Orthopedic resident's learning curve for arthroscopic subscapularis tendon repair: short-term clinical and radiographic outcomes

Comparison of Outcomes between Open and Arthroscopic Rotator Cuff Repair

Objective

The objective of this retrospective cohort study is to evaluate the long-term clinical and functional outcomes of two surgical techniques for rotator cuff repair, namely, open and arthroscopic methods.

Methods

A total of 100 patients diagnosed with rotator cuff tears and treated at Seyhan State Hospital in the past five years were enrolled, considering the same inclusion criteria for both groups. The study groups consisted of 50 patients who underwent open rotator cuff repair and 50 patients who underwent arthroscopic rotator cuff repair. We used the SPSS programme to analyse the data, focusing on parameters such as postoperative recovery time, functional capacity scores, pain levels measured by the VAS scale, quality of life evaluated by the SF-36 scores, and complication rates.

Results

Both methods resulted in similar recovery times and functional capacity scores, but patients treated with the open method reported slightly lower pain levels (average VAS score: 2.8) compared to those treated with the arthroscopic method (average VAS score: 3.1). The study also found slightly better quality of life scores in the arthroscopic group (average SF-36 score: 71.4) compared to the open surgery group (average SF-36 score: 68.7). The complications rates were lower in the arthroscopic group (2%) than in the open surgery group (4%), but these differences were not statistically significant.

Conclusions

The study suggests that, while there are no significant differences in terms of clinical outcomes between the two surgical methods, short-term pain levels may be influenced by the more frequent application of acromioplasty in arthroscopic methods. Therefore, the choice of the surgical method should be made based on the unique characteristics, including the location and size, the patient's overall health status, and the surgeon's experience. These findings should be used as a guide and not as absolute results.

Sleep Deprivation Adversely Impacts Resident Performance for Simulated Arthroscopy

Purpose

The purpose of the study was to assess the performance of residents in orthopaedics before and after a 24-hour shift on a shoulder arthroscopy simulator. The primary study endpoint was an overall performance score (OPS) generated by the simulator.

Methods

A prospective, comparative study of 120 simulator trials by 10 resident junior surgeons was performed in our university hospital’s simulation center between May and November 2018. To avoid memorization bias, all participants performed the same exercise 10 times on a VirtaMed ArthroS simulator prior to the study. Each resident’s performance (the OPS, the operating time, the proportion of procedures with iatrogenic lesions, the camera path length and the hook path length) in two different simulated arthroscopy exercise tasks was assessed once before and once after a 24-hour shift. This sequence was performed three times during the semester, and the change over time in performance was also evaluated.

Results

The OPS was significantly lower after the night shift (P = 0.035 for the first exercise, and P = 0.025 for the second).

Conclusion

In a group of previously trained resident junior surgeons, overall performance with an arthroscopy simulator was significantly worse after a 24-hour shift. The study of secondary parameters of the OPS and the subgroup analysis based on the sleep time and Epworth score vary depending on the type of exercise performed arthroscopically. However, the use of a simulator after a night shift did not prevent the trainee from improving his/her level of performance over time.

Level of Evidence

II, a prospective, comparative study

Clinical outcome and repair integrity after arthroscopic rotator cuff repair significantly improved during the surgeon's learning curve

HYPOTHESIS AND BACKGROUND

Whether learning curve could affect the surgical outcome after arthroscopic rotator cuff repair is still unknown. The purpose of this study was to evaluate surgical learning curve for clinical outcome and retear rate after arthroscopic rotator cuff repairs that were performed by the beginner shoulder surgeon. We hypothesized that clinical outcome and retear rate would improve over time with the accumulation of a surgeon's experience.

METHODS

This retrospective study consisted of 200 consecutive patients who had arthroscopic rotator cuff repairs, performed by a single surgeon between 2011 and 2018. We included symptomatic rotator cuff tears involving the supraspinatus/infraspinatus and/or subscapularis tendon and follow-up magnetic resonance imaging evaluations of repair integrity 6 months after surgery. Surgeon's learning was evaluated with calculation of cumulative retear rate and cumulative summation (CUSUM) analysis. Clinical outcomes and the retear rates were compared between group A (the first-half 100 patients) and group B (the latter-half of 100 patients).

RESULTS

The mean follow-up period was 21 months (range, 12-55). The overall retear rate was 13% (26 patients). The CUSUM analysis showed that after patient number 97, the curve was maintained below the level of acceptable failure rate, suggesting the competency was obtained consistently. Comparing between groups, retear rate showed significant decrease from 18% in group A to 8% in group B (P = .036). Notably, retear rate in small to medium-sized tears (<3 cm) significantly decreased from 26% (12 of 46 patients) in group A to 2% (1 of 49 patients) in group B (P = .001). However, analysis in large to massive tears (≥3 cm) failed to show difference between groups (30%, 6 of 20, in group A and 25%, 6 of 24, in group B; P = .711). In multivariate analysis, higher fatty infiltration of the supraspinatus muscle (P = .008), more severe muscle atrophy of the teres minor (P = .010), and belonging to group A (P = .011) were associated with retear.

CONCLUSION

Clinical outcomes and retear rate after arthroscopic rotator cuff repairs significantly improved during the learning curve period of a beginner shoulder surgeon.

Does Structured Postgraduate Training Affect the Learning Curve in Direct Anterior Total Hip Arthroplasty? A Single Surgeon's First 200 Cases

Background

The direct anterior approach (DAA) used for primary total hip arthroplasty has been shown to improve early postoperative outcomes, but prior studies have identified a marked learning curve for surgeons transitioning to this approach. However, these studies do not capture surgeons with postgraduate fellowship training in DAA. Therefore, the purpose of this study was to evaluate the learning curve by comparing perioperative outcomes for the first 100 to latter 100 cases and first 50 to final 50 cases.

