John J. Harrast

Trends in hip arthroscopy

BACKGROUND Recent advances in diagnosis and instrumentation have facilitated the arthroscopic treatment of hip pathology. However, little has been reported on trends in the utilization of hip arthroscopy. The purpose of this study was to examine changes in the use of hip arthroscopy as reflected in the American Board of Orthopaedic Surgery (ABOS) database. We also surveyed directors of both sports and joint reconstruction fellowships to determine attitudes toward hip arthroscopy training. METHODS The number of hip arthroscopy cases in the ABOS database during 1999 through 2009 was determined. A survey was devised to determine the type of hip arthroscopy training that was currently being offered at the fellowship level. RESULTS The number of hip arthroscopy procedures performed by ABOS candidates increased significantly from 0.02 cases per candidate in 1999 to 0.36 cases per candidate in 2009 (p < 0.0001). From 2003 through 2009, a significantly greater percentage of ABOS candidates with sports fellowship training (10.4%) than candidates without such training (2.9%) performed hip arthroscopy (p < 0.0001). During this same time period, candidates in the Northeast and Northwest performed the most hip arthroscopy procedures as a percentage of total procedures (p < 0.0001). Nearly half of the sports and joint reconstruction fellowships that included hip arthroscopy as a component of the training in 2010 had added it within the past three years. Fellows performed fewer than twenty hip arthroscopy cases per year in the majority of training programs. CONCLUSIONS The number of hip arthroscopy procedures performed by candidates taking Part II of the ABOS examination increased eighteenfold between 1999 and 2009. This increase is likely the result of several factors, including an increase in the number of programs offering training in hip arthroscopy.

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.

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.

The validity and reliability of a Total Hip Arthroplasty Outcome Evaluation Questionnaire.

The Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT), the Task Force on Outcome Studies of The American Academy of Orthopaedic Surgeons, and The Hip Society reached a consensus on the nomenclature to be used for the evaluation of the results of total hip arthroplasty. The Task Force of The American Academy of Orthopaedic Surgeons, to assess the results of total hip arthroplasty from the perspective of the patient, subsequently developed a questionnaire that incorporated this nomenclature. The validity and reliability data regarding this questionnaire are reported in this study. Twenty-five patients participated in the reliability test. The non-response rate was five (0.5 per cent) of 941 possible responses. Test-retest reliability was determined by calculating the Spearman correlation coefficients for each question. The coefficients ranged from 0.41 to 1.0 over a mean test-retest interval of sixteen days. Most items had Spearman coefficients that were greater than 0.50, indicating good or excellent reliability. Validity was assessed, for the fifty-four patients who participated, by calculating the Spearman correlation coefficients for the items regarding pain in the affected hip, limitation of usual activities, capacity for walking without support, and the Sickness Impact Profile. The coefficients ranged from 0.11 (pain and limitation of activity) to 0.56 (Sickness Impact Profile and limitation of activity). These coefficients reflected modest associations, as anticipated, indicating that pain, function, and health status are related yet distinct concepts.(ABSTRACT TRUNCATED AT 250 WORDS)

Geographic variation in the surgical treatment of degenerative cervical disc disease: American Board of Orthopedic Surgery Quality Improvement Initiative; part II candidates.

Study Design. Retrospective case series. Objective. To examine and document the change in rates and the geographic variation in procedure type and utilization of plating by orthopedic surgeons for anterior cervical discectomy–fusion. Summary of Background. Age- and sex-adjusted rates of cervical spine surgery have not increased, but the rate of cervical spinal fusion has, accounting for 41% of all fusion procedures in 2004. Methods. Records were selected from the American Board of Orthopedic Surgeons part II examination from 1999 to 2008. Current Procedural Terminology (CPT) and International Classification of Diseases, 9th Revision, Clinical Modification (ICDM-9-CM) codes were used to determine utilization of structural allograft, autograft/interbody devices, and anterior cervical plating over time and within geographic region. Main outcome measures were physician workforce, and rates and variation of procedure types. Results. From 1999 to 2008, the number of self-declared orthopedic spine surgeon candidates increased 24%. Over this period, the annual number of discectomies with fusions for degenerative cervical disc disease increased by 67%, whereas the number of such operations per surgeon operating on at least 1 such case increased 48% (P = 0.018). Interbody device (0%–31%; P < 0.0001), anterior cervical plating (39%–79%; P < 0.0001), and allograft (14%–59%; P < 0.0001) use increased, whereas autograft use decreased (86%–10%; P < 0.0001). The Southwest and Southeast were more likely than the Midwest to use interbody devices (OR: 2.42 and 1.66, respectively). The Southwest and Northeast were more likely than the Midwest to use autograft (OR: 1.55 and 1.49). The Southwest, Northeast, and Southeast were less likely to use allograft than the Midwest (OR: 0.408, 0.742, and 0.770). The Northeast was less likely and the Southeast more likely than the Midwest to utilize anterior cervical plating (OR: 0.67 and 1.33). Surgical complications were more often associated with autograft compared with allograft (OR: 1.61). Conclusion. From 1999 to 2008, the number of orthopedic surgeon candidates performing spine surgery has increased. These surgeons are performing more fusions and utilizing more structural allografts, interbody devices, and/or anterior cervical plates. Regional variations also remain in the types of constructs utilized.

