Sports Medicine Fellowship Training Significantly Increases Sports Case Volume: An Analysis of ACGME Case Log Data from 2006 to 2019

Complications, Reoperations, and Readmissions After Common Arthroscopic Sports Medicine Procedures of the Knee: An Analysis of the ABOS Part II Oral Examination Case List Database

BACKGROUND

Arthroscopic knee surgeries are among the most commonly performed orthopaedic surgeries, yet complications of these procedures are relatively understudied.

PURPOSE

To determine the rate of complications, reoperations, and readmissions for arthroscopic knee surgeries by procedure, patient characteristics, and physician fellowship training status using a large national database.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Data were collected from the American Board of Orthopaedic Surgery (ABOS) database for early-career orthopaedic surgeons taking the ABOS Part II Oral Examination between 2003 and 2022. We queried the type and frequency of complications, unexpected 90-day reoperations, and readmissions for patients undergoing sports medicine knee arthroscopy. Chi-square test and analysis of variance were used to determine the effect of fellowship training status, geographic region of practice, patient age, and patient sex on outcomes of interest.

RESULTS

Of 138,823 knee arthroscopic procedures, 10,450 complications were self-reported, making for an overall complication rate of 7.53%. Unexpected 90-day reoperation and readmission rates were calculated to be 1.16% and 0.91%, respectively. Posterior cruciate ligament reconstruction had the highest complication rate (26.38%). Sports medicine fellowship-trained physicians had a significantly higher rate of complications (P < .001) compared with their non-sports medicine fellowship-trained peers (8.43% and 7.06%, respectively). Female patients had a higher complication rate (7.72%) than males (7.40%) (P = .02). Patients aged 20 to 29 had the highest rate of complications and reoperations (10.29% and 1.56%, respectively), whereas patients aged 70 to 79 had the highest rate of readmission (1.47%). Geographic regions of practice had significantly different complication and reoperation rates (P < .01). The rate of deep venous thrombus was 0.57%, and the rate of pulmonary embolism was 0.12%. Forty-two patients died, for an overall 0.03% mortality rate.

CONCLUSION

The overall rate of self-reported complications was 7.53%, and the 90-day rate of unexpected reoperation and unexpected readmission was 1.16% and 0.91%, respectively. Patient sex, patient age, sports medicine fellowship training status, and geographic region of practice all affected rates of complications, reoperations, and readmissions. Knee arthroscopy carries many risks of which patients should be aware before undergoing these procedures.

Establishing Benchmarks for Case Minimum Requirements During Accreditation Council for Graduate Medical Education-Accredited Orthopaedic Sports Medicine Fellowship Training

BACKGROUND

Accrediting bodies and professional societies for surgical education are increasingly recognizing the need for case minimum requirements to enhance standardized training.

PURPOSE

To determine case volume benchmarks for operative training during Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic sports medicine fellowships in the United States.

STUDY DESIGN

Cross-sectional analysis; Level of evidence, 3.

METHODS

Case volume percentiles were calculated across ACGME-defined case categories and temporal changes analyzed with linear regression. Variability was defined as the fold difference between the 90th and 10th percentiles by case volume. Sensitivity analyses were performed to identify potential targets for case minimum requirements.

RESULTS

Case logs from 1281 orthopaedic sports medicine fellows were analyzed. There was an increase in the mean reported case volume over the study period (from 323.3 ± 125.0 to 375.6 ± 144.0; P = .049). Pediatric patients accounted for a minority of cases (annual range, 6%-7%). The bottom 10th and 30th percentiles of fellows reported a total of 179 and 239 cases, respectively. Most cases were reported in the rotator cuff (29%), meniscus (26%), and knee instability (21%) categories. Variability in the reported case volume was greatest in hip arthroscopic surgery (37.0), patellofemoral instability (15.5), the foot and ankle (12.9), and elbow instability (10.7). Variability decreased for knee instability (P = .006) and total (P = .028) cases over the study period but increased for foot and ankle (P = .002), knee multiligament repair/reconstruction (P = .008), and knee osteotomy (P = .025) cases.

CONCLUSION

Surgical benchmarks can assist future trainees and faculty identify areas to improve the operative experience and reduce variability during fellowship training. The operative experience of recent fellows suggests a potential case minimum target between 179 and 239 cases to achieve the 10th and 30th percentiles, respectively. However, further research is needed to establish evidence-based case minimum requirements for ACGME-accredited orthopaedic sports medicine fellowship training.

