Alex M. Meyer

Purpose: To evaluate the content, construct, concurrent, and transfer validity of the Fundamentals of Arthroscopic Surgery Training (FAST) program and to determine whether FAST testing performance correlated with arthroscopic performance in the operating room. Methods: Participants were postgraduate years 1 to 3 (PGY1‐3) orthopaedic residents from 7 programs who completed a 2‐day FAST Training and Surgical Skills Assessment Course at the Orthopaedic Learning Center in February 2020. Residents underwent pre/postcourse surgical skills assessment in the operating room to determine baseline skills and measure transfer validity. Performance on surgical cases was measured using the Arthroscopic Surgical Skill Evaluation Tool, American Board of Orthopaedic Surgery's Operative Performance Score (O‐Score), and the Procedure‐Specific Checklist Tool (P‐Tool). Baseline, training, and postcourse FAST testing was completed. Construct, concurrent, and content validity were assessed. Results: Thirty‐four (100%) participants completed the curriculum; 100% of residents and faculty agreed that FAST training improved arthroscopic skills (content validity). Expert‐novice comparisons showed significant performance differences for 5 of 6 modules (construct validity). Post‐training pass rates improved across all modules except the maze. Each FAST module passed correlated with a 1.24‐point increase in Arthroscopic Surgical Skill Evaluation Tool score for simulated cadaveric arthroscopy ( P < .001) and improved VirtaMed knee and shoulder simulator metrics (concurrent validity). Each FAST module passed correlated with a 3.86 ( P < .001) Arthroscopic Surgical Skill Evaluation Tool (0‐33 scale) improvement, a 4.52 ( P < .001) American Board of Orthopaedic Surgery's O‐Score (8‐40 scale) improvement, and a 1.29 ( P < .001) American Board of Orthopaedic Surgery's Procedure‐Specific Tool (1‐5 scale) improvement in the operating room (transfer validity). Conclusions: Performance on the FAST testing was significantly associated with improved arthroscopic performance on cadaveric, simulated, and live surgical assessments, showing content, construct, concurrent, and transfer validity within this cohort. Clinical Relevance: The FAST program provides a structured, measurable method for developing fundamental arthroscopic skills early in orthopaedic residency, offering programs an evidence‐based option for standardized assessment and targeted skills training.

Purpose: To develop and implement a simulation‐based arthroscopy curriculum for orthopaedic surgery interns to be completed during their required orthopaedic intern skills month and to evaluate its effectiveness, feasibility, and impact on resident confidence. Methods: Twenty‐one first year residents prospectively completed arthroscopic skill evaluation using VirtaMed augmented reality surgical simulator for the Fundamentals of Arthroscopy Surgical Training (FAST), shoulder, and knee models. Participants then completed the self‐confidence score for surgical trainees survey. Then, they completed simulation training modules on each model over the course of their 1‐month intern skills rotation. Each module contained 13‐14 exercises. Following training, skill evaluations were repeated for each module and self‐confidence survey was repeated. Results: One hundred percent of eligible participants were enrolled, and 100% completed the curriculum. Participant performance improved for all 3 modules (FAST, knee, shoulder). In the FAST modules, pretest to posttest scores for image centering improved from 64.1% to 95.5% ( P < .001), and triangulation and probing improved from 73.5% to 88.4% ( P = .019). In the knee modules, performance improved on diagnostic arthroscopy from 49.9% to 88.8% ( P = .003) and on loose body removal from 40.0% to 75.3% ( P < .001). In the shoulder modules, performance improved on the diagnostic arthroscopy from 89.9% to 98.9% ( P = .011) and for loose body removal from 77.8% to 95.2% ( P = .002). Self‐confidence scale improved from 15.4 to 21.2 ( P < .001). Acceptability of intervention measure, intervention appropriateness measure, and feasibility of intervention was 4.8, 4.6, and 4.7 respectively. Total self‐paced time to completion was 4.9 h for all 3 sections. The shoulder took the most time (1.8 hours), followed by the knee (1.6 hours) and FAST (1.5 hours). Conclusions: The proposed arthroscopy simulation curriculum showed improvement in speed and skill on the arthroscopy simulator and improved personal confidence for orthopaedic surgery interns. It was able to be completed in less than 5 hours with 100% completion rate. Clinical Relevance: Arthroscopy is an essential skill for orthopaedic surgery residents. High‐fidelity simulation is effective at teaching these skills in a safe and controlled environment.

