Is anterior knee pain following anterior cruciate ligament reconstruction a consideration for graft choice, and the influence of COVID: a qualitative analysis in recreational athletes.

BACKGROUND: We set out to investigate whether anterior knee pain following anterior cruciate ligament reconstruction has a significant effect on patients, and whether it should influence graft choice. METHODS: This was a qualitative analysis of a set of recreational athletes treated at a university hospital at about 1 year following anterior cruciate ligament reconstruction surgery. Participants were interviewed by an orthopaedic fellow and resident using structured, open-ended questions. Inductive theme analysis was used to code the data. RESULTS: There were 4 major themes: (1) Our hypothesis was that patients would be given adequate information to make an appropriate graft choice. This hypothesis was rejected. Discussion took place, but with little details or rationale for the graft choice. The predominant theme was that the surgeon made the decision, and there was a lack of reliable information for the patient to make a choice. (2) The overall theme was that most patients had no anterior knee pain, and it did not interfere with activities of daily living. (3) One theme was that patients were able to resume all sports without restriction, but in some, the anterior knee pain interfered with the more demanding activities such as impact, cutting, and pivoting. A separate theme was that fear was a major impediment to return to sports and was not related to the anterior knee pain. (4) The overriding theme was that the generalized closures associated with the COVID-19 pandemic slowed the rehabilitation process. Although virtual care was available in general, it was not particularly satisfactory. Patients indicated that they had not been able to return to the gym or to their sporting activities as a result. CONCLUSIONS: Amongst non-competitive athletes, anterior knee pain post-anterior cruciate ligament reconstruction surgery does not significantly affect activities of daily living. Although there is a minor effect on sporting activities, the inability to return to sports is related to factors such as the COVID-19 pandemic, fear, or insufficient rehabilitation, rather than anterior knee pain. Overall, anterior knee pain is not a significant factor that plays a role in determining graft choice.

Wide Variability in Return-to-Sport Criteria used by Team Physicians After Anterior Cruciate Ligament Reconstruction in Elite Athletes-A Qualitative Study.

Purpose: The purpose of this study is to explore currently used readiness to return to sport (RTS) criteria after anterior cruciate ligament reconstruction (ACLR) used in elite athletes to gain novel insights into the RTS decision-making process of professional team physicians. Methods: Eighteen qualitative semistructured interviews with professional team physicians were conducted by a single trained interviewer. The interviews were used to identify team physician concepts and themes regarding the criteria used to determine RTS after ACLR. General inductive analysis and a coding process were used to identify themes and subthemes arising from the data. A hierarchical approach in coding helped to link themes. Results: The most important RTS criteria included muscle strength, followed by satisfactory functional testing including hop tests, a satisfactory clinical examination, joint stability, psychological readiness, time since the ACLR surgery, absence of joint effusion, subjective feeling of knee stability, pain-free return to sporting movements, completion of a sport-specific rehabilitation, and at last allied team support. Conclusions: This study identified 4 main themes, including (1) objective findings, (2) informative feedback of the team members, (3) subjective findings, and (4) type of sport and time to surgery as having the most influence on RTS decision after ACLR. However, interviews showed that even among professional team physicians, the main criteria to RTS in these categories were inconsistent. A definitive set of conclusive guidelines could not be established and would be a fruitful and useful area for future research through further quantitative studies and international consensus meetings along the foundation of the presenting study. Level of Evidence: V, evidence-based practices, qualitative study.

Injection of Bone Marrow Aspirate for Glenohumeral Joint Osteoarthritis: A Pilot Randomized Control Trial.

PURPOSE: To compare the efficacy of a single, intra-articular, nonconcentrated bone marrow aspirate (BMA) injection in comparison to cortisone for the treatment of glenohumeral joint osteoarthritis (GHJ OA). METHODS: Inclusion criteria were patients between the ages of 18 and 75 with a diagnosis of GHJ OA on radiograph. Patients were randomized to receive an ultrasound-guided, intra-articular cortisone injection or BMA injection (without concentration). The primary outcome measure was the Western Ontario Osteoarthritis of the Shoulder (WOOS) index at 12 months. Secondary outcome measures were the QuickDASH, EuroQOL 5-dimensions 5-level questionnaire (EQ-5D-5L) and visual analogue scale. RESULTS: The study included 25 shoulders of 22 patients who completed baseline and 12 months' patient-reported outcome measures (12 shoulders received cortisone, 13 shoulders received BMA) after the study was terminated early by changes in Health Canada regulations. Baseline characteristics demonstrated a significant difference in the ages of the 2 groups, with the BMA group being older (61.6 vs 53.8 mean years, P = 0.021). For the BMA group, a significant improvement was seen in the WOOS index (P = 0.002), the QuickDASH (P < 0.001), and the EQ-5D-5L pain dimension (P = 0.004) between baseline and 12 months. No significant difference was seen for any outcome in the cortisone group between baseline and 12 months. No significant difference was demonstrated between changes in the WOOS scores from baseline to 12 months when compared between groups (P = 0.07). However, a significant difference in changes in scores was seen in the QuickDASH (P = 0.006) and the EQ-5D-5L pain scores (P = 0.003) and the EQ-5D-5L health scores (P = 0.032) in favor of BMA. CONCLUSIONS: The results of this study demonstrate that patients with GHJ OA treated with BMA have superior changes in the QuickDASH and EQ-5D-5L pain and health scores but not in the WOOS outcomes measures at 12 months post injection when compared to patients treated with cortisone. However, because of the limited number of patients as a result of the early termination of the study, larger randomized studies are required to confirm these findings. LEVEL OF EVIDENCE: Level II, randomized controlled trial.

