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Original article
peer-reviewed

Defining the Critical Elements of the Most Common Arthroscopic Procedures: A Consensus of Orthopaedic Sports Medicine Surgeons



Abstract

Objective

To define the critical elements of common procedures in arthroscopic surgery.

Methods

A survey was administered to surgeons associated with the American Orthopaedic Society for Sports Medicine (AOSSM) to determine the critical elements for four common arthroscopic procedures: anterior cruciate ligament (ACL) reconstruction, knee arthroscopy with meniscal debridement or repair, rotator cuff repair (RCR), and capsulorrhaphy for anterior glenohumeral instability (Bankart repair). Respondents were asked which steps necessitated their direct supervision. The level of experience and practice demographics were also recorded.

Results

For all applicable procedures, patient positioning and closure were not considered critical steps. Establishing arthroscopic portals was critical for all procedures, except knee arthroscopy. Diagnostic arthroscopy was only critical in ACL reconstruction. Private practice surgeons considered every step of these common procedures to be critical elements. Less experienced surgeons were more likely to regard certain aspects of a procedure critical. Surgeons with >15 years of experience considered diagnostic arthroscopy critical to all procedures, whereas those with <15 years of experience did not. Unlike surgeons with a resident as first assist, surgeons with a physician assistant (PA) or nurse practitioner (NP) found every step of each procedure to be critical except closure and positioning.

Conclusion

Across all procedures, only patient positioning and closure were consistently regarded as non-critical elements. There were significant differences in responses according to experience and practice setting. Future research is necessary to determine the implications of these findings and guide the definition of the “critical portions” of surgery.

Introduction

Every operation is a sequence of numerous, distinct steps that carry their own potential for complications. Academic teaching hospitals train resident surgeons by allowing them to assist in these operations and take an increasingly important role as both their knowledge and skills mature. The notion of “critical” steps of surgery, or those requiring the presence and direct supervision of the attending surgeon, has been implemented into nearly every document pertaining to surgery, from patient consent forms to national guidelines, and even billing clauses [1-2]. Recently, the Boston Globe’s investigation on the practice of concurrent surgeries drew controversy over “double booking” – the process of overlapping surgical cases booked under one attending surgeon in multiple rooms [1,3]. Questions of patient safety, ethical consent, health care costs, and medical education and training have arisen from this investigation despite the clear language in patient consent forms that reassures patients that an attending surgeon will be present for all “critical parts” of the procedure.

In April 2016, the American College of Surgeons’ (ACS') Statement of Principles was revised and distinguishes between “concurrent” and “overlapping” surgeries based on whether the “critical steps” of the two procedures occur simultaneously or sequentially [4]. This statement deems concurrent surgeries inappropriate, as they do not allow the presence of an attending surgeon during the “critical” steps of surgery occurring simultaneously. The Center for Medicare and Medicaid Services (CMS) has also declared that a supervising physician must be present for all “critical portions” of a procedure in order to qualify for reimbursement [2]. While the language in these consent forms is consistent across academic centers, this notion of “critical parts” of surgery still remains unclear, as it is open to various interpretations. To date, there has been no study establishing criteria for critical surgical steps in arthroscopic surgery, although it has been implied that such steps are “defined” for all common surgical procedures [5].

The purpose of the current study was to define the critical elements in four of the most common arthroscopic sports medicine procedures: anterior cruciate ligament (ACL) reconstruction, rotator cuff repair (RCR), knee arthroscopy, and anterior capsulorrhaphy with labral repair for glenohumeral instability (Bankart procedure). Herein, we report the results of a survey distributed to orthopedic sports medicine surgeons. We hypothesized that for each procedure, patient positioning, portal establishment, diagnostic arthroscopy, and closure would not be considered critical steps.

