Experienced Arthroscopic Surgeon Research Articles

A novel arthroscopy training program based on a 3D printed simulator

BackgroundArthroscopy is the most important and exciting contribution to sports medicine of the last 100 years. One of its main limitations, however, is the steep learning curve it requires, which is not easy to beat given the scarcity and the high price of arthroscopy simulators. Hypothesis/purposeTo describe and evaluate the effectiveness of an open-access arthroscopy training program based on a 3D-printed simulator. MethodsA model was designed, which was to be printed on a fused filament fabrication (FFF) 3D printer for home use with polylactic acid (PLA) filaments. Fourteen exercises were prepared, each with its timeframe and conceptual goals, arranged from least difficult to most challenging. Exercises were designed to assist subjects in developing the skills of an experienced arthroscopic surgeon through use of the simulator. Twenty subjects from nine hospitals completed the arthroscopy training program. Performance in each exercise was evaluated according to the Arthroscopic Surgical Skill Evaluation Tool (ASSET), taking into account the number of times a student had to repeat each exercise to complete it successfully. ResultsThe mean ASSET score for each exercise was 22 points (IQR 19–25) and the mean number of times students had to repeat each exercise was 16 (95% CI 15.27–17.97). Eighty-five percent of subjects completed the program. The device was printed without difficulty by an independent investigator without prior knowledge of 3D printing. The price of the device was under US$ 12. ConclusionSubjects exhibited an improvement in their basic arthroscopic skills on the simulator. The number of times each of them had to repeat each exercise was similar, which is indicative of a smooth progression of difficulty along the program. The device proved easy to print, accessible, economical, and effective. This is the first structured program based on an open-access arthroscopic simulator to obtain satisfactory results.

In vivo biomechanical measurement and haptic simulation of portal placement procedure in shoulder arthroscopic surgery

A survey of 67 experienced orthopedic surgeons indicated that precise portal placement was the most important skill in arthroscopic surgery. However, none of the currently available virtual reality simulators include simulation / training in portal placement, including haptic feedback of the necessary puncture force. This study aimed to: (1) measure the in vivo force and stiffness during a portal placement procedure in an actual operating room and (2) implement active haptic simulation of a portal placement procedure using the measured in vivo data. We measured the force required for port placement and the stiffness of the joint capsule during portal placement procedures performed by an experienced arthroscopic surgeon. Based on the acquired mechanical property values, we developed a cable-driven active haptic simulator designed to train the portal placement skill and evaluated the validity of the simulated haptics. Ten patients diagnosed with rotator cuff tears were enrolled in this experiment. The maximum peak force and joint capsule stiffness during posterior portal placement procedures were 66.46 (±10.76N) and 2560.82(±252.92) N/m, respectively. We then designed an active haptic simulator using the acquired data. Our cable-driven mechanism structure had a friction force of 3.763 ± 0.341 N, less than 6% of the mean puncture force. Simulator performance was evaluated by comparing the target stiffness and force with the stiffness and force reproduced by the device. R-squared values were 0.998 for puncture force replication and 0.902 for stiffness replication, indicating that the in vivo data can be used to implement a realistic haptic simulator.

Accuracy of Lelli Test For Anterior Cruciate Ligament Tear

Introduction: The anterior cruciate ligament (ACL) is an important stabilizer of the knee. Rupture of the ACL, unfortunately, is a common sports injury. Three most accurate test routinely applied in clinical practice to determine ACL injuries are the Anterior drawer, Lachman, and pivot shift tests test .In this study we evaluate the accuracy of Lelli test for detecting ACL tear and compare it with those tests. Methods: This study included 80 patients attending sports clinic at Department of orthopedics, Tribhuvan University, Teaching Hospital from December 2013 to November 2014, aged between 20-45 years with knee symptoms of giving way/locking/pain following sports or non sports injury .Clinical history and detail clinical assessment of knee for instability including Anterior drawer test, Lachman test, Pivot shift test ,Lelli test were performed by standard technique and recorded in the Performa. All patient underwent knee arthroscopic evaluation and needful procedure by an experienced arthroscopic surgeon. Arthroscopy findings of ACL tear was recorded and used to assess the reliability of clinical test. Results: In this study sensitivity of Anterior drawer test, Lachman test , Pivot shift test , Lelli test was 80.00%(CI 62.53-90.93),91.42%(CI 75.81-97.75) ,51.42%(CI 34.27-68.27), 85.71%(CI 68.95-94.61) respectively and Specificity was 93.33%(CI 80.68-98.28), 95.55%(CI 83.36-99.22), 100%(CI 90.20- 100.00) , 91.11%(CI 77.87-97.11) respectively. Conclusion: Lelli test being simple test can be routinely used in evaluation of ACL function in both acute and chronic knee injury.

