Inside-out Technique Research Articles

Affording Social Experience for Adolescents Using Immersive Virtual Reality: A Moderated Mediation Analysis

Background: Immersive virtual reality (IVR) serves as a promising tool to provide adolescents with enriched social experience due to its high-fidelity simulations and multimodal interaction. This study aims to design and develop a multi-user IVR collaborative game utilizing simultaneous localization and mapping (SLAM)-based inside-out tracking technique to foster social experience among students. Also, this study explored the mechanism by which technology acceptance affected social experience in the IVR collaboration game, focusing on the mediating effects of presence, collective efficacy, and group effectiveness, as well as the moderating effect of social–emotional competence (SEC). Methods: A total of 104 seventh graders from a middle school in Central China participated in this study and completed the questionnaire. Finally, 87 valid questionnaire responses were retrieved. Results: The results revealed that technology acceptance both directly and indirectly influenced social experience. The mediation analysis revealed a key pathway influencing social experience: technology acceptance → presence → collective efficacy → group effectiveness → social experience. However, no moderating effect of SEC was found in the relationship between technology acceptance and social experience, group effectiveness, and social experience. Conclusions: Based on these results, more appropriate IVR interventions could be developed for social–emotional learning among children and adolescents.

Comparison of Sexual Functions in Transobturator Tape Surgeries Performed with Inside-Out Technique and Outside-In Technique

Comparison of Sexual Functions in Transobturator Tape Surgeries Performed with Inside-Out Technique and Outside-In Technique

Failure and complication rates following meniscal all-inside and inside-out repairs: A systematic review and meta-analysis.

This study examines failure rates, complication rates and patient-reported outcome measures (PROMs) for meniscal all-inside (AI) and inside-out (IO) repair techniques. A systematic search was conducted on PubMed, Embase and Cochrane (inception to January 2024) assessing for Level I-III studies evaluating outcomes after meniscal repair. The primary outcome regarded differences in failure rates between AI and IO repair techniques. Secondary outcomes included a comparison of complication rates and PROMs. Quality assessment was performed using the Grading of Recommendations Assessment, Development and Evaluation and Methodological Index for Non-Randomized Studies criteria. A meta-analysis was conducted for outcomes reported by more than three comparative studies. A total of 24 studies (13 studies and 912 menisci for AI vs. 17 studies and 1,117 menisci for IO) were included. The mean follow-up ranges were 22-192 months (AI) and 18.5-155 months (IO). The overall reported AI failure rate ranged from 5% to 35% compared to 0% to 25% within the IO group. When comparing meniscal repair failure rates in the setting of concomitant anterior cruciate ligament reconstruction, the AI group had a failure rate (AI: 5%-34%; IO: 0%-12.9%). The complication rate ranged from 0% to 40% for AI and 0% to 20.5% for IO. Post-operative PROM scores ranged from 81.2 to 93.8 (AI) versus 89.6 to 94 (IO) for IKDC and 4.0-7.02 (AI) versus 4.0-8.0 (IO) for Tegner. Upon pooling of six comparative studies, a significantly lower failure rate favouring the IO technique was observed (15.9% AI vs. 11.1% IO; p = 0.02), although this result was influenced by a study with a predominantly elite athlete population. Moreover, no significant differences were found regarding complication rates between cohorts (7.3% AI vs. 4.8% IO; p = 0.86). The present study underscores comparable clinical success between AI and IO meniscal repair techniques, with both techniques demonstrating similar complication rates. However, the AI repair technique was associated with 1.77 times higher odds of failure compared to the IO cohort. Level III.

Anterior quadratus lumborum block provided superior pain control and reduced opioid consumption in kidney transplantation: A randomized controlled trial.

