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Background: Despite the ongoing opioid epidemic, most patients are still prescribed a significant number of opioid medications for pain management after arthroscopic surgery. There is a need for consensus among orthopaedic surgeons and solutions to aid providers in analgesic strategies that reduce the use of opioid pain medications., Purpose: This position statement was developed with a comprehensive systematic review and meta-analysis of exclusively randomized controlled trials (RCTs) to synthesize the best available evidence for managing acute postoperative pain after arthroscopic surgery., Study Design: Position statement., Methods: The Embase, MEDLINE, PubMed, Scopus, and Web of Science databases were searched from inception until August 10, 2022. Keywords included arthroscopy , opioids , analgesia , and pain , and associated variations. We included exclusively RCTs on adult patients to gather the best available evidence for managing acute postoperative pain after arthroscopic surgery. Patient characteristics, pain, and opioid data were extracted, data were analyzed, and trial bias was evaluated., Results: A total of 21 RCTs were identified related to the prescription of opioid-sparing pain medication after arthroscopic surgery. The following recommendations regarding noninvasive, postoperative pain management strategies were made: (1) multimodal oral nonopioid analgesic regimens-including at least 1 of acetaminophen-a nonsteroidal anti-inflammatory drug-can significantly reduce opioid consumption with no change in pain scores; (2) cryotherapy is likely to help with pain management, although the evidence on the optimal method of application (continuous-flow vs ice pack application) is unclear; (3) and (4) limited RCT evidence supports the efficacy of transcutaneous electrical nerve stimulation and relaxation exercises in reducing opioid consumption after arthroscopy; and (5) limited RCT evidence exists against the efficacy of transdermal lidocaine patches in reducing opioid consumption., Conclusion: A range of nonopioid strategies exist that can reduce postarthroscopic procedural opioid consumption with equivalent vocal pain outcomes. Optimal strategies include multimodal analgesia with education and restricted/reduced opioid prescription., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: O.R.A. has received nonconsulting fees from CONMED. I.W. has received consulting fees from DePuy Mitek, Smith & Nephew, COMED, and Bioventus. J.W. has received research support from Arthrex, CONMED, Linvatec, Ossur, Smith & Nephew, and Zimmer Biomet; and education payments from Arthrex, CONMED, Linvatec, Ossur, Smith & Nephew, and Zimmer Biomet. J.G. has received research support from JRF Ortho, Arthrex, MiMedX, and InGeneron; education payments from Arthrex; and consulting fees from JRF Ortho, Vericel, Arthrex, and Tactile Orthopaedics. M.P. has received consulting fees from Arthrex and CONMED. R.D. has received research support from Smith & Nephew and honoraria from Sanofi. R.M. has received education payments from Arthrex, Gemini Medical, Smith & Nephew, and Linvatec; and consulting fees from Smith & Nephew. M.E.L. has received research support from Arthrex, CONMED, Linvatec, Ossur, Smith & Nephew, and Zimmer Biomet; and education payments from Arthrex, CONMED, Linvatec, Ossur, Smith & Nephew, and Zimmer Biomet. B.M. has received consulting fees from Arthrex and honoraria from Pendopharm. R.K.M has received a grant from Smith & Nephew; consulting fees from Smith & Nephew and Arthrex; nonconsulting fees from Tactile Orthopaedics; royalties from Tactile Orthopaedics; stock from Tactile Orthopaedics; and is on the Board for Tactile Orthopaedics. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

