The Role of Arthroscopic Simulation in Teaching Surgical Skills: A Systematic Review of the Literature.

BACKGROUND: Following the introduction of worktime regulations across the world along with existing concerns over the nonuniform nature of the traditional apprenticeship model, an alternative method for teaching surgical skills is being sought. Simulation training offers a safe and standardized environment to develop and improve surgical skills. The purpose of the present study was to review the existing and most recent research into the utility of arthroscopic simulators in training and the teaching of surgical skills. METHODS: A systematic review of the MEDLINE, Embase, and Cochrane Library databases for English-language articles published between 2014 and November 2017 was conducted. Search terms included arthroscopy or arthroscopic with simulation or simulator. RESULTS: We identified a total of 27 relevant studies involving simulated ankle, knee, shoulder, hip, and simple box arthroscopic environments. The majority of these studies demonstrated construct validity, while a few demonstrated transfer, face, and content validity. CONCLUSIONS: Our review suggests that there is a considerable evidence base regarding the use of arthroscopic simulators for training purposes. Further work should focus on the development of a standardized simulator training course that can be contrasted against current intraoperative training in large-scale multicenter trials with long-term follow-up.

Late Presentation of Infected Silicone Granulomas in the Lower Limb.

INTRODUCTION: Dermal fillers are used for multiple cosmetic indications including gluteal and thigh augmentation. Complications, although infrequent, are increasing due to the dramatic growth of dermal filler use. Our aim was to describe how the complication of infected silicone granulomas can present following lower limb augmentation. METHODS: Two cases presented with pain, oedema, and erythema at the site of previous silicone filler injection, following a considerable delay after the last injection (range 4-7 years). We collected data on their biochemistry, haematology, histology, microbiology, and imaging at the time of presentation. RESULTS: Complications included prolonged cellulitis with recurrent abscesses at sites of previous silicone dermal filler injection. Histology revealed infiltration of chronic inflammatory cells suggestive of silicone granuloma in both cases. Patients were reluctant to divulge use of cosmetic fillers or failed to recognise their significance given the time delay making diagnosis difficult. Delayed or recurring infections can suggest the presence of atypical organisms and we present the first reported case of silicone granuloma infection with Propionibacterium acnes. CONCLUSIONS: Microorganisms can induce immune-mediated hypersensitivity and are believed to be the trigger for delayed activation of a quiescent foreign body to a granulomatous reaction. The substantial time delay between injection and reaction must be recognised and may be attributable to atypical microorganisms or biofilm formation. Previous antibiotic use can affect expedient microbiological diagnosis and treatment requires close collaboration with microbiologists. It is important that clinicians are aware of these important complications which are becoming more common with increased use of filler augmentation.

The Clavicle Trial: A Multicenter Randomized Controlled Trial Comparing Operative with Nonoperative Treatment of Displaced Midshaft Clavicle Fractures.

BACKGROUND: The treatment of displaced midshaft clavicle fractures remains controversial. METHODS: We undertook a multicenter randomized controlled trial to compare effectiveness and safety between nonoperative management and ORIF (open reduction and internal fixation) for displaced midshaft clavicle fractures in adults. Three hundred and one eligible adult patients were randomized to 1 of the 2 treatment groups and followed at 6 weeks, 3 months, and 9 months after recruitment. The primary outcome was the rate of radiographically evident nonunion at 3 months following treatment. Secondary outcomes were the rate of radiographically evident nonunion at 9 months, limb function measured using the Constant-Murley Score and DASH (Disabilities of the Arm, Shoulder and Hand) score, and patient satisfaction. RESULTS: There was no difference in the proportion of patients with radiographic evidence of nonunion at 3 months between the operative (28%) and nonoperative (27%) groups, whereas at 9 months the proportion with nonunion was significantly lower (p < 0.001) in the operative group (0.8%) than in the nonoperative group (11%). The DASH and Constant-Murley scores and patient satisfaction were all significantly better in the operative group than in the nonoperative group at 6 weeks and 3 months. CONCLUSIONS: Although at 3 months there was no evidence that surgery had reduced the rate of nonunion of displaced midshaft clavicle fractures, at 9 months nonoperative treatment had led to a significantly higher nonunion rate (11% compared with <1%). The rate of secondary surgical intervention during the trial period was 12 (11%) of the 147 patients in the nonoperative group. ORIF is a safe and reliable intervention with superior early functional outcomes and should be considered for patients who sustain this common injury. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Surgical interventions for treating fractures of the olecranon in adults.

