Efficacy and Validation of a Simulation-Based Compartment Syndrome Instructional Course.

Background: This study reports the validity and effectiveness of a simulation-based compartment syndrome instructional course. Methods: Six post-graduation year one (PGY1) orthopaedic residents and six PGY5 residents participated in the study. All PGY1 residents participated in a four-hour compartment syndrome training simulation. An anatomic compartment model was used to test needle placement accuracy in four leg muscle compartments. Pre-training, immediate post-training, and one-month post-training performance data were collected from all PGY1 residents, as well as data from a onetime assessment of all PGY5 residents. These assessments included a paper test for lower leg anatomy (anatomy module), a procedural test of needle placement accuracy using an anatomic compartment syndrome simulation module (needle placement module), and an assessment of ability to measure compartment pressure via low cost simulation (pressure measurement module). Face validity of the needle placement module and pressure measurement module were assessed using a structured questionnaire given to all 12 study participants and three orthopaedic faculty. Results: The PGY1 residents demonstrated significant improvement at immediate post-training in all three assessments compared to their pre-training performances (anatomy p=0.019, needle placement p=0.026, pressure measurement p=0.033 and Objective Structured Assessment of Technical Skill (OSATS) score for pressure measurement p <0.0001). This performance was maintained at the one-month post-training assessment. Immediate post-training and one-month post-training PGY1 resident performances were comparable with PGY5 resident performance in all tests.Fifteen participants rated the face validity of the needle placement and pressure measurement modules. For the needle placement module, 73.3% of participants highly rated (4 out of 5 or greater) for realism, 86.7% highly rated for being an effective tool for teaching, and 80% highly rated for needing the model to be available throughout their training. The pressure measurement module did not receive high face validity ratings. Conclusions: With minimal, inexpensive training, the performance of junior residents in a compartment syndrome simulation was improved to a level comparable with senior residents. In addition, this performance was maintained at one-month post-training. The compartment syndrome anatomic module had highly-rated face validity. Clinical Relevance: Training junior residents to accurately diagnose compartment syndrome using a realistic simulation may allow for greater diagnostic accuracy in the clinical setting.

Percutaneous Reduction and Screw Fixation of Displaced Intra-articular Fractures of the Calcaneus.

BACKGROUND: Extensile open approaches to reduce and fix intra-articular calcaneal fractures are associated with high levels of wound complications. To avoid these complications, a technique of percutaneous reduction and fixation with screws alone was developed. This study assessed the clinical outcomes, radiographs, and postoperative CT scans after operative treatment with this technique. METHODS: 153 consecutive patients with 182 intra-articular calcaneal fractures were reviewed. All patients were assessed for early postoperative complications at 3 months from the injury. The clinical results were assessed for patients seen at a minimum of 1 year after surgery (mean follow-up of 2.6 years; 90 patients, 106 feet). In patients who had both preoperative and postoperative CT scans (50 patients, 60 feet), the articular reduction was quantitatively analyzed. RESULTS: At the 3-month follow-up, there were 1% superficial infections and 1% rate of screw irritation. The complications at a minimum of 1 year after injury included screw irritation 9.3%, subtalar osteoarthritis requiring subtalar fusion 5.5%, malunion 1.8%, and deep infection 0.9%. Bohler angle, calcaneal facet height, and width were significantly improved postoperatively ( P < .01). Bohler angle increased on average +24.1 degrees postoperatively with a loss of angle of 4.9 degrees at the 3-month follow-up. There was significant improvement ( P < .01) in posterior talocalcaneal joint reduction on postoperative CT scan but residual displacement remained. At the final follow-up, 54.5% of the patients reported a residual pain level of 3 or lower. CONCLUSION: This study suggests that reasonable early results could be achieved from the percutaneous treatment of intra-articular calcaneal fractures using screws alone based on articular reduction and level of residual pain. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Comparison of Outcomes and Complications of Isolated Acetabular Fractures and Acetabular Fractures With Associated Injuries.

