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Tabaie SA, Schermerhorn JT, Baird M, Lattanza L, Ode G, Mesfin A. AOA Critical Issues: Perceptions on the State of Diversity, Equity, and Inclusion in Orthopaedic Surgery: A Survey of the AOA Membership. J Bone Joint Surg Am 2023; 105:1920-1926. [PMID: 37651571 DOI: 10.2106/jbjs.23.00392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND Orthopaedic surgery continues to trail other specialties in increasing diversity among its physician workforce. Various efforts have been and are currently being made to not only increase diversity, but also promote equity and inclusion in the field. The purpose of this study was to survey members of the American Orthopaedic Association (AOA) to determine how leaders in orthopaedics view diversity, equity, and inclusion (DEI) at the present time and to understand their perspective while moving into the future. METHODS An anonymous 11-question survey was disseminated online to AOA members in May 2022. These individuals were identified by the AOA membership directory and the email ListServe. The survey included free-response and multiple-choice questions. Demographic information was self-identified, and both qualitative and quantitative data were collected. RESULTS Of the 1,657 AOA members who were provided the survey, 262 (15.8%) responded. Approximately 29.5% (77) and 45.6% (119) of the surveyed population ranked "retention of underrepresented populations in orthopaedic residency (women, URiM)" as "very important" or "absolutely essential," respectively. The answers to the free-response questions identified multiple core themes that responders were passionate about, namely resident and attending physician recruitment and retention, as well as resident selection. CONCLUSIONS Leaders in the field of orthopaedic surgery desire for action to be taken in the field of DEI. The findings of this survey denote positive attitudes even though many inequalities still pervade the field of orthopaedics. Through mentorship, objective evaluation, transparency, and continued intentional action, orthopaedic surgery is well-positioned to continue to move forward with DEI.
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Affiliation(s)
| | | | - Michael Baird
- Walter Reed National Military Medical Center, Bethesda, Maryland
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Guerra Bresson H, Baumann Q, El Koussaify J, Benayoun M, Maillot C, Rousseau MA, Boyer P. 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. Orthop Traumatol Surg Res 2023; 109:103552. [PMID: 36649789 DOI: 10.1016/j.otsr.2023.103552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 11/08/2022] [Accepted: 12/13/2022] [Indexed: 01/15/2023]
Abstract
INTRODUCTION 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. MATERIALS AND METHODS 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. RESULTS 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. CONCLUSION 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. LEVEL OF EVIDENCE III, comparative prospective study.
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Affiliation(s)
- Héléna Guerra Bresson
- Service de chirurgie orthopedique et traumatologique, Hôpital Bichat - Claude-Bernard, Paris, France.
| | - Quentin Baumann
- Service de chirurgie orthopedique et traumatologique, Hôpital Bichat - Claude-Bernard, Paris, France
| | - Jad El Koussaify
- Service de chirurgie orthopedique et traumatologique, Hôpital Bichat - Claude-Bernard, Paris, France
| | - Marie Benayoun
- Service de chirurgie orthopedique et traumatologique, Hôpital Bichat - Claude-Bernard, Paris, France
| | - Cédric Maillot
- Service de chirurgie orthopedique et traumatologique, Hôpital Bichat - Claude-Bernard, Paris, France
| | - Marc-Antoine Rousseau
- Service de chirurgie orthopedique et traumatologique, Hôpital Bichat - Claude-Bernard, Paris, France
| | - Patrick Boyer
- Service de chirurgie orthopedique et traumatologique, Hôpital Bichat - Claude-Bernard, Paris, France
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Anetzberger H, Kugler A, John D, Kopf S, Becker R, Reppenhagen S. The number of arthroscopies performed by trainees does not deduce the level of their arthroscopic proficiency. Knee Surg Sports Traumatol Arthrosc 2023; 31:4231-4238. [PMID: 37296326 DOI: 10.1007/s00167-023-07471-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE It is reasonable to question whether the case volume is a suitable proxy for the manual competence of an arthroscopic surgeon. The aim of this study was to evaluate the correlation between the number of arthroscopies previously performed and the arthroscopic skills acquired using a standardized simulator test. METHODS A total of 97 resident and early orthopaedic surgeons who participated in arthroscopic simulator training courses were divided into five groups based on their self-reported number of arthroscopic surgeries: (1) none, (2) < 10, (3) 10 to 19, (4) 20 to 39 and (5) 40 to 100. Arthroscopic manual skills were evaluated with a simulator by means of the diagnostic arthroscopy skill score (DASS) before and after training. Seventy-five points out of 100 must be achieved to pass the test. RESULTS In the pretest, only three trainees in group 5 passed the arthroscopic skill test, and all other participants failed. Group 5 (57 ± 17 points; n = 17) scored significantly higher than the other groups (group 1: 30 ± 14, n = 20; group 2: 35 ± 14, n = 24; group 3: 35 ± 18, n = 23; and group 4: 33 ± 17, n = 13). After a two-day simulator training, trainees showed a significant increase in performance. In group 5, participants scored 81 ± 17 points, which was significantly higher than the other groups (group 1: 75 ± 16; group 2: 75 ± 14; group 3: 69 ± 15; and group 4: 73 ± 13). While self-reported arthroscopic procedures were n.s. associated with higher log odds of passing the test (p = 0.423), the points scored in the pretest were found to be a good predictor of whether a trainee would pass the test (p < 0.05). A positive correlation was observed between the points scored in the pretest and the posttest (p < 0.05, r = 0.59, r2 = 0.34). CONCLUSIONS The number of previously performed arthroscopies is not a reliable indicator of the skills level of orthopaedic residents. A reasonable alternative in the future would be to verify arthroscopic proficiency on the simulator by means of a score as a pass-fail examination. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Hermann Anetzberger
- Orthopädische Gemeinschaftspraxis am OEZ, Hanauer Str. 65, 80993, Munich, Germany.
| | - Andreas Kugler
- Zentrum für Gelenkchirurgie im MVZ am Nordbad, Schleißheimer Straße 130, 80797, Munich, Germany
| | - Dominik John
- Gelenk.Bonn, Bonner Talweg 61, 53113, Bonn, Germany
| | - Sebastian Kopf
- Zentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Brandenburg der Medizinischen Hochschule Brandenburg Theodor Fontane, Hochstraße 29, 14770, Brandenburg an der Havel, Germany
| | - Roland Becker
- Zentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Brandenburg der Medizinischen Hochschule Brandenburg Theodor Fontane, Hochstraße 29, 14770, Brandenburg an der Havel, Germany
| | - Stephan Reppenhagen
- Orthopädische Klinik König-Ludwig-Haus, Brettreichstraße 11, 97074, Würzburg, Germany
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Validity of a Novel Digitally Enhanced Skills Training Station for Freehand Distal Interlocking. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58060773. [PMID: 35744036 PMCID: PMC9229787 DOI: 10.3390/medicina58060773] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/03/2022] [Accepted: 06/03/2022] [Indexed: 11/22/2022]
Abstract
Background and Objectives: Freehand distal interlocking of intramedullary nails is technically demanding and prone to handling issues. It requires precise placement of a screw through the nail under fluoroscopy guidance and can result in a time consuming and radiation expensive procedure. Dedicated training could help overcome these problems. The aim of this study was to assess construct and face validity of new Digitally Enhanced Hands-On Surgical Training (DEHST) concept and device for training of distal interlocking of intramedullary nails. Materials and Methods: Twenty-nine novices and twenty-four expert surgeons performed interlocking on a DEHST device. Construct validity was evaluated by comparing captured performance metrics—number of X-rays, nail hole roundness, drill tip position and drill hole accuracy—between experts and novices. Face validity was evaluated with a questionnaire concerning training potential and quality of simulated reality using a 7-point Likert scale. Results: Face validity: mean realism of the training device was rated 6.3 (range 4–7). Training potential and need for distal interlocking training were both rated with a mean of 6.5 (range 5–7), with no significant differences between experts and novices, p ≥ 0.234. All participants (100%) stated that the device is useful for procedural training of distal nail interlocking, 96% wanted to have it at their institution and 98% would recommend it to colleagues. Construct validity: total number of X-rays was significantly higher for novices (20.9 ± 6.4 versus 15.5 ± 5.3, p = 0.003). Success rate (ratio of hit and miss attempts) was significantly higher for experts (novices hit: n = 15; 55.6%; experts hit: n = 19; 83%, p = 0.040). Conclusion: The evaluated training device for distal interlocking of intramedullary nails yielded high scores in terms of training capability and realism. Furthermore, construct validity was proven by reliably discriminating between experts and novices. Participants indicate high further training potential as the device may be easily adapted to other surgical tasks.
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Surgical simulation training should become a mandatory part of orthopaedic education. J Exp Orthop 2022; 9:22. [PMID: 35229207 PMCID: PMC8884100 DOI: 10.1186/s40634-022-00455-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 02/11/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose Ethical concerns and increasing economic constraints of hospitals have caused a reduction in proper training and education. It has been hypothesized that due to the lack of a one-to-one apprenticeship throughout the residency, surgical simulation training is essential. Methods Between June 2020 and June 2021, residents from teaching hospitals in Switzerland, France, Germany, and Luxembourg were surveyed to learn about their experience with and thoughts on surgical simulation training. Survey responses were analysed using descriptive statistics. Results Of the 596 residents surveyed, 557 residents (51% female, 49% male) from Switzerland (270), France (214), Germany (52) and Luxembourg (21) agreed to anonymous data analysis. Among those giving consent, 100% considered that simulation training was important for their practical education and 84% thought that simulation training should become a mandatory part of their curriculum, with an average estimated training time of 42 ± 51 h per year, based on the survey. Conclusions This study suggests that surgical simulation training is well accepted and even demanded among surgical residents as an alternative training solution able to address some of the limitations and challenges of the current one-to-one apprenticeship model. There is a wide variation among the residents regarding the number of training hours required, underscoring the need for structured performance-based simulator training.
