Arthroscopic proficiency: A survey of orthopaedic sports medicine fellowship directors and orthopaedic surgery department chairs

doi:10.1053/jars.2002.31699

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 18, Issue 7, September 2002, Pages 795-800

https://doi.org/10.1053/jars.2002.31699 Get rights and content

Abstract

Purpose: The goal of this study was to evaluate the opinion of sports medicine fellowship directors and orthopaedic surgery department chairpersons on how many repetitions the average resident needs to become proficient in several common arthroscopic procedures. Type of Study: A cross-sectional study. Methods: A questionnaire was mailed to all fellowship directors on a list maintained by the American Academy of Orthopaedic Surgeons and to all department chairpersons on a list maintained by the American Medical Association. Respondents were asked to estimate the number of operations needed for a trainee to reach minimal proficiency (able to perform procedure skin-to-skin with supervision) and proficiency (capable of performing procedure without supervision) for 5 common arthroscopic procedures: diagnostic knee scope, partial medial meniscectomy, anterior cruciate ligament (ACL) reconstruction, diagnostic shoulder scope, and subacromial decompression. Results: A total of 164 of 230 (71%) people responded to the questionnaire. Department chairpersons who did not perform arthroscopy consistently estimated two thirds the number of operations that department chairpersons who did perform arthroscopy and nearly half the number of operations estimated by fellowship directors. Chairpersons who did perform arthroscopy had responses more similar to fellowship directors than to department heads who did not perform arthroscopy. Conclusions: These results indicate that, in the opinion of physicians involved in the education of residents and fellows, it may take a substantial number of repetitions to become proficient in arthroscopy. Physicians who perform little or no arthroscopy themselves may underestimate its difficulty. Interestingly, there was substantial variability in the number of repetitions estimated to achieve proficiency in all procedures. The results of this study may be helpful in designing arthroscopic training programs for orthopaedic residents or sports medicine fellows; however, the wide variability in opinions may indicate difficulty in reaching a consensus.

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 7 (September), 2002: pp 795–800

Section snippets

Methods

During the summer of 1999, a cross-sectional study of orthopaedic department chairs and sports medicine fellowship directors in the United States was conducted. A questionnaire was mailed to all 150 orthopaedic department chairs on a list maintained by the American Medical Association and to all 80 sports medicine fellowship directors on a list maintained by the American Academy of Orthopaedic Surgeons.

The first part of the questionnaire requested demographic data for each respondent and their

Results

Questionnaires were returned by 55 of 80 fellowship directors (69%), and 109 of 150 (73%) orthopaedic department chairpersons, for an overall response rate of 71%. The respondents in the survey were divided into 3 groups: sports medicine fellowship directors (FD), department chairs who performed any arthroscopy (DCAS), and department chairs who did not perform any arthroscopy (DCNS). There were a variable number of responses for certain questions because in some cases the department chairs were

Discussion

The only formal published criteria found in the literature that addressed the issue of competence in arthroscopic surgery were from the German Speaking Society of Arthroscopy. To become an instructor in this society, applicants must personally perform 250 arthroscopic procedures (50 diagnostic, 120 partial meniscectomies, and 80 ACL reconstructions).²³ The AANA requires that applicants for active membership must be board certified and perform a minimum of 50 arthroscopic procedures per year.²⁴

Acknowledgements

Acknowledgment: The authors thank Ulrich Bosch, M.D., for his efforts in helping us gather important information for this project.

References (39)

DJ Anastakis et al.
Visual-spatial abilities in surgical training
Am J Surg
(2000)
AH Morris et al.
Guidelines for privileges in athroscopic surgery
Arthroscopy
(1993)
JB. Marshall
Technical proficiency of trainees performing colonoscopy: A learning curve
Gastrointest Endosc
(1995)
E Schwartz et al.
Endoscopic estimation of size: Improved accuracy by directed teaching
Gastrointest Endosc
(1995)
GW. Cundiff
Analysis of the effectiveness of an endoscopy education program in improving residents' laparoscopic skills
Obstet Gynecol
(1997)
A Chak et al.
Prospective assessment of colonoscopic intubation skills in trainees
Gastrointest Endosc
(1996)
R Ziegler et al.
Virtual reality arthroscopy training simulator
Comput Biol Med
(1995)
RD Meyer et al.
Arthroscopy using a “black box” technique
Arthroscopy
(1993)
RW. Jackson
History of arthroscopy
RW. Jackson
The introduction of arthroscopy to North America
Clin Orthop
(2000)

IR Crothers et al.

