Papers by Kartik Logishetty
Orthopaedic proceedings/Journal of bone and joint surgery. British volume. Orthopaedic proceedings, May 2, 2024
Orthopaedic proceedings/Journal of bone and joint surgery. British volume. Orthopaedic proceedings, May 2, 2024
Bioengineering
Three-dimensional planning of hip arthroplasty is associated with better visualisation of anatomi... more Three-dimensional planning of hip arthroplasty is associated with better visualisation of anatomical landmarks and enhanced mapping for preoperative implant sizing, which can lead to a decrease in surgical time and complications. Despite the advantages of hip resurfacing arthroplasty (HRA), it is considered a technically challenging procedure and associated with inaccurate implant placement. This study aimed to examine the validity, reliability, and usability of preoperative 3D Hip Planner software for HRA. Fifty random cases of various hip osteoarthritis severity were planned twice by two junior trainees using the 3D Hip Planner within a one-month interval. Outcome measures included femoral/cup implant size, stem-shaft angle, and cup inclination angle, and were assessed by comparing outcomes from 2D and 3D planning. An adapted unified theory of acceptance and use of technology (UTAUT) survey was used for software usability. Bland–Altman plots between 3D and 2D planning for stem-sha...
Bone & Joint Open
AimsMetal-on-metal hip resurfacing (MoM-HR) has seen decreased usage due to safety and longevity ... more AimsMetal-on-metal hip resurfacing (MoM-HR) has seen decreased usage due to safety and longevity concerns. Joint registries have highlighted the risks in females, smaller hips, and hip dysplasia. This study aimed to identify if reported risk factors are linked to revision in a long-term follow-up of MoM-HR performed by a non-designer surgeon.MethodsA retrospective review of consecutive MoM hip arthroplasties (MoM-HRAs) using Birmingham Hip Resurfacing was conducted. Data on procedure side, indication, implant sizes and orientation, highest blood cobalt and chromium ion concentrations, and all-cause revision were collected from local and UK National Joint Registry records.ResultsA total of 243 hips (205 patients (163 male, 80 female; mean age at surgery 55.3 years (range 25.7 to 75.3)) with MoM-HRA performed between April 2003 and October 2020 were included. Mean follow-up was 11.2 years (range 0.3 to 17.8). Osteoarthritis was the most common indication (93.8%), and 13 hips (5.3%; 7M...
BJS open, Nov 1, 2021
Background: Reduced hands-on operating experience has challenged the development of complex decis... more Background: Reduced hands-on operating experience has challenged the development of complex decision-making skills for modern surgical trainees. Cognitive task analysis-(CTA-)based training is a methodical solution to extract the intricate cognitive processes of experts and impart this information to novices. Its use has been successful in high-risk industries such as the military and aviation, though its application for learning surgery is more recent. This systematic review aims to synthesize the evidence evaluating the efficacy of CTA-based training to enable surgeons to acquire procedural skills and knowledge. Methods: The PRISMA guidelines were followed. Four databases, including MEDLINE, EMBASE, Web of Science and Cochrane CENTRAL, were searched from inception to February 2021. Randomized controlled trials and observational studies evaluating the training effect of CTA-based interventions on novices' procedural knowledge or technical performance were included. Meta-analyses were performed using a random-effects model. Results: The initial search yielded 2205 articles, with 12 meeting the full inclusion criteria. Seven studies used surgical trainees as study subjects, four used medical students and one study used a combination. Surgical trainees enrolled into CTA-based training groups had enhanced procedural knowledge (standardized mean difference (SMD) 1.36 (95 per cent c.i. 0.67 to 2.05), P < 0.001) and superior technical performance (SMD 2.06 (95 per cent c.i. 1.17 to 2.96), P < 0.001) in comparison with groups that used conventional training methods. Conclusion: CTA-based training is an effective way to learn the cognitive skills of a surgical procedure, making it a useful adjunct to current surgical training.
