Practice Patterns in Primary Breast Augmentation: A 16-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery.

BACKGROUND: As part of the continuous certification process, the American Board of Plastic Surgery collects case data for specific tracer procedures in aesthetic surgery to assess practice improvement by the diplomates. These case-based data provide valuable information on national trends in clinical practice. The current study was performed to analyze practice patterns in aesthetic primary breast augmentation. METHODS: Breast augmentation tracer data were reviewed from 2005 to 2021 and grouped into an early cohort (EC), from 2005 through 2014, and a recent cohort (RC), from 2015 through 2021. Fisher exact tests and two-sample t tests compared demographic characteristics of the patients, surgical techniques, and complication rates. RESULTS: Patients in the RC were slightly older (34 versus 35 years; P < 0.001), more likely to have ptosis greater than 22 cm (20% versus 23%; P < 0.0001), less likely to smoke (12% versus 8%; P < 0.0001), and less likely to undergo a preoperative mammogram (29% versus 24%; P < 0.0001). From a technical standpoint, inframammary incisions have become more common (68% versus 80%; P < 0.0001), whereas periareolar incision use has decreased (24% versus 14%; P < 0.0001). Submuscular plane placement has increased (22% versus 56%; P < 0.0001), while subglandular placement has decreased (19% versus 7%; P < 0.0001). Silicone implants are most popular (58% versus 82%; P < 0.0001). Textured implant use increased from 2011 (2%) to 2016 (16%), followed by a sharp decline to 0% by 2021. Trends follow U.S. Food and Drug Administration approvals and warnings. CONCLUSIONS: This study highlights evolving trends in aesthetic breast augmentation over the past 16 years. The most common technique remains a smooth silicone prosthesis placed in the subpectoral plane through an inframammary incision.

American Board of Orthopaedic Surgery's Initiatives Toward Competency-Based Education.

The American Board of Orthopaedic Surgery (ABOS) is the national organization charged with defining education standards for graduate medical education in orthopaedic surgery. The purpose of this article is to describe initiatives taken by the ABOS to develop assessments of competency of residents to document their progress toward the independent practice of orthopaedic surgery and provide feedback for improved performance during training. These initiatives are called the ABOS Knowledge, Skills, and Behavior Program. Web-based assessment tools have been developed and validated to measure competence. These assessments guide resident progress through residency education and better define the competency level by the end of training. The background and rationale for these initiatives and how they serve as steps toward competency-based education in orthopaedic residency education in the United States will be reviewed with a vision of a hybrid of time and competency-based orthopaedic residency education that will remain 5 years in length, with residents assessed using standardized tools.

Use of the Behavior Assessment Tool in 18 Pilot Residency Programs.

BACKGROUND: The purpose of this study was to determine the feasibility and evaluate the effectiveness of the American Board of Orthopaedic Surgery Behavior Tool (ABOSBT) for measuring professionalism. METHODS: Through collaboration between the American Board of Orthopaedic Surgery and American Orthopaedic Association's Council of Residency Directors, 18 residency programs piloted the use of the ABOSBT. Residents requested assessments from faculty at the end of their clinical rotations, and a 360° request was performed near the end of the academic year. Program Directors (PDs) rated individual resident professionalism (based on historical observation) at the outset of the study, for comparison to the ABOSBT results. RESULTS: Nine thousand eight hundred ninety-two evaluations were completed using the ABOSBT for 449 different residents by 1,012 evaluators. 97.6% of all evaluations were scored level 4 or 5 (high levels of professional behavior) across all of the 5 domains. In total, 2.4% of all evaluations scored level 3 or below reflecting poorer performance. Of 431 residents, the ABOSBT identified 26 of 32 residents who were low performers (2 or more < level 3 scores in a domain) and who also scored "below expectations" by the PD at the start of the pilot project (81% sensitivity and 57% specificity), including 13 of these residents scoring poorly in all 5 domains. Evaluators found the ABOSBT was easy to use (96%) and that it was an effective tool to assess resident professional behavior (81%). CONCLUSIONS: The ABOSBT was able to identify 2.4% low score evaluations (

