Trends in Arthroscopic Procedures Performed During Orthopaedic Residency: An Analysis of Accreditation Council for Graduate Medical Education Case Log Data

Evaluating effectiveness of cadaveric arthroscopic training for orthopaedic residents: A comparison of joints and training levels

Purpose

This study aimed to evaluate the effects and interactions of training level and different joints on the outcomes of cadaveric arthroscopic training courses for orthopaedic residents.

Methods

This prospective study enrolled 16 orthopaedic residents who voluntarily participated in a cadaveric training programme involving the shoulder, elbow, wrist, knee and ankle joints. Outcomes were quantitatively assessed using task-specific checklists and the Arthroscopic Surgery Skill Evaluation Tool. Two-way analysis of variance (ANOVA) was conducted to determine the significance of the interactions between joint and years of training.

Results

Resident scores significantly increased after the dedicated lectures in all five joints (p = 0.003 for the shoulder module, p < 0.001 for the other joints). Two-way ANOVA revealed that the progress made after the dedicated lectures was significantly impacted by the joint (p = 0.006) and training level × joint interaction (p = 0.005) but not by the training level (p = 0.47). The simple effect of the joint was examined using Sidak's multiple comparison test. Among junior residents, the dedicated lectures resulted in more substantial progress in elbow and wrist arthroscopy when compared to shoulder arthroscopy (p = 0.020 and p = 0.043, respectively).

Conclusions

The results suggest that, in cadaveric arthroscopic training courses for orthopaedic residents, training outcomes are primarily impacted by the specific joint being trained rather than the training level. Specifically, junior residents demonstrated greater improvement with training in procedures that are less commonly encountered during on-the-job training, such as elbow and wrist arthroscopy.

Clinical Relevance

These findings suggest the need to prioritise wrist and elbow arthroscopic training for junior residents to optimise educational outcomes.

Level of Evidence

Level III.

Orthopedic surgery residents reported increased shoulder procedure volumes during the COVID-19 pandemic

Background

The purpose of this study is to evaluate the impact of the COVID-19 pandemic on shoulder procedure volumes reported to the Accreditation Council for Graduate Medical Education by orthopedic surgery residents.

Methods

We performed a retrospective review of Accreditation Council for Graduate Medical Education case logs reporting data from graduating orthopedic surgery residents during the academic years of 2006-2022. Data were queried for all patients for the following shoulder Current Procedural Terminology codes: incision, excision, intro or removal, repair/revision/reconstruction, fracture and/or dislocation, manipulation, arthroscopy, trauma, and total procedures performed. Individual t-tests were used to compare case log trends of graduating academic years before (classes of 2018 and 2019) and during (classes of 2020, 2021, and 2022) the COVID-19 pandemic. Statistical significance was established to be P <.05 for total procedure types, but at P <.005 during category comparisons to protect against alpha errors.

Results

Reported mean total shoulder procedures per resident steadily increased each year from 2017 to 2022, but the only significant increase was seen when comparing the graduating classes of 2020 to 2021 (157.9 vs. 165.7, P =.02). Stratification of these procedures by subgroup revealed a significant increase in manipulation procedures from 2021 to 2022 (7.3 vs. 8.8, P =.001).

Discussion/Conclusion

COVID-19 did not have a negative impact on logged shoulder procedure volume. Orthopedic surgery residents graduating during the COVID-19 pandemic reported more shoulder procedures than those graduating prepandemic. However, shoulder procedure log trends should be longitudinally investigated, as preceding years of procedural opportunities may underestimate the pandemic's impact.

What is the place of wrist arthroscopy in surgical residents' training? Wrist Arthroscopy in Residents Survey (WARS)

INTRODUCTION

Wrist arthroscopy has become an essential method in the management of patients suffering from wrist pathologies. This technique must be mastered by residents wishing to specialize in upper limb surgery. However, no study has evaluated residents' access to wrist arthroscopy.

HYPOTHESIS

Residents have difficulty accessing wrist arthroscopy surgery during their training.

MATERIALS AND METHODS

We sent out an online questionnaire to all orthopedic and plastic surgery referents in France. Data were collected over a 6-month period from December 2020 to May 2021. A descriptive statistical analysis was performed.

