Development and Implementation of International Curricula for Joint Replacement and Preservation.

The number of patients undergoing joint replacement and preservation procedures continues to increase worldwide. Globally, there is no standardized educational pathway, training program, or recognized certification program for surgeons in these procedures. Development and implementation of new competency-based curricula to deliver specific educational events and resources may help trainees and practicing surgeons be able to perform these procedures more effectively and therefore improve patient outcomes in their respective countries. Ideally, a curriculum would be globally standardized and professionally designed to interactively meet the needs of surgeons. A competency-based approach with built-in assessment and evaluation processes is today's educational standard.

International Collaboration in Total Joint Arthroplasty: A Framework for Establishing Meaningful International Alliances.

Despite the increase in utilization of total joint arthroplasty (TJA) throughout high-income countries, there is a lack of access to basic surgical care, including TJA, in low- and middle-income countries (LMICs). Multiple strategies, including short-term surgical trips, establishment of local TJA centers, and education-based international academic collaborations, have been used to bridge the gap in access to quality TJA. The authors review the obstacles to providing TJA in LMICs, the outcomes of the 3 strategies in use to bridge gaps, and a framework for the establishment and maintenance of meaningful international collaborations.

Learning Curves in Arthroplasty in Orthopedic Trainees.

The NHS is adapting to a changing environment, in which economical constraints have forced theatres to maximise efficiency. An environment in which working hours and surgical exposure has been reduced and outcomes are being published. Litigation is high, and patients are living longer with higher demands. We ask, will traditional methods of apprentiship type training suffice in producing competent arthroplasty surgeons when hands on experience is falling. We review learning curves and assessment tools available to accurately assess competency and support trainee orthopaedic surgeons in their acquisition of surgical proficiency.

Are Oral and Maxillofacial Surgery Residents Trained Adequately in Alloplastic Total Temporomandibular Joint Replacement?

PURPOSE: To assess the current level of experience and training that oral and maxillofacial surgery (OMS) residents receive in alloplastic temporomandibular joint (TMJ) total joint replacement (TJR) at OMS training programs in the United States. MATERIALS AND METHODS: A questionnaire was developed using REDCap (Chicago, IL), and an on-line link was emailed to the program directors of all 101 OMS training programs in the United States accredited by the Commission on Dental Accreditation. The questionnaire included 20 questions related to the program's alloplastic TMJ TJR curriculum and clinical experience. In addition, a Likert scale was used to assess the respondents' opinions on resident training and the future of alloplastic TMJ TJR education and its clinical effect and usage. RESULTS: The study sample included 53 respondents (52.5%). Of the 53 responding OMS programs, 94% provide TMJ TJR didactic lectures presented by OMS faculty. The alloplastic TMJ TJR procedures averaged 0 to 6 annually per program; however, 25% of the programs reported more than 10 cases annually. Infection and continued pain were reported as the most common reasons for alloplastic TMJ TJR device replacement. CONCLUSIONS: It appears that adequate didactic and clinical training is being provided to OMS residents in alloplastic TMJ TJR during their training. Additional studies might elucidate the actual geographic distribution of OMS surgeons who perform alloplastic TMJ TJR procedures.

Effect of surgical experience on imageless computer-assisted femoral component positioning in hip resurfacing--a preclinical study.

BACKGROUND: The clinical outcome of hip resurfacing (HR) as a demanding surgical technique associated with a substantial learning curve depends on the position of the femoral component. The aim of the study was to investigate the effects of the level of surgical experience on computer-assisted imageless navigation concerning precision of femoral component positioning, notching, and oversizing rate, as well as operative time. METHODS: Three surgeons with different levels of experience in both HR and computer-assisted surgery (CAS) prepared the femoral heads of 54 synthetic femurs using the Durom(TM) Hip Resurfacing (Zimmer, Warsaw, IN, USA) system. Each surgeon prepared a total of 18 proximal femurs using the Navitrack® system (ORTHOsoft Inc., Montreal, Canada) or the conventional free-hand Durom(TM) K-wire positioning jig. The differences between planned and postoperative stem shaft angle (SSA) and anteversion angle in standardized x-rays were measured and the operative time, not including the time for calibrating the CAS-system, was documented. Notching was evaluated by the three surgeons in a randomized manner. Oversizing was determined by the difference of the preoperative determined cap and the cap size advised by the CAS-system. RESULTS: CAS significantly reduced the overall mean deviation between planned and postoperative SSA in comparison with the conventional procedure (mean ± SD, 1 ± 1.7° vs. 7.4 ± 4.4°, P < 0.01) regardless of the surgeon's level of experience. The incidence of either varus or valgus SSA deviations exceeding 5° were 1/27 for CAS and 15/27 for the conventional method, respectively (P < 0.001), corresponding to a reduction by 97%. Using CAS, the rate of notching was reduced by 100%. CONCLUSIONS: The accuracy of femoral HR component orientation is significantly increased by use of CAS regardless of the surgeon's level of experience in our preclinical study. Thus, imageless computer-assisted navigation can be a valuable tool to improve implant positioning in HR for surgeons at any stage of their learning curve.