OBJECTIVE: To compare patients with acetabular fractures that are isolated (acetabular fracture alone) and acetabular fracture presenting with additional nonacetabular injury using functional outcomes, complications, and readmissions. DESIGN: Retrospective review. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Two hundred fifteen patients underwent open surgical treatment for acetabular fracture between 2003 and 2012 with age ≥18 years and minimum 1-year follow-up inclusive of functional scores and complications. INTERVENTION: Surgical treatment of acetabular fracture. MAIN OUTCOME MEASUREMENTS: Postoperative functional outcomes at 1 year as assessed with the Short Form 36 (SF-36) Health Survey Questionnaire and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), postoperative complications including readmissions. RESULTS: Acetabular fractures patients with associated nonacetabular injuries exhibited a longer length of hospital stay (P < 0.0001) and higher readmission rate within 90 days (P = 0.012) compared with patients in the isolated injury group. Acetabular fracture with either chest or abdominal injury had the longest average hospital stay (19.2 and 19.1 days, respectively). Functional scores between 2 groups were comparable at 1-year follow-up, except acetabular fractures with pelvic ring injury, which had a significantly lower physical component score of SF-36 (P = 0.007) compared with the isolated group. CONCLUSIONS: Acetabular fractures with associated nonacetabular injuries have longer hospital stays, higher complications, and readmissions. Specifically, patients with associated truncal injury had worse clinical outcome and longer hospital stays. These conclusions should be taken into account when counseling patients with acetabular fractures, as additional injuries will greatly affect the course of treatment and the outcomes. LEVEL OF EVIDENCE: Prognostic level III. See Instructions for Authors for a complete description of levels of evidence.

Knee, Shoulder, and Fundamentals of Arthroscopic Surgery Training: Validation of a Virtual Arthroscopy Simulator.

PURPOSE: To validate the knee, shoulder, and virtual Fundamentals of Arthroscopic Training (FAST) modules on a virtual arthroscopy simulator via correlations with arthroscopy case experience and postgraduate year. METHODS: Orthopaedic residents and faculty from one institution performed a standardized sequence of knee, shoulder, and FAST modules to evaluate baseline arthroscopy skills. Total operation time, camera path length, and composite total score (metric derived from multiple simulator measurements) were compared with case experience and postgraduate level. Values reported are Pearson r; alpha = 0.05. RESULTS: 35 orthopaedic residents (6 per postgraduate year), 2 fellows, and 3 faculty members (2 sports, 1 foot and ankle), including 30 male and 5 female residents, were voluntarily enrolled March to June 2015. Knee: training year correlated significantly with year-averaged knee composite score, r = 0.92, P = .004, 95% confidence interval (CI) = 0.84, 0.96; operation time, r = -0.92, P = .004, 95% CI = -0.96, -0.84; and camera path length, r = -0.97, P = .0004, 95% CI = -0.98, -0.93. Knee arthroscopy case experience correlated significantly with composite score, r = 0.58, P = .0008, 95% CI = 0.27, 0.77; operation time, r = -0.54, P = .002, 95% CI = -0.75, -0.22; and camera path length, r = -0.62, P = .0003, 95% CI = -0.8, -0.33. Shoulder: training year correlated strongly with average shoulder composite score, r = 0.90, P = .006, 95% CI = 0.81, 0.95; operation time, r = -0.94, P = .001, 95% CI = -0.97, -0.89; and camera path length, r = -0.89, P = .007, 95% CI = -0.95, -0.80. Shoulder arthroscopy case experience correlated significantly with average composite score, r = 0.52, P = .003, 95% CI = 0.2, 0.74; strongly with operation time, r = -0.62, P = .0002, 95% CI = -0.8, -0.33; and camera path length, r = -0.37, P = .044, 95% CI = -0.64, -0.01, by training year. FAST: training year correlated significantly with 3 combined FAST activity average composite scores, r = 0.81, P = .0279, 95% CI = 0.65, 0.90; operation times, r = -0.86, P = .012, 95% CI = -0.93, -0.74; and camera path lengths, r = -0.85, P = .015, 95% CI = -0.92, -0.72. Total arthroscopy cases performed did not correlate significantly with overall FAST performance. CONCLUSIONS: We found significant correlations between both training year and knee and shoulder arthroscopy experience when compared with performance as measured by composite score, camera path length, and operation time during a simulated diagnostic knee and shoulder arthroscopy, respectively. Three FAST activities demonstrated significant correlations with training year but not arthroscopy case experience as measured by composite score, camera path length, and operation time. CLINICAL RELEVANCE: We attempt to validate an arthroscopy simulator that could be used to supplement arthroscopy skills training for orthopaedic residents.

