Does Sawbone-Based Arthroscopy Module (SBAM) Can Help Elbow Surgeons?

A 70° Arthroscope Provides Better Visualization of the Medial Side of the Elbow Than a 30° Arthroscope

Purpose

To assess and quantify the improvement in visualization of humeral insertion of the medial collateral ligament (MCL) using a 70° scope compared with a 30° scope during elbow arthroscopy.

Methods

Twenty patients undergoing elbow arthroscopy for different pathologic conditions were enrolled in this single-center study. Visualization of the medial gutter of the elbow was evaluated by using both the 70° and the 30°scope. During the procedure, a needle was inserted at 45° with respect to the axis of the forearm, directed toward the intra-articular humeral emergence of the MCL. Four areas were established: the body (Z1), the lanceolate part (Z2), the tip of the needle (Z3), and the medial portion of the trochlea (Z4). The visible areas during arthroscopy using 2 different scopes were collected.

Results

The 70° scope allowed the detection of the first 3 areas in all patients (Z1, Z2, and Z3) and the visualization of the last area (Z4) in 19 patients (95%). On the other hand, the 30° scope allowed the detection of Z1 in 85% of patients, Z2 in 60% of patients, and Z3 in only 5% of patients. The medial portion of the trochlea was never visualized with the 30° scope. These findings were statistically significant.

Conclusions

The 70° scope improves visualization of the medial elbow compartment during elbow arthroscopy compared to the 30° scope, enhancing the extent of joint visualization and potentially permitting the detection of otherwise missed injuries in the difficult-to-reach areas of the joint.

Level of Evidence

Level II, diagnostic, prospective, cohort study.

Simulation training to retool practicing orthopedic surgeons is rare

Purpose

Modern surgical practice is continuously changing as technology develops. New techniques are often implemented after a surgeon has made the transition to independent clinical practice. There is therefore a need to 'retool' technical skills. Additionally, practicing surgeons must maintain and develop skills such as leadership, communication, critical thinking, teaching, and mentoring. Our aim was to perform a scoping review to assess the current status of simulation education for practicing Orthopedic Surgeons (OS).

Methods

A 10 year search of PubMed, ERIC, and Web of Science was performed with a medical librarian. Controlled vocabulary Medical Subject Headings terms and natural language were developed with subject matter experts describing simulation, training and OS. Two trained reviewers evaluated all abstracts for inclusion. Exclusion criteria were articles that did not assess simulation education involving practicing OS. Data were extracted from the included full text articles by two reviewers: details of study design, type of participants, type of simulation and role of OS in the educational event.

Results

Initial search identified 1824 articles of which 443 were duplicates, and 1381 articles were further screened. Of these, 1155 were excluded, 226 full text articles were assessed for eligibility and 80 included in analysis. Most were published in the last 6 years and from the United States. The majority (99%) described technical skill simulations (arthroscopy 56%, screw placement 23%, ligament reconstruction 19%). OS were rarely the only learners with 91% studies also having residents participate. OS were the targeted learner in 6% studies. OS provided content validity for 15 (19%) and construct validity in 59 (74%) studies.

Conclusions

Simulation training to educate practicing OS is rare. OS are often used to validate work rather than being the center of an educational endeavor. A refocusing is needed to provide adequate training for practicing surgeons to retool skills as new techniques become available.

Novel Radiographic Indexes for Elbow Stability Assessment: Part A-Cadaveric Validation

INTRODUCTION

Elbow bony stability relies primarily on the high anatomic congruency between the humeral trochlea and the ulnar greater sigmoid notch. No practical tools are available to distinguish different morphotypes of the proximal ulna and herewith predict elbow stability. The aim of this study was to assess inter-observer reproducibility, evaluate diagnostic performance and determine responsiveness to change after simulated coronoid process fracture for three novel elbow radiographic indexes.

METHODS

Ten fresh-frozen cadaver specimens of upper limbs from human donors were available for this study. Three primary indexes were defined, as well as two derived angles: Trochlear Depth Index (TDI); Posterior Coverage Index (PCI); Anterior Coverage Index (ACI); radiographic coverage angle (RCA); olecranon-diaphisary angle (ODA). Each index was first measured on standardized lateral radiographs and subsequently by direct measurement after open dissection. Finally, a type II coronoid fracture (Regan and Morrey classification) was created on each specimen and both radiographic and open measurements were repeated. All measurements were conducted by two orthopaedic surgeons and two dedicated musculoskeletal radiologists.