BACKGROUND: Fractures of the olecranon (the bony tip of the elbow) account for approximately 1% of all upper extremity fractures. Surgical intervention is often required to restore elbow function. Two key methods of surgery are tension band wire fixation and plate fixation. OBJECTIVES: To assess the effects (benefits and harms) of different surgical interventions in the treatment of olecranon fractures in adults. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (22 September 2014), the Cochrane Central Register of Controlled Trials (CENTRAL, 2014, Issue 8), MEDLINE (1946 to September week 2 2014), EMBASE (1980 to 19 September 2014), trial registers, conference proceedings and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials (RCT) and quasi-RCTs that compared different surgical interventions for the treatment of olecranon fractures in adults. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, risk of bias assessment and data extraction. The primary outcomes of this review were function, pain and adverse events. MAIN RESULTS: We included six small trials involving 244 adults with olecranon fractures. Of these, four were RCTs and two were quasi-RCTs; both of were at high risk of selection bias. All six trials were at high risk of performance bias, reflecting lack of blinding, and four trials were at high risk of detection bias. The quality of the evidence for most outcomes was generally very low because of limitations in study design and implementation, and either imprecision of the results or inadequate outcome measures. Thus, we are very uncertain about the estimates of effect.One trial (41 participants) comparing plate fixation with standard tension band wiring provided very low quality evidence at 16 to 86 weeks' follow-up of a better clinical outcome after plate fixation (good outcome (little pain or loss of elbow motion): 19/22 versus 9/19, risk ratio (RR) 1.82 favouring plate fixation, 95% confidence interval (CI) 1.10 to 3.01). There was very low quality evidence of less symptomatic prominent metalwork after plate fixation (1/22 versus 8/19; RR 0.11, 95% CI 0.01 to 0.79). The results for other adverse effects (infection and delayed or non-union) were inconclusive. Evidence is pending from a newly (September 2014) completed trial (67 participants) making the same comparison.Four trials compared four different modified techniques of tension band wiring (i.e. additional intramedullary screw fixation, biodegradable pins, Netz pins and cable pin system) versus standard tension band wiring. There was very low quality evidence of little difference at six to 14 months in function assessed by a non-validated scoring tool from the addition of an intramedullary screw. However, there were fewer cases of metalwork prominence in the intramedullary screw group (1/15 versus 8/15; RR 2.00, 95% CI 1.15 to 3.49; one trial; 30 participants). There was very low quality evidence from one trial (25 participants) of little difference in subjectively or objectively assessed good outcome at a mean of 20 months between tension band wiring with biodegradable implants versus metal implants. There were no adverse events, either non-union or sinus or fluid accumulation, reported. All 10 participants in the metalwork group had an extra operation to remove their metalwork at one year. One trial, which did not report on function or pain, provided very low quality evidence of lower rates of metalwork for any reason or for symptoms after Netz pin tension band wiring compared with standard tension band wiring (11/21 with Netz pin versus 17/25 with standard tension band wiring; RR 0.77, 95% CI 0.47 to 1.26; 46 participants); this evidence also supports the possibility of higher rates of metalwork removal for Netz pins. Two intra-operative complications occurred in the Netz pin group. The fourth trial, which compared the cable pin system with standard procedure, found low quality evidence that cable pin improved functional outcome at a mean of 21 months (Mayo Elbow Performance Score (MEPS), range 0 to 100: best outcome: mean difference (MD) 7.89 favouring cable pin, 95% CI 3.14 to 12.64; one trial; 62 participants). It also found low quality evidence of fewer postoperative complications in the cable pin group (1/30 with cable pin system versus 7/32 standard tension band wiring; RR 0.15, 95% CI 0.02 to 1.17), although the evidence did not rule out the converse.One trial provided very low quality evidence of similar patient-reported function using the Disabilities of the Arm, Shoulder and Hand questionnaire (0 to 100: worst function) at two or more years after fixation using a novel olecranon memory connector (OMC) compared with locking plate fixation (MD -0.70 favouring OMC, 95% CI -4.20 to 2.80; 40 participants). The only adverse event was a superficial infection in the locking plate group. AUTHORS' CONCLUSIONS: There is insufficient evidence to draw robust conclusions on the relative effects of the surgical interventions evaluated by the included trials. Further evidence, including patient-reported data, on the relative effects of plate versus tension band wiring is already pending from one recently completed RCT. Further RCTs, using good quality methods and reporting validated patient-reported measures of function, pain and activities of daily living at set follow-ups, are needed, including checking positive findings such as those relating to the use of an intramedullary screw and the cable pin system. Such trials should also include the systematic assessment of complications, further treatment including routine removal of metalwork and use of resources.