Archives of Orthopaedic and Trauma Surgery, Jul 28, 2021
Introduction Immersive Virtual Reality (iVR) is a novel technology which can enhance surgical tra... more Introduction Immersive Virtual Reality (iVR) is a novel technology which can enhance surgical training in a virtual environment without supervision. However, it is untested for the training to select, assemble and deliver instrumentation in orthopaedic surgery-typically performed by scrub nurses. This study investigates the impact of an iVR curriculum on this facet of the technically demanding revision total knee arthroplasty. Materials and methods Ten scrub nurses completed training in four iVR sessions over a 4-week period. Initially, nurses completed a baseline real-world assessment, performing their role with real equipment in a simulated operation assessment. Each subsequent iVR session involved a guided mode, where the software taught participants the procedural choreography and assembly of instrumentation in a simulated operating room. In the latter three sessions, nurses also undertook an assessment in iVR. Outcome measures were related to procedural sequence, duration of surgery and efficiency of movement. Transfer of skills from iVR to the real world was assessed in a post-training simulated operation assessment. A pre-and post-training questionnaire assessed the participants knowledge, confidence and anxiety. Results Operative time reduced by an average of 47% across the 3 unguided sessions (mean 55.5 ± 17.6 min to 29.3 ± 12.1 min, p > 0.001). Assistive prompts reduced by 75% (34.1 ± 16.8 to 8.6 ± 8.8, p < 0.001), dominant hand motion by 28% (881.3 ± 178.5 m to 643.3 ± 119.8 m, p < 0.001) and head motion by 36% (459.9 ± 99.7 m to 292.6 ± 85.3 m, p < 0.001). Real-world skill improved from 11% prior to iVR training to 84% correct post-training. Participants reported increased confidence and reduced anxiety in scrubbing for rTKA procedures (p < 0.001). Conclusions For scrub nurses, unfamiliarity with complex surgical procedures or equipment is common. Immersive VR training improved their understanding, technical skills and efficiency. These iVR-learnt skills transferred into the real world.
Journal of Bone and Joint Surgery, American Volume, Sep 20, 2019
Background: For total hip arthroplasty (THA), cognitive training prior to performing real surgery... more Background: For total hip arthroplasty (THA), cognitive training prior to performing real surgery may be an effective adjunct alongside simulation to shorten the learning curve. This study sought to create a cognitive training tool (CTT) to perform anterior approach (AA)-THA, which was validated by expert surgeons, and test its use as a training tool compared with conventional material. Methods: We employed a modified Delphi method with 4 expert surgeons from 3 international centers of excellence. Surgeons were independently observed performing THA before undergoing semistructured cognitive task analysis (CTA) and before completing successive rounds of surveys until a consensus was reached. Thirty-six surgical residents (postgraduate year [PGY]-1 through PGY-4) were randomized to cognitive training or training with a standard operation manual with surgical videos before performing a simulated AA-THA. Results: The consensus CTA defined THA in 11 phases, in which were embedded 46 basic steps, 36 decision points, and 42 critical errors and linked strategies. This CTA was mapped onto an open-access web-based CTT. Surgeons who prepared with the CTT performed a simulated THA 35% more quickly (time, mean 28 versus 38 minutes) with 69% fewer errors in instrument selection (mean 29 versus 49 instances), and required 92% fewer prompts (mean 13 versus 25 instances). They were more accurate in acetabular cup orientation (inclination error, mean 8°versus 10°; anteversion error, mean 14°versus 22°). Conclusions: This validated CTT for arthroplasty provides structure for competency-based learning. It is more effective at preparing orthopaedic trainees for a complex procedure than conventional materials, as well as for learning sequence, instrumentation utilization, and motor skills. Clinical Relevance: Cognitive training combines education on decision-making, knowledge, and technical skill. It is an inexpensive technique to teach surgeons to perform hip arthroplasty and is more effective than current preparation methods.
British Journal of Sports Medicine, Aug 21, 2013
Traumatic anterior shoulder instability (TASI) accounts for 95% of glenohumeral dislocations and ... more Traumatic anterior shoulder instability (TASI) accounts for 95% of glenohumeral dislocations and is associated with soft tissue and bony pathoanatomies. Non-operative treatments include slings, bracing and physiotherapy. Operative treatment is common, including bony and soft-tissue reconstructions performed through open or arthroscopic approaches. There is management variation in patient pathways for TASI including when to refer and when to operate. A scoping review of systematic reviews, randomised controlled trials, comparing operative with non-operative treatments and different operative treatments were the methods followed. Search was conducted for online bibliographic databases and reference lists of relevant articles from 2002 to 2012. Systematic reviews were appraised using AMSTAR (assessment of multiple systematic reviews) criteria. Controlled trials were appraised using the CONSORT (consolidation of standards of reporting trials) tool. Analysis of the reviews did not offer strong evidence for a best treatment option for TASI. No studies directly compare open, arthroscopic and structured rehabilitation programmes. Evaluation of arthroscopic studies and comparison to open procedures was difficult, as many of the arthroscopic techniques included are no longer used. Recurrence rate was generally considered the best measure of operative success, but was poorly documented throughout all studies. There was conflicting evidence on the optimal timing of intervention and no consensus on any scoring system or outcome measure. There is no agreement about which validated outcome tool should be used for assessing shoulder instability in patients. There is limited evidence regarding the comparative effectiveness of surgical and non-surgical treatment of TASI, including a lack of evidence regarding the optimal timing of such treatments. There is a need for a well-structured randomised control trial to assess the efficacy of surgical and non-surgical interventions for this common type of shoulder instability.
