Background:
Arthroscopic hip labral repair is a technically challenging and demanding surgical technique with a steep learning curve. Arthroscopic simulation allows trainees to develop these skills ...in a safe environment.
Purpose:
The purpose of this study was to evaluate the use of a combination of assessment ratings for the performance of arthroscopic hip labral repair on a dry model.
Study Design:
Cross-sectional study; Level of evidence, 3.
Methods:
A total of 47 participants including orthopaedic surgery residents (n = 37), sports medicine fellows (n = 5), and staff surgeons (n = 5) performed arthroscopic hip labral repair on a dry model. Prior arthroscopic experience was noted. Participants were evaluated by 2 orthopaedic surgeons using a task-specific checklist, the Arthroscopic Surgical Skill Evaluation Tool (ASSET), task completion time, and a final global rating scale. All procedures were video-recorded and scored by an orthopaedic fellow blinded to the level of training of each participant.
Results:
The internal consistency/reliability (Cronbach alpha) using the total ASSET score for the procedure was high (intraclass correlation coefficient > 0.9). One-way analysis of variance for the total ASSET score demonstrated a difference between participants based on the level of training (F3,43 = 27.8, P < .001). A good correlation was seen between the ASSET score and previous exposure to arthroscopic procedures (r = 0.52-0.73, P < .001). The interrater reliability for the ASSET score was excellent (>0.9).
Conclusion:
The results of this study demonstrate that the use of dry models to assess the performance of arthroscopic hip labral repair by trainees is both valid and reliable. Further research will be required to demonstrate a correlation with performance on cadaveric specimens or in the operating room.
Background
The Pavlik harness is the most common initial treatment for developmental dysplasia of the hip worldwide. During treatment, parents are required to re-apply the harness at home. Teaching ...parents how to apply the harness is therefore paramount to success. While simulated learning for medical training is commonplace, it has not yet been trialed in teaching parents how to apply a Pavlik harness.
Methods
A group of parents underwent a simulated learning module for Pavlik harness application. Parents were evaluated pre- and post-exposure and at one month after testing. A validated objective structured assessment of technical skill (OSATS) and a global rating scale (GRS) specific to Pavlik harness application were used for evaluation. A control group of parents was also tested at both time points. A clinical expert group was used to determine competency. ANOVA and t tests were used to assess differences between groups and over time.
Results
Parent scores on the OSATS improved to the level of expert clinicians both immediately post-intervention and at retention testing. However, on the GRS, only half were considered competent due to their inability to achieve the required hip positions. The control group did not improve nor were they considered competent.
Conclusions
The use of a simulated learning module improves both the confidence and skill level of parents in the application of the Pavlik harness. However, the challenges parents face in understanding the more detailed subtleties of medical care suggest that they still require an appropriate level of supervision by clinicians to ensure effective treatment.
The purpose of this study was to develop a multifaceted examination to assess the competence of fellows following completion of a sports medicine fellowship.
Orthopedic sports medicine fellows over 2 ...academic years were invited to participate in the study. Clinical skills were evaluated with objective structured clinical examinations, multiple-choice question examinations, an in-training evaluation report and a surgical logbook. Fellows’ performance of 3 technical procedures was assessed both intraoperatively and on cadavers: anterior cruciate ligament reconstruction (ACLR), arthroscopic rotator cuff repair (RCR) and arthroscopic shoulder Bankart repair. Technical procedural skills were assessed using previously validated task-specific checklists and the Arthroscopic Surgical Skill Evaluation Tool (ASSET) global rating scale.
Over 2 years, 12 fellows were assessed. The Cronbach α for the technical assessments was greater than 0.8, and the interrater reliability for the cadaveric assessments was greater than 0.78, indicating satisfactory reliability. When assessed in the operating room, all fellows were determined to have achieved a minimal level of competence in the 3 surgical procedures, with the exception of 1 fellow who was not able achieve competence in ACLR. When their performance on cadaveric specimens was assessed, 2 of 12 (17%) fellows were not able to demonstrate a minimal level of competence in ACLR, 2 of 10 (20%) were not able to demonstrate a minimal level of competence for RCR and 3 of 10 (30%) were not able to demonstrate a minimal level of competence for Bankart repair.
There was a disparity between fellows’ performance in the operating room and their performance in the high-fidelity cadaveric setting, suggesting that technical performance in the operating room may not be the most appropriate measure for assessment of fellows’ competence.