RESULTS

Regarding the 98 responses obtained, we observed that 77.54% of residents have seen between 0 and 10 wrist arthroscopies and 35.71% have never seen a wrist arthroscopy. In addition, only 23.80% of residents have had access to training on cadavers, and 57.14% of residents were trained in private facilities.

DISCUSSION

Access to the operating room remains difficult for residents in upper limb surgery. Our results suggest that wrist arthroscopy training could be improved. New training methods could be adapted for wrist arthroscopy and to overcome the lack of access to wrist arthroscopy for residents.

LEVEL OF INCIDENCE

IV.

Ankle Arthroscopy Procedural Volume Is Low Among Graduating Orthopaedic Surgery Residents

Purpose

To evaluate graduating orthopaedic resident case volume and variability for ankle arthroscopy from 2016 to 2020.

Methods

The Accreditation Council for Graduate Medical Education surgical case log data from 2016 to 2020 for graduating United States orthopaedic surgery residents was assessed. Arthroscopy procedures of the leg/ankle were categorized. The average number of cases performed per resident was compared from 2016 to 2020 to determine the percent change in case volume. The 10th, 30th, 50th, 70th, and 90th percentiles of case volumes from 2016 to 2020 were presented to demonstrate case volume variability.

Results

There was no significant change in the average number of leg/ankle arthroscopy cases from 2016 to 2020 (6.2 ± 5 [range 0-35] vs 6.1 ± 6 [range 0-76] P = .732), despite a 19% increase in the average number of total leg/ankle procedures performed over time (168.4 ± 47 [range 55-414] in 2016; 200.8 ± 57 in 2020 [range 67-601], P < .001). There was wide variability in ankle arthroscopy case volume among residents. The 90th percentile of residents performed 13 cases in 2020, compared with 5 in 50th percentile, and 1 in the 10th percentile.

Conclusions

Orthopaedic surgery resident exposure to ankle arthroscopy has remained low and highly variable overtime, despite an overall increase in the total number of leg/ankle procedures performed.

Clinical Relevance

Understanding ankle arthroscopy in case volume and variability is important for programs to ensure that orthopaedic residents are gaining adequate exposure to increasingly popular procedures. Orthopaedic surgery residency programs should explore methods to increase resident exposure to ankle arthroscopy.

Impact of 2013 ACGME Minimum Case Requirements on Orthopedic Resident Operative Volume

In 2013, the Accreditation Council for Graduate Medical Education (ACGME) mandated orthopedic surgery residents to perform at least 1000 surgical cases during residency and specified "case minimums" for 15 core procedure categories. We assessed trends in the volume and variability of graduating orthopedic surgery resident caseload since the implementation of these case minimums. We performed a retrospective linear regression analysis of ACGME-published case log data of US orthopedic residents graduating from 2014 to 2019, with trend analysis, comparison of case volume between residents in 10th and 90th percentiles, and comparison of logged cases vs case minimums for core procedures. Median total procedures performed increased from 1464 (range, 592-2842) in 2014 to 1709 (range, 870-3318) in 2019, representing a 17% increase in case volume (P<.001). Residents performing at the 90th percentile logged twice as many cases as residents performing at the 10th percentile. Of the core procedures, carpal tunnel release and total knee arthroplasty most greatly exceeded ACGME requirements (performed at 4.3 to 4.7 times the minimums, respectively). Graduating resident case volume increased significantly from 2014 to 2019. Variability in operative experience remains high and did not change significantly during the study period. [Orthopedics. 2022;45(1):25-30.].

Fundamentals of Arthroscopy Fluid Management and Strategies to Safely Improve Visualization

Arthroscopy has become increasingly relevant to various subspecialties within the orthopaedic surgery. From a patient safety standpoint and surgical efficiency standpoint, it is critical to know the fundamental concepts of fluid management such as those related to the fluid, pressure, and flow. A satisfactory field of view during arthroscopy can be achieved with the use of gravity-dependent or automated fluid management systems. Fluid management parameters and their physiological impact on the patient should be continuously monitored to avoid morbidity or delayed recovery. Local and systemic complications can occur from careless use of techniques that improve visualization such as tourniquet, epinephrine-diluted irrigation, and controlled hypotensive anesthesia. The purpose of this article is to review the fundamental concepts of fluid management in arthroscopy and the techniques to safely improve arthroscopic visualization.