Arthroscopy, May 1, 2013
To determine whether a global rating scale (GRS) with construct validity can also be used to asse... more To 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. Methods: An 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 subject's 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. Results: Objective assessment with motion analysis defined the surgeon's 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 ¼ À0.58 for time, r ¼ À0.58 for path length, and r ¼ À0.51 for hand movements). The inter-rater reliability among 3 trained assessors using the GRS was excellent (Cronbach a ¼ 0.88). Conclusions: When 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. Clinical Relevance: An 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.
Journal of Orthopaedics and Traumatology, Aug 17, 2018
Background: The purpose of this study was to examine the gait pattern of total hip arthroplasty (... more Background: The purpose of this study was to examine the gait pattern of total hip arthroplasty (THA) patients with a new short femoral stem at different speeds and inclinations. Materials and methods: A total of 40 unilateral THA patients were tested on an instrumented treadmill. They comprised two groups (shorter stemmed THA n = 20, longer stemmed THA n = 20), both which had the same surgical posterior approach. The shorter femoral stemmed patients were taken from an ongoing hip trial with minimum 12 months postop. The comparative longer THR group with similar disease and severity were taken from a gait database along with a demographically similar group of healthy controls (n = 35). All subjects were tested through their entire range of gait speeds and inclines with ground reaction forces collected. Body weight scaling was applied and a symmetry index to compare the implanted hip to the contralateral normal hip. An analysis of variance with significance set at α = 0.05 was used. Results: The experimental groups were matched demographically and implant groups for patient reported outcome measures and radiological disease. Both THA groups walked slower than controls, but symmetry at all intervals for all groups were not significantly different. Push-off loading was less favourable for both the shorter and longer stemmed THR groups (p < 0.05) depending on speed. Conclusions: Irrespective of femoral stem length, symmetry for ground reaction forces for both THA groups were returned to a normal range when compared to controls. However individual implant performance showed inferior (p < 0.05) push-off forces and normalised step length in both THR groups when compared to controls. Level of evidence: III.
British journal of hospital medicine, Dec 2, 2018
Revue de Chirurgie Orthopédique et Traumatologique, May 1, 2021
Abstract This note describes a surgical technique to kinematically align a medial Oxford® UKA. Ap... more Abstract This note describes a surgical technique to kinematically align a medial Oxford® UKA. Applying kinematic alignment principles is an alternative, personalised, physiological, and potentially clinically advantageous method for implanting the medial Oxford® UKA. Further investigations are needed to better define the reproducibility and clinical impact of this new surgical technique.
Journal of Biomechanics, Oct 1, 2017
Letter to the Editor regarding 'How symmetric are metal-on-metal hip resurfacing patients during ... more Letter to the Editor regarding 'How symmetric are metal-on-metal hip resurfacing patients during gait? Insights for the rehabilitation' We read with great interest the article written by Resende and colleagues (Resende et al., 2017) entitled, 'How symmetric are metal-on-metal hip resurfacing patients during gait? Insights for the rehabilitation' Hip resurfacing arthroplasty (HRA) is a contentious subject given the high profile withdrawal of the DePuy Orthopaedic ASR metal-on-metal (MoM) implant (DePuy-ASR) due to high failure rates (de Steiger et al., 2011; Prosser et al., 2010). In their welldesigned kinematic study (Resende et al., 2017), the authors assessed whether a unilateral DePuy ASR HRA can result in symmetric gait. We applaud such a study, which aims to take assessment beyond functional scores, which have many well-documented limitations (Fitzpatrick et al., 1998). Despite analysing a withdrawn implant, the study demonstrates that all 12 ASR HRA patients having reported no pain. This is particularly reassuring as the mean time from surgery to gait assessment was 45 months, which puts this group of patients at the highest risk as most revisions occur in the early mid-term (Curtin et al., 2017; Laaksonen et al., 2017). Sadly, though, there was no mention of serum metal ions. It is well reported that raised serum metal ions are correlated to adverse local tissue reactions (ALTRs) (Laaksonen et al., 2017; Reito et al., 2013), which would negatively alter hip biomechanics. The prevalence of ALTRs in asymptomatic patients is also high (Chang et al., 2012; Wynn-Jones et al., 2011). Moreover, the research looked at lower limb kinematic function and there is no evidence that these patients had any further imaging (ultrasound or MARS MRI) to ensure that there was not any surrounding soft tissue destruction. These omissions, which are now standard recommendations (MHRA, 2017), make it difficult to conclude as to whether these were well functioning or failing hips. Furthermore the authors present what appears to be a retrospective study as no preoperative data was presented. It is important to have baseline data in order to appreciate the effect of the intervention, which could be significantly worse or better. A single snapshot study, particularly with small numbers, could easily draw incorrect conclusions. Given this, the title of this paper would be better changed to 'How symmetric are ASR hip resurfacing patients during gait'. Instead, the current title of the study would be better addressed by prospectively evaluating a HRA implant with a proven track record to answer the important question of whether HRA results in symmetric gait, and to give insight for rehabilitation.
