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Arthroscopy training in France: A resident perception and self-assessment
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Original article
Arthroscopy training in France: A resident perception and self-assessment Charles Pioger a,d,∗ , Édouard Harly b,c , Simon Rattier d,c , Aurore Blancheton e,c , Elise Loock f,c , Charles Grob g,c , Quentin Baumann d,c , Corentin Pangaud h,d , Junior French Arthroscopic Societyd a
Service de chirurgie orthopédique, hôpital La Pitié Salpêtrière, 83, boulevard de l’Hôpital, 75013 Paris, France Service de chirurgie orthopédique, hôpital Pellegrin, place Amélie Raba-Léon, 33000 Bordeaux, France c Société francophone d’arthroscopie Junior (SFAJ), 15, rue Ampère, 92500 Rueil-Malmaison, France d Service de chirurgie orthopédique, hôpital d’Amiens-Picardie, 1, Rond-Point du Professeur Christian-Cabrol, 80054 Amiens, France e Service de chirurgie orthopédique, hôpital de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes, France f Service de chirurgie orthopédique, hôpital de Lille, 2, avenue Oscar-Lambret, 59000 Lille, France g Service de chirurgie orthopédique, hôpital de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France h Service de chirurgie orthopédique, hôpital Sainte-Marguerite, 270, boulevard de Sainte-Marguerite, 13009 Marseille, France b
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Article history: Received 4 July 2019 Accepted 11 September 2019 Available online xxx Keywords: Education Residency Arthroscopy Virtual reality simulator
a b s t r a c t Background: Arthroscopic surgery is a steadily expanding component of orthopaedic practice that changes continuously as new techniques and indications develop. The many arthroscopy training activities offered to residents include fellowships, practice on cadaver specimens and simulators, and teaching in the operating room. Current practices for arthroscopy training of orthopaedic residents in France have not yet been evaluated. The objectives of this study were to describe current arthroscopy training practices and to assess the perceptions and expectations of residents and junior physicians in France, in order to contribute to the development of a new training strategy for residents. Hypothesis: Residents and junior physicians perceive gaps in their arthroscopy training. Methods: Between November 2018 and February 2019, the Junior French Arthroscopy Society (Société Francophone d’Arthroscopie Junior, SFAJ) conducted a descriptive epidemiological survey of 918 residents, clinical fellows, and junior physicians in orthopaedic surgery departments in France. The data were collected via an online questionnaire sent by e-mail. The questionnaire had items on demographics; perceptions of, and expectations about, arthroscopy skills training during the residency; and experience in performing arthroscopic procedures. Results: Of the 918 residents, 106 responded to the questionnaire. Most respondents were near the end of their training: 26 (24.8%) were 4th-year residents, 23 (21.6%) were 5th-year residents, 15 (14.3%) were clinical fellows, and 13 (12.4%) were junior physicians. Among respondents, 42 (40%) had performed fewer than 5 simple arthroscopy procedures as the main operator and 73 (69.5%) felt they were not, or would not be, capable of performing arthroscopic procedures without supervision by the end of their residency. Conclusion: The survey findings highlighted the challenges encountered by French orthopaedics residents in acquiring satisfactory arthroscopy skills during their residency. They also suggested avenues for improvement such as simulator training or the development of training on cadaver specimens. Level of evidence: IV, descriptive survey. © 2019 Elsevier Masson SAS. All rights reserved.
∗ Corresponding author. E-mail address: [email protected] (C. Pioger). https://doi.org/10.1016/j.otsr.2019.09.013 1877-0568/© 2019 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Pioger C, et al. Arthroscopy training in France: A resident perception and self-assessment. Orthop Traumatol Surg Res (2019), https://doi.org/10.1016/j.otsr.2019.09.013
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1. Introduction
2.3. Statistical analysis
Arthroscopic surgery is a rapidly expanding field in which the acquisition of proficiency is deemed a key component of orthopaedic surgery training [1,2]. Nevertheless, orthopaedic residents, notably in the US, have expressed a perception of being less well trained in arthroscopic surgery than in open surgery. Thus, 67% of orthopaedic surgery residents in the US felt the time spent on arthroscopic training was insufficient [3]. The resources available for teaching the arthroscopy skills that must be acquired by the well-rounded orthopaedic surgeon include observation and participation in procedures performed by senior surgeons in the operating room, subspecialty fellowship training [4], practice on cadaver specimens in the anatomy laboratory, and the more recently introduced simulator training techniques. Residents have expressed preferences for some of these resources over others [5]. However, efficacy varies across training methods. The recently introduced simulation tools, including virtual reality simulator training, are generating vigorous debate. In one survey, residents identified operating room experience as the most valuable training resource [6]. Other studies, however, depict virtual reality simulation as a novel training method that offers multiple advantages[7–9]. At the knee and shoulder, the history of arthroscopic procedures extends over several decades in university centres. Other joints, such as the wrist, hip, and ankle, were found amenable to arthroscopic surgery more recently. Few surgeons are experienced in arthroscopy at these sites, which has a long learning curve that is challenging to complete due to the small number of procedures performed [10]. The objectives of this study were to describe current arthroscopy training practices and to assess the perceptions and expectations of residents and junior physicians in France, with the goal of contributing to the development of a new training strategy for residents. The hypothesis was that residents and junior physicians perceive gaps in their arthroscopy training.
The variables were described as n (%). For some variables, the values were collapsed into relevant categories (e.g., age group and desired proportion of arthroscopy in the overall professional activity).
2. Material and methods 2.1. Study design From November 2018 to February 2019, the Junior French Arthroscopy Society (Société Francophone d’Arthroscopie Junior, SFAJ) conducted a survey of residents, fellows, and junior physicians in orthopaedic departments in France who were aged 18 to 35 years and were following the advanced orthopaedic surgery curriculum. E-mail addresses of 918 eligible individuals obtained from the Young Orthopaedic Surgeon’s Association (Collège des Jeunes Orthopédistes, CJO) and SFAJ were used to send an online questionnaire. The questionnaire was also spread via Facebook, Twitter, and LinkedIn. 2.2. Questionnaire The questionnaire had 48 items in the following eight sections: demographic data, skills training during the residency, arthroscopy experience, scientific studies, inter-university arthroscopy degree, interactions with scientific societies (conferences and training sessions), personal perception of arthroscopy training, and location and pathways of training (residency rotations, inter-university degree, fellowship) (Table 1). Some of the items were open (e.g., in which city did you train?) and others were closed, allowing for a yes/no answer (e.g., are you a member of the SFAJ?) or for the reporting of a quantitative continuous variable (e.g., how many arthroscopies have you performed?).