Resident Independence Performing Common Orthopaedic Procedures at the End of Training: Perspective of the Graduated Resident.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) has established minimum exposure rates for specific orthopaedic procedures during residency but has not established the achievement of competence at the end of training. The determination of independence performing surgical procedures remains undefined and may depend on the perspective of the observer. The purpose of this study was to understand the perceptions of recently graduated orthopaedic residents on the number of cases needed to achieve independence and on the ability to perform common orthopaedic procedures at the end of training. METHODS: We conducted a web survey of all 727 recently graduated U.S. orthopaedic residents sitting for the 2018 American Board of Orthopaedic Surgery Part I Examination in July 2018. The surveyed participants were asked to assess the ability to independently perform 26 common adult and pediatric orthopaedic procedures as well as to recommend the number of cases to achieve independence at the end of training. We compared these data to the ACGME Minimum Numbers and the average ACGME resident experience data for residents who graduated from 2010 to 2012. RESULTS: For 14 (78%) of the 18 adult procedures, >80% of respondents reported the ability to perform independently, and for 7 (88%) of the 8 pediatric procedures, >90% reported the ability to perform independently. The resident-recommended number of cases for independence was greater than the ACGME Minimum Numbers for all but 1 adult procedure. For 18 of the 26 adult and pediatric procedures, the mean 2010 to 2012 graduated resident exposure was significantly less than the mean number recommended for independence by 2018 graduates (p < 0.05). CONCLUSIONS: Overall, recently graduated residents reported high self-perceived independence in performing the majority of the common adult and pediatric orthopaedic surgical procedures included in this study. In general, recently graduated residents recommended a greater number of case exposures to achieve independence than the ACGME Minimum Numbers.

Perceptions of the Recommended Resident Experience with Common Orthopaedic Procedures: A Survey of Program Directors and Early Practice Surgeons.

BACKGROUND: U.S. orthopaedic residency training is anchored by the Accreditation Council for Graduate Medical Education (ACGME) requirements, which include minimum numbers for 15 categories of procedures. The face validity of these recommendations and expectations for exposure to other common procedures has not been rigorously investigated. The main goals of this investigation were to understand the perceptions of program directors and early practice surgeons regarding the number of cases needed in residency training and to report which of the most commonly performed procedures residents should be able to perform independently upon graduation. METHODS: We sent surveys to 157 current program directors of ACMGE-approved orthopaedic surgery residency programs and to all examinees sitting for the American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination in 2017, requesting that they estimate the minimum number of exposures for the 22 adult and 24 pediatric procedures that are most commonly performed during residency and the first 2 years in practice. Where applicable, we compared these with the ACGME "Minimum Numbers" and the average ACGME resident experience data from 2010 to 2012 for resident graduates. For each of the 46 procedures, participants were asked if every orthopaedic resident should be able to independently perform the procedure upon graduation. We compared the percent for independence between the early practice surgeons and the program directors. RESULTS: For the majority of adult and pediatric procedures, the early practitioners reported significantly higher numbers of cases needing to be performed during residency than the program directors. ACGME Minimum Numbers were always lower than the case numbers that were recommended by the early practice surgeons and the program directors. Overall we found good-to-excellent agreement for independence at graduation between program directors and early practitioners for adult cases (intraclass correlation coefficient [ICC], 0.98; 95% confidence interval [CI], 0.82 to 0.99) and moderate-to-good agreement for pediatric cases (ICC, 0.96; 95% CI, 0.74, 0.99). CONCLUSIONS: The program directors frequently perceived the need for resident operative case exposure to common orthopaedic procedures to be lower than that estimated by the early practice surgeons. Both program directors and early practice surgeons generally agreed on which common cases residents should be able to perform independently by graduation.

Resident Surgical Skills Web-Based Evaluation: A Comparison of 2 Assessment Tools.

BACKGROUND: Evaluation of surgical skill competency is necessary as graduate medical education moves toward a competency-based curriculum. This study by the American Board of Orthopaedic Surgery (ABOS) and the Council of Orthopaedic Residency Directors (CORD) compares 2 web-based evaluation tools that assess the level of autonomy that is demonstrated by residents during surgical procedures in the operating room as measured by faculty. METHODS: Two hundred and ninety-four residents from 16 orthopaedic surgery residency programs were evaluated by 370 faculty using 2 web-based evaluation tools in a crossover design in which residents requested faculty review of their surgical skills before starting a case. One thousand, one hundred and fifty Ottawa Surgical Competency Operating Room Evaluation (O-Score) assessments, which included a 9-question evaluation of 8 steps of the surgical procedure, were compared with 1,186 P-score evaluations, which included a single-question summative evaluation. Twenty-five different surgical procedures were evaluated. RESULTS: There were no significant differences in rates of resident requests or faculty completion of the 2 scores. The most common surgical procedures that were assessed were total knee arthroplasty (n = 254, 11%), carpal tunnel release (n = 191, 8%), open reduction and internal fixation (ORIF) of stable hip fractures (n = 170, 7%), ORIF of simple ankle fractures (n = 169, 7%), and total hip arthroplasty (n = 166, 7%). Both instruments disclosed significant differences in competency among entry, intermediate, and advanced-level residents. The findings support the construct validity of the evaluation method. The survey results indicated that >70% of the faculty were confident that use of either the P-score or the O-score allowed them to distinguish a resident who can perform the surgery independently from one who needs additional training. CONCLUSIONS: This research has led to the modification of the O-score and the P-score into a combined OP-score instrument. The ABOS envisions that the OP-score instrument can be used with an expanded number of surgical procedures as a required element of residency training in the near future. CLINICAL RELEVANCE: This study allows the profession of orthopaedic surgery education to take a leadership role in the measurement of competence for surgical skills for orthopaedic surgeons in residency training, an important clinically relevant topic to the practice of orthopaedic surgery.