A Review of Orthopaedic Resident Case Logs to Identify Fluctuations in Exposure to Adult Orthopaedic Procedures

INTRODUCTION

Orthopaedic surgery resident case exposure is an important component of surgical training and is monitored by the Accreditation Council for Graduate Medical Education (ACGME) to ensure resident readiness for graduation. The purpose of this study was to investigate trends in exposure to adult orthopaedic surgical procedures and analyze the impact of the 2013 update in ACGME case logging expectations.

METHODS

A retrospective review of ACGME case log data was conducted for adult orthopaedic procedures performed by graduating orthopaedic surgery residents from 2012 to 2020. Trends in the number of cases logged and the case share by anatomical location were investigated. Linear regression analysis was performed to analyze changes in case number over the 9-year period.

RESULTS

For all surgical categories, there was stability in the average case number per resident from 2012 to 2013, followed by a precipitous decrease from 2013 to 2014. From 2014 to 2020, there has been a gradual increase in case number for all categories except "other musculoskeletal (MSK)," resulting in a total 46% recovery since the 2014 decline. Concomitant with the decline, there was a relative increase in pelvis/hip and femur/knee procedures and decrease in shoulder, other MSK, and spine procedures. From 2014 to 2020, shoulder, humerus/elbow, pelvis/hip, leg/ankle, foot/toes, and spine cases have gradually accounted for a larger proportion of total cases while femur/knee and "other MSK" cases have accounted for less.

CONCLUSIONS

The 2013 update in ACGME case logging expectations was associated with a significant decrease in case number. This is likely a reflection of residents correctly entering 1 primary Current Procedural Terminology code for each surgical case. Programs should be aware of a general increase in case number since 2014 and acknowledge the fact that some procedure types may be given priority from a logging standpoint when multiple Current Procedural Terminology codes apply.

ACGME Case Volume Minimums Decrease the Number of Shoulder and Knee Arthroscopies Performed by Residents

Purpose

The purpose of this study was to examine how the implementation of Accreditation Council of Graduate Medical Education (ACGME) case minimums in 2013 has affected the number of shoulder and knee arthroscopies performed by orthopaedic surgery residents during their clinical training.

Methods

The ACGME orthopaedic surgery case log data from graduation years 2007 to 2019 was used to evaluate the number of shoulder and knee arthroscopies performed. The mean and median number of cases performed per resident were compared for the years prior to implementation of the ACGME case minimum (2007-2012) and after (2013-2019).

Results

The ACGME orthopaedic surgery case minimums resulted in a significant decrease in the mean number of shoulder and knee arthroscopies performed. The mean number of shoulder arthroscopies performed in the years before and after the case minimum requirement were 109.8 and 82.0 (P = .025), respectively. The mean number of knee arthroscopies performed in the years before and after the case minimum requirement were 178.6 and 124.8 (P = .006), respectively. Residents in the tenth percentile of cases performed still met the required ACGME case minimums each year. The mean total of all cases performed in the years before and after the case minimum requirement were 2045.5 and 1699.3 (P = .038), respectively.

Conclusions

The number of shoulder and knee arthroscopies performed by orthopaedic surgery residents significantly decreased after the implementation of ACGME case minimums, which may be due to underreporting of cases.

Clinical Relevance

This study may demonstrate the effect of the implementation of the ACGME case minimums on the number of shoulder and knee arthroscopies performed by orthopaedic surgery residents.

Orthopaedic Surgery Sports Medicine Fellows See Substantial Increase in Hip Arthroscopy Procedural Volume With High Variability From 2011 to 2016

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

CLINICAL RELEVANCE

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.

The Top 50 Most-Cited Shoulder Arthroscopy Studies

Purpose

To determine the 50 most frequently cited studies in the orthopaedic shoulder arthroscopy literature and to conduct a bibliometric analysis of these studies.