Materials & Methods

A web-based survey was developed by the authors at our institution and administered using Qualtrics software (Provo, UT, US), a survey platform for online data collection and analysis. The questionnaire consisted of 11 questions. The first seven questions were directed at surgeon demographics (years in practice, private versus academics, urban versus rural, geographic location, fellowship training, and first assistant). Each of the final four questions focused on a particular procedure, specifically ACL reconstruction, RCR, knee arthroscopy with meniscal treatment, and Bankart procedures. The order of the procedures was randomized for each respondent. Each of the procedures was separated into its constituent elements, including the positioning, portal placement, diagnostic arthroscopy, closure, and major steps in each respective procedure. The following statement headed each of these questions: “Which are the “critical” elements of surgery requiring your direct supervision in the operating room? Check ALL boxes that apply.” Respondents selected the portions of each procedure that necessitate their direct supervision in the operating room. If any of the major aspects of the procedure were selected by respondents, a sub-menu appeared with further questions. For the purpose of this study, a “critical” element of arthroscopic surgery was defined as a surgical step selected by the majority of respondents (>50%).

A link to the survey was emailed to 2016 members of the American Orthopaedic Society for Sports Medicine (AOSSM). Between August and September 2017, 343 physicians responded to the survey, corresponding to a response rate of 17% (343/2016).

Statistical analyses were performed with SPSS (IBM v24.0, Chicago, IL, US). An unadjusted univariate analysis was performed using independent sample t-tests for continuous data and Chi-squared or Fisher exact tests for categorical variables. Correlations between continuous variables were examined using the Pearson correlation coefficient test. Statistical significance was defined as p < 0.05.

Results

A total of 343 surgeons responded to the survey. Responder demographics are presented in Table 1. The majority of respondents practiced in a major city (55.9%) with over 15 years of surgical experience (55%). Among respondents, the first assistant during surgery was a resident physician (30%), a physician assistant (PA) (45.9%), a nurse practitioner (NP) (4.1%), or other (20%). For all procedures, patient positioning and closure were not designated as critical elements. Diagnostic arthroscopy was not considered critical in any procedure, except for ACL reconstruction. The establishment of portals was a critical element of all procedures except knee arthroscopy.

All Responders (%)
No. of Attending Surgeons 343 (17)
Years in Practice, n (%), N=340
1-5 Years 30 (8.8)
6-10 Years 85 (25.0)
11-15 Years 38 (11.2)
15+ Years 187 (55.0)
Sports Medicine/Shoulder Fellowship Completed, n (%), N=341
Sports Medicine 306 (89.7)
Shoulder 7 (2.1)
Neither 28 (8.2)
Practice Classification, n (%), N=341
Academic 83 (24.3)
Private 183 (53.7)
Privademic 75 (22.0)
Practice Location, n (%), N=340
Northeast 102 (30.0)
South 77 (22.6)
West 40 (11.8)
Central 85 (25.0)
Southwest 29 (8.5)
Outside of USA 7 (2.1)
Practice Location Classification, n (%), N=340
Major City 190 (55.9)
Minor City 130 (38.9)
Rural 20 (5.9)
Cases Performed Each Year, n (%), N=341
<100 6 (1.8)
100-250 68 (19.9)
250-500 186 (54.5)
500-700 57 (16.7)
>700 24 (7.0)
First Assistant During Surgery, n (%), N=340
Resident (MD/DO) 102 (30.0)
Physician Assistant 156 (45.9)
Nurse Practitioner 14 (4.1)
Other 68 (20.0)

Among all respondents

For knee arthroscopy, meniscal debridement (66%), meniscal repair (95%), and chondral procedures (79%) were critical. When performing a meniscal debridement, determining which tears require meniscectomy (64%), identifying the proper amount of meniscus to resect (63.3%), and performing the meniscectomy (53%) were all considered critical. Additionally, all aspects of performing a meniscal repair were critical (Table 2). For chondral procedures, microfracture was deemed critical (76%) while performing a chondroplasty was not (47%).

