Gregg Nicandri

A cadaveric study examining acromioclavicular joint congruity after different methods of coracoclavicular loop repair

A basic principle in the treatment of joint injuries is to restore congruity with the hope that restoration may lessen the incidence of late arthritis. The acromioclavicular (AC) joint is frequently injured. Many AC joint injuries are treated nonoperatively; others are treated surgically. Coracoclavicular loop repair of the AC joint is believed to lead to anterior displacement of the clavicle relative to the acromion. This cadaveric study evaluated the effectiveness of three techniques of coracoclavicular loop repair in restoring AC joint congruity through measurement of anterior displacement. Fourteen shoulders were repaired by the three different techniques, all of which consisted of fixation through a drill hole in the clavicle and around the crook of the coracoid with a suture. The techniques only varied by the placement of the drill hole in the clavicle (ie, either posterior, middle, or anterior). The results of this study indicate that as the drill hole moved anteriorly on the clavicle, joint congruity was more closely approached and less anterior displacement of the clavicle occurred. However, none of the methods of coracoclavicular loop fixation restored full AC joint congruity.

Improving residency training in arthroscopic knee surgery with use of a virtual-reality simulator: A randomized blinded study

BACKGROUND There is a paucity of articles in the surgical literature demonstrating transfer validity (transfer of training). The purpose of this study was to assess whether skills learned on the ArthroSim virtual-reality arthroscopic knee simulator transferred to greater skill levels in the operating room. METHODS Postgraduate year-3 orthopaedic residents were randomized into simulator-trained and control groups at seven academic institutions. The experimental group trained on the simulator, performing a knee diagnostic arthroscopy procedure to a predetermined proficiency level based on the average proficiency of five community-based orthopaedic surgeons performing the same procedure on the simulator. The residents in the control group continued their institution-specific orthopaedic education and training. Both groups then performed a diagnostic knee arthroscopy procedure on a live patient. Video recordings of the arthroscopic surgery were analyzed by five pairs of expert arthroscopic surgeons blinded to the identity of the residents. A proprietary global rating scale and a procedural checklist, which included visualization and probing scales, were used for rating. RESULTS Forty-eight (89%) of the fifty-four postgraduate year-3 residents from seven academic institutions completed the study. The simulator-trained group averaged eleven hours of training on the simulator to reach proficiency. The simulator-trained group performed significantly better when rated according to our procedural checklist (p = 0.031), including probing skills (p = 0.016) but not visualization skills (p = 0.34), compared with the control group. The procedural checklist weighted probing skills double the weight of visualization skills. The global rating scale failed to reach significance (p = 0.061) because of one extreme outlier. The duration of the procedure was not significant. This lack of a significant difference seemed to be related to the fact that residents in the control group were less thorough, which shortened their time to completion of the arthroscopic procedure. CONCLUSIONS We have demonstrated transfer validity (transfer of training) that residents trained to proficiency on a high-fidelity realistic virtual-reality arthroscopic knee simulator showed a greater skill level in the operating room compared with the control group. CLINICAL RELEVANCE We believe that the results of our study will stimulate residency program directors to incorporate surgical simulation into the core curriculum of their residency programs.

The Arthroscopic Surgical Skill Evaluation Tool (ASSET)

Background: Surgeries employing arthroscopic techniques are among the most commonly performed in orthopaedic clinical practice; however, valid and reliable methods of assessing the arthroscopic skill of orthopaedic surgeons are lacking. Hypothesis: The Arthroscopic Surgery Skill Evaluation Tool (ASSET) will demonstrate content validity, concurrent criterion-oriented validity, and reliability when used to assess the technical ability of surgeons performing diagnostic knee arthroscopic surgery on cadaveric specimens. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Content validity was determined by a group of 7 experts using the Delphi method. Intra-articular performance of a right and left diagnostic knee arthroscopic procedure was recorded for 28 residents and 2 sports medicine fellowship–trained attending surgeons. Surgeon performance was assessed by 2 blinded raters using the ASSET. Concurrent criterion-oriented validity, interrater reliability, and test-retest reliability were evaluated. Results: Content validity: The content development group identified 8 arthroscopic skill domains to evaluate using the ASSET. Concurrent criterion-oriented validity: Significant differences in the total ASSET score (P < .05) between novice, intermediate, and advanced experience groups were identified. Interrater reliability: The ASSET scores assigned by each rater were strongly correlated (r = 0.91, P < .01), and the intraclass correlation coefficient between raters for the total ASSET score was 0.90. Test-retest reliability: There was a significant correlation between ASSET scores for both procedures attempted by each surgeon (r = 0.79, P < .01). Conclusion: The ASSET appears to be a useful, valid, and reliable method for assessing surgeon performance of diagnostic knee arthroscopic surgery in cadaveric specimens. Studies are ongoing to determine its generalizability to other procedures as well as to the live operating room and other simulated environments.

