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.

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.

Sleep Deprivation Adversely Impacts Resident Performance for Simulated Arthroscopy.

PURPOSE: The purpose of the study was to assess the performance of residents in orthopaedics before and after a 24-hour shift on a shoulder arthroscopy simulator. The primary study endpoint was an overall performance score (OPS) generated by the simulator. METHODS: A prospective, comparative study of 120 simulator trials by 10 resident junior surgeons was performed in our university hospital's simulation center between May and November 2018. To avoid memorization bias, all participants performed the same exercise 10 times on a VirtaMed ArthroS simulator prior to the study. Each resident's performance (the OPS, the operating time, the proportion of procedures with iatrogenic lesions, the camera path length and the hook path length) in two different simulated arthroscopy exercise tasks was assessed once before and once after a 24-hour shift. This sequence was performed three times during the semester, and the change over time in performance was also evaluated. RESULTS: The OPS was significantly lower after the night shift (P = 0.035 for the first exercise, and P = 0.025 for the second). CONCLUSION: In a group of previously trained resident junior surgeons, overall performance with an arthroscopy simulator was significantly worse after a 24-hour shift. The study of secondary parameters of the OPS and the subgroup analysis based on the sleep time and Epworth score vary depending on the type of exercise performed arthroscopically. However, the use of a simulator after a night shift did not prevent the trainee from improving his/her level of performance over time. LEVEL OF EVIDENCE: II, a prospective, comparative study.

Diagnostic value of the hourglass biceps test for the detection of intra-articular long head of the biceps hypertrophy.

BACKGROUND: Shoulder surgeons performing tenodesis note a great variability in morphology of the proximal biceps. The hourglass biceps test measures the integrity of the intra-articular biceps tendon. The hourglass maneuver (HM) is positive when there is a passive flexion deficit compared to the contralateral shoulder in a relaxed patient in the supine position. HYPOTHESIS: Preoperative HM is correlated with an increased width of the biceps portion resected during tenodesis. METHODS: This prospective study evaluated all patients (N = 58) who underwent biceps tenodesis between January and September 2019. Two groups of patients were compared: group 1 (n = 20) had a positive HM and group 2 had a negative HM (n = 38). The smallest (s) and largest (L) width of the tendon were measured intraoperatively, and the L/s ratio was calculated. The HM was then evaluated as a diagnostic test by creating a contingency table and determining the sensitivity and specificity of the test for different L/s ratios. A receiver operating characteristic curve was created and the area under the curve (AUC) was calculated. RESULTS: A nonsignificant difference was found between the mean largest biceps width in group 1 compared to group 2 (11.65 mm [range: 5-21] vs. 9.71 mm [range: 6-20], respectively; P < .05). The AUC was 0.81; the sensitivity was 68.9% and specificity, 80.8%. CONCLUSION: Preoperative positivity of the HM is linked to the increased width of the biceps portion resected during tenodesis. The hourglass biceps test should be predictive of intraoperative hourglass biceps according to our definition.

Publication rate of studies presented at the French Arthroscopic Society Meeting in 2014.

INTRODUCTION: Publication rates for studies reported at French Arthroscopic Society (Société francophone d'arthroscopie, SFA) meetings are not known. A comprehensive search of podium presentations to the 2014 SFA meeting was performed, assessing: (1) publication rate for meeting abstracts, and (2) bibliometric parameters including journal Impact Factor. HYPOTHESIS: The full-text publication rate for abstracts accepted for the 2014 French Arthroscopic Society (SFA) meeting was around 47.1%: i.e., the rate reported for the 2013 meeting of the French Society of Orthopedic Surgery and Traumatology (SoFCOT). MATERIAL AND METHODS: Bibliometric analysis of all abstracts accepted for the 2014 SFA annual meeting was undertaken by the Junior French Arthroscopic Society (SFA Junior), who collated the podium presentations. Reported studies were retrospective in 43 cases (54%) and prospective in 36 (46%). They consisted in clinical studies in 52/79 cases (66%), experimental studies in 4 (5%), cadaver or animal studies in 13 (16.5%), epidemiological studies in 8 (10%), a case report in 1 (1.2%) and a literature review in 1 (1.2%). Thirty-two (40.5%) concerned the shoulder and 31 (39%) the knee. Publication was checked on systematic PubMed-Medline search of authors' names. Articles found on PubMed-Medline were downloaded into the SIGAPS scientific publication search, management and analysis system database. Journal impact factor and SIGAPS category (A to E) were obtained, as were number of citations and h-index. This was a descriptive study, assessing numbers; results were reported as number and percentage. RESULTS: Overall publication rate was 31/79 (39.2%): 20/31 clinical studies (64.5%), 6 cadaver studies (19.4%), 3 epidemiology studies (9.7%), 1 experimental study (3.2%) and 1 literature review (3.2%). Mean 2014 SFA meeting-to-publication time was 18.7 months [range, -2 to 60 months]. Journal SIGAPS categories were A for 4 articles (13.3%), B for 13 (43.3%), C for 3 (10%), D for 9 (30%), with no E category articles but 1 article (3.3%) without SIGAPS category. CONCLUSION: The publication rate for abstracts accepted for report to the 2014 SFA annual meeting was lower than for the 2013 SoFCOT meeting. The high level of the journals in question testified to the quality of the studies reported at the SFA meeting. LEVEL OF EVIDENCE: IV, retrospective study.