Methods

The Clarivate Analytics Web of Knowledge database was used to gather data and metrics using Boolean queries to capture all possible iterations of shoulder arthroscopy research. The search list was sorted so that articles were organized in descending order based on the number of citations and included or excluded based on relevance to shoulder arthroscopy. The information extracted for each article included author name, publication year, country of origin, journal name, article type, and the level of evidence.

Results

For these 50 studies, the total number of citations was calculated to be 13,910, with an average of 278.2 citations per paper. The most-cited article was cited 1134 times, whereas the second- and third-most cited articles were cited 920 and 745 times, respectively. All 50 articles were published in English and came from 7 different orthopaedic journals. The United States was responsible for most of the included articles (31), followed by France (9) and Japan (3).

Conclusions

The majority of the most-cited articles in shoulder arthroscopy are case series and descriptive studies originating from the United States. In addition, more than one half of the top 50 most-cited studies were published after 2004, which suggests that article age may be less important in the accumulation of citations for a rapidly growing field like shoulder arthroscopy.

Clinical Relevance

The top 50 most-cited studies list will provide researchers, medical students, residents, and fellows with a foundational list of the most important and influential academic contributions to shoulder arthroscopy.

Decrease in Resident Arthroscopic Case Volume After 2013 Implementation of Minimum Case Requirements

Purpose

To analyze graduating U.S. orthopaedic resident case logs to determine temporal trends in knee and shoulder arthroscopic case volumes, as well as changes in the variability of caseload volumes since the implementation of Accreditation Council for Graduate Medical Education (ACGME) minimum case requirements (“case minimums”) in 2013.

Methods

We abstracted ACGME-published case log data for all U.S. orthopaedic surgery residents who graduated from 2007 to 2013 (before implementation of case minimums) and from 2014 to 2019 (after implementation). Using a case–control study design, we compared mean numbers of arthroscopic knee and shoulder cases reported per resident between the 2 time periods by using unpaired 2-tailed t tests. P values < .05 were considered significant.

Results

The mean number of arthroscopy knee cases reported by residents decreased from 164 before implementation of case minimums to 107 after implementation (P < .001). The mean number of shoulder cases decreased similarly from 98 to 66 (P < .001). Among residents with caseload volumes in the 90th percentile (“high-volume caseloads”) the decrease was greatest, with 38% fewer knee cases and 41% fewer shoulder cases logged. The ratio of the number of cases in the 90th percentile of caseload to the number in the 10th percentile decreased significantly after implementation of case minimums (P < .001).

Conclusions

After implementation of ACGME case minimums in 2013, the numbers of arthroscopic knee and shoulder cases reported by graduating U.S. orthopaedic surgery residents decreased significantly. The disparity between the number of cases that constitutes a high-volume caseload and the number that constitutes a low-volume caseload narrowed, suggesting greater uniformity in resident exposure to these procedures across training programs.

Level of Evidence

Level III, retrospective comparative study.

Trends and Complications of Arthroscopic-Assisted Tibial Plateau Fracture Fixation: A Matched Cohort Analysis

Purpose

To determine trends in arthroscopic-assisted tibial plateau fracture fixation (AATPFF), to evaluate trends in the overall rate of tibial plateau fracture fixation, and to compare postoperative complications between AATPFF and traditional tibial plateau fixation.

Methods

A retrospective review of patients undergoing AATPFF and traditional tibial plateau fixation was conducted using the Humana Inc. administrative database from 2007 to 2016. A 1:1 propensity match was utilized to match patients in the 2 study groups based on age, sex, obesity, diabetes, hypertension, chronic obstructive pulmonary disease, depression or anxiety, and smoking history. Postoperative complications were grouped as minor medical complications, major medical complications, surgical complications, emergency department visits, and reoperation. Linear regression analysis was used to assess trends and Pearson's χ² test was used to compare postoperative complications with statistical significance defined as P < .05.