Practical management of knee dislocations: a selective angiography protocol to detect limb-threatening vascular injuries.

Knee dislocations are relatively uncommon but potentially catastrophic injuries. In athletes, these injuries generally result from high-energy traumatic mechanisms such as collisions in football and rugby, high-velocity falls in skiing, and falls from heights in gymnastics and extreme sports. Knee dislocations are frequently associated with coincident neurological or vascular injuries. Recognition of vascular injury is particularly challenging because vascular compromise may not be immediately associated with clinical signs of ischemia and may result from injuries without complete or evident dislocation. This article reviews the rationale behind selective angiography, adjunctive vascular testing, and the need for observation after multiligament knee trauma. An algorithm for the diagnosis of vascular injuries is presented.

Do the Skills Acquired by Novice Surgeons Using Anatomic Dry Models Transfer Effectively to the Task of Diagnostic Knee Arthroscopy Performed on Cadaveric Specimens

BACKGROUND The use of surgical simulation in orthopaedic education is increasing; however, its ideal place within the training curriculum remains unknown. The purpose of this study was to determine the effectiveness of training novice surgeons on an anatomic dry model of the knee prior to training them to perform diagnostic arthroscopy on cadaveric specimens. METHODS Fourteen medical students were randomly assigned to two groups. The experimental group was trained to perform diagnostic arthroscopy of the knee on anatomic dry models prior to training on cadaveric specimens. The control group was trained only on cadaveric specimens. Proficiency was assessed with use of a modified version of a previously validated objective assessment of arthroscopic skill, the Basic Arthroscopic Knee Skill Scoring System (BAKSSS). The mean number of trials required to attain minimal proficiency when performing diagnostic knee arthroscopy was compared between the groups. The cumulative transfer effectiveness ratio (CTER) was calculated to measure the transfer of skills acquired by the experimental group. RESULTS The mean number of trials to demonstrate minimum proficiency was significantly lower in the experimental group (2.57) than in the control group (4.57) (p < 0.01). The mean time to demonstrate proficiency was also significantly less in the experimental group (37.51 minutes) than in the control group (60.48 minutes) (p < 0.01). The CTER of dry-model training for the task of performing diagnostic knee arthroscopy on cadaveric specimens was 0.2. CONCLUSIONS Previous training utilizing an anatomic dry knee model resulted in improved proficiency for novice surgeons learning to perform diagnostic knee arthroscopy on cadaveric specimens. A CTER of 0.2 suggests that dry models can serve as a useful adjunct to cadaveric training for diagnostic knee arthroscopy but cannot entirely replace it within the orthopaedic curriculum. Further work is necessary to determine the optimal amount of training on anatomic dry models that will maximize transfer effectiveness and to determine how well skills obtained in the simulated environment transfer to the operating room.

Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12- to 48-month outcomes.

Objectives: To report clinical and functional outcomes following fixation of tibial posterior cruciate ligament (PCL) avulsion fractures through a modified open posterior approach when combined with a rehabilitation program emphasizing early range of motion. Design: Retrospective case series. Setting: Level I trauma center. Patients: From March 4, 2000 to May 8, 2003, there were 16 cases of PCL tibial avulsion injuries presented to our institution, with 10 patients available for follow up at 12 to 48 months (mean 28 months). Intervention: Fixation of tibial PCL avulsion fractures was with a lag screw and washer placed through a modified open posterior approach. Range of motion was begun on postoperative day 1. Main Outcome Measurements: Clinical stability, range of motion, gastrocnemius muscle strength, radiographic appearance, and each patients overall health-related quality of life (using the musculoskeletal functional assessment tool) were evaluated at final follow up. Results: The average musculoskeletal functional assessment score was 14. (Musculoskeletal functional assessment scores range from 0-100, with higher scores indicating poorer function.) All patients achieved union of their fracture and had clinically stable knees at the latest follow-up. Flexion difference greater than 10 degrees (P = 0.16), extension difference greater than 2 degrees (P = 0.38), and heel raise difference more than 8 repetitions (P = 0.23) were not demonstrated in comparison to the normal side. Conclusions: Treatment of tibial PCL avulsion fractures, which includes fixation through a modified open posterior approach and early postoperative range of motion, results in healing of the fracture, good functional outcomes, stability to posterior draw testing, and does not lead to gastrocnemius weakness or significant range of motion deficits at 12 to 48 months postoperatively.