Overall Knee Arthroscopy Critical Elements, n (%), N=343
Establishing Portals 154 (44.9)
Diagnostic Arthroscopy 166 (48.4)
Meniscal Debridement 225 (65.6) *
Meniscal Repair 327 (95.3) *
Chondral Procedures 271 (79.0) *
Closure 12 (3.5)
None 5 (1.5)
Positioning 47 (13.7)
Knee Arthroscopy Critical Establishing Portal Elements, n (%), N=343
Anterior Portals 141 (41.1)
Posterior Portals for Meniscal Root Repair 143 (41.7)
Knee Arthroscopy Critical Meniscal Debridement Elements, n (%), N=343
Identifying which Tears Need Meniscectomy vs Repair 218 (63.6) *
Identifying Amount of Meniscal Debridement 217 (63.3) *
Performing Meniscectomy with Shaver and/or Biter 180 (52.5) *
Knee Arthroscopy Critical Meniscal Repair Elements, n (%), N=343
Establishing Technique (All inside/Outside In/ Inside Out) 284 (82.8) *
Approach if using Outside In/ Inside Out 268 (78.1) *
Identifying Location of Suture Placement 282 (82.2) *
All-Inside Repair 296 (86.3) *
Passing Sutures for Outside-in or Inside-out 287 (83.7) *
Tying Knots 204 (59.5) *
Knee Arthroscopy Critical Chondral Procedure Elements, n (%), N=343
Microfracture 260 (75.8) *
Chondroplasty 161 (46.9)

For ACL reconstruction, all steps were critical except preparing the footprints, closing, and positioning (Table 3). With regard to autograft harvesting during ACL reconstruction, identifying (65%) and stripping the hamstring tendons (69%), selecting the size of bone-patella-bone (BTB) graft (63%), and harvesting the BTB graft with a microsagittal saw (81%) were critical steps, but preparation of the graft on the back table was not (20%). Performing a notchplasty and debriding the ACL ligament were not considered critical steps. Regarding tunnel placement, identifying the proper location (95%), holding the drill guide (68%), and drilling the tunnels (61%) were critical steps. Lastly, the steps of graft fixation were all critical, except for cycling the graft. This included shuttling the graft, determining the appropriate graft tension, and securing the graft with interference screws or aperture fixation.

Overall ACL Reconstruction Critical Elements, n (%), N=343
Establishing Portals 180 (52.5) *
Graft Harvest 300 (87.5) *
Diagnostic Arthroscopy 179 (52.2) *
Debridement/Preparation of Footprints 189 (55.1) *
Tunnel Placement 335 (97.7) *
Graft Fixation 316 (92.1) *
Closing Patella Tendon/Closure 64 (18.7)
None 1 (0.3)
Positioning 96 (28.0)
ACL Reconstruction Critical Graft Harvest Elements, n (%), N=343
Surgical Approach 166 (48.4)
Identifying Hamstring Tendons 224 (65.3) *
Stripping Tendons with Tendon Stripper 237 (69.1) *
BTB - Selecting Size of Patella Graft 215 (62.7) *
BTB - Using Microsagittal Saw to Harvest Bone Plugs 277 (80.8) *
Preparing Graft on Back Table 67 (19.5)
ACL Reconstruction Critical Debridement/Footprint Preparation Elements, n (%), N=343
Notchplasty 142 (41.4)
Debriding Footprints/ Removing ACL Stump 149 (43.4)
ACL Reconstruction Critical Tunnel Placement Elements, n (%), N=343
Identifying Tunnel Position 324 (94.5) *
Holding Guide for Guide Pins 232 (67.6) *
Drilling Tunnels 210 (61.2) *
ACL Reconstruction Critical Graft Fixation Elements, n (%), N=343
Graft Passage/Shuttling 249 (72.6) *
Cycling Graft 139 (40.5)
Determining Appropriate Graft Tension 260 (75.8) *
Placing Interference Screws / Aperture Fixation 298 (86.9) *

For rotator cuff repair, establishing portals (54%), preparing the footprint (64%), and repairing the tendon (94%) were critical. Positioning, diagnostic arthroscopy, subacromial bursectomy, and closure were found to be non-critical steps (Table 4). Further evaluation found that all aspects of repairing the tendon were critical, including identifying suture placement, passing sutures, identifying the number and location of anchors, determining single versus double row, and tying suture knots.