When developing educational simulators, meaningful haptic feedback is important. To our knowledge, no shoulder arthroplasty surgical simulator exists. This study focuses on simulating vibration haptics of glenoid reaming for shoulder arthroplasty using a novel glenoid reaming simulator., Methods: We validated a novel custom simulator constructed using a vibration transducer transmitting simulated reaming vibrations to a powered nonwearing reamer tip through a 3D-printed glenoid. Validation and system fidelity were evaluated by 9 fellowship-trained shoulder surgeon experts performing a series of simulated reamings. We then completed the validation process through a questionnaire focused on experts' experience with the simulator., Results: Experts correctly identified 52% ± 8% of surface profiles and 69% ± 21% of cartilage layers. Experts identified the vibration interface between simulated cartilage and subchondral bone (77% ± 23% of the time), indicating high fidelity for the system. An interclass correlation coefficient for experts' reaming to the subchondral plate was 0.682 (confidence interval 0.262-0.908). On a general questionnaire, the perceived utility of the simulator as a teaching tool was highly ranked (4/5), and experts scored "ease of instrument manipulation" (4.19/5) and "realism of the simulator" (4.11/5) the highest. The mean global evaluation score was 6.8/10 (range 5-10)., Conclusions: We examined a simulated glenoid reamer and feasibility of haptic vibrational feedback for training. Experts validated simulated vibration feedback for glenoid simulation reaming, and the results suggested that this may be a useful additional training adjuvant., Level of Evidence: Level II, prospective study., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A526)., (Copyright © 2023 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Background: Exercise is widely regarded to improve pain and function in patients with knee osteoarthritis (OA) through building supportive muscle mass, facilitating weight loss, and through the other beneficial effects associated with it., Purpose: To explore literature that presents clinical guidelines for the use of exercise in the treatment of knee OA to inform an evidence-based position statement for the Arthroscopy Association of Canada., Study Design: Position statement., Methods: PubMed, MEDLINE, Embase, and Cochrane databases were searched for guidelines commenting on the role of exercise for knee OA. The search was limited to guidelines published in the last 10 years. Articles were screened for relevance, focusing on recently published research with clinical guidelines. Inclusion criteria involved all articles providing clinical guidelines for exercise and knee OA., Results: Eight guidelines were identified. All eight recommended exercise as an important component of treatment for knee OA, with 6/8 strongly recommending it., Conclusion: Exercise is an effective and important component of the non-pharmacological management of knee OA. The Arthroscopy Association of Canada strongly recommends the use of exercise in the management of knee OA., (© The Author(s) 2021.)

Objective: The complexity of minimally invasive surgery (MIS) requires that trainees practice MIS skills in numerous training sessions. The goal of these training sessions is to learn how to move the instruments smoothly without damaging the surrounding tissue and achieving operative tasks with accuracy. In order to enhance the efficiency of these training sessions, the proficiency of the trainees should be assessed using an objective assessment method. Several performance metrics have been proposed and analyzed for MIS tasks. The differentiation of various levels of expertise is limited without the presence of an external evaluator., Methods: In this study, novel objective performance metrics are proposed based on mechanical energy expenditure and work. The three components of these metrics are potential energy, kinetic energy, and work. These components are optimally combined through both one-step and two-step methods. Evaluation of these metrics is accomplished for suturing and knot-tying tasks based on the performance of 30 subjects across four levels of experience., Results: The results of this study show that the one-step combined metric provides 47 and 60 accuracy in determining the level of expertise of subjects for the suturing and knot-tying tasks, respectively. The two-step combined metric provided 67 accuracy for both of the tasks studied., Conclusion: The results indicate that energy expenditure is a useful metric for developing objective and efficient assessment methods., Significance: These metrics can be used to evaluate and determine the proficiency levels of trainees, provide feedback and, consequently, enhance surgical simulators.

Background: Observational learning plays an important role in surgical skills training, following the traditional model of learning from expertise. Recent findings have, however, highlighted the benefit of observing not only expert performance but also error-strewn performance. The aim of this study was to determine which model (novice vs. expert) would lead to the greatest benefits when learning robotically assisted surgical skills., Methods: 120 medical students with no prior experience of robotically-assisted surgery completed a ring-carrying training task on three occasions; baseline, post-intervention and at one-week follow-up. The observation intervention consisted of a video model performing the ring-carrying task, with participants randomly assigned to view an expert model, a novice model, a mixed expert/novice model or no observation (control group). Participants were assessed for task performance and surgical instrument control., Results: There were significant group differences post-intervention, with expert and novice observation groups outperforming the control group, but there were no clear group differences at a retention test one week later. There was no difference in performance between the expert-observing and error-observing groups., Conclusions: Similar benefits were found when observing the traditional expert model or the error-strewn model, suggesting that viewing poor performance may be as beneficial as viewing expertise in the early acquisition of robotic surgical skills. Further work is required to understand, then inform, the optimal curriculum design when utilising observational learning in surgical training.