There is poor reliability of Böhler's angle and the crucial angle of Gissane in assessing displaced intra-articular calcaneal fractures.

BACKGROUND: Two-dimensional measurements are used to describe displaced intra-articular calcaneal fractures (DIACF). Our study evaluates the performance of Böhler's angle (BA) and the crucial angle of Gissane (CAG) among orthopedic surgeons. METHODS: Thirty-four pre- and post-operative lateral foot radiographs from patients with DIACF were shown to four orthopedic surgeons who measured BA and the CAG. The intra- and inter-observer reliability were calculated using the intra-class correlation coefficient (ICC). Additionally, we calculated frequency of consensus given an allowed discrepancy. We then determined the tolerance limit for each measurement. RESULTS: The ICC for inter-observer reliability of BA was 0.83 in the first session and 0.77 in the second. The ICC for intra-observer reliability ranged from 0.83 to 0.98. For the CAG, the inter-observer ICC was 0.28 and 0.1 in the two sessions. Intra-observer ICC ranged from 0.16 to 0.67. With an allowed discrepancy of 20°, there was lack of consensus for BA in 37.5% and for the CAG in 59% of measurements on average. The 95% confidence interval for 90% agreement in BA involved a range of 76°. For CAG, the 95% confidence interval of tolerance for 90% agreement was 56°. CONCLUSIONS: For BA and CAG, there is frequent disagreement among experienced observers, even given a wide tolerance range. We recommend use of caution when applying BA as currently measured in making treatment decisions for DIACF. LEVEL OF CLINICAL EVIDENCE: Diagnostic, level III.

Asymmetric Bilateral Hip Dislocations: A Case Report and Historical Review of the Literature.

BACKGROUND: Asymmetric bilateral hip dislocations are a rare injury pattern in which one hip dislocates posteriorly, and the contralateral hip dislocates anteriorly. We report a case of bilateral asymmetric hip dislocations and provide a comprehensive review of all available reports, identifying 104 total cases, which is 70 more than previously reported. PURPOSE: To review and evaluate the total body of literature regarding bilateral asymmetric hip dislocations. METHODS: Comprehensive literature review and analysis of all reports of bilateral asymmetric hip dislocations with concurrent case report. RESULTS AND CONCLUSIONS: Bilateral, asymmetric represent approximately 0.01%-0.02% of all joint dislocations. There has been a substantial increase in the number of case reports in the literature in the last 10 years. Males are more likely than females to incur this injury pattern and the most common mode of injury is motor vehicle accident Urgent closed reduction should be attempted in an efficient and safe manner to avoid potential complications, and open reduction should be considered in irreducible dislocations. Post reduction management should include stability assessment and CT to assess for associated injuries and intraarticular fragments; although no clear guidelines for post-reduction treatment emerged. Common complications include: nerve palsies, AVN and heterotopic ossification.

Surgical Coaching from Head-Mounted Video in the Training of Fluoroscopically Guided Articular Fracture Surgery.