Overall Rotator Cuff Repair Critical Elements, n (%), N=343
Establishing Portals 185 (53.9) *
Diagnostic Arthroscopy 171 (49.9)
Subacromial Bursectomy 149 (43.4)
Preparing Footprint 221 (64.4) *
Repairing Tendon 323 (94.2) *
Closure 13 (3.8)
None 2 (0.6)
Positioning 96 (28.0)
Rotator Cuff Repair Critical Establishing Portal Elements, n (%), N=343
Portals in Lateral Decubitus Position 152 (44.3)
Portals in Beach Chair Position 133 (38.8)
Rotator Cuff Repair Critical Subacromial Bursectomy Elements, n (%), N=343
Bursectomy 129 (37.6)
Acromioplasty 143 (41.7)
Tear Assessment 147 (42.9)
Rotator Cuff Repair Critical Footprint Preparation Elements, n (%), N=343
Using Shaver/Burr to Decorticate Humeral Footprint 176 (51.3) *
Debriding Tendon Edges 163 (47.5)
Tendon Mobilization 215 (62.7) *
Marginal Convergence 217 (63.3) *
Interval Slide 206 (60.1) *
Rotator Cuff Repair Critical Tendon Repair Elements, n (%), N=343
Identifying Location of Suture Placement 298 (86.9) *
Passing Sutures with Suture Passer 261 (76.1) *
Passing Sutures with Suture Lasso 212 (61.8) *
Identifying Number of Anchors 285 (83.1) *
Identifying Location of Anchors 306 (89.2) *
Determining Singer vs Double Row 274 (79.9) *
Tying Suture Knots 258 (75.2) *

For arthroscopic anterior capsulorrhaphy with labral repair (or Bankart procedure), the critical elements were the establishment of portals (64%), glenoid preparation (80%), passing sutures (90%), and placing anchors (93%) (Table 5). Within glenoid preparation, both the mobilization of the labrum and decorticating the glenoid neck were critical. Passing sutures, the selection of the number and placement of anchors, drilling for anchors, and tying suture knots were all found to be critical. Similar to arthroscopic rotator cuff repair, diagnostic arthroscopy and closure were not critical.

Overall Capsulorrhaphy, Anterior; with Labral Repair (i.e. Bankart Procedure) Critical Elements, n (%), N=343
Establishing Portals 221 (64.4) *
Diagnostic Arthroscopy 169 (49.3)
Preparing Glenoid 274 (79.9) *
Passing Sutures 309 (90.1) *
Placing Anchors 320 (93.3) *
Closure 6 (1.7)
Positioning 107 (31.2)
Bankart Repair Critical Establishing Portals Elements, n (%), N=343
Portals in Lateral Decubitus Position 185 (53.9) *
Portals in Beach Chair Position 139 (40.5)
Bankart Repair Critical Glenoid Preparation Elements, n (%), N=343
Mobilizing Labrum 271 (79.0) *
Decorticating Glenoid Neck 240 (70.0) *
Bankart Repair Critical Passing Sutures Elements, n (%), N=343
Passing Sutures at 3 o'clock Position 225 (65.6) *
Passing Sutures at 5-6 o'clock Position 307 (89.5) *
Bankart Repair Critical Placing Anchors Elements, n (%), N=343
Selecting Number of Anchors 276 (80.5) *
Selecting Location of Anchors 308 (89.8) *
Using Knotless Anchors 226 (65.9) *
Using Traditional Anchors 228 (66.5) *
Drilling Anchors 274 (79.9) *
Tying Suture Knots 255 (74.3) *

Private versus academic

For knee arthroscopy, private practice surgeons rated all aspects of knee arthroscopy except closure and positioning to be critical. Academic surgeons, on the other hand, did not find portal establishment (p<0.0001) or diagnostic arthroscopy (p<0.0001) to be critical. With regards to chondral procedures, private surgeons found chondroplasty to be a critical element while academic surgeons did not (p=0.007). For ACL reconstruction, private surgeons rated portal establishment (p<0.0001), diagnostic arthroscopy (p<0.0001), and debridement of footprint/ACL (p=0.012) to be critical while academic surgeons did not.