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Anetzberger H, Becker R, Eickhoff H, Seibert FJ, Döring B, Haasters F, Mohr M, Reppenhagen S. The Diagnostic Arthroscopy Skill Score (DASS): a reliable and suitable assessment tool for arthroscopic skill training. Knee Surg Sports Traumatol Arthrosc 2022; 30:349-360. [PMID: 33914120 DOI: 10.1007/s00167-021-06554-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To develop and validate a novel score to more objectively assess the performance of diagnostic knee arthroscopy using a simulator. METHODS A Diagnostic Arthroscopy Skill Score (DASS) was developed by ten AGA (AGA-Society for Arthroscopy and Joint-Surgery) instructors for the assessment of arthroscopic skills. DASS consists of two parts: the evaluation of standardized diagnostic knee arthroscopy (DASSpart1) and the evaluation of manual dexterity, including ambidexterity and triangulation, using objective measurement parameters (DASSpart2). Content validity was determined by the Delphi method. One hundred and eleven videos of diagnostic knee arthroscopies were recorded during simulator training courses and evaluated by six specially trained instructors using DASS. Construct validity, measurement error calculated by the minimum detectable change (MDC), internal consistency using Cronbach's alpha and interrater and intrarater reliability were assessed. The Bland-Altman method was used to calculate the intrarater agreement. RESULTS Six skill domains were identified and evaluated for each knee compartment. DASS, DASSpart1, and DASSpart2 showed construct validity, with experts achieving significantly higher scores than competents and novices. MDC was 4.5 ± 1.7 points for DASSpart1. There was high internal consistency for all domains in each compartment from 0.78 to 0.86. The interrater reliability showed high agreement between the six raters (ICC = 0.94). The evaluation of intrarater reliability demonstrated good and excellent agreement for five raters (ICC > 0.80) and moderate agreement for one rater (ICC = 0.68). The Bland-Altman comparison showed no difference between the first and second evaluations in five out of six raters. Precision, estimated by the regression analysis and comparison with the method of Bland and Altman, was excellent for four raters and moderate for two raters. CONCLUSIONS The results of this study indicate good validity and reliability of DASS for the assessment of the surgical performance of diagnostic knee arthroscopy during simulator training. Standardized training is recommended before arthroscopy surgery is considered in patients. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Hermann Anetzberger
- Orthopädische Gemeinschaftspraxis am OEZ, Hanauer Str. 65, 80993, Munich, Germany.
| | - Roland Becker
- Zentrum für Orthopädie und Unfallchirurgie, Medizinische Hochschule Theodor Fontane, Hochstraße 29, 14770, Brandenburg an der Havel, Germany.
| | - Hansjörg Eickhoff
- Orthopädie und Unfallchirurgie, Abteilung Arthroskopie u. Schulterchirurgie, GFO-Kliniken Troisdorf, Hospitalstr. 45, 53840, Troisdorf, Germany
| | - Franz Josef Seibert
- Medizinische Universität Graz, Universitätsklinik für Orthopädie und Traumatologie LKH-Uniklinikum, Auenbruggerplatz 7a, 8010, Graz, Austria
| | - Bernd Döring
- Zentrum für Orthopädie und Unfallchirurgie, Medizinische Hochschule Theodor Fontane, Hochstraße 29, 14770, Brandenburg an der Havel, Germany
| | - Florian Haasters
- Schönklinik München Harlaching, Harlachinger Straße 51, 81547, Munich, Germany
| | - Michael Mohr
- Orthopädisches Zentrum Bad Säckingen, Rudolf-Eberle-Platz 3, 79713, Bad Säckingen, Germany
| | - Stephan Reppenhagen
- Orthopädische Klinik König-Ludwig-Haus, Brettreichstraße 11, 97074, Würzburg, Germany
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Ibitayo AT, Kale NN, Miskimin C, Mulcahey MK. Sports Medicine Fellowship Training Significantly Increases Sports Case Volume: An Analysis of ACGME Case Log Data from 2006 to 2019. Arthrosc Sports Med Rehabil 2021; 3:e1713-e1717. [PMID: 34977624 PMCID: PMC8689202 DOI: 10.1016/j.asmr.2021.07.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 07/26/2021] [Indexed: 12/16/2022] Open
Abstract
Purpose 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. Methods 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. Results 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. Conclusions 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. Clinical Relevance 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.
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Affiliation(s)
- Ayooluwa T Ibitayo
- St. George's University School of Medicine, True Blue, Grenada, West Indies
| | | | - Cadence Miskimin
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
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Kelly BC, Constantinescu DS, Pavlis W, Vap AR. Arthroscopic Versus Open Rotator Cuff Repair: Fellowship-Trained Orthopaedic Surgeons Prefer Arthroscopy and Self-Report a Lower Complication Rate. Arthrosc Sports Med Rehabil 2021; 3:e1865-e1871. [PMID: 34977642 PMCID: PMC8689246 DOI: 10.1016/j.asmr.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 09/02/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose 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. Methods 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. Results 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). Conclusions 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. Clinical Relevance Understanding the effects of fellowship training may guide mentors and future trainees.
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Lim TK, Bae KH, Choi YS, Kim JH, Yoo JC. Clinical outcome and repair integrity after arthroscopic rotator cuff repair significantly improved during the surgeon's learning curve. J Shoulder Elbow Surg 2021; 30:1881-1890. [PMID: 33271322 DOI: 10.1016/j.jse.2020.10.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS AND BACKGROUND 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. METHODS 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). RESULTS 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. CONCLUSION Clinical outcomes and retear rate after arthroscopic rotator cuff repairs significantly improved during the learning curve period of a beginner shoulder surgeon.
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Affiliation(s)
- Tae Kang Lim
- Department of Orthopaedic Surgery, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Republic of Korea.
| | - Kyu Hwan Bae
- Department of Orthopaedic Surgery, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Republic of Korea
| | - Yun Sun Choi
- Department of Radiology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Republic of Korea
| | - Jong Ho Kim
- Department of Orthopaedic Surgery, Yeouido St. Mary's Hospital, Catholic University of Korea, Seoul, Republic of Korea
| | - Jae Chul Yoo
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Karamchandani U, Bhattacharyya R, Patel R, Oussedik S, Bhattacharya R, Gupte C. Training Surgeons to Perform Arthroscopic All-Inside Meniscal Repair: A Randomized Controlled Trial Evaluating the Effectiveness of a Novel Cognitive Task Analysis Teaching Tool, Imperial College London/University College London Meniscus Repair Cognitive Task Analysis (IUMeRCTA). Am J Sports Med 2021; 49:2341-2350. [PMID: 34166100 PMCID: PMC8283189 DOI: 10.1177/03635465211021652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND All-inside meniscal repair is an increasingly common technique for the surgical treatment of meniscal tears. There are currently no standardized techniques for training residents in this procedure. Cognitive task analysis (CTA) is a method of analyzing and standardizing key steps in a procedure that allows training to be conducted in a validated and reproducible manner. PURPOSE (1) To design a digital CTA teaching tool for a standardized all-inside meniscal repair. (2) To evaluate whether CTA-trained residents would perform better in a meniscal repair task compared with a control group who underwent traditional apprenticeship methods of training. STUDY DESIGN Controlled laboratory study. METHODS Three expert knee surgeons were interviewed using a modified Delphi method to generate a consensus among the ideal technical steps, cognitive decision points, and common errors and solutions for an all-inside meniscal repair. This written information was then combined with visual and audio components and integrated onto a digital platform to create the Imperial College London/University College London Meniscus Repair Cognitive Task Analysis (IUMeRCTA) tool. Eighteen novice residents were randomized into an intervention group (digital CTA tool) and control group (equipment instruction manual). Both groups performed an all-inside meniscal repair on high-fidelity, phantom knee models and were assessed by expert surgeons, blinded to the interventions, using a validated global rating scale (GRS). After a power calculation, median GRS scores were compared between groups using the Mann-Whitney U test; significance was set at P < .05. RESULTS For the IUMeRCTA tool design, the procedure was divided into 55 steps across 9 phases: (1) preoperative planning, (2) theater and patient setup, (3) portal placement, (4) meniscal examination, (5) tear reduction, (6) suture planning, (7) suture insertion, (8) repair completion, and (9) postoperative care and rehabilitation. For the trial, the intervention group (mean ± SD GRS, 32 ± 2.9) performed significantly better than did the control group (GRS, 24 ± 3.3; P < .001). CONCLUSION This is the first CTA tool to demonstrate objective benefits in training novices to perform an arthroscopic all-inside meniscal repair. CLINICAL RELEVANCE The IUMeRCTA tool is an easily accessible and effective adjunct to traditional teaching that enhances learning the all-inside meniscal repair for novice surgeons.
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Affiliation(s)
- Urvi Karamchandani
- Department of Surgery and Cancer, Imperial College London, London, UK,Department of Orthopaedics, Imperial College NHS Trust, UK
| | - Rahul Bhattacharyya
- Department of Surgery and Cancer, Imperial College London, London, UK,Department of Orthopaedics, Imperial College NHS Trust, UK
| | - Rahul Patel
- Department of Orthopaedics, University College London Hospitals NHS Trust, UK,Wellington Knee Unit, London, UK
| | - Sam Oussedik
- Department of Orthopaedics, University College London Hospitals NHS Trust, UK,Wellington Knee Unit, London, UK
| | - Rajarshi Bhattacharya
- Department of Surgery and Cancer, Imperial College London, London, UK,Department of Orthopaedics, Imperial College NHS Trust, UK
| | - Chinmay Gupte
- Department of Surgery and Cancer, Imperial College London, London, UK,Department of Orthopaedics, Imperial College NHS Trust, UK,Wellington Knee Unit, London, UK,Chinmay Gupte, PhD, MA, BM BCh, MSk Lab, Imperial College London, 2nd Floor, Sir Michael Uren Hub, 86 Wood Lane, London W12 0BZ, UK ()
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11
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Gordon AM, Flanigan DC, Malik AT, Vasileff W. Orthopaedic Surgery Sports Medicine Fellows See Substantial Increase in Hip Arthroscopy Procedural Volume With High Variability From 2011 to 2016. Arthroscopy 2021; 37:521-527. [PMID: 33022366 DOI: 10.1016/j.arthro.2020.09.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Adam M Gordon
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, U.S.A
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, U.S.A
| | - Azeem Tariq Malik
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, U.S.A
| | - William Vasileff
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, U.S.A..
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12
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Swiatek PR, Weiner J, Alvandi BA, Johnson D, Butler B, Tjong V, Terry MA. Evaluating the Early Impact of the COVID-19 Pandemic on Sports Surgery Fellowship Education. Cureus 2021; 13:e12943. [PMID: 33654620 PMCID: PMC7910193 DOI: 10.7759/cureus.12943] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2021] [Indexed: 11/15/2022] Open
Abstract
Purpose The COVID-19 pandemic forced many hospitals to cancel elective surgeries to minimize the risk of viral transmission and ensure the availability of vital health resources. The unintended consequences of this action on the education and training of orthopaedic sports surgeons are unknown. The purpose of this study is to measure the impact of COVID-19 on orthopaedic sports surgery fellows, their education and training, and their readiness for practice. Methods A comprehensive survey was created and distributed to all U.S. fellows and fellowship directors registered with the American Orthopaedic Society for Sports Medicine. Responses were collected between April 22, 2020, and May 5, 2020. Results Fifty-one sports fellows and twenty-nine sports fellowship directors completed the survey. Over 80.4% of fellows reported a greater than 50% decrease in the case volume since the cessation of elective cases. Average hours worked per week decreased by 58.2% during the pandemic. Fellows reported completing an average of 324.6 ± 97.4 cases prior to the COVID-19 crisis and 86.0% expected to complete at least 11% to 25% fewer cases by graduation compared to previous fellows. 87.5% of fellows were not concerned about their ability to complete their fellowship training but more than one-third of fellows voiced concerns to their fellowship directors regarding their readiness for independent practice. Fellowship directors were generally not concerned that COVID-19 would prevent their fellows from completing the fellowship. At least 54.2% are somewhat concerned about the impact of COVID-19 on their future job opportunities. Conclusions The COVID-19 pandemic has universally affected work hours and case volume of sports fellows. Nevertheless, most sports fellows feel prepared to enter practice and are generally supported by the confidence of their fellowship directors. The results of this survey emphasize the importance of the fellowship year in sports training and highlight the future of online education and simulation as useful adjuncts.
