Editorial Commentary: I Used to Be an Under-represented Minority.

Women and under-represented minorities continue to reflect the lack of diversity in the field of orthopaedic surgery, the cause of which can best be described as multifactorial. That this predicament needs to be remedied is without controversy. How this can be achieved is the bigger question. A top-down approach has been relatively ineffective, and a bolder, more foundational bottom-up approach, in which a "pipeline of talent" is nurtured, may be a solution.

Arthroscopic Rotator Cuff Repair Metrics: Establishing Face, Content, and Construct Validity in a Cadaveric Model.

PURPOSE: To create and determine face validity and content validity of arthroscopic rotator cuff repair (ARCR) performance metrics, to confirm construct validity of the metrics coupled with a cadaveric shoulder, and to establish a performance benchmark for the procedure on a cadaveric shoulder. METHODS: Five experienced arthroscopic shoulder surgeons created step, error, and sentinel error metrics for an ARCR. Fourteen shoulder arthroscopy faculty members from the Arthroscopy Association of North America formed the modified Delphi panel to assess face and content validity. Eight Arthroscopy Association of North America shoulder arthroscopy faculty members (experienced group) were compared with 9 postgraduate year 4 or 5 orthopaedic residents (novice group) in their ability to perform an ARCR. Instructions were given to perform a diagnostic arthroscopy and a 2-anchor, 4-simple suture repair of a 2-cm supraspinatus tear. The procedure was videotaped in its entirety and independently scored in blinded fashion by trained, paired reviewers. RESULTS: Delphi panel consensus for 42 steps and 66 potential errors was obtained. Overall performance assessment showed a mean inter-rater reliability of 0.93. Novice surgeons completed 17% fewer steps (32.1 vs 37.5, P = .001) and enacted 2.5 times more errors than the experienced group (6.21 vs 2.5, P = .012). Fifty percent of the experienced group members and none of the novice group members achieved the proficiency benchmark of a minimum of 37 steps completed with 3 or fewer errors. CONCLUSIONS: Face validity and content validity for the ARCR metrics, along with construct validity for the metrics and cadaveric shoulder, were verified. A proficiency benchmark was established based on the mean performance of an experienced group of arthroscopic shoulder surgeons. CLINICAL RELEVANCE: Validated procedural metrics combined with the use of a cadaveric shoulder can be used to accurately assess the performance of an ARCR.

Grafts and Patches in Rotator Cuff Surgery: Bioinductive Scaffolds, Augmentation, Interposition, and Superior Capsule Reconstruction.

Rotator cuff repair can be challenging because of the compromised state of the tendon tissue. These challenges range from simply degenerative tendons to complete tendon loss in patients which can impair soft-tissue healing. Various grafts and patches are currently available to help address these challenges. The ideal solution for the treatment of irreparable rotator cuff tears or those prone to retear remains controversial. Sometimes augmentation with a patch is appropriate. However, at times a completely retracted and immobile tendon remnant is found. Reconstruction of the superior capsule has demonstrated promising results in several short-term series. The indications for these procedures, the optimal surgical technique, and their limitations are evolving. This chapter discusses the current literature related to bioinductive scaffolds, graft augmentation, graft interposition, and superior capsular reconstruction.

Safety evaluation of a laxity-minimizing suture at 5 days and 6 weeks after repair of a sheep infraspinatus tendon.