Objective Assessment of Knot-Tying Proficiency With the Fundamentals of Arthroscopic Surgery Training Program Workstation and Knot Tester

To assess a new method for biomechanical assessment of arthroscopic knots and to establish proficiency benchmarks using the Fundamentals of Arthroscopic Surgery Training (FAST) Program workstation and knot tester. The first study group included 20 faculty at an Arthroscopy Association of North America resident arthroscopy course (19.9 ± 8.25 years in practice). The second group comprised 30 experienced surgeons attending an Arthroscopy Association of North America fall course (17.1 ± 19.3 years in practice). The training group included 44 postgraduate year 4 or 5 orthopaedic residents in a randomized, prospective study of proficiency-based training, with 3 subgroups: group A, standard training (n= 14); group B, workstation practice (n= 14); and group C, proficiency-based progression using the knot tester (n= 16). Each subject tied 5 arthroscopic knots backed up by 3 reversed hitches on alternating posts. Knots were tied under video control around a metal mandrel through a cannula within an opaque dome (FAST workstation). Each suture loop was stressed statically at 15 lb for 15 seconds. A calibrated sizer measured loop expansion. Knot failure was defined as 3 mm of loop expansion or greater. In the faculty group, 24% of knots "failed" under load. Performance was inconsistent: 12 faculty had all knots pass, whereas 2 had all knots fail. In the second group of practicing surgeons, 21% of the knots failed under load. Overall, 56 of 250 knots (22%) tied by experienced surgeons failed. For the postgraduate year 4 or 5 residents, the aggregate knot failure rate was 26% for the 220 knots tied. Group C residents had an 11% knot failure rate (half the overall faculty rate, P= .013). The FAST workstation and knot tester offer a simple and reproducible educational approach for enhancement of arthroscopic knot-tying skills. Our data suggest that there is significant room for improvement in the quality and consistency of these important arthroscopic skills, even for experienced arthroscopic surgeons. Level II, prospective comparative study.

Assessing Performance in Shoulder Arthroscopy: The Imperial Global Arthroscopy Rating Scale (IGARS).

Surgical training is undergoing major changes with reduced resident work hours and an increasing focus on patient safety and surgical aptitude. The aim of this study was to create a valid, reliable method for an assessment of arthroscopic skills that is independent of time and place and is designed for both real and simulated settings. The validity of the scale was tested using a virtual reality shoulder arthroscopy simulator. The study consisted of two parts. In the first part, an Imperial Global Arthroscopy Rating Scale for assessing technical performance was developed using a Delphi method. Application of this scale required installing a dual-camera system to synchronously record the simulator screen and body movements of trainees to allow an assessment that is independent of time and place. The scale includes aspects such as efficient portal positioning, angles of instrument insertion, proficiency in handling the arthroscope and adequately manipulating the camera, and triangulation skills. In the second part of the study, a validation study was conducted. Two experienced arthroscopic surgeons, blinded to the identities and experience of the participants, each assessed forty-nine subjects performing three different tests using the Imperial Global Arthroscopy Rating Scale. Results were analyzed using two-way analysis of variance with measures of absolute agreement. The intraclass correlation coefficient was calculated for each test to assess inter-rater reliability. The scale demonstrated high internal consistency (Cronbach alpha, 0.918). The intraclass correlation coefficient demonstrated high agreement between the assessors: 0.91 (p < 0.001). Construct validity was evaluated using Kruskal-Wallis one-way analysis of variance (chi-square test, 29.826; p < 0.001), demonstrating that the Imperial Global Arthroscopy Rating Scale distinguishes significantly between subjects with different levels of experience utilizing a virtual reality simulator. The Imperial Global Arthroscopy Rating Scale has a high internal consistency and excellent inter-rater reliability and offers an approach for assessing technical performance in basic arthroscopy on a virtual reality simulator. The Imperial Global Arthroscopy Rating Scale provides detailed information on surgical skills. Although it requires further validation in the operating room, this scale, which is independent of time and place, offers a robust and reliable method for assessing arthroscopic technical skills.