Future patient demand for shoulder arthroplasty by younger patients: national projections.

BACKGROUND: The outcomes of shoulder arthroplasties in younger patients (55 years or younger) are not as reliable compared with those of the general population. Greater risk of revision and higher complication rates in younger patients present direct costs to the healthcare system and indirect costs to the patient in terms of quality of life. Previous studies have suggested an increased demand for shoulder arthroplasties overall, but to our knowledge, the demand in younger patients has not been explored. QUESTIONS/PURPOSES: We asked: (1) What was the demand for shoulder arthroplasties between 2002 and 2011 in the United States for all patients and a specific subpopulation of patients who were 55 years old or younger? (2) How is the demand for shoulder arthroplasties in younger patients projected to change through 2030? (3) How is procedural demand projected to change in younger patients through 2030, and specifically, what can we anticipate in terms of hemiarthroplasty volume compared with that of total shoulder arthroplasty? METHODS: We used the National Inpatient Sample database to identify primary shoulder arthroplasties performed between 2002 and 2011. A Poisson regression model was developed using the National Inpatient Sample data and United States Census Bureau projections on future population changes to predict estimated national demand for total shoulder arthroplasties and hemiarthroplasties in all patients and in the subpopulation 55 years old or younger. This model was projected until 2030, with associated 95% CIs. We then specifically analyzed the projected demand of hemiarthroplasties and compared this with demand for all arthroplasty procedures in the younger patient population. RESULTS: Demand for shoulder arthroplasties in patients 55 years or younger is increasing at a rate of 8.2% per year (95% CI, 7.06%-9.35%), compared with a growth rate of 12.1% (95% CI, 8.35%-16.02%) per year for patients older than 55 years. In 2002, 15.9% (3587 of 22,617 captured in the National Inpatient Sample) of primary shoulder arthroplasties were performed in patients 55 years old or younger. In 2011, the relative size of the younger patient population had decreased to 11.0% (7001 of 63,784) of all recipients of shoulder arthroplasties. The demand for primary shoulder arthroplasties among younger patients is projected to increase by 333.3% (95% CI, 257.0%-432.5%) from 2011 to 2030. However, in patients older than 55 years demand is projected to increase by 755.4% (95% CI, 380.7%-1511.1%). Therefore, despite the increased predicted demand for shoulder arthroplasties in younger patients, they are predicted to account for only 4% of all recipients by 2030. The rate of hemiarthroplasties in patients 55 years or younger showed a 16.5% decline per year (95% CI, 16.1%-17.1%) from 2002 (53.6% of all arthroplasties) to 2011 (34.2% of all arthroplasties). By 2030, hemiarthroplasties are projected to account for only 23.5% of all shoulder arthroplasties in patients 55 years or younger. CONCLUSIONS: The demand for shoulder arthroplasties in younger patients continues to increase in the United States; however, rates of hemiarthroplasties are declining. The demand has substantial implications for future revision arthroplasties, which include the direct healthcare costs of revision arthroplasty, the indirect societal burden of missed productivity owing to time away from work, and the increased burden of the need for qualified surgeons to meet the demand. Despite the increasing rate of arthroplasties performed in younger patients, current and projected demands remain greater for older patients, indicating a disproportionately greater need for shoulder arthroplasties in older patients. This is in contrast to the trends observed in the literature regarding hip and knee arthroplasties that show projected demands to be greater in younger patients. Factors responsible for the difference in demand require further investigation but may be related to changing indications, reported poorer outcomes in younger patients, the increased popularity of reverse shoulder arthroplasties in the elderly, or the evolution of nonarthroplasty options. LEVEL OF EVIDENCE: Level III, prognostic study.

Effects of total ankle arthroplasty training course on physician practice patterns and complication rates.

BACKGROUND: The purpose of this retrospective survey study was to determine the short-term effects of the AAOS/AOFAS total ankle arthroplasty (TAA) training course on participant practice patterns, implant preferences, and complication rates. METHODS: An anonymous digital survey was administered via email to all 2012 and 2013 participants. Data regarding industry courses attended, implant system preferences, surgical indications, case volume, patient age, complication rates, and overall perceptions of TAA in the three months before and after the course were collected and analyzed. RESULTS: Of the 87 participants contacted, 43 (49%) completed the entire survey. STAR (Small Bone Innovations, Inc., Morrisville, PA) was the most preferred implant before the course with 15 individuals listing it as top preference. A large percentage of participants (67%) changed implant preferences after the course. Of the 29 participants who changed preferences, 48% switched to INBONE II (Wright Medical, Arlington, TN) and 24% to STAR. Average number of TAAs performed in the 3 months before the course was 1.3 and increased significantly in the following 3 months to 2.1. Total number of reported intraoperative complications decreased from 12 before the course to 6 after, the most common being malleolar fractures. Overall, 84% of participants indicated that the course positively changed their use and perceptions of TAA and current implant systems. CONCLUSION: The main finding of this study was that the AAOS/AOFAS TAA training course changed implant system preferences, surgical indications, number of cases performed, and complication rates among participants in the short-term.

