The Knee Arthroscopy Learning Curve: Quantitative Assessment of Surgical Skills Justin L. Hodgins, M.D., Christian Veillette, M.D., M.Sc., David Biau, M.D., Ph.D., and Ranil Sonnadara, Ph.D.

Purpose: To assess orthopaedic trainees performing diagnostic knee arthroscopies and evaluate procedural competence using a novel statistical method, the Cumulative Summation Test for Learning Curve (LC-CUSUM). Methods: Twenty orthopaedic trainees in postgraduate year (PGY) 1 through 5 performed diagnostic knee arthroscopy and were evaluated intraoperatively with a validated 10-point knee task-specific checklist (TSCL) and 50-point global rating scale (GRS). A score of 40 points or greater (of 50 points) for the GRS and 8 points or greater (of 10 points) for the knee TSCL was considered to indicate a successful procedure. For the LC-CUSUM analysis, adequate performance was defined as a 10% failure rate, inadequate performance was defined as a 30% failure rate, and an acceptable deviation from adequate performance was defined as 10%. A limit h equal to 1.6 was selected to give a true-discovery rate of 90% and a falsediscovery rate of 10% over 50 procedures. Results: A total of 340 consecutive procedures were performed by 20 trainees during the 12-month study period. The cumulative number of arthroscopic procedures performed by trainees before study start increased with increasing PGY. The median number of arthroscopic procedures performed per trainee was 16.5 (interquartile range, 14 to 21.75). Competency in knee arthroscopy for the TSCL was achieved by 8 trainees (40%), after a median of 16 procedures (interquartile range, 13 to 20), and for the GRS by only a single trainee (5%), after 14 procedures. Threshold-adjusted curves stratified by PGY level enabled multiple trainees to achieve competency for both the TSCL and GRS. Conclusions: The LC-CUSUM can be successfully applied to knee arthroscopy to provide an individualized assessment of performance and quantitatively demonstrate competency for basic arthroscopic tasks. Clinical Relevance: The LC-CUSUM is an effective method to evaluate procedure competence in arthroscopic training and can provide objective feedback and benchmarks in the learning phase.

T

he achievement of arthroscopic technical proficiency is a complex task. Early arthroscopic learning can be associated with iatrogenic injury, often as damage to articular cartilage, and the process is inefficient in terms of time and cost.1-3 The boundaries of arthroscopic capabilities continue to expand, as do the technical From the Department of Orthopaedic Surgery, University of Toronto (J.L.H.), and Toronto Western Hospital (C.V.), Toronto, Ontario; McMaster University (R.S.), Hamilton, Ontario, Canada; and Département de Chirurgie Orthopédique, Hôpital Cochin (D.B.), Paris, France. Investigation performed within the Division of Orthopaedics, University of Toronto Sports Medicine Program, Women’s College Hospital, and University Health Network, Toronto, Ontario, Canada. The authors report the following potential conflict of interest or source of funding: C.V. receives support from Smith & Nephew, Biomet, and Stryker. Received August 21, 2013; accepted February 13, 2014. Address correspondence to Justin L. Hodgins, M.D., Department of Orthopaedic Surgery, University of Toronto, 827-111 Elizabeth St, Toronto, ON M5G 1P7, Canada. E-mail: [email protected] Crown Copyright Ó 2014 Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America. 0749-8063/13609/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.02.021

demands of the procedures. When combined with the implementation of work-hour restrictions, low case loads, and variable quality in both arthroscopic teaching and instructor skill, the adequacy of arthroscopic training during residency has become an increasing concern.4,5 The required operative experience and instruction to attain technical competencies remain uncertain, and few specific guidelines exist within the arthroscopic community.6 Traditionally, arthroscopic skills have been assessed in the operating room and competency has been determined by 1 of 2 methods. In the first method, a predetermined number of cases are prescribed, which fails to take into account that not all individuals may achieve proficiency during the allotted number of procedures.7 Alternatively, observation by a senior surgeon is used, but the subjectivity of this method has been criticized and it has been shown that the actual level of skill is not necessarily reflected.8 To combat inefficiencies, emphasis is shifting to the application of surgical skill assessment tools that have been validated in simulated environments and cadaveric models.9-11 However, these instruments