Objectives:
The most common presentation of knee osteochondritis dissecans (OCD) is a stable lesion on the lateral aspect of the medial femoral condyle (MFC) in an adolescent or pre-adolescent ...athlete. The standard of care for primary treatment is non-operative, and includes rest/activity modification and often weight bearing protection or bracing. Failed conservative management often leads arthroscopy and drilling of the lesion. Two different primary drilling techniques have been utilized, but no prospective studies have compared their relative effectiveness. The study hypothesis was that retro-articular drilling (RAD), the slightly newer technique, would not be inferior to trans-articular (TAD), with regard to rate of healing, time to return to sports (RTS), and patient-reported outcome scores (PROs).
Methods:
Skeletally immature (n=113) patients presenting with MRI-confirmed stable OCD of the MFC who did not demonstrate substantial healing after a minimum of 3 months of non-operative treatment were prospectively enrolled by one of seventeen surgeon-investigators (at 14 centers, representing all major geographic regions in the U.S.) and randomized to TAD or RAD. Post-operatively, serial radiographs were obtained every 6 weeks to assess healing, and PROs were obtained at 6 months, 12 months, and 24 months. Twelve patients were closed out at time of surgery due to lesion instability detected during arthroscopy. Power analysis determined that in order to detect a difference in 2-year IKDC score between RA and TA groups with 80% power, sample sizes of 37 subjects per group would be required if the true standard deviation were 15. This analysis was based on conducting an independent samples Student’s t-test with alpha set to 5%.
Results:
Ninety-one study subjects were included, consisting of 51 TAD and 40 RAD patients, respectively, with the two groups being similar in age (12.6 years vs. 11.9 years), sex distribution (45% vs. 27% female, p=0.081), and 2-year PRO response rate (both 90%). No significant differences between TAD and RAD were detected in follow-up Pedi-IKDC, Lysholm, Marx knee activity score, or KOOS QOL scores (Table 1). Revision/additional OCD surgery occurred in 10% of patients in RAD and 4% in TAD (p=0.40). 73% of TAD patients reached a ‘healed’ status at a mean of 1.15 years, compared with 60% RAD patients at a mean of 1.21 years.
Conclusions:
While both primary forms of OCD drilling (TAD and RAD) showed consistent post-operative healing, achieving a completely ‘healed’ status was often a more prolonged process, taking approximately 1 year, despite clinical improvement and RTS being achieved much sooner. PROs were similar between drilling techniques. Significantly higher powered studies are needed to better elucidate the greater revision surgery rates in RAD compared with TAD, but overall risk is low and absolute risk only 6%. The current data support either drilling technique, which may be technically simpler, without the need for fluoroscopy, with TAD, and may be more protective of the chondral articular surface with RAD.
Objective
Consistent terminology to describe the diagnostic criteria for fibromyalgia (FM) and myofascial pain syndrome (MPS) is required to address the reported inadequacies in diagnosis. The ...present review investigated intervention studies in FM and MPS populations to determine the lexicon of the current diagnostic criteria used to identify chronic musculoskeletal pain patients.
Methods
Following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines, we conducted a scoping review to review systematically the literature obtained from five scientific databases between 1997 and February 2017. Included studies consisted of intervention studies that involved symptomatic musculoskeletal pain patients, of any age or gender, presenting with FM or MPS. Included studies were evaluated for musculoskeletal condition and the diagnostic criteria used to identify patient conditions. Extraction of study criteria focused on whether diagnostic criteria were explicitly stated, the diagnostic criteria used, physical findings, symptomatic duration and the profession of the healthcare provider who confirmed diagnosis.
Results
We identified 493 interventions, of which 410 were related to FM and 83 to MPS. The lexicon of the diagnostic criteria used for MPS tended to be less consistent in comparison to FM criteria, with notable differences in all comparative categories.
Conclusions
The current review identified inconsistencies associated with the lexicon of the diagnostic criteria used to diagnose FM and MPS, and showed that there is wide variability in the terminology currently being used. These findings may have important implications for future development of consistent criteria to diagnose FM and MPS patients accurately.
Background:
Osteochondritis dissecans (OCD) is a vexing condition for patients, parents, and physicians because of the frequent slow healing and nonhealing that leads to prolonged treatment. Several ...features on plain radiographs have been identified as predictors of healing, but the reliability of their measurement has not been established.
Purpose:
To determine the inter- and intrarater reliability of several radiographic features used in the diagnosis, treatment, and prognosis of OCD femoral condyle lesions.
Study Design:
Cohort study (Diagnosis); Level of evidence, 3.
Methods:
Pretreatment anteroposterior, lateral, and notch radiographs of 45 knees containing OCD lesions of the medial or lateral femoral condyle were reviewed in blinded fashion by 7 orthopaedic physician raters from different institutions over a secure web portal at 2 time points over a month apart. Classification variables included lesion location, growth plate maturity, parent bone radiodensity, progeny bone fragmentation, progeny bone displacement, progeny bone contour, lesion boundary, and radiodensity of the lesion center and rim. Condylar width and lesion size were measured on all views. Interrater reliability was assessed using free-marginal kappa and intraclass correlations. Intrarater reliability was assessed using the Cohen kappa, linear-weighted kappa, and intraclass correlations based on measurement type.