Cartilage Restoration Surgery: Incidence Rates, Complications, and Trends as Reported by the American Board of Orthopaedic Surgery Part II Candidates.

PURPOSE: To evaluate the current status of advanced cartilage restoration procedures among newly trained orthopaedic surgeons in the United States. METHODS: The American Board of Orthopaedic Surgery database was queried to identify all advanced cartilage restoration procedure cases submitted by American Board of Orthopaedic Surgery part II board certification examination candidates from 2003 to 2015. All documented autologous chondrocyte implantation, autologous osteochondral transfer, osteochondral allograft transplantation, and marrow stimulation techniques (MSTs) procedures were analyzed. Analysis was performed to describe trends in annual incidence, types of complications, concomitant procedures, and geographical differences in incidence of advanced cartilage procedures. RESULTS: From 2003 to 2015, a total of 2,827 surgeons submitted 7,522 cartilage restoration procedures, with 7,060 cases documented as MST (80.01%). The number of cartilage cases decreased significantly from 2003 to in 2015 (P <.001), with MST having the largest decline (P < .001). The incidence of open osteochondral allograft transplantation (odds ratio = 1.35; P = .023) and open autologous osteochondral transfer (odds ratio = 0.84; P = .004) increased over the study period. Overall, the majority of patients (57.0%) were male; however, female patients were on average significantly older than male patients (P < .001). Cartilage procedures were performed concomitantly with a realignment osteotomy procedure in 1.7% of cases. The incidence of surgical complications increased throughout the study period from 2.9% in 2003 to 9.5% in 2015 (P < .001). CONCLUSIONS: Cartilage restoration procedures, specifically MSTs, are being decreasingly performed among recently trained orthopaedic surgeons. In contrast, complication rates have been increasing since 2003, demonstrating a possible paradigm shift toward more complex cartilage procedures, specifically osteochondral grafting procedures. CLINICAL RELEVANCE: This study demonstrates a significant decline in the use of MSTs by recently trained orthopaedic surgeons. In addition, an increase in several more complex cartilage restoration procedures was found. Taken in sum, these changes may reflect a shift in residency and fellowship training away from marrow stimulation procedures that elicit a fibrocartilage reparative tissue and toward more complex procedures that provide a more hyaline-like articular cartilage surface.

Operative Experience During Orthopaedic Residency Compared with Early Practice in the U.S.

BACKGROUND: The goal of surgical education is to prepare the trainee for independent practice; however, the relevance of the current residency experience to practice remains uncertain. The purpose of this study was to identify the surgical procedures most frequently performed in orthopaedic residency and in early surgical practice and to identify surgical procedures performed more often or less often in orthopaedic residency compared with early surgical practice. METHODS: This retrospective cohort study included American Medical Association (AMA) Current Procedural Terminology (CPT) codes (n = 4,329,561 procedures) reported by all U.S. orthopaedic surgery residents completing residency between 2010 and 2012 (n = 1,978) and AMA CPT codes for all procedures (n = 413,370) reported by U.S. orthopaedic surgeons who took the American Board of Orthopaedic Surgery Part II certifying examination between 2013 and 2015 (n = 2,205). Relative rates were determined for AMA CPT codes and AMA CPT code categories for adult and pediatric surgeries that had frequencies of ≥0.1% for both practitioners and residents. RESULTS: The top 25 adult AMA CPT code categories contributed 82.1% of the total case volume for residents and 82.4% for practitioners. Knee and shoulder arthroscopy were the most frequently performed procedures in adults in both residency and early practice. Humerus/elbow fracture and/or dislocation procedures and "other musculoskeletal-introduction or removal" procedures were the most frequently performed procedures in pediatric cases in both residency and early practice. Of the total 78 adult and 82 pediatric code categories included in our analysis that had a frequency of >1% in residency or early practice, there were 4 adult and 6 pediatric code categories demonstrating 44% to 1,164% greater frequency in residency than in early practice, and there were 8 adult and 7 pediatric code categories demonstrating 26% to 73% less frequency in residency than in early practice. CONCLUSIONS: Similarity between residency and early practice experience is generally strong. However, we identified several AMA CPT code categories and individual CPT codes for which the level of exposure during residency varied substantially from early practice experience. These findings can help residencies ensure adequate trainee exposure to procedures performed commonly in early practice.

