General: Entrenamiento virtual para hacerlo bien

Fundamental arthroscopic skill differentiation with virtual reality simulation

Rose K, Pedowitz R.

Arthroscopy. 2015 Feb;31(2):299-305
doi: 10.1016/j.arthro.2014.08.016

Abstract

PURPOSE:
The purpose of this study was to investigate the use and validity of virtual reality modules as part of the educational approach to mastering arthroscopy in a safe environment by assessing the ability to distinguish between experience levels. Additionally, the study aimed to evaluate whether experts have greater ambidexterity than do novices.

METHODS:
Three virtual reality modules (Swemac/Augmented Reality Systems, Linkoping, Sweden) were created to test fundamental arthroscopic skills. Thirty participants-10 experts consisting of faculty, 10 intermediate participants consisting of orthopaedic residents, and 10 novices consisting of medical students-performed each exercise. Steady and Telescope was designed to train centering and image stability. Steady and Probe was designed to train basic triangulation. Track and Moving Target was designed to train coordinated motions of arthroscope and probe. Metrics reflecting speed, accuracy, and efficiency of motion were used to measure construct validity.

RESULTS:
Steady and Probe and Track a Moving Target both exhibited construct validity, with better performance by experts and intermediate participants than by novices (P < .05), whereas Steady and Telescope did not show validity. There was an overall trend toward better ambidexterity as a function of greater surgical experience, with experts consistently more proficient than novices throughout all 3 modules.

CONCLUSIONS:
This study represents a new way to assess basic arthroscopy skills using virtual reality modules developed through task deconstruction. Participants with the most arthroscopic experience performed better and were more consistent than novices on all 3 virtual reality modules. Greater arthroscopic experience correlates with more symmetry of ambidextrous performance. However, further adjustment of the modules may better simulate fundamental arthroscopic skills and discriminate between experience levels.

CLINICAL RELEVANCE:
Arthroscopy training is a critical element of orthopaedic surgery resident training. Developing techniques to safely and effectively train these skills is critical for patient safety and resident education.

Rodilla/Knee: Ojo con la gonartritis séptica posoperatoria

Joint infection after knee arthroscopy: Medicolegal aspects
S. Marmora, T. Farmanb, A. Lortat-Jacobc
Orthopaedics & Traumatology: Surgery & Research (2009) 95, 278—283

Summary

Introduction:
Septic knee arthritis following arthroscopy is a rare but dreaded complication: it might compromise patients’ functional prognosis and engage surgeon’s liability. This study ana- lyzes the context of such infection occurrences, their management as well as their medicolegal consequences.

Patients and methods:
Twenty-two cases of knee septic arthritis following arthroscopy were examined during the medicolegal litigation process and collected for assessment from a medi- cal liability specialised insurer. Half of the patients were manual workers who worked on their knees, and seven knees had a previous surgical history. The procedures performed at arthroscopy included seven ligamentoplasties, nine meniscotomies, three arthroscopic lavages, one arthrol- ysis, one chondroma removal and one plica resection. Seven patients, to some point, received corticosteroids: three preoperative joint injections, three intraoperative injections, and one oral corticotherapy.

Results:
Clinical signs of septic arthritis appeared after a median interval of 8 days (0—37), twice after a hemarthrosis and once after an articular burn. The median delay before treatment initiation was 4.2 days, and in 10 cases this therapeutic delay exceeded 3 days. On average, 3.5 additional procedures (1—9) were required to treat the infection and its residual sequels. Two total knee prostheses were implanted. Only two patients were free of disabling sequellae, and in five patients these sequels affected their livelihood. The medicolegal consequences were a partially permanent disability averaging 5% (0—20), a total temporary work incapacity of 120 days (40—790), a suffering burden averaging 3 out of 7 (0—4,5) points on the scale conventionally used in France. Twelve of these legal claims led to court ordered patient compensation.

Discussion:
Some risk factors of articular infection are known and well-identified. They can be linked to the patient’s condition (addiction to smoking, surgical history, professional activity)
or to medical management (intra-articular corticoid injections, interventions under oral anti- coagulants, inadvertently overheated irrigation fluid). When infection is suspected, it is often the needle-aspirated fluid’s inappropriate handling (such as absence of bacteriological testing or defective waiting time for the results), which delays the diagnostic or therapeutic manage- ment of this complication. All failures of infection diagnosis or treatment heavily contribute to malpractice claims against the surgeon. Early and appropriate management of postoperative infections helps limiting the risk of functional sequellae for the patient and reduces the risk of malpractice litigation for the practitioner.