The research aimed to assess the effectiveness of inside-out anterior quadratus lumborum (QL3) block and local wound infiltration in managing postoperative pain and total morphine dosage following kidney transplantation. In this prospective, randomized, double-blind study; 46 end-stage renal disease patients undergoing kidney transplantation were randomly allocated into 2 groups: a QL group (n = 23) receiving 20 mL of 0.25% bupivacaine using the ultrasound-assisted inside-out technique before wound closure, while the local wound infiltration (LA) group (n = 23) receiving the same dose around the surgical wound and drain at the time of skin closure. The primary outcome measure was the numerical pain rating scale, with secondary outcomes including amount of morphine consumption at various postoperative time points (2nd, 4th, 6th, 12th, 18th and 24th hours). Patients in the QL group had significantly lower numerical rating scale scores at the 2nd and 4th hours, both at rest and during movement (P < .05). Although pain scores at rest and during movement at later time points were lower in the QL group compared to the LA group, these differences were not statistically significant. Cumulative morphine consumption at postoperative 4th, 6th, 12th, 18th and 24th hours was significantly lower in the QL group (P < .05). No patients experienced complications from the QL3 block. Ultrasound-assisted inside-out QL3 block significantly reduced postoperative pain levels at the 2nd and 4th hours, both at rest and during movement, and led to a reduction in cumulative morphine consumption from the 4th hour postoperatively, and persisting throughout the 24-hour period.

Continuous Meniscal Repair Technique Allows for Shorter Operative Time and Learning Curve Compared With Traditional Vertical Mattress Technique in Controlled Arthroscopic Training in Porcine Model

To compare the amount of time used to perform meniscal suturing on a standardized lesion using either a traditional or continuous arthroscopic suturing technique. A preclinical study was carried out with 21 medical doctors who underwent training in the 2 modalities of meniscal repair by arthroscopy in an animal model laboratory. Participants performed both types of sutures with a previously standardized lesion. The execution time of the techniques was measured, and an experienced surgeon evaluated the stability of a meniscal tear after the repair. Data were analyzed using a t test for paired samples to calculate the difference between the execution times of the techniques. The time required to perform the continuous meniscal suture was shorter than that of the traditional suture. After statistical analysis, the time difference between the techniques was significant (mean difference 4:17 ± 5:30 minutes; 95% confidence interval, 1:46-6:46 minutes). Surgeons took less time than residents for the traditional suture (P= .036), but the times were similar for the continuous suture. This suggests that experience level has a greater effect on the time needed for the traditional suture than for the continuous suture. The continuous suture technique was performed in a shorter time compared with the traditional suture technique in a porcine model. The results of this preclinical study suggest that the continuous vertical inside-out meniscal suture technique can enhance surgical procedures for longitudinal tears requiring ≥4 stitches, offering a faster and more intuitive learning curve compared with the traditional inside-out suture technique.

Inside-out repair of complex tears in the posterior horn of the lateral meniscus

All-inside meniscus devices are preferred over inside-out sutures for complex tears in the posterior horn of the lateral meniscus due to the ease of use, avoidance of additional skin incisions, and reduced surgical time. However, inside-out sutures have the advantages of being less traumatic due to smaller diameter needles, better healing rate, and less chance of injuries to posterior neurovascular structures due to direct visualization and protection. To the author’s knowledge, the inside-out repair technique has been described only for vertical tears and not for complex tears in the posterior horn of the lateral meniscus. This video describes the technique of repairing complex lateral meniscus tears with inside-out sutures using various suture configurations. The lateral meniscus tear pattern is identified. A posterolateral safety incision is made, and a retractor is placed posterior to the capsule. The popliteal vein is identified at this step and kept under visualization to avoid injury. Meniscal repair configurations such as “H,” “X,” and “A” patterns and simple vertical or horizontal sutures are planned according to the tear pattern. Sutures are passed using inside-out meniscal sutures, 18G spinal needle, self-retrieving suture devices or a combination of those, and tied over the capsule using sliding knots while the repair site is arthroscopically visualized.