BACKGROUND: The ideal rotator cuff repair achieves high initial fixation strength and secure tendon-to-bone apposition until biological healing occurs. A suture that reacts to the local stress environment by minimizing suture laxity across the repair could theoretically maintain soft-tissue apposition to bone and therefore improve healing. METHODS: By use of an in vivo ovine shoulder model, the infraspinatus tendon was transected and then repaired with either a laxity-minimizing suture or a traditional high tensile suture. The purpose of this study was to evaluate both sutures' safety at 5 days and 6 weeks after repair. RESULTS: The macroscopic and microscopic analyses of the repair sites showed similar amounts of surgical trauma. There was no evidence of cheese wiring or tissue necrosis of the repaired tendons for either suture. There was no evidence of systematic toxicity in any animal. The maximum gap between cut edges of the tendon for repairs with the predicate suture was approximately twice the gap for the laxity-minimizing suture. CONCLUSION: The laxity-minimizing suture was as safe at 5 days and 6 weeks as the predicate suture. Neither suture contributed to local tissue damage or particle generation leading to adverse systematic consequences. An additional observation was that the maximum gap between cut edges of the tendon for repairs with the predicate suture was approximately twice the gap for the laxity-minimizing suture.

Inter-rater Reliability for Metrics Scored in a Binary Fashion-Performance Assessment for an Arthroscopic Bankart Repair.

PURPOSE: To determine the inter-rater reliability (IRR) of a procedure-specific checklist scored in a binary fashion for the evaluation of surgical skill and whether it meets a minimum level of agreement (≥0.8 between 2 raters) required for high-stakes assessment. METHODS: In a prospective randomized and blinded fashion, and after detailed assessment training, 10 Arthroscopy Association of North America Master/Associate Master faculty arthroscopic surgeons (in 5 pairs) with an average of 21 years of surgical experience assessed the video-recorded 3-anchor arthroscopic Bankart repair performance of 44 postgraduate year 4 or 5 residents from 21 Accreditation Council for Graduate Medical Education orthopaedic residency training programs from across the United States. RESULTS: No paired scores of resident surgeon performance evaluated by the 5 teams of faculty assessors dropped below the 0.8 IRR level (mean = 0.93; range 0.84-0.99; standard deviation = 0.035). A comparison between the 5 assessor groups with 1 factor analysis of variance showed that there was no significant difference between the groups (P = .205). Pearson's product-moment correlation coefficient revealed a strong and statistically significant negative correlation, that is, -0.856 (P < .000), indicating that as intra-operative error rate scores increased, the IRR decreased. CONCLUSIONS: Arthroscopy Association of North America shoulder faculty raters from across the United States showed high levels of IRR in the assessment of an arthroscopic 3-anchor Bankart repair procedure. All paired assessments were above the 0.8 level and the mean IRR of all resident assessments was 0.93, indicating that they could be used for high-stakes decisions. CLINICAL RELEVANCE: With the move toward outcomes-based performance evaluation for graduate medical education, high-stakes assessments of surgical skill will require robust, reliable measurement tools that are able to withstand challenge. Surgical checklists employing metrics scored in a binary fashion meet the need and can show a high (>80%) IRR.

Editorial Commentary: Outcomes After Patch Use in Rotator Cuff Surgery: Searching for the "Holy Grail".

Rotator cuff integrity after repair is the basis for a better patient outcome, and the use of adjunctive graft material may result in a demonstrable benefit toward achieving that end.

Arthroscopic Management of Anterior, Posterior, and Multidirectional Shoulder Instabilities.

Arthroscopic shoulder stabilization offers several potential advantages compared with open surgery, including the opportunity to more accurately evaluate the glenohumeral joint at the time of diagnostic assessment; comprehensively address multiple pathologic lesions that may be identified; and avoid potential complications unique to open stabilization, such as postoperative subscapularis failure. A thorough understanding of normal shoulder anatomy and biomechanics, along with the pathoanatomy responsible for anterior, posterior, and multidirectional shoulder instability patterns, is very important in the management of patients who have shoulder instability. The treating physician also must be familiar with diagnostic imaging and physical examination maneuvers that are required to accurately diagnose shoulder instability.

The Bankart Performance Metrics Combined With a Shoulder Model Simulator Create a Precise and Accurate Training Tool for Measuring Surgeon Skill.