Background: Proximal humerus fractures (PHFs) are increasingly prevalent, particularly in the geriatric population, where they represent a significant burden both individually and societally. Vascular injury, though rare, can have profound implications for management and outcomes. The presence of these concomitant injuries has been shown to be associated with an increased length of hospital stay, total cost, and patient mortality underscoring the critical need for accurate identification of both osseous and vascular injuries to provide appropriate, comprehensive care. Despite extensive research, controversy remains regarding the optimal management of these injuries. Nonoperative management is suitable for fractures meeting specific criteria, while operative options vary based on fracture characteristics, patient factors, and surgeon expertise. The rise in reverse total shoulder arthroplasty (RSA) as a treatment of complex fracture patterns reflects evolving trends in clinical practice. Clinical Scenario: This report presents the case of a 76-year-old woman with a complex, 4-part PHF dislocation sustained secondary to a ground-level fall. On examination, she exhibited diminished radial nerve sensation with wrist extension weakness but was otherwise neurovascularly intact. Cross sectional imaging demonstrated significant medialization of an anterior fracture dislocation of the proximal humerus. Computed tomography angiography of the left upper extremity showed a markedly tortuous axillary artery with possible intimal injury, prompting a multidisciplinary approach. Treatment Approach: A shared decision-making model led to combination surgical case with vascular and orthopaedic surgery for subclavian artery exposure followed by RSA. Postoperatively, the patient recovered without complication, demonstrating the importance of an individualized, multidisciplinary strategy for managing complex PHF with associated vascular insult. Conclusion: This case highlights the critical role of recognition of potential neurovascular injuries due to traumatic events and coordinated management of osseous and vascular injuries in complex PHF. We also describe a combined surgical approach and interdisciplinary coordination for PHF dislocations with concern for vascular compromise. Glenohumeral fracture dislocations are high-risk injuries where RSA offers predictable outcomes for complex fracture patterns but demands careful consideration in the setting of possible vascular trauma.