3. Results Completed questionnaires were returned by 106 individuals and form the basis for this study. Table 2 reports the main characteristics of the respondents. The respondents were aged 24 years or older; among them, 58 (54.3%) were 28 to 32 years of age. The only respondent who was older than 35 years was excluded from the analysis. Most of the French university training and research units were represented, the only exceptions being Rennes, Reims, Limoges, and units in overseas departments. The majority of respondents were nearing the end of their training, with 26 (24.8%) 4th-year residents, 23 (21.6%) 5th-year residents, 15 (14.3%) clinical fellows, and 13 (12.4%) junior physicians. In addition, 15 (14.3%) respondents were fellowship residents, gold-medal residents, or acting residents. Most respondents planned that arthroscopy would account for less than half their overall professional activity. The desired proportion of arthroscopic activity was 20% to 50% for 56.2% of respondents, 0% to 20% for 9.5% of respondents, and more than 50% for 34.4% of respondents (Fig. 1). When asked about desired practice modalities, 47 (44.8%) respondents chose private practice only, 22 (21%) both private and hospital practice, and 9 (8.6%) hospital practice only; 27 respondents had not yet decided. 3.1. Arthroscopy experience acquired during training The questionnaire asked about experience being the main operator for simple arthroscopy procedures, defined as long head of biceps tenotomy, meniscectomy, and arthroscopic joint exploration. Among the respondents, 42 (40%) reported performing fewer than 5, and 29 (27.6%) more than 30, simple arthroscopy procedures. Another questionnaire item asked about being the main operator or primary assistant for complex arthroscopy procedures defined as anterior cruciate ligament (ACL) reconstruction, cuff repair, and Bankart repair. Among the respondents, 40% reported experience with at least 5 cases and 28.6% with over 30 cases. Finally, 73 (69.5%) respondents reported having observed at least 5 arthroscopic procedures on joints other than the knee and shoulder (hand, hip, ankle) since the beginning of their training. 3.2. Residency training When asked about the type of healthcare institution that provided the highest quality arthroscopy training, 30 (28.6%) respondents named community hospitals, 31 (29.5%) private hospitals, and 33 (31.4%) university hospitals. The remaining 11 respondents had no opinion on this point (Table 3). Finally, the vast majority of respondents (n = 98, 93.3%) were favourable to having a rotation validated in a private institution. 3.3. Inter-university arthroscopy degree Among the respondents, 32 (30.5%) had obtained, and 24 (22.9%) were taking, the inter-university degree in arthroscopy. The remaining 49 (46.7%) participants had never registered for the inter-university arthroscopy degree. Most of the respondents who had completed or were following the inter-university curriculum
Please cite this article in press as: Pioger C, et al. Arthroscopy training in France: A resident perception and self-assessment. Orthop Traumatol Surg Res (2019), https://doi.org/10.1016/j.otsr.2019.09.013
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Type of institution providing the best training Views a rotation in a private hospital favourably If yes, which modality? Number of pathology lab sessions/year Number of simulator sessions/year Experience Simple arthroscopies/semester (diagnostic/tenotomy/meniscectomy . . .) Complex arthroscopies/semester (cuff repair/Bankart/Ligament reconstruction) Arthroscopy on joints other than shoulder and knee Scientific Studies Oral communication E-poster Article Number of articles read
Inter-university degree in arthroscopy Semester of degree completion Theoretical training
Skills training Ease in finding a supervisor Are you aware of the validation modalities? Resources for further training E-learning Case studies with experts Case studies without experts Dissection Are you aware that this inter-university degree is scheduled for elimination? Scientific societies and conferences Are you a member of SFA Junior? Do you follow SFA Junior on social media? Attendance at SFA meetings Attendance at the SFA Junior meeting session Attendance at the Young Arthroscopist Meeting (JJA) Opinions Arthroscopy learning curve? Proficient in arthroscopy At residency completion? At completion of post-residency training? Selecting patients to arthroscopy? Your sources of advice regarding arthroscopy
Training site Arthroscopy training? Does the industry contribute to your training? Rotations outside the subdivision What are your sources for rotations outside the subdivision? Waiting time? a b c
Response F/M 24-28/29-32/33-35 Resident (semester n◦ )/fellow–junior physician < 20%/20-50%/51-80%/> 80% Hospital/Private practice/Both/Undecided 0 to 10 Number in a university hospital Number in a community hospital Number in a private hospital university/community/private Yes/No Validating rotation/Fellowship/DIUa supervisor/Weekly visit/Monthly visit 0 to 10 0 to 10 <5/5-15/16-30/>30
0 to 10
>1/week 1/week 1/month 1/semester None 1st to 10th/after residency completion Highly satisfactory Satisfactory Difficult/Inadequate Impossible/Useless
Yes/No/Unsure
Yes/No Frequency: 1/week - 1/month–1/quarter 1/semester - 1/year Yes/No Yes/No Programme: satisfactory/unsatisfactory?
Linear/Stepwise/Exponential
Yes/No Yes/insufficiently/No Your seniors The literature Curriculum for the DESb /DESCc /DIU Other University hospital/community hospital/private hospital/DIU/the industry YES/NO Yes 1/Yes > 1/Yes > 2 NO impossible/NO useless Seniors/other residents Platform, e.g., INVIVOX 0/6 months/1 year/Longer
Interuniversity degree in arthroscopy. Advanced studies degree. Complementary advanced studies degree.
Please cite this article in press as: Pioger C, et al. Arthroscopy training in France: A resident perception and self-assessment. Orthop Traumatol Surg Res (2019), https://doi.org/10.1016/j.otsr.2019.09.013
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Respondents n = 105 Sex, n (%) Male Female Age group (years), n (%) 24 29 33 Years of training, n (%) 1st-year resident 2nd-year resident 3rd-year resident 4th-year resident 5th-year resident Fellows and junior physicians Other City of training, n (%) Paris Lyon Marseille Lille Bordeaux Strasbourg Other
86 (81.9) 19 (18.1) 29 (27.6) 57 (54.3) 19 (18.1) 2 (1.9) 5 (4.8) 6 (5.7) 26 (21.9) 23 (26.7) 28 (26.7) 15 (14.3) 24 (22.9) 9 (8.6) 6 (5.7) 7 (6.7) 7 (6.7) 4 (3.7) 48 (45.7)
Fig. 2. Perceptions of theoretical teaching during the inter-university arthroscopy degree.
Fig. 3. Perceptions of skills training during the inter-university arthroscopy degree.
Fig. 1. Desired proportion of arthroscopic activity.
