Validation of Two Novel and Complementary Training Platforms for Small Joint Arthroscopy

PURPOSE

We developed 2 complementary low-fidelity models to be used to create the tool skills needed to perform small joint arthroscopy. The purpose of the study was to establish the face and construct validity of the 2 models.

METHODS

The "foundation model" was constructed from lemon and radish sections, and the "advanced model" was constructed from a chicken knee. Using both models, novice, intermediate, and experienced participants were asked to perform specific tasks and were timed and scored on their performance. The experienced surgeons were given a 16-item survey to rate how closely each model emulated reality to determine face validity.

RESULTS

For the foundation model, the mean total time for the completion of tasks was 1,138 seconds for novices, 1,059 seconds for intermediates, and 631 seconds for experienced, with significant differences between the groups for time to complete 2 of the tasks. With a maximum possible score of 50 points for the correct performance of all tasks, the mean total performance score was 23 for novices, 31.8 for intermediates, and 42.2 for experienced operators. For the advanced model, the mean total time for completion was 266 seconds for novices, 147 seconds for intermediates, and 72 seconds for experienced participants. With a maximum possible score of 31 points for the correct performance of all tasks, the mean total performance score was 1.9 for novices, 15.0 for intermediates, and 24.3 for experienced participants. The average scores for the face validity surveys using a 5-point Likert scale were 4.2 and 4.5 of 5 possible points for the foundation and advanced models, respectively.

CONCLUSIONS

Experienced operators completed the tasks more quickly and had higher performance scores than the operators in other groups. This correlation between experience and performance suggests that both models have construct validity. The face validity scores were on the upper end of the scale, suggesting that both models emulate reality for experienced operators.

CLINICAL RELEVANCE

These novel models provide low-cost, available and valid simulations conducive to high-repetition training.

Teaching Tracheostomy Tube Changes: Comparison of Operant Learning Versus Traditional Demonstration

Objective

Tracheostomy tube change is a multistep skill that must be performed rapidly and precisely. Despite the critical importance of this skill, there is wide variation in teaching protocols.

Methods

An innovative operant conditioning teaching methodology was employed and compared to traditional educational techniques. Medical student volunteers at a tertiary care academic institution (Albert Einstein College of Medicine) were recruited and randomly distributed into 2 groups: operant vs traditional (control). Following the educational session, each group was provided with practice time and then asked to perform 10 tracheostomy tube changes. Performance was recorded and scored by blinded raters using deidentified video recordings.

Results

The operant learning group (OLG) demonstrated greater accuracy in performing a tracheostomy tube change than the traditional demonstration group. Twelve of 13 operant learners performed the skill accurately each time compared to 3 of 13 in the traditional group (P = 0.002). The median lesson time was longer for the OLG (535 seconds) than for the traditional group, (200 seconds P < 0.001). The average time per tracheostomy change was not significantly different between the 2 groups (operant learners mean 7.1 seconds, traditional learners mean 7.5 seconds, P = 0.427).

Discussion

Although the operant conditioning methodology necessarily requires a greater time to teach, the results support this methodology over traditional learning modalities as it enhances accuracy in the acquired skill. Operant learning methodology is under consideration for other skills and education sessions in our program. Future steps include the application and adaptation of this education model to students and residents in other settings and fields.

Implications for Practice

Operant learning is effective for teaching multistep skills such as tracheostomy tube changes with decreased error rates.

Systematic Review of Injuries in the Men's and Women's National Basketball Association

BACKGROUND

Numerous studies have reported the incidence and outcomes of injuries in the men's and women's National Basketball Association (NBA and WNBA, respectively).

PURPOSE

To synthesize published data regarding the incidence and outcomes of all injuries in the NBA and WNBA in a comprehensive review.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched 3 electronic databases (PubMed, MEDLINE, Embase) for studies of all levels of evidence since 1990 pertaining to injuries sustained by active players in the NBA and WNBA. Studies were excluded if the cohort of interest included ≤3 active players.

