Arthroscopic Simulation: The Future of Surgical Training: A Systematic Review.

BACKGROUND: Arthroscopic simulation has rapidly evolved recently with the introduction of higher-fidelity simulation models, such as virtual reality simulators, which provide trainees an environment to practice skills without causing undue harm to patients. Simulation training also offers a uniform approach to learn surgical skills with immediate feedback. The aim of this article is to review the recent research investigating the use of arthroscopy simulators in training and the teaching of surgical skills. METHODS: A systematic review of the Embase, MEDLINE, and Cochrane Library databases for English-language articles published before December 2019 was conducted. The search terms included arthroscopy or arthroscopic in combination with simulation or simulator. RESULTS: We identified a total of 44 relevant studies involving benchtop or virtually simulated ankle, knee, shoulder, and hip arthroscopy environments. The majority of these studies demonstrated construct and transfer validity; considerably fewer studies demonstrated content and face validity. CONCLUSIONS: Our review indicates that there is a considerable evidence base regarding the use of arthroscopy simulators for training purposes. Further work should focus on the development of a more uniform simulator training course that can be compared with current intraoperative training in large-scale trials with long-term follow-up at tertiary centers

Delay to diagnosis and specialist consultation following anterior cruciate ligament injury: A study investigating the nature of, and factors associated with, pathway delay

Background: Historically the identification of ACL injuries upon initial presentation is low and considerable diagnostic delays have been reported. However, specific evidence on the individual elements of, and factors which influence delay, is lacking. Aims: The overarching aim was to provide a comprehensive picture of delay to diagnosis and specialist consultation, including factors which influence delay. An additional aim was to determine whether the approach to examining acute knee injuries varied as a consequence of varying patient presentation or experience of the assessing clinician. Methods: Study 1: Cross -sectional survey. Study 2: Non-participant direct observation methodology. Results: Data from 194 patients were analysed in the survey. Only 15.5% of patients were given a correct diagnosis of ACL rupture at the initial consultation. Median delay to diagnosis was 67.5 days (IQR= 15 to 178 days) and specialist consultation 108 days (IQR= 38 to 292 days). The factors most influential on delay were whether a follow-up appointment was arranged after attending A&E, whether the site of attendance operated an acute knee clinic and whether MRI was performed. The direct observation study showed wide variation in approach to injury assessment. Specialist clinicians performed the most comprehensive examination. A&E clinicians were more likely to assess for bony, neurovascular and gross tendon injuries as opposed to ligamentous or meniscal injury. Conclusions: The diagnostic rate of ACL injury at initial presentation remains low. Considerable delays to diagnosis and specialist consultation are apparent following ACL injury, the majority of which is attributable to health system delay

Kinematics and degenerative change in ligament-injured knees

The aim of the work presented in this thesis was to examine the associations between the kinematics of the knee characterised by the tibiofemoral contact pattern, and degenerative change, in the context of anterior cruciate ligament (ACL) injury. While the natural history of degenerative change following knee injury is well understood, the role of kinematics in these changes is unclear. Kinematics of the knee has been described in a variety of ways, most commonly by describing motion according to the six degrees of freedom of the knee. The advantage of mapping the tibiofemoral contact pattern is that it describes events at the articular surface, important to degenerative change. It was hypothesised that the tibiofemoral contact pattern would be affected by injury to the knee. A model of ACL injury was chosen because the kinematics of the knee have been shown to be affected by ACL injury, and because the majority of chronic ACL-deficient knees develop osteoarthritis, the associations between kinematics and degenerative change could be explored. A technique of tibiofemoral contact pattern mapping was established using MRI, as a quantifiable measure of knee kinematics. The tibiofemoral contact pattern was recorded from 0º to 90º knee flexion while subjects performed a leg-press against a 150N load, using sagittal magnetic resonance imaging (MRI) scans. The technique was tested and found to be reliable, allowing a description of the tibiofemoral contact pattern in 12 healthy subjects. The tibiofemoral contact patterns of knee pathology were then examined in a series of studies of subjects at a variety of stages of chronicity of ligament injury and osteoarthritis. Twenty subjects with recent ACL injury, 23 subjects with chronic ACL deficiency of at least 10 years standing, and 14 subjects with established osteoarthritis of the knee were recruited. The 20 subjects with recent ACL injury were examined again at 12 weeks and 2 years following knee reconstruction. The tibiofemoral contact patterns were examined for each group of subjects and the associations between changes in the contact patterns and evidence of joint damage explored. Evidence of joint damage and severity of osteoarthritis were recorded from xrays, diagnostic MRI, operation reports and bone densitometry at the tibial and femoral condyles of the knee. Each of the three groups with knee pathology exhibited different characteristics in the tibiofemoral contact pattern, and these differences were associated with severity of joint damage and osteoarthritis. The recently ACL-injured knees demonstrated a tibiofemoral contact pattern that was posterior on the tibial plateau, particularly in the lateral compartment. Those with chronic ACL deficiency demonstrated differences in the contact pattern in the medial compartment, associated with severity of damage to the knee joint. Osteoarthritic knees showed reduced femoral roll back and longitudinal rotation that normally occur during knee flexion. Two years following knee reconstruction there was no difference between the contact pattern of the reconstructed and healthy contralateral knees. This technique of tibiofemoral contact pattern mapping is sensitive to the abnormal characteristics of kinematics in ligament injury and osteoarthritis. This is the first time the tibiofemoral contact characteristics of chronic ACL-deficient and osteoarthritis knees have been described and links examined between tibiofemoral contact patterns and degenerative change