Entrustable Professional Activities in Orthopaedics.

BACKGROUND: An entrustable professional activity (EPA) is defined as a core task of a specialty that is entrusted to a trainee once sufficient competence has been reached. A group of EPAs reflects the activities that clinicians commonly do on a day-to-day basis. Lists of EPAs have been created for most medical subspecialties, but not orthopaedic surgery. The aim of this study was to create a peer-reviewed list of essential EPAs that a resident must perform independently before completing orthopaedic residency training. METHODS: A focus group of 7 orthopaedic surgeons from the University of Toronto developed a comprehensive list of 285 EPAs. For each subspecialty group, the opinions of at least 15 academic and nonacademic surgeons, as well as subspecialty-trained and non-subspecialty-trained surgeons, were used. The modified Delphi method was used to rank EPAs on a five-point scale from not important to mandatory for a resident to competent before exiting training. Two Delphi rounds were used, using a threshold of >50% of surgeons considering the EPA as mandatory before being considered for the next round. A final list of EPAs was ratified using the focus group of academic surgeons involved in the study. RESULTS: Seventy-five (75) of 107 (70%) surgeons invited responded to the survey. Nearly half (129) of the 285 EPAs were discarded after the first round of Delphi. A further 118 EPAs were discarded after the second Delphi round, leaving 49 final EPAs, across 9 subspecialties in orthopaedic surgery. CONCLUSIONS: Expert consensus was used to create a list of EPAs considered mandatory for completion of resident training in orthopaedics in our province. The final 49 peer-reviewed EPAs will be a valuable benchmark in curriculum design and assessment in orthopaedic surgery in the competency-based era for other programs.

A Comparison of Quadriceps Tendon Autograft With Bone-Patellar Tendon-Bone Autograft and Hamstring Tendon Autograft for Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review and Quantitative Synthesis.

OBJECTIVE: There is growing enthusiasm for the increased use of quadriceps tendon (QT) autograft for primary anterior cruciate ligament reconstruction (ACLR). The purpose of this analysis was to synthesize and quantitatively assess the available evidence comparing QT autograft with hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografts, regarding functional outcomes, knee stability, anterior knee pain, and revision rates. DATA SOURCES: A search in MEDLINE, EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials for eligible studies up to May 2018 was conducted. Two reviewers selected studies based on inclusion criteria and assessed methodological quality. Outcomes analyzed were anterior knee pain, graft failure rates, knee stability, functional outcomes, and adverse events. Pooled analyses were performed for continuous and dichotomous variables where appropriate. MAIN RESULTS: Ten studies (1 randomized trial and 9 nonrandomized cohorts) met our inclusion criteria, which included 1398 patients. The analysis showed no statistical difference in anterior knee pain when comparing QT and HT autografts, but a significant difference between QT and BPTB autografts [odds ratio, 0.15 (95% confidence interval, 0.08-0.27); P < 0.001]. There were no differences between all 3 autografts in revision rates, knee stability, and patient-reported functional outcomes. CONCLUSIONS: Quadriceps tendon autograft is a suitable graft alternative for primary ACLR, as it achieves good clinical outcomes with a low incidence of anterior knee pain. Given the limited quality of the included studies, there is a need for a well-designed multicenter randomized control trial comparing QT autograft with other primary ACL autografts to confirm our findings. LEVEL OF EVIDENCE: Level IV systematic review.

Postoperative Pain Is Associated With Psychological and Physical Readiness to Return to Sports One-Year After Anterior Cruciate Ligament Reconstruction.

PURPOSE: To identify whether any patient factors, injury factors, or symptom severity scores are associated with either psychological or physical readiness to return to sport after anterior cruciate ligament reconstruction (ACLR). METHODS: Consecutive patients with an ACL injury that required surgical treatment were included in this study. All patients completed the single-legged hop testing and the Anterior Cruciate Ligament Return to Sport Index (ACL-RSI) at 1 year postoperatively. Multivariable regression analysis models were used to determine whether an independent relationship existed between baseline patient factors (age, sex, BMI, preinjury Marx Activity Score), injury factors (meniscal tear and chondral injury), physical symptoms (Knee Injury and Osteoarthritis Outcome Score [KOOS] for pain and symptoms), and the dependent variables of physical and psychological readiness to return to sport (single-legged hop and ACL-RSI). RESULTS: Of the 113 patients who were included, 37% were female, and the mean age of our population was 28.2 years (SD = 8.1). Multivariable regression models demonstrated that patient-reported pain symptoms at 1 year postoperatively, as measured by the KOOS pain subscale, was significantly associated with both ACL-RSI score (Beta estimate: 1.11 [95% CI: .62-1.60] P < .001) and the ability to pass the single-legged hop test (OR: 1.07 [95% CI: 1.004-1.142] P = .037). CONCLUSIONS: Patients with higher reported pain levels at 1 year following ACLR have lower psychological and physical readiness to return to sport. LEVEL OF EVIDENCE: Level 3, retrospective cohort study.