RESULTS

All three indexes showed good or moderate inter-observer reliability and moderate accuracy and precision when compared to the gold standard (open measurement). A significant change between the radiographic TDI and ACI before and after simulated coronoid fracture was observed [TDI: decrease from 0.45 ± 0.03 to 0.39 ± 0.08 (p = 0.035); ACI: decrease from 1.90 ± 0.17 to 1.58 ± 0.21 (p = 0.001)]. As expected, no significant changes were documented for the PCI. Based on these data, a predictive model was generated, able to identify coronoid fractures with a sensitivity of 80% and a specificity of 100%.

CONCLUSION

New, simple and easily reproducible radiological indexes to describe the congruency of the greater sigmoid notch have been proposed. TDI and ACI change significantly after a simulated coronoid fracture, indicating a good responsiveness of these parameters to a pathological condition. Furthermore, combining TDI and ACI in a regression model equation allowed to identify simulated fractures with high sensitivity and specificity. The newly proposed indexes are, therefore, promising tools to improve diagnostic accuracy of coronoid fractures and show potential to enhance perioperative diagnostic also in cases of elbow instability and stiffness.

LEVEL OF EVIDENCE

Basic science study.

CLINICAL RELEVANCE

The newly proposed indexes are promising tools to improve diagnostic accuracy of coronoid fractures as well as to enhance perioperative diagnostic for elbow instability and stiffness.

Novel Radiographic Indexes for Elbow Stability Assessment: Part B-Preliminary Clinical Study

INTRODUCTION

The coronoid process plays a key-role in preserving elbow stability. Currently, there are no radiographic indexes conceived to assess the intrinsic elbow stability and the joint congruency. The aim of this study is to present new radiological parameters, which will help assess the intrinsic stability of the ulnohumeral joint and to define normal values of these indexes in a normal, healthy population.

METHODS

Four independent observers (two orthopaedic surgeons and two radiologists) selected lateral view X-rays of subjects with no history of upper limb disease or surgery. The following radiographic indexes were defined: trochlear depth index (TDI); anterior coverage index (ACI); posterior coverage index (PCI); olecranon-coronoid angle (OCA); radiographic coverage angle (RCA). Inter-observer and intra-observer reproducibility were assessed for each index.

RESULTS

126 subjects were included. Standardized lateral elbow radiographs (62 left and 64 right elbows) were obtained and analysed. The mean TDI was 0.46 ± 0.06 (0.3-1.6), the mean ACI was 2.0 ± 0.2 (1.6-3.1) and the mean PCI was 1.3 ± 0.1 (1.0-1.9). The mean RCA was 179.6 ± 8.3° (normalized RCA: 49.9 ± 2.3%) and the mean OCA was 24.6 ± 3.7°. The indexes had a high-grade of inter-observer and intra-observer reliability for each of the four observers. Significantly higher values were found for males for TDI, ACI, PCI and RCA.

CONCLUSION

The novel radiological parameters described are simple, reliable and easily reproducible. These features make them a promising tool for radiographic evaluation both for orthopaedic surgeons and for radiologists in the emergency department setting or during outpatient services.

LEVEL OF EVIDENCE

Basic Science Study (Case Series).

CLINICAL RELEVANCE

The novel radiological parameters described are reliable, easily reproducible and become handy for orthopaedic surgeons as well as radiologists in daily clinical practice.

Validation of a Practical Forearm Supination Strength Measurement Technique in the Large Sample Cohort

INTRODUCTION

The strength of forearm in pronation and supination (P/S) is an important clinical assessment during pre-operative examination as well as in post-operative evaluation. Many clinical trials concerning the measurement of forearm P/S strength were performed using a dynamometer fixed on the wall. The aim of this study was to bring out a simple and reliable technique for the measurement of P/S strength using a dynamometer manually supported and stabilized by an examiner. We hypothesized that there are no differences in evaluation of elbow P/S strength using the dynamometer fixed or the dynamometer stabilized by an operator in healthy people.

METHODS

The study was performed on a cross-sectional cohort of 100 healthy subjects without any history of injuries or previous surgery of the upper limbs. Isometric forearm P/S strengths were measured on the dominant and non-dominant forearms, using the dynamometer fixed on a table, and using the same dynamometer kept by an operator. The measurements were repeated in triplicate at 45°, 90° and 120° of elbow flexion in both upper limbs for all patients.

RESULTS

A total of 100 subjects (50 females, 50 males) were included in the study group. The mean age was 46.5 years (range 25-52 years). Female and male subjects showed no significant differences concerning the mean age (F/M ratio 0.50/0.50). The mean body mass index of all participants was 24.34 ± 3.66 kg/m2.No significant statistics difference was reported between the P/S strength measured using the two detection methods in our study group (45°, 90° and 120° of elbow flexion and both upper limbs).

CONCLUSION

The manually stabilized technique is a valid and reliable technique to assess the P/S strength of the forearm. This is a simple and effective method that may be reproduced in our daily clinical practice as well as in sportive practice.