RESULTS

The initial search of the 3 databases yielded 1253 unique studies, of which 49 met final inclusion criteria for this review. Only 4 studies included athletes in the WNBA. Based on the mean annual incidence, the 5 most common orthopaedic sports injuries sustained in the NBA were concussions (9.5-14.9 per year), fractures of the hand (3.5-5.5 per year), lower extremity stress fractures (4.8 per year), meniscal tears (2.3-3.3 per year), and anterior cruciate ligament tears (1.5-2.6 per year). Cartilage defects treated using microfracture, Achilles tendon ruptures, and anterior cruciate ligament injuries were 3 injuries that led to significant reductions in performance measurements after injury.

CONCLUSION

With advances in sports technology and statistical analysis, there is rapidly growing interest in injuries among professional basketball athletes. High-quality prospective studies are needed to understand the prevalence and effect of injuries on player performance and career length. This information can inform preventative and treatment measures taken by health care providers to protect players and guide safe return to play at a high level.

The Value of 2 Orthopaedic Learning Platforms from the Learners' and Educators' Point of View

Online learning platforms are a staple of orthopaedic resident education. These platforms typically address a user's knowledge base, aiming to improve OITE and AAOS Board Examination scores. Orthopaedic residents often use these platforms as their primary educational resource. However, an orthopaedic surgeon is more than an orthopaedic knowledge base; acquisition of clinical acumen is integral as well. We sought to investigate the following: From a learner's and educator's perspective, do Orthobullets (OB) and Clinical Classroom (CC) contribute to both knowledge base and clinical acumen?

Validating a Low-Fidelity Model for Microsurgical Anastomosis Training

With cost, size, and availability in mind, we developed a low-fidelity microsurgery anastomosis model for mastery of the tool skills needed to execute microsurgical procedures. The model combined the use of a cannulated Konnyaku Shirataki (KS) noodle with a low-cost, industrial inspection, trinocular stereo (IITS) microscope. The purpose of this study was to establish face and construct validity of this novel "combined" microsurgery training tool.

Methods

Fifteen participants, divided into 3 groups based on microsurgery experience, attempted microsurgical anastomoses of a cannulated KS noodle using the IITS microscope. Participants were asked to (1) manipulate the noodle ends adjacent to each other, (2) place a single 7-0 nylon suture through the opposed ends, and (3) complete the anastomosis. To determine construct validity, the performance of the microsurgical repair (maximum score 53 points) and time-to-anastomosis was assessed. To determine face validity, microsurgeons were given a 25-item, 5-point scale survey rating their experience with the model.

Results

Participants included 5 microsurgeons, 5 experienced trainees, and 5 novices. The microsurgeons judged the IITS microscope to be a close analog to an operating microscope (4.6/5 points), the combined model to have high educational value (4.7/5 points), and somewhat technical similarity with microsurgery in the operating room (OR) (3.7/5 points). The median technical score was 50 among microsurgeons, 40 among experienced trainees, and 27 among novices. Increased training level was associated with greater technical score among all 3 groups (p=0.002). The median time-to-anastomosis was 5.88 minutes for microsurgeons, 8.37 minutes for experienced trainees, and 17.10 minutes for novices. Increased training level was associated with shorter time-to-anastomosis (p=0.003).

Conclusion

The use of the KS noodle with a benchtop stereo microscope is a novel approach to microsurgical training. It is inexpensive, available, conducive to high-repetition training, and suited to many learning environments. Microsurgeons found that this combined model was representative of microsurgery in the OR, and we concluded face validity. Furthermore, an association was demonstrated between training level and performance on the model, suggesting construct validity.

The Grapefruit: An Alternative Arthroscopic Tool Skill Platform

PURPOSE

To establish the construct validity of an arthroscopic training model that teaches arthroscopic tool skills including triangulation, grasping, precision biting, implant delivery and ambidexterity and uses a whole grapefruit for its training platform.

METHODS

For the grapefruit training model (GTM), an arthroscope and arthroscopic instruments were introduced through portals cut in the grapefruit skin of a whole prepared grapefruit. After institutional review board approval, participants performed a set of tasks inside the grapefruit. Performance for each component was assessed by recording errors, achievement of criteria, and time to completion. A total of 19 medical students, orthopaedic surgery residents, and fellowship-trained orthopaedic surgeons were included in the analysis and were divided into 3 groups based on arthroscopic experience. One-way analysis of variance (ANOVA) and the post hoc Tukey test were used for statistical analysis.