Fibrin Clot–Augmented Meniscal Repair

Background: Failure rate of meniscal repair can reach 25%. Multiple techniques have been used to increase meniscal healing, notably biological augmentation techniques. One of them is fibrin clot–augmented meniscal repair, which will be described in this video. Indications: This technique is indicated mainly for the lesions with a high failure rate. This includes large, horizontal, and radial tears and even for meniscal cysts, especially in a stable knee. This technique can also be used in revision meniscal suture when failure is no longer an option. Surgical Technique: Fibrin clot is prepared from sterile peripheral venous blood from the patient. A plastic syringe is used to stir the blood in a sterile glass container. The fibrin clot is then formed and washed rigorously with saline solution. Rolling the fibrin clot which is fixed to the syringe allows to give the fibrillar aspect of the clot. The formed fibrin clot is now solid enough to be manipulated and can be fixed to a vicryl suture thread allowing it to enter the knee and be fixed inside the meniscal lesion. The clot is wrapped inside the meniscal lesion with inside-out or outside-in suture technique. Results: We used this technique for multiple types of lesions, like bucket handle meniscal tear, horizontal meniscal cleavage, parrot beak tear, and even in lesions within white-white zone. The postoperative protocol is the same as standard inside-out meniscal repair. This technique has been used in the literature with promising results. Conclusion: The fibrin clot–augmented meniscal repair is a demanding but promising technique. We need further follow-up to confirm its effectiveness. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Arthroscopic Repair of radial meniscal tear by Double Vertical cross sutures through Inside-Out technique

Arthroscopic Repair of radial meniscal tear by Double Vertical cross sutures through Inside-Out technique

Circumferential Cross-Stitch Suture for Longitudinal Lateral Meniscal Tear Around the Popliteal Tendon Hiatus Region

Lateral meniscal repair of the popliteal hiatus is technically demanding. The inside-out technique requires an additional incision and carries the risk of posterolateral soft tissue damage to the knee joint. In addition, the presence of the popliteal tendon limits the route of the suture thread. Within the current trend of the all-inside suture technique, meniscal suture-based all-inside repair demonstrates biomechanical advantages over anchor-based all-inside repair. We introduce a meniscal suture-based all-inside meniscal repair technique for longitudinal lateral meniscal tears.

Creating an Immersive Virtual Reality Game Space for Multiuser, Synchronous Co-Located Collaboration: Design Considerations and Influencing Factors

The last decade has witnessed the rapid development of immersive virtual reality (IVR) and its application in various contexts. However, its application in supporting real-time virtual collaboration has been quite rare due to technical barriers and the lack of validated design principles. To address this research gap, this study designed and developed an IVR space to enable multiuser synchronous co-located collaboration to complete a fantasy game. An evaluation study (N = 95) was conducted to explore its useful design considerations and the influencing factors for collaboration experience in the game. The IVR space was enabled by the simultaneous localization and mapping (SLAM)-based inside-out tracking technique and was informed by four essential design considerations for promoting effective collaboration in IVR, namely, the role script, learning task, collaboration mechanism, and communication design. The study results revealed that students in general were satisfied with their collaboration experience in IVR, with social presence and collaboration competency as significant predictors of collective efficacy and social experience. Based on both quantitative and qualitative results, this study proposes four validated principles for designing effective IVR spaces to support synchronous co-located collaboration.

Femoral Tunnel Position in Anatomical Double-bundle ACL Reconstruction is not Affected by Blumensaat's Line Morphology.

The aim of this study was to reveal the influence of the morphological variations of the Blumensaat's line on anteromedial (AM) and posterolateral (PL) femoral tunnel position in anatomical double-bundle anterior cruciate ligament (ACL) reconstruction.Fifty-three subjects undergoing anatomical double-bundle ACL reconstruction were included (29 female, 24 male; median age 27.4 years; range: 14-50 years). Using an inside-out transportal technique, the PL tunnel position was made on a line drawn vertically from the bottommost point of the lateral condyle at 90 degrees of knee flexion, spanning a distance of 5 to 8 mm, to the edge of the joint cartilage. AM tunnel position was made 2 mm distal to the PL tunnel position. Following Iriuchishima's classification, the morphology of the Blumensaat's line was classified into straight and hill (large and small) types. Femoral tunnel position was determined using the quadrant method. A Mann-Whitney U test was performed to compare straight and hill type knees according to AM and PL femoral tunnel position.There were 18 straight and 35 hill type knees (13 small and 22 large hill). AM and PL femoral tunnel position in straight type knees were 21.7 ± 7.0 and 33.6 ± 10.5% in the shallow-deep direction, and 42.1 ± 11.1 and 72.1 ± 8.5% in the high-low direction, respectively. In hill type knees, AM and PL femoral tunnel position were 21.3 ± 5.8 and 36.9 ± 7.1% in the shallow-deep direction, and 44.6 ± 10.7 and 72.1 ± 9.7% in the high-low direction, respectively. No significant difference in AM or PL femoral tunnel position was detected between straight and hill type knees.AM and PL femoral tunnel position in anatomical double-bundle ACL reconstruction was not affected by the morphological variations of the Blumensaat's line. Surgeons do not need to consider Blumensaat's line morphology if AM and PL femoral tunnel position is targeted at the bottommost point of the lateral condyle. This was a level of evidence III study.

