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Simulation-based surgical skills training is recognized as a valuable method to improve trainees’ performance and broadly perceived as essential for the establishment of a comprehensive curriculum in surgical education. However, there needs to be improvement in several areas for meaningful integration of simulation into surgical education. The purpose of this focused review is to summarize the obstacles to a comprehensive integration of simulation-based surgical skills training into surgical education and board certification and suggest potential solutions for those obstacles. First and foremost, validated simulators need to be rigorously assessed to ensure their feasibility and cost-effectiveness. All simulation-based courses should include clear objectives and outcome measures (with metrics) for the skills to be practiced by trainees. Furthermore, these courses should address a wide range of issues, including assessment of trainees’ problem-solving and decision-making abilities and remediation of poor performance. Finally, which simulation-based surgical skills courses will become a standard part of the curriculum across training programs and which will be of value in board certification should be precisely defined. Sufficient progress in these areas will prevent excessive development of training and assessment tools with duplicative effort and large variability in quality.

“Spinal Cord Injury without Radiographic Abnormality” (SCIWORA) is a term that denotes objective clinical signs of posttraumatic spinal cord injury without evidence of fracture or malalignment on plain radiographs and computed tomography (CT) of the spine. SCIWORA is most commonly seen in children with a predilection for the cervical spinal cord due to the increased mobility of the cervical spine, the inherent ligamentous laxity, and the large head-to-body ratio during childhood. However, SCIWORA can also be seen in adults and, in rare cases, the thoracolumbar spinal cord can be affected too. Magnetic resonance imaging (MRI) has become a valuable diagnostic tool in patients with SCIWORA because of its superior ability to identify soft tissue lesions such as cord edema, hematomas and transections, and discoligamentous injuries that may not be visualized in plain radiographs and CT. The mainstay of treatment in patients with SCIWORA is nonoperative management including steroid therapy, immobilization, and avoidance of activities that may increase the risk of exacerbation or recurrent injury. Although the role of operative treatment in SCIWORA can be controversial, surgical alternatives such as decompression and fusion should be considered in selected patients with clinical and MRI evidence of persistent spinal cord compression and instability.

Traumatic lumbosacral dislocation is a rare, high-energy mechanism injury characterized by displacement of the fifth lumbar vertebra in relation to the sacrum. Due to the violent trauma typically associated with this lesion, there are often severe, coexisting injuries. High-quality radiographic studies, in addition to appropriate utilization of CT scan and MRI, are essential for proper evaluation and diagnosis. Although reports in the literature include nonoperative and operative management, most authors advocate for surgical treatment with open reduction and decompression with instrumentation and fusion. Despite advances in early diagnosis and management, this injury type is associated with significant morbidity and mortality, and long-term patient outcomes remain unclear.

Traumatic cervical syndrome comprises the various symptoms that occur as a result of external force such as that of a traffic accident. In 1995, the Quebec Task Force on whiplash-associated disorders (WAD) formulated the Quebec classification, with accompanying clinical practice guidelines. These guidelines were in accordance with the stated clinical isolated or combined symptoms of the syndrome: neck pain, headaches, dizziness, numbness of head or face, eye pain, vision loss, double vision, tinnitus, hearing loss, nausea, and numbness and/or weakness of extremities. In recent years, cerebrospinal fluid hypovolemia or fibromyalgia has been recognized as a major notable cause of a variety of symptoms, although many clinical questions remain regarding the pathology of this syndrome. Therefore, its diagnosis and treatment should be conducted extremely carefully. While the Quebec classification and its guidelines are very useful for the normalization and standardization of symptoms of traumatic cervical syndrome, in the future, we would like to see the emergence of new guidelines that better address the diversity of this disease.

Endothelial progenitor cells (EPCs) derived from bone marrow and blood can differentiate into endothelial cells and promote neovascularization. In addition, EPCs are a promising cell source for the repair of various types of vascularized tissues and have been used in animal experiments and clinical trials for tissue repair. In this review, we focused on the kinetics of endogenous EPCs during tissue repair and the application of EPCs or stem cell populations containing EPCs for tissue regeneration in musculoskeletal and neural tissues including the bone, skeletal muscle, ligaments, spinal cord, and peripheral nerves. EPCs can be mobilized from bone marrow and recruited to injured tissue to contribute to neovascularization and tissue repair. In addition, EPCs or stem cell populations containing EPCs promote neovascularization and tissue repair through their differentiation to endothelial cells or tissue-specific cells, the upregulation of growth factors, and the induction and activation of endogenous stem cells. Human peripheral blood CD34(+) cells containing EPCs have been used in clinical trials of bone repair. Thus, EPCs are a promising cell source for the treatment of musculoskeletal and neural tissue injury.

Mahmut Nedim Doral1,2, Murat Bozkurt3, Egemen Turhan4, Gürhan Dönmez2, Murat Demirel5, Defne Kaya2, Kivanç Atesok7, Özgür Ahmet Atay1, Nicola Maffulli61Department of Orthopedics and Traumatology, 2Department of Sports Medicine, Hacettepe University School of Medicine, Sihhiye, Ankara, Turkey; 3Department of Orthopedics and Traumatology, Ankara Etlik Ihtisas Training and Research Hospital, Ankara, Turkey; 4Department of Orthopedics and Traumatology, Zonguldak Karaelmas University School of Medicine, Zonguldak, Turkey; 5Department of Orthopedics and Traumatology, Ankara Bayindir Medical Center, Ankara, Turkey; 6Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK; 7St. Michael's Hospital Division of Orthopaedics Musculoskeletal Research Lab, Toronto, Ontario, CanadaAbstract: Although the Achilles tendon (AT) is the strongest tendon in the human body, rupture of this tendon is one of the most common sports injuries in the athletic population. Despite numerous nonoperative and operative methods that have been described, there is no universal agreement about the optimal management strategy of acute total AT ruptures. The management of AT ruptures should aim to minimize the morbidity of the injury, optimize rapid return to full function, and prevent complications. Since endoscopy-assisted percutaneous AT repair allows direct visualization of the synovia and protects the paratenon that is important in biological healing of the AT, this technique becomes a reasonable treatment option in AT ruptures. Furthermore, Achilles tendoscopy technique may decrease the complications about the sural nerve. Also, early functional postoperative physiotherapy following surgery may improve the surgical outcomes.Keywords: Achilles tendon rupture, percutaneous repair, endoscopic control, growth factors

EDITORIAL - Developing Stem Cell-Based Therapeutic Strategies in Orthopaedic Surgery