For RCR, private surgeons rated portal establishment (p<0.0001), diagnostic arthroscopy (p<0.0001), and subacromial decompression (p=0.006) as critical steps while academic surgeons did not. For the Bankart procedure, private surgeons rated diagnostic arthroscopy (p<0.0001) and portal establishment (p<0.0001) as critical while academic surgeons did not (Table 6).

  Academic Private P-value
Number of Responders 83 183 -
Overall ACL Reconstruction Critical Elements, n (%), N=266
Establishing Portals 28 (33.7) 121 (66.1) <0.0001
Diagnostic Arthroscopy 28 (33.7) 122 (66.7) <0.0001
Debridement/Preparation of Footprints 40 (48.2) 118 (64.5) 0.012
Closing Patella Tendon/Closure 4 (4.8) 44 (24.0) <0.0001
Positioning 17 (20.5) 62 (33.9) 0.027
ACL Reconstruction Critical Graft Harvest Elements, n (%), N=266
Surgical Approach 27 (32.5) 110 (60.1) <0.0001
ACL Reconstruction Critical Debridement/Footprint Preparation Elements, n (%), N=266
Notchplasty 28 (33.7) 89 (48.6) 0.023
Debriding Footprints/ Removing ACL Stump 31 (37.3) 94 (51.4) 0.034
ACL Reconstruction Critical Tunnel Placement Elements, n (%), N=266
Identifying Tunnel Position 75 (90.4) 178 (97.3) 0.027
Overall Knee Arthroscopy Critical Elements, n (%), N=266
Establishing Portals 20 (24.1) 102 (55.7) <0.0001
Diagnostic Arthroscopy 24 (28.9) 109 (59.6) <0.0001
Knee Arthroscopy Critical Establishing Portal Elements, n (%), N=266
Anterior Portals 18 (21.7) 96 (52.5) <0.0001
Posterior Portals for Meniscal Root Repair 18 (21.7) 96 (52.5) <0.0001
Knee Arthroscopy Critical Chondral Procedure Elements, n (%), N=266
Chondroplasty 31 (37.3) 101 (55.2) 0.007
Overall Rotator Cuff Repair Critical Elements, n (%), N=266
Establishing Portals 27 (32.5) 123 (67.2) <0.0001
Diagnostic Arthroscopy 23 (27.7) 114 (62.3) <0.0001
Subacromial Bursectomy 28 (33.7) 95 (51.9) 0.006
Positioning 15 (18.1) 62 (33.9) 0.008
Rotator Cuff Repair Critical Establishing Portal Elements, n (%), N=266
Portals in Lateral Decubitus Position 24 (28.9) 102 (55.7) <0.0001
Portals in Beach Chair Position 20 (24.1) 87 (47.5) <0.0001
Rotator Cuff Repair Critical Subacromial Bursectomy Elements, n (%), N=266
Bursectomy 20 (24.1) 89 (48.6) <0.0001
Acromioplasty 25 (30.1) 93 (50.8) 0.002
Tear Assessment 28 (33.7) 93 (50.8) 0.01
Rotator Cuff Repair Critical Footprint Preparation Elements, n (%), N=266
Using Shaver/Burr to Decorticate Humeral Footprint 34 (41.0) 108 (59.0) 0.006
Debriding Tendon Edges 32 (38.6) 100 (54.6) 0.015
Overall Capsulorrhaphy, Anterior; with Labral Repair (i.e. Bankart Procedure) Critical Elements, n (%), N=266
Establishing Portals 39 (47.0) 135 (73.8) <0.0001
Diagnostic Arthroscopy 24 (28.9) 112 (61.2) <0.0001
Bankart Repair Critical Establishing Portals Elements, n (%), N=266
Portals in Lateral Decubitus Position 33 (39.8) 115 (62.8) <0.0001
Portals in Beach Chair Position 23 (27.7) 85 (46.4) 0.004