RESULTS

One-way ANOVA showed significant differences in both time to completion and errors between groups, F(2, 16) = 16.10, P < .001; F(2, 16) = 17.43, P < .001. Group A had a longer time to completion and more errors than group B (P = .025, P = .019), and group B had a longer time to completion and more errors than group C (P = .023, P = .018).

CONCLUSIONS

The GTM is an easily assembled and an alternative arthroscopic training model that bridges the gap between box trainers, cadavers, and virtual reality simulators. Our findings suggest construct validity when evaluating its use for teaching the basic arthroscopic tool skills. As such, it is a useful addition to the arthroscopic training toolbox.

CLINICAL RELEVANCE

There is a need for validated low-cost arthroscopic training models that are easily accessible.

Is Teaching Simple Surgical Skills Using an Operant Learning Program More Effective Than Teaching by Demonstration?

BACKGROUND

A surgical procedure is a complex behavior that can be constructed from foundation or component behaviors. Both the component and the composite behaviors built from them are much more likely to recur if it they are reinforced (operant learning). Behaviors in humans have been successfully reinforced using the acoustic stimulus from a mechanical clicker, where the clicker serves as a conditioned reinforcer that communicates in a way that is language- and judgment-free; however, to our knowledge, the use of operant-learning principles has not been formally evaluated for acquisition of surgical skills.

QUESTIONS/PURPOSES

Two surgical tasks were taught and compared using two teaching strategies: (1) an operant learning methodology using a conditioned, acoustic reinforcer (a clicker) for positive reinforcement; and (2) a more classical approach using demonstration alone. Our goal was to determine whether a group that is taught a surgical skill using an operant learning procedure would more precisely perform that skill than a group that is taught by demonstration alone.

METHODS

Two specific behaviors, "tying the locking, sliding knot" and "making a low-angle drill hole," were taught to the 2014 Postgraduate Year (PGY)-1 class and first- and second-year medical students, using an operant learning procedure incorporating precise scripts along with acoustic feedback. The control groups, composed of PGY-1 and -2 nonorthopaedic surgical residents and first- and second-year medical students, were taught using demonstration alone. The precision and speed of each behavior was recorded for each individual by a single experienced surgeon, skilled in operant learning. The groups were then compared.

RESULTS

The operant learning group achieved better precision tying the locking, sliding knot than did the control group. Twelve of the 12 test group learners tied the knot and precisely performed all six component steps, whereas only four of the 12 control group learners tied the knot and correctly performed all six component steps (the test group median was 10 [range, 10-10], the control group median was 0 [range, 0-10], p = 0.004). However, the median "time to tie the first knot" for the test group was longer than for the control group (test group median 271 seconds [range, 184-626 seconds], control group median 163 seconds [range 93-900 seconds], p = 0.017), whereas the "time to tie 10 of the locking, sliding knots" was the same for both groups (test group mean 95 seconds ± SD = 15 [range, 67-120 seconds], control group mean 95 seconds ± SD = 28 [range, 62-139 seconds], p = 0.996). For the low-angle drill hole test, the test group more consistently achieved the ideal six-step behavior for precisely drilling the low-angle hole compared with the control group (p = 0.006 for the median number of technique success comparison with an odds ratio [at the 95% confidence interval] of 82.3 [29.1-232.8]). The mean time to drill 10 low-angle holes was not different between the test group (mean 193 seconds ± SD = 26 [range, 153-222 seconds]) and the control group (mean 146 seconds ± SD = 63 [range, 114-294 seconds]) (p = 0.084).

CONCLUSIONS

Operant learning occurs as the behavior is constructed and is highly reinforced with the result measured, not in the time saved, but in the ultimate outcome of an accurately built complex behavior.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Avoiding Complications and Technical Variability During Arthroscopically Assisted Transtibial ACL Reconstructions by Using a C-Arm With Image Intensifier

BACKGROUND

Surgical reconstruction of the anterior cruciate ligament (ACL) can be complicated by incorrect and variable tunnel placement, graft tunnel mismatch, cortical breaches, and inadequate fixation due to screw divergence. This is the first report describing the use of a C-arm with image intensifier employed for the sole purpose of eliminating those complications during transtibial ACL reconstruction.