Table 3 Type of healthcare institution providing the highest quality arthroscopy training, according to the 105 questionnaire respondents. Type of healthcare institution, n (%) of respondents n = 105 Community hospital Private hospital University hospital No opinion
30 (28.6%) 31 (29.5%) 33 (31.4%) 11 (10.5%)
were nearing the end of their residency: 38.4% and 43.6%, respectively, registered during the 4th and 5th residency year. The theoretical teaching received as part of the inter-university degree was deemed very comprehensive, comprehensive, and acceptable by 19.6%, 47.1%, and 25.5% of degree participants,
respectively; the remaining 7.9% felt the theoretical teaching was inadequate (Fig. 2). Corresponding proportions for skills training were 26%, 28%, 22%, and 16% (Fig. 3). Finally, nearly a third (32.3%) of degree participants experienced difficulties in finding a supervisor for their inter-university degree work.
3.4. Annual SFA meetings Among the respondents, 41.9% had never attended an SFA meeting, 26.7% had attended a single meeting, and 31.4% had attending more than one meeting (Fig. 4).
3.5. Arthroscopy proficiency Among the respondents, 73 (69.5%) felt they were not, or would not be at the end of their training, proficient in performing arthroscopy procedures without supervision. In addition, 40 (38.1%) residents and clinical fellows felt they were unable to select patients to arthroscopy.
Please cite this article in press as: Pioger C, et al. Arthroscopy training in France: A resident perception and self-assessment. Orthop Traumatol Surg Res (2019), https://doi.org/10.1016/j.otsr.2019.09.013
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Fig. 4. Attendance to French Arthroscopy Society (SFA) meetings.
3.6. Avenues for improvement Among the arthroscopy training resources listed in the questionnaires, e-learning was approved by 76.2% of respondents, case study review with an expert by 88.6%, simulator skills training by 87.6%, and attendance to demonstrations on cadaver specimens by 93.3%. 4. Discussion The results of this survey indicate that orthopaedic surgery residents and clinical fellows are dissatisfied with their arthroscopy training. Most (69.5%) respondents felt they were not, or would not be, fully proficient at the end of their residency. Furthermore, 40% of respondents, most of whom were nearing the end of their training, had performed fewer than 5 simple arthroscopy procedures as the main operator. These findings are consistent with a report by the Arthroscopy Association of North America (AANA) that an orthopaedics surgery residency is not an arthroscopy residency [11]. In addition, several recent studies point to considerable variability in arthroscopy training across universities and, perhaps also across students [1,12]. The number of arthroscopy procedures that must be performed to acquire proficiency remains unclear [2]. Nevertheless, the number of arthroscopies performed can serve as a measure of the skills acquired by orthopaedic surgery residents [13,14]. A questionnaire survey was conducted by Leonard et al. among residents and consultants attending an international orthopaedic conference [15]. The respondents felt that the number of procedures needed to achieve proficiency, defined as the ability to perform the procedure without supervision, was 63 to 70 for partial medial meniscectomy and more than 100 for ACL reconstruction. Among residents surveyed by Keith et al., 70% felt comfortable after performing at least 30 arthroscopies but nearly 30% cited a higher number of at least 40 [8]. Several scientific societies have determined minimum arthroscopy volumes required to become a member. The AANA, for instance, requires at least 50 arthroscopies per year and the
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American Board of Orthopaedic Surgery (ABOS) at least 75 arthroscopies in addition to 1 year of sports surgery fellowship training [16,17]. The perception of inadequate arthroscopy training revealed by our survey probably explains why the respondents felt they had not acquired, or would not acquire, proficiency by the end of their residency. Hall et al. [3] found a similar lack of confidence of residents in their ability to perform arthroscopic procedures without supervision after their residency. Thus, the confidence level was 75%-80% for simple procedures (diagnostic arthroscopy) but dropped to about 50% for more complex procedures such as cuff repair or ACL reconstruction. The findings from this survey invite questions about the potential offered by new training resources and by observation and participation in the operating room. Among resources, cadaver specimen demonstrations were the most highly appreciated by the respondents. Camp et al. reported a twice faster rate of knee arthroscopy proficiency acquisition with cadaver specimen training compared to simulator training [18]. Thus, cadaver specimen training may perform better than simulation, which was the second preferred resource in our survey. However, cadaver specimens are less widely available than are virtual reality simulators, which are not yet used routinely for arthroscopy training in France. Many studies have shown better arthroscopy skills among residents who trained on simulators compared to those without access to this resource [9,19–22]. In addition, in a study by Cannon et al. operating room performance was better among residents who had trained on a simulator than among controls who had not [23]. In France, the reform of the third and last part of the medical school curriculum invites a discussion of whether simulation training should be made mandatory [24]. As with the US, funding restrictions may prove to be the main limiting factor [25]. Among the respondents, over 90% had a favourable opinion of training in private hospitals, either as a validating rotation within the usual residency curriculum or as a fellowship. Surgeons surveyed by Vitale et al., stated that a sports medicine fellowship was the best training method for arthroscopic cuff repair, followed by practice on cadaver specimens [26]. The main limitation of this study is the questionnaire design. Furthermore, given the fairly low response rate, the findings may not apply to the entire population of residents in France. However, our response rate was within the range usually obtained in surveys of medical residents [3,8,27]. No analysis was performed to determine whether the level of arthroscopic activity correlated with year of training. Such an analysis would probably have further highlighted the inadequacies of residency training, since clinical fellows and junior physicians clearly perform larger numbers of arthroscopies than do residents.
5. Conclusion The results of this survey highlighted the obstacles encountered by residents in France as they seek to acquire adequate training in arthroscopy procedures. They also identify several avenues for improvement. A reappraisal of current training modalities is in order to better support the development of arthroscopy skills among residents in France. Increased use of simulation is an option that holds considerable appeal and is viewed favourable by residents.
Disclosure of interest The authors declare that they have no competing interest.
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Funding None. Study managed under the aegis of French Arthroscopy Society. Authors’ contribution Charles Pioger, corresponding author: writing and study coordination. Édouard Harly, Charles Grob, Quentin Baumann: helped in writing. Simon Rattier: data collection and result analysis. Elise Loock, Aurore Blancheton: survey creation and on-line release. Corentin Pangaud: helped in study design and writing.