Methods

The first 200 consecutive primary total hip arthroplasties performed by a single surgeon were prospectively followed up for up to 2 years postoperatively. Data on demographic and perioperative factors, 90-day readmissions, and short- and long-term complications were collected. Radiographic outcomes included acetabular cup anteversion and abduction measurements. Logistic regressions were used to calculate odds ratios and confidence intervals for surgical time greater than 2 hours.

Results

The first 100 and second 100 cases had significant differences in operative times (118.1 vs 110.4 minutes, P = .009), acetabular abduction (38.3 vs 35.5 degrees, P = .001) and anteversion (13.5 vs 15.1 degrees, P = .009), and incidence of neuropraxia (41 vs 9%, P < .001). Estimated blood loss, transfusions, discharge disposition, length of stay, readmission, and other complications had no statistical significance between the first and second 100 cases. The first 50 cases had higher odds of surgical time greater than 2 hours (odds ratio = 5.2, 95% confidence interval = 1.84-14.75, P = .002) than the final 50 cases.

Conclusions

When compared with the existing literature, incorporation of DAA into fellowship training can lead to reduction in fractures and reoperation rates.

Surgical outcomes for post-traumatic stiffness after elbow fracture: comparison between open and arthroscopic procedures for intra- and extra-articular elbow fractures

HYPOTHESIS

We hypothesized that arthroscopic osteocapsular arthroplasty has a comparable outcome to that of the corresponding open procedure.

METHODS

Patients treated with osteocapsular arthroplasty for post-traumatic stiffness were assigned to open procedure (OPEN) and arthroscopic procedure (ARTHRO) groups. The clinical outcomes were measured based on range of motion (ROM), Mayo Elbow Performance Score (MEPS), and visual analog scale (VAS) score. Based on the initial trauma, the patients were grouped into either intra-articular fracture (I) or extra-articular fracture (E) groups, followed by comparison of the 2 groups.

RESULTS

The overall, ROM, VAS, and MEPS scores showed improvement in both groups. Preoperative VAS scores improved from 6.6 ± 1.4 to 2.2 ± 0.9 following OPEN and from 6.5 ± 1.2 to 2.1 ± 1.0 following ARTHRO. Preoperative flexion improved from 88° ± 14° to 113° ± 17° following OPEN and from 102° ± 15° to 122° ± 8° following ARTHRO. Preoperative extension improved from 36° ± 14° to 17° ± 12° following OPEN and from 30° ± 8° to 15° ± 7.4° following ARTHRO. Preoperative MEPS improved from 48.9 ± 11.5 to 80.0 ± 14.8 following OPEN and from 52.3 ± 12.2 to 80.8 ± 7.9 following ARTHRO. All values for the clinical outcomes were worse in group I than in group E.

CONCLUSIONS

Arthroscopic osteocapsular arthroplasty is comparable to the corresponding open procedure with regard to the use of our indications. The clinical outcomes in the intra-articular fracture group as a previous trauma were worse than those in the extra-articular fracture group.

Clinical Outcome of Osteocapsular Arthroplasty for Primary Osteoarthritis of the Elbow: Comparison of Arthroscopic and Open Procedure

PURPOSE

To compare clinical and radiologic outcomes following open (OPEN) and arthroscopic (ARTHRO) osteocapsular arthroplasty for primary elbow osteoarthritis.

METHODS

Patients treated with osteocapsular arthroplasty between January 2010 and December 2015 were divided into OPEN and ARTHRO groups. OPEN was performed from January 2010 to October 2012, and ARTHRO from November 2012 to December 2015. OPEN and ARTHRO were performed in 35 and 52 elbows, respectively. Clinical outcome was measured using range of motion (ROM) arc, functional score (Mayo Elbow Performance Score [MEPS]), and pain score (visual analog scale [VAS]). Conventional radiography was used for outcome analysis. Outcomes were analyzed according to ulnohumeral joint (UHJ) narrowing using the computed tomography-based modified Broberg and Morrey classification.

RESULTS

Mean follow-up time was 36.6 ± 14.4 (24-89) and 35.4 ± 14.2 (24-83) months following OPEN and ARTHRO, respectively. Average ages were 50.0 ± 7.0 (40-63) and 52.4+10.4 (41-75) years in OPEN and ARTHRO groups, respectively. Overall scores for ROM (preoperative to final follow-up: 65.5° ± 22.8 to 112.0° ± 50.9, P < .01), MEPS (42.9 ± 13.7 to 73.7 ± 16.6, P < .01), and VAS (6.6 ± 1.3 to 4.0 ± 2.3, P < .01) were improved. Preoperative ROM improved from 64.0° ± 23.3 to 118.0° ± 17.8 following OPEN and 66.5° ± 22.6 to 108.0° ± 24.0 following ARTHRO. Preoperative MEPS improved from 40.7 ± 15.6 to 73.6 ± 16.7 following OPEN and 44.3 ± 12.2 to 73.8 ± 16.7 following ARTHRO. Preoperative VAS improved from 6.9 ± 1.2 to 3.9 ± 2.6 following OPEN and 6.4 ± 1.3 to 4.1 ± 2.0 following arthro. In both groups, the last follow-up VAS score and MEPS were worse in the narrowing group (UHJ <2 mm, grades 2 and 3) than in the intact group (UHJ >2 mm, grade 1) (P < .01).

CONCLUSIONS

Arthroscopic osteocapsular arthroplasty is comparable to the OPEN procedure in managing primary osteoarthritis of the elbow; however, the OPEN procedure shows the better outcome in improvement of flexion limitation. Neither procedures can guarantee an excellent outcome in the patients with severe UHJ narrowing.

LEVEL OF EVIDENCE

Level III, retrospective comparative trial.