Richard L. Angelo

Metric Development for an Arthroscopic Bankart Procedure: Assessment of Face and Content Validity

PURPOSE To establish the metrics (operational definitions) necessary to characterize a reference arthroscopic Bankart procedure, and to seek consensus from experienced shoulder arthroscopists on the appropriateness of the steps, as well as errors identified. METHODS Three experienced arthroscopic shoulder surgeons and an experimental psychologist (comprising the Metrics Group) deconstructed an arthroscopic Bankart procedure. Fourteen full-length videos were analyzed to identify the essential steps and potential errors. Sentinel (i.e., more serious) errors were defined as either (1) potentially jeopardizing the procedure outcome or (2) creating iatrogenic damage to the shoulder. The metrics were stress tested for clarity and the ability to be scored in binary fashion during a video review as either occurring or not occurring. The metrics were subjected to analysis by a panel of 27 experienced arthroscopic shoulder surgeons to obtain face and content validity using a modified Delphi Panel methodology (consensus opinion of experienced surgeons rendered by cyclical deliberations). RESULTS Forty-five steps and 13 phases characterizing an arthroscopic Bankart procedure were identified. Seventy-seven procedural errors were specified, with 20 designated as sentinel errors. The modified Delphi Panel deliberation created the following changes: 2 metrics were deleted, 1 was added, and 5 were modified. Consensus on the resulting Bankart metrics was obtained and face and content validity verified. CONCLUSIONS This study confirms that a core group of experienced arthroscopic surgeons is able to perform task deconstruction of an arthroscopic Bankart repair and create unambiguous step and error definitions (metrics) that accurately characterize the essential components of the procedure. Analysis and revision by a larger panel of experienced arthroscopists were able to validate the Bankart metrics. CLINICAL RELEVANCE The ability to perform task deconstruction and validate the resulting metrics will play a key role in improving surgical skills training and assessing trainee progression toward proficiency.

Magellan and Copernicus: Arthroscopy Association of North America Seeking Excellence in Education.

ne of the most important missions of the OArthroscopy Association of North America (AANA) is the education of its membership. In July 2009, the President’s Council of AANA met and discussed potential methods and strategies to upgrade the society’s educational programming. In the past, this has been accomplished primarily using a “bottom-up” approach, that is asking, “what are our most effective and highest rated programs?” and “how can we then improve on our current offerings?” Tasked by the President’s Council, a group of thought leaders from AANA chose to use a distinctly unique methodology using a different approach, or “top-down strategy.” They proposed to go out into the world and examine other businesses, industries, and professions that train highly skilled individuals and examine the best practice strategies that those other entities use. In May 2010, AANA president, Felix (Buddy) Savoie III, M.D., appointed a task force with First Vice President Richard Angelo, M.D., as its chair. The mandate for that task force was to “sail around the entire world” across different disciplines, seeking answers to the question, “What are the most effective methods being used to educate and train those individuals working in highlyskilled technical professions?” This effort to “sail the world” in search of educational pearls became known as the AANA Magellan Project (although Ferdinand Magellan did not complete the journey himself, his expedition was credited with being the first to circumnavigate the globe, or sail around the world). As promising educational strategies were discovered, the intent was for AANA to apply those educational methods to training surgeons in the principles and best practice of arthroscopic surgery. The Magellan Project included 6 subcommittees: Didactic, Surgical Skills, Electronic Media, Simulation, Outcomes/Metrics, and Health Policy/Advocacy. Within the focus of each of the subcommittees, the members conducted extensive research into potential concepts and ideas that AANA might employ to enhance surgeon education. For example, Dr. Savoie was able to provide the Outcomes/Metrics subcommittee with several contacts at the National Aeronautics