Results

In total, 522 patients underwent AATPFF and 3920 patients underwent traditional tibial plateau fracture fixation. There was a 4-fold increase in the use of AATPFF over the study period (P = .0173). Similarly, there was an increase in the utilization of traditional tibial plateau fracture fixation, although to a lesser extent (1.33-fold). After propensity matching, the traditional fixation group demonstrated significantly higher rates of minor medical complications (8.2% vs 2.7%, P = .0002), major medical complications (9.9% vs 4.6%, P = .0018), surgical complications (13.2% vs 2.7%, P < .0001), and emergency department visits (21.4% vs 13.5%, P < .0001) within 90 days of surgery compared with the AATPFF group. There was no difference in reoperation rates within 90 days between the 2 groups (2.9% vs 3.6%, P = .85).

Conclusions

The incidence of tibial plateau fracture fixation is increasing, however, use of AATPFF is increasing at a faster rate compared to traditional techniques. Furthermore, the addition of knee arthroscopy to fracture fixation does not increase the risk of complication, reoperation, or emergency department visit within 90 days.

Level of Evidence

III, retrospective matched cohort.

Simulation-Based Arthroscopic Skills Using a Spaced Retraining Schedule Reduces Short-Term Task Completion Time and Camera Path Length

PURPOSE

To investigate whether acquiring basic knee arthroscopic skills via a spaced retraining schedule could prevent skills deterioration and achieve further skills improvement.

METHODS

In the learning phase, 16 residents with no previous hands-on experience in practicing arthroscopic skills were asked to perform basic arthroscopic tasks on a simulator until they attained perfect scores in each task. Immediately after completing the learning phase, a pretest was performed to assess their performance. Next, they were randomly assigned into 2 groups. The spaced retraining group, which undertook a spaced repetitive training phase with a fixed-time interval, returned on days 2, 4 and 6 to repeat the same tasks for 20 minutes per day, whereas the control group did nothing. On day 7, all participants performed a posttest. A 2 × 2 mixed analysis of variance model was used for statistical analysis.

RESULTS

Significant differences between the 2 groups were found in task completion time (P = .003) and camera path length (P = .043) but not cartilage injury (P = .186). Residents in the spaced retraining group decreased their task completion time (163.2 ± 23.9 seconds) whereas the task time in the control group increased (351.3 ± 25.5 seconds). The same pattern was found with the camera path length.

CONCLUSIONS

Implementing a spaced retraining schedule in 1 week resulted in a reduced task completion time and camera path length but no significant reduction in cartilage injury. It appears that introducing a spaced retraining schedule to retain arthroscopic skills acquired through massed learning may be advantageous.

CLINICAL RELEVANCE

In consideration of the training time available to residents and the trend toward massed learning, this spaced retraining schedule may offer a cost-effective and convenient way for residents to maintain and improve their basic arthroscopic skills with no significant increase in time invested.

Arthroscopy training in France: A resident perception and self-assessment

BACKGROUND

Arthroscopic surgery is a steadily expanding component of orthopaedic practice that changes continuously as new techniques and indications develop. The many arthroscopy training activities offered to residents include fellowships, practice on cadaver specimens and simulators, and teaching in the operating room. Current practices for arthroscopy training of orthopaedic residents in France have not yet been evaluated. The objectives of this study were to describe current arthroscopy training practices and to assess the perceptions and expectations of residents and junior physicians in France, in order to contribute to the development of a new training strategy for residents.

HYPOTHESIS

Residents and junior physicians perceive gaps in their arthroscopy training.

METHODS

Between November 2018 and February 2019, the Junior French Arthroscopy Society (Société Francophone d'Arthroscopie Junior, SFAJ) conducted a descriptive epidemiological survey of 918 residents, clinical fellows, and junior physicians in orthopaedic surgery departments in France. The data were collected via an online questionnaire sent by e-mail. The questionnaire had items on demographics; perceptions of, and expectations about, arthroscopy skills training during the residency; and experience in performing arthroscopic procedures.

RESULTS

Of the 918 residents, 106 responded to the questionnaire. Most respondents were near the end of their training: 26 (24.8%) were 4th-year residents, 23 (21.6%) were 5th-year residents, 15 (14.3%) were clinical fellows, and 13 (12.4%) were junior physicians. Among respondents, 42 (40%) had performed fewer than 5 simple arthroscopy procedures as the main operator and 73 (69.5%) felt they were not, or would not be, capable of performing arthroscopic procedures without supervision by the end of their residency.