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have not yet been applied to trainees performing live arthroscopic procedures, and the best method to translate serial evaluation scores into interpretable feedback remains unclear. Technical competency assessment in other surgical disciplines has identified a statistical tool that determines when a predefined level of performance has been achieved, the Cumulative Summation Test for Learning Curve (LC-CUSUM).12-15 It allows for a quantitative assessment of an individual learning process and provides a graphical representation of the learning curve.16,17 Within the fields of obstetrics and gynecology, the LC-CUSUM has been successfully applied to evaluate fetoscopic laser ablation, embryo transfer, and fetal ultrasound quality control.12-15,18 First, the acceptable quality of a procedure is determined; this is depicted by achieving a particular success rate or a minimum evaluated score. Serial evaluations are then completed and inputted into the LC-CUSUM to generate a graphical interpretation of the learning phase. When the curve stabilizes, the predefined level of performance has been achieved. For example, a study investigating competence in performing fetal ultrasound examinations set an acceptable absolute error in birth weight estimation of greater than 15%. The LC-CUSUM determined that the appropriate level of accuracy had been consistently achieved by 3 different trainees after performing 20, 166, and 177 ultrasound examinations, showing the variability in technical ability that may exist among individual trainees.18 For an endoscopist, the learning curve of retrograde cholangiopancreatography over an 8-year period was analyzed retrospectively using the LC-CUSUM and signaled that, at the 79th procedure, sufficient evidence had accumulated to prove the endoscopist competent.17 The LC-CUSUM provides both objective and individualized assessment that aggregates evaluations into a decisiondcompetent or not competent. The purpose of this study is to assess orthopaedic trainees performing diagnostic knee arthroscopies and evaluate procedural competence using a novel statistical method, the LC-CUSUM. It was hypothesized that no difference in competency would be shown between senior- and junior-level trainees and that the LC-CUSUM would be an effective method to examine arthroscopic learning curves by providing objective visual feedback.

Methods Subjects Research ethics board approval for the study was obtained from 3 university-affiliated hospitals. The subjects comprised 20 orthopaedic trainees in postgraduate year (PGY) 1 through 5 performing diagnostic knee arthroscopy and partial meniscectomy during 3-month orthopaedic sports medicine rotations in the academic year of July 1,

2011, to June 30, 2012. As expected, the cumulative number of arthroscopic procedures performed before study start increased with increasing PGY (Table 1). Each participant was allocated a random numerical identifier that was to be listed on his or her evaluation sheets. Participation was voluntary, individuals completed a demographic questionnaire on study entry, and the number of arthroscopic procedures performed before study start was recorded from the University of Toronto’s POWER case-log database.19 We included only those procedures for which the resident’s participation as the primary surgical assistant was documented as greater than 51% to 100%. Supervising staff surgeons observed orthopaedic trainees as they performed diagnostic knee arthroscopies and partial meniscectomies on patients, and they completed a 2-page evaluation assessing performance for each procedure. There were 6 staff surgeons for the knee arthroscopy evaluation; each was a board-certified practitioner with a subspecialty interest in arthroscopy. The trainees were blinded to the scores of their evaluations. Assessment Tool The instrument chosen for the intraoperative evaluation of knee arthroscopy was the Basic Arthroscopic Knee Skill Scoring System (BAKSSS),10 a validated objective assessment tool consisting of a task-specific checklist (TSCL) and a global rating scale (GRS). The 10-point TSCL records which components of the procedure are completed, with the first 7 items consisting of relevant landmarks in diagnostic knee arthroscopy and the last 3 items evaluating the quality of the partial meniscectomy (Fig 1A). The GRS is a 50-point scale consisting of a 1- to 5-point Likert-type scale separated into 10 categories, each evaluating a different quality of the procedure (Fig 1B). Evaluations were only administered if the trainee had participated in the procedure from its start, including correct portal placement and insertion of the arthroscope. When the staff surgeon intervened because of a failure of timely progression or for technical reasons, the assessment instruments were completed for the steps up to that point in the procedure only and the evaluation was considered to be over. The primary

Table 1. Relation Between PGY of Training and Number of Knee Arthroscopies Performed Before Study Start No. of Arthroscopic Procedures PGY 1 2 3 4 5

No. of Subjects 5 3 8 1 3

NA, not applicable.