Is hybrid imaging (SPECT/CT) a useful adjunct in the management of suspected facet joints arthropathy?

PURPOSE: The purpose of this study was to assess the value of SPECT/CT imaging in patients with chronic spinal pain. METHODS: This was a retrospective consecutive study. Patients with chronic neck or back pain from outpatient spinal clinics with clinical features raising the possibility of a facetogenic pain generator and non-conclusive MRI/CT findings were included. Imaging was performed on a dual-headed, hybrid SPECT/CT γ-camera with a low-dose CT transmission scan acquired after the SPECT study. SPECT/CT studies were viewed in the coronal, axial, and sagittal planes and in 3-dimensional mode. Descriptive statistical analysis was performed. RESULTS: Seventy-two patients were included (37 females, 35 males, mean age of 53.9 years). There were 25 cervical spine scans and 49 lumbar spine scans. In the cervical spine group, 13 (52 %) patients had scintigraphically active cervical facet joint arthropathy and ten (36 %) had other pathology identified. Two thirds of patients diagnosed with facet joint arthropathy received steroid guided injections following their scans. In the lumbar spine group 34 (69.4 %) patients had scintigraphically active lumbar facet joint arthropathy and eight had other pathology identified. Twenty patients (58.8 %) diagnosed with facet joint arthropathy subsequently received steroid guided injections. CONCLUSIONS: Hybrid SPECT/CT imaging identified potential pain generators in 92 % of cervical spine scans and 86 % of lumbar spine scans. The scan precisely localised SPECT positive facet joint targets in 65 % of the referral population and a clinical decision to inject was made in 60 % of these cases.

Conservative management versus open reduction and internal fixation for mid-shaft clavicle fractures in adults--the Clavicle Trial: study protocol for a multicentre randomized controlled trial.

BACKGROUND: Clavicle fractures account for around 4% of all fractures and up to 44% of fractures of the shoulder girdle. Fractures of the middle third (or mid-shaft) account for approximately 80% of all clavicle fractures. Management of this group of fractures is often challenging and the outcome can be unsatisfactory. In particular it is not clear whether surgery produces better outcomes than non-surgical management. Currently there is much variation in the use of surgery and a lack of good quality evidence to inform our decision. METHODS/DESIGN: We aim to undertake a multicentre randomised controlled trial evaluating the effectiveness and safety of conservative management versus open reduction and internal fixation for displaced mid-shaft clavicle fractures in adults. Surgical treatment will be performed using the Acumed clavicle fixation system. Conservative management will consist of immobilisation in a sling at the side in internal rotation for 6 weeks or until clinical or radiological union. We aim to recruit 300 patients. These patients will be followed-up for at least 9 months. The primary endpoint will be the rate of non-union at 3 months following treatment. Secondary endpoints will be limb function measured using the Constant-Murley Score and the Disabilities of the Arm, Shoulder and Hand (DASH) Score at 3 and 9 months post-operatively. DISCUSSION: This article presents the protocol for a multicentre randomised controlled trial. It gives extensive details of, and the basis for, the chosen methods, and describes the key measures taken to avoid bias and to ensure validity. TRIAL REGISTRATION: United Kingdom Clinical Research Network ID: 8665. The date of registration of the trial is 07/09/2006. The date the first patient was recruited is 18/12/2007.

