Robert Middleton

Validating a global rating scale to monitor individual resident learning curves during arthroscopic knee meniscal repair.

PURPOSEnTo determine whether a global rating scale (GRS) with construct validity can also be used to assess the learning curve of individual orthopaedic trainees during simulated arthroscopic knee meniscal repair.nnnMETHODSnAn established arthroscopic GRS was used to evaluate the technical skill of 19 orthopaedic residents performing a standardized arthroscopic meniscal repair in a bioskills laboratory. The residents had diagnostic knee arthroscopy experience but no experience with arthroscopic meniscal repair. Residents were videotaped performing an arthroscopic meniscal repair on 12 separate occasions. Their performance was assessed by use of the GRS and motion analysis objectively measuring the time taken to complete tasks, path length of the subjects hands, and number of hand movements. One author assessed all 228 videos, whereas 2 other authors rated 34 randomly selected videos, testing the interobserver reliability of the GRS. The validity of the GRS was tested against the motion analysis.nnnRESULTSnObjective assessment with motion analysis defined the surgeons learning curve, showing significant improvement by each subject over 12 episodes (P < .0001). The GRS also showed a similar learning curve with significant improvements in performance (P < .0001). The median GRS score improved from 15 of 34 (interquartile range, 14 to 17) at baseline to 22 of 34 (interquartile range, 19 to 23) in the final period. There was a moderate correlation (P < .0001, Spearman test) between the GRS and motion analysis parameters (r = -0.58 for time, r = -0.58 for path length, and r = -0.51 for hand movements). The inter-rater reliability among 3 trained assessors using the GRS was excellent (Cronbach α = 0.88).nnnCONCLUSIONSnWhen compared with motion analysis, an established arthroscopic GRS, with construct validity, also offers a moderately feasible method to monitor the learning curve of individual residents during simulated knee meniscal repair.nnnCLINICAL RELEVANCEnAn arthroscopic GRS can be used for monitoring skill improvement during knee meniscal repair and has the potential for use as a training and assessment tool in the real operating room.

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

BACKGROUNDnWith 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.nnnMETHODSnSixty-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.nnnRESULTSnAll 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).nnnCONCLUSIONSnNo single global rating scale demonstrated superiority as an assessment tool.nnnCLINICAL RELEVANCEnFor 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.

Simulation-Based Training Platforms for Arthroscopy: A Randomized Comparison of Virtual Reality Learning to Benchtop Learning

PURPOSEnTo determine whether a virtual reality (VR) arthroscopy simulator or benchtop (BT) arthroscopy simulator showed superiority as a training tool.nnnMETHODSnArthroscopic novices were randomized to a training program on a BT or a VR knee arthroscopy simulator. The VR simulator provided user performance feedback. Individuals performed a diagnostic arthroscopy on both simulators before and after the training program. Performance was assessed using wireless objective motion analysis and a global rating scale.nnnRESULTSnThe groups (8 in the VR group, 9 in the BT group) were well matched at baseline across all parameters (P > .05). Training on each simulator resulted in significant performance improvements across all parameters (P < .05). BT training conferred a significant improvement in all parameters when trainees were reassessed on the VR simulator (P < .05). In contrast, VR training did not confer improvement in performance when trainees were reassessed on the BT simulator (P > .05). BT-trained subjects outperformed VR-trained subjects in all parameters during final assessments on the BT simulator (P < .05). There was no difference in objective performance between VR-trained and BT-trained subjects on final VR simulator wireless objective motion analysis assessment (P > .05).nnnCONCLUSIONSnBoth simulators delivered improvements in arthroscopic skills. BT training led to skills that readily transferred to the VR simulator. Skills acquired after VR training did not transfer as readily to the BT simulator. Despite trainees receiving automated metric feedback from the VR simulator, the results suggest a greater gain in psychomotor skills for BT training. Further work is required to determine if this finding persists in the operating room.nnnCLINICAL RELEVANCEnThis study suggests that there are differences in skills acquired on different simulators and skills learnt on some simulators may be more transferable. Further work in identifying user feedback metrics that enhance learning is also required.