Results:
Raters had excellent reliability for differentiating medial and lateral lesions and growth plate maturity and for measuring condylar width and lesion size. In the subset of knees with visible bone in the lesion, the fragmentation, displacement, boundary, central radiodensity, and contour (concave/nonconcave) of the lesion bone were classified with moderate to substantial reliability. The radiodensity of the lesion rim and surrounding epiphyseal bone were classified with poor to fair reliability.
Conclusion:
Many diagnostic features of femoral condyle OCD lesions can be reliably classified on plain radiographs, supporting their future testing in multifactorial classification systems and multicenter research to develop prognostic algorithms. Other radiographic features should be excluded, however, because of poor reliability.
A cross-sectional survey of senior neurosurgical and orthopedic residents.
To evaluate the confidence of senior orthopedic and neurosurgery residents in performing spinal surgical procedures and ...their need for further training. The content and exposure to spine training as well as anticipated practice profile were characterized.
Spinal surgery is performed by specialists with backgrounds in orthopedic surgery and neurosurgery. As this subspecialty evolves, the need to modify training programs to keep up with technological and medical advances becomes increasingly clear. The primary objective of this study was to evaluate the self-assessed confidence and perceived need for further training of senior orthopedic and neurosurgical residents in performing a number of spinal surgical procedures.
An evaluation of self-assessed surgical competence of senior orthopedic and neurosurgery residents in Canada was undertaken by mail-out questionnaire. A follow-up questionnaire was mailed to nonresponders 3 months later. Survey results were summarized using SPSS statistical software, and descriptive and comparative analyses were performed.
Significant differences in time and exposure to spine training differentiated the neurosurgical and orthopedic residencies (37% and 16% of total residency time devoted to spine, respectively). Neurosurgical residents reported significantly higher levels of confidence for all 25 surgical procedures. Of those residents anticipating incorporating spine into their practice, 29% of neurosurgery residents planned on entering a spine fellowship compared with 17% of their orthopedic colleagues.
Training in spine surgery constitutes a considerably larger proportion of neurosurgery residency than orthopedic residency. Neurosurgery residents graduate with significantly higher levels of confidence to perform spine surgery, while orthopedic residents report significantly higher need for additional training in spine surgery. The majority of neurosurgery graduates report that they will include spine in their clinical practice, while most orthopedic graduates will exclude it.
Background:
The reliability of assessing healing on plain radiographs has not been well-established for knee osteochondritis dissecans (OCD).
Purpose:
To determine the inter- and intrarater ...reliability of specific radiographic criteria in judging healing of femoral condyle OCD.
Study Design:
Cohort study (Diagnosis); Level of evidence, 3.
Methods:
Ten orthopedic sports surgeons rated the radiographic healing of 30 knee OCD lesions at 2 time points, a minimum of 1 month apart. First, raters compared pretreatment and 2-year follow-up radiographs on “overall healing” and on 5 subfeatures of healing, including OCD boundary, sclerosis, size, shape, and ossification using a continuous slider scale. “Overall healing” was also rated using a 7-tier ordinal scale. Raters then compared the same 30 pretreatment knee radiographs in a stepwise progression to the 2-, 4-, 7-, 12-, and 24-month follow-up radiographs on “overall healing” using a continuous slider scale. Interrater and intrarater reliability were assessed using intraclass correlations (ICC) derived from a 2-way mixed effects analysis of variance for absolute agreement.
Results:
Overall healing of the OCD lesions from pretreatment to 2-year follow-up radiographs was rated with excellent interrater reliability (ICC = 0.94) and intrarater reliability (ICC = 0.84) when using a continuous scale. The reliability of the 5 subfeatures of healing was also excellent (interrater ICCs of 0.87-0.89; intrarater ICCs of 0.74-0.84). The 7-tier ordinal scale rating of overall healing had lower interrater (ICC = 0.61) and intrarater (ICC = 0.68) reliability. The overall healing of OCD lesions at the 5 time points up to 24 months had interrater ICCs of 0.81-0.88 and intrarater ICCs of 0.65-0.70.
Conclusion:
Interrater reliability was excellent when judging the overall healing of OCD femoral condyle lesions on radiographs as well as on 5 specific features of healing on 2-year follow-up radiographs. Continuous scale rating of OCD radiographic healing yielded higher reliability than the ordinal scale rating. Raters showed substantial to excellent agreement of OCD overall radiographic healing measured on a continuous scale at 2, 4, 7, 12, and 24 months after starting treatment.
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