npj digital medicine, Jul 19, 2022
The use of digital technology is increasing rapidly across surgical specialities, yet there is no... more The use of digital technology is increasing rapidly across surgical specialities, yet there is no consensus for the term 'digital surgery'. This is critical as digital health technologies present technical, governance, and legal challenges which are unique to the surgeon and surgical patient. We aim to define the term digital surgery and the ethical issues surrounding its clinical application, and to identify barriers and research goals for future practice. 38 international experts, across the fields of surgery, AI, industry, law, ethics and policy, participated in a four-round Delphi exercise. Issues were generated by an expert panel and public panel through a scoping questionnaire around key themes identified from the literature and voted upon in two subsequent questionnaire rounds. Consensus was defined if >70% of the panel deemed the statement important and <30% unimportant. A final online meeting was held to discuss consensus statements. The definition of digital surgery as the use of technology for the enhancement of preoperative planning, surgical performance, therapeutic support, or training, to improve outcomes and reduce harm achieved 100% consensus agreement. We highlight key ethical issues concerning data, privacy, confidentiality and public trust, consent, law, litigation and liability, and commercial partnerships within digital surgery and identify barriers and research goals for future practice. Developers and users of digital surgery must not only have an awareness of the ethical issues surrounding digital applications in healthcare, but also the ethical considerations unique to digital surgery. Future research into these issues must involve all digital surgery stakeholders including patients.
The bone & joint journal, Dec 1, 2019
Aims Arthroplasty skills need to be acquired safely during training, yet operative experience is ... more Aims Arthroplasty skills need to be acquired safely during training, yet operative experience is increasingly hard to acquire by trainees. Virtual reality (VR) training using headsets and motion-tracked controllers can simulate complex open procedures in a fully immersive operating theatre. The present study aimed to determine if trainees trained using VR perform better than those using conventional preparation for performing total hip arthroplasty (THA). Patients and Methods A total of 24 surgical trainees (seven female, 17 male; mean age 29 years (28 to 31)) volunteered to participate in this observer-blinded 1:1 randomized controlled trial. They had no prior experience of anterior approach THA. Of these 24 trainees, 12 completed a six-week VR training programme in a simulation laboratory, while the other 12 received only conventional preparatory materials for learning THA. All trainees then performed a cadaveric THA, assessed independently by two hip surgeons. The primary outcome was technical and non-technical surgical performance measured by a THA-specific procedurebased assessment (PBA). Secondary outcomes were step completion measured by a taskspecific checklist, error in acetabular component orientation, and procedure duration. Results VR-trained surgeons performed at a higher level than controls, with a median PBA of Level 3a (procedure performed with minimal guidance or intervention) versus Level 2a (guidance required for most/all of the procedure or part performed). VR-trained surgeons completed 33% more key steps than controls (mean 22 (sd 3) vs 12 (sd 3)), were 12° more accurate in component orientation (mean error 4° (sd 6°) vs 16° (sd 17°)), and were 18% faster (mean 42 minutes (sd 7) vs 51 minutes (sd 9)).