Long-term Outcomes of Multiligament Knee Injuries in American Football Players

BACKGROUND

Long-term outcomes for isolated anterior cruciate ligament (ACL) reconstructions in competitive American football athletes are well reported in the literature, but little data currently exist regarding multiligament knee injury (MLKI) reconstruction outcomes.

PURPOSE

To examine patient-reported and return-to-sport outcomes of competitive American football athletes who underwent primary, single-staged, multiligament knee reconstruction.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We identified patients from our institution's prospectively collected data repository between 2001 and 2020 who underwent single-staged surgical reconstruction of an MLKI sustained during competitive participation in American football. We assessed patient-reported outcomes at a minimum of 2 years after surgery using the International Knee Documentation Committee (IKDC) Subjective Knee Form and questions regarding surgical satisfaction and return to sport. Successful return to sport was defined as a return to preinjury level of competition. We summarized all outcome data and compared outcomes between 2-ligament and >2-ligament groups and between ACL-only MLKI injury and bicruciate MLKI injury groups using independent t test for IKDC scores and chi-square test for return to sport. Additionally, we evaluated predictors of postoperative IKDC scores using linear regression and predictors of return to sport using logistic regression.

RESULTS

Outcome data were successfully collected for 53 of 73 total eligible patients (73%; mean follow-up time, 7.7 ± 4.0 years; all male; mean age at surgery, 18.1 ± 2.7 years). The mean postoperative IKDC score was 84 ± 16. The most common level of preinjury competition was high school (n = 36; 68%), followed by college (n = 10; 19%). Seven patients did not return to sport competition at any level due to limitations from their knee surgery, and 82% of patients that attempted to return to preinjury level of sport were able to do so. A total of 50 patients (94%) were satisfied or very satisfied with their surgical outcome. The 2-ligament (n = 39) and >2-ligament (n = 14) groups did not significantly differ in IKDC scores (P = .96) or proportions with successful return to sport (P = .77). Similarly, the ACL-MLKI injury (n = 39) and bicruciate MLKI injury (n = 14) groups did not significantly differ in IKDC scores (P = .89) or proportions with successful return to sport (P = .77). Age and body mass index were not significantly associated with IKDC scores or successful return to sport at follow-up (all P > .05).

CONCLUSION

This study may represent the largest cohort of competitive American football athletes evaluated for longitudinal outcomes after multiligament knee reconstruction. Despite the severity of these injuries, we found good knee-related function and that the large majority of athletes who attempted to return to sport were successful. The majority of athletes (94%) were satisfied with their operative treatment.

Orthopedic surgery residents reported increased shoulder procedure volumes during the COVID-19 pandemic

Background

The purpose of this study is to evaluate the impact of the COVID-19 pandemic on shoulder procedure volumes reported to the Accreditation Council for Graduate Medical Education by orthopedic surgery residents.

Methods

We performed a retrospective review of Accreditation Council for Graduate Medical Education case logs reporting data from graduating orthopedic surgery residents during the academic years of 2006-2022. Data were queried for all patients for the following shoulder Current Procedural Terminology codes: incision, excision, intro or removal, repair/revision/reconstruction, fracture and/or dislocation, manipulation, arthroscopy, trauma, and total procedures performed. Individual t-tests were used to compare case log trends of graduating academic years before (classes of 2018 and 2019) and during (classes of 2020, 2021, and 2022) the COVID-19 pandemic. Statistical significance was established to be P <.05 for total procedure types, but at P <.005 during category comparisons to protect against alpha errors.

Results

Reported mean total shoulder procedures per resident steadily increased each year from 2017 to 2022, but the only significant increase was seen when comparing the graduating classes of 2020 to 2021 (157.9 vs. 165.7, P =.02). Stratification of these procedures by subgroup revealed a significant increase in manipulation procedures from 2021 to 2022 (7.3 vs. 8.8, P =.001).

Discussion/Conclusion

COVID-19 did not have a negative impact on logged shoulder procedure volume. Orthopedic surgery residents graduating during the COVID-19 pandemic reported more shoulder procedures than those graduating prepandemic. However, shoulder procedure log trends should be longitudinally investigated, as preceding years of procedural opportunities may underestimate the pandemic's impact.