Trends in Primary and Revision Hip Arthroplasty Among Orthopedic Surgeons Who Take the American Board of Orthopedics Part II Examination.

BACKGROUND: A certified list of all operative cases performed within a 6-month period is a required prerequisite for surgeons taking the American Board of Orthopaedic Surgery Part II oral examination. Using the American Board of Orthopaedic Surgery secure Internet database database containing these cases, this study (1) assessed changing trends for primary and revision total hip arthroplasty (THA) and (2) compared practices and early postoperative complications between 2 groups of examinees, those with and without adult reconstruction fellowship training. METHODS: Secure Internet database was searched for all 2003-2013 procedures with a Current Procedural Terminology code for THA, hip resurfacing, hemiarthroplasty, revision hip arthroplasty, conversion to THA, or removal of hip implant (Girdlestone, static, or dynamic spacer). RESULTS: Adult reconstruction fellowship-trained surgeons performed 60% of the more than 33,000 surgeries identified (average 28.1) and nonfellowship-trained surgeons performed 40% (average 5.2) (P < .001). Fellowship-trained surgeons performed significantly more revision surgeries for infection (71% vs 29%)(P < .001). High-volume surgeons had significantly fewer complications in both primary (11.1% vs 19.6%) and revision surgeries (29% vs 35.5%) (P < .001). Those who passed the Part II examination reported higher rates of complications (21.5% vs 19.9%). CONCLUSION: In early practice, primary and revision hip arthroplasties are often performed by surgeons without adult reconstruction fellowship training. Complications are less frequently reported by surgeons with larger volumes of joint replacement surgery who perform either primary or more complex cases. Primary hip arthroplasty is increasingly performed by surgeons early in practice who have completed an adult reconstructive fellowship after residency training. This trend is even more pronounced for more complex cases such as revision or management of infection.

Frequency and complications after operative fixation of clavicular fractures.

BACKGROUND: The purpose of this study was to analyze whether a recent trend in evidence supporting operative treatment of clavicular fractures is matched with an increase in operative fixation and complication rates in the United States. METHODS: The American Board of Orthopaedic Surgery database was reviewed for cases with Current Procedural Terminology (American Medical Association, Chicago, IL, USA) code 23515 (clavicle open reduction internal fixation [ORIF]) from 1999 to 2010. The procedure rate for each year and the number of procedures for each candidate performing clavicle ORIF were calculated to determine if a change had occurred in the frequency of ORIF for clavicular fractures. Complication and outcome data were also reviewed. RESULTS: In 2010 vs, 1999, there were statistically significant increases in the mean number of clavicle ORIF performed among all candidates (0.89 vs. 0.13; P < .0001) and in the mean number of clavicle ORIF per candidate performing clavicle ORIF (2.47 vs. 1.20, P < .0473). The difference in the percentage of part II candidates performing clavicle ORIF from the start to the end of the study (11% vs. 36%) was significant (P < .0001). There was a significant increase in the clavicle ORIF percentage of total cases (0.11% vs. 0.74%, P < .0001). The most common complication was hardware failure (4%). CONCLUSION: The rate of ORIF of clavicular fractures has increased in candidates taking part II of the American Board of Orthopaedic Surgery, with a low complication rate. The increase in operative fixation during this interval may have been influenced by literature suggesting improved outcomes in patients treated with operative stabilization of their clavicular fracture.

Trends in primary and revision knee arthroplasty among orthopaedic surgeons who take the American Board of Orthopaedics part II exam.