PURPOSE

To determine if the use of a C-arm with image intensifier during arthroscopically assisted transtibial ACL reconstruction (IIAA-TACLR) eliminated common complications associated with bone-patellar tendon-bone ACL reconstruction, including screw divergence, cortical breaches, graft-tunnel mismatch, and improper positioning of the femoral and tibial tunnels.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 110 consecutive patients (112 reconstructed knees) underwent identical IIAA-TACLR using a bone-patellar tendon-bone autograft performed by a single surgeon. Intra- and postoperative radiographic images and operative reports were evaluated for each patient looking for evidence of cortical breeching and screw divergence. Precision of femoral tunnel placement was evaluated using a sector map modified from Bernard et al. Graft recession distance and tibial α angles were recorded.

RESULTS

There were no femoral or tibial cortical breaches noted intraoperatively or on postoperative images. There were no instances of loss of fixation screw major thread engagement. There were no instances of graft-tunnel mismatch. The positions of the femoral tunnels were accurate and precise, falling into the desired sector of our location map (sector 1). Tibial α angles and graft recession distances varied widely.

CONCLUSION

The use of the C-arm with image intensifier enabled accurate and precise tunnel placement and completely eliminated cortical breach, graft-tunnel mismatch, and screw divergence during IIAA-TACLR by allowing incremental adjustment of the tibial tunnel and knee flexion angle. Incremental adjustment was essential to accomplish this. Importantly, a C-arm with image intensifier can be used with any ACL reconstruction that incorporates tunnels in the technique, with the expectation of increase in accuracy and precision and the elimination of common complications.

CLINICAL RELEVANCE

The use of an image intensifier during transtibial ACL reconstruction will substantially reduce the common complications associated with the procedure and improve both accuracy and precision of tibial and femoral tunnel placement. Use of an image intensifier unit is generalizable to an individual surgeon's preferences for graft choices and drilling techniques and will be especially valuable when the intercondylar architecture is altered from injury, time, or prior surgery.

The use of intraoperative fluoroscopy to reduce femoral interference screw divergence during endoscopic anterior cruciate ligament reconstruction

Femoral interference screw divergence can potentially have detrimental consequences in the rehabilitation of anterior cruciate ligament (ACL) reconstruction. Several biomechanical studies suggest that divergence angles greater than 15 degrees significantly decrease the pullout strength of the graft. Numerous techniques have been described in the literature that address this issue; however, the use of an image intensifier intraoperatively is not frequently discussed. We describe a technique in which fluoroscopy is used to confirm the proper position of the femoral interference screw at the time of the procedure, and therefore minimizes the incidence of significant screw divergence. Radiographic analysis of 62 patients who underwent endoscopic ACL reconstruction using bone-patellar tendon-bone autograft using this technique revealed significant divergence in only 3% of patients.

"Press test" for office diagnosis of triangular fibrocartilage complex tears of the wrist

We present a simple provocative diagnostic office test for detection of triangular fibrocartilage complex tears of the wrist. Twenty-seven patients with a working diagnosis of a triangular fibrocartilage complex tear complained of wrist pain caused by forceful use; 18 had a history of trauma. A "press test" was performed in each, requiring the seated patient to push the body weight up off a chair using the affected wrist, creating an axial ulnar load. A positive test provoked focal ulnar wrist pain replicating the discomfort that had prompted the patient to seek medical attention. Thirteen patients improved with conservative treatment. Seventeen underwent magnetic resonance imaging (showing 13 tears and 4 normal results) and two patients had arthrograms (both had tears). Fourteen patients had wrist arthroscopy; all had triangular fibrocartilage complex tears, which were debrided, with postoperative clinical improvement. As verified by arthroscopy, the press test had 100% sensitivity in preoperative tear detection compared with 79% for magnetic resonance imaging. The press test is recommended as a useful, free, noninvasive clinical test for triangular fibrocartilage complex tears of the wrist.

Fluoroscopic assist in anterior cruciate ligament reconstruction

When creating the femoral tunnel during endoscopic anterior cruciate ligament reconstruction, the potential exists for penetration of the posterior femoral cortex. In addition, during placement of the proximal fixation screw, the screw can deviate from its intended path. We have used an image intensifier intraoperatively to obtain a lateral view of the knee to enable the assessment of tunnel placement and screw alignment. This technique assures the accurate placement of the tibial and femoral tunnels and helps avoid screw divergence from the graft.