[12]
[13]
[14]
[15]
[16] [17]
References [18] [1] Gil JA, Waryasz GR, Owens BD, Daniels AH. Variability of arthroscopy case volume in orthopaedic surgery residency. Arthroscopy 2016;32:892–7, http://dx.doi.org/10.1016/j.arthro.2016.01.018. [2] O’Neill PJ, Cosgarea AJ, Freedman JA, Queale WS, McFarland EG. Arthroscopic proficiency: a survey of orthopaedic sports medicine fellowship directors and orthopaedic surgery department chairs. Arthroscopy 2002;18:795–800. [3] Hall MP, Kaplan KM, Gorczynski CT, Zuckerman JD, Rosen JE. Assessment of arthroscopic training in U.S. orthopedic surgery residency programs–a resident self-assessment. Bull NYU Hosp Jt Dis 2010;68:5–10. [4] Daniels AH, DiGiovanni CW. Is subspecialty fellowship training emerging as a necessary component of contemporary orthopaedic surgery education? J Grad Med Educ 2014;6:218–21, http://dx.doi.org/10.4300/JGME-D-14-00120.1. [5] Koehler R, John T, Lawler J, Moorman C, Nicandri G. Arthroscopic training resources in orthopedic resident education. J Knee Surg 2015;28:67–74, http://dx.doi.org/10.1055/s-0034-1368142. [6] Wolf BR, Britton CL. How orthopaedic residents perceive educational resources. Iowa Orthop J 2013;33:185–90. [7] Hui Y, Safir O, Dubrowski A, Carnahan H. What skills should simulation training in arthroscopy teach residents? A focus on resident input. Int J Comput Assist Radiol Surg 2013;8:945–53, http://dx.doi.org/10.1007/s11548-013-0833-7. [8] Keith K, Hansen DM, Johannessen MA. Perceived Value of a Skills Laboratory With Virtual Reality Simulator Training in Arthroscopy: A Survey of Orthopedic Surgery Residents. J Am Osteopath Assoc 2018;118:667–72, http://dx.doi.org/10.7556/jaoa.2018.146. [9] Frank RM, Wang KC, Davey A, Cotter EJ, Cole BJ, Romeo AA, et al. Utility of modern arthroscopic simulator training models: a metaanalysis and updated systematic review. Arthroscopy 2018;34:1650–77, http://dx.doi.org/10.1016/j.arthro.2017.10.048. [10] Hoppe DJ, de Sa D, Simunovic N, Bhandari M, Safran MR, Larson CM, et al. The learning curve for hip arthroscopy: a systematic review. Arthroscopy 2014;30:389–97, http://dx.doi.org/10.1016/j.arthro.2013.11.012. [11] Committee on Ethics, Standards, the Board of Directors of the Arthroscopy Association of North America. Suggested guidelines for the practice of
[19]
[20]
[21]
[22]
[23]
[24] [25]
[26]
[27]
arthroscopic surgery. Committee on Ethics and Standards and the Board of Directors of the Arthroscopy Association of North America. Arthroscopy 2011;27:A28, http://dx.doi.org/10.1016/S0749-8063(11)00344-6. Hinds RM, Gottschalk MB, Strauss EJ, Capo JT. Trends in Arthroscopic Procedures Performed During Orthopaedic Residency: An Analysis of Accreditation Council for Graduate Medical Education Case Log Data. Arthroscopy 2016;32:645–50, http://dx.doi.org/10.1016/j.arthro.2015.11.015. Malangoni MA, Biester TW, Jones AT, Klingensmith ME, Lewis FR. Operative experience of surgery residents: trends and challenges. J Surg Educ 2013;70:783–8, http://dx.doi.org/10.1016/j.jsurg.2013.09.015. Robbins L, Bostrom M, Craig E, Sculco TP. Proposals for change in orthopaedic education: recommendations from an orthopaedic residency directors’ peer forum. J Bone Joint Surg Am 2010;92:245–9, http://dx.doi.org/10.2106/JBJS.I.00210. Leonard M, Kennedy J, Kiely P, Murphy PG. Knee arthroscopy: how much training is necessary? A cross-sectional study. Eur J Orthop Surg Traumatol 2007;17:359–62, http://dx.doi.org/10.1007/s00590-007-0197-1. Arthroscopy Association of North America web site. Available at: http://www.aana.org/membership/category.html. Accessed January 2008. The American Board of Orthopaedic Surgery website: Availat: http://www.abos.org/ ModDefault.aspx?module=Dipl able omates§ion=SportsOver.Accessed October 31, 2009. Camp CL, Krych AJ, Stuart MJ, Regnier TD, Mills KM, Turner NS. Improving Resident Performance in Knee Arthroscopy: A Prospective Value Assessment of Simulators and Cadaveric Skills Laboratories. J Bone Joint Surg Am 2016;98:220–5, http://dx.doi.org/10.2106/JBJS.O.00440. Henn RF, Shah N, Warner JJP, Gomoll AH. Shoulder arthroscopy simulator training improves shoulder arthroscopy performance in a cadaveric model. Arthroscopy 2013;29:982–5, http://dx.doi.org/10.1016/j.arthro.2013.02.013. Aïm F, Lonjon G, Hannouche D, Nizard R. Effectiveness of Virtual Reality Training in Orthopaedic Surgery. Arthroscopy 2016;32:224–32, http://dx.doi.org/10.1016/j.arthro.2015.07.023. Rebolledo BJ, Hammann-Scala J, Leali A, Ranawat AS. Arthroscopy skills development with a surgical simulator: a comparative study in orthopaedic surgery residents. Am J Sports Med 2015;43:1526–9, http://dx.doi.org/10.1177/0363546515574064. Yari SS, Jandhyala CK, Sharareh B, Athiviraham A, Shybut TB. Efficacy of a virtual arthroscopic simulator for orthopaedic surgery residents by year in training. Orthop J Sports Med 2018;6, http://dx.doi.org/10.1177/2325967118810176 [2325967118810176]. Cannon WD, Garrett WE, Hunter RE, Sweeney HJ, Eckhoff DG, Nicandri GT, et al. Improving residency training in arthroscopic knee surgery with use of a virtual-reality simulator. A randomized blinded study. J Bone Joint Surg Am 2014;96:1798–806, http://dx.doi.org/10.2106/JBJS.N.00058. Harly E, Azzolin L, Walbron P, Common H, Baumann Q. Simulateur d’arthroscopie: vers une formation obligatoire? Maîtrise Orthopédique 2017. Karam MD, Pedowitz RA, Natividad H, Murray J, Marsh JL. Current and future use of surgical skills training laboratories in orthopaedic resident education: a national survey. J Bone Joint Surg Am 2013;95:e4, http://dx.doi.org/10.2106/JBJS.L.00177. Vitale MA, Kleweno CP, Jacir AM, Levine WN, Bigliani LU, Ahmad CS. Training resources in arthroscopic rotator cuff repair. J Bone Joint Surg Am 2007;89:1393–8, http://dx.doi.org/10.2106/JBJS.F.01089. Burns KEA, Duffett M, Kho ME, Meade MO, Adhikari NKJ, Sinuff T, et al. A guide for the design and conduct of self-administered surveys of clinicians. CMAJ 2008;179:245–52, http://dx.doi.org/10.1503/cmaj.080372.