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

BACKGROUND: Arthroscopic surgery is a steadily expanding component of orthopaedic practice that changes continuously as new techniques and indications develop. The many arthroscopy training activities offered to residents include fellowships, practice on cadaver specimens and simulators, and teaching in the operating room. Current practices for arthroscopy training of orthopaedic residents in France have not yet been evaluated. The objectives of this study were to describe current arthroscopy training practices and to assess the perceptions and expectations of residents and junior physicians in France, in order to contribute to the development of a new training strategy for residents. HYPOTHESIS: Residents and junior physicians perceive gaps in their arthroscopy training. METHODS: Between November 2018 and February 2019, the Junior French Arthroscopy Society (Société Francophone d'Arthroscopie Junior, SFAJ) conducted a descriptive epidemiological survey of 918 residents, clinical fellows, and junior physicians in orthopaedic surgery departments in France. The data were collected via an online questionnaire sent by e-mail. The questionnaire had items on demographics; perceptions of, and expectations about, arthroscopy skills training during the residency; and experience in performing arthroscopic procedures. RESULTS: Of the 918 residents, 106 responded to the questionnaire. Most respondents were near the end of their training: 26 (24.8%) were 4th-year residents, 23 (21.6%) were 5th-year residents, 15 (14.3%) were clinical fellows, and 13 (12.4%) were junior physicians. Among respondents, 42 (40%) had performed fewer than 5 simple arthroscopy procedures as the main operator and 73 (69.5%) felt they were not, or would not be, capable of performing arthroscopic procedures without supervision by the end of their residency. CONCLUSION: The survey findings highlighted the challenges encountered by French orthopaedics residents in acquiring satisfactory arthroscopy skills during their residency. They also suggested avenues for improvement such as simulator training or the development of training on cadaver specimens. LEVEL OF EVIDENCE: IV, descriptive survey.

Lessons taught by a knee arthroscopy simulator about participants in a European arthroscopy training programme.

BACKGROUND: Arthroscopy simulators offer safe and reproducible training to orthopaedic residents, thereby obviating the need for cadaver specimens. In addition, they collect data that can serve to investigate learning curves and evaluate training programmes with the goal of improving the quality of arthroscopy teaching. In this study, a cohort of surgeons was evaluated before and after a European theoretical and practical training programme that used a knee arthroscopy simulator. The primary objective was to assess whether the overall performance score was improved by the training programme. The secondary objectives were to determine which tasks and skills were improved by the programme, to compare a novice group to an experienced group, and to identify targets for improvement. HYPOTHESIS: A theoretical and practical training course improves the scores achieved on an arthroscopy simulator task. METHODS: A prospective comparative study was performed in 34 surgeons during the advanced arthroscopy training course organised by the European Paediatric Orthopaedic Society (EPOS) in January 2018. All participants performed a diagnostic task on the VirtaMed ArthroS™ simulator before and after the programme. The participants were divided into two groups based on number of knee arthroscopies performed each year, i.e.,>20 (experienced group) vs.≤20 (inexperienced group). The following parameters were compared between the two groups: overall score, operative time, percentage of iatrogenic injuries, camera and hook path lengths, and success in identifying anatomical structures. RESULTS: The overall score on the diagnostic task was 199 before and 203 after the training programme (p=0.02). The operative time decreased significantly, from 185 to 115.9seconds (p<0.01). Camera path length decreased from 85.2 to 49.2cm and hook path length from 65.5 to 15.0cm (p<0.05). The mean proportion of arthroscopies with iatrogenic tibial cartilage injuries diminished from 2.7%±1.7% (range, 0-6.7) to 1.8%±1.8% (range, 0-7) (p=0.03); no change occurred in femoral injuries. When each group was assessed separately, the only significant change found in the experienced group was a decrease in operative time, whereas in the inexperienced group all parameters improved significantly. However, visualisation of anatomical structures was unchanged. CONCLUSION: Participation in the training programme improved overall performance, and the gains were greatest in the inexperienced group. During the post-training evaluation, some of the major anatomical structures were classified by the simulator as incompletely visualised, raising concern about a risk of underdiagnosis during arthroscopic explorations. LEVEL OF EVIDENCE: III, prospective comparative study.