Evaluation of skill level between trainees and community orthopaedic surgeons using a virtual reality arthroscopic knee simulator.

BACKGROUND Several virtual reality simulators have been developed to assist orthopaedic surgeons in acquiring the skills necessary to perform arthroscopic surgery. The purpose of this study was to assess the construct validity of the ArthroSim virtual reality arthroscopy simulator by evaluating whether skills acquired through increased experience in the operating room lead to improved performance on the simulator. METHODS Using the simulator, six postgraduate year-1 orthopaedic residents were compared with six postgraduate year-5 residents and with six community-based orthopaedic surgeons when performing diagnostic arthroscopy. The time to perform the procedure was recorded. To ensure that subjects did not sacrifice the quality of the procedure to complete the task in a shorter time, the simulator was programmed to provide a completeness score that indicated whether the surgeon accurately performed all of the steps of diagnostic arthroscopy in the correct sequence. RESULTS The mean time to perform the procedure by each group was 610 seconds for community-based orthopaedic surgeons, 745 seconds for postgraduate year-5 residents, and 1028 seconds for postgraduate year-1 residents. Both the postgraduate year-5 residents and the community-based orthopaedic surgeons performed the procedure in significantly less time (p = 0.006) than the postgraduate year-1 residents. There was a trend toward significance (p = 0.055) in time to complete the procedure when the postgraduate year-5 residents were compared with the community-based orthopaedic surgeons. The mean level of completeness as assigned by the simulator for each group was 85% for the community-based orthopaedic surgeons, 79% for the postgraduate year-5 residents, and 71% for the postgraduate year-1 residents. As expected, these differences were not significant, indicating that the three groups had achieved an acceptable level of consistency in their performance of the procedure. CONCLUSIONS Higher levels of surgeon experience resulted in improved efficiency when performing diagnostic knee arthroscopy on the simulator. Further validation studies utilizing the simulator are currently under way and the additional simulated tasks of arthroscopic meniscectomy, meniscal repair, microfracture, and loose body removal are being developed.

Analysis of subscapularis integrity and function after lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty using ultrasound and validated clinical outcome measures

BACKGROUND The optimal method-subscapularis peel (SP) or lesser tuberosity osteotomy (LTO)-for takedown of the subscapularis during total shoulder arthroplasty (TSA) is controversial. This study compares the functional outcomes in a 2-surgeon cohort using the 2 techniques. METHODS Patients who underwent TSA with a minimum 1 year of follow-up were evaluated. Physical and ultrasound examinations of the operative shoulder were performed. Radiographs were evaluated for osteotomy healing. Patients completed the Western Ontario Osteoarthritis of the Shoulder (WOOS) index, Disability of the Arm, Shoulder, and Hand (DASH), and Constant Scores. RESULTS Subscapularis tenotomy (n = 32) and LTO (n = 28) patients were similar in age, hand dominance, and sex. Follow-up duration for subscapularis tenotomy and LTO patients differed (31.7 vs 22.1 months, P = .003). SP patients demonstrated increased external rotation (69° ± 12° vs 60° ± 11°). Belly press and bear hug resistance were not significantly different. WOOS (P = .13), DASH (P = .71), and Constant Scores (P = .80) were not significantly different. After controlling for follow-up imbalance, the WOOS score difference was statistically significant (91.5 ± 10.2 for LTO vs 82.1 ± 18.9 for SP, P = .05) but not clinically significant. By ultrasonography assessment, 4 subscapularis tendons were abnormal in the SP group (3 attenuated, 1 ruptured), and all tendons were normal in the LTO group. Patients with an abnormal ultrasound result had significantly inferior WOOS (88 ± 15 vs 65 ± 18) and DASH (11.5 ± 11.4 vs 25.9 ± 11.2) scores. Belly press resistance was significantly decreased, bear hug resistance trended lower, and external rotation was increased in the abnormal ultrasound group. CONCLUSIONS Abnormal subscapularis tendons identified by ultrasonography only in the SP group correlate with clinically significant inferior functional outcome scores.