Years in practice

Based on years of experience, surgeons with less experience (<15 years) did not rate portal establishment, diagnostic arthroscopy, or ligament debridement/notchplasty as critical ACL reconstruction steps while older surgeons did. Similar results were obtained for knee arthroscopy, with portal establishment and diagnostic arthroscopy regarded as non-critical by younger surgeons but critical by those with greater than 15 years of experience. Surgeons with less experience did not regard chondroplasty and meniscal debridement as critical, while the more experienced surgeons did (p=0.032, p= 0.004, respectively). For RCR, experienced surgeons considered decorticating footprint (p= 0.38) and debriding tendon edges (p=0.183) to be critical while less experienced surgeons did not, however, the difference did not meet significance. All surgeons regardless of experience considered every aspect of the tendon repair (passing sutures, identifying the location of anchors, placing anchors, tying knots) to be critical. When comparing across surgeons for the Bankart procedure, closure and patient positioning were similarly regarded as non-critical aspects of the procedure. Younger surgeons, however, did not consider diagnostic arthroscopy to be critical (47% vs. 50%, p=0.535). Both cohorts regarded all sub-steps of this procedure to be critical and there were no differences between them.

First assistant

When comparing across years in practice, there was no difference in first assistant utilization. First assistants included residents, physician assistants (PAs), and nurse practitioners (NPs). Unlike surgeons with a resident as first assist, surgeons with a PA or NP found every step of each procedure to be critical except closure and positioning (Table 7). For all procedures, when a resident was first assistant, positioning, portal establishment, diagnostic arthroscopy, and closure were not found to be critical. For ACL reconstruction, when a resident was the first assistant, the only critical steps were graft harvest, tunnel placement, and graft fixation. For knee arthroscopy, chondroplasty was not found to be critical when a resident was first assistant. For RCR, tendon repair was the only critical step.