Limiting the Risk of Osteoarthritis After Anterior Cruciate Ligament Injury: Are Health Care Providers Missing the Opportunity to Intervene?

OBJECTIVE: To understand what sports orthopedic surgeons (OS), primary care physicians (PCPs) with sports medicine training, and physical therapists (PTs) managing nonelite athletes with anterior cruciate ligament (ACL) injury tell their patients about their osteoarthritis (OA) risk. METHODS: An electronic survey was distributed by the Canadian Academy of Sport and Exercise Medicine (PCPs, OS), the Sports and Orthopedic Divisions of the Canadian Physiotherapy Association (PTs), and to OS identified through the Royal College of Physicians and Surgeons and the Canadian Orthopaedic Association. The survey included 4 sections: demographics, factors discussed, timing of discussions, and discussion of risk factors and their management. Proportions or means with 95% confidence intervals were calculated. RESULTS: A total of 501 health care professionals (HCPs) responded (98 PCPs, 263 PTs, and 140 OS). Of those responding, 70-77% of physicians reported always discussing OA risk, but only 35% of PTs did. All HCPs reported that patient activities perceived as detrimental to knee health, ACL reinjury, and simultaneous injury to other structures in the knee were most often the reason for discussing OA risk. OA risk was discussed at initial management post-injury (65-94%), with few discussing risk subsequently. Eighty percent of physicians and 99% of PTs indicated that PTs were suited to provide OA risk and management information. CONCLUSION: HCPs routinely managing people with ACL injury do not consistently discuss OA risk post-injury with them. Educational strategies for HCPs are urgently needed to develop care pathways inclusive of support for OA risk management following ACL injury.

Determining the Patient Acceptable Symptomatic State for Patients Undergoing Arthroscopic Partial Meniscectomy in the Knee.

BACKGROUND: Arthroscopic partial meniscectomy is one of the most common procedures in orthopaedic surgery. The patient acceptable symptomatic state (PASS), which defines a level of symptoms above which patients consider themselves well, remains to be well-defined in this population. PURPOSE: Using an anchor-based approach, our goal was to determine the 1-year PASS for the Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee (IKDC) Subjective Knee Form, the Western Ontario Meniscal Evaluation Tool (WOMET), and the Marx Activity Scale (MAS) in patients who were treated with partial knee meniscectomy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A consecutive series of patients with knee meniscal tears and a Kellgren-Lawrence grade of 0 to 2 treated with arthroscopic partial meniscectomy were eligible. The KOOS (0-100), IKDC (0-100), WOMET (0-100), and MAS (0-16) were administered at baseline and 12 months postoperatively. An external anchor question at 1 year postoperatively was used to determine PASS values. A receiver operating characteristic curve (ROC) analysis was used to determine the PASS value at which patients considered their status to be satisfactory. RESULTS: The study included 110 patients (mean ± SD age, 53.8 ± 12.0 years), 57.3% were male, and the follow-up rate was 82%. In total, 70% of patients had an Outerbridge arthroscopic grade of 2 or lower. Based on ROC analysis, the 1-year postoperative PASS values (sensitivity, specificity) were 64.3 (47.8, 100.0) for KOOS Symptoms, 81.6 (71.6, 100.0) for KOOS Pain, 82.4 (82.1, 86.4) for KOOS Function in Daily Living, 71.0 (62.7, 81.8) for KOOS Function in Sport and Recreation, 51.0 (83.6, 95.5) for KOOS Knee-Related Quality of Life, 56.2 (82.1, 100.0) for IKDC, 58.5 (79.1, 100.0) for WOMET, and 7.0 (44.8, 68.2) for MAS. Baseline scores did not affect the PASS threshold across the different instruments. However, patients with higher baseline scores were more likely to achieve the PASS for the KOOS Symptoms (odds ratio [OR], 2.808; P = .047), IKDC (OR, 4.735; P = .006), and WOMET (OR, 2.985; P = .036). Age, sex, and cartilage status were not significantly related to the odds of achieving the PASS for any of the patient-reported outcome measures. CONCLUSION: These findings allow researchers and clinicians to determine whether partial meniscectomy is meaningful to patients at the individual level and will be helpful for responder analysis in future trials related to the treatment of meniscal abnormality.