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Affiliation(s)
- Peter R Swiatek
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Joseph Weiner
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Bejan A Alvandi
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Daniel Johnson
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Bennet Butler
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Vehniah Tjong
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Michael A Terry
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
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13
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Chu AK, Law RW, Greschner JM, Hyer CF. Effectiveness of the Cadaver Lab in Podiatric Surgery Residency Programs. J Foot Ankle Surg 2021; 59:246-252. [PMID: 32130985 DOI: 10.1053/j.jfas.2019.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 08/11/2019] [Indexed: 02/03/2023]
Abstract
Since the inception of the first surgical training system by Sir William Stewart Halsted, resident surgical skill development has been promulgated in teaching hospitals. Currently, the Council on Podiatric Medical Education does not mandate the availability of a cadaver lab as a residency curriculum requirement. The purpose of the present study is to assess the structure of the cadaver lab and availability in the current podiatric surgical training programs. A survey was sent electronically to 229 American Association of Colleges of Podiatric Medicine-approved residency programs, excluding OhioHealth, across all residency programs. A total of 173 (6.9%) residents from 74 (32.3%) residency programs completed the survey. This survey analyzed the characteristics and perception of the current state of cadaver lab in podiatric residency. The most reported type of cadaver labs available were medical company sponsored and hospital sponsored. Other hands-on training, including inanimate simulators (n = 24) and animal models (n = 5), was also reported. Overall, 87.9% of the surveyed residents found that cadaver lab is either extremely beneficial (57.8%) or somewhat beneficial (30.1%). The most important factors perceived in a successful cadaver lab were faculty instruction (n = 78), accessibility of lab (n = 46), and availability of instrumentation/hardware (n = 26). This qualitative survey is the first study to address the uniformity, perception, and potential value of the cadaver lab in a podiatric surgical residency.
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Affiliation(s)
- Anson K Chu
- Chief Resident, Grant Medical Center, Columbus, OH; Resident Physician, Grant Medical Center, Columbus, OH.
| | - Rona W Law
- Resident Physician, Grant Medical Center, Columbus, OH
| | | | - Christopher F Hyer
- Faculty, Grant Medical Center, Columbus, OH; Fellowship-Trained Foot and Ankle Surgeon, Orthopedic Foot and Ankle Center, Westerville, OH; Residency Program Director, Grant Medical Center, Columbus, OH
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14
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Anetzberger H, Mohr M, Eickhoff H, Seibert FJ, Döring B, Reppenhagen S. Drei Jahre AGA Simulatortraining Arthroskopie. ARTHROSKOPIE 2021. [DOI: 10.1007/s00142-020-00428-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Erquicia J, Gil González S, Barrera Sancho A, Hernández Fernández G, Pelfort López X. Impact of cadaveric practices on arthroscopic knee training for Orthopaedic Surgery and Traumatology residents. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021. [DOI: 10.1016/j.recote.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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16
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Erquicia JI, Gil González S, Barrera Sancho A, Hernández Fernández G, Pelfort López X. Impact of cadaveric practices on arthroscopic knee training for Orthopaedic Surgery and Traumatology residents. Rev Esp Cir Ortop Traumatol (Engl Ed) 2020; 65:41-46. [PMID: 33229300 DOI: 10.1016/j.recot.2020.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 06/25/2020] [Accepted: 07/15/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There currently is a considerable variability in the content of training programs and courses for orthopaedic surgeons in training. Besides this, there is still no consensus regarding which is the most effective methodology for improving learning of the technique or for its qualitative evaluation. A study was carried out to assess the influence of carrying out a cadaveric practical course on the acquisition of arthroscopic technical skills in fifth-year residents. MATERIAL AND METHODS A knee arthroscopy cadaveric course was performed in which 48 students participated. Different technical aspects during a knee arthroscopy, as well as the residents skill and the execution time were evaluated before and after the course using a specific questionnaire. RESULTS There was a significant statistic improvement between the initial and final evaluation, increasing from 11,7 till 17,1 (maximum 20) points. Also, a significant improvement in all the parameters analysed was observed; the identification of anatomic structures (p = 0.001), the palpation of specific structures (p = 0.032), and the time necessary for the arthroscopic knee check (p = 0.015). CONCLUSIONS A knee arthroscopy cadaveric course improves significantly the technical skills of surgeons in training.
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Affiliation(s)
- J I Erquicia
- Hospital Universitari Quirón-Dexeus, ICATME-EQUILAE, Barcelona, España; Departamento de Cirugía Ortopédica y Traumatología, Consorci Sanitari de l'Anoia - Hospital d'Igualada, Igualada, Barcelona, España
| | - S Gil González
- Departamento de Cirugía Ortopédica y Traumatología, Consorci Sanitari de l'Anoia - Hospital d'Igualada, Igualada, Barcelona, España.
| | - A Barrera Sancho
- Departamento de Cirugía Ortopédica y Traumatología, Consorci Sanitari de l'Anoia - Hospital d'Igualada, Igualada, Barcelona, España
| | - G Hernández Fernández
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Central de la Defensa Gómez Ulla, Madrid, España
| | - X Pelfort López
- Departamento de Cirugía Ortopédica y Traumatología, Consorci Sanitari Parc Taulí, Sabadell, España
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Arthroscopy training in France: A resident perception and self-assessment. Orthop Traumatol Surg Res 2019; 105:S397-S402. [PMID: 31564632 DOI: 10.1016/j.otsr.2019.09.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 09/11/2019] [Indexed: 02/02/2023]
Abstract
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.
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18
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van der Heijden LLM, Reijman M, van der Steen MCM, Janssen RPA, Tuijthof GJM. Validation of Simendo Knee Arthroscopy Virtual Reality Simulator. Arthroscopy 2019; 35:2385-2390. [PMID: 31053458 DOI: 10.1016/j.arthro.2019.01.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 01/16/2019] [Accepted: 01/18/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the face and construct validity as well as educational value and user-friendliness of the Simendo knee arthroscopy virtual reality simulator. METHODS Sixty participants were recruited and equally divided into novices (0 arthroscopic procedures), intermediates (1-59 arthroscopic procedures), and experts (60 or more arthroscopic procedures). Participants were excluded if they had previously trained with the studied simulator. Construct validity, that is, the ability to discriminate between different levels of expertise, was examined by a navigation task. All participants were asked to perform 5 navigation trials within 10 minutes. Face validity, educational value, and user-friendliness were examined by questionnaires before and after the navigation trials. Face validity is the subjective impression of how closely the simulation replicates the real environment. RESULTS The novices were significantly slower than the intermediates in the first (P < .001) and the third (P = .031) trial. The novices were significantly slower than the experts in all trials (P = .016), except for the fifth (P = .054). The experts were significantly faster than the intermediates in every trial except for the fourth (P = .069). Median task time for the fifth trial was 63 seconds (44-80 seconds) for novices, 58 seconds (46-80 seconds) for intermediates, and 41 seconds (33-55 seconds) for experts. Ninety-two percent of all participants agreed that the simulator can be used to train for surgical inspection, and 95% indicated sufficient user-friendliness. CONCLUSIONS Based on the results, this knee simulator can be applied to train the basic arthroscopic hand-eye coordination skills at the start of resident education programs. Further testing is necessary to determine whether the skills are retained. CLINICAL RELEVANCE The simulator is partly validated, which contributes to training of basic arthroscopic skills without compromising patient safety.
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Affiliation(s)
| | - Max Reijman
- Department of Orthopedic Surgery and Trauma, Máxima Medical Center, Eindhoven, The Netherlands
| | | | - Rob P A Janssen
- Department of Orthopedic Surgery and Trauma, Máxima Medical Center, Eindhoven, The Netherlands
| | - Gabrielle J M Tuijthof
- Department of Orthopedic Surgery, Academic Center for Evidence Based Sports Medicine, Academic Medical Center, Amsterdam, The Netherlands; Research Centre Smart Devices, Zuyd University of Applied Sciences, Heerlen, The Netherlands
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Garfjeld Roberts P, Alvand A, Gallieri M, Hargrove C, Rees J. Objectively Assessing Intraoperative Arthroscopic Skills Performance and the Transfer of Simulation Training in Knee Arthroscopy: A Randomized Controlled Trial. Arthroscopy 2019; 35:1197-1209.e1. [PMID: 30878329 DOI: 10.1016/j.arthro.2018.11.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/07/2018] [Accepted: 11/12/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To objectively investigate the transfer validity of simulation training using wireless elbow-worn motion sensors intraoperatively to assess whether surgical simulation leads to improvements in intraoperative arthroscopic performance. METHODS In this randomized controlled trial, postgraduate year 2 to 3 trainees in nationally approved orthopaedic surgery posts were randomized to standard junior residency training (control group) or standard training plus additional weekly simulation training (intervention group). Both groups performed a supervised real-life diagnostic knee arthroscopy in the operating room at 13 weeks. Performance was measured using wireless elbow-worn motion sensors recording objective surgical performance metrics: number of hand movements, smoothness, and time taken. A participant-supervisor performance ratio was used to adjust for variation in case mix and difficulty. The study took place in a surgical simulation suite and the orthopaedic operating rooms of a university teaching hospital. RESULTS The intervention group objectively outperformed the control group in all outcome metrics. Procedures performed by the intervention group required fewer hand movements (544 [interquartile range (IQR), 465-593] vs 893 [IQR, 747-1,242]; P < .001), had smoother movements (25,842 ms-3 [IQR, 20,867-27,468 ms-3] vs 36,846 ms-3 [IQR, 29,840-53,949 ms-3]; P < .001), and took less time (320 seconds [IQR, 294-392 seconds] vs 573 seconds [IQR, 477-860 seconds]; P < .001) than those performed by the control group. The cases were comparable between the groups. Standardized to the supervisor's performance, the intervention group required fewer hand movements (1.9 [IQR, 1.5-2.1] vs 3.3 [IQR, 2.2-4.8]; P = .0091), required less time (1.2 [IQR, 1.1-1.7] vs 2.6 [IQR, 1.6-3.0]; P = .0037), and were smoother (2.1 [IQR, 1.8-2.8] vs 4.3 [IQR, 2.8-5.4]; P = .0037) than the control group, but they did not perform as well as their supervisors. CONCLUSIONS This study uses intraoperative motion-analysis technology to objectively show that surgical simulation training improves actual intraoperative technical skills performance. CLINICAL RELEVANCE The described wireless objective assessment method complements the subjective observational performance assessments commonly used. Further studies are required to assess how these measures of intraoperative performance correlate to patient outcomes. Intraoperative motion analysis is translatable across surgical specialties, offering potential for objective assessment of progression through competency-based training, revalidation, and talent selection for specialist training.
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Affiliation(s)
- Patrick Garfjeld Roberts
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, England.
| | - Abtin Alvand
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | | | | | - Jonathan Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, England
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Chae S, Jung SW, Park HS. In vivo biomechanical measurement and haptic simulation of portal placement procedure in shoulder arthroscopic surgery. PLoS One 2018; 13:e0193736. [PMID: 29494691 PMCID: PMC5833274 DOI: 10.1371/journal.pone.0193736] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 02/16/2018] [Indexed: 01/22/2023] Open
Abstract
A survey of 67 experienced orthopedic surgeons indicated that precise portal placement was the most important skill in arthroscopic surgery. However, none of the currently available virtual reality simulators include simulation / training in portal placement, including haptic feedback of the necessary puncture force. This study aimed to: (1) measure the in vivo force and stiffness during a portal placement procedure in an actual operating room and (2) implement active haptic simulation of a portal placement procedure using the measured in vivo data. We measured the force required for port placement and the stiffness of the joint capsule during portal placement procedures performed by an experienced arthroscopic surgeon. Based on the acquired mechanical property values, we developed a cable-driven active haptic simulator designed to train the portal placement skill and evaluated the validity of the simulated haptics. Ten patients diagnosed with rotator cuff tears were enrolled in this experiment. The maximum peak force and joint capsule stiffness during posterior portal placement procedures were 66.46 (±10.76N) and 2560.82(±252.92) N/m, respectively. We then designed an active haptic simulator using the acquired data. Our cable-driven mechanism structure had a friction force of 3.763 ± 0.341 N, less than 6% of the mean puncture force. Simulator performance was evaluated by comparing the target stiffness and force with the stiffness and force reproduced by the device. R-squared values were 0.998 for puncture force replication and 0.902 for stiffness replication, indicating that the in vivo data can be used to implement a realistic haptic simulator.