Level of evidence: Level IV; economic and decision analysis, retrospective study

Tobillo/Ankle/Knöchel/Cheville: Microfracturas por artroscopia en jóvenes con lesiones pequeñas

Functional and MRI Outcomes After Arthroscopic Microfracture for Treatment of Osteochondral Lesions of the Distal Tibial Plafond
Keir A. Ross, Charles P. Hannon, Timothy W. Deyer, Niall A. Smyth, MaCalus Hogan, Huong T. Do,  John G. Kennedy,
J Bone Joint Surg Am, 2014 Oct 15;96(20):1708-1715.

Abstract

Background: Osteochondral lesions of the distal tibial plafond are uncommon compared with talar lesions. The objective of this study was to assess functional and magnetic resonance imaging (MRI) outcomes following microfracture for tibial osteochondral lesions.

Methods: Thirty-one tibial osteochondral lesions in thirty-one ankles underwent arthroscopic microfracture. The Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) general health questionnaire were used to obtain patient-reported functional outcome scores preoperatively and postoperatively. MRI scans were assessed postoperatively with use of the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score for twenty-three ankles.

Results: The average age was thirty-seven years (range, fifteen to sixty-eight years), and the average lesion area was 38 mm2 (range, 7.1 to 113 mm2). Twelve ankles had a kissing lesion on the opposing surface of the talus, and two ankles had a concomitant osteochondral lesion elsewhere on the talus. FAOS and SF-12 scores were significantly improved (p < 0.01) at the time of follow-up, at an average of forty-four months. The average postoperative MOCART score was 69.4 (range, 10 to 95), with a lower score in the ankles with kissing lesions (62.8) than in the ankles with an isolated lesion (73.6). Increasing age negatively impacted improvement in SF-12 (p < 0.01) and MOCART (p = 0.04) scores. Increasing lesion area was negatively correlated with MOCART scores (p = 0.04) but was not associated with FAOS or SF-12 scores. Lesion location and the presence of kissing lesions showed no association with functional or MRI outcomes.

Conclusions: Arthroscopic microfracture provided functional improvements, but the optimal treatment strategy for tibial osteochondral lesions remains unclear. The repair tissue assessed on MRI was inferior to normal hyaline cartilage. The MRI outcomes appeared to deteriorate with increasing lesion area, and both functional and MRI outcomes appeared to deteriorate with increasing age.

Level of Evidence: Therapeutic Level IV

Cadera/Hip/Hüfte/Hanche: Tras la artroscopia de cadera, habría que cerrar bien la cápsula

Anterior hip dislocation 5 months after hip arthroscopy
Daniel C Austin, John G Horneff, John D Kelly
Arthroscopy: the Journal of Arthroscopic & related Surgery 2014, 30 (10): 1380-2

Hip dislocation subsequent to hip arthroscopy is a rare complication. We report on a case of low-energy anterior hip dislocation that occurred 5 months after hip arthroscopy, a period notably longer than any previously reported event. The patient was a track and field athlete who presented and received treatment for a labral tear and cam lesion. The athlete then dislocated her hip postoperatively during competitive jumping, a motion that requires significant hip flexion and extension. The most likely cause of the anterior dislocation was failure to close the capsule at the completion of surgery, lending credibility to recent trends in the literature suggesting routine capsular closure. We believe that a partial psoas release also contributed to dynamic hip instability because of increased femoral anteversion in this patient. This case suggests that hip capsule closure should be considered at the completion of every procedure and that a psoas release should be avoided in patients with significant anteversion. Furthermore, the biomechanics of competitive jumping may make these athletes more prone to dislocation and require more conservative return-to-sport recommendations.

Rodilla/Knee/Knie/Genou: La meniscectomía medial parcial no daña tanto tras cinco años

Does Decreased Meniscal Thickness Affect Surgical Outcomes After Medial Meniscectomy?