PURPOSE: A certified list of all operative cases performed within a six month period is required of surgeons by the American Board of Orthopaedic Surgery (ABOS) as a prerequisite to taking the Part II Oral Examination. Using the data on these cases collected and maintained by ABOS, this study assessed the influence of prior fellowship training in adult reconstruction on the volume and surgeon-reported complication rate of knee joint arthroplasty cases over time. METHODS: All data were self reported to a secure Internet database (SCRIBE) by candidates who applied to take Part II of the ABOS Examination for the first time. This database was searched for all procedures done between 2003 and 2013 with CPT codes for total and revision knee arthroplasty and removal of knee implant (static or dynamic spacer) to determine procedural volumes and early complication rates among Board-eligible orthopaedic surgeons with and without adult reconstructive fellowship training. RESULTS: More than 43,000 knee arthroplasty surgeries were identified. Surgeons who had completed adult reconstruction fellowship training after residency performed 55 % of total knee arthroplasties, averaging 33.5 knee arthroplasties during the six month case-collection period compared to 7.4 procedures by non-fellowship-trained surgeons (p < 0.001). Adult reconstruction fellowship-trained surgeons performed significantly more revisions for infection (average 6.6 versus 2.2 revisions) (p < 0.001). Adult reconstruction fellowship training did not significantly affect complication rates for primary arthroplasty but was associated with an increased complication rate for revisions. Those surgeons who performed more than 100 arthroplasties a year reported significantly fewer complications in primary arthroplasties (12.7 % versus 16.9 %) (p < 0.001). Over time, an increasing percentage of arthroplasties were done by surgeons with adult reconstruction fellowship training. CONCLUSIONS: Adult reconstruction fellowship-trained surgeons performed an increasing number of primary and more complex knee arthroplasties from 2003 to 2013. Surgeons who perform a larger volume of knee arthroplasty surgeries report fewer early complications than surgeons with fewer cases. LEVEL OF EVIDENCE: 4.

Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Part II candidates.

BACKGROUND: Tears of the superior labrum (superior labrum anterior and posterior [SLAP] lesions) of the shoulder are uncommon injuries; however, the incidence of surgical correction seems to be increasing. PURPOSE: To report the findings of a review of a proprietary descriptive database that catalogs cases for the purpose of board certification on the demographics of SLAP lesion repair. It is the authors' impression that the percentage of cases of SLAP lesion repairs reported by young orthopaedic surgeons is high and that complications associated with this are not insignificant. STUDY DESIGN: Cohort study; level of evidence, 3. METHODS: We searched the American Board of Orthopedic Surgery (ABOS) part II database to evaluate changes in treatment over time and to identify available outcomes and associated complications of arthroscopic repair of SLAP lesions. The database was searched for all SLAP lesions (ICD-9 code 840.7) and SLAP repairs (CPT code 29807) for the years 2003 through 2008. Utilization was analyzed by geographic region and was also obtained based on applicant subspecialty declaration. RESULTS: There were 4975 SLAP repairs, representing 9.4% of all applicants' shoulder cases. Mean follow-up was 8.9 weeks because of the time-limited case collection period. There were 78.4% who were men, and 21.6% of patients were women. The percentage of shoulder cases that were SLAP repairs increased over the study period from 9.4% to 10.1% by 2008 (P = .0163). Mean age of male patients was 36.4 ± 13.0 years, with a maximum of 85 years. Mean age of female patients was 40.9 ± 14.0 years, with a maximum of 88 years. Pain was reported as absent in only 26.3% of patients at follow-up and function as normal in only 13.1%. There were 40.1% of applicants who self-reported their patients to have an excellent result. The self-reported complication rate was 4.4%. Declared sports medicine specialists had a higher percentage of SLAP repairs than did general orthopaedic surgeons: 12.4% versus 9.2%. CONCLUSION: The percentage of shoulder cases that are SLAP repairs reported by the candidates is 3 times the published incidence supported by the current literature. The large number of repairs in middle-aged and elderly patients is concerning. Focusing on educating young orthopaedic surgeons to appropriately recognize and treat symptomatic SLAP lesions may bring the rate of SLAP repairs down.

Practice patterns for arthroscopy of osteoarthritis of the knee in the United States.