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Original article
Arthroscopy training in France: A resident perception and self-assessment Charles Pioger a,d,∗ , Édouard Harly b,c , Simon Rattier d,c , Aurore Blancheton e,c , Elise Loock f,c , Charles Grob g,c , Quentin Baumann d,c , Corentin Pangaud h,d , Junior French Arthroscopic Societyd a
Service de chirurgie orthopédique, hôpital La Pitié Salpêtrière, 83, boulevard de l’Hôpital, 75013 Paris, France Service de chirurgie orthopédique, hôpital Pellegrin, place Amélie Raba-Léon, 33000 Bordeaux, France c Société francophone d’arthroscopie Junior (SFAJ), 15, rue Ampère, 92500 Rueil-Malmaison, France d Service de chirurgie orthopédique, hôpital d’Amiens-Picardie, 1, Rond-Point du Professeur Christian-Cabrol, 80054 Amiens, France e Service de chirurgie orthopédique, hôpital de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes, France f Service de chirurgie orthopédique, hôpital de Lille, 2, avenue Oscar-Lambret, 59000 Lille, France g Service de chirurgie orthopédique, hôpital de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France h Service de chirurgie orthopédique, hôpital Sainte-Marguerite, 270, boulevard de Sainte-Marguerite, 13009 Marseille, France b
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Article history: Received 4 July 2019 Accepted 11 September 2019 Available online xxx Keywords: Education Residency Arthroscopy Virtual reality simulator
a b s t r a c t Background: Arthroscopic surgery is a steadily expanding component of orthopaedic practice that changes continuously as new techniques and indications develop. The many arthroscopy training activities offered to residents include fellowships, practice on cadaver specimens and simulators, and teaching in the operating room. Current practices for arthroscopy training of orthopaedic residents in France have not yet been evaluated. The objectives of this study were to describe current arthroscopy training practices and to assess the perceptions and expectations of residents and junior physicians in France, in order to contribute to the development of a new training strategy for residents. Hypothesis: Residents and junior physicians perceive gaps in their arthroscopy training. Methods: Between November 2018 and February 2019, the Junior French Arthroscopy Society (Société Francophone d’Arthroscopie Junior, SFAJ) conducted a descriptive epidemiological survey of 918 residents, clinical fellows, and junior physicians in orthopaedic surgery departments in France. The data were collected via an online questionnaire sent by e-mail. The questionnaire had items on demographics; perceptions of, and expectations about, arthroscopy skills training during the residency; and experience in performing arthroscopic procedures. Results: Of the 918 residents, 106 responded to the questionnaire. Most respondents were near the end of their training: 26 (24.8%) were 4th-year residents, 23 (21.6%) were 5th-year residents, 15 (14.3%) were clinical fellows, and 13 (12.4%) were junior physicians. Among respondents, 42 (40%) had performed fewer than 5 simple arthroscopy procedures as the main operator and 73 (69.5%) felt they were not, or would not be, capable of performing arthroscopic procedures without supervision by the end of their residency. Conclusion: The survey findings highlighted the challenges encountered by French orthopaedics residents in acquiring satisfactory arthroscopy skills during their residency. They also suggested avenues for improvement such as simulator training or the development of training on cadaver specimens. Level of evidence: IV, descriptive survey. © 2019 Elsevier Masson SAS. All rights reserved.
∗ Corresponding author. E-mail address: [email protected] (C. Pioger). https://doi.org/10.1016/j.otsr.2019.09.013 1877-0568/© 2019 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Pioger C, et al. Arthroscopy training in France: A resident perception and self-assessment. Orthop Traumatol Surg Res (2019), https://doi.org/10.1016/j.otsr.2019.09.013
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1. Introduction
2.3. Statistical analysis
Arthroscopic surgery is a rapidly expanding field in which the acquisition of proficiency is deemed a key component of orthopaedic surgery training [1,2]. Nevertheless, orthopaedic residents, notably in the US, have expressed a perception of being less well trained in arthroscopic surgery than in open surgery. Thus, 67% of orthopaedic surgery residents in the US felt the time spent on arthroscopic training was insufficient [3]. The resources available for teaching the arthroscopy skills that must be acquired by the well-rounded orthopaedic surgeon include observation and participation in procedures performed by senior surgeons in the operating room, subspecialty fellowship training [4], practice on cadaver specimens in the anatomy laboratory, and the more recently introduced simulator training techniques. Residents have expressed preferences for some of these resources over others [5]. However, efficacy varies across training methods. The recently introduced simulation tools, including virtual reality simulator training, are generating vigorous debate. In one survey, residents identified operating room experience as the most valuable training resource [6]. Other studies, however, depict virtual reality simulation as a novel training method that offers multiple advantages[7–9]. At the knee and shoulder, the history of arthroscopic procedures extends over several decades in university centres. Other joints, such as the wrist, hip, and ankle, were found amenable to arthroscopic surgery more recently. Few surgeons are experienced in arthroscopy at these sites, which has a long learning curve that is challenging to complete due to the small number of procedures performed [10]. The objectives of this study were to describe current arthroscopy training practices and to assess the perceptions and expectations of residents and junior physicians in France, with the goal of contributing to the development of a new training strategy for residents. The hypothesis was that residents and junior physicians perceive gaps in their arthroscopy training.
The variables were described as n (%). For some variables, the values were collapsed into relevant categories (e.g., age group and desired proportion of arthroscopy in the overall professional activity).
2. Material and methods 2.1. Study design From November 2018 to February 2019, the Junior French Arthroscopy Society (Société Francophone d’Arthroscopie Junior, SFAJ) conducted a survey of residents, fellows, and junior physicians in orthopaedic departments in France who were aged 18 to 35 years and were following the advanced orthopaedic surgery curriculum. E-mail addresses of 918 eligible individuals obtained from the Young Orthopaedic Surgeon’s Association (Collège des Jeunes Orthopédistes, CJO) and SFAJ were used to send an online questionnaire. The questionnaire was also spread via Facebook, Twitter, and LinkedIn. 2.2. Questionnaire The questionnaire had 48 items in the following eight sections: demographic data, skills training during the residency, arthroscopy experience, scientific studies, inter-university arthroscopy degree, interactions with scientific societies (conferences and training sessions), personal perception of arthroscopy training, and location and pathways of training (residency rotations, inter-university degree, fellowship) (Table 1). Some of the items were open (e.g., in which city did you train?) and others were closed, allowing for a yes/no answer (e.g., are you a member of the SFAJ?) or for the reporting of a quantitative continuous variable (e.g., how many arthroscopies have you performed?).