PURPOSE: To determine if a dry shoulder model simulator coupled with previously validated performance metrics for an arthroscopic Bankart repair (ABR) would be a valid tool with the ability to discriminate between the performance of experienced and novice surgeons, and to establish a proficiency benchmark for an ABR using a model simulator. METHODS: We compared an experienced group of arthroscopic shoulder surgeons (Arthroscopy Association of North America faculty) (n = 12) with a novice group (n = 7) (postgraduate year 4 or 5 orthopaedic residents). All surgeons were instructed to perform a diagnostic arthroscopy and a 3 suture anchor Bankart repair on a dry shoulder model. Each procedure was videotaped in its entirety and scored in blinded fashion independently by 2 trained reviewers. Scoring used previously validated metrics for an ABR and included steps, errors, and "sentinel" (more serious) errors. RESULTS: The inter-rater reliability among pairs of raters averaged 0.93. The experienced group made 63% fewer errors, committed 79% fewer sentinel errors, and performed the procedure in 42% less time than the novice group (all significant differences). The greatest difference in errors between the groups involved anchor preparation and insertion, suture delivery and management, and knot tying. CONCLUSIONS: The tool comprised by validated ABR metrics coupled with a dry shoulder model simulator is able to accurately distinguish between the performance of experienced and novice orthopaedic surgeons. A performance benchmark based on the mean performance of the experienced group includes completion of a 3 anchor Bankart repair, enacting no more than 4 total errors and 1 sentinel error. CLINICAL RELEVANCE: The combination of performance metrics and an arthroscopic shoulder model simulator can be used to improve the effectiveness of surgical skills training for an ABR. The methodology used may serve as a template for outcomes-based procedural skills training in general.

Metric Development for an Arthroscopic Bankart Procedure: Assessment of Face and Content Validity.

PURPOSE: To establish the metrics (operational definitions) necessary to characterize a reference arthroscopic Bankart procedure, and to seek consensus from experienced shoulder arthroscopists on the appropriateness of the steps, as well as errors identified. METHODS: Three experienced arthroscopic shoulder surgeons and an experimental psychologist (comprising the Metrics Group) deconstructed an arthroscopic Bankart procedure. Fourteen full-length videos were analyzed to identify the essential steps and potential errors. Sentinel (i.e., more serious) errors were defined as either (1) potentially jeopardizing the procedure outcome or (2) creating iatrogenic damage to the shoulder. The metrics were stress tested for clarity and the ability to be scored in binary fashion during a video review as either occurring or not occurring. The metrics were subjected to analysis by a panel of 27 experienced arthroscopic shoulder surgeons to obtain face and content validity using a modified Delphi Panel methodology (consensus opinion of experienced surgeons rendered by cyclical deliberations). RESULTS: Forty-five steps and 13 phases characterizing an arthroscopic Bankart procedure were identified. Seventy-seven procedural errors were specified, with 20 designated as sentinel errors. The modified Delphi Panel deliberation created the following changes: 2 metrics were deleted, 1 was added, and 5 were modified. Consensus on the resulting Bankart metrics was obtained and face and content validity verified. CONCLUSIONS: This study confirms that a core group of experienced arthroscopic surgeons is able to perform task deconstruction of an arthroscopic Bankart repair and create unambiguous step and error definitions (metrics) that accurately characterize the essential components of the procedure. Analysis and revision by a larger panel of experienced arthroscopists were able to validate the Bankart metrics. CLINICAL RELEVANCE: The ability to perform task deconstruction and validate the resulting metrics will play a key role in improving surgical skills training and assessing trainee progression toward proficiency.

The Bankart Performance Metrics Combined With a Cadaveric Shoulder Create a Precise and Accurate Assessment Tool for Measuring Surgeon Skill.