Kim SJ, Lee SK, Kim SH, Jeong JH, Kim HS, Lee SW, Lee JH, Jung M.

Am J Sports Med. 2014 Aug 12

Abstract

BACKGROUND:

There have been no clinical studies regarding the effect of decreased meniscal thickness on outcomes after meniscectomy.

PURPOSE:

To examine the postoperative outcomes of partial meniscectomy with or without horizontal resection compared with the outcomes of subtotal meniscectomy and to evaluate the influence of decreased thickness of the medial meniscus on outcomes after partial meniscectomy.

STUDY DESIGN:

Cohort study; Level of evidence, 3.

METHODS:

A total of 312 patients who underwent medial meniscectomy were retrospectively reviewed. Patients were divided into 3 groups: group A (n = 84) included patients with partial meniscectomy with vertical resection, group B (n = 140) consisted of those with partial meniscectomy with horizontal resection, and group C (n = 88) included those with subtotal meniscectomy. Clinical function was evaluated by use of the Lysholm knee scoring scale, International Knee Documentation Committee (IKDC) subjective knee evaluation form, and Tapper and Hoover grading system. Radiologic evaluation was performed with the IKDC radiographic assessment scale as well as with measurements of the medial compartment height at the tibiofemoral joint. Preoperative values and postoperative values measured 5 years after operation were assessed.

RESULTS:

Functional outcomes in group C were inferior to those in groups A and B according to the Lysholm knee score (mean ± SD for group A = 96.1 ± 4.7, group B = 94.9 ± 5.2, group C = 84.8 ± 11.4; P < .001), IKDC subjective score (group A = 92.1 ± 6.5, group B = 91.3 ± 8.8, group C = 81 ± 11.4; P < .001), and Tapper and Hoover grading system (P = .003). There was no significant difference in scores between groups A and B. With regard to radiologic evaluation, the IKDC radiographic grade for group C was worse than the grades for groups A and B (P < .001); there was no significant difference between groups A and B. However, the postoperative joint space on the affected side was higher for group A (4.7 ± 0.6 mm) than for groups B (4.3 ± 0.5 mm; P < .001) and C (3.7 ± 0.8 mm; P < .001). The joint space was higher in group B than in group C (P < .001).

CONCLUSION:

Despite joint space narrowing, decreases in meniscal thickness after partial meniscectomy for horizontal tear had no additional adverse effect on 5-year functional and radiographic outcomes compared with conventional partial meniscectomy preserving whole meniscal thickness. In treating horizontal tears of the meniscus, partial meniscectomy with complete resection of the unstable leaf was an effective method in a 5-year follow-up study.:

Hombro/Shoulder/Schulter: hay que acordarse del os acromiale

Os acromiale: a review and an introduction of a new surgical technique for management.

Johnston PS, Paxton ES, Gordon V, Kraeutler MJ, Abboud JA, Williams GR

Orthop. Clin. North Am. 2013 Oct; 44(4):635-44.

Abstract

Os acromiale is a common finding in shoulder surgery. We review the anatomy, prevalence, pathophysiology, and treatment options for this diagnosis. In addition, we report on a case series of 6 patients with a symptomatic meso os acromiale who were treated with a new technique involving arthroscopic acromioplasty in conjunction with the excision of the acromial nonunion site. We have demonstrated this novel treatment method to be a safe and effective technique in this case series. This arthroscopic partial resection of an os acromiale is considered to be an alternative option for treating a symptomatic meso os acromiale.

General: respuestas clínicas basadas pobremente

Arthroscopic and Sports Medicine Science: Looking Beyond the Level of Evidence (for Now)

James H. Lubowitz, M.D. (Assistant Editor-in-Chief), Matthew T. Provencher, M.D. (Deputy Editor), Gary G. Poehling, M.D. (Editor-in-Chief)

Volume 30, Issue 3 , Pages 281-282, March 2014

For now, arthroscopic and sports medicine scientists and clinicians may simply need to look beyond level of evidence when trying to answer clinical questions, because the truth is, studies of high levels of evidence are scant. As we said in January when celebrating the 2013 Level I Evidence prize, “Seriously?” As we noted, Arthroscopy published only 12 Level I evidence studies during the 12 months of 2013. To us, this seems like very few.