Mean (SD) 0 12.3 (5.8) 14.8 (5.8) 30 (NA) 35 (4.1)

Range 0 8-19 9-27 d 32-40

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Fig 1. (A) TSCL evaluation instrument. (B) GRS evaluation instrument. (ACL, anterior cruciate ligament; PCL, posterior cruciate ligament.)

outcome was the demonstration of competency by an orthopaedic trainee in diagnostic knee arthroscopy and partial meniscectomy as depicted by the TSCL. Secondary outcomes included the demonstration of competency by the GRS and the number of procedures required to achieve competency for diagnostic knee arthroscopy and partial meniscectomy.

Statistical Methods The LC-CUSUM is a statistical tool used to determine when a trainee has reached a predefined level of performance.17 The LC-CUSUM sequentially tests the null hypothesis that performance is unacceptable. A score (St) is computed from successive procedures, with successes yielding an increase in the total score and

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Fig 1. (Continued).

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KNEE ARTHROSCOPY LEARNING CURVE Table 2. Competency Results

Total No. GRS TSCL

Study Participants 20

Arthroscopies Performed 340

Competency

Median Procedure Number/ Mean Procedure Number

Interquartile Range (Quartile 1 to Quartile 3)

1 participant 8 participants

d/14 16/17.7

d 13.5 to 20

failures yielding a decrease. Once the score reaches a predefined value (h), the null hypothesis is rejected and performance is considered acceptable and the trainee competent. Graphically, the cumulative LC-CUSUM score is displayed on the y-axis against procedures on the x-axis. The performance of the trainee is considered inadequate as long as the score remains below the limit h. Once the decision limit h has been reached, the trainee is considered competent. A limit h equal to 1.6 was selected to give a true-discovery rate (akin to power) of 90% and a false-discovery rate (akin to type I error) of 10% over 50 procedures. In accordance with the original study, a clinically significant difference of 10 points and 2 points was used for the GRS and TSCL, respectively. Therefore a score of 40 points or greater (of 50 points) for the GRS and 8 points or greater (of 10 points) for the TSCL was considered to indicate a successful procedure. If the minimum score was not achieved, the procedure was considered a failure. For the LC-CUSUM limits, adequate performance was defined as a 10% failure rate, inadequate performance was defined as a 30% failure rate, and an acceptable deviation from adequate performance was defined as 10%. These performance limits were based on criteria outlined in other surgical specialties in which the LCCUSUM had been introduced to evaluate procedural competence.12,14,18 A trainee was considered competent once the performance limits described above had been achieved, as depicted by the LC-CUSUM graph. The median number of procedures (first and third quartile range, or interquartile range) needed to reach competency for each procedure was calculated. Statistical analysis was performed using R software (R Foundation for Statistical Computing, Vienna, Austria).

Results A total of 340 arthroscopic procedures performed by the 20 orthopaedic trainees were evaluated during the 12-month study period. The number of arthroscopic procedures was asymmetrically distributed among the trainees, with a median of 16.5 (interquartile range, 14 to 21.75). The LC-CUSUM scores were calculated, and competencies for the TSCL and GRS for each trainee were determined (Table 2). Competency for the TSCL was achieved by 8 trainees (40%), after a median of 16 procedures (interquartile range, 13.5 to 20). Competency for the GRS was only achieved by a single

individual (5%), after 14 procedures (Fig 2). The partition of trainees according PGY level is shown in Table 3. For the 8 trainees who were able to achieve competency for the TSCL, lower absolute numbers of knee arthroscopies were required to obtain competency with increasing PGY level (24 procedures for PGY 1; 16 procedures for PGY 2 and for PGY 3; and 13 procedures for PGY 5).