Meniscus tears and repair: assessing failure rates of all-inside and outside-in methods

Meniscal repair procedures are on the rise due to an enhanced understanding of the adverse long-term effects associated with the loss of meniscal tissue. Although meniscal repair has a higher reoperation rates compared to meniscectomy, recent systematic reviews indicate improved long-term outcomes with meniscal repair. Even though there are a lot of studies that compare the results of all-inside and inside-out techniques there are only few that evaluate all-inside and outside-in approaches. This study aims to review the relevant literature on the epidemiology, mechanism of injury, clinical presentation and imaging of meniscus and to compare the failure rates and time to failure of AI and OI meniscal repairs. PubMed and Scopus were searched for studies published between January 2014 and January 2024 reporting on meniscus repair outcomes using “outside-in” or “all-inside” techniques with a minimal duration of 6 months for follow-up. Failure was characterized as the recurrence of clinical symptoms or the need for a meniscal reintervention. Over 50 English-language articles were analyzed between 2000 and 2022. After conducting a review and data analysis, it is observed that the “all-inside” technique is more frequently chosen as a treatment method, possibly due to its simpler execution. Both total and percentage rates of failures are higher using this technique, amounting to 79 cases and reaching 16%, compared to “outside-in” approach, which is less commonly chosen, but has lower frequency of failures totaling 6 cases and 5%.

Direct Inside-Out Observation of Superficial White Matter Fasciculi in the Human Brain.

Background: Recent methodological advances in the study of the cerebral white matter have left short association fibers relatively underexplored due to their compact and juxtacortical nature, which represent significant challenges for both post-mortem post-cortex removal dissection and magnetic resonance-based diffusion imaging. Objective: To introduce a novel inside-out post-mortem fiber dissection technique to assess short association fiber anatomy. Methods: Six cerebral specimens were obtained from a body donation program and underwent fixation in formalin. Following two freezing and thawing cycles, a standardized protocol involving peeling fibers from deep structures towards the cortex was developed. Results: The inside-out technique effectively exposed the superficial white matter. The procedure revealed distinguishable intergyral fibers, demonstrating their dissectability and enabling the identification of their orientation. The assessment of layer thickness was possible through direct observation and ex vivo morphological magnetic resonance imaging. Conclusion: The inside-out fiber technique effectively demonstrates intergyral association fibers in the post-mortem human brain. It adds to the neuroscience armamentarium, overcoming methodological obstacles and offering an anatomical substrate essential for neural circuit modeling and the evaluation of neuroimaging congruence. Impact statement The inside-out fiber dissection technique enables a totally new perception of cerebral connectivity as the observer navigates inside the parenchyma and looks toward the cerebral surface with the subcortical white matter and the cortical mantle in place. This approach has proven very effective for exposing intergyral association fibers, which have shown to be much more distinguishable from an inner perspective. It gave rise to unprecedented images of the human superficial white matter and allowed, for the first time, direct observation of this vast mantle of fascicles on entire cerebral hemisphere aspects.