Yeast perfusion fluid contamination in pancreas transplantation.

1. Franchi M, Ghezzi F, Benedetti-Panici PL, et al. A multicentre collaborative study on the use of cold scalpel and electrocautery for midline abdominal incision. Am J Surg 2001;181:128–132. 2. Israelsson LA, Jonsson T, Knutsson A. Suture technique and wound healing in midline laparotomy incision. Eur J Surg 1996;162:605–609. 3. Alexander JW, Korelitz J, Alezander NS. Prevention of wound infection. A case for closed suction drainage to remove wound fluids deficient in opsonic proteins. Am J Surg 1976;132:59–63. 4. MangramAJ, Horan TC, PearsonML, Silver LC, JarvisWR. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999;20:247–278. 5. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Am J Infect Control 1992;20:271–274. 6. Chowdri NA, Qadri SA, Parray FQ, Gagloo MA. Role of subcutaneous drains in obese patients undergoing elective cholecystectomy. A cohort study. Int J Surg 2007;5:404–407. 7. Mahmoud NN, Turpin RS, Yang G, Saunders WB. Impact of surgical site infections on length of stay and costs in selected colorectal procedures. Surg Infect 2009;10: 539–544.

Patient-reported outcome measures for patients with meniscal tears: a systematic review of measurement properties and evaluation with the COSMIN checklist

Objective Meniscal tears occur frequently in the population and the most common surgical treatment, arthroscopic partial meniscectomy, is performed in approximately twou2009million cases worldwide each year. The purpose of this systematic review is to summarise and critically appraise the evidence for the use of patient-reported outcome measures (PROMs) in patients with meniscal tears. Design A systematic review was undertaken. Data on reported measurement properties were extracted and the quality of the studies appraised according to Consensus-based Standards for the Selection of Health Measurement Instruments. Data sources A search of MEDLINE, Embase, AMED and PsycINFO, unlimited by language or publication date (last search 20 February 2017). Eligibility criteria for selecting studies Development and validation studies reporting the measurement properties of PROMs in patients with meniscal tears were included. Results 11 studies and 10 PROMs were included. The overall quality of studies was poor. For measurement of symptoms and functional status, there is only very limited evidence supporting the selection of either the Lysholm Knee Scale, International Knee Documentation Committee Subjective Knee Form or the Dutch version of the Knee injury and Osteoarthritis Outcome Score. For measuring health-related quality of life, only limited evidence supports the selection of the Western Ontario Meniscal Evaluation Tool (WOMET). Of all the PROMs evaluated, WOMET has the strongest evidence for content validity. Conclusion For patients with meniscal tears, there is poor quality and incomplete evidence regarding the validity of the currently available PROMs. Further research is required to ensure these PROMs truly reflect the symptoms, function and quality of life of patients with meniscal tears. PROSPERO registration number CRD42017056847.

Can Surgical Trainees Achieve Arthroscopic Competence at the End of Training Programs? A Cross-sectional Study Highlighting the Impact of Working Time Directives

PURPOSEnTo provide training guidance on procedure numbers by assessing how the number of previously performed arthroscopic procedures relate to both competent and expert performance in simulated arthroscopic shoulder tasks.nnnMETHODSnA cross-sectional study that assessed simulated shoulder arthroscopic performance was undertaken. A total of 45 participants of varying experience performed 2 validated tasks: a simple diagnostic task and a more complex Bankart labral repair task. All participants provided logbook numbers for previously performed arthroscopies. Performance was assessed with the Global Rating Scale and motion analysis. Receiver operating characteristic curve analyses were conducted to identify optimum cut points for task proficiency at both competent and expert levels.nnnRESULTSnIncreasing surgical experience resulted in significantly better performance for both tasks as assessed by Global Rating Scale or motion analysis (P < .0001). Receiver operating characteristic curve analyses demonstrated 52 previous arthroscopies were needed to perform to a competent level at the diagnostic task and 248 to be competent at the complex task. To perform at an expert level, 290 and 476 previous arthroscopies, respectively, were needed.nnnCONCLUSIONSnThis study provides quantified guidance for arthroscopic training and highlights the positive relationship between arthroscopic case load and arthroscopic competency. We have estimated that the number of arthroscopies required to achieve competency in a basic arthroscopic task exceed those recommended in some countries. These estimates provide useful guidance to those responsible for training program.nnnCLINICAL RELEVANCEnThe numbers to achieve competent arthroscopic performance in the assessed simulated tasks exceed what is recommended and what is possible during surgical training programs in some countries.