PURPOSE: To determine if previously validated performance metrics for an arthroscopic Bankart repair (ABR) coupled with a cadaveric shoulder are a valid assessment tool with the ability to discriminate between the performances of experienced and novice surgeons and to establish a proficiency benchmark for an ABR using a cadaveric shoulder. METHODS: Ten master/associate master faculty from an Arthroscopy Association of North America Resident Course (experienced group) were compared with 12 postgraduate year 4 and postgraduate year 5 orthopaedic residents (novice group). Each group was instructed to perform a diagnostic arthroscopy and a 3 suture anchor Bankart repair on a cadaveric shoulder. The procedure was videotaped in its entirety and independently scored in blinded fashion by a pair of trained reviewers. Scoring was based on defined and previously validated metrics for an ABR and included steps, errors, "sentinel" (more serious) errors, and time. RESULTS: The inter-rater reliability was 0.92. Novice surgeons made 50% more errors (5.86 v 2.95, P = .013), showed more performance variability (SD, 1.86 v 0.55), and took longer to perform the procedure (45.5 minutes v 25.9 minutes, P < .001). The greatest difference in errors related to suture delivery and management (exclusive of knot tying) (1.95 v 0.45, P = .024). CONCLUSIONS: The assessment tool composed of validated arthroscopic Bankart metrics coupled with a cadaveric shoulder accurately distinguishes the performance of experienced from novice orthopaedic surgeons. A benchmark based on the mean performance of the experienced group includes completion of a 3-anchor Bankart repair, and enacting no more than 3 total errors and 1 sentinel error. CLINICAL RELEVANCE: Validated procedural metrics combined with the use of a cadaveric shoulder can be used to assess the performance of an ABR. The methodology used may serve as a template for outcomes-based procedural skills training in general.

Objective Assessment of Knot-Tying Proficiency With the Fundamentals of Arthroscopic Surgery Training Program Workstation and Knot Tester.

PURPOSE: To assess a new method for biomechanical assessment of arthroscopic knots and to establish proficiency benchmarks using the Fundamentals of Arthroscopic Surgery Training (FAST) Program workstation and knot tester. METHODS: The first study group included 20 faculty at an Arthroscopy Association of North America resident arthroscopy course (19.9 ± 8.25 years in practice). The second group comprised 30 experienced surgeons attending an Arthroscopy Association of North America fall course (17.1 ± 19.3 years in practice). The training group included 44 postgraduate year 4 or 5 orthopaedic residents in a randomized, prospective study of proficiency-based training, with 3 subgroups: group A, standard training (n = 14); group B, workstation practice (n = 14); and group C, proficiency-based progression using the knot tester (n = 16). Each subject tied 5 arthroscopic knots backed up by 3 reversed hitches on alternating posts. Knots were tied under video control around a metal mandrel through a cannula within an opaque dome (FAST workstation). Each suture loop was stressed statically at 15 lb for 15 seconds. A calibrated sizer measured loop expansion. Knot failure was defined as 3 mm of loop expansion or greater. RESULTS: In the faculty group, 24% of knots "failed" under load. Performance was inconsistent: 12 faculty had all knots pass, whereas 2 had all knots fail. In the second group of practicing surgeons, 21% of the knots failed under load. Overall, 56 of 250 knots (22%) tied by experienced surgeons failed. For the postgraduate year 4 or 5 residents, the aggregate knot failure rate was 26% for the 220 knots tied. Group C residents had an 11% knot failure rate (half the overall faculty rate, P = .013). CONCLUSIONS: The FAST workstation and knot tester offer a simple and reproducible educational approach for enhancement of arthroscopic knot-tying skills. Our data suggest that there is significant room for improvement in the quality and consistency of these important arthroscopic skills, even for experienced arthroscopic surgeons. LEVEL OF EVIDENCE: Level II, prospective comparative study.

A Proficiency-Based Progression Training Curriculum Coupled With a Model Simulator Results in the Acquisition of a Superior Arthroscopic Bankart Skill Set.