Sagittal MR images of the knee: a low-signal band parallel to the posterior cruciate ligament caused by a displaced bucket-handle tear

A low-signal band parallel and anterior to the posterior cruciate ligament has been noted on sagittal MR images of the knee in some patients with other evidence for medial meniscal tears. It was hypothesized that this low-signal band represented the mesially displaced fragment of a bucket-handle tear. To verify this, we retrospectively reviewed MR and arthroscopic findings in 54 consecutive patients. Arthroscopy showed a bucket-handle tear of the medial meniscus in seven patients and was considered diagnostic. Sagittal MR images were reviewed without knowledge of the arthroscopic results. The presence of a curvilinear low-signal band above the tibial cortex anterior, inferior, and parallel to the posterior cruciate ligament was identified on MR images in all seven of the patients in whom the presence of a bucket-handle medial meniscal tear was confirmed by arthroscopy. Our findings suggest that a low-signal band anterior and parallel to the posterior cruciate ligament on sagittal MR images of the knee is caused by a mesially displaced bucket-handle tear of the medial meniscus.

Living with artificial grass: a knowledge update. Part 2: Epidemiology

Part 2 of our study evaluated the effect of artificial grass on the athletes that play on it. In this section we have reviewed the epidemiological studies that have evaluated the influence that artificial grass has on the frequency and site of injury to American football players. From this review we have concluded that play and practice on an artificial surface is probably responsible for an increase in the relative risk of injury to the lower extremity of the participants. However, it is evident that more well controlled studies are necessary to completely clarify this issue.

Living with artificial grass: a knowledge update. Part 1: Basic science

Part I of this two part study reviews the development and characteristics of artificial grass, and the influence of this surface on the American football player. Artificial grass was initially developed to provide city children with increased play space and thus enable them to maintain a fitness level equal to their peers in more rural locales. Today, artificial grass fields allow for increased use when field availability is limited, or for a grass substitute where grass will not grow. However, epidemiologic studies suggest that there is an increased risk of lower extremity injury to the football athlete playing on an artificial grass field. By reviewing available studies, a knowledge base can be formed that can serve to direct future investigations concerning the influence of artificial grass surfaces and injury and, ultimately, how that influence can be affected.

The effect of lateral meniscectomy on motion of the knee

With the use of a five-degrees-of-freedom testing apparatus, we studied changes in the motion of the knees of cadavera after isolated resection of the lateral meniscus, with section of the anterior cruciate ligament and resection of the medial meniscus. Primary anterior and posterior translations were not affected by lateral meniscectomy. When lateral meniscectomy was done in addition to resection of the anterior cruciate ligament, anterior translation did not increase compared with that measured after isolated section of the anterior cruciate ligament. However, when the means of the paired differences in anterior translation were compared, a significant increase was found. This differed from the results after excision of the medial meniscus and section of the anterior cruciate ligament; in that situation, medial meniscectomy resulted in significantly more anterior translation.

Arthroscopic removal of entrapped debris following dislocation of a total hip arthroplasty

The entrapment of a foreign body within a dislocated hip prosthesis is an unusual occurrence. Dislodgement of the fragments by closed reduction should be attempted to try to extricate the fragment from the femoral head and acetabular cup interface. If closed techniques prove unsuccessful, arthroscopy can be used to guide instrumented removal of the interposed fragments.

Multiple joint sepsis by Hemophilus influenza in an adult

The bacterium Hemophilus influenza, also known as the Pfeiffer bacillus, is generally regarded as a disease of infancy and early childhood. An occurrence in adulthood is rare. A 43-year-old woman developed septic arthritis of more than one joint caused by Hemophilus influenza. The infrequency of this infection and the degree of difficulty in diagnosis is confirmed by a review of the literature.

An anteromedial approach to the posterior cruciate ligament

A straight anteromedial incision for the exposure of the medial, posteromedial, and posterior ligaments of the knee provides favorable exposure of the distal attachment site of the posterior cruciate ligament. This approach enables a medial parapatellar arthrotomy to be performed through the same incision. The key elements of the exposure are the reflection of the semimembranosus tendon and detachment of the posterior capsule from the medial meniscus.

