Kash Akhtar

The Global Economic Cost of Osteoarthritis: How the UK Compares

Aims. To examine all relevant literature on the economic costs of osteoarthritis in the UK, and to compare such costs globally. Methods. A search of MEDLINE was performed. The search was expanded beyond peer-reviewed journals into publications by the department of health, national orthopaedic associations, national authorities and registries, and arthritis charities. Results. No UK studies were identified in the literature search. 3 European, 6 North American, and 2 Asian studies were reviewed. Significant variation in direct and indirect costs were seen in these studies. Costs for topical and oral NSAIDs were estimated to be £19.2 million and £25.65 million, respectively. Cost of hip and knee replacements was estimated to exceed £850 million, arthroscopic surgery for osteoarthritis was estimated to be £1.34 million. Indirect costs from OA caused a loss of economic production over £3.2 billion, £43 million was spent on community services and £215 million on social services for osteoarthritis. Conclusions. While estimates of economic costs can be made using information from non-published data, there remains a lack of original research looking at the direct or indirect costs of osteoarthritis in the UK. Differing methodology in calculating costs from overseas studies makes direct comparison with the UK difficult.

Current concepts of the management of anterior cruciate ligament injuries in children

Recent reports have suggested an increase in the number of anterior cruciate ligament (ACL) injuries in children, although their true incidence is unknown. The prognosis of the ACL-deficient knee in young active individuals is poor because of secondary meniscal tears, persistent instability and early-onset osteoarthritis. The aim of surgical reconstruction is to provide stability while avoiding physeal injury. Techniques of reconstruction include transphyseal, extraphyseal or partial physeal sparing procedures. In this paper we review the management of ACL tears in skeletally immature patients.

The role of simulation in developing surgical skills

Surgical training has followed the master-apprentice model for centuries but is currently undergoing a paradigm shift. The traditional model is inefficient with no guarantee of case mix, quality, or quantity. There is a growing focus on competency-based medical education in response to restrictions on doctors’ working hours and the traditional mantra of “see one, do one, teach one” is being increasingly questioned. The medical profession is subject to more scrutiny than ever before and is facing mounting financial, clinical, and political pressures. Simulation may be a means of addressing these challenges. It provides a way for trainees to practice technical tasks in a protected environment without putting patients at risk and helps to shorten the learning curve. The evidence for simulation-based training in orthopedic surgery using synthetic models, cadavers, and virtual reality simulators is constantly developing, though further work is needed to ensure the transfer of skills to the operating theatre.

Evidence-based surgical training in orthopaedics: how many arthroscopies of the knee are needed to achieve consultant level performance?

Despite being one of the most common orthopaedic operations, it is still not known how many arthroscopies of the knee must be performed during training in order to develop the skills required to become a Consultant. A total of 54 subjects were divided into five groups according to clinical experience: Novices (n = 10), Junior trainees (n = 10), Registrars (n = 18), Fellows (n = 10) and Consultants (n = 6). After viewing an instructional presentation, each subject performed a simple diagnostic arthroscopy of the knee on a simulator with visualisation and probing of ten anatomical landmarks. Performance was assessed using a validated global rating scale (GRS). Comparisons were made against clinical experience measured by the number of arthroscopies which had been undertaken, and ROC curve analysis was used to determine the number of procedures needed to perform at the level of the Consultants. There were marked differences between the groups. There was significant improvement in performance with increasing experience (p < 0.05). ROC curve analysis identified that approximately 170 procedures were required to achieve the level of skills of a Consultant. We suggest that this approach to identify what represents the level of surgical skills of a Consultant should be used more widely so that standards of training are maintained through the development of an evidenced-based curriculum.

Which Global Rating Scale? A Comparison of the ASSET, BAKSSS, and IGARS for the Assessment of Simulated Arthroscopic Skills.

BACKGROUND With the move to competency-based models of surgical training, a number of assessment methods have been developed. Of these, global rating scales have emerged as popular tools, and several are specific to the assessment of arthroscopic skills. Our aim was to determine which one of a group of commonly used global rating scales demonstrated superiority in the assessment of simulated arthroscopic skills. METHODS Sixty-three individuals of varying surgical experience performed a number of arthroscopic tasks on a virtual reality simulator (VirtaMed ArthroS). Performance was blindly assessed by two observers using three commonly used global rating scales used to assess simulated skills. Performance was also assessed by validated objective motion analysis. RESULTS All of the global rating scales demonstrated construct validity, with significant differences between each skill level and each arthroscopic task (p < 0.002, Mann-Whitney U test). Interrater reliability was excellent for each global rating scale. Correlations of global rating scale ratings with motion analysis were high and strong for each global rating scale when correlated with time taken (Spearman rho, -0.95 to -0.76; p < 0.001), and correlation with total path length was significant and moderately strong (Spearman rho, -0.94 to -0.64; p < 0.001). CONCLUSIONS No single global rating scale demonstrated superiority as an assessment tool. CLINICAL RELEVANCE For these commonly used arthroscopic global rating scales, none was particularly superior and any one score could therefore be used. Agreement on using a single score seems sensible, and it would seem unnecessary to develop further scales with the same domains for these purposes.

Formative Assessment of Procedural Skills: Students' Responses to the Objective Structured Clinical Examination and the Integrated Performance Procedural Instrument.