3. Results Completed questionnaires were returned by 106 individuals and form the basis for this study. Table 2 reports the main characteristics of the respondents. The respondents were aged 24 years or older; among them, 58 (54.3%) were 28 to 32 years of age. The only respondent who was older than 35 years was excluded from the analysis. Most of the French university training and research units were represented, the only exceptions being Rennes, Reims, Limoges, and units in overseas departments. The majority of respondents were nearing the end of their training, with 26 (24.8%) 4th-year residents, 23 (21.6%) 5th-year residents, 15 (14.3%) clinical fellows, and 13 (12.4%) junior physicians. In addition, 15 (14.3%) respondents were fellowship residents, gold-medal residents, or acting residents. Most respondents planned that arthroscopy would account for less than half their overall professional activity. The desired proportion of arthroscopic activity was 20% to 50% for 56.2% of respondents, 0% to 20% for 9.5% of respondents, and more than 50% for 34.4% of respondents (Fig. 1). When asked about desired practice modalities, 47 (44.8%) respondents chose private practice only, 22 (21%) both private and hospital practice, and 9 (8.6%) hospital practice only; 27 respondents had not yet decided. 3.1. Arthroscopy experience acquired during training The questionnaire asked about experience being the main operator for simple arthroscopy procedures, defined as long head of biceps tenotomy, meniscectomy, and arthroscopic joint exploration. Among the respondents, 42 (40%) reported performing fewer than 5, and 29 (27.6%) more than 30, simple arthroscopy procedures. Another questionnaire item asked about being the main operator or primary assistant for complex arthroscopy procedures defined as anterior cruciate ligament (ACL) reconstruction, cuff repair, and Bankart repair. Among the respondents, 40% reported experience with at least 5 cases and 28.6% with over 30 cases. Finally, 73 (69.5%) respondents reported having observed at least 5 arthroscopic procedures on joints other than the knee and shoulder (hand, hip, ankle) since the beginning of their training. 3.2. Residency training When asked about the type of healthcare institution that provided the highest quality arthroscopy training, 30 (28.6%) respondents named community hospitals, 31 (29.5%) private hospitals, and 33 (31.4%) university hospitals. The remaining 11 respondents had no opinion on this point (Table 3). Finally, the vast majority of respondents (n = 98, 93.3%) were favourable to having a rotation validated in a private institution. 3.3. Inter-university arthroscopy degree Among the respondents, 32 (30.5%) had obtained, and 24 (22.9%) were taking, the inter-university degree in arthroscopy. The remaining 49 (46.7%) participants had never registered for the inter-university arthroscopy degree. Most of the respondents who had completed or were following the inter-university curriculum
Please cite this article in press as: Pioger C, et al. Arthroscopy training in France: A resident perception and self-assessment. Orthop Traumatol Surg Res (2019), https://doi.org/10.1016/j.otsr.2019.09.013
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Type of institution providing the best training Views a rotation in a private hospital favourably If yes, which modality? Number of pathology lab sessions/year Number of simulator sessions/year Experience Simple arthroscopies/semester (diagnostic/tenotomy/meniscectomy . . .) Complex arthroscopies/semester (cuff repair/Bankart/Ligament reconstruction) Arthroscopy on joints other than shoulder and knee Scientific Studies Oral communication E-poster Article Number of articles read
Inter-university degree in arthroscopy Semester of degree completion Theoretical training
Skills training Ease in finding a supervisor Are you aware of the validation modalities? Resources for further training E-learning Case studies with experts Case studies without experts Dissection Are you aware that this inter-university degree is scheduled for elimination? Scientific societies and conferences Are you a member of SFA Junior? Do you follow SFA Junior on social media? Attendance at SFA meetings Attendance at the SFA Junior meeting session Attendance at the Young Arthroscopist Meeting (JJA) Opinions Arthroscopy learning curve? Proficient in arthroscopy At residency completion? At completion of post-residency training? Selecting patients to arthroscopy? Your sources of advice regarding arthroscopy
Training site Arthroscopy training? Does the industry contribute to your training? Rotations outside the subdivision What are your sources for rotations outside the subdivision? Waiting time? a b c
Response F/M 24-28/29-32/33-35 Resident (semester n◦ )/fellow–junior physician < 20%/20-50%/51-80%/> 80% Hospital/Private practice/Both/Undecided 0 to 10 Number in a university hospital Number in a community hospital Number in a private hospital university/community/private Yes/No Validating rotation/Fellowship/DIUa supervisor/Weekly visit/Monthly visit 0 to 10 0 to 10 <5/5-15/16-30/>30
0 to 10
>1/week 1/week 1/month 1/semester None 1st to 10th/after residency completion Highly satisfactory Satisfactory Difficult/Inadequate Impossible/Useless
Yes/No/Unsure
Yes/No Frequency: 1/week - 1/month–1/quarter 1/semester - 1/year Yes/No Yes/No Programme: satisfactory/unsatisfactory?
Linear/Stepwise/Exponential
Yes/No Yes/insufficiently/No Your seniors The literature Curriculum for the DESb /DESCc /DIU Other University hospital/community hospital/private hospital/DIU/the industry YES/NO Yes 1/Yes > 1/Yes > 2 NO impossible/NO useless Seniors/other residents Platform, e.g., INVIVOX 0/6 months/1 year/Longer
Interuniversity degree in arthroscopy. Advanced studies degree. Complementary advanced studies degree.
Please cite this article in press as: Pioger C, et al. Arthroscopy training in France: A resident perception and self-assessment. Orthop Traumatol Surg Res (2019), https://doi.org/10.1016/j.otsr.2019.09.013
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Respondents n = 105 Sex, n (%) Male Female Age group (years), n (%) 24 29 33 Years of training, n (%) 1st-year resident 2nd-year resident 3rd-year resident 4th-year resident 5th-year resident Fellows and junior physicians Other City of training, n (%) Paris Lyon Marseille Lille Bordeaux Strasbourg Other
86 (81.9) 19 (18.1) 29 (27.6) 57 (54.3) 19 (18.1) 2 (1.9) 5 (4.8) 6 (5.7) 26 (21.9) 23 (26.7) 28 (26.7) 15 (14.3) 24 (22.9) 9 (8.6) 6 (5.7) 7 (6.7) 7 (6.7) 4 (3.7) 48 (45.7)
Fig. 2. Perceptions of theoretical teaching during the inter-university arthroscopy degree.
Fig. 3. Perceptions of skills training during the inter-university arthroscopy degree.
Fig. 1. Desired proportion of arthroscopic activity.
Table 3 Type of healthcare institution providing the highest quality arthroscopy training, according to the 105 questionnaire respondents. Type of healthcare institution, n (%) of respondents n = 105 Community hospital Private hospital University hospital No opinion
30 (28.6%) 31 (29.5%) 33 (31.4%) 11 (10.5%)
were nearing the end of their residency: 38.4% and 43.6%, respectively, registered during the 4th and 5th residency year. The theoretical teaching received as part of the inter-university degree was deemed very comprehensive, comprehensive, and acceptable by 19.6%, 47.1%, and 25.5% of degree participants,
respectively; the remaining 7.9% felt the theoretical teaching was inadequate (Fig. 2). Corresponding proportions for skills training were 26%, 28%, 22%, and 16% (Fig. 3). Finally, nearly a third (32.3%) of degree participants experienced difficulties in finding a supervisor for their inter-university degree work.