British journal of hospital medicine, Oct 2, 2020
Tibial plateau fractures are peri-articular knee fractures of the proximal tibia. The presentatio... more Tibial plateau fractures are peri-articular knee fractures of the proximal tibia. The presentation is dependent on the mechanism of injury. The tibial plateau is the bony platform of the distal half of the knee joint, and is made up of a medial and lateral condyle separated by the intercondylar eminence. The presentation of tibial plateau fractures can vary greatly as a result of the bimodal mechanism of injury and patient characteristics. The patient should be assessed for life- and limb-threatening injuries in accordance with British Orthopaedic Association Standards of Trauma guidelines. Imaging is undertaken to understand configuration of the fracture, which is classified by the Schatzker classification. Definitive management of the fracture depends on the severity, ranging from conservative to surgical management. Surgery is required for more severe tibial plateau fractures to restore articular congruity, mechanical alignment, ligamentous stability and to permit early mobilisation. Medium-term functional outcome after tibial plateau fractures is generally excellent when anatomy and stability is restored. At least half of patients return to their original level of physical activity. Surgical management of tibial plateau fractures is not without complication. Risk factors include postoperative arthritis, bicondylar and comminuted fractures, meniscal removal, instability, malalignment and articular incongruity. Tibial plateau fractures account for 1% of all fractures, and typically occur either as a fragility fracture or secondary to a high-energy impact. These latter injuries are associated with extensive soft tissue injury, life- and limb-threatening complications and long-term sequelae. While outcomes are generally good, severe injuries are at higher risk of infection and post-traumatic arthritis requiring knee arthroplasty. This article considers the anatomy, diagnosis and evidence-based management strategies for tibial plateau fracture.
Orthopaedic Proceedings, Feb 21, 2018
Introduction Current work-hour restrictions and cost pressures have highlighted the limitations o... more Introduction Current work-hour restrictions and cost pressures have highlighted the limitations of apprenticeship-based learning, and led to the development of alternative methods to improve the skills of orthopaedic trainees outside of the clinical environment. These methods include using synthetic bones and simulators in the laboratory setting. Educational theory highlights the importance of context for effective learning, yet full-immersion simulation facilities are prohibitively expensive. This study explored the concept of contextualised training day in trauma & orthopaedics. Methods Fifteen novice surgeons provided feedback after completing three teaching modules: 1)OSCE-style Problem-based Learning of Orthopaedic Trauma in the Fracture Clinic Setting, utilising an actor and radiographs to teach history, examination, diagnostic and management skills 2)The positioning, preparing and draping of a patient, and Examination under anaesthesia (EUA) for arthroscopic knee surgery, utilising an operating table and theatre equipment to teach procedural and examination skills 3)Simulator based training for diagnostic shoulder and knee arthroscopy; and Bankart repair, utilising arthroscopic stack and synthetic joint models to develop arthroscopic motor skill and procedural knowledge Findings The combination of simulated patients and part-task trainers (a simulator that simulates a limited component of a clinical procedure) created a multimodal clinical context. The three novel teaching modules allowed the integration of technical and non-technical skills in low-cost and high-fidelity orthopaedic simulation environments.
Clinical Orthopaedics and Related Research, 2016
The authors certify that they, or any members of their immediate families, have no commercial ass... more The authors certify that they, or any members of their immediate families, have no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.
Orthopaedics & traumatology: surgery & research, May 1, 2021
This note describes a surgical technique to kinematically align a medial Oxford® UKA. Applying ki... more This note describes a surgical technique to kinematically align a medial Oxford® UKA. Applying kinematic alignment principles is an alternative, personalised, physiological, and potentially clinically advantageous method for implanting the medial Oxford® UKA. Further investigations are needed to better define the reproducibility and clinical impact of this new surgical technique.
Orthopaedic Proceedings
Superior teamwork in the operating theatre is associated with improved technical performance and ... more Superior teamwork in the operating theatre is associated with improved technical performance and clinical outcomes. Yet modern rota patterns, workforce shortages, and increasing complexity of surgery, means that there is less familiarity between staff and the required choreography. Immersive Virtual Reality (iVR) can successfully train surgical staff individually, however iVR team training has yet to be investigated. We aimed to design a multiplayer iVR platform for anterior approach total hip arthroplasty (AA-THA) and assess if multiplayer iVR training was superior to single player training for acquisition of both technical and non-technical skills.An iVR platform with choreographed roles for the surgeon and scrub nurse was developed using Cognitive Task Analysis. Forty participants were randomised to individual or team iVR training. Individually- trained participants practiced alongside virtual avatar counterparts, whilst teams trained live in pairs. Both groups underwent five iVR...
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Papers by Kartik Logishetty