Purpose  Shoulder pain and disability pose a diagnostic challenge owing to the numerous etiologies and the potential for multiple disorders to exist simultaneously. The evidence to support the use of clinical tests for superior labral anterior to posterior complex (SLAP) is weak or absent. The purpose of this study is to determine the diagnostic validity of physical examination maneuvers for SLAP lesions by performing a methodologically rigorous, clinically applicable study. Methods  We recruited consecutive new shoulder patients reporting pain and/or disability. The physician took a history and indicated their certainty about each possible diagnosis ("certain the diagnosis is absent/present," or "uncertain requires further testing"). The clinician performed the physical tests for diagnoses where uncertainty remained. Magnetic resonance imaging arthrogram and arthroscopic examination were the gold standards. We calculated sensitivity, specificity, and likelihood ratios (LRs) and investigated whether combinations of the top tests provided stronger predictions. Results  Ninety-three patients underwent physical examination for SLAP lesions. When using the presence of a SLAP lesion (Types I-V) as disease positive, none of the tests was sensitive (10.3-33.3) although they were moderately specific (61.3-92.6). When disease positive was defined as repaired SLAP lesion (including biceps tenodesis or tenotomy), the sensitivity (10.5-38.7) and specificity (70.6-93.8) of tests improved although not by a substantial amount. None of the tests was found to be clinically useful for predicting repairable SLAP lesions with all LRs close to one. The compression rotation test had the best LR for both definitions of disease (SLAP tear present = 1.8 and SLAP repaired = 1.67). There was no optimal combination of tests for diagnosing repairable SLAP lesions, with at least two tests positive providing the best combination of measurement properties (sensitivity 46.1% and specificity 64.7%). Conclusion  Our study demonstrates that the physical examination tests for SLAP lesions are poor diagnostic indicators of disease. Performing a combination of tests will likely help, although the magnitude of the improvement is minimal. These authors caution clinicians placing confidence in the physical examination tests for SLAP lesions rather we suggest that clinicians rely on diagnostic imaging to confirm this diagnosis.

Minimally invasive skills assessment methods are essential in developing efficient surgical simulators and implementing consistent skills evaluation. Although numerous methods have been investigated in the literature, there is still a need to further improve the accuracy of surgical skills assessment. Energy expenditure can be an indication of motor skills proficiency. The goals of this study are to develop objective metrics based on energy expenditure, normalize these metrics, and investigate classifying trainees using these metrics. To this end, different forms of energy consisting of mechanical energy and work were considered and their values were divided by the related value of an ideal performance to develop normalized metrics. These metrics were used as inputs for various machine learning algorithms including support vector machines (SVM) and neural networks (NNs) for classification. The accuracy of the combination of the normalized energy-based metrics with these classifiers was evaluated through a leave-one-subject-out cross-validation. The proposed method was validated using 26 subjects at two experience levels (novices and experts) in three arthroscopic tasks. The results showed that there are statistically significant differences between novices and experts for almost all of the normalized energy-based metrics. The accuracy of classification using SVM and NN methods was between 70% and 95% for the various tasks. The results show that the normalized energy-based metrics and their combination with SVM and NN classifiers are capable of providing accurate classification of trainees. The assessment method proposed in this study can enhance surgical training by providing appropriate feedback to trainees about their level of expertise and can be used in the evaluation of proficiency., Competing Interests: The authors declare no conflict of interest.

Objective  The purpose of this article is to determine whether patient-reported history items are predictive of shoulder pathology and have the potential for use in triaging patients with shoulder pathology to orthopaedic outpatient clinics. Setting  It is set at two tertiary orthopaedic clinics. Patients  All new patients reporting pain and/or disability of the shoulder joint were prospectively recruited. A total of 193 patients were enrolled, 15 of whom withdrew, leaving 178 patients composing the study sample. Design  Patients completed a questionnaire on the history of their pathology, then the surgeon took a thorough history indicating the most likely diagnosis. The clinician then performed appropriate physical examination. Arthroscopy was the reference standard for those undergoing surgery and magnetic resonance imaging (MRI) with arthrogram for all others. We calculated the sensitivity, specificity, and likelihood ratios (LRs) of history items alone and in combination. We used the LRs to generate a clinical decision algorithm. Main Outcome Measures  Diagnosis was determined through arthroscopy or MRI arthrogram. Reporting was standardized to ensure review of all structures. Results  The physical examination and history agreed in 75% of cases. Of those that did not agree, the physical examination misdirected the diagnosis in 47% of our cases. In particular, history items were strong predictors of anterior and posterior instability and subscapularis tears and were combined in a tool to be utilized for screening patients. Conclusion  The patient-reported history items were effective for diagnosing shoulder pathology and should be considered for use in a triaging instrument.

Adhesive capsulitis is a common and challenging condition to treat. Arthroscopic capsular release is usually contemplated when conservative treatment fails or when there is severe and/or chronic loss of range of motion. This procedure can be difficult to perform because of difficult access to the joint, poor visualization, and loss of working space from retraction of the joint capsule. The articular surfaces and the axillary nerve are also at higher risk of injury. Arthroscopic scissors, shavers, and electrocautery are typically used to perform the capsular release. To perform a safer and more precise arthroscopic shoulder capsular release, a creative and innovative use of a flexible hip arthroscopy radiofrequency ablator is described.