A conservative approach to quadricepsplasty: description of a modified surgical technique and a report of three cases.

Various techniques have been described for the treatment of soft tissue extension contracture of the knee. Some involve large exposures, and others can result in a permanent extensor lag. We describe a technique with limited exposure, avoiding transverse incisions in the rectus femoris. Through a midline incision, the extensor expansion is exposed. The rectus femoris is separated from the vastus medialis, lateralis, and intermedius to form a strap-like structure. Vastus intermedius is separated from the patella. If firm, careful manipulation of the knee is unsuccessful, the incisions are extended distally along both sides of the patella and patellar tendon, releasing the extensor mechanism from any underlying heterotopic bone, and further manipulation of the knee is performed. Postoperatively, a rehabilitation program is begun. A good outcome following this technique is described in 3 knees presenting with severe restriction of knee flexion. There were no wound complications and no residual extensor lag.

A randomized, double-blind, placebo-controlled trial of donepezil hydrochloride (Aricept) for reducing the incidence of postoperative delirium after elective total hip replacement.

OBJECTIVES: This was a pilot, phase 2a study to assess methodological feasibility and the safety and efficacy of donepezil in preventing postoperative delirium after elective total hip replacement surgery in older people without pre-existing dementia. The hypothesis was that donepezil would reduce the incidence of postoperative delirium. METHODS: A double blind, placebo controlled, parallel group randomized trial was undertaken. Patients were block randomized pre-operatively to receive placebo or donepezil 5 mg immediately following surgery and every 24 h thereafter for a further three days. The main outcome was the incidence of delirium (using the Delirium Symptom Interview). The secondary outcome was length of hospital stay. RESULTS: Thirty-three patients (mean age 67 years; 17 males, 16 females) completed the study (19 donepezil, 14 placebo). Donepezil was well tolerated with no serious adverse events. Postoperative delirium occurred in 21.2% of subjects. Donepezil did not significantly reduce the incidence of delirium. The unadjusted risk ratio (donepezil vs placebo) for delirium was 0.29 (95% CI = 0.06,1.30) (chi(2) ([1]) = 3.06; p = 0.08). Mean length of hospital stay was 9.9 days for the donepezil group vs 12.1 days in the placebo group; difference in means = -2.2 days (95% CI = -0.39,4.78) (t([31]) = 1.73: p = 0.09). CONCLUSIONS: The experimental paradigm was feasible and acceptable. Donepezil did not significantly reduce the incidence of delirium or length of hospital stay, however for both outcomes there was a consistent trend suggesting possible benefit. The sample size required for a definitive trial (99% power, alpha 0.05) would be 95 subjects per arm.

Common misconceptions of normal hip joint relations on pelvic radiographs.

This study defines normal bilateral variations in offset and hip center location on pelvic radiographs. The relationship of the femoral head center to the tip of the greater trochanter and that of offset to medullary canal diameter are also defined. Measurements of the offset, hip center location, height of the tip of the greater trochanter from the femoral head center, and medullary canal diameter were carried out on 100 normal pelvic radiographs. The offset of one hip was found to predict that of the contralateral hip to within 4.62 mm with 95% confidence. Their hip center locations differed by 6.3 mm. The tip of the greater trochanter was, on average, 8 mm higher than the femoral head center. Although offset generally increased with an increase in medullary canal diameter, frequent discrepancies occurred in their relationship.