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Affiliation(s)
- Sanghoon Chae
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, South Korea
| | - Sung-Weon Jung
- Department of Orthopaedic surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Hyung-Soon Park
- Department of Mechanical Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, South Korea
- * E-mail:
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Losco M, Familiari F, Giron F, Papalia R. Use and Effectiveness of the Cadaver-Lab in Orthopaedic and Traumatology Education: An Italian Survey. JOINTS 2017; 5:197-201. [PMID: 29270555 PMCID: PMC5738488 DOI: 10.1055/s-0037-1608949] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose
The purpose of this study is to provide basic information on the availability and current use of cadaver laboratories in the education of orthopaedic residents and trainees and to determine the interest for the implementation of this type of training.
Methods
All Orthopaedic residents and trainees who attended a cadaver laboratory organized by SIGASCOT (Italian Society of the Knee, Arthroscopy, Sports Traumatology, Cartilage and Orthopaedic Technology) between 2013 and 2016 were asked to complete a survey on the availability and current use of cadaver laboratories in the education of Orthopaedic residents and trainees. The survey was sent via e-mail to 102 Orthopaedic residents and trainees. All data were analyzed and all responses are presented as counts, percentages, or means.
Results
Thirty-eight (37.2%) Orthopaedics and traumatology residents and trainees completed the survey and were included in this analysis. Eighteen trainees (18/38; 44.3%) attended a cadaver laboratory focused on lower limb surgery, whereas 20 (20/38; 52.7%) on upper limb surgery. Twenty participants (55.7%) perceived skills laboratory sessions as extremely beneficial to the understanding and becoming familiar with the normal surgical anatomy; moreover, 16 (45.7%) participants considered the cadaver laboratory extremely beneficial to the understanding of a specific surgical technique and very beneficial (44.4%) to become confident with arthroscopic or other specific surgical instruments. Over 60% of participants perceived cadaver laboratory to be very to extremely beneficial to increase confidence and speed in the operating room (OR), and more than a half of them considered skills laboratory sessions to be extremely beneficial to increase participation and decrease the occurrence of damages in the real surgical activity.
Conclusion
Orthopaedic residents and trainees found the addition of a cadaver laboratory for teaching surgical skills a significant benefit to both their overall education and surgical skills training.
Level of Evidence
Level IV, survey study.
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Affiliation(s)
- Michele Losco
- Department of Orthopaedic and Trauma Surgery, AOUC Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Filippo Familiari
- Department of Orthopaedic and Trauma Surgery, Università degli Studi "Magna Graecia" di Catanzaro, Campus Universitario "Salvatore Venuta" Viale Europa, Rome, Italy
| | - Francesco Giron
- Department of Orthopaedic and Trauma Surgery, Ospedale Villa Salus, Mestre, Italy
| | - Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, Policlinico Universitario Campus Bio-Medico, Rome, Italy
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Dean B, Jones L, Garfjeld Roberts P, Rees J. What is Known About the Attributes of a Successful Surgical Trainer? A Systematic Review. JOURNAL OF SURGICAL EDUCATION 2017; 74:843-850. [PMID: 28392267 DOI: 10.1016/j.jsurg.2017.01.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/19/2016] [Accepted: 01/23/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Surgical training has been subject to significant upheaval in recent years with an increasingly rigorous assessment regimen for trainees. The assessment of surgical trainers is less well evolved by comparison. Recent proposals from the Royal College of Surgeons of England recommend "professionalising the trainers." However, they do not suggest any accepted or validated methods of trainer assessment, nor do they indicate how these might be implemented and monitored in a real-world training program to determine their effect on trainee outcomes. AIM To determine what is known about the attributes of successful surgical trainers. METHODS We conducted a systematic review of the scientific literature using the preferred reporting items for systematic reviews and meta-analyses and Cochrane guidelines of the Medline database using specific search criteria. The qualitative analysis involved grouping trainer attributes together into "themes" within 4 "super-themes." Each theme needed to be mentioned by a minimum of 5 studies. RESULTS After review of the full study texts a total of 14 studies met the inclusion criteria. Thirteen studies involved the views of trainees, whereas only 1 study solely assessed the views of trainers. There was a wide variety of study designs and types of participants. The attribute themes are listed in brackets after each super-theme: "character" (approachability, patience, enthusiasm, encouraging/supportiveness), "procedural" (willingness to let trainee operate, balance between supervision and independence), "teamwork and communication" (sets educational aims and objectives, ability to use appropriate feedback, communication skills, and time availability to train) and "clinical" (capable, good relationships with patients, and the health care team). CONCLUSIONS This detailed review describes several perceived important themes for the positive attributes of surgical trainers. The identification of these key attributes is only of value if their presence is confirmed by effective and feasible evaluation, and if the possession of such attributes in trainers is proven to have a positive effect on training. In times of reduced training opportunities, exploring the topics raised by this review through future education research is warranted.
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Affiliation(s)
- Ben Dean
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, United Kingdom
| | - Luke Jones
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, United Kingdom
| | - Patrick Garfjeld Roberts
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, United Kingdom.
| | - Jonathan Rees
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, United Kingdom
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Middleton RM, Vo A, Ferguson J, Judge A, Alvand A, Price AJ, Rees JL. Can Surgical Trainees Achieve Arthroscopic Competence at the End of Training Programs? A Cross-sectional Study Highlighting the Impact of Working Time Directives. Arthroscopy 2017; 33:1151-1158. [PMID: 28110806 DOI: 10.1016/j.arthro.2016.10.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 10/14/2016] [Accepted: 10/24/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To provide training guidance on procedure numbers by assessing how the number of previously performed arthroscopic procedures relate to both competent and expert performance in simulated arthroscopic shoulder tasks. METHODS A cross-sectional study that assessed simulated shoulder arthroscopic performance was undertaken. A total of 45 participants of varying experience performed 2 validated tasks: a simple diagnostic task and a more complex Bankart labral repair task. All participants provided logbook numbers for previously performed arthroscopies. Performance was assessed with the Global Rating Scale and motion analysis. Receiver operating characteristic curve analyses were conducted to identify optimum cut points for task proficiency at both "competent" and "expert" levels. RESULTS Increasing surgical experience resulted in significantly better performance for both tasks as assessed by Global Rating Scale or motion analysis (P < .0001). Receiver operating characteristic curve analyses demonstrated 52 previous arthroscopies were needed to perform to a competent level at the diagnostic task and 248 to be competent at the complex task. To perform at an expert level, 290 and 476 previous arthroscopies, respectively, were needed. CONCLUSIONS This study provides quantified guidance for arthroscopic training and highlights the positive relationship between arthroscopic case load and arthroscopic competency. We have estimated that the number of arthroscopies required to achieve competency in a basic arthroscopic task exceed those recommended in some countries. These estimates provide useful guidance to those responsible for training program. CLINICAL RELEVANCE The numbers to achieve competent arthroscopic performance in the assessed simulated tasks exceed what is recommended and what is possible during surgical training programs in some countries.
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Affiliation(s)
- Robert M Middleton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, England.
| | - Austin Vo
- Austin & Monash Health, Melbourne, Australia
| | - Jamie Ferguson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, England; MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, England
| | - Abtin Alvand
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | - Andrew J Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | - Jonathan L Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, England
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Ekhtiari S, Kay J, de Sa D, Simunovic N, Musahl V, Peterson DC, Ayeni OR. What Makes a Successful Survey? A Systematic Review of Surveys Used in Anterior Cruciate Ligament Reconstruction. Arthroscopy 2017; 33:1072-1079.e3. [PMID: 28351554 DOI: 10.1016/j.arthro.2017.01.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 01/03/2017] [Accepted: 01/05/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To characterize and assess the methodological quality of patient and physician surveys related to anterior cruciate ligament reconstruction, and to analyze the factors influencing response rate. METHODS The databases MEDLINE, Embase, and PubMed were searched from database inception to search date and screened in duplicate for relevant studies. Data regarding survey characteristics, response rates, and distribution methods were extracted. A previously published list of recommendations for high-quality surveys in orthopaedics was used as a scale to assess survey quality (12 items scored 0, 1, or 2; maximum score = 24). RESULTS Of the initial 1,276 studies, 53 studies published between 1986 and 2016 met the inclusion criteria. Sixty-four percent of studies were distributed to physicians, compared with 32% distributed to patients and less than 4% to coaches. The median number of items in each survey was 10.5, and the average response rate was 73% (range: 18% to 100%). In-person distribution was the most common method (40%), followed by web-based methods (28%) and mail (25%). Response rates were highest for surveys targeted at patients (77%, P < .0001) and those delivered in-person (94%, P < .0001). The median quality score was 12/24 (range = 8.5/24 to 21/24). There was high inter-rater agreement using the quality scale (intraclass correlation coefficient = 0.92), but there was no correlation with the response rate (Rho = -0.01, P = .97). CONCLUSIONS Response rates vary based on target audience and distribution methods, with patients responding at a significantly higher rate than physicians and in-person distribution yielding significantly higher response rates than web or mail surveys. LEVEL OF EVIDENCE Level IV, systematic review of Level IV studies.
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Affiliation(s)
- Seper Ekhtiari
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey Kay
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Simunovic
- Centre for Evidence Based Orthopaedics, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Volker Musahl
- Division of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Devin C Peterson
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
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Cowan JB, Seeley MA, Irwin TA, Caird MS. Computer-Simulated Arthroscopic Knee Surgery: Effects of Distraction on Resident Performance. Orthopedics 2016; 39:e240-5. [PMID: 26811955 DOI: 10.3928/01477447-20160119-05] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 07/22/2015] [Indexed: 02/03/2023]
Abstract
Orthopedic surgeons cite "full focus" and "distraction control" as important factors for achieving excellent outcomes. Surgical simulation is a safe and cost-effective way for residents to practice surgical skills, and it is a suitable tool to study the effects of distraction on resident surgical performance. This study investigated the effects of distraction on arthroscopic knee simulator performance among residents at various levels of experience. The authors hypothesized that environmental distractions would negatively affect performance. Twenty-five orthopedic surgery residents performed a diagnostic knee arthroscopy computer simulation according to a checklist of structures to identify and tasks to complete. Participants were evaluated on arthroscopy time, number of chondral injuries, instances of looking down at their hands, and completion of checklist items. Residents repeated this task at least 2 weeks later while simultaneously answering distracting questions. During distracted simulation, the residents had significantly fewer completed checklist items (P<.02) compared with the initial simulation. Senior residents completed the initial simulation in less time (P<.001), with fewer chondral injuries (P<.005) and fewer instances of looking down at their hands (P<.012), compared with junior residents. Senior residents also completed 97% of the diagnostic checklist, whereas junior residents completed 89% (P<.019). During distracted simulation, senior residents continued to complete tasks more quickly (P<.006) and with fewer instances of looking down at their hands (P<.042). Residents at all levels appear to be susceptible to the detrimental effects of distraction when performing arthroscopic simulation. Addressing even straightforward questions intraoperatively may affect surgeon performance.