Experienced laparoscopic surgeons are automated to the “fulcrum effect”: An ergonomic demonstration

Endoscopy

(1999)

J DesCoteaux et al.

Learning surgical technical skills

Can J Surg

(1995)

JA. Bergfeld

Issues with accreditation and certification of orthopedic surgery fellowships

J Bone Joint Surg Am

(1998)

GE. Omer

Certificates of added qualifications in orthopaedic surgery: A position in support of the certificates

J Bone Joint Surg Am

(1994)

A. Sarmiento

Certificates of added qualification in orthopaedic surgery: A position against the certificates

J Bone Joint Surg Am

(1994)

Accreditation Council for Graduate Medical Eduation

Program requirements for residency education in orthopaedic surgery

(1998)

Residency Review Committee

Residency program information form. Chicago, IL, Orthopaedic Surgery of the Accreditation Council for Graduate Medical Education

(1998)

Arthroscopy Association of North America

Suggested guidelines for the practice of arthroscopic surgery. Rosemont, IL

(1993)

OW Cass et al.

Objective evaluation of endoscopy skills during training

Ann Intern Med

(1993)

Cited by (74)

Arthroscopic approach in initial training: Study of a novice cohort using inverse direct and indirect approaches and its implication in the development of training programs
2023, Orthopaedics and Traumatology: Surgery and Research
Arthroscopic training includes successive stages of observation, reproduction and then repetition. Learning through simulation in 2D virtual reality makes it possible to repeat these different stages to enhance the learner's experience in complete safety and a shorter timeframe. Some procedures require inversion of the optical and instrumental approaches in the axial plane, disrupting the existing psychomotor and technical skills. The objective of this study was to compare the degree of difficulty and the distribution of results for the same exercise carried out alternately in classical holding and inverted holding of the instruments in a cohort of novice learners.
Twenty-two medical students, novices in arthroscopic surgery, participated in the study. Each performed an exercise consisting of grasping ten targets with arthroscopic forceps and placing them in a basket on the VirtaMed ArthroS™ simulator. The exercise was performed with the scope and grasping instrument pointed away from the operator, “catch the stars front” (CTSF), then directed towards the operator, “catch the stars back” (CTSB). The simulator recorded several parameters making up an overall composite score (“overall performance score”, OPS) out of 120 points. Voluntary abandonment of the exercise was also collected.
All students completed the CTSF exercise but 6 dropped out of the CTSB exercise (27%, p = 0.01). In the CTSF exercise, the average OPS was higher with 45.9 points versus 22.8 points in the CTSB exercise (p < 0.001). By detailing the components of the OPS score, the parameters of interest on the Fundamentals of Arthroscopic Training (FAST) module of the simulator included: the distance traveled by the scope and the grasping forceps was significantly greater in the CTSB group (p < 0.001), the duration of the exercise was significantly greater in the CTSB group (p < 0.001), the time spent with the instruments in the videoscopic field was significantly lower in the CTSB group (p = 0.001) and finally the absence of a significant difference in the camera alignment compared to the horizontal plane between the two groups.
The exercise with the instruments directed towards the operator is more difficult with a greater distribution for all the secondary criteria except for the camera alignment, which suggests that it could be more discriminating. The dropout rate is also higher. It would therefore be interesting to introduce CTSB type training in initial training programs in arthroscopy.
III, comparative prospective study.
Arthroscopic approach in initial training: study of a novice cohort using inverse direct and indirect approaches and its implication in the development of training programs
2023, Revue de Chirurgie Orthopedique et Traumatologique
L’apprentissage de l’arthroscopie comprend des étapes successives d’observation, de reproduction puis de répétition. L’apprentissage par simulation en réalité virtuelle 2D permet de répéter ces différents temps pour accroître l’expérience de l’apprenant en toute sécurité et dans un laps de temps plus réduit. Certaines procédures nécessitent une inversion des voies d’abord optique et instrumental dans le plan axial, perturbant les aptitudes psychotechniques déjà acquises. L’objectif de cette étude est de comparer la difficulté et la distribution des résultats d’un même exercice réalisé alternativement en tenue classique et en tenue inversée des instruments dans une cohorte d’apprenants novices.