Assessment of clinical skills is a critical element of undergraduate medical education. We compare a traditional approach to procedural skills assessment – the Objective Structured Clinical Examination (OSCE) with the Integrated Performance Procedural Instrument (IPPI). In both approaches, students work through ‘stations’ or ‘scenarios’ undertaking defined tasks. In the IPPI, all tasks are contextualised, requiring students to integrate technical, communication and other professional skills. The aim of this study was to explore students’ responses to these two assessments. Third‐year medical students participated in formative OSCE and IPPI sessions on consecutive days. Although performance data were collected in both assessments, quantitative data are not presented here. Group interviews with students were conducted by independent researchers. Data were analysed thematically. The OSCE and the IPPI were both valued, but for different reasons. Preference for the OSCE reflected the format of the summative assessment. The IPPI was valued for the opportunity to practise patient‐centred care in a simulated setting which integrated technical, communication and other professional skills. We posit that scenario‐based assessments such as the IPPI reflect real‐world issues of patient‐centred care. Although the limitations of this study prevent wide extrapolation, we encourage curriculum developers to consider the influence of assessments on what and how their students learn.

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

BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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. CLINICAL RELEVANCE 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.

Remote assessment and learner‐centred feedback on procedural skills

T he Imperial College Feedback and Assessment System (ICFAS) is an innovative approach to providing feedback to trainees on their performance in clinical procedural skills. ICFAS consists of a combination of existing technologies–video recording, networked mobile computers (laptop and handheld) and content management. The technical elements of the system are described in the literature. In this paper we use the Integrated Procedural Performance Instrument (IPPI) to illustrate two features of ICFAS– remote rating and learner-centred feedback. Briefly, IPPI combines bench-top training models with simulated patients (professional actors) in a quasi-clinical setting, enabling trainees to integrate technical, communication and other professional skills essential for safe practice of procedural skills (Figure 1). During a 2-hour training session, a trainee completes eight scenarios (for example, urinary catheterisation, suturing) in a similar process to an Objective Structured Clinical Examination (OSCE). Procedures offer varying levels of challenge, with ‘patients’ who may be anxious, disabled, angry or unable to speak the clinician’s language.

The Transferability of Generic Minimally Invasive Surgical Skills: Is There Crossover of Core Skills Between Laparoscopy and Arthroscopy?

OBJECTIVE The primary objective was observing transferability of minimally invasive surgical skills between virtual reality simulators for laparoscopy and arthroscopy. Secondary objectives were to assess face validity and acceptability. DESIGN Prospective single-blinded crossover randomized controlled trial. SETTING MSk Laboratory, Imperial College London. PARTICIPANTS Student doctors naïve to simulation and minimally invasive techniques. METHODS A total of 72 medical students were randomized into 4 groups (2 control groups and 2 training groups), and tested on haptic virtual reality simulators. Group 1 (control; n = 16) performed a partial laparoscopic cholecystectomy and Group 2 (control; n = 16) performed a diagnostic knee arthroscopy. Both groups then repeated the same task a week later. Group 3 (training; n = 20) completed a partial laparoscopic cholecystectomy, followed by an arthroscopic training program, and repeated the laparoscopic cholecystectomy a week later. Group 4 (training; n = 20) performed a diagnostic knee arthroscopy, followed by a laparoscopic training program, and then repeated the initial arthroscopic test a week later. The time taken, instrument path length, and speed were recorded for each participant and analyzed. RESULTS Time taken for task: All 4 cohorts were significantly quicker on their second attempt but the 2 training groups outperformed the 2 control groups, with the laparoscopy-trained group improving the most (p < 0.05). Economy of movement: All cohorts had a significant improvement in left hand path length (p < 0.01) but there was no difference for right hand path length. Left hand speed: Only the 2 training groups showed significant improvement with the laparoscopy-trained group improving the most (p < 0.05). Right hand speed: All cohorts improved significantly with the laparoscopy-trained group improving the most (p < 0.05). Face validity and acceptability were established for both simulators. CONCLUSION This study showed that minimally invasive surgical skills learnt on a laparoscopy simulator are transferable to arthroscopy and vice versa, with greater effect after training on the laparoscopy simulator.

Does Video Gaming Affect Orthopaedic Skills Acquisition? A Prospective Cohort-Study

Introduction Previous studies have suggested that there is a positive correlation between the extent of video gaming and efficiency of surgical skill acquisition on laparoscopic and endovascular surgical simulators amongst trainees. However, the link between video gaming and orthopaedic trauma simulation remains unexamined, in particular dynamic hip screw (DHS) stimulation. Objective To assess effect of prior video gaming experience on virtual-reality (VR) haptic-enabled DHS simulator performance. Methods 38 medical students, naïve to VR surgical simulation, were recruited and stratified relative to their video gaming exposure. Group 1 (n = 19, video-gamers) were defined as those who play more than one hour per day in the last calendar year. Group 2 (n = 19, non-gamers) were defined as those who play video games less than one hour per calendar year. Both cohorts performed five attempts on completing a VR DHS procedure and repeated the task after a week. Metrics assessed included time taken for task, simulated flouroscopy time and screw position. Median and Bonett-Price 95% confidence intervals were calculated for seven real-time objective performance metrics. Data was confirmed as non-parametric by the Kolmogorov-Smirnov test. Analysis was performed using the Mann-Whitney U test for independent data whilst the Wilcoxon signed ranked test was used for paired data. A result was deemed significant when a two-tailed p-value was less than 0.05. Results All 38 subjects completed the study. The groups were not significantly different at baseline. After ten attempts, there was no difference between Group 1 and Group 2 in any of the metrics tested. These included time taken for task, simulated fluoroscopy time, number of retries, tip-apex distance, percentage cut-out and global score. Conclusion Contrary to previous literature findings, there was no correlation between video gaming experience and gaining competency on a VR DHS simulator.