Factors Associated With Variation in Outcomes in Bariatric Surgery Centers of Excellence

ministered at embryo transfer found a lower baseline pregnancy rate to favor an association between acupuncture and clinical pregnancy rates.2 Increased age and multiple IVF cycles of women in the included trials may partly explain this finding. We acknowledge that increased acupuncture treatment sessions and frequency prior to the time of embryo transfer may yield different results. Hopefully our findings will refocus research to areas suggesting clinical benefit. Gu notes that 36.1% of women did not complete the treatment. An intention-to-treat analysis required inclusion of the 193 women whose IVF cycles were canceled and the 90 women who could not attend all 3 sessions. A per-protocol analysis found no difference in the study outcomes by attendance at all sessions vs fewer than 3 sessions. Chen and colleagues speculate that the higher trends in miscarriage rates may be attributed to inexperienced practitioners. It is unlikely that acupuncturist inexperience explains this observation. Most study practitioners were very experienced with significantly more than the minimum 2 years of clinical experience, and this group of experienced practitioners delivered most study treatments. Chen and colleagues propose that the negative outcome resulted from a nonspecific effect of the sham control, as the live birth rate was higher than the estimated baseline proposed in the sample size calculation. We acknowledged in the article that the sham control may not be inert. The overall effect of acupuncture may result from needling, specific non-needling components (palpation, education, selfcare, and diagnosis), and nonspecific components including time, attention, credibility, and expectation. In our trial and other studies using similar sham controls, needling components, such as acupuncture point location, needle insertion and stimulation, and the number of needles, were controlled. The nonspecific effect from sham may be attributed to sensory and psychosocial cues.5 Although we agree that a standard care group would have been useful to include, this may not be practical when working with clinical populations that have a strong financial and emotional investment in attaining a family.

Editorial Commentary: Healthy Skepticism: An Invaluable Trait

Using a switching stick from the posterior portal is a frequently employed method of identifying the location for the subscapularis split for a shoulder arthroscopic Latarjet. However, in a recent cadaveric study, in none of the 20 specimens studied did this technique result in the split being placed in the preferred position-the junction of the superior two-thirds and the inferior one-third of the subscapularis. As a result, if the position of the coracoid graft is too superior, the anteroinferior extension of the glenoid arc and the vector of the conjoined sling may be suboptimal and fail to restrain humeral head translation. There is thus a need for a more reliable method for establishing the subscapularis split in patients with shoulder instability and significant glenoid bone loss. Moreover, in comparison to the open Latarjet surgical technique, an arthroscopic Latarjet procedure is notably more complex, technically challenging, and involves a demanding learning curve. For any procedure, the morbidity curve is inversely related to the learning curve-the lower one is on the learning curve, the greater the expected complications. The area beneath the morbidity curve is related to increased costs to manage complications and suboptimal outcomes. Study, practice, acquisition, and refinement of the necessary skills needed to perform a complex procedure should be done primarily in the cadaver lab. It is imperative that each of us critically evaluate our own experience and clinical practice to determine if we have or expect to generate the critical volume necessary to successfully master the arthroscopic Latarjet techniques and to retain the expertise needed for optimal patient outcomes.

Editorial Commentary: “A Brush Too Broad” (Validation, Global Rating Scales, and the Like…What Do They Really Mean?)

Surgical simulation will play an increasingly important role in helping to train surgical skills. Tools of varying fidelity including benchtop models and virtual reality computer-generated simulations will be needed to most effectively train for accomplishing specific tasks and techniques. We must search for and identify how best to employ simulation to enable the trainee to master the requisite skills. It is imperative that in our investigation, validation methodologies, rating scales, and statistical tools be rigorously and accurately employed lest we be led astray by acceptance and assumption too freely given. The measure of our effectiveness will be whether or not patients enjoy improved outcomes and experience a reduction in surgical errors and complications.

Editorial Commentary: A Task May Be Done Quickly, but Not Necessarily Well.

The value of video gaming in relation to endoscopic surgical skills is explored in this article. Subjects who had more experience and performed better on 3-dimensional games also performed better on an arthroscopic simulator during tasks requiring manipulation of tools. Although the correlation is established, no data are presented to support causation. Video gaming holds promise in assisting the trainee attempting to develop components of endoscopic skill. Further investigation is required to demonstrate that improvements in performance can be expected to result.