PURPOSE: To determine the effectiveness of proficiency-based progression (PBP) training using simulation both compared with the same training without proficiency requirements and compared with a traditional resident course for learning to perform an arthroscopic Bankart repair (ABR). METHODS: In a prospective, randomized, blinded study, 44 postgraduate year 4 or 5 orthopaedic residents from 21 Accreditation Council for Graduate Medical Education-approved US orthopaedic residency programs were randomly assigned to 1 of 3 skills training protocols for learning to perform an ABR: group A, traditional (routine Arthroscopy Association of North America Resident Course) (control, n = 14); group B, simulator (modified curriculum adding a shoulder model simulator) (n = 14); or group C, PBP (PBP plus the simulator) (n = 16). At the completion of training, all subjects performed a 3 suture anchor ABR on a cadaveric shoulder, which was videotaped and scored in blinded fashion with the use of previously validated metrics. RESULTS: The PBP-trained group (group C) made 56% fewer objectively assessed errors than the traditionally trained group (group A) (P = .011) and 41% fewer than group B (P = .049) (both comparisons were statistically significant). The proficiency benchmark was achieved on the final repair by 68.7% of participants in group C compared with 36.7% in group B and 28.6% in group A. When compared with group A, group B participants were 1.4 times, group C participants were 5.5 times, and group C(PBP) participants (who met all intermediate proficiency benchmarks) were 7.5 times as likely to achieve the final proficiency benchmark. CONCLUSIONS: A PBP training curriculum and protocol coupled with the use of a shoulder model simulator and previously validated metrics produces a superior arthroscopic Bankart skill set when compared with traditional and simulator-enhanced training methods. CLINICAL RELEVANCE: Surgical training combining PBP and a simulator is efficient and effective. Patient safety could be improved if surgical trainees participated in PBP training using a simulator before treating surgical patients.

The treatment of primary anterior shoulder dislocations.

The treatment of primary anterior shoulder dislocations is complex and challenging. The goal of treatment is to achieve a stable, pain-free shoulder with a full range of motion. The currently available evidence on the outcomes of nonsurgical treatment and immediate surgical stabilization conflicts; decision making must also take into account patient-specific variables, including age, occupation, functional demands, sports participation, physical characteristics, and compliance. Although recurrence rates after anterior shoulder dislocation are difficult to pinpoint, abundant data indicate that the shoulder is more vulnerable to instability after a first traumatic dislocation. Relatively young patient age at the time of injury is the most consistent and significant prognostic factor for recurrent instability. Male gender is independently predictive of recurrent instability. Most recent studies have not identified sports participation or a type of sports activity as correlated with the risk of recurrent instability. Nonsurgical treatment typically involves closed reduction, a period of immobilization, and physical therapy for strengthening the rotator cuff and scapular stabilizers. The evidence for this treatment strategy is largely anecdotal, and the literature on its efficacy is inconclusive. Several recent studies suggested that immobilization of the shoulder in external rotation after a primary traumatic anterior shoulder dislocation may decrease the risk of recurrent instability more than conventional sling immobilization. The limited evidence available from randomized, controlled trials supports early surgical stabilization of a first traumatic anterior dislocation in high-risk young adults who engage in demanding physical activities. Although different outcome tools were used, the reported recurrence rates and functional outcomes consistently and significantly favored surgical treatment over nonsurgical treatment in this population of young, active patients. Early or prophylactic stabilization is not advisable unless the patient has a high risk of recurrence.

Biceps tendon and superior labrum injuries: decision making.