Comparison of the syndesmotic staple to the transsyndesmotic screw: a biomechanical study.

Background: Controversy still exists about treatment of syndesmotic injuries. This study compared the fixation strengths and biomechanical characteristics of two types of ankle fracture syndesmotic fixation devices: the barbed, round staple and the 4.5-mm cortical screw. Methods: Cadaveric testing was done on 21 fresh-frozen knee disarticulation specimens in biaxial servohydraulic Instron testing equipment. Submaximal torsional loads were applied to specimens in intact and Weber C bimalleolar fracture states. The specimens were then fixed with one of two techniques and again subjected to submaximal torsion and torsion to failure. Biomechanical parameters measured included tibiofibular translation and rotation, maximal torque to failure, and degrees of rotation at failure. Results: Compared to the intact state before testing, the staple held the fibula in a more anatomic position than the screw for mediolateral and anterior displacements (p < 0.01). With submaximal torsional testing, the staple restored 85% of the tibiofibular external rotation and all of the posterior translation values as compared to the intact state. The screw resulted in 203% more tibiofibular medial translation and 115% more external rotation than the intact state. The degree of tibial rotation during submaximal torsional loading was restored to within 15% of intact values but was 21% less with the screw. There was no statistical difference between the screw and staple when tested in load to failure. Tibio-talar rotation at failure was statistically different with the staple construct, allowing more rotation as compared to the screw. Conclusion: The staple restored a more physiologic position of the fibula compared to the syndesmotic screw. Both provided similar performance for the load to failure testing, while the screw reduced tibial rotation more after cyclic loading. There was more tibial rotation before failure for the staple, suggesting a more elastic construct. This study provides biomechanical data to support the clinical use of the syndesmotic staple.

Using the arthroscopic surgery skill evaluation tool as a pass-fail examination.

BACKGROUND Examination of arthroscopic skill requires evaluation tools that are valid and reliable with clear criteria for passing. The Arthroscopic Surgery Skill Evaluation Tool was developed as a video-based assessment of technical skill with criteria for passing established by a panel of experts. The purpose of this study was to test the validity and reliability of the Arthroscopic Surgery Skill Evaluation Tool as a pass-fail examination of arthroscopic skill. METHODS Twenty-eight residents and two sports medicine faculty members were recorded performing diagnostic knee arthroscopy on a left and right cadaveric specimen in our arthroscopic skills laboratory. Procedure videos were evaluated with use of the Arthroscopic Surgery Skill Evaluation Tool by two raters blind to subject identity. Subjects were considered to pass the Arthroscopic Surgery Skill Evaluation Tool when they attained scores of ≥ 3 on all eight assessment domains. RESULTS The raters agreed on a pass-fail rating for fifty-five of sixty videos rated with an interclass correlation coefficient value of 0.83. Ten of thirty participants were assigned passing scores by both raters for both diagnostic arthroscopies performed in the laboratory. Receiver operating characteristic analysis demonstrated that logging more than eighty arthroscopic cases or performing more than thirty-five arthroscopic knee cases was predictive of attaining a passing Arthroscopic Surgery Skill Evaluation Tool score on both procedures performed in the laboratory. CONCLUSIONS The Arthroscopic Surgery Skill Evaluation Tool is valid and reliable as a pass-fail examination of diagnostic arthroscopy of the knee in the simulation laboratory. CLINICAL RELEVANCE This study demonstrates that the Arthroscopic Surgery Skill Evaluation Tool may be a useful tool for pass-fail examination of diagnostic arthroscopy of the knee in the simulation laboratory. Further study is necessary to determine whether the Arthroscopic Surgery Skill Evaluation Tool can be used for the assessment of multiple arthroscopic procedures and whether it can be used to evaluate arthroscopic procedures performed in the operating room.