Vingt-deux étudiants en médecine, novices en chirurgie arthroscopique ont participé à l’étude. Chacun réalisait un exercice consistant à saisir dix cibles avec une pince arthroscopique et à les déposer dans un panier sur le simulateur VirtaMed ArthroS™. L’exercice a été réalisé avec le scope et la pince dirigés vers l’opposé de l’opérateur, « catch the stars front » (CTSF), puis dirigés vers l’opérateur, « catch the stars back » (CTSB). Le simulateur relevait plusieurs paramètres composant un score global composite (« overall performance score », OPS) sur 120 points. L’abandon volontaire de l’exercice a également été colligé.
Tous les étudiants ont complété l’exercice CTSF mais 6 ont abandonné l’exercice CTSB (27 %, p = 0,01). Dans l’exercice CTSF, l’OPS moyen est plus élevé avec 45,9 points vs 22,8 points dans l’exercice CTSB (p < 0,001). En détaillant les composantes du score OPS, les paramètres d’intérêts sur le module FAST du simulateur étaient la distance parcourue par le scope et la pince significativement supérieure dans le groupe CTSB (p < 0,001), la durée de l’exercice significativement supérieure dans le groupe CTSB (p < 0,001), le temps passé avec les instruments dans le champ vidéoscopique significativement inférieur dans le groupe CTSB (p = 0,001) et enfin l’absence de différence significative dans l’alignement de la caméra par rapport à l’horizon entre les 2 groupes.
L’exercice par voies avec les instruments dirigés vers l’opérateur est plus difficile avec une distribution plus importante pour tous les critères secondaires sauf pour l’alignement de la caméra ce qui suggère qu’il pourrait être plus discriminant. Le taux d’abandon est également plus élevé. Il serait donc intéressant d’introduire des entraînements type CTSB dans les programmes de formation initiale en arthroscopie.
III, étude prospective comparative.
Sports Medicine Fellowship Training Significantly Increases Sports Case Volume: An Analysis of ACGME Case Log Data from 2006 to 2019
2021, Arthroscopy, Sports Medicine, and Rehabilitation
The purpose of this study was to determine the experiential benefit of completing a sports medicine fellowship for orthopaedic surgeons specializing in the treatment of sports injuries.
Accreditation Council for Graduate Medical Education case logs were examined for sports medicine cases performed by orthopaedic surgery residents from 2006 to 2019 and for orthopaedic sports medicine fellows from 2010 to 2019. The average number of arthroscopic cases was evaluated for residents and fellows according to each body group. Additional data based on subcategorization of arthroscopic cases was analyzed as well. A Student t-test was conducted to compare the means between the groups.
Orthopaedic sports medicine fellows reported 274.9% more shoulder (260.6 ± 77.31 vs 94.8 ± 23.7, P < .0001), 685.6% more humerus/elbow (17.1 ± 6.14 vs 2.5 ± .508, P < .0001), 596.7% more pelvis/hip (41.4 ± 25.40 vs 6.9 ± 2.97, P < .0001), 188.1% more femur/knee (281.4 ± 57.85 vs 149.6 ± 34.09, P < .0001), and 264.1% more foot/ankle (16.9 ± 5.58 vs 6.4 ± .600, P < .0001) sports cases compared to orthopaedic surgery residents. Orthopaedic sports medicine fellows performed significantly more shoulder arthroscopy cases (126.8 ± 3.96 vs 86.0 ± 22.26, P = .032) and knee arthroscopy cases (179.4 ± 8.98 vs 101.75 ± 33.51, P = .015) than residents over a 5-year period.
On average, orthopaedic sports medicine fellowships significantly increase sports case volume of orthopaedic trainees, especially in the upper extremity. Notable increases were in the shoulder, femur/knee, and pelvis/hip. We have demonstrated that orthopaedic sports medicine fellowships significantly increase exposure to sports medicine related cases.
It is important for case volume to be evaluated across orthopaedic sports medicine fellowships because they must ensure that fellows receive adequate training in orthopaedic sports medicine.
Arthroscopic Versus Open Rotator Cuff Repair: Fellowship-Trained Orthopaedic Surgeons Prefer Arthroscopy and Self-Report a Lower Complication Rate
2021, Arthroscopy, Sports Medicine, and Rehabilitation
To evaluate whether fellowship training had an effect on the practice pattern and complication rates among Part II examinees of the American Board of Orthopaedic Surgery (ABOS) for rotator cuff repair (RCR) from 2007-2017.
The ABOS database was queried for arthroscopic (Current Procedural Terminology [CPT] code 29827) and open/mini-open (CPT codes: 23410, 23412) RCR performed from 2007-2017. Excluded were procedures that did not included CPT codes 29827, 23410, 23412. A comparison between arthroscopic and open/mini-open use as well as self-reported complications were assessed based on recorded fellowship training.
A total of 31,907 RCR were reported over the past 10 years (2007-2017). The percentage of RCR procedures performed using arthroscopic technique vs open/mini-open varied among surgeons who completed one fellowship: Sports Medicine (92.5 % arthroscopy; 7.5 % mini/open), Shoulder & Elbow (91.3 % arthroscopy; 8.7% mini/open), and Hand & Upper Extremity (69.6 % arthroscopy; 30.4 % open). Total complication rates varied among surgeons who completed one fellowship: Sports Medicine (11.5 %), Shoulder & Elbow (13.5 %), and Hand & Upper Extremity (13.4 %). Surgeons completing one fellowship in either Sports Medicine, Shoulder & Elbow, Hand & Upper Extremity all reported significantly lower complication rates using arthroscopic over mini/open technique (P < .001).