Discussion Although procedural competence was demonstrated by a number of trainees, overall competency, especially for the GRS instrument, was poorer than predicted. The capacity to demonstrate competency is influenced by prior arthroscopic experience, and considerable variation existed among individual trainees. Most of the technical learning curve data in arthroscopic training have been limited to the demonstration of construct validity of simulated environments or the introduction of new intraoperative assessment tools rather than the examination of individual learning processes.2,10,20-26 The use of this type of evaluation process as a pass-fail examination to assess diagnostic arthroscopy of the knee has been validated within the cadaveric model.27 Emphasis is now shifting toward the development of instruments to evaluate complex tasks such as meniscal repair.28,29 However, these outcome instruments rate individual procedures and only provide a static picture of the evaluation process. The LC-CUSUM is designed to interpret serial evaluations and decide when the learning curve for a procedure is complete. It has been successfully applied to the examination of technical competencies in other surgical specialties, including obstetrics and gynecology, ophthalmology, and general surgery.15-18 Of the 20 trainees performing diagnostic knee arthroscopy and partial meniscectomy, 8 were able to achieve competency for the TSCL, after a median of 16 procedures, and only a single individual achieved competency for the GRS, after 14 procedures. This finding is consistent with previous findings showing that the TSCL is a less sensitive instrument and illustrates that the fundamental steps for the procedure can be learned with minimal experience.10 The inability of many senior residents to achieve competency for basic arthroscopic tasks in the knee based on evaluation with the LC-CUSUM is surprising. Previous studies have suggested that high

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Fig 2. LC-CUSUM scores for diagnostic knee arthroscopy and partial meniscectomy: TSCL (A) and GRS (B). Once the threshold (h) has been reached, the trainee has achieved competency.

case volumes may be required, but the absolute quantity for proficiency remains unclear.6,7,19 More concerning, commonly performed arthroscopic procedures such as anterior cruciate ligament reconstruction, rotator cuff repair, and shoulder stabilization are far more complex and technically demanding than diagnostic procedures. It is possible that the case volumes were too small and that, with a higher number of procedures, trainees would have been able to cross the threshold of competency. The proximity and projected path of the curves in the knee

GRS (Fig 2B) support this hypothesis. Ultimately, trainees may require longer arthroscopic rotations with increased frequency of cases and overall case volumes to obtain competency. Evidence from a survey of arthroscopic training in US orthopaedic residency programs suggests that residents feel less prepared during arthroscopic training compared with that during open procedures.30 This is the rationale for the augmenting of arthroscopic training with surgical simulation, bioskills laboratories, and psychomotor conditioning.21-26

Table 3. Arthroscopic Procedures Required to Achieve Competency in Knee Arthroscopy According to PGY

PGY 1 2 3 4 5

No. of Subjects 5 3 8 1 3

Q1, quartile 1; Q3, quartile 3.

Median No. of Procedures Performed (Q1/Q3) 18 (15.5/22.5) 22 (21/23) 15 (14/20) 10 11 (7/18)

Median No. of Procedures Performed to Achieve Competency (Q1/Q2) GRS d d d d 14 (d)

TSCL 24 (d) 16 (13.5/20) 16 (14.5/18.5) d 13 (d)

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Fig 3. Variation in individual trainee LC-CUSUM scores for knee arthroscopy.