BACKGROUND: Knee arthroscopy is one of the most common orthopaedic procedures performed in the United States. The publication of a randomized controlled trial of arthroscopy versus sham surgery by Moseley et al in 2002 showed no efficacy and challenged the role of arthroscopy for the treatment of osteoarthritis. HYPOTHESIS: (1) Knee arthroscopy for osteoarthritis has decreased after the publication of the study by Moseley et al, (2) arthroscopy as a percentage of orthopaedic cases has decreased, and (3) the average age of patients undergoing arthroscopy has decreased. STUDY DESIGN: Descriptive epidemiology study. METHODS: The authors examined the American Board of Orthopaedic Surgery (ABOS) database that includes 6-month case logs for each examinee sitting for the Part II board examination for 1999 to 2009. Knee arthroscopy cases were identified by CPT (Current Procedural Terminology) code and knee osteoarthritis diagnosis was defined by ICD-9 (International Classification of Diseases, 9th Revision) code. Piecewise linear regression was used to evaluate knee arthroscopy before and after the publication of the Moseley et al article in 2002. RESULTS: The number of knee arthroscopy cases for patients with osteoarthritis had greatly decreased by 2009 after peaking in 2001 (1621 vs 966 total cases, 2.36 vs 1.40 cases per surgeon). Cases classified as chondroplasty also decreased from 10.0% to 5.8% of knee arthroscopies (P < .0001). In addition, the total number of knee arthroscopy cases per surgeon decreased from a high of 11.9 in 2003 to a low of 8.6 in 2009. As expected, knee arthroscopy as a percentage of total orthopaedic cases decreased from a high of 9.9% in 2003 to 6.6% in 2009 (P < .0001). CONCLUSION: Knee arthroscopy for patients with osteoarthritis among orthopaedic surgeons during their ABOS examination case collection period has decreased after the publication of a highly publicized article demonstrating a lack of efficacy of this procedure. Further study is needed to determine if this change occurred in the orthopaedic community at large or if practice patterns only changed for surgeons during their board collection periods. CLINICAL RELEVANCE: Randomized controlled trials can be effective in changing orthopaedic surgeon practice.

The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery.

BACKGROUND: The concept of "Sign Your Site" was established in 1997 to prevent wrong-site surgery in the U.S., and this was expanded to the mandated Universal Protocol in 2008. However, the true incidence of wrong-site surgery in the U.S. is not known, nor do we know whether the incidence has changed. The American Board of Orthopaedic Surgery (ABOS) requires that candidates for Board certification provide a list of their cases, including surgical complications, whether wrong-site surgery was performed, and whether they complied with the "Sign Your Site" practice. Each candidate attests to the accuracy of his or her notarized case list. The purpose of this study was to report the incidence and nature of wrong-site surgery self-reported by orthopaedic surgeon candidates for certification between 1999 and 2010 and to assess whether any change was associated with the timeline of implementation of the Universal Protocol. METHODS: The ABOS database was queried for the number of examinees, cases, and wrong-site surgery cases reported; a description of each wrong-site surgery case; whether the site was signed; and the surgeon's subspecialty. RESULTS: From 1999 through 2010, 9255 orthopaedic surgeons submitted 1,291,396 cases, and sixty-one of these surgeons reported performing seventy-six wrong-site surgical procedures. Spine surgeons were the most likely to report wrong-site surgery, most commonly single-level lumbar laminotomy. The rate of wrong-site surgical procedures before and after implementation of the Universal Protocol mandate was not significantly different. Eighteen of the twenty wrong-site surgical procedures performed since ABOS data collection for "Sign Your Site" began had been signed preoperatively. CONCLUSIONS: Keeping patients safe remains an essential goal worthy of enormous effort. This study suggests that additional layers of precautions may yield diminishing returns and that attention should be focused on methods to prevent wrong-level spine surgery. Improving communication among the health-care team and shared responsibility may bring us closer to eliminating wrong-site surgery.

Are recent graduates of orthopaedic training programs performing less fracture care? American Board of Orthopedic Surgeons part II: a quality improvement initiative.

OBJECTIVES: The purpose of this study was to evaluate whether there has been a change in the amount of fracture care performed by recent graduates of orthopaedic residency programs over time. DESIGN: Retrospective review. SETTING: American Board of Orthopaedic Surgery (ABOS) Part II database. PARTICIPANTS: Candidates applying for Part II of the second part of the Orthopaedic (ABOS) certification. INTERVENTION: The ABOS Part II database was searched from years 1999 to 2008 for Current Procedural Terminology codes indicating 1) "simpler fractures" that any candidate surgeon should be able to perform; 2) "complex fractures" that are often referred to surgeons with specialty training; and 3) "emergent cases" that should be done emergently by a physician. MAIN OUTCOME MEASURE: Logistic regression and chi-square tests were used to evaluate whether there has been a change in the amount of fracture care among recent graduates of orthopaedic residency programs over time. RESULTS: Over the 10-year period (1999-2008), a total of 95,922 cases were in the simpler fractures category; 16,523 were classified as complex fractures and 17,789 were classified as emergent cases. The overall number of cases by fracture type increased from 1999 to 2008 as did the average number of surgery cases performed by surgeons in each category over the 6-month collection period. Simpler fracture cases increased 18% (8304-9784 cases) with the average number surgically treated by surgeons performing at least one simple fracture case also increasing 18% (14.1-16.6 cases per surgeon). Complex fracture cases increased 51% (1266-1916 cases) with the average number of these cases per surgeon operating at least one complex fracture case increasing 52% (3.3-5.0 cases per surgeon). Emergent fracture cases increased 92% (1178-2264 cases) with the average number of these cases per surgeon operating at least one emergent fracture case increasing 49% (4.5-6.7 cases per surgeon). CONCLUSION: From the data presented here, candidate orthopaedic surgeons are treating fractures as least as often as young surgeons were 10 years ago.