Among ABOS Part II examinees completing a Sports Medicine, Shoulder and Elbow or Hand and Upper Extremity fellowship, Sports Medicine trained surgeons had significantly greater rates of performing arthroscopic over open RCR and significantly lower self-reported intraoperative complication rates.
Understanding the effects of fellowship training may guide mentors and future trainees.
Clinical outcome and repair integrity after arthroscopic rotator cuff repair significantly improved during the surgeon's learning curve
2021, Journal of Shoulder and Elbow Surgery
Whether learning curve could affect the surgical outcome after arthroscopic rotator cuff repair is still unknown. The purpose of this study was to evaluate surgical learning curve for clinical outcome and retear rate after arthroscopic rotator cuff repairs that were performed by the beginner shoulder surgeon. We hypothesized that clinical outcome and retear rate would improve over time with the accumulation of a surgeon’s experience.
This retrospective study consisted of 200 consecutive patients who had arthroscopic rotator cuff repairs, performed by a single surgeon between 2011 and 2018. We included symptomatic rotator cuff tears involving the supraspinatus/infraspinatus and/or subscapularis tendon and follow-up magnetic resonance imaging evaluations of repair integrity 6 months after surgery. Surgeon’s learning was evaluated with calculation of cumulative retear rate and cumulative summation (CUSUM) analysis. Clinical outcomes and the retear rates were compared between group A (the first-half 100 patients) and group B (the latter-half of 100 patients).
The mean follow-up period was 21 months (range, 12-55). The overall retear rate was 13% (26 patients). The CUSUM analysis showed that after patient number 97, the curve was maintained below the level of acceptable failure rate, suggesting the competency was obtained consistently. Comparing between groups, retear rate showed significant decrease from 18% in group A to 8% in group B (P = .036). Notably, retear rate in small to medium-sized tears (<3 cm) significantly decreased from 26% (12 of 46 patients) in group A to 2% (1 of 49 patients) in group B (P = .001). However, analysis in large to massive tears (≥3 cm) failed to show difference between groups (30%, 6 of 20, in group A and 25%, 6 of 24, in group B; P = .711). In multivariate analysis, higher fatty infiltration of the supraspinatus muscle (P = .008), more severe muscle atrophy of the teres minor (P = .010), and belonging to group A (P = .011) were associated with retear.
Clinical outcomes and retear rate after arthroscopic rotator cuff repairs significantly improved during the learning curve period of a beginner shoulder surgeon.
Orthopaedic Surgery Sports Medicine Fellows See Substantial Increase in Hip Arthroscopy Procedural Volume With High Variability From 2011 to 2016
2021, Arthroscopy - Journal of Arthroscopic and Related Surgery
To analyze the trends in operative experience, specifically procedures of the shoulder, hip and knee, of fellows graduating from Accreditation Council for Graduate Medical Education orthopaedic sports medicine fellowships between 2011 and 2016.
The 2011-2016 Accreditation Council for Graduate Medical Education orthopaedic surgery sports medicine fellow case logs were retrieved for analysis. Trends in the mean case volume for procedures of the shoulder, hip, and knee were analyzed. Linear regression was used to identify significant changes in trends over time for each surgical case/procedure. Variation in case volume between fellows in the lowest (10th) and highest (90th) centile was assessed for first and last year of the study.
The average number of total procedures per fellow minimally decreased by 3.5% from 2011 to 2016 (726 to 701 cases) (P < .001). The mean total number of hip procedures significantly increased by 155% from 24.9 to 63.5 (P = .049). There were no significant differences in the mean total number of shoulder (P = .88) and knee procedures (P = .54). Arthroscopic hip procedures had the largest increase from 2011 to 2016 (14.1 to 57.8 [+310%], P = .049). There was greater than 2-fold difference in total procedural volume between fellows in the 10th and 90th percentile for 2011 and 2016, with the greatest variation (64-fold) for arthroscopic hip procedures.
In this study there was a 2.6-fold increase in hip procedures, largely driven by a 310% rise in arthroscopic hip cases. The average procedural volume per fellow minimally decreased, with no change in the mean number of shoulder and knee procedures.
Understanding variability in case exposure among orthopaedic sports medicine fellowships is important for programs to ensure that fellows are appropriately exposed to all facets of sports medicine procedures.