BACKGROUND: The evolving surgical skills education paradigm in orthopaedics has generated a strong demand for validated educational tools and methodologies. This study aimed to confirm that a one-on-one faculty coaching review of the head-mounted video recording of a resident's surgical performance on a validated articular fracture simulation trainer would substantially improve subsequent performance. METHODS: Fifteen first-year or second-year orthopaedic surgery residents reduced and fixed a standardized intra-articular tibial plafond fracture model under fluoroscopic guidance. Their performances were recorded by a head-mounted video camera. Prior to repeating the procedure six weeks later, eight subjects (the intervention group) reviewed the video of their performance with an orthopaedic traumatologist, and seven subjects (the control group) did not. Cohort performance was compared with respect to task duration, number of fluoroscopic images, and scores on the Objective Structured Assessment of Technical Skills (OSATS) as evaluated by fellowship-trained orthopaedic traumatologists blinded to the residents' year in training and prior surgical experience. RESULTS: The initial performance OSATS scores were not significantly different (p ≥ 0.05) between the control and intervention groups. Assessments of their repeat performance showed a significant net interval improvement (p < 0.05) in OSATS scores in the intervention group (mean [and standard deviation], 21 ± 8 points) compared with the control group (6 ± 3 points). The mean fluoroscopy utilization had a significant net decrease (p < 0.05) in the intervention group (-5.4 ± 11.7 points) compared with the control group (5.3 ± 7.0 points). Task duration in the repeat performance was similar between both groups. CONCLUSIONS: Personalized video-based feedback improved performance on a standardized articular fracture trainer for first-year and second-year residents. The described technique may further enhance resident surgical skills education.

Tibialis Anterior Tendon Transfer for Relapsing Idiopathic Clubfoot.

INTRODUCTION: A relapsed idiopathic clubfoot can be effectively treated with transfer of the entire tibialis anterior tendon to the mid-dorsum of the foot following repeated manipulations and serial casts. STEP 1 PREOPERATIVE PLANNING: Ensure that the foot has been adequately corrected for tendon transfer by performing both clinical and radiographic evaluation. STEP 2 PREPARE THE PATIENT: Position the patient supine, induce general anesthesia, and perform a caudal block for postoperative pain management. STEP 3 IDENTIFY AND RELEASE THE TIBIALIS ANTERIOR TENDON FROM ITS INSERTION: Identify the tibialis anterior tendon and release its insertion on the medial cuneiform and first metatarsal bones. STEP 4 PREPARE THE TENDON AND SURROUNDING TISSUES FOR TRANSFER: Release obstructing tissues and prepare the freed tendon for lateral transfer to the mid-dorsum of the foot. STEP 5 PREPARE THE LATERAL CUNEIFORM FOR TENDON TRANSFER AND FIXATION: Identify the lateral cuneiform with fluoroscopy and prepare it for transfer of the tibialis anterior tendon. STEP 6 TRANSFER AND SECURE THE TENDON: Make a subcutaneous path, transfer the tendon, and secure it in the osseous tunnel of the lateral cuneiform. STEP 7 POSTOPERATIVE CARE: We apply a long leg cast and restrict patients to non-weight-bearing for six weeks. RESULTS: The tibialis anterior tendon transfer has been used to treat relapsing idiopathic clubfoot with great success for more than fifty years.IndicationsContraindicationsPitfalls & Challenges.

Development of an orthopaedic surgical skills curriculum for post-graduate year one resident learners - the University of Iowa experience.

Orthopaedic surgery requires a high degree of technical skill. Current orthopaedic surgical education is based largely on an apprenticeship model. In addition to mounting evidence of the value of simulation, recent mandated requirements will undoubtedly lead to increased emphasis on surgical skills and simulation training. The University of Iowa's Department of Orthopaedic Surgery has created and implemented a month long surgical skills training program for PGY-1 residents. The goal of the program was to improve the basic surgical skills of six PGY-1 orthopaedic surgery residents and prepare them for future operative experiences. A modular curriculum was created by members of the orthopaedic faculty which encompassed basic skills felt to be important to the general orthopaedic surgeon. For each module multiple assessment techniques were utilized to provide constructive critique, identify errors and enhance the performance intensity of trainees. Based on feedback and debriefing surveys, the resident trainees were unanimously satisfied with the content of the surgical skills month, and felt it should remain a permanent part of our educational program. This manuscript will describe the development of the curriculum, the execution of the actual skills sessions and analysis of feedback from the residents and share valuable lessons learned and insights for future skills programs.