Surgical trends in Bankart repair: an analysis of data from the American Board of Orthopaedic Surgery certification examination.

BACKGROUND: Arthroscopic Bankart repair emerged in the 1990s as a minimally invasive alternative to open repair. The optimal technique of surgical stabilization of the unstable glenohumeral joint remains controversial. HYPOTHESIS: A review of the American Board of Orthopaedic Surgery (ABOS) data would show a trend toward an increasing number of arthroscopic versus open Bankart procedures. STUDY DESIGN: Descriptive epidemiology study. METHODS: A query of the ABOS database for all cases of open or arthroscopic Bankart repair from 2003 through 2008 was performed, as the CPT (Current Procedural Terminology) codes for arthroscopic repair were introduced in 2003. All cases coded with CPT codes for arthroscopic Bankart repair (29806) or open Bankart repair (23455) were reviewed. Additional data were obtained on the surgeons (year of procedure, geographic location, fellowship training, subspecialty examination area) as well as the patients (age, gender, follow-up length, complications, objective outcome measures [pain, deformity, function, and satisfaction]). RESULTS: From 2003 to 2008, a total of 4562 Bankart repair cases were reported, composing 8.6% of the total number of shoulder surgery cases in the ABOS database. From 2003 to 2005, 71.2% of Bankart repairs were arthroscopic, compared with 87.7% between 2006 and 2008 (P < .0001). Surgeons having obtained subspecialty training in sports medicine performed the majority (65.3%) of Bankart repairs. Over the entire period, sports-trained surgeons also performed a higher proportion of arthroscopic repairs (84.1%) compared with surgeons without this training (71.9%) (P < .0001). However, by 2008 both non-fellowship-trained and sports medicine fellowship-trained surgeons performed arthroscopic repair in 90% of cases. Surgeons in the Northeast region performed a significantly greater proportion of arthroscopic Bankart repairs (84.7%) than did surgeons in other regions (78.6%) (P < .0001) from 2003 to 2008. The most commonly reported complications were nerve palsy/injury and dislocation, with a rate of nerve injury of 2.2% in the open group compared to 0.3% in the arthroscopic group (P < .0001), and dislocation rate of 1.2% with open stabilization compared with 0.4% arthroscopically (P = .0039). CONCLUSION: Review of the ABOS data shows a trend toward arthroscopic shoulder stabilization over time, with the use of open repair declining. Reported complications were lower overall in the arthroscopic stabilization group when compared with open surgeries.

Fractures of the distal part of the radius. The evolution of practice over time. Where's the evidence?

BACKGROUND: During the administration of the oral (Part II) examinations for the American Board of Orthopaedic Surgery over the past nine years, it has been observed that orthopaedic surgeons are opting more often for open treatment as opposed to percutaneous fixation of distal radial fractures. Evidence to support this change in treatment is thought to be deficient. The present study was designed to identify changes in practice patterns regarding operative fixation of distal radial fractures between 1999 and 2007 and to assess the results of those treatments over time. METHODS: As a part of the certification process, Part II candidates submit a six-month case list to the American Board of Orthopaedic Surgery. In the present study, we searched the American Board of Orthopaedic Surgery Part II database to evaluate changes in treatment over time and to identify available outcomes and associated complications of open and percutaneous fixation of distal radial fractures. All distal radial fractures that had been treated surgically over a nine-year period (1999 to 2007) were reviewed. The fractures were categorized according to fixation method with use of surgeon self-reported surgical procedure codes. Comparisons of percentage treatment type by year were made. Utilization was analyzed by geographic region, and open and percutaneous fixation were compared with regard to complications and outcomes as self-reported by candidates during the online application process. RESULTS: The proportion of fractures that were stabilized with open surgical treatment increased from 42% in 1999 to 81% in 2007 (p < 0.0001). Although the differences were small, surgeon-reported outcomes revealed that a higher percentage of patients who had been managed with percutaneous fixation had no pain and normal function but some deformity as compared with patients who had had open treatment. Patients who had been managed with percutaneous fixation had a higher overall complication rate (14.0% compared with 12.3%; p < 0.006) and a higher rate of infection (5.0% compared with 2.6%; p < 0.0001) than those who had been managed with open treatment. Patients who had had open treatment had a higher rate of nerve palsy and/or injury (2.0% compared with 1.2%; p = 0.001). No other differences in the reported complication rates were found between the two techniques. CONCLUSIONS: A striking shift in fixation strategy for distal radial fractures occurred over the past decade among younger orthopaedic surgeons in the United States. These changes occurred despite a lack of improvement in surgeon-perceived functional outcomes.