Exploring Innovative Rehabilitation for the Knee using Ehealth, Biofeedback and Online Communities

Knee pain is regarded as an inevitable outcome in an ageing population and subsequent management, treatment and rehabilitation may exacerbate demand on stretched health services globally. Knee pain can be influenced by a number of factors; gender, body mass, activity profile, arthrokinematics, patient biopsychosociology and predisposing injury or trauma. Treatment options are typically viewed as pharmacological and non-pharmacological. Exercise and physical therapy are key elements within the latter option, alongside surgical procedures. Knee pain sufferers may vindicate their condition through clinical diagnosis and shift of locus of control; compliance to exercise interventions can depend on the scope of this shift. Such values should be acknowledged when monitoring individualised progression in the management of knee pain. Technology may have a role to play in capturing and influencing compliance within the scope of knee rehabilitation. The main aim of this thesis was to explore the use of innovative rehabilitation interventions for the knee that integrated eHealth, biofeedback and online communities. As this constitutes a complex scenario, this thesis has been reported using elements of the Medical Research Council (MRC) framework for the development and evaluation of complex interventions to improve health (Blackwood et al., 2010; Craig et al., 2008); notably the Preclinical (theory) stage, the Phase I (modelling) stage, and Phase II (exploratory trial). The findings further inform the options for rehabilitation around knee pain, encompassing latest generation techniques for addressing progressive joint disease and eHealth initiatives. These also included options for self-management and reporting that could be generalised to knee pain sufferers; an approach informed by the exploration of the reported experiences of individuals engaging with an online health community for knee pain. The eHealth component of the thesis looked to explore the use of simple Web 2.0 solutions and readily available domiciliary equipment for efficacy and accessibility

Impact of Ear Occlusion on In-Ear Sounds Generated by Intra-oral Behaviors

We conducted a case study with one volunteer and a recording setup to detect sounds induced by the actions: jaw clenching, tooth grinding, reading, eating, and drinking. The setup consisted of two in-ear microphones, where the left ear was semi-occluded with a commercially available earpiece and the right ear was occluded with a mouldable silicon ear piece. Investigations in the time and frequency domains demonstrated that for behaviors such as eating, tooth grinding, and reading, sounds could be recorded with both sensors. For jaw clenching, however, occluding the ear with a mouldable piece was necessary to enable its detection. This can be attributed to the fact that the mouldable ear piece sealed the ear canal and isolated it from the environment, resulting in a detectable change in pressure. In conclusion, our work suggests that detecting behaviors such as eating, grinding, reading with a semi-occluded ear is possible, whereas, behaviors such as clenching require the complete occlusion of the ear if the activity should be easily detectable. Nevertheless, the latter approach may limit real-world applicability because it hinders the hearing capabilities.</p