Bone wax following proximal femoral osteotomy in total hip replacement

Any means of reducing blood loss during total hip replacement is beneficial. Following femoral neck osteotomy, the cut femoral end is usually left. This is a potential source of significant low pressure ooze, which can account for a sizeable proportion of intraoperative blood loss and may also obscure the surgical field. Cheap and easily available bone wax, first described in 1892, can be smeared across the cut trabecular surface following femoral osteotomy (Fig 1). The wax is later removed on broaching the femur. This simple and cost effective method can limit bone bleeding intraoperatively and can help maintain a clear surgical field. n n n nFigure 1 n nBone wax applied to femoral osteotomy demonstrating complete haemostasis from cut surface

Enhanced recovery programmes in knee arthroplasty: current concepts

The concept of a multimodal approach to improve the care of surgical patients was first proposed by Kehlet in the 1990s. Measures to optimise the surgical patient, and minimise perioperative stresses, aimed to improve postoperative outcomes. Although originally introduced in colorectal surgery, these ‘enhanced recovery programmes’ have now seen widespread uptake in multiple surgical specialities, including orthopaedics. Patients undergoing knee arthroplasty are well suited to an enhanced recovery approach. These programmes optimise the patient at each stage of the surgical journey, including preoperative optimisation of fitness, perioperative anaesthetic and surgical techniques and finally postoperative rehabilitation and discharge plans. The available evidence supports a number of improvements after programme introduction, including shorter length of stay, morbidity and economics. However, the impact on other outcomes is less clear. One of the issues in the field is a lack of consensus on what interventions an enhanced recovery programme should contain and the specifics of these interventions. As a result, individual units develop their own programmes, making the interpretation and comparison of their impact difficult. This article discusses interventions that could be considered for inclusion in an enhanced recovery programme for knee arthroplasty.

Surgical management of the elderly elbow

The elbow has a major role in helping with the positioning of the hand in space. Any pathology of the joint can result in pain, loss of function and difficulties with activities of daily living. With an increasingly elderly population the degenerative conditions affecting the elbow are becoming more prevalent. Besides traumatic injury, the more commonly encountered problems are osteoarthritis, inflammatory arthritis, nerve compression and stiffness. An awareness of these conditions is important for those who provide care to this patient group. Whilst many of these conditions can be managed conservatively in primary care, some patients are referred to secondary care and elect for surgical treatments. This review considers the surgical treatments for the common elbow pathologies in the elderly population, including the potential complications associated with such treatments.

Successful use of Alteplase during cardiopulmonary resuscitation following massive PE in a patient presenting with ischaemic stroke and haemorrhagic transformation.

The management of patients with acute stroke regarding treatment of thromboembolism is supported by a limited evidence base. We present the case of a 55-year-old female patient who initially presented with an ischaemic cerebral infarct with haemorrhagic transformation. Her clinical recovery was complicated by cardiac arrest secondary to massive pulmonary embolism. This was successfully treated with cardiopulmonary resuscitation and thrombolysis using Alteplase, which led to a full recovery to the pre-arrest state with no evidence of haemorrhagic complication. The patient was successfully discharged to a specialist centre for on-going stroke rehabilitation with no additional neurological impact. Despite the limited evidence base we believe this case highlights that thrombolysis can be used in select patients with haemorrhagic transformation of stroke and serious thromboembolic complications to achieve a positive outcome.