Development of a certification examination for orthopedic sports medicine fellows

Background: The purpose of this study was to develop a multifaceted examination to assess the competence of fellows following completion of a sports medicine fellowship. Methods: Orthopedic sports medicine fellows over 2 academic years were invited to participate in the study. Clinical skills were evaluated with objective structured clinical examinations, multiple-choice question examinations, an in-training evaluation report and a surgical logbook. Fellows' performance of 3 technical procedures was assessed both intraoperatively and on cadavers: anterior cruciate ligament reconstruction (ACLR), arthroscopic rotator cuff repair (RCR) and arthroscopic shoulder Bankart repair. Technical procedural skills were assessed using previously validated task-specific checklists and the Arthroscopic Surgical Skill Evaluation Tool (ASSET) global rating scale. Results: Over 2 years, 12 fellows were assessed. The Cronbach α for the technical assessments was greater than 0.8, and the interrater reliability for the cadaveric assessments was greater than 0.78, indicating satisfactory reliability. When assessed in the operating room, all fellows were determined to have achieved a minimal level of competence in the 3 surgical procedures, with the exception of 1 fellow who was not able achieve competence in ACLR. When their performance on cadaveric specimens was assessed, 2 of 12 (17%) fellows were not able to demonstrate a minimal level of competence in ACLR, 2 of 10 (20%) were not able to demonstrate a minimal level of competence for RCR and 3 of 10 (30%) were not able to demonstrate a minimal level of competence for Bankart repair. Conclusion: There was a disparity between fellows' performance in the operating room and their performance in the high-fidelity cadaveric setting, suggesting that technical performance in the operating room may not be the most appropriate measure for assessment of fellows' competence.

Contexte: Le but de cette étude était de concevoir un examen à plusieurs volets pour évaluer la compétence des moniteurs cliniques à la fin de leur formation en médecine sportive. Méthodes: Après leur formation de 2 ans pour devenir orthopédistes en médecine sportive, les moniteurs cliniques ont été invités à participer à l'étude. Leurs habiletés cliniques ont été évaluées au moyen d'examens cliniques objectifs structurés, de questionnaires à choix multiple, d'un rapport d'évaluation en cours de formation et d'un journal de bord chirurgical. Leur habileté à réaliser 3 techniques chirurgicales différentes a été évaluée au bloc opératoire et sur des cadavres : reconstruction du ligament croisé antérieur (RLCA), réparation arthroscopique de la coiffe des rotateurs (RACR) et intervention de Bankart sous endoscopie pour l'épaule. Les habiletés techniques ont été évaluées au moyen de listes de vérification spécifiques aux tâches validées et au moyen de l'outil d'évaluation globale ASSET (Arthroscopic Surgical Skill Evaluation). Résultats: Sur une période de 2 ans, 12 moniteurs ont été évalués. Le coefficient α de Cronbach pour les évaluations techniques a été supérieur à 0,8, et la fiabilité inter-examinateurs pour l'évaluation des interventions sur des cadavres a été supérieure à 0,78, soit une fiabilité jugée satisfaisante. Lors de l'évaluation au bloc opératoire, on a jugé que tous les moniteurs détenaient le niveau minimum de compétences pour exécuter les 3 techniques chirurgicales, à l'exception d'un seul qui n'a pas atteint le niveau de compétence pour la RLCA. À l'évaluation de leurs compétences pour les interventions sur des cadavres, 2 sur 12 (17 %) n'ont pas atteint le niveau minimum de compétence pour la RLCA, 2 sur 10 (20 %) pour la RACR et 3 sur 10 (30 %) pour l'intervention de Bankart. Conclusion: On a noté une disparité dans la compétence des moniteurs entre le bloc opératoire et le contexte cadavérique haute fidélité, ce qui donne à penser que le rendement technique au bloc opératoire pourrait ne pas être le moyen le plus approprié d'évaluer la compétence des moniteurs cliniques.

Bone Marrow Mesenchymal Stromal Cell Treatment in Patients with Osteoarthritis Results in Overall Improvement in Pain and Symptoms and Reduces Synovial Inflammation.

Patients with late-stage Kellgren-Lawrence knee osteoarthritis received a single intra-articular injection of 1, 10, or 50 million bone marrow mesenchymal stromal cells (BM-MSCs) in a phase I/IIa trial to assess safety and efficacy using a broad toolset of analytical methods. Besides safety, outcomes included patient-reported outcome measures (PROMs): Knee Injury and Osteoarthritis Outcome Score (KOOS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); contrast-enhanced magnetic resonance imaging (MRI) for cartilage morphology (Whole Organ MRI Scores [WORMS]), collagen content (T2 scores), and synovitis; and inflammation and cartilage turnover biomarkers, all over 12 months. BM-MSCs were characterized by a panel of anti-inflammatory markers to predict clinical efficacy. There were no serious adverse events, although four patients had minor, transient adverse events. There were significant overall improvements in KOOS pain, symptoms, quality of life, and WOMAC stiffness relative to baseline; the 50 million dose achieved clinically relevant improvements across most PROMs. WORMS and T2 scores did not change relative to baseline. However, cartilage catabolic biomarkers and MRI synovitis were significantly lower at higher doses. Pro-inflammatory monocytes/macrophages and interleukin 12 levels decreased in the synovial fluid after MSC injection. The panel of BM-MSC anti-inflammatory markers was strongly predictive of PROMs over 12 months. Autologous BM-MSCs are safe and result in significant improvements in PROMs at 12 months. Our analytical tools provide important insights into BM-MSC dosing and BM-MSC reduction of synovial inflammation and cartilage degradation and provide a highly predictive donor selection criterion that will be critical in translating MSC therapy for osteoarthritis. Stem Cells Translational Medicine 2019;8:746&757.