All-Inside and Inside-Out Repair Techniques for Bucket-Handle Meniscus Tears Both Result in Improved Patient Outcomes and a Broad Range of Failure Rates: A Systematic Review

To compare patient-reported outcomes, failure rates, risk factors for failure, and complications in patients with bucket-handle meniscus tears (BHMTs) undergoing repair with inside-out (IO) versus all-inside (AI) techniques. A literature search was performed using the PubMed, Embase, and Scopus databases from database inception to August 2023 according to the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria consisted of Level I to IV clinical studies published in the past 10 years with greater than 2 years of follow-up that evaluated patient-reported outcome scores and/or the incidence of failure after IO or AI repairs for BHMTs. Clinical studies not reporting outcomes or failure rates, older studies using outdated implants, animal studies, reviews, letters to the editor, case reports, cadaveric studies, and articles not written in the English language or with English-language translation were excluded. Study quality was assessed using the Methodological Index for Non-randomized Studies (MINORS) criteria. Outcomes were reported as ranges and qualitatively compared. A total of 16 studies published from 2013 to 2023, consisting of 1,062 patients with BHMTs, were identified. Thirteen studies (14 cohorts, 649 patients) reported on AI repair (mean age range, 23.7-32 years) and 7 studies (7 cohorts, 413 patients) reported on IO repair (mean age range, 16.7-34.6 years). Both groups had improved postoperative Lysholm and Tegner scores. Decreased range of motion was the most commonly reported complication in the AI group (range, 2.6%-4%), whereas adhesions for arthrofibrosis were the most commonly reported complication in the IO group (n= 12; range, 6%-7.9%). The overall reported failure rate ranged from 6.9% to 20.5% within the AI group and from 0% to 20% within the IO group. AI and IO repair techniques for BHMTs both result in improved Lysholm and Tegner scores. However, broad ranges of failure are reported in the literature, with overall failure rates ranging from 6.9% to 20.5% after AI repair and from 0% to 20% after IO repair. Younger age and isolated medial BHMT repair are the most frequently reported risk factors for the AI technique, whereas postoperative stiffness is the most frequently reported complication after both repair techniques. Level IV, systematic review of Level I to IV studies.

Inside-Out Anchor Placement: A Technique to Instrument Far Medial Anchors in Acetabular Labral Repair

Labral tears most commonly occur anteriorly between the 12- and 3-o’clock positions, with the 12-o’clock position denoted as superior and the 3-o’clock position denoted as anterior. When approaching the 3-o’clock position and beyond, suture anchor placement becomes difficult given the challenging arthroscopic trajectory and an overall thin anterior rim of cortical bone for anchor purchase, resulting in a narrow angle of safe drilling. The purpose of this technical note is to present a safe and reproducible method of suture anchor placement during acetabular labral repair approaching the 3- and 4-o’clock positions, with the 12-o’clock position representing the superior anatomic location and the 3-o’clock position representing the anterior anatomic location regardless of hip laterality. We use an inside-out anchor placement technique to place far medial anchors, which differs from the conventional techniques (e.g., outside-in technique) in which anchor placement is performed along the external margin of the acetabular labrum.

OUTCOME OF TREATMENT FOLLOWING PRIMARY ARTHROSCOPIC REPAIR OF BUCKET HANDLE MENISCUS TEARS IN ADULTS

AimsWe studied the outcomes following arthroscopic primary repair of bucket handle meniscus tears to determine the incidence of re-tears and the functional outcomes of these patients.MethodologyProspective cohort study. Over a 4-year period (2016 to 2020), 35 adult patients presented with a bucket handle tear of the meniscus. Arthroscopic meniscal repair was performed using either the all inside technique or a combination of all-inside and inside-out techniques. 15 patients also underwent simultaneous arthroscopic anterior cruciate ligament reconstruction. Functional knee scores were assessed using IKDC and Lysholm scores.ResultsMean patient age at surgery was 27 years (range, 17 to 53years). Medial meniscus was torn in 20 and lateral in 15 cases. Zone of tear was white on white in 19, red on white in 9 and red on red in 7 cases. Average delay from injury to surgery was 4 months. At a mean follow-up of 4.5 years, the meniscus repair failed in 3 patients (8.5 %). Outcome following re-tear was meniscus excision. Average IKDC scores in patients with intact repair were 74.04 against 56.67 in patients with a failed repair (p&lt; 0.0001). Similarly, Lyshlom scores were 88.96 and 67.333, respectively (p&lt;0.0001).ConclusionThe survivorship of primary repair of bucket handle meniscus tears in our series was 91.5% at medium term follow-up. Functional outcomes were significantly poor in patients with a failed repair compared to those with an intact repair.