The effect of resident participation on short-term outcomes after orthopaedic surgery.

BACKGROUND: The influence of resident involvement on short-term outcomes after orthopaedic surgery is mostly unknown. QUESTIONS/PURPOSES: The purposes of our study were to examine the effects of resident involvement in surgical cases on short-term morbidity, mortality, operating time, hospital length of stay, and reoperation rate and to analyze these parameters by level of training. METHODS: The 2005­2011 American College of Surgeons National Surgical Quality Improvement Program data set was queried using Current Procedural Terminology codes for 66,817 cases across six orthopaedic procedural domains: 28,686 primary total joint arthroplasties (TJAs), 2412 revision TJAs, 16,832 basic and 5916 advanced arthroscopies, 8221 lower extremity traumas, and 4750 spine arthrodeses (fusions). Bivariate and multivariate logistic regression and propensity scores were used to build models of risk adjustment. We compared the morbidity and mortality rates, length of operating time, hospital length of stay, and reoperation rate for cases with or without resident involvement. For cases with resident participation, we analyzed the same parameters by training level. RESULTS: Resident participation was associated with higher morbidity in TJAs (odds ratio [OR], 1.6; range, 1.4­1.9), lower extremity trauma (OR, 1.3; range, 1.2­1.5), and fusion (OR, 1.4; range, 1.2­1.7) after adjustment. However, resident involvement was not associated with increased mortality. Operative time was greater (all p < 0.001) with resident involvement in all procedural domains. Longer hospital length of stay was associated with resident participation in lower extremity trauma (p < 0.001) and fusion cases (p = 0.003), but resident participation did not affect length of stay in other domains. Resident involvement was associated with greater 30-day reoperation rates for cases of lower extremity trauma (p = 0.041) and fusion (p < 0.001). Level of resident training did not consistently influence surgical outcomes. CONCLUSIONS: Results of our study suggest resident involvement in surgical procedures is not associated with increased short-term major morbidity and mortality after select cases in orthopaedic surgery. Findings of longer operating times and differences in minor morbidity should lead to future initiatives to provide resident surgical skills training and improve perioperative efficiency in the academic setting. LEVEL OF EVIDENCE: Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Reflections on current methods for evaluating skills during joint replacement surgery: a scoping review.

Valid and reliable techniques for assessing performance are essential to surgical education, especially with the emergence of competency-based frameworks. Despite this, there is a paucity of adequate tools for the evaluation of skills required during joint replacement surgery. In this scoping review, we examine current methods for assessing surgeons' competency in joint replacement procedures in both simulated and clinical environments. The ability of many of the tools currently in use to make valid, reliable and comprehensive assessments of performance is unclear. Furthermore, many simulation-based assessments have been criticised for a lack of transferability to the clinical setting. It is imperative that more effective methods of assessment are developed and implemented in order to improve our ability to evaluate the performance of skills relating to total joint replacement. This will enable educators to provide formative feedback to learners throughout the training process to ensure that they have attained core competencies upon completion of their training. This should help ensure positive patient outcomes as the surgical trainees enter independent practice.

Patient education as a strategy for provider education and engagement: a case study using myJointReplacement.ca.

MyJointReplacement.ca was initiated to integrate patient and provider perspectives with the evidence on joint replacement care into a patient education website to promote consistency in practice. The project's leadership ensured that the project fit into a larger system change initiative. The literature was reviewed and a qualitative study determined patient perspectives on what information was required. Findings were discussed with providers and integrated into the website. The site hosts nearly 1,700 one-hour sessions monthly. In a survey of 50 providers, 40 providers (80%) indicated that they would align their practice with the findings, and 45% (90%) believed that the site reflected best practice. Over 80% (n = 70) of patients surveyed indicated that the site increased their knowledge. It was concluded that developing a patient education website is an innovative approach to provider education if supported by leadership that can integrate the initiative into a broader context.

Setting up and evaluating patient information open evenings.

Staff at the Victoria infirmary patient preadmission clinic for major joint-replacement surgery recognised that the amount of information patients are given before a procedure is impossible to retain. This can lead to patients feeling ill-informed and less confident in their health care providers. An open evening was arranged to provide patients, accompanied by a friend or relative, with access to information on all aspects of their journey of care, while giving them the opportunity to meet staff and ask questions. The success of the event has resulted in it becoming a regular occurrence.