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Design and implementation of the 2012 Canadian shoulder course for senior orthopedic residents. Orthop Traumatol Surg Res 2016; 102:885-890. [PMID: 27743999 DOI: 10.1016/j.otsr.2016.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 07/26/2016] [Accepted: 08/18/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND The objective of the present paper is to analyze the first edition of a comprehensive shoulder course for senior orthopedic surgery residents and the chosen evaluation tools. HYPOTHESIS A course focusing on shoulder surgery, requested by graduating residents in orthopedic surgery, will have a strong level of satisfaction and help improve skills, knowledge, and problem solving abilities in this domain as measured by a pre and post-test. MATERIAL AND METHODS A two-day course was created with practical sessions, lectures, and case studies. Participants were given a multiple choice pre and post course test and evaluation questionnaires after each session. RESULTS Sixty residents attended the course. Nine of the fifteen sessions scored above the 90% satisfaction cut-off; none of the sessions scored below 80%. However, only one question showed a statistically significant improvement after the course. DISCUSSION Response to this course was overwhelmingly positive and the sessions received positive evaluations. However, the method to evaluate residents was not adequate; residents reported learning on their freeform evaluations but this was not represented on the multiple choice evaluation method. Evaluation tools and course duration will be modified in future iterations to improve assessment and teaching. LEVEL OF EVIDENCE IV. STUDY DESIGN Observational.
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Huri G, Cabuk YS, Gursoy S, Akkaya M, Ozkan S, Oztuna V, Aydingoz O, Senkoylu A. Evaluation of the orthopaedics and traumatology resident education in Turkey: A descriptive study. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2016; 50:567-571. [PMID: 27713071 PMCID: PMC6197597 DOI: 10.1016/j.aott.2016.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 12/01/2015] [Accepted: 09/28/2015] [Indexed: 11/25/2022]
Abstract
Objective The objective of this study is to describe the current situation regarding the training, working conditions, future plans, fields of interest and satisfaction of orthopaedics and traumatology residents in Turkey. Methods A descriptive survey questionnaire consisting of 24 questions was designed to identify the problems and solution suggestions concerning training of orthopaedic residents. All orthopaedics and traumatology residents who took the 2013 Progress Testing for Speciality in Medicine (UEGS) held by Turkish Orthopaedics and Traumatology Education Council (TOTEK) were surveyed in the class at the end thereof as well as the young orthopaedic surgeons who were reached through the email groups of Turkish Society of Orthopaedics and Traumatology – Residents and Young Attendings Council (TOTBID-AGUH). Results A total of 725 residents and 132 young attendings were surveyed. The most outstanding answers are as follows: 62,7% of the respondents replied to the question “Is there a training program/Is it being applied” as “yes/yes”. It was found out that 94,3% of the respondents wanted to be involved in a rotation abroad. The “patient care” was the most common answer, with a ratio of 36,9%, to the question “What's the priority of the department you are studying in?”. Regarding work conditions, “many emergency on-calls” was found to be the most important parameter affecting life conditions (p < 0.05). Conclusion Aiming to identify the challenges that orthopaedics and traumatology residents in Turkey face as regards their training, this survey stands as a pioneering study with a high participation rate. Analysis of survey data highlights the importance of several key factors such as the development of training programs and increasing the time spent with academicians as well as spreading and promotion of log book application.
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Regarding "Trends in Arthroscopic Procedures Performed During Orthopaedic Residency: An Analysis of Accreditation Council for Graduate Medical Education Case Log Data". Arthroscopy 2016; 32:1226-8. [PMID: 27373172 DOI: 10.1016/j.arthro.2016.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 05/04/2016] [Indexed: 02/02/2023]
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Stunt JJ, Kerkhoffs GMMJ, Horeman T, van Dijk CN, Tuijthof GJM. Validation of the PASSPORT V2 training environment for arthroscopic skills. Knee Surg Sports Traumatol Arthrosc 2016; 24:2038-45. [PMID: 25103120 DOI: 10.1007/s00167-014-3213-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 07/28/2014] [Indexed: 01/22/2023]
Abstract
PURPOSE Virtual reality simulators used in the education of orthopaedic residents often lack realistic haptic feedback. To solve this, the (Practice Arthroscopic Surgical Skills for Perfect Operative Real-life Treatment) PASSPORT simulator was developed, which was subjected to fundamental changes: improved realism and user interface. The purpose was to demonstrate its face and construct validity. METHODS Thirty-one participants were divided into three groups having different levels of arthroscopic experience. Participants answered questions regarding general information and the outer appearance of the simulator for face validity. Construct validity was assessed with one standardized navigation task, which was timed. Face validity, educational value and user-friendliness were determined with two representative exercises and by asking participants to fill out the questionnaire. A value of 7 or greater was considered sufficient. RESULTS Construct validity was demonstrated between experts and novices. Median task time for the fifth trial was 55 s (range 17-139 s) for the novices, 33 s (range 17-59 s) for the intermediates, and 26 s (range 14-52 s) for the experts. Median task times of three trials were not significantly different between the novices and intermediates, and none of the trials between intermediates and experts. Face validity, educational value and user-friendliness were perceived as sufficient (median >7). The presence of realistic tactile feedback was considered the biggest asset of the simulator. CONCLUSION Proper preparation for arthroscopic operations will increase the quality of real-life surgery and patients' safety. The PASSPORT simulator can assist in achieving this, as it showed construct and face validity, and its physical nature offered adequate haptic feedback during training. This indicates that PASSPORT has potential to evolve as a valuable training modality.
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Affiliation(s)
- J J Stunt
- Department of Orthopedic Surgery, Orthopedic Research Center Amsterdam, Academic Medical Centre, G4-262 Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - G M M J Kerkhoffs
- Department of Orthopedic Surgery, Orthopedic Research Center Amsterdam, Academic Medical Centre, G4-262 Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - T Horeman
- Department of Biomechanical Engineering, Faculty of Mechanical, Materials and Maritime Engineering, Delft University of Technology, Delft, The Netherlands
| | - C N van Dijk
- Department of Orthopedic Surgery, Orthopedic Research Center Amsterdam, Academic Medical Centre, G4-262 Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - G J M Tuijthof
- Department of Orthopedic Surgery, Orthopedic Research Center Amsterdam, Academic Medical Centre, G4-262 Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Biomechanical Engineering, Faculty of Mechanical, Materials and Maritime Engineering, Delft University of Technology, Delft, The Netherlands
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Rahm S, Germann M, Hingsammer A, Wieser K, Gerber C. Validation of a virtual reality-based simulator for shoulder arthroscopy. Knee Surg Sports Traumatol Arthrosc 2016; 24:1730-7. [PMID: 26860098 DOI: 10.1007/s00167-016-4022-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 01/21/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE This study was to determine face and construct validity of a new virtual reality-based shoulder arthroscopy simulator which uses passive haptic feedback. METHODS Fifty-one participants including 25 novices (<20 shoulder arthroscopies) and 26 experts (>100 shoulder arthroscopies) completed two tests: for assessment of face validity, a questionnaire was filled out concerning quality of simulated reality and training potential using a 7-point Likert scale (range 1-7). Construct validity was tested by comparing simulator metrics (operation time in seconds, camera and grasper pathway in centimetre and grasper openings) between novices and experts test results. RESULTS Overall simulated reality was rated high with a median value of 5.5 (range 2.8-7) points. Training capacity scored a median value of 5.8 (range 3-7) points. Experts were significantly faster in the diagnostic test with a median of 91 (range 37-208) s than novices with 1177 (range 81-383) s (p < 0.0001) and in the therapeutic test 102 (range 58-283) s versus 229 (range 114-399) s (p < 0.0001). Similar results were seen in the other metric values except in the camera pathway in the therapeutic test. CONCLUSION The tested simulator achieved high scores in terms of realism and training capability. It reliably discriminated between novices and experts. Further improvements of the simulator, especially in the field of therapeutic arthroscopy, might improve its value as training and assessment tool for shoulder arthroscopy skills. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Stefan Rahm
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Marco Germann
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Andreas Hingsammer
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Karl Wieser
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Christian Gerber
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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Abstract
Introduction. Currently, there are no definitive guidelines for the resection of a cam lesion. The purpose of this study was to investigate factors indicating the potential differences in low and high volume hip arthroscopists in marking the area of resection in cam lesions using X-rays for preoperative planning. Methods. Thirty-nine surgeons with varying levels of hip arthroscopy experience participated in the study. Surgeons filled out a survey and traced the area of optimal resection on radiographs with varying amounts of cam FAI. Participants were grouped by number of hip arthroscopies performed, years of surgical experience, and number of surgeries performed. Results. Surgeons who perform osteoplasty as a high percentage of their total hip surgeries per year correlate to the total number of hip arthroscopies performed per year (r=0.412, p<0.05) and number of years of experience (r=0.72, p<0.01). Surgeons performing greater than 50 cases per year traced a larger resection area for 3 different patients’ radiographs as compared to those performing less than 50 cases per year (117%, 143%, and 173%, p<0.05). Conclusions. This study demonstrates that surgeons with less experience (decreased number of years operating and total number of surgeries) plan for resecting less cam than do experienced surgeons.
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Koehler RJ, Goldblatt JP, Maloney MD, Voloshin I, Nicandri GT. Assessing Diagnostic Arthroscopy Performance in the Operating Room Using the Arthroscopic Surgery Skill Evaluation Tool (ASSET). Arthroscopy 2015; 31:2314-9.e2. [PMID: 26319640 DOI: 10.1016/j.arthro.2015.06.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 05/21/2015] [Accepted: 06/06/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the validity and reliability of using the Arthroscopic Surgery Skill Evaluation Tool (ASSET) to assess arthroscopic skill in the operating room. METHODS Eight orthopaedic residents, 1 sports medicine fellow, and 3 sports medicine faculty members recorded the diagnostic portion of 3 shoulder and 3 knee procedures in the operating room. Two blinded raters used the ASSET to assess each recorded procedure video. Criterion for a passing score on a procedure was attaining a 3 or greater in all 8 domains assessed. RESULTS In total 70 videos (36 shoulder, 34 knee) were evaluated by each rater. The attending/fellow group was assigned significantly higher mean ASSET scores compared with resident groups for both procedures (P = .01). The attending/fellow group also had the highest passing percentage (95.8%). Raters were in agreement for total ASSET scores assigned to both diagnostic arthroscopy of the shoulder (intraclass correlation coefficient [ICC] = 0.84) and knee (ICC = 0.81). Agreement on individual ASSET domains was moderate (ICC = 0.61 to 0.80) for all domains except safety and difficulty of procedure. Raters concurred on the pass-fail evaluation in 62 of 70 (88.6%) of procedures evaluated. CONCLUSIONS Using the ASSET to assess surgical skills in the operating room is feasible, reliable, and valid. CLINICAL RELEVANCE When combined with previously published results using the ASSET, the ASSET may provide a validated and reliable method for evaluating arthroscopic surgical skills in the surgical simulation lab and operating room.