  Resident First Assist PA/NP P-value
Number of Responders 102 169 -
Overall ACL Reconstruction Critical Elements, n (%), N=343
Establishing Portals 33 (32.4) 105 (61.8) <0.0001
Diagnostic Arthroscopy 30 (29.4) 110 (64.7) <0.0001
Debridement/Preparation of Footprints 39 (38.2) 110 (64.7) <0.0001
Closing Patella Tendon/Closure 6 (5.9) 35 (20.6) 0.001
ACL Reconstruction Critical Graft Harvest Elements, n (%), N=272
Surgical Approach 29 (28.4) 100 (58.8) <0.0001
ACL Reconstruction Critical Debridement/Footprint Preparation Elements, n (%), N=272
Notchplasty 23 (22.5) 88 (51.8) <0.0001
Debriding Footprints/ Removing ACL Stump 29 (28.4) 87 (51.2) <0.0001
ACL Reconstruction Critical Tunnel Placement Elements, n (%), N=272
Identifying Tunnel Position 91 (89.2) 169 (99.4) <0.0001
Overall Knee Arthroscopy Critical Elements, n (%), N=272
Establishing Portals 25 (24.5) 93 (54.7) <0.0001
Diagnostic Arthroscopy 28 (27.5) 103 (60.6) <0.0001
Meniscal Debridement 60 (58.8) 124 (72.9) 0.016
Positioning 6 (5.9) 23 (13.5) 0.048
Knee Arthroscopy Critical Establishing Portal Elements, n (%), N=272
Anterior Portals 20 (19.6) 87 (51.2) <0.0001
Posterior Portals for Meniscal Root Repair 21 (20.6) 87 (51.2) <0.0001
Knee Arthroscopy Critical Meniscal Debridement Elements, n (%), N=272
Identifying which Tears Need Meniscectomy vs Repair 56 (54.9) 122 (71.8) 0.005
Identifying Amount of Meniscal Debridement 58 (56.9) 119 (70.0) 0.028
Performing Meniscectomy with Shaver and/or Biter 41 (40.2) 103 (60.6) 0.001
Knee Arthroscopy Critical Meniscal Repair Elements, n (%), N=272
Establishing Technique (All inside/Outside In/ Inside Out) 77 (75.5) 148 (87.1) 0.015
Approach if using Outside In/ Inside Out 75 (73.5) 143 (84.1) 0.034
Tying Knots 54 (52.9) 111 (65.3) 0.043
Knee Arthroscopy Critical Chondral Procedure Elements, n (%), N=272
Chondroplasty 35 (34.3) 92 (54.1) 0.002
Overall Rotator Cuff Repair Critical Elements, n (%), N=272
Establishing Portals 31 (30.4) 110 (64.7) <0.0001
Diagnostic Arthroscopy 27 (26.5) 108 (63.5) <0.0001
Subacromial Bursectomy 28 (27.5) 91 (53.5) <0.0001
Preparing Footprint 57 (55.9) 118 (69.4) 0.024
Rotator Cuff Repair Critical Establishing Portal Elements, n (%), N=272
Portals in Lateral Decubitus Position 23 (22.5) 92 (54.1) <0.0001
Portals in Beach Chair Position 22 (21.6) 79 (46.5) <0.0001
Rotator Cuff Repair Critical Subacromial Bursectomy Elements, n (%), N=272
Bursectomy 18 (17.6) 83 (48.8) <0.0001
Acromioplasty 23 (22.5) 90 (52.9) <0.0001
Tear Assessment 28 (27.5) 89 (52.4) <0.0001
Rotator Cuff Repair Critical Footprint Preparation Elements, n (%), N=272
Using Shaver/Burr to Decorticate Humeral Footprint 39 (38.2) 98 (57.6) 0.002
Debriding Tendon Edges 36 (35.3) 90 (52.9) 0.005
Tendong Mobilization 55 (53.9) 115 (67.6) 0.024
Marginal Convergence 55 (53.9) 116 (68.2) 0.018
Interval Slide 51 (50.0) 112 (65.9) 0.01
Rotator Cuff Repair Critical Tendon Repair Elements, n (%), N=272
Identifying Location of Suture Placement 84 (82.4) 154 (90.6) 0.047
Identifying Location of Anchors 88 (86.3) 160 (94.1) 0.027
Overall Capsulorrhaphy, Anterior; with Labral Repair (i.e. Bankart Procedure) Critical Elements, n (%), N=272
Establishing Portals 50 (49.0) 124 (72.9) <0.0001
Diagnostic Arthroscopy 26 (25.5) 108 (63.5) <0.0001
Bankart Repair Critical Establishing Portals Elements, n (%), N=272
Portals in Lateral Decubitus Position 37 (36.3) 108 (63.5) <0.0001
Portals in Beach Chair Position 31 (30.4) 77 (45.3) 0.015
Bankart Repair Critical Glenoid Preparation Elements, n (%), N=272
Decorticating Glenoid Neck 64 (62.7) 128 (75.3) 0.028

Discussion

Every surgical procedure is a series of steps, some more critical than others. Some steps of a procedure are so important that any misstep or lack of guidance may expose the patient to undue harm. Despite their crucial role in surgical training, billing and the ethicality of concurrent surgery, the “critical steps” of arthroscopy procedures have not yet been clearly defined and interpretation has fallen in the hands of the surgeon. The current study aims to reach a greater consensus of which steps are generally deemed critical by surgeons and to identify how this may vary according to certain demographic parameters. The elucidation of critical elements for surgical procedures has potential ramifications on surgical education, concurrent surgery, surgical billing, and medical ethics.