Inter-surgeon variability in the identification of clock face landmarks when placing suture anchors in arthroscopic Bankart repair.

BACKGROUND: The accuracy of surgeons in utilizing the clock face method for anchor placement has never been investigated. Our hypothesis was that shoulder arthroscopy surgeons would be able to place suture anchors at predetermined positions with accuracy and reliability. METHODS: Ten cadaveric shoulders were used. Five fellowship-trained shoulder arthroscopy surgeons were directed to place a suture anchor at 3:30, 4:30, and 5:30 clock in two shoulders each. The position of the anchors was determined with computed tomography. The accuracy of placement was calculated and data analyzed with one-way analysis of variance. The intraclass correlation coefficients were calculated. RESULTS: The overall accuracy was 57%. The accuracy of anchor placement at the 3:30 position was 40% (average position 2:24 o'clock), it was 50% at the 4:30 position (average position 3:42 o'clock) and 80% at the 5:30 position (average position 5:03 o'clock). No statistical difference in accuracy between the placement of the superior, middle, and inferior anchors (p = 0.145) was seen. The intraclass correlation coefficient for inter-surgeon reliability was 0.4 (fair) while the intraclass correlation coefficient for intra-surgeon reliability was 0.6 (moderate). DISCUSSION: The findings of this study suggest a moderate degree of accuracy and fair to moderate inter- and intra-surgeon reliability when using the clock face system to guide anchor placement.

Graft-Tunnel Mismatch in Endoscopic ACL Reconstruction: Reliability of Measuring Tunnel Lengths and Intra-articular Distance.

BACKGROUND: A continued technical challenge for surgeons performing bone-patellar tendon-bone anterior cruciate ligament (ACL) reconstruction with endoscopic techniques is graft-tunnel mismatch. If tibial tunnel and intra-articular distances could be reliably estimated, surgeons could adjust the length of the femoral tunnel to minimize graft-tunnel mismatch. PURPOSE/HYPOTHESIS: To determine whether arthroscopic measurement of the following was reliable: femoral tunnel distance (FTD), tibial tunnel distance (TTD), intra-articular distance (IAD), and total distance (TD; sum of these 3 measurements). It was hypothesized that intraoperative measurement of these distances would be reliable. STUDY DESIGN: Controlled laboratory study. METHODS: Eight sports fellowship-trained orthopedic surgeons independently performed arthroscopic measurements of the FTD, TTD, IAD, and TD in 7 cadaveric knees in which femoral and tibial tunnels had been drilled. Each surgeon performed the measurements twice using an EndoButton depth gauge. Following this, each parameter was measured open with a medial parapatellar approach. Finally, a computed tomography (CT) scan of each knee was performed, with the FTD, TTD, and IAD measured by a musculoskeletal radiologist. Inter- and intrarater reliability of the arthroscopic measurements was calculated, as well as the correlation between arthroscopic measurements and open and CT measurements. RESULTS: Interrater reliability for the arthroscopic measurements was 0.8 for FTD, 0.89 for TTD, 0.61 for IAD, and 0.76 (range, 0.54-0.93) for TD. Intrarater reliability was 0.94 for FTD, 0.97 for TTD, 0.83 for IAD, and 0.93 for TD. The correlation between arthroscopic and open measurements was 0.9 for FTD, 0.94 for TTD, 0.4 for IAD, and 0.84 for TD. The correlation between arthroscopic and CT measurements was 0.85 for FTD, 0.92 for TTD, and 0.71 for IAD. CONCLUSION: The results of this study show that arthroscopic measurement of FTD and TTD has a high degree of intra- and interrater reliability, while that of IAD and TD demonstrates high intrarater reliability but moderate interrater reliability. CLINICAL RELEVANCE: Reliable measurement of the TTD and IAD can potentially allow adjustment of the FTD, minimizing graft-tunnel mismatch in endoscopic ACL reconstruction.

Validation of a Dry Model for Assessing the Performance of Arthroscopic Hip Labral Repair.