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Affiliation(s)
- Ryan J Koehler
- Department of Orthopaedic Surgery, Vanderbilt Orthopaedic Institute, Vanderbilt University, Nashville, Tennessee, U.S.A..
| | - John P Goldblatt
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Michael D Maloney
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Ilya Voloshin
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Gregg T Nicandri
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
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Validation of the ArthroS virtual reality simulator for arthroscopic skills. Knee Surg Sports Traumatol Arthrosc 2015; 23:3436-42. [PMID: 25026928 DOI: 10.1007/s00167-014-3101-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 05/27/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Virtual reality simulator training has become important for acquiring arthroscopic skills. A new simulator for knee arthroscopy ArthroS™ has been developed. The purpose of this study was to demonstrate face and construct validity, executed according to a protocol used previously to validate arthroscopic simulators. METHODS Twenty-seven participants were divided into three groups having different levels of arthroscopic experience. Participants answered questions regarding general information and the outer appearance of the simulator for face validity. Construct validity was assessed with one standardized navigation task. Face validity, educational value and user friendliness were further determined by giving participants three exercises and by asking them to fill out the questionnaire. RESULTS Construct validity was demonstrated between experts and beginners. Median task times were not significantly different for all repetitions between novices and intermediates, and between intermediates and experts. Median face validity was 8.3 for the outer appearance, 6.5 for the intra-articular joint and 4.7 for surgical instruments. Educational value and user friendliness were perceived as nonsatisfactory, especially because of the lack of tactile feedback. CONCLUSION The ArthroS™ demonstrated construct validity between novices and experts, but did not demonstrate full face validity. Future improvements should be mainly focused on the development of tactile feedback. It is necessary that a newly presented simulator is validated to prove it actually contributes to proficiency of skills.
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Gandhi MJ, Anderton MJ, Funk L. Arthroscopic Skills Acquisition Tools: An Online Simulator for Arthroscopy Training. Arthroscopy 2015; 31:1671-9. [PMID: 26070927 DOI: 10.1016/j.arthro.2015.03.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 02/20/2015] [Accepted: 03/13/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate correlations between objective performances measured by a new online arthroscopic skills acquisition tool (ASAT, in which "shape match" with inverted controls requires lifting shapes and releasing them into their corresponding silhouettes) and a validated virtual reality (VR) shoulder arthroscopy simulator (Insight Arthro VR; GMV, Madrid, Spain). METHODS Forty-nine medical students familiarized themselves with 5 ASATs. They were then assessed using a sixth ASAT (shape match with inverted controls) and 4 VR tasks (operating room, visualize, locate and palpate, and pendulum) on the VR simulator. Correlations were assessed between 11 ASAT measures and 15 VR measures using Pearson correlation coefficients. RESULTS Time taken and delta distance (actual distance minus minimum distance traveled) were the most frequent and correlated ASAT measures. Time taken correlated with the VR locate-and-palpate time (r = 0.596, P < .001), visualize time (r = 0.381, P = .007), and pendulum time (r = 0.646, P < .001), whereas delta distance correlated with the locate-and-palpate camera distance (r = 0.667, P < .001), instrument distance (r = 0.664, P < .001), visualize distance (r = 0.4, P = .004), pendulum camera distance (r = 0.538, P < .001), and instrument distance (r = 0.539, P < .001). CONCLUSIONS There were significant correlations between performance measures on the ASAT and a validated arthroscopic VR simulator. CLINICAL RELEVANCE Arthroscopic simulators are available but are limited by their high cost and availability. ASATs may overcome these limitations by using widely available Internet-based software and basic input devices.
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Affiliation(s)
- Maulik J Gandhi
- Orthopaedic Institute, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, England.
| | | | - Lennard Funk
- Upper Limb Unit, Wrightington Hospital, Wigan, England
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Gilmer BB, Guerrero DM, Coleman NW, Chamberlain AM, Warme WJ. Orthopaedic Residents Improve Confidence and Knot-Tying Speed With a Skills Course. Arthroscopy 2015; 31:1343-8.e2. [PMID: 25863727 DOI: 10.1016/j.arthro.2015.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 01/27/2015] [Accepted: 02/06/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the effect of a knot-tying module, within an arthroscopic training course, on resident speed, resident confidence, and biomechanical quality of arthroscopically tied knots. METHODS Sixty-four participants (8 postgraduate year [PGY]-3 and 8 PGY-4 orthopaedic residents annually for 4 years) were enrolled in a 5-day training course, which included a daily knot-tying module. Self-assessed confidence was obtained by pre-course (day 1) and post-course (day 5) questionnaire. Each participant tied 5 sequential knots using an arthroscopic knot-tying station. Time per knot was recorded in seconds. Knots were later preloaded, cycled, and tested for peak load to failure and displacement change. Mean peak load to failure, displacement change, speed, and confidence were compared before and after training. RESULTS The mean time to complete 5 knots was significantly faster after training (12.8 minutes before the course [day 1] v 9.39 minutes after the course [day 5]) (P < .0001). Confidence improved from pre-course (mean, 3.3) to post-course (mean, 7.8) questionnaires (P < .0001). No statistically significant difference was found between peak force for pre-course (mean, 136 N) and post-course (mean, 138 N) knots (P = .076). No statistically significant difference was detected in mean displacement change (mean, 3.51 mm before the course v 3.57 mm after the course) (P = .61). Comparison of PGY-3 and PGY-4 residents was significant only for a higher pre-course confidence in PGY-4 residents (P = .02). CONCLUSIONS Participation in an arthroscopic knot-tying module improves resident speed and confidence in tying arthroscopic knots. Our data did not show a significant change in peak load to failure or loop security with training. These findings suggest that participation in a knot-tying module improves efficiency regarding arthroscopic knot tying by residents. CLINICAL RELEVANCE Residents who practice arthroscopic knot tying 5 days per year as part of an arthroscopic training course may be more efficient in the operating room.
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Affiliation(s)
- Brian B Gilmer
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, U.S.A..
| | - Dolores M Guerrero
- Department of Biomedical Research, Mammoth Orthopedic Institute, Mammoth Lakes, California, U.S.A
| | - Nathan W Coleman
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Aaron M Chamberlain
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Winston J Warme
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, U.S.A
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Fucentese SF, Rahm S, Wieser K, Spillmann J, Harders M, Koch PP. Evaluation of a virtual-reality-based simulator using passive haptic feedback for knee arthroscopy. Knee Surg Sports Traumatol Arthrosc 2015; 23:1077-85. [PMID: 24519617 DOI: 10.1007/s00167-014-2888-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 01/30/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The aim of this work is to determine face validity and construct validity of a new virtual-reality-based simulator for diagnostic and therapeutic knee arthroscopy. METHODS The study tests a novel arthroscopic simulator based on passive haptics. Sixty-eight participants were grouped into novices, intermediates, and experts. All participants completed two exercises. In order to establish face validity, all participants filled out a questionnaire concerning different aspects of simulator realism, training capacity, and different statements using a seven-point Likert scale (range 1-7). Construct validity was tested by comparing various simulator metric values between novices and experts. RESULTS Face validity could be established: overall realism was rated with a mean value of 5.5 points. Global training capacity scored a mean value of 5.9. Participants considered the simulator as useful for procedural training of diagnostic and therapeutic arthroscopy. In the foreign body removal exercise, experts were overall significantly faster in the whole procedure (6 min 24 s vs. 8 min 24 s, p < 0.001), took less time to complete the diagnostic tour (2 min 49 s vs. 3 min 32 s, p = 0.027), and had a shorter camera path length (186 vs. 246 cm, p = 0.006). CONCLUSION The simulator achieved high scores in terms of realism. It was regarded as a useful training tool, which is also capable of differentiating between varying levels of arthroscopic experience. Nevertheless, further improvements of the simulator especially in the field of therapeutic arthroscopy are desirable. In general, the findings support that virtual-reality-based simulation using passive haptics has the potential to complement conventional training of knee arthroscopy skills. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Sandro F Fucentese
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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Samora JB, Bashook P, Jones A, Milbrandt T, Mazzocca AD, Quinn RH. Orthopaedic Graduate Medical Education: A Changing Paradigm. JBJS Rev 2014; 2:01874474-201411000-00001. [DOI: 10.2106/jbjs.rvw.n.00005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
Surgical training has followed the master-apprentice model for centuries but is currently undergoing a paradigm shift. The traditional model is inefficient with no guarantee of case mix, quality, or quantity. There is a growing focus on competency-based medical education in response to restrictions on doctors' working hours and the traditional mantra of "see one, do one, teach one" is being increasingly questioned. The medical profession is subject to more scrutiny than ever before and is facing mounting financial, clinical, and political pressures. Simulation may be a means of addressing these challenges. It provides a way for trainees to practice technical tasks in a protected environment without putting patients at risk and helps to shorten the learning curve. The evidence for simulation-based training in orthopedic surgery using synthetic models, cadavers, and virtual reality simulators is constantly developing, though further work is needed to ensure the transfer of skills to the operating theatre.
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Obdeijn MC, van Baalen SJ, Horeman T, Liverneaux P, Tuijthof GJM. The use of navigation forces for assessment of wrist arthroscopy skills level. J Wrist Surg 2014; 3:132-138. [PMID: 25077049 PMCID: PMC4078157 DOI: 10.1055/s-0034-1373838] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Purpose To provide an efficient learning process, feedback on performance is crucial. In skills laboratories, it is possible to measure the skills and progression of skills of the trainees objectively. This requires metrics that represent the learning curve of the trainee, which were investigated for wrist arthroscopy. The research questions were: What are the forces used by novices during wrist arthroscopy?What aspects of these navigation forces are discriminative for the wrist arthroscopy skills level?Methods A cadaver wrist was mounted in a custom-made distraction device mounted in front of a force platform (ForceTrap). Eleven novices were invited to perform two tasks on the wrist: Insertion of the scope through the 3-4 portal and the hook through the 6R portal, and visualization of the hook in the center of the imageNavigation through the wrist from radial to ulnar with probing and visualization of five predefined landmarksThe second task was repeated 10 times. The absolute force (F abs) and the direction of force were measured. The angle α is defined in the vertical plane, and the angle β in the horizontal plane. Results The median F abs used by novices remained below the force threshold as defined from the expert data (7.3 N). However, the direction of the applied forces by novices in both planes was not consistent with expert data and showed a wider range. Also, there was no improvement after more trials. Conclusion Our study suggests by the absence of a learning curve for the novices and a significant difference between novices and experts that novices can benefit from feedback on the magnitude and direction of forces to improve their performance.
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Affiliation(s)
- Miryam C. Obdeijn
- Department of Plastic, Reconstructive and Hand Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sophie J. van Baalen
- Department of Technical Medicine, University of Twente, MIRA Institute for Biomedical Technology and Technical Medicine Enschede, The Netherlands
| | - Tim Horeman
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Philippe Liverneaux
- Department of Hand Surgery, Strasbourg University Hospitals. Illkirch, France
| | - Gabrielle J. M. Tuijthof
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Hodgins JL, Veillette C, Biau D, Sonnadara R. The knee arthroscopy learning curve: quantitative assessment of surgical skills. Arthroscopy 2014; 30:613-21. [PMID: 24725315 DOI: 10.1016/j.arthro.2014.02.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 02/09/2014] [Accepted: 02/13/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess orthopaedic trainees performing diagnostic knee arthroscopies and evaluate procedural competence using a novel statistical method, the Cumulative Summation Test for Learning Curve (LC-CUSUM). METHODS Twenty orthopaedic trainees in postgraduate year (PGY) 1 through 5 performed diagnostic knee arthroscopy and were evaluated intraoperatively with a validated 10-point knee task-specific checklist (TSCL) and 50-point global rating scale (GRS). A score of 40 points or greater (of 50 points) for the GRS and 8 points or greater (of 10 points) for the knee TSCL was considered to indicate a successful procedure. For the LC-CUSUM analysis, adequate performance was defined as a 10% failure rate, inadequate performance was defined as a 30% failure rate, and an acceptable deviation from adequate performance was defined as 10%. A limit h equal to 1.6 was selected to give a true-discovery rate of 90% and a false-discovery rate of 10% over 50 procedures. RESULTS A total of 340 consecutive procedures were performed by 20 trainees during the 12-month study period. The cumulative number of arthroscopic procedures performed by trainees before study start increased with increasing PGY. The median number of arthroscopic procedures performed per trainee was 16.5 (interquartile range, 14 to 21.75). Competency in knee arthroscopy for the TSCL was achieved by 8 trainees (40%), after a median of 16 procedures (interquartile range, 13 to 20), and for the GRS by only a single trainee (5%), after 14 procedures. Threshold-adjusted curves stratified by PGY level enabled multiple trainees to achieve competency for both the TSCL and GRS. CONCLUSIONS The LC-CUSUM can be successfully applied to knee arthroscopy to provide an individualized assessment of performance and quantitatively demonstrate competency for basic arthroscopic tasks. CLINICAL RELEVANCE The LC-CUSUM is an effective method to evaluate procedure competence in arthroscopic training and can provide objective feedback and benchmarks in the learning phase.