Recent press reports have suggested that there is an increase in adverse patient outcomes and longer procedure times when an attending surgeon is operating in two different surgical suites [1]. The concept of concurrent surgeries in orthopedic literature is limited; however, a recent analysis of overlapping surgery in the ambulatory setting has been described. Zhang et al. performed a retrospective review over a three-year period and found that 68% of cases were concurrent while 32% were not [6]. They found no difference in the postoperative complication rate between the cohorts (1.1% vs. 1.3%, p=0.811). They also concluded that overlapping surgery yields an equivalent operating time in an ambulatory setting [6]. National registry data from the American College of Surgeons in greater than 20,000 knee and shoulder arthroscopic cases has shown these procedures to be inherently safe, with a 30-day complication rate of 1.6% and 0.99%, respectively [7-8].

We report that for the most common arthroscopic sports medicine surgeries, there was considerable variability in the elements deemed “critical” by the surveyed respondents. Patient positioning and closure were not deemed critical steps among all procedures. Diagnostic arthroscopy was only critical when performing ACL reconstruction. Interestingly, the establishment of arthroscopic portals was viewed as critical for all procedures except knee arthroscopy.

We found significant differences between academic and private practice surgeons, suggesting that the notion of “critical element” may be influenced by the surgical setting. Notably, nearly all steps in all four procedures were considered critical by private practice surgeons. Often, surgeons practicing in a private setting lack highly trained surgical assistants, such as residents and fellows, who are qualified and capable of performing a number of operative steps independently. As a result, nearly every step of a surgical procedure in a private practice requires the direct supervision of the surgeon.

Younger surgeons, defined as those with less than 15 years of practice, were significantly less likely to consider diagnostic arthroscopy and portal establishment as critical steps of the procedure. The difference is likely, in part, due to a comfort level with arthroscopy cases since nearly 98% of the younger respondents had completed a sports medicine fellowship compared to only 82% of the more experienced surgeons (p<0.01).

Although completely novel in the sports medicine literature, there are limitations to the current study. First, the study is limited by the response rate. The survey was distributed to over 2,000 surgeons; however, only 17% responded to the survey. One reason for an imperfect response rate may be that there is no way of identifying how many surgeons received the email. Some of these emails may have been processed as spam or the email listed is not the primary email used by the surgeon. Overall, establishing a consensus regarding the “critical” elements of surgery may necessitate a more robust sample size. Lastly, a potential limitation is that there are likely other factors that influence how surgeons classify different steps of surgery. Patient characteristics, including body weight, comorbid conditions, anatomic variations, and prior arthroscopic procedures, may significantly influence a surgeon’s perception of the surgical procedure.

Conclusions

The notion of “critical” is used colloquially by the medical community in the form of national guidelines, consent forms, and reimbursement regulations. Until now, there have not been any attempts to define critical steps of arthroscopic sports medicine procedures. For four of the most common arthroscopic sports medicine procedures, elements that were not regarded as critical routinely included positioning, the establishment of portals, and closure. However, given the variability based on surgical subspecialty, surgical setting, and surgeon experience, it is difficult to reach a general consensus and standardized definitions of “critical” elements should be established by professional sports medicine societies.


References

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Original article
peer-reviewed

Defining the Critical Elements of the Most Common Arthroscopic Procedures: A Consensus of Orthopaedic Sports Medicine Surgeons


Author Information

David A. Porter

Orthopaedics, Baptist Health South Florida, Coral Gables, USA

Joseph L. Laratta

Orthopaedics, Norton Healthcare, Norton Leatherman Spine Center, Louisville, USA

Jamal N. Shillingford

Orthopaedics, Norton Healthcare, Norton Leatherman Spine Center, Louisville, USA

David Trofa

Orthopedics, Columbia University Medical, New York, USA

Hemant Reddy Corresponding Author

Orthopaedics, Northeast Ohio Medical University (NEOMED), Rootstown, USA

John W. Uribe

Orthopaedics, Baptist Health South Florida, Coral Gables, USA

Gautam P. Yagnik

Orthopaedics, Baptist Health South Florida, Coral Gables, USA


Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.


Original article
peer-reviewed

Defining the Critical Elements of the Most Common Arthroscopic Procedures: A Consensus of Orthopaedic Sports Medicine Surgeons


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