BACKGROUND: Arthroscopic hip labral repair is a technically challenging and demanding surgical technique with a steep learning curve. Arthroscopic simulation allows trainees to develop these skills in a safe environment. PURPOSE: The purpose of this study was to evaluate the use of a combination of assessment ratings for the performance of arthroscopic hip labral repair on a dry model. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 47 participants including orthopaedic surgery residents (n = 37), sports medicine fellows (n = 5), and staff surgeons (n = 5) performed arthroscopic hip labral repair on a dry model. Prior arthroscopic experience was noted. Participants were evaluated by 2 orthopaedic surgeons using a task-specific checklist, the Arthroscopic Surgical Skill Evaluation Tool (ASSET), task completion time, and a final global rating scale. All procedures were video-recorded and scored by an orthopaedic fellow blinded to the level of training of each participant. RESULTS: The internal consistency/reliability (Cronbach alpha) using the total ASSET score for the procedure was high (intraclass correlation coefficient > 0.9). One-way analysis of variance for the total ASSET score demonstrated a difference between participants based on the level of training ( F3,43 = 27.8, P < .001). A good correlation was seen between the ASSET score and previous exposure to arthroscopic procedures ( r = 0.52-0.73, P < .001). The interrater reliability for the ASSET score was excellent (>0.9). CONCLUSION: The results of this study demonstrate that the use of dry models to assess the performance of arthroscopic hip labral repair by trainees is both valid and reliable. Further research will be required to demonstrate a correlation with performance on cadaveric specimens or in the operating room.

Performance Assessment of Arthroscopic Rotator Cuff Repair and Labral Repair in a Dry Shoulder Simulator.

PURPOSE: To evaluate the use of dry models to assess performance of arthroscopic rotator cuff repair (RCR) and labral repair (LR). METHODS: Residents, fellows, and sports medicine staff performed an arthroscopic RCR and LR on a dry model. Any prior RCR and LR experience was noted. Staff surgeons assessed participants by use of task-specific checklists, the Arthroscopic Surgical Skill Evaluation Tool (ASSET), and a final overall global rating. All procedures were video recorded and were scored by a fellow blinded to the year of training of each participant. RESULTS: A total of 51 participants and 46 participants performed arthroscopic RCR and LR, respectively, on dry models. The internal consistency or reliability (Cronbach α) using the total ASSET score for the RCR and LR was high (>0.9). One-way analysis of variance for the total ASSET score showed a difference between participants based on year of training (P < .001) for both procedures. The inter-rater reliability for the ASSET score was excellent (>0.9) for both procedures. A good correlation was seen between the ASSET score and the year of training, as well as the previous number of sports rotations. CONCLUSIONS: The results of this study show evidence of construct validity when using dry models to assess performance of arthroscopic RCR and LR by residents. CLINICAL RELEVANCE: The results of this study support the use of arthroscopic simulation in the training of residents and fellows learning arthroscopic shoulder surgery.

Reliability and Validity of the Arthroscopic International Cartilage Repair Society Classification System: Correlation With Histological Assessment of Depth.

PURPOSE: To determine the interobserver reliability of the International Cartilage Repair Society (ICRS) grading system of chondral lesions in cadavers, to determine the intraobserver reliability of the ICRS grading system comparing arthroscopy and video assessment, and to compare the arthroscopic ICRS grading system with histological grading of lesion depth. METHODS: Eighteen lesions in 5 cadaveric knee specimens were arthroscopically graded by 7 fellowship-trained arthroscopic surgeons using the ICRS classification system. The arthroscopic video of each lesion was sent to the surgeons 6 weeks later for repeat grading and determination of intraobserver reliability. Lesions were biopsied, and the depth of the cartilage lesion was assessed. Reliability was calculated using intraclass correlations. RESULTS: The interobserver reliability was 0.67 (95% confidence interval, 0.5-0.89) for the arthroscopic grading, and the intraobserver reliability with the video grading was 0.8 (95% confidence interval, 0.67-0.9). A high correlation was seen between the arthroscopic grading of depth and the histological grading of depth (0.91); on average, surgeons graded lesions using arthroscopy a mean of 0.37 (range, 0-0.86) deeper than the histological grade. CONCLUSIONS: The arthroscopic ICRS classification system has good interobserver and intraobserver reliability. A high correlation with histological assessment of depth provides evidence of validity for this classification system. CLINICAL RELEVANCE: As cartilage lesions are treated on the basis of the arthroscopic ICRS classification, it is important to ascertain the reliability and validity of this method.

The effect of patient, provider and surgical factors on survivorship of high tibial osteotomy to total knee arthroplasty: a population-based study.

PURPOSE: The aim of this study was to identify the survivorship of high tibial osteotomy (HTO) to total knee arthroplasty (TKA) on a population level, and identify the patient, provider and surgical factors that influenced eventual TKA. METHODS: Administrative records from physician billings and hospital admissions were used to identify all adults in Ontario, Canada, who underwent an HTO from 1994 to 2010. The primary outcome was time to TKA, which was estimated using Kaplan-Meier (KM) survival analysis. A Cox proportional hazards model examined the risk associated with patient factors (age, sex, income and co-morbidity score), provider factors (hospital status, surgeon volume and surgeon year in practice) and surgical factors (concurrent ligament reconstruction or bone grafting; and previous chondral or meniscal surgery). RESULTS: A total of 2671 patients who underwent HTO met inclusion. The median age was 46 years (interquartile range 39-53 years), and 62 % were male. The KM survivorship of HTO to TKA at 10 years was 0.67 ± 0.01. Older age [HR 1.05 (95 % CI 1.04, 1.06), p < 0.001; 5 % increased risk for each year over age 46], female sex [HR 1.35 (95 % CI 1.17, 1.55), p < 0.001], higher comorbidity score [HR 1.58 (95 % CI 1.12, 2.22), p = 0.009] and a prior history of arthroscopy/meniscectomy [HR 1.24 (95 % CI 1.08, 1.43), p = 0.002] increased the risk of eventual TKA. However, HTO with concurrent ligament reconstruction was associated with lower [HR 0.62 (95 % CI 0.43, 0.88), p = 0.008] risk of eventual TKA. CONCLUSION: In this population, two-thirds of patients were able to avoid a TKA for 10 years after HTO. Specific factors such as older age, female sex, higher comorbidity and prior meniscectomy lowered survival rates. An understanding of patient risk factors for conversion to TKA may help guide surgeons in their selection of patients who will benefit most from HTO. LEVEL OF EVIDENCE: Retrospective cohort study, III.