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Affiliation(s)
- Justin L Hodgins
- Department of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada.
| | | | - David Biau
- Département de Chirurgie Orthopédique, Hôpital Cochin, Paris, France
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Cannon WD, Nicandri GT, Reinig K, Mevis H, Wittstein J. Evaluation of skill level between trainees and community orthopaedic surgeons using a virtual reality arthroscopic knee simulator. J Bone Joint Surg Am 2014; 96:e57. [PMID: 24695934 DOI: 10.2106/jbjs.m.00779] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Several virtual reality simulators have been developed to assist orthopaedic surgeons in acquiring the skills necessary to perform arthroscopic surgery. The purpose of this study was to assess the construct validity of the ArthroSim virtual reality arthroscopy simulator by evaluating whether skills acquired through increased experience in the operating room lead to improved performance on the simulator. METHODS Using the simulator, six postgraduate year-1 orthopaedic residents were compared with six postgraduate year-5 residents and with six community-based orthopaedic surgeons when performing diagnostic arthroscopy. The time to perform the procedure was recorded. To ensure that subjects did not sacrifice the quality of the procedure to complete the task in a shorter time, the simulator was programmed to provide a completeness score that indicated whether the surgeon accurately performed all of the steps of diagnostic arthroscopy in the correct sequence. RESULTS The mean time to perform the procedure by each group was 610 seconds for community-based orthopaedic surgeons, 745 seconds for postgraduate year-5 residents, and 1028 seconds for postgraduate year-1 residents. Both the postgraduate year-5 residents and the community-based orthopaedic surgeons performed the procedure in significantly less time (p = 0.006) than the postgraduate year-1 residents. There was a trend toward significance (p = 0.055) in time to complete the procedure when the postgraduate year-5 residents were compared with the community-based orthopaedic surgeons. The mean level of completeness as assigned by the simulator for each group was 85% for the community-based orthopaedic surgeons, 79% for the postgraduate year-5 residents, and 71% for the postgraduate year-1 residents. As expected, these differences were not significant, indicating that the three groups had achieved an acceptable level of consistency in their performance of the procedure. CONCLUSIONS Higher levels of surgeon experience resulted in improved efficiency when performing diagnostic knee arthroscopy on the simulator. Further validation studies utilizing the simulator are currently under way and the additional simulated tasks of arthroscopic meniscectomy, meniscal repair, microfracture, and loose body removal are being developed.
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Affiliation(s)
- W Dilworth Cannon
- Department of Orthopaedic Surgery, University of California San Francisco, 1500 Owens Street, San Francisco, CA 94158. E-mail address:
| | - Gregg T Nicandri
- Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14642
| | - Karl Reinig
- Department of Cell and Developmental Biology, Colorado School of Medicine, 12801 East 17th Avenue, MS 8108, Aurora, CO 80045
| | - Howard Mevis
- CME Course Operations and Practice Management, American Academy of Orthopaedic Surgeons, 6300 North River Road, Rosemont, IL 60018
| | - Jocelyn Wittstein
- Bassett Shoulder and Sports Medicine Research Institute, Bassett Healthcare Network, 1 Atwell Road, Cooperstown, NY 13326
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Frank RM, Erickson B, Frank JM, Bush-Joseph CA, Bach BR, Cole BJ, Romeo AA, Provencher MT, Verma NN. Utility of modern arthroscopic simulator training models. Arthroscopy 2014; 30:121-33. [PMID: 24290789 DOI: 10.1016/j.arthro.2013.09.084] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 09/19/2013] [Accepted: 09/26/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to review the published literature on modern arthroscopic simulator training models to (1) determine the ability to transfer skills learned on the model to the operating room and (2) determine the learning curve required to translate such skills. METHODS A systematic review of all studies using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. Two independent reviewers then analyzed studies deemed appropriate for inclusion. Study data collected included participant demographic characteristics, simulator model, type and number of tasks, method of analysis, and results of training, when available. Given the different methods used in each study, descriptive analysis was performed. RESULTS Nineteen studies met the inclusion criteria (9 shoulder, 9 knee, and 1 hip). A total of 465 participants with a mean age of 30 years were evaluated. Twelve studies (63%) compared task performance among participants of different experience levels, with 100% reporting a positive correlation between experience level and simulator performance. Eight studies (42%) evaluated task performance before and after simulator training, with 6 studies showing improvement after training; 1 study noted no difference in performance after 1 hour of training. One study commented on improved operating room performance after simulator training. No studies commented on the number of training sessions needed to translate skills learned on the models to the operating room. CONCLUSIONS This review suggests that practice on arthroscopic simulators improves performance on arthroscopic simulators. We cannot, however, definitively comment on whether simulator training correlates to an improved skill set in the operating room. Further work is needed to determine the type and number of training sessions needed to translate arthroscopic skills learned on the models to the operating room. LEVEL OF EVIDENCE Level IV, systematic review of studies with Level I through IV evidence.
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Affiliation(s)
- Rachel M Frank
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Rush Medical College of Rush University, Chicago, Illinois, U.S.A..
| | - Brandon Erickson
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Rush Medical College of Rush University, Chicago, Illinois, U.S.A
| | - Jonathan M Frank
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Rush Medical College of Rush University, Chicago, Illinois, U.S.A
| | - Charles A Bush-Joseph
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Rush Medical College of Rush University, Chicago, Illinois, U.S.A
| | - Bernard R Bach
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Rush Medical College of Rush University, Chicago, Illinois, U.S.A
| | - Brian J Cole
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Rush Medical College of Rush University, Chicago, Illinois, U.S.A
| | - Anthony A Romeo
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Rush Medical College of Rush University, Chicago, Illinois, U.S.A
| | - Matthew T Provencher
- Sports Medicine Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Nikhil N Verma
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Rush Medical College of Rush University, Chicago, Illinois, U.S.A
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Koehler RJ, Nicandri GT. Using the arthroscopic surgery skill evaluation tool as a pass-fail examination. J Bone Joint Surg Am 2013; 95:e1871-6. [PMID: 24306710 PMCID: PMC4574927 DOI: 10.2106/jbjs.m.00340] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Examination of arthroscopic skill requires evaluation tools that are valid and reliable with clear criteria for passing. The Arthroscopic Surgery Skill Evaluation Tool was developed as a video-based assessment of technical skill with criteria for passing established by a panel of experts. The purpose of this study was to test the validity and reliability of the Arthroscopic Surgery Skill Evaluation Tool as a pass-fail examination of arthroscopic skill. METHODS Twenty-eight residents and two sports medicine faculty members were recorded performing diagnostic knee arthroscopy on a left and right cadaveric specimen in our arthroscopic skills laboratory. Procedure videos were evaluated with use of the Arthroscopic Surgery Skill Evaluation Tool by two raters blind to subject identity. Subjects were considered to pass the Arthroscopic Surgery Skill Evaluation Tool when they attained scores of ≥ 3 on all eight assessment domains. RESULTS The raters agreed on a pass-fail rating for fifty-five of sixty videos rated with an interclass correlation coefficient value of 0.83. Ten of thirty participants were assigned passing scores by both raters for both diagnostic arthroscopies performed in the laboratory. Receiver operating characteristic analysis demonstrated that logging more than eighty arthroscopic cases or performing more than thirty-five arthroscopic knee cases was predictive of attaining a passing Arthroscopic Surgery Skill Evaluation Tool score on both procedures performed in the laboratory. CONCLUSIONS The Arthroscopic Surgery Skill Evaluation Tool is valid and reliable as a pass-fail examination of diagnostic arthroscopy of the knee in the simulation laboratory. CLINICAL RELEVANCE This study demonstrates that the Arthroscopic Surgery Skill Evaluation Tool may be a useful tool for pass-fail examination of diagnostic arthroscopy of the knee in the simulation laboratory. Further study is necessary to determine whether the Arthroscopic Surgery Skill Evaluation Tool can be used for the assessment of multiple arthroscopic procedures and whether it can be used to evaluate arthroscopic procedures performed in the operating room.
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Affiliation(s)
- Ryan J. Koehler
- Department of Orthopaedic Surgery, University of
Rochester, 601 Elmwood Avenue, Box 665, Rochester, NY 14642. E-mail address for G.T.
Nicandri:
| | - Gregg T. Nicandri
- Department of Orthopaedic Surgery, University of
Rochester, 601 Elmwood Avenue, Box 665, Rochester, NY 14642. E-mail address for G.T.
Nicandri:
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Kang HJ, Koh IH, Jang JW, Choi YR. Endoscopic versus open release in patients with de Quervain's tenosynovitis: a randomised trial. Bone Joint J 2013; 95-B:947-51. [PMID: 23814248 DOI: 10.1302/0301-620x.95b7.31486] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The purpose of this study was to compare the outcome and complications of endoscopic versus open release for the treatment of de Quervain's tenosynovitis. Patients with this condition were randomised to undergo either endoscopic (n = 27) or open release (n = 25). Visual Analogue Scale (VAS) pain and Disabilities of Arm, Shoulder, and Hand (DASH) scores were measured at 12 and 24 weeks after surgery. Scar satisfaction was measured using a VAS scale. The mean pain and DASH scores improved significantly at 12 weeks and 24 weeks (p < 0.001) in both groups. The scores were marginally lower in the endoscopic group compared to the open group at 12 weeks (p = 0.012 and p = 0.002, respectively); however, only the DASH score showed a clinically important difference. There were no differences between the groups at 24 weeks. The mean VAS scar satisfaction score was higher in the endoscopic group at 24 weeks (p < 0.001). Transient superficial radial nerve injury occurred in three patients in the endoscopic group compared with nine in the open release group (p = 0.033). We conclude that endoscopic release for de Quervain's tenosynovitis seems to provide earlier improvement after surgery, with fewer superficial radial nerve complications and greater scar satisfaction, when compared with open release.
