. Eleven applications were identified; the four most common were skill assessment (41%), visual attention assessment (22%), workload measurement (17%), and skills training (10%). A summary was provided of the various ways ET could be used to inform surgical practice, and three areas were identified for the improvement of future ET studies in surgery.

CONCLUSIONS

This review provided a comprehensive summary of the various applications of ET in surgery and how ET could be used to inform surgical practice, including how to use ET to improve surgical education. The information provided in this review can also aid in the design and conduct of future ET surgical studies.

Diagnostic accuracy of clinical tests assessing ligamentous injury of the ankle syndesmosis: A systematic review with meta-analysis

OBJECTIVE

To summarise and evaluate research on the diagnostic accuracy of clinical tests for ligamentous injury of the ankle syndesmosis.

METHODS

CINAHL, Embase, and MEDLINE were searched from inception to February 12, 2021. Studies comparing clinical examination to arthroscopy, magnetic resonance imaging, or ultrasound were considered eligible. Meta-analysis was based on random effect modelling and limited to studies fulfilling all QUADAS-2 criteria. Sensitivity (SN), specificity (SP) and likelihood ratios determined diagnostic accuracy, all with 95% confidence intervals (CI).

RESULTS

Six studies were included (512 participants; 13 clinical tests; 29% median prevalence). No individual test was associated with both high sensitivity and high specificity. Tests with the highest sensitivity were: palpation [SN 92% (95%CI 79-98)] and dorsiflexion lunge [SN 75% (95% CI 64-84%); n = 2 studies]. Tests with the highest specificity were: squeeze test [SP 85% (95% CI 81-89%); n = 4 studies] and external rotation [SP 78% (95% CI 73-82%); n = 4 studies].

CONCLUSIONS

Clinical examination should involve initial clustering of tests with high sensitivity (palpation; dorsiflexion lunge), followed by a test with high specificity (squeeze). However, as these tests cannot definitively stratify syndesmotic injuries into stable vs unstable, decisions on optimal management (conservative vs surgery) require additional imaging or arthroscopy.

Optimizing Return to Play for Common and Controversial Foot and Ankle Sports Injuries

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Surgical decision-making should consider factors to help optimize return to play for athletes with foot and ankle injuries, including injuries to the syndesmosis, the Achilles tendon, the fifth metatarsal, and the Lisfranc complex. Understanding influential factors on return to play may help orthopaedic surgeons counsel athletes and coaches on expectations for a timeline to return to play and performance metrics.

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Outcomes after rigid and flexible fixation for syndesmotic injuries are generally favorable. Some data support an earlier return to sport and higher functional scores with flexible fixation, in addition to lower rates of reoperation and a decreased incidence of malreduction, particularly with deltoid repair, if indicated.

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Minimally invasive techniques for Achilles tendon repair have been shown to have a decreased risk of wound complications. Athletes undergoing Achilles repair should expect to miss a full season of play to recover.

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Athletes with fifth metatarsal fractures have better return-to-play outcomes with surgical management and can expect a high return-to-play rate within approximately 3 months of surgery.

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Percutaneous treatment of Lisfranc injuries may expedite return to play relative to open procedures.

A New and More Sensitive View for the Detection of Syndesmotic Instability

OBJECTIVES

We hypothesize that a single syndesmotic view, capturing both sagittal and coronal tibiofibular displacement, will be more sensitive than a mortise view to detect syndesmotic instability.

METHODS

Ten fresh frozen human lower limbs were used to test the new syndesmotic view with simulated syndesmosis injury. The anteroinferior tibiofibular ligament, interosseous membrane, and posteroinferior tibiofibular ligament were sectioned sequentially. At each stage, the syndesmosis was tested using the external rotation stress (ERS) test and lateral stress test (LST). For each stress condition, a true mortise view and the new syndesmotic view were performed. Medial clear space and tibiofibular clear space (TFCS) were measured on a mortise view, and TFCS was measured on a syndesmotic view (TFCS-s). Wilcoxon signed-rank tests were used to compare measurements.

RESULTS

Syndesmotic view enabled instability detection with a 2-ligament dissection at a mean increase in TFCS-s of 2.37 mm (P = 0.021) and 1.98 mm (P = 0.011), using the ERS and LST, respectively. TFCS on the mortise view was significantly different only with a complete injury. Medial clear space did not vary significantly with injury increments. Sensitivity was 66% and 61% using ERS and LST, respectively, for the TFCS-s, compared with 27% and 33%, respectively, for the TFCS. Specificity was similar for TFCS and TFCS-s.

CONCLUSIONS

This study was able to demonstrate that the syndesmotic view is more sensitive than the mortise view in detecting syndesmotic instability in a cadaveric model. It is particularly helpful to uncover instability secondary to an incomplete syndesmosis injury requiring fixation.