Return to play following ACL reconstruction: survey among experienced arthroscopic surgeons (AGA instructors)

There is a lack of consensus regarding appropriate criteria attesting patient's unrestricted sports activities after ACL reconstruction. The purpose of this study was to perform a survey among experienced arthroscopic surgeons regarding their return to play guidelines in these patients. A six-item questionnaire was distributed among experienced arthroscopic surgeons (instructors of the German speaking society of arthroscopy, AGA). Study participants were asked to choose from multiple choice answers and had the possibility answering in an open discussion field. The response rate of the survey was 85.7 %. A total of 83.5 % used autologous hamstring grafts for ACL reconstruction in athletes followed by BPTB (37.2 %) and quadriceps tendon graft (12 %). Approximately 63.5 % recommended a time point later than 6 months allowing return to play after ACL reconstruction in the athlete (after 4 and 6 months 2.3 and 35.3 %, respectively). 76.6 % recommended starting with sports specific rehabilitation after 4 months (21.6 % after 6 months). The most frequent criterion (multiple answers) to allow return to play was negative Lachman test (81.7 % positive answers) followed by free range of motion (78.4 %), negative pivot shift (60.1 %), anterior drawer (45.4 %), proprioception test (43.1 %), muscular strength analysis (40.8 %), single-leg hop jump test (39.0 %), KT 1000 measurement (16.1 %), and MRI (4.1 %). Of the surgeons 85.8 % did not use any of the given scores as criterion to allow return to competitive sports (subjective IKDC score 10.6 %, Lysholm score 8.3 %, objective IKDC score 7.4 %, Tegner activity scale 3.7 %). In conclusion, the majority of surgeons do not consider muscle function, jump tests, alignment tests, and proprioception as relevant return to sports criterion. However, these are two crucial parameters for return to sports.

Endoscopic treatment of posteriorly localized talar cysts

This study presents the short-term follow-up results from our case series of patients with posteriorly localized intraosseous talar cysts. Patients were treated via hindfoot endoscopy in the prone position. We evaluated six ankles of five patients treated with hindfoot endoscopy for intraosseous cysts localized to the posterior portion of talus. Three patients were men and two were women. The median age of the patients was 34 (22-40) years. The bilateral case was treated with a sole operation. The median preoperative AOFAS score was 69 (38-72) points. Additionally, all patients were found to have flexor hallucis longus (FHL) tendinitis in clinical and radiologic evaluations; large os trigoni were detected in five affected ankles. Debridement of scar tissue and FHL tendinitis, resection of os trigoni, and curettage and grafting of the cysts were completed endoscopically with one surgery. The cavities were filled with autografts in all patients except one. Hydroxyapatite was used in one case. The pathologic diagnoses were intraosseous ganglia in three feet and simple bone cysts in the remainder. The preoperative diagnoses were unchanged postoperatively. The median postoperative follow-up was 27 (12-74) months. In all patients, graft union was confirmed with computed tomography. The median AOFAS score improved to 90 (75-100) points postoperatively. There were no complications. All patients were satisfied with their results. Hindfoot endoscopy can be used for the treatment of intraosseous talar cysts that are posteriorly localized. Significant advantages of this method include lower morbidity and shorter postoperative hospitalization time. Hindfoot endoscopy is a safe and effective method for treating talar cystic lesions and is an attractive option for experienced arthroscopic surgeons. IV.

How valid is the arthroscopic diagnosis of cartilage lesions? Results of an opinion survey among highly experienced arthroscopic surgeons

AimIn general, arthroscopy is considered the “gold standard” for the evaluation of cartilage lesions. In this multicenter survey, we ascertained the general opinion of surgeons regarding arthroscopic cartilage diagnoses.MethodA total of 301 highly experienced arthroscopists (instructors of the AGA, the German-speaking society of arthroscopy) were contacted in writing with a request to complete the survey.ResultsThe data from 105 respondents (34.8% of those contacted) were used for the investigation. In the grading of the cartilage lesions, the Outerbridge classification was most frequently used (n = 87), followed by the ICRS protocol (n = 8) and the Insall score (n = 3). The majority (61%) of the arthroscopic surgeons felt that differentiation between healthy cartilage and low-grade cartilage lesions was simple. For differentiation between grade I and grade II lesions, and for differentiation between grade II and grade III lesions, 41.9 and 51.4%, respectively, thought that there was a “need for improvement”. In the case of grade IV lesions, 70.5% of the surgeons thought that the diagnosis was valid. The respondents also judged the utility of incorporating objective measurements (e.g., intraoperative biomechanical tests): 13.3% (n = 14) responded that such measurements would be “very useful” and 61.9% (n = 65) responded that they would be “somewhat useful”.ConclusionsAmong surgeons, arthroscopy was not perceived to be as reliable as a “gold standard” for the diagnosis of cartilage lesions. The majority of experienced arthroscopists felt unsure of the results in general, or at least in some cases. A universal and definitive grading system for lesions appears to be needed. For questionable cases, measurement devices are needed for objective cartilage grading.