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Affiliation(s)
- H J Kang
- Yonsei University College of Medicine, Department of Orthopaedic Surgery, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, South Korea
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Hodgins JL, Veillette C. Arthroscopic proficiency: methods in evaluating competency. BMC MEDICAL EDUCATION 2013; 13:61. [PMID: 23631421 PMCID: PMC3643847 DOI: 10.1186/1472-6920-13-61] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 04/22/2013] [Indexed: 05/25/2023]
Abstract
BACKGROUND The current paradigm of arthroscopic training lacks objective evaluation of technical ability and its adequacy is concerning given the accelerating complexity of the field. To combat insufficiencies, emphasis is shifting towards skill acquisition outside the operating room and sophisticated assessment tools. We reviewed (1) the validity of cadaver and surgical simulation in arthroscopic training, (2) the role of psychomotor analysis and arthroscopic technical ability, (3) what validated assessment tools are available to evaluate technical competency, and (4) the quantification of arthroscopic proficiency. METHODS The Medline and Embase databases were searched for published articles in the English literature pertaining to arthroscopic competence, arthroscopic assessment and evaluation and objective measures of arthroscopic technical skill. Abstracts were independently evaluated and exclusion criteria included articles outside the scope of knee and shoulder arthroscopy as well as original articles about specific therapies, outcomes and diagnoses leaving 52 articles cited in this review. RESULTS Simulated arthroscopic environments exhibit high levels of internal validity and consistency for simple arthroscopic tasks, however the ability to transfer complex skills to the operating room has not yet been established. Instrument and force trajectory data can discriminate between technical ability for basic arthroscopic parameters and may serve as useful adjuncts to more comprehensive techniques. There is a need for arthroscopic assessment tools for standardized evaluation and objective feedback of technical skills, yet few comprehensive instruments exist, especially for the shoulder. Opinion on the required arthroscopic experience to obtain proficiency remains guarded and few governing bodies specify absolute quantities. CONCLUSIONS Further validation is required to demonstrate the transfer of complex arthroscopic skills from simulated environments to the operating room and provide objective parameters to base evaluation. There is a deficiency of validated assessment tools for technical competencies and little consensus of what constitutes a sufficient case volume within the arthroscopy community.
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Affiliation(s)
- Justin L Hodgins
- Division of Orthopaedics, Toronto Western Hospital, Toronto, Canada
| | - Christian Veillette
- Division of Orthopaedics, Toronto Western Hospital, Toronto, Canada
- University of Toronto Sports Medicine Program, Women’s College Hospital, Toronto, Canada
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Cook JA, Ramsay CR, Carr AJ, Rees JL. A questionnaire elicitation of surgeons' belief about learning within a surgical trial. PLoS One 2012; 7:e49178. [PMID: 23145113 PMCID: PMC3493499 DOI: 10.1371/journal.pone.0049178] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 10/08/2012] [Indexed: 11/18/2022] Open
Abstract
Introduction Surgeons gain expertise as they repeatedly conduct a procedure. Such learning is widely acknowledged to pose a challenge to evaluating new surgical procedures. Most surgical trials report little if any information on learning. We elicited surgeons’ belief regarding learning within the context of a randomised trial which assessed two surgical procedures. Materials and Methods Surgeons participating in the UKUFF trial were sent a postal questionnaire requesting details on current practice, prior experience and their belief regarding acquiring proficiency and the learning curve of operation time for two surgical procedures (open and arthroscopic rotator cuff repair). Results In total 52 (58%) participating surgeons returned a completed questionnaire. The median (IQR) number of procedures required to acquire proficiency were 17 (10,23) and 35 (23,50) for the open and arthroscopic repairs respectively. The distribution of surgeons’ belief regarding the initial point had median (IQR) of 109 (69,128) and 145 (97,171) minutes for open and arthroscopic repair respectively. Corresponding values for the plateau point were 60 (46, 82) and 79 (58, 110). Conclusions We have shown that information on the current practice, prior experience and beliefs on the learning process of a surgical procedure can be elicited using a short questionnaire. The approach could aid the interpretation of trial results in terms of generalisability and be used a priori in the design of a trial.
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Affiliation(s)
- Jonathan A Cook
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom.
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Elliott MJ, Caprise PA, Henning AE, Kurtz CA, Sekiya JK. Diagnostic knee arthroscopy: a pilot study to evaluate surgical skills. Arthroscopy 2012; 28:218-24. [PMID: 22035780 DOI: 10.1016/j.arthro.2011.07.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 07/21/2011] [Accepted: 07/27/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE To develop a scoring system to evaluate individual proficiency at diagnostic knee arthroscopy. METHODS This was a prospective blinded study. Subjects included residents in postgraduate year (PGY) 1 through PGY 5 (n = 20) and staff surgeons (n = 10). All subjects performed a diagnostic arthroscopy on a cadaveric knee. Subjects were evaluated on both completeness and time required to complete the arthroscopy. The examiner viewed the arthroscopy from a remote location and was blinded to the level of training of the subjects. During the arthroscopy, 15 areas required assessment to achieve a score of 75 points. An additional 25 points were awarded depending on the time it took to complete the arthroscopy. A maximum of 100 points were available (Total score = Arthroscopy score + Time score). RESULTS Thirty subjects were divided into 3 groups: group 1 (PGY 1 or 2) (n = 12), group 2 (PGY 3, 4, or 5) (n = 8), and group 3 (staff) (n = 10). In group 1 the mean total score was 28.25 points, the mean time to complete arthroscopy was 11.9 minutes, and the mean number of structures not examined was 8.67. In group 2 the mean total score was 76 points, the mean time to complete arthroscopy was 8.2 minutes, and the mean number of structures not examined was 1.75. In group 3 the mean total score was 100 points, the mean time to complete arthroscopy was 4.6 minutes, and the mean number of structures not examined was 0. Statistically significant differences by use of an analysis of variance test were noted for the total score, total time, and number of missed structures (P < .001). CONCLUSIONS Using our skills assessment tool, we were able to evaluate subjects and determine their relative technical skill level in performing a diagnostic arthroscopy. This tool was able to distinguish among the novice, experienced, and expert levels in performing diagnostic arthroscopy. LEVEL OF EVIDENCE Level III, development of diagnostic criteria on the basis of consecutive subjects.
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Affiliation(s)
- Michael J Elliott
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA.
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Tuijthof GJM, Visser P, Sierevelt IN, Van Dijk CN, Kerkhoffs GMMJ. Does perception of usefulness of arthroscopic simulators differ with levels of experience? Clin Orthop Relat Res 2011; 469:1701-8. [PMID: 21290203 PMCID: PMC3094627 DOI: 10.1007/s11999-011-1797-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Accepted: 12/13/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Some commercial simulators are available for training basic arthroscopic skills. However, it is unclear if these simulators allow training for their intended purposes and whether the perception of usefulness relates to level of experience. QUESTIONS/PURPOSES We addressed the following questions: (1) Do commercial simulators have construct (times to perform tasks) and face validity (realism), and (2) is the perception of usefulness (educational value and user-friendliness) related to level of experience? METHODS We evaluated two commercially available virtual reality simulators (Simulators A and B) and recruited 11 and nine novices (no arthroscopies), four and four intermediates (one to 59 arthroscopies), and seven and nine experts (> 60 arthroscopies) to test the devices. To assess construct validity, we recorded the median time per experience group for each of five repetitions of one identical navigation task. To assess face validity, we used a questionnaire to judge up to three simulator characteristic tasks; the questionnaire asked about the realism, perception of educational value, and perception of user-friendliness. RESULTS We observed partial construct validity for Simulators A and B and considered face validity satisfactory for both simulators for simulating the outer appearance and human joint, but barely satisfactory for the instruments. Simulators A and B had equal educational value according to the participants. User-friendliness was judged better for Simulator B although both were graded satisfactory. The perception of usefulness did not differ with level of experience. CONCLUSIONS Our observations suggest training on either simulator is reasonable preparation for real-life arthroscopy, although there is room for improvement for both simulators.
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Affiliation(s)
- Gabriëlle J M Tuijthof
- Department of Orthopedic Surgery, Orthopedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Arthroscopic treatment for limitation of motion of the elbow: the learning curve. Knee Surg Sports Traumatol Arthrosc 2011; 19:1013-8. [PMID: 21127837 DOI: 10.1007/s00167-010-1334-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Accepted: 10/25/2010] [Indexed: 12/24/2022]
Abstract
PURPOSE The aim of this study was to demonstrate our learning curve in arthroscopic treatment for limitation of motion of the elbow. METHODS To verify the surrogates for learning curve, operative time in 120 consecutive elbows were plotted by case number and the learning curve was illustrated by the best-fit curve. The study population was divided into eight consecutive blocks (15 patients per block) by observing a notable change in the learning from the curve. Mean operative time and mean improvement in motion and clinical score in each block were compared. RESULTS Mean operative time decreased significantly from the first block to the second block (133-98). No further significant change was noted thereafter. Contrarily, no significant increase in motion improvement or clinical score improvement was identified but a significant decrease was found between the fourth and fifth block (47-36 and 30-24, respectively). Operative time was negatively correlated with preoperative range of motion (P=0.003). Clinical score improvement was also negatively correlated with preoperative range of motion (P<0.001). Motion improvement was more strongly correlated with preoperative range of motion (P<0.001). CONCLUSIONS This study demonstrated a learning curve in which a significant decrease in operative time was shown after an initial 15 patients. Motion and clinical score improvement were not satisfactory surrogate for learning curve and found to be closely related to preoperative range of motion. Qualification of the learning curve for arthroscopic treatment for limitation of motion of the elbow provides a guide for surgeons assuming the expected time line to become proficient in this technique.
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Tuijthof GJM, Horeman T, Schafroth MU, Blankevoort L, Kerkhoffs GMMJ. Probing forces of menisci: what levels are safe for arthroscopic surgery. Knee Surg Sports Traumatol Arthrosc 2011; 19:248-54. [PMID: 20814661 PMCID: PMC3023859 DOI: 10.1007/s00167-010-1251-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Accepted: 08/09/2010] [Indexed: 01/22/2023]
Abstract
PURPOSE to facilitate effective learning, feedback on performance during arthroscopic training is essential. Less attention has been paid to feedback on monitoring safe handling of delicate tissues such as meniscus. The goal is to measure in vitro probing forces of menisci and compare them with a theoretical maximum probing force (TMPF). METHOD menisci samples of ten cadavers were mounted on force platforms to measure probing forces up to 20 N in three directions. Nineteen subjects participated: six novices (experience <60 arthroscopies), ten intermediates (>60 arthroscopies), and three faculty (>250 a year). All had to perform three tasks on each meniscus sample with an arthroscopic probe: push three times on the superior meniscal surface, perform one continuous run on the superior meniscal surface, and push three times on the inferior meniscal surface. The absolute maximum probing force (AMPF) was determined for each condition. A multivariable linear regression analysis was performed to assess the influence of experience on the force magnitude (P < 0.05). AMPFs were compared to the TMPF (estimated to be 8.5 N). RESULTS the AMPF of the push task was on average 2.8 N (standard deviation (SD) of 0.8 N), of the continuous run task 2.5 N (SD 0.9 N), and of the pull task 3.9 N (SD 2.0 N). Significant difference was present between experts and novices (P < 0.05). The AMPFs are in the same order of magnitude as the TMPF. CONCLUSION the results indicate the necessity of using a safety level for tissue manipulation when training arthroscopy and a value for is magnitude.
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Affiliation(s)
- Gabriëlle J. M. Tuijthof
- Department of Orthopedic Surgery, Orthopedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Tim Horeman
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Matthias U. Schafroth
- Department of Orthopedic Surgery, Orthopedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Leendert Blankevoort
- Department of Orthopedic Surgery, Orthopedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Gino M. M. J. Kerkhoffs
- Department of Orthopedic Surgery, Orthopedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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