Diagnosis of Engaging Bipolar Bone Defects in the Shoulder Using 2-Dimensional Computed Tomography: A Cadaveric Study.

BACKGROUND: Anatomic studies have demonstrated that bipolar glenoid and humeral bone loss have a cumulative effect on shoulder instability and that these defects may engage in functional positions depending on their size and location, potentially resulting in failure of stabilization procedures. Determining which lesions pose a risk for engagement remains challenging, with arthroscopic assessments and a 3-dimensional computed tomography (CT)-based glenoid track method being accepted approaches at this time. PURPOSE: The purpose was to investigate the interaction of humeral and glenoid bone defects on shoulder engagement in a cadaveric model. Two alternative approaches to predicting engagement were evaluated: (1) CT of the shoulder in abduction and external rotation (ABER) and (2) measurement of the glenoid lesion width and measurement of a novel parameter, the intact anterior articular angle (IAAA), on conventional 2-dimensional multiplane reformats. STUDY DESIGN: Controlled laboratory study. METHODS: Hill-Sachs and glenoid defects of varying sizes were created in 12 cadaveric upper limbs, producing 45 bipolar defect combinations. The defect characteristics were assessed using CT with the shoulder in a neutral position. ABER CT was performed with the shoulder positioned in 60° of glenohumeral abduction (corresponding to 90° of abduction relative to the trunk) and 90° of external rotation. The IAAA was measured as the cartilage arc angle anterior to the Hill-Sachs defect on the axial slice bisecting the humeral head. The performance of the ABER CT and IAAA approaches to predicting engagement were compared with the glenoid track method. RESULTS: Of the 45 defect combinations, 24 (53%) were classified as engaging using the glenoid track method. ABER CT predicted engagement accurately in 43 of 45 (96%), with a sensitivity and specificity of 92% and 100%, respectively. A logistic model based on the glenoid defect width and IAAA provided a prediction accuracy of 87%, with a sensitivity and specificity of 92% and 81%, respectively. CONCLUSION/CLINICAL RELEVANCE: Bipolar lesions at risk for engagement can be identified accurately using an ABER CT scan or by performing 2-dimensional measurements of the glenoid defect width and IAAA on conventional CT multiplane reformats. This information will be useful for surgical planning in the setting of bipolar bone defects before shoulder stabilization.

Use of an Objective Structured Assessment of Technical Skill After a Sports Medicine Rotation.

PURPOSE: The purpose of this study was to determine if the use of an Objective Structured Assessment of Technical skill (OSATS), using dry models, would be a valid method of assessing residents' ability to perform sports medicine procedures after training in a competency-based model. METHODS: Over 18 months, 27 residents (19 junior [postgraduate year (PGY) 1-3] and 8 senior [PGY 4-5]) sat the OSATS after their rotation, in addition to 14 sports medicine staff and fellows. Each resident was provided a list of 10 procedures in which they were expected to show competence. At the end of the rotation, each resident undertook an OSATS composed of 6 stations sampled from the 10 procedures using dry models-faculty used the Arthroscopic Surgical Skill Evaluation Tool (ASSET), task-specific checklists, as well as an overall 5-point global rating scale (GRS) to score each resident. Each procedure was videotaped for blinded review. RESULTS: The overall reliability of the OSATS (0.9) and the inter-rater reliability (0.9) were both high. A significant difference by year in training was seen for the overall GRS, the total ASSET score, and the total checklist score, as well as for each technical procedure (P < .001). Further analysis revealed a significant difference in the total ASSET score between junior (mean 18.4, 95% confidence interval [CI] 16.8 to 19.9) and senior residents (24.2, 95% CI 22.7 to 25.6), senior residents and fellows (30.1, 95% CI 28.2 to 31.9), as well as between fellows and faculty (37, 95% CI 36.1 to 27.8) (P < .05). CONCLUSIONS: The results of this study show that an OSATS using dry models shows evidence of validity when used to assess performance of technical procedures after a sports medicine rotation. However, junior residents were not able to perform as well as senior residents, suggesting that overall surgical experience is as important as intensive teaching. CLINICAL RELEVANCE: As postgraduate medical training shifts to a competency-based model, methods of assessing performance of technical procedures become necessary.