CONCLUSION

The survey findings highlighted the challenges encountered by French orthopaedics residents in acquiring satisfactory arthroscopy skills during their residency. They also suggested avenues for improvement such as simulator training or the development of training on cadaver specimens.

LEVEL OF EVIDENCE

IV, descriptive survey.

Did a Minimum Case Requirement Improve Resident Surgical Volume for Closed Wrist and Forearm Fracture Treatment in Orthopedic Surgery?

OBJECTIVE

The purpose of this study is to determine whether the 2013 implementation of ACGME minimum case requirements was associated with increased documented case volume of closed manipulation of forearm and wrist fractures (CMFWF) for graduating orthopedic surgery residents.

DESIGN

We reviewed ACGME case log data for CMFWF among graduating orthopedic surgery residents from 2007 to 2016. Annual national mean, and median number of CMFWF performed by residents in the 10th, 30th, 50th, and 90th case volume percentile were evaluated. Preminimum (2007-2010) data was compared to postminimum (2013-2016) values to assess the impact of ACGME minimum requirements on resident case volume.

SETTING

Review of publically available ACMGE Orthopedic Surgery Residency Program case log data.

PARTICIPANTS

ACGME case log data for orthopedic surgery residents graduating between 2007 and 2016.

RESULTS

National mean number of CMFWF increased significantly pre- to postminimum requirement (30.0 ± 2.84 to 45.0 ± 3.36, p < 0.001). Between 2010 and 2016 there was a 1100%, 300%, 83%, and 9% increase in the median number of CMFWF within the 10th, 30th, 50th, and 90th percentiles, respectively.

CONCLUSIONS

ACGME's 2013 case minimum requirement corresponded to an increase in case counts for CMFWF; the greatest increase occurred in residents below the 50th percentile of case volume. Implementation of case minimum requirements may allow for more accurate depiction of resident experience and program strengths with regards to procedural exposure. However, the current case log system measures only case quantity, which may inaccurately depict mastery of given procedures. Future work should focus not only on improving case counts in underperforming residents and training sites, but also on refining metrics that ensure accurate assessment of resident skill for essential orthopedic procedures prior to graduation.

Wrist Arthroscopy: Can We Gain Proficiency Through Knee Arthroscopy Simulation?

OBJECTIVE

Wrist arthroscopy is a challenging discipline with limited training exposure during residency. The purpose of this study was to evaluate the effectiveness of virtual knee arthroscopy simulation training for gaining proficiency in wrist arthroscopy.

DESIGN

Participants were recorded performing a cadaveric wrist arthroscopy simulation. The residents then practiced knee arthroscopy on a virtual reality simulator and repeated the wrist arthroscopy simulation. All videos were blinded prior to assessment. Proficiency was graded using the Arthroscopic Surgery Skill Evaluation Tool global rating scale. In addition, participants were asked to complete a survey assessing the value of the virtual reality knee arthroscopy simulator for wrist arthroscopy.

SETTING

Orthopaedic Surgery Residency Program, Carolinas Medical Center, a large, public, nonprofit hospital located in Charlotte, North Carolina.

PARTICIPANTS

Orthopaedic residents at our center were asked to participate in the simulation training. Participation was voluntary and nonincentivized. All orthopaedic residents at our institution (N = 27) agreed to participate. In total, there were 10 Intern (PGY-0 and PGY-1), 10 Junior (PGY-2 and PGY-3), and 7 Senior (PGY-4 and PGY-5) residents. In addition, a fellowship-trained hand surgeon was recruited to participate in the study, performing the wrist arthoscopy simulation. Two additional fellowship-trained hand surgeons, for a total of 3, assessed the blinded videos.

RESULTS

There was a trend toward better wrist Arthroscopic Surgery Skill Evaluation Tool scores by training level, although the difference was not statistically significant. Interns improved by an average of 1.8 points between baseline and postknee simulation tests. Junior and senior residents decreased by 1.6 and 5.0 points, respectively.