All-inside suture meniscal repair using suture passer.

In recent years, to save the meniscus and prevent the progression of knee osteoarthritis, the indications for meniscus repair have been expanding instead of partial menisectomy. Accordingly, various repair techniques for meniscus tears have been developed. The conventional inside-out and outside-in meniscus repair techniques and all-inside repair technique with an implant/anchor can be classified as trans-capsular (TC) repair from the perspective of suture with penetrating capsule. Recently, new suture passers for all-inside meniscus repair have been developed. To distinguish from conventional all-inside repair with implant/anchors, all-inside repair with only suture using these suture passers was described as all-inside suture (AIS) repair. This AIS repair could achieve meniscus-to-meniscus suture across the tear without interposition of soft tissues including the capsule between suture and meniscus, leading direct gap closing of torn edges. In this respect, AIS repair is considered to be "anatomical meniscus repair". Actually, some reports showed biomechanical and clinical advantages of AIS repair. However, there is still limited evidence in clinical practice. Moreover, there are some disadvantages for AIS repair. Not only further studies but also development of new devices and surgical techniques for AIS should be required. This review describes the current status of AIS repair for each type of tear.

The experience with the Inside-Out Technique for resection of Craniopharyngiomas during Endoscopic Endonasal Approaches (EEAs)

The experience with the Inside-Out Technique for resection of Craniopharyngiomas during Endoscopic Endonasal Approaches (EEAs)

The Inside-Out Technique of Deep Medial Collateral Ligament Release Could Provide Good Visualization during Knee Arthroscopy

During knee arthroscopy, clear vision of the intra-articular structures is essential. Two techniques have been described to aid in visualization by releasing the medial collateral ligament (MCL). The outside-in technique remains the most widely used, but injury to the saphenous nerve is one of the potential risks when performing this technique. On the other hand, the inside-out techniques for releasing the deep MCL (dMCL) tend to be safer since the procedure was done under direct visualization through an anteromedial portal. This study was a retrospective case series of 22 patients who underwent the dMCL release using an inside-out technique. The outcomes reported are medial joint space opening, neurovascular injury, and residual morbidities such as pain and valgus knee instability after the procedure.

Retrospective Study of Minimal Three-Year Follow-Up of Transforaminal Endoscopic Discectomy for Lumbar Disc Herniation: 5000 Multicenter Cases.

Objective The objective of this study was to investigate the long-term effects of percutaneous transforaminal endoscopic lumbar discectomy (PTELD) and clarify the differences between outside-in and inside-out techniques. Methodology This was a multicenter retrospective study with a chart review of questionnaires about patients' quality of life. Patients were recruited from three hospitals in China. Based on certain inclusion and exclusion criteria, we enrolled in the study 5000 patients aged ≥18 years diagnosed with lumbar disc herniation who received PTELD from September 2015 to September 2019. The outside-in technique (n=2039) was compared with the inside-out technique for PTELD (n=1890) on the Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and the Short Form 36 (SF-36) of the Health Survey Questionnaire (physical component)both pre-operatively and post-operatively. Results VAS, ODI, andSF-36 significantly improved just after surgery for both techniques compared with pre-operative status. Nevertheless, significant differences existed between the two techniques concerning VAS for leg pain, VAS for back pain, ODI, and SF-36 at 0.5 monthspost-operatively. The above indices steadily improved within six months after both techniques, after which they did not significantly improve. In detail, outside-in patients suffered more back pain and worse ODI and SF-36 (physical) but had more relief from leg pain 0.5 months after surgery in terms of VAS. As for recovery rate from symptoms, there were only significant differences in recovery rate for leg pain and back pain at the first 1.5 months post-operatively. As for satisfaction rates, the outside-in technique had better results than the inside-out technique at both 0.5 months and 12 months. Conclusion Both techniques could relieve the symptoms of lumbar disc herniation. However, patients in the outside-in group suffered more back pain and a bigger risk of nerve injury than those in the inside-out group.