3.4. Annual SFA meetings Among the respondents, 41.9% had never attended an SFA meeting, 26.7% had attended a single meeting, and 31.4% had attending more than one meeting (Fig. 4).
3.5. Arthroscopy proficiency Among the respondents, 73 (69.5%) felt they were not, or would not be at the end of their training, proficient in performing arthroscopy procedures without supervision. In addition, 40 (38.1%) residents and clinical fellows felt they were unable to select patients to arthroscopy.
Please cite this article in press as: Pioger C, et al. Arthroscopy training in France: A resident perception and self-assessment. Orthop Traumatol Surg Res (2019), https://doi.org/10.1016/j.otsr.2019.09.013
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Fig. 4. Attendance to French Arthroscopy Society (SFA) meetings.
3.6. Avenues for improvement Among the arthroscopy training resources listed in the questionnaires, e-learning was approved by 76.2% of respondents, case study review with an expert by 88.6%, simulator skills training by 87.6%, and attendance to demonstrations on cadaver specimens by 93.3%. 4. Discussion The results of this survey indicate that orthopaedic surgery residents and clinical fellows are dissatisfied with their arthroscopy training. Most (69.5%) respondents felt they were not, or would not be, fully proficient at the end of their residency. Furthermore, 40% of respondents, most of whom were nearing the end of their training, had performed fewer than 5 simple arthroscopy procedures as the main operator. These findings are consistent with a report by the Arthroscopy Association of North America (AANA) that an orthopaedics surgery residency is not an arthroscopy residency [11]. In addition, several recent studies point to considerable variability in arthroscopy training across universities and, perhaps also across students [1,12]. The number of arthroscopy procedures that must be performed to acquire proficiency remains unclear [2]. Nevertheless, the number of arthroscopies performed can serve as a measure of the skills acquired by orthopaedic surgery residents [13,14]. A questionnaire survey was conducted by Leonard et al. among residents and consultants attending an international orthopaedic conference [15]. The respondents felt that the number of procedures needed to achieve proficiency, defined as the ability to perform the procedure without supervision, was 63 to 70 for partial medial meniscectomy and more than 100 for ACL reconstruction. Among residents surveyed by Keith et al., 70% felt comfortable after performing at least 30 arthroscopies but nearly 30% cited a higher number of at least 40 [8]. Several scientific societies have determined minimum arthroscopy volumes required to become a member. The AANA, for instance, requires at least 50 arthroscopies per year and the
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American Board of Orthopaedic Surgery (ABOS) at least 75 arthroscopies in addition to 1 year of sports surgery fellowship training [16,17]. The perception of inadequate arthroscopy training revealed by our survey probably explains why the respondents felt they had not acquired, or would not acquire, proficiency by the end of their residency. Hall et al. [3] found a similar lack of confidence of residents in their ability to perform arthroscopic procedures without supervision after their residency. Thus, the confidence level was 75%-80% for simple procedures (diagnostic arthroscopy) but dropped to about 50% for more complex procedures such as cuff repair or ACL reconstruction. The findings from this survey invite questions about the potential offered by new training resources and by observation and participation in the operating room. Among resources, cadaver specimen demonstrations were the most highly appreciated by the respondents. Camp et al. reported a twice faster rate of knee arthroscopy proficiency acquisition with cadaver specimen training compared to simulator training [18]. Thus, cadaver specimen training may perform better than simulation, which was the second preferred resource in our survey. However, cadaver specimens are less widely available than are virtual reality simulators, which are not yet used routinely for arthroscopy training in France. Many studies have shown better arthroscopy skills among residents who trained on simulators compared to those without access to this resource [9,19–22]. In addition, in a study by Cannon et al. operating room performance was better among residents who had trained on a simulator than among controls who had not [23]. In France, the reform of the third and last part of the medical school curriculum invites a discussion of whether simulation training should be made mandatory [24]. As with the US, funding restrictions may prove to be the main limiting factor [25]. Among the respondents, over 90% had a favourable opinion of training in private hospitals, either as a validating rotation within the usual residency curriculum or as a fellowship. Surgeons surveyed by Vitale et al., stated that a sports medicine fellowship was the best training method for arthroscopic cuff repair, followed by practice on cadaver specimens [26]. The main limitation of this study is the questionnaire design. Furthermore, given the fairly low response rate, the findings may not apply to the entire population of residents in France. However, our response rate was within the range usually obtained in surveys of medical residents [3,8,27]. No analysis was performed to determine whether the level of arthroscopic activity correlated with year of training. Such an analysis would probably have further highlighted the inadequacies of residency training, since clinical fellows and junior physicians clearly perform larger numbers of arthroscopies than do residents.
5. Conclusion The results of this survey highlighted the obstacles encountered by residents in France as they seek to acquire adequate training in arthroscopy procedures. They also identify several avenues for improvement. A reappraisal of current training modalities is in order to better support the development of arthroscopy skills among residents in France. Increased use of simulation is an option that holds considerable appeal and is viewed favourable by residents.
Disclosure of interest The authors declare that they have no competing interest.
Please cite this article in press as: Pioger C, et al. Arthroscopy training in France: A resident perception and self-assessment. Orthop Traumatol Surg Res (2019), https://doi.org/10.1016/j.otsr.2019.09.013
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Funding None. Study managed under the aegis of French Arthroscopy Society. Authors’ contribution Charles Pioger, corresponding author: writing and study coordination. Édouard Harly, Charles Grob, Quentin Baumann: helped in writing. Simon Rattier: data collection and result analysis. Elise Loock, Aurore Blancheton: survey creation and on-line release. Corentin Pangaud: helped in study design and writing.