CONCLUSIONS

Knee arthroscopy simulation training did not objectively improve wrist arthroscopy proficiency among residents. A wrist-specific arthroscopy simulation program is needed if measurable competence through simulation is desired.

Do Orthopaedic Resident and Fellow Case Logs Accurately Reflect Surgical Case Volume?

OBJECTIVE

The purpose of this study is to determine whether orthopedic resident and fellow case logs accurately reflect trainee case volume.

DESIGN

For each orthopedic case performed at our institution between 7/1/14 and 10/31/14, the names of trainees who participated were obtained from the chart. The trainee Accreditation Council for Graduate Medical Education case logs were queried to determine if the procedure in question was logged and, if so, which current procedural terminology (CPT) codes were reported. The CPT codes reported by the trainees were compared to those reported by the attendings in the billing database. To ascertain the opinions of trainees regarding coding, a survey was conducted.

SETTING

University of Maryland Medical Center (Baltimore, MD), a tertiary and quaternary care center which features a state-wide trauma referral center as well as orthopedic residency and fellowship training programs.

PARTICIPANTS

All orthopedic surgery residents and fellows present at the institution during the study period.

RESULTS

Trainees failed to log their cases 24% of the time (465/1925), including 25% (283/1117) for residents and 23% (182/808) for fellows (p = 0.16). Among cases that were logged, CPT codes were missed 46% of the time (673/1460) and extra codes were added 28% of the time (412/1460) compared to the attendings. In the survey, most trainees stated that it was "extremely" or "very" important for them to be able to code correctly (83%; 29/35).

CONCLUSIONS

In this study of orthopedic trainee case logging practices, cases were not logged 24% of the time. Caution should be taken with activities which rely on trainee case logs given the potential for inaccuracy.

Variation in pediatric orthopedic case volume among residents: an assessment of Accreditation Council for Graduate Medical Education case logs

The aim of this investigation was to examine graduating orthopedic resident case logs to evaluate trends in performing pediatric orthopedic procedures and compare pediatric orthopedic case volume among residents in the 90th, 50th, and 10th percentiles (by case volume) to identify caseload variation. Accreditation Council for Graduate Medical Education orthopedic resident case logs were examined for graduating years 2007-2013. Linear regression analyses were carried out to assess temporal trends in pediatric orthopedic case volume. Subgroup analyses were carried out to assess trends in cases by anatomic location. Comparisons of the number of pediatric cases performed by the 90th, 50th, and 10th percentiles of graduating residents were also performed. Pediatric orthopedic case volume increased significantly per graduating resident (295.9-373.2; P<0.001) from 2007 to 2013. Graduating residents in the 90th (494-573; P=0.001), 50th (264-334; P<0.001), and 10th (144-216; P=0.003) percentiles of case volume all sustained significant increases in the number of pediatric orthopedic cases performed. Subgroup analyses showed significant increases in pediatric orthopedic shoulder (4.8-7.3; P<0.001), humerus/elbow (25.9-32.7; P<0.001), forearm/wrist (28.6-40.4; P<0.001), hand/finger (15-16.9; P=0.005), femur/knee (44.5-51.9; P=0.002), leg/ankle (39.4-41.1; P=0.004), and spine case volume (24.9-33.6; P<0.001). On average, graduating residents in the 90th, 50th, and 10th percentiles performed 524, 302, and 169 cases, respectively. The current investigation shows significant growth in the number of pediatric orthopedic cases performed by graduating residents, particularly among upper extremity procedures. However, considerable variation in pediatric orthopedic case volume exists among residents. Although the educational effects of this case volume variation are incompletely understood, the current investigation may be beneficial in efforts to improve pediatric orthopedic educational quality.

Prior Generic Arthroscopic Volume Correlates with Hip Arthroscopic Proficiency: A Simulator Study

BACKGROUND

Changing trends in surgical education and patient expectation are leading to proficiency models of progression and the use of simulators. Hip arthroscopy is increasingly performed and has a steep learning curve mainly addressed during fellowship training. The aim of this study was to assess the impact of previous generic arthroscopic experience on performance at a simulated hip arthroscopy task to both estimate the minimum case numbers that correlate with expert proficiency levels and help to guide selection for hip arthroscopy fellowships.