Beach chair position with instrumental distraction for arthroscopic and open shoulder surgeries

Arthroscopy is widely used in the diagnosis and treatment of shoulder disorders. It can be performed in the lateral or sitting position (beach chair). Both have advantages and disadvantages. We present a simple, inexpensive, versatile, portable, continuous distraction device for arthroscopic, combined, and open shoulder surgeries in the sitting position that offers the advantages of the 2 classic positions without their disadvantages. The device was used in 101 consecutive procedures: 61 rotator cuff repairs (29 arthroscopic, 18 mini-open, 14 open), 4 two-part humeral fractures, 1 septic arthritis, 3 calcifying tendinitis, 9 capsular releases, 8 Bankart repairs (6 arthroscopic, 2 open), 13 acromioplasty and biceps tenotomy, and 2 superior labrum anteroposterior repairs. Our experience with this device is extremely positive. We have had no complications and have used it for shoulder arthroscopy, open, and combined surgeries. We have also not had difficulty visualizing or approaching the glenohumeral and subacromial spaces in the treatment of shoulder disorders. It is a safe, practical, easy, and fast set up. Its versatility makes it particularly helpful for the less experienced arthroscopic surgeon.

Arthroscopic management of tibial plateau fractures

Since the mid 1980 s the arthroscopically and radiologically controlled management of tibial plateau fractures is an established part of arthroscopic surgery of the knee. The aim of this study is to analyse the results of this method in our patient population. Between January 1, 1994 and December 31, 1998 59 patients were operated under arthroscopic and radiologic control. Of the 59 tibial plateau fractures there were concomitant ligamentous injuries in 21 cases. In 34 cases an additional arthroscopic procedure was performed (partial meniscectomy 19 times, a meniscal repair 7 times. An arthroscopic procedure was necessary because of chondral lesions 14 times, and in 10 cases a rupture of the ACL was found, which was treated by resection). None of the 8 patients with lateral wedge fracture had a concomitant intraarticular lesion. The intraoperative use of Endobon provided good mechanical stability, but it is not always necessary. The negative aspect of Endobon, however, is the high cost. The number of complications in our series was low (3 intra- and 6 postoperative complications). The average follow-up interval was 48 months. According to the Lysholm-Score, 41 patients investigated obtained an average of 84 points. Because of its good results this procedure can be recommended when conducted by an experienced arthroscopic surgeon. However, the range of indications is limited to special tibial plateau fractures. In case of intraoperative problems or complications we recommend an early change to conventional methods of internal fixation of tibial plateau fractures.

An animal model for TMJ arthroscopy

Initial reports show that arthroscopy in experienced hands is technically an accurate and easily performed procedure. IT2 Although there have been reports of good therapeutic success,3S4 occasionally serious complications have occurred, including middle ear perforation5 It is, therefore, essential that the oral and maxillofacial surgeon wishing to perform arthroscopic surgery on the temporomandibular joint is exposed to a graduated learning experience to develop the art of arthroscopic diagnosis and surgery. This includes the correct intraarticular placement of the arthroscope, correlation of the arthroscopic view to joint anatomy, manipulation of cutting and rotatory instruments under arthroscopic vision, and control of minor technical problems like hemorrhage. Obtaining such progressive experience can be difficult. Options include the use of rubber manikins,6 but these are of limited value. Other possibilities are practice on patients scheduled for open operation, practice under the supervision of an experienced arthroscopic surgeon, or the use of an animal model. Animal models have proved useful for surgical practice in the not dissimilar area of microsurgery. The sheep has been reported as being a suitable model for temporomandibular joint surgery.’ The joint is similar in size and internal structure to humans, but the joint is lateral to, rather than beneath, the middle cranial fossa. Because sheep are ruminants, there is a wide range of both lateral and anterior-posterior movement of the condyle in the fairly flat glenoid fossa. Thus, there is a generous and easily accessible anterior and posterior formix to the superior joint space. Sheep are also cheap, readily available, and ethically acceptable.