Quantitative Assessment of Surgical Competence: The Arthroscopic Learning Curve (SS-58)

Abstract

To assess orthopaedic trainees performing consecutive knee and shoulder arthroscopies and evaluate procedural competence using a novel statistical method. Subjects included orthopaedic trainees in post-graduate year (PGY) 1 through 5 (n = 22) performing diagnostic knee or shoulder arthroscopy during a 3-month sports rotation. Intraoperative evaluations were completed by supervising staff physicians using a validated 10- (knee) or 14-point (shoulder) Task-Specific Checklist (TSCL) and 50-point Global Rating Scale (GRS). For the Cumulative Summation Test for Learning Curve (LC-CUSUM) analysis, a TSCL < 8 (knee) or 11 (shoulder) and GRS < 40 were considered a failure with a maximum of 10% poor procedures defined as adequate performance. Performance limits included acceptable deviation of 10% from adequate performance, a true discovery rate of 90% and a false discovery rate of 90%. The LC-CUSUM was then plotted to assess the learning phase for individual trainees. A total of 433 (340 knee, 93 shoulder) consecutive procedures were performed during the 12-month study period. Competency in knee arthroscopy for the TSCL was achieved by 8 trainees (n = 17) requiring 13 to 24 procedures and a single trainee for the GRS requiring 14 procedures. All trainees (n = 5) failed to demonstrate competency for the TSCL and GRS in shoulder arthroscopy after a mean of 18.6 procedures. Threshold adjusted curves stratified by PGY level enabled multiple trainees to achieve competency in both knee and shoulder diagnostic arthroscopy. The LC-CUSUM can be successfully applied to knee and shoulder arthroscopy to provide an individualized assessment of performance and quantitatively demonstrate competency. 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.