How to set the bar in competency-based medical education: standard setting after an Objective Structured Clinical Examination (OSCE).

BACKGROUND: The goal of the Objective Structured Clinical Examination (OSCE) in Competency-based Medical Education (CBME) is to establish a minimal level of competence. The purpose of this study was to 1) to determine the credibility and acceptability of the modified Angoff method of standard setting in the setting of CBME, using the Borderline Group (BG) method and the Borderline Regression (BLR) method as a reference standard; 2) to determine if it is feasible to set different standards for junior and senior residents, and 3) to determine the desired characteristics of the judges applying the modified Angoff method. METHODS: The results of a previous OSCE study (21 junior residents, 18 senior residents, and six fellows) were used. Three groups of judges performed the modified Angoff method for both junior and senior residents: 1) sports medicine surgeons, 2) non-sports medicine orthopedic surgeons, and 3) sports fellows. Judges defined a borderline resident as a resident performing at a level between competent and a novice at each station. For each checklist item, the judges answered yes or no for "will the borderline/advanced beginner examinee respond correctly to this item?" The pass mark was calculated by averaging the scores. This pass mark was compared to that created using both the BG and the BLR methods. RESULTS: A paired t-test showed that all examiner groups expected senior residents to get significantly higher percentage of checklist items correct compared to junior residents (all stations p < 0.001). There were no significant differences due to judge type. For senior residents, there were no significant differences between the cut scores determined by the modified Angoff method and the BG/BLR method. For junior residents, the cut scores determined by the modified Angoff method were lower than the cut scores determined by the BG/BLR Method (all p < 0.01). CONCLUSION: The results of this study show that the modified Angoff method is an acceptable method of setting different pass marks for senior and junior residents. The use of this method enables both senior and junior residents to sit the same OSCE, preferable in the regular assessment environment of CBME.

Cognitive and Psychomotor Entrustable Professional Activities: Can Simulators Help Assess Competency in Trainees?

BACKGROUND: An entrustable professional activity describes a professional task that postgraduate residents must master during their training. The use of simulation to assess performance of entrustable professional activities requires further investigation. QUESTIONS/PURPOSES: (1) Is simulation-based assessment of resident performance of entrustable professional activities reliable? (2) Is there evidence of important differences between Postgraduate Year (PGY)-1 and PGY-4 residents when performing simulated entrustable professional activities? METHODS: Three entrustable professional activities were chosen from a list of competencies: management of the patient for total knee arthroplasty (TKA); management of the patient with an intertrochanteric hip fracture; and management of the patient with an ankle fracture. Each assessment of entrustable professional activity was 40 minutes long with three components: preoperative management of a patient (history-taking, examination, image interpretation); performance of a technical procedure on a sawbones model; and postoperative management of a patient (postoperative orders, management of complications). Residents were assessed by six faculty members who used checklists based on a modified Delphi technique, an overall global rating scale as well as a previously validated global rating scale for the technical procedure component of each activity. Nine PGY-1 and nine PGY-4 residents participated in our simulated assessment. We assessed reliability by calculating the internal consistency of the mean global rating for each activity as well as the interrater reliability between the faculty assessment and blinded review of videotaped encounters. We sought evidence of a difference in performance between PGY-1 and PGY-4 residents on the overall global rating scale for each station of each entrustable professional activity. RESULTS: The reliability (Cronbach's α) for the hip fracture activity was 0.88, it was 0.89 for the ankle fracture activity, and it was 0.84 for the TKA activity. A strong correlation was seen between blinded observer video review and faculty scores (mean 0.87 [0.07], p < 0.001). For the hip fracture entrustable professional activity, the PGY-4 group had a higher mean global rating scale than the PGY-1 group for preoperative management (3.56 [0.5] versus 2.33 [0.5], p < 0.001), postoperative management (3.67 [0.5] versus 2.22 [0.7], p < 0.001), and technical procedures (3.11 [0.3] versus 3.67 [0.5], p = 0.015). For the TKA activity, the PGY-4 group scored higher for postoperative management (3.5 [0.8] versus 2.67 [0.5], p = 0.016) and technical procedures (3.22 [0.9] versus 2.22 [0.9], p = 0.04) than the PGY-1 group, but no difference for preoperative management with the numbers available (PGY-4, 3.44 [0.7] versus PGY-1 2.89 [0.8], p = 0.14). For the ankle fracture activity, the PGY-4 group scored higher for postoperative management (3.22 [0.8] versus 2.33 [0.7], p = 0.18) and technical procedures (3.22 [1.2] versus 2.0 [0.7], p = 0.018) than the PGY-1 groups, but no difference for preoperative management with the numbers available (PGY-4, 3.22 [0.8] versus PGY-1, 2.78 [0.7], p = 0.23). CONCLUSIONS: The results of our study show that simulated assessment of entrustable professional activities may be used to determine the ability of a resident to perform professional tasks that are critical components of medical training. In this manner, educators can ensure that competent performance of these skills in the simulated setting occurs before actual practice with patients in the clinical setting.