Next, the evaluation parameters may have been too rigorous. Consensus on the minimum quality of an arthroscopic procedure and consistency during subsequent procedures to be considered a competent arthroscopist has not been reached. In our investigation the minimum score to consider an individual procedure a success or failure was adapted from the validation study for the BAKSSS. Likewise, the parameters defining acceptable versus unacceptable performance for the LC-CUSUM were developed by mutual agreement of the participating surgeons. There remains a considerable gap on how best to define and evaluate competency within the arthroscopic community. Our study provides insight into how it may be possible to start quantitating this process for individual trainees and provide feedback, but evaluation method standardization is still required before specific case volumes for competency can be suggested. Comparison of individual learning curves showed considerable variation among trainees (Fig 3). When we observed those with similar arthroscopic experience, some individuals showed rapid progression (green curve) whereas others were characterized by early

Fig 4. GRS LC-CUSUM scores for diagnostic knee arthroscopy and partial meniscectomy adjusted according to PGY level.

successes and failures before accelerating to competency (blue curve). Furthermore, some traineesddespite performing numerous proceduresdfailed to show evidence of improvement (aqua curve). This is consistent with the notion that some trainees are unable to achieve competence in basic arthroscopic tasks despite sustained practice.31 This concept replicated that in a randomized study suggesting that the ability of trainees to acquire and develop technical skills may have an impact on individual career choices.32 Other variations in the curves are best explained by overall arthroscopic experience because trainees were evaluated during different phases of the learning process. For example, the number of procedures required to achieve competency for the knee TSCL decreased with increasing PGY level (Table 3). In this case the observation period was shifted forward in time for senior trainees compared with those with less arthroscopic experience, as reflected by fewer study procedures required to demonstrate competency. In addition to the determination of absolute competency, the LC-CUSUM has other applications. The

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generation of visual benchmarks for objective feedback and tailored assessments is possible. The performance limits of the test can be adjusted from those of an expert arthroscopist and competency to what would be appropriate for a given training level. For instance, if acceptable performance for the knee GRS were deemed 40 points or greater for PGY 5, 35 points or greater for PGY 3 to 4, and 30 points or greater for PGY 1 to 2, the resultant learning curves would show multiple trainees deemed competent for their level of training (Fig 4). Trainees can be evaluated against the expected performance for their level of training and be given direct feedback. Those with deficiencies can be objectively identified and given additional training, whereas those deemed competent could be accelerated through the process. Lessons learned while optimizing the learning curve could help curb inefficiencies in arthroscopic education and reduce time, cost, and patient morbidity. Ultimately, subsequent investigations are required to further standardize the evaluation process and define performance limits to help determine absolute case volumes required for competency. Limitations We note limitations to our study. Blinded assessment of outcomes was not feasible given the number of arthroscopic procedures performed at multiple hospital sites. Assessors were supervising surgeons aware of the trainees’ PGY levels, potentially introducing bias into the evaluations. The small sample size should also be recognized as a limitation of the investigation because the median number of evaluations completed for each trainee was 16.5. The BAKSSS is an objective evaluation tool validated within the knee model, consisting of a TSCL and a GRS.10,33 It is a simple and practical tool that can generate benchmarks to facilitate monitoring during orthopaedic training. Since its introduction, the construct validity and inter-rater reliability of the instrument have been reproduced.34 This instrument is limited to the assessment of basic arthroscopic skills and does not necessarily reflect competency in complex procedures or assess competency in clinical practice. At the study start, the BAKSSS was the only evaluation tool that had been described; since that time, more comprehensive and sensitive instruments have become available.9,20 The Arthroscopic Skills Assessment Form is a 100-point tool used to objectively evaluate diagnostic knee arthroscopy, assigning points for correctly identifying structures and time to completion, as well as including point deductions for iatrogenic cartilage injury. The Objective Assessment of Arthroscopic Skills consists of multiple skill domains, each rated on an expertisebased scale with 5 skill-level options, and has shown excellent internal consistency and test-retest reliability.19 The Arthroscopic Surgery Skill Evaluation Tool is a video-based assessment tool that has been validated in a

simulated environment and shown to be reliable for pass-fail assessment of basic arthroscopic skills.35

Conclusions The LC-CUSUM can be successfully applied to knee arthroscopy to provide an individualized assessment of performance and quantitatively demonstrate competency for basic arthroscopic tasks.

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The knee arthroscopy learning curve: quantitative assessment of surgical skills.

To assess orthopaedic trainees performing diagnostic knee arthroscopies and evaluate procedural competence using a novel statistical method, the Cumul...
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