[12]
[13]
[14]
[15]
[16] [17]
References [18] [1] Gil JA, Waryasz GR, Owens BD, Daniels AH. Variability of arthroscopy case volume in orthopaedic surgery residency. Arthroscopy 2016;32:892–7, http://dx.doi.org/10.1016/j.arthro.2016.01.018. [2] O’Neill PJ, Cosgarea AJ, Freedman JA, Queale WS, McFarland EG. Arthroscopic proficiency: a survey of orthopaedic sports medicine fellowship directors and orthopaedic surgery department chairs. Arthroscopy 2002;18:795–800. [3] Hall MP, Kaplan KM, Gorczynski CT, Zuckerman JD, Rosen JE. Assessment of arthroscopic training in U.S. orthopedic surgery residency programs–a resident self-assessment. Bull NYU Hosp Jt Dis 2010;68:5–10. [4] Daniels AH, DiGiovanni CW. Is subspecialty fellowship training emerging as a necessary component of contemporary orthopaedic surgery education? J Grad Med Educ 2014;6:218–21, http://dx.doi.org/10.4300/JGME-D-14-00120.1. [5] Koehler R, John T, Lawler J, Moorman C, Nicandri G. Arthroscopic training resources in orthopedic resident education. J Knee Surg 2015;28:67–74, http://dx.doi.org/10.1055/s-0034-1368142. [6] Wolf BR, Britton CL. How orthopaedic residents perceive educational resources. Iowa Orthop J 2013;33:185–90. [7] Hui Y, Safir O, Dubrowski A, Carnahan H. What skills should simulation training in arthroscopy teach residents? A focus on resident input. Int J Comput Assist Radiol Surg 2013;8:945–53, http://dx.doi.org/10.1007/s11548-013-0833-7. [8] Keith K, Hansen DM, Johannessen MA. Perceived Value of a Skills Laboratory With Virtual Reality Simulator Training in Arthroscopy: A Survey of Orthopedic Surgery Residents. J Am Osteopath Assoc 2018;118:667–72, http://dx.doi.org/10.7556/jaoa.2018.146. [9] Frank RM, Wang KC, Davey A, Cotter EJ, Cole BJ, Romeo AA, et al. Utility of modern arthroscopic simulator training models: a metaanalysis and updated systematic review. Arthroscopy 2018;34:1650–77, http://dx.doi.org/10.1016/j.arthro.2017.10.048. [10] Hoppe DJ, de Sa D, Simunovic N, Bhandari M, Safran MR, Larson CM, et al. The learning curve for hip arthroscopy: a systematic review. Arthroscopy 2014;30:389–97, http://dx.doi.org/10.1016/j.arthro.2013.11.012. [11] Committee on Ethics, Standards, the Board of Directors of the Arthroscopy Association of North America. Suggested guidelines for the practice of
[19]
[20]
[21]
[22]
[23]
[24] [25]
[26]
[27]
arthroscopic surgery. Committee on Ethics and Standards and the Board of Directors of the Arthroscopy Association of North America. Arthroscopy 2011;27:A28, http://dx.doi.org/10.1016/S0749-8063(11)00344-6. Hinds RM, Gottschalk MB, Strauss EJ, Capo JT. Trends in Arthroscopic Procedures Performed During Orthopaedic Residency: An Analysis of Accreditation Council for Graduate Medical Education Case Log Data. Arthroscopy 2016;32:645–50, http://dx.doi.org/10.1016/j.arthro.2015.11.015. Malangoni MA, Biester TW, Jones AT, Klingensmith ME, Lewis FR. Operative experience of surgery residents: trends and challenges. J Surg Educ 2013;70:783–8, http://dx.doi.org/10.1016/j.jsurg.2013.09.015. Robbins L, Bostrom M, Craig E, Sculco TP. Proposals for change in orthopaedic education: recommendations from an orthopaedic residency directors’ peer forum. J Bone Joint Surg Am 2010;92:245–9, http://dx.doi.org/10.2106/JBJS.I.00210. Leonard M, Kennedy J, Kiely P, Murphy PG. Knee arthroscopy: how much training is necessary? A cross-sectional study. Eur J Orthop Surg Traumatol 2007;17:359–62, http://dx.doi.org/10.1007/s00590-007-0197-1. Arthroscopy Association of North America web site. Available at: http://www.aana.org/membership/category.html. Accessed January 2008. The American Board of Orthopaedic Surgery website: Availat: http://www.abos.org/ ModDefault.aspx?module=Dipl able omates§ion=SportsOver.Accessed October 31, 2009. Camp CL, Krych AJ, Stuart MJ, Regnier TD, Mills KM, Turner NS. Improving Resident Performance in Knee Arthroscopy: A Prospective Value Assessment of Simulators and Cadaveric Skills Laboratories. J Bone Joint Surg Am 2016;98:220–5, http://dx.doi.org/10.2106/JBJS.O.00440. Henn RF, Shah N, Warner JJP, Gomoll AH. Shoulder arthroscopy simulator training improves shoulder arthroscopy performance in a cadaveric model. Arthroscopy 2013;29:982–5, http://dx.doi.org/10.1016/j.arthro.2013.02.013. Aïm F, Lonjon G, Hannouche D, Nizard R. Effectiveness of Virtual Reality Training in Orthopaedic Surgery. Arthroscopy 2016;32:224–32, http://dx.doi.org/10.1016/j.arthro.2015.07.023. Rebolledo BJ, Hammann-Scala J, Leali A, Ranawat AS. Arthroscopy skills development with a surgical simulator: a comparative study in orthopaedic surgery residents. Am J Sports Med 2015;43:1526–9, http://dx.doi.org/10.1177/0363546515574064. Yari SS, Jandhyala CK, Sharareh B, Athiviraham A, Shybut TB. Efficacy of a virtual arthroscopic simulator for orthopaedic surgery residents by year in training. Orthop J Sports Med 2018;6, http://dx.doi.org/10.1177/2325967118810176 [2325967118810176]. Cannon WD, Garrett WE, Hunter RE, Sweeney HJ, Eckhoff DG, Nicandri GT, et al. Improving residency training in arthroscopic knee surgery with use of a virtual-reality simulator. A randomized blinded study. J Bone Joint Surg Am 2014;96:1798–806, http://dx.doi.org/10.2106/JBJS.N.00058. Harly E, Azzolin L, Walbron P, Common H, Baumann Q. Simulateur d’arthroscopie: vers une formation obligatoire? Maîtrise Orthopédique 2017. Karam MD, Pedowitz RA, Natividad H, Murray J, Marsh JL. Current and future use of surgical skills training laboratories in orthopaedic resident education: a national survey. J Bone Joint Surg Am 2013;95:e4, http://dx.doi.org/10.2106/JBJS.L.00177. Vitale MA, Kleweno CP, Jacir AM, Levine WN, Bigliani LU, Ahmad CS. Training resources in arthroscopic rotator cuff repair. J Bone Joint Surg Am 2007;89:1393–8, http://dx.doi.org/10.2106/JBJS.F.01089. Burns KEA, Duffett M, Kho ME, Meade MO, Adhikari NKJ, Sinuff T, et al. A guide for the design and conduct of self-administered surveys of clinicians. CMAJ 2008;179:245–52, http://dx.doi.org/10.1503/cmaj.080372.
Please cite this article in press as: Pioger C, et al. Arthroscopy training in France: A resident perception and self-assessment. Orthop Traumatol Surg Res (2019), https://doi.org/10.1016/j.otsr.2019.09.013