View all citing articles on Scopus

^*: Address correspondence and reprint requests to Edward G. McFarland, M.D., Johns Hopkins Sports Medicine, 10753 Falls Rd, Suite 215, Lutherville, MD 21093, U.S.A. E-mail: [email protected]

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Original ArticlesArthroscopic proficiency: A survey of orthopaedic sports medicine fellowship directors and orthopaedic surgery department chairs*

Abstract

Section snippets

Methods

Results

Discussion

Acknowledgements

Am J Surg

Arthroscopy

Gastrointest Endosc

Gastrointest Endosc

Obstet Gynecol

Gastrointest Endosc

Comput Biol Med

Arthroscopy

History of arthroscopy

The introduction of arthroscopy to North America

Clin Orthop

Experienced laparoscopic surgeons are automated to the “fulcrum effect”: An ergonomic demonstration

Endoscopy

Learning surgical technical skills

Can J Surg

Issues with accreditation and certification of orthopedic surgery fellowships

J Bone Joint Surg Am

Certificates of added qualifications in orthopaedic surgery: A position in support of the certificates

J Bone Joint Surg Am

Certificates of added qualification in orthopaedic surgery: A position against the certificates

J Bone Joint Surg Am

Program requirements for residency education in orthopaedic surgery

Residency program information form. Chicago, IL, Orthopaedic Surgery of the Accreditation Council for Graduate Medical Education

Suggested guidelines for the practice of arthroscopic surgery. Rosemont, IL

Objective evaluation of endoscopy skills during training

Ann Intern Med

Original Articles
Arthroscopic proficiency: A survey of orthopaedic sports medicine fellowship directors and orthopaedic surgery department chairs*