Medial restraints to anterior-posterior motion of the knee

We investigated the motion of cadaver knees before and after section of the medial structures and anterior cruciate ligament. The knees were tested using a 5-degrees-of-freedom in vitro knee-testing apparatus that measured anterior-posterior, medial-hateral, and axial displacement as well as internal-external and valgus-varus rotation. The fiexion angle could be varied but was fixed for each individual test. A 125-newton anterior-posterior force was applied perpendicular to the tibial shaft and the resulting motion of the knee was measured. In five knees the anterior cruciate ligament was cut first, followed by progressive cuts of the structures on the medial side (superficial medial collateral ligament, deep medial ligament, oblique fibers of the superficial medial ligament, and the posteromedial part of the capsule). Conversely, in five knees the medial structures were progressively cut first, followed by section of the anterior cruciate ligament. Tests were performed after each cut. With an intact anterior cruciate ligament, progressive cutting of the medial side had no effect on anterior and posterior displacements. When section of the medial structures followed cutting of the anterior cruciate ligament, anterior displacement exceeded that seen after isolated section of the anterior cruciate ligament. The anterior and posterior load-tests were repeated with the tibia fixed in 5 degrees of internal and 5 degrees of external rotation. Fixed external notation had no effect on anterior and posterior displacements. Fixed internal rotation significantly decreased anterior displacement only when both the anterior cruciate ligament and the medial structures were cut. The amounts of tibial rotation and tibial torque resulting from the applied anterior and posterior forces were low compared with our previous results, and we attributed this to decreased constraints on motion of the knee in the current testing apparatus.

CLINICAL RELEVANCE

Athletic injuries of the knee frequently involve both the anterior cruciate ligament and the medial side of the knee. Clinical studies have demonstrated that combined injuries of the anterior cruciate and medial collateral ligaments often cannot be successfully managed conservatively. Our in vitro findings support the clinical data and suggest that injuries to the medial structures further compromise anterior stability when they accompany anterior cruciate injuries.

An instrument for the placement of multiple sutures for knee meniscus or ligament repair

An inexpensive plastic suture guide originally developed for prosthetic valve insertion is useful for the placement of multiple, consecutive sutures in torn menisci or ligaments of the knee joint. The device is time-saving and reliable.

Meniscal lesions associated with anterior cruciate ligament injury

The menisci frequently are injured during anterior cruciate ligament (ACL) injury or degenerate in a period of several years. The meniscus, in addition to transferring force across the joint, prevents tibial displacement on the femur if the ACL is injured. Ten per cent to 30% of the peripheral meniscus has circulation; healing can occur if a tear communicates with this region. Arthroscopic partial meniscectomy in irreparable tears can be helpful in some patients with meniscus-derived complaints. Total meniscectomy should be avoided in ACL insufficient knees when possible. Accurate meniscal reattachment with ligamentous reconstruction should restore knee stability.

The effect of medial meniscectomy on anterior-posterior motion of the knee

We used an in vitro knee-testing apparatus to measure anterior-posterior displacement of the tibia on the femur and the accompanying tibial rotation in response to an applied anterior-posterior force. Testing was performed on nine intact knees, on five knees after medial meniscectomy, on three knees after isolated section of the anterior cruciate ligament, and on eight knees after both excision of the medial meniscus and section of the anterior cruciate ligament. The induced anterior-posterior displacement and the coupled rotation were unaffected by meniscectomy. Isolated section of the anterior cruciate ligament allowed a significant (p less than 0.05) increase in anterior displacement but had no effect on posterior displacement. The coupled internal rotation associated with anterior displacement was lost after section of the anterior cruciate ligament. Excision of the medial meniscus and section of the anterior cruciate ligament allowed significantly (p less than 0.05) greater increases in anterior displacement than those already increased by isolated section of the anterior cruciate ligament.

Simultaneous dislocation of the interphalangeal and metacarpophalangeal joints of the thumb: a case report

A complete dislocation of the proximal phalanx of the thumb is presented. At 6 months after the injury, the patient had a painless right thumb with a full range of motion. No such similar case has been found in the literature.