Although the anatomy of the biceps tendon and the restraining structures within the rotator interval are well defined, biceps function is not clearly understood. Biceps pathology is often associated with rotator cuff disease. Although careful clinical examinations along with diagnostic testing can accurately identify patients with biceps pathology, arthroscopy is extremely valuable in the diagnosis and treatment of biceps pathology. Surgical treatment options for biceps pathology include decompression, débridement, tenotomy, and tenodesis. Several factors must be considered in this decision. The most important factors when deciding between tenodesis or tenotomy are the activity expectations of the patient, cosmesis, patient compliance, associated pathology, and patient age. Those older than 60 years tolerate a tenotomy with the fewest adverse effects. Various arthroscopic tenodesis techniques exist, including an interference screw in bone, suture anchor fixation, and suture to adjacent tissue fixation. An open subpectoral tenodesis is another option and appropriate for a retracted biceps rupture or when the biceps disease extends distal to the bicipital groove. A superior labrum anterior and posterior (SLAP) lesion at the attachment site of the biceps tendon to the superior glenoid labrum is uncommon. Clinically significant SLAP lesions are found in about 5% of all shoulder arthroscopies and may be mistaken for normal superior labral variations. Clinical examinations and diagnostic imaging tests for SLAP lesions are often unreliable, and the ultimate diagnostic confirmation is made by arthroscopy. Surgical treatment is focused on the reattachment of the unstable biceps-labral complex.

Arthroscopic Implantation of a Bio-Inductive Collagen Scaffold for Treatment of an Articular-Sided Partial Rotator Cuff Tear.

The treatment of articular-sided partial rotator cuff tears remains a challenge to the treating orthopaedic surgeon. Treatment algorithms have included nonoperative management, debridement alone, and debridement and subacromial decompression, as well as articular-sided rotator cuff repair and completion of the tear on the bursal side followed by a traditional arthroscopic rotator cuff repair. Implantation of a bio-inductive collagen scaffold on the bursal side of the rotator cuff to potentially heal an articular-sided tear represents a novel approach to this difficult clinical entity.

Meniscal allograft replacement: a 1-year to 6-year experience.

PURPOSE: Progressive degenerative arthritis leading to premature pain and functional loss in the postmeniscectomy state is a well- recognized and debilitating condition. Meniscal allograft replacement may be a suitable, early treatment alternative for this population at risk. The purpose of this study was to examine the potential benefits of meniscal allograft replacement on relieving pain and restoring function. TYPE OF STUDY: Retrospective clinical review. METHODS: From 1993 to 1999, 29 menisci were implanted in 28 patients. Of these, 25 patients (26 menisci) were available for review. All patients had a minimum of 12 months of follow-up, with an average of 33 months. Study participants included 17 men and 8 women with primary symptoms of pain or instability at study onset. Eighteen patients had grades I through III Outerbridge chondromalacia changes and 7 demonstrated grade IV changes in the affected compartment. Data were collected using the International Knee Documentation Committee (IKDC), Lysholm II, and Tegner scoring systems as well as a visual analogue scale (VAS) for pain measurement. RESULTS: Our findings revealed that following meniscal allograft replacement, pain was significantly reduced and function was improved (P <.001). In addition, IKDC scores for activity were reported as normal or nearly normal in 17 subjects and abnormal in 8 participants. Outerbridge grade had a significant impact on final outcome; only 3 of 7 with grade IV changes achieved normal or nearly normal scores versus 14 of 18 in those with lesser Outerbridge changes. Isolated implants fared the same as those combined with an ACL reconstruction. Overall satisfaction reported by the subjects averaged 83%. Ten second-look procedures revealed 5 normal menisci, 3 with shrinkage, and 2 with recurrent tears. CONCLUSIONS: Earlier results from this population of patients indicated substantial pain relief and improved function. The durability of these early results has not met the test of time for those with exposed subchondral bone. However, statistically significant early and midterm improvements in pain, symptoms, and functional status continue to be noteworthy in the properly selected patient.

SLAP lesions in the overhead athlete.

The diagnosis and management of SLAP lesions in the overhead athlete remains a challenge for the sports medicine specialist due to variable anatomy, changes with aging, concomitant pathology, lack of dependable physical findings on examination, and lack of sensitivity and specificity with imaging studies. This article presents a comprehensive review of the epidemiology, relevant anatomy, proposed pathogenesis, diagnostic approach, and outcomes of nonoperative and operative management of SLAP lesions in the overhead athlete.