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.

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.

Performance of candidates selecting the subspecialty of spine surgery for the Part II American Board of Orthopaedic Surgery oral certification examination.

The American Board of Orthopaedic Surgery (ABOS) was founded in 1934 to establish standards for the certification of orthopaedic surgeons and educational requirements for postgraduate training in orthopaedic surgery. Educational standards have been well established for residency training, with specific requirements spelled out to successfully complete the five-year accredited orthopaedic residency program. These requirements are clearly noted on the ABOS web site1. Over the past fifteen years, there has been a rapid increase in the number of postgraduate fellowship programs encompassing the multiple subspecialties of orthopaedic surgery. At present, >90% of graduates take a postgraduate fellowship upon completion of their residency training according to ABOS internal documentation obtained from application material. Fellowships in the subspecialties of orthopaedic surgery accredited by the Accreditation Council for Graduate Medical Education (ACGME) are available in the Graduate Medical Education Directory published by the American Medical Association2. There is a wide disparity in the number of accredited or non-accredited fellowships depending on the subspecialty selected. For instance, surgery of the hand and sports medicine have almost 100% of their fellowships accredited by the ACGME with stringent educational, training, and faculty requirements overseen by the Residency Review Committee for Orthopaedic Surgery. Other subspecialties have far fewer accredited programs. These include spine surgery, which has eighteen accredited fellowships of approximately seventy-five available programs. Presently, the ABOS has not mandated educational and training requirements for fellowships as it has previously for resident training. The ABOS recognizes that postgraduate fellowship training has become an accepted path following completion of residency. The board is also aware that non-accredited fellowships are not subject to the same educational and training requirement reviews that accredited fellowships undergo on a regular basis. From 2006 to 2010, there were 359 candidates who sat for the ABOS Part II oral examination as …

Incidence and Complications of Open Hip Preservation Surgery: An ABOS Database Review

Hip preservation surgery encompasses various surgical procedures that have the goal of decreasing the progression of osteoarthritis, preserving normal hip function, and delaying the need for arthroplasty. These procedures can encompass arthroscopic, open, and combined techniques. This study investigated the trends and complications associated with open hip preservation surgery performed by candidates undergoing Part II of the American Board of Orthopaedic Surgery examination. The American Board of Orthopaedic Surgery Part II surgeon case database was queried from the years 2003 to 2013 for Current Procedural Terminology (CPT) codes related to open hip preservation surgery in patients 10 years and older. Patient demographics, fellowship training, geographic location, and complications were extracted from the database. These data were analyzed to determine the incidence by year of individual procedures and complications. During the study period, 644 cases (352 male, 292 female; mean age, 29.7 years) and 730 CPT codes were reported. The most commonly reported fellowship was pediatric orthopedics. No trend was observed in the overall incidence of these surgeries, but there was an increase in the number of cases performed in the Midwest. There were 212 reported complications, with a rate of 33% per case, or 29% per CPT code (range, 12.5%-100% per CPT code). Complications reported ranged from infection to death. The incidence of complications over time showed no discernible trend. Based on the results of this study, the yearly incidence and complications associated with open hip preservation surgery performed by surgeons undergoing board certification should continue at a predictable rate. [Orthopedics. 2017; 40(1):e109-e116.].