METHODS

Fifty-two participants were recruited to a cross-sectional study. Four consultants (expert hip arthroscopists), 28 trainees (residents and fellows), and 20 novices (interns and medical students) performed a standardized bench-top simulated hip arthroscopy task. A validated global rating scale (GRS) score and motion analysis were used to assess surgical performance. Prior arthroscopic experience was recorded from surgical electronic logbooks. Receiver operating characteristic (ROC) curve analyses were conducted to identify optimum cut-points for task proficiency at both expert and competent GRS levels.

RESULTS

There were significant differences (p < 0.05) between the arthroscopic ability of all experience groups based on GRS assessment and for all motion analysis metrics. There was a significant positive correlation between logbook numbers and GRS scores (p < 0.0001). ROC curve analysis demonstrated that a minimum of 610 prior arthroscopic procedures were necessary to achieve an expert GRS score, and 78 prior arthroscopic procedures were necessary for a competent score.

CONCLUSIONS

Performing a basic hip arthroscopy task competently requires substantial previous generic arthroscopic experience. The numbers identified in this study provide targets for residents. Program directors appointing to hip arthroscopy fellowship training posts may find these results useful as a guide during the selection process.

Orthopedic resident's learning curve for arthroscopic subscapularis tendon repair: short-term clinical and radiographic outcomes

BACKGROUND

Arthroscopic subscapularis (SSC) repair is a technically demanding procedure with a long learning curve. As effective completion of resident's practical experience remains controversial, a prospective clinical study was performed to assess the functional and anatomical outcomes of subscapularis (SSC) arthroscopic repair by orthopedic residents. The pathological anatomy of the tears, the surgical approach and the difficulties encountered at the beginning of the learning curve were reported.

MATERIALS AND METHODS

Between June 2009 and June 2010, 30 patients with rotator cuff tear were preoperatively evaluated with clinical exam, Constant and UCLA scores. Surgery was performed under arthroscopy by a team of three orthopedic surgeons in training. A SSC tear, if present, was recorded and treated. The same clinical exam and functional scores were repeated at minimum 6 months of follow-up. Subscapularis strength recovery and tendon healing were investigated with arthromagnetic resonance imaging.

RESULTS

A SSC tear was observed in 11 cases out of 30 and treated arthroscopically. The clinical scores improved in all patients: the average Constant score increased from 34 ± 14 to 77 ± 11 and the UCLA score from 11 ± 5 to 29 ± 3. The SSC tests were negative in all patients with the exception of one. Tendon healing was observed in 10 out of 11 cases.

CONCLUSIONS

Arthroscopic SSC repair performed by educated residents is possible and leads to good clinical and anatomical results. Surgery duration progressively improved as the learning curve advanced.

LEVEL OF EVIDENCE

Level 2.

Variability in Trauma Case Volume in Orthopedic Surgery Residents

Orthopedic trauma surgery is a critical component of resident education. Surgical case logs obtained from the Accreditation Council of Graduate Medical Students from 2009 to 2013 for orthopedic surgery residents were examined for variability between the 90^th and 10^th percentiles in regards to the volume of cases performed. There was an upward trend in the mean number of cases performed by senior residents from 484.4 in 2009 to 534.5 in 2013, representing a 10.3% increase. There was a statistically significant increase in the number of cases performed for humerus/elbow, forearm/wrist, and pelvis/hip during this period (P<0.05). Although the difference between the 10^th and 90^th percentile case volumes narrowed over the study period, the difference between these groups remained significant in 2013 (P=0.02). In 2013, all categories of trauma cases had a greater than 2.2-fold difference between the 10^th and 90^th percentile of residents for numbers of trauma cases performed. Although case volume is not the sole determinant of residency education and competency, evidence suggests that case volume plays a crucial role in surgeon confidence and efficiency in performing surgery. Further studies are needed to better understand the effect of this variability seen among residents performing orthopedic trauma surgery.