The Spinal Appearance Questionnaire: results of reliability, validity, and responsiveness testing in patients with idiopathic scoliosis.

STUDY DESIGN: Prospective, sequential enrollment. OBJECTIVE: We report the development and testing of the Spinal Appearance Questionnaire (SAQ) for reliability, validity, and responsiveness in patients with idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: The SAQ was designed to measure patients' and their parents' perception of their spinal deformity's appearance using standardized drawings and questions. This study was designed to test the instrument's psychometric properties. METHODS: The SAQ was administered as a test-retest to idiopathic scoliosis patients and parents for reliability and initial validity assessment (Group I). It was then administered to patients before surgery and 1 year after surgery (Group II) for responsiveness and further validity testing. Finally, both the SAQ and SRS instruments were administered to adolescent idiopathic patients before surgery and 1 year after surgery (Group III) for comparison of the 2 instruments. RESULTS: Group I: The individual scale items had good to excellent reliability (Spearman's rho, 0.57-0.99) and high internal scale consistency (Cronbach's alpha >0.7). The mean scale scores differentiated between curves greater than 30 degrees and lesser curves (P < 0.01). Surgery improved scores compared with those with "surgery recommended." Group II: The domains correlated with clinical and radiographic aspects of the deformity before surgery. All of the domains showed significant difference after surgery (P < 0.0001) and large effect size for all domains except for the patient chest domain. Group III: Both the SAQ and the SRS instruments had significant improvement in all of their domains except for the SRS Activity scale. The relative efficiency of the SAQ domains to the SRS appearance domain (the most responsive SRS domain) was greater for 5 SAQ domains. CONCLUSION: The SAQ is reliable, responsive to curve improvement, and shows strong evidence of validity. It provides more detail than the SRS in the appearance domain, and provides explanation of spinal deformity's concerns and improvements.

The International Knee Documentation Committee Subjective Knee Evaluation Form: normative data.

BACKGROUND: The International Knee Documentation Committee Subjective Knee Evaluation Form may be used to measure symptoms, function, and sports activity for people with a variety of knee disorders, including ligamentous and meniscal injuries, osteoarthritis, and patellofemoral dysfunction. To date, normative data have not been established for this valid, reliable, and responsive outcomes instrument. PURPOSE: To provide clinicians and researchers with normative data to facilitate the interpretation of results on the International Knee Documentation Committee Subjective Knee Evaluation Form. STUDY DESIGN: Cross-sectional survey. METHODS: The Subjective Knee Evaluation Form was mailed to 600 people in each of 8 age/gender categories (18-24 years, 25-34 years, 35-50 years, and 51-65 years for both male subjects and female subjects). Participants were drawn from a panel of 550 000 households (1 300 000 subjects) representative of noninstitutionalized persons in the United States and were matched to data from the United States Census Bureau on geographical region, market size, income, and household size. RESULTS: Complete data were available for 5246 knees. Twenty-eight percent of respondents reported an injury, weakness, or other problem with one or both knees. Normative data were determined for respondents as a whole and for the subset of respondents with no history of knee problems. Mean scores were determined for men aged 18 to 24 years (89 +/- 18), 25 to 34 years (89 +/- 16), 35 to 50 years (85 +/- 19), and 51 to 55 years (77 +/- 23); mean scores were also determined for women aged 18 to 24 years (86 +/- 19), 25 to 34 years (86 +/- 19), 35 to 50 years (80 +/- 23), and 51 to 65 years (71 +/- 26). Scores were higher for the subset of respondents with no history of current or prior knee problems. CONCLUSION: Scores on the International Knee Documentation Committee Subjective Knee Evaluation Form vary by age, gender, and history of knee problems. The normative data collected in this article will allow clinicians to interpret how patients with knee injuries are functioning relative to their age- and gender-matched peers and will enable researchers to determine the clinical outcomes of treatment.