Background: The aim of this study was to systematically review the literature on concomitant repair of superior labral and rotator cuff tears, in light of the paucity of published clinical evidence. Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses compliant search of PubMed, Embase, and Cochrane Library databases was performed for clinical studies of patients undergoing combined repairs of the rotator cuff and superior labrum. Results: Ten studies comprising 241 shoulders were included, with a mean age of 52.6 years and mean follow-up of 29.0 months; 67.9% were male patients. Functional outcomes included the mean postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Score of 88.6, University of California at Los Angeles Shoulder Score of 30.6, constant score of 90.4, Simple Shoulder Test score of 8.6, and visual analog scale score of 1.1. Range of motion outcomes demonstrated mean postoperative forward flexion of 159°, external rotation of 68°, and internal rotation of 17°. The overall return-to-play rate was 76.8%, with 67.9% returning to preinjury level. The overall complication rate was 4.1% with an 18.9% rate of rotator cuff retear and 2.4% reoperation rate. Conclusion: Arthroscopic concomitant repair of superior labral and rotator cuff tears results in good functional outcomes and range of motion, along with a low reoperation rate. Among athletes, there are moderate rates of return but lower rates of return to the same level of play. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Anterior shoulder dislocations are a common injury, especially in the young, active, male population ¹ . Soft-tissue treatment options for shoulder instability include arthroscopic or open Bankart repair, with open Bankart repair historically having lower rates of recurrence and reoperation, faster return to activity ^2–4 , and a similar quality of life compared with arthroscopic repair ⁵ . More recent literature has suggested similar recurrence rates between arthroscopic and open procedures ⁶ . However, open Bankart repair may be indicated in cases of recurrent instability, especially if the patient participates in high-risk sports, because open repair can provide more capsular shift through the use of extra-capsular knots ⁷ . Performing a subscapularis split decreases the likelihood of subscapularis tendon avulsion following subscapularis tendon tenotomy and subsequent repair, as has been described in the literature ⁸ . Description: Indications for open Bankart repair include failure of arthroscopic Bankart repair, multiple dislocations, with subcritical bone loss. This surgical technique is performed via the deltopectoral approach. The subscapularis tendon is exposed and “spared” by splitting the fibers with use of a longitudinal incision between the upper 2/3 and lower 1/3 of the subscapularis. We begin the split medially near the myotendinous junction. Because the subscapularis becomes increasingly difficult to separate from the capsule as it tracks laterally, a RAY-TEC sponge is utilized to bluntly dissect. A T-shaped laterally based capsulotomy is made to expose the glenohumeral joint. The vertical aspect is made first, followed by the horizontal aspect from lateral to medial, extending to the labrum. A Fukuda retractor is placed through the split to hold the humeral head laterally. The labrum is elevated, and the glenoid is prepared with rasp. Then labrum is repaired with knotted suture anchors until it is secure. One anchor is utilized for each “hour” of the clock face, with a minimum of 3 anchors. The anchors are placed on the articular margin of the glenoid. Sutures are passed from the anchor through the capsule and tied outside the capsule. The capsulotomy is then repaired with use of a suture. The suture is utilized to pull the inferior portion superiorly. The inferior portion is taken superiorly, and the superior leaflet is imbricated over the top. Finally, an examination is performed to ensure that the humeral head can be translated to but not over the anterior and posterior glenoid rims. No repair of the subscapularis tendon insertion is required. The incision is closed with deep dermal and subcuticular suture. Alternatives: Nonoperative treatment options include rotator cuff and periscapular strengthening or immobilization. Operative treatment options include open Bankart repair with subscapularis tenotomy and repair, arthroscopic Bankart repair, or bone block augmentation procedures. Rationale: This procedure is different from the alternative treatments in that it is an open procedure, which allows for a more robust repair because the capsule can be shifted and doubled over, leading to the described decreased recurrence and reoperation rates. Open Bankart repair is better suited for large lesions that would be difficult to repair via arthroscopy. This procedure differs from other open Bankart techniques because the subscapularis is split rather than tenotomized, which removes the need to repair the tendon and decreases the rate of avulsion of the subscapularis tendon repair. Finally, this procedure is less invasive than the Latarjet procedure because it does not require osseous osteotomies and fixation. Expected Outcomes: This procedure provides adequate capsular shift and visualization of the Bankart lesion without the increased risk of postoperative subscapularis tendon injury. Important Tips: If the subscapularis split alone does not provide adequate visualization, portions of the subscapularis tendon can be released from the lesser tuberosity. The location and origin of the upper and lower subscapular nerves can have variable courses, which could theoretically put them at risk for iatrogenic injury; however, studies have shown this subscapularis split technique to be safe from and prevent denervation of the muscle. Acronyms and Abbreviations: GBL = glenoid bone loss EUA = examination under anesthesia MRI = magnetic resonance imaging HSL = Hill-Sachs lesion AHCA = anterior humeral circumflex artery

Optimization of perioperative analgesia has important implications for patient satisfaction and short-term outcomes. This study’s purpose is to assess if preoperative gabapentin or intraoperative ketorolac influences postoperative pain or time to discharge following hip arthroscopy. In total, 409 patients who underwent hip arthroscopic femoroplasty and/or acetabuloplasty with a single surgeon for femoroacetabular impingement were retrospectively reviewed (September 2017 to February 2021). The effect of preoperative gabapentin or intraoperative ketorolac on postoperative visual analog scale (VAS) pain scores, perioperative opioids in morphine milligram equivalents (MMEs), time in post-anesthesia care unit (PACU), second-stage recovery and time to discharge was assessed using unadjusted and adjusted t-tests, and generalized linear models controlling for operative time, traction time, preoperative MME, intraoperative MME and postoperative MME were compared between the groups of gabapentin to no gabapentin and ketorolac to no ketorolac. There was no difference in first PACU VAS pain score, final PACU VAS score, VAS pain score prior to discharge, average VAS pain score or pain level on follow-up call in the unadjusted or adjusted analysis for the preoperative gabapentin or intraoperative ketorolac groups. Females had higher first PACU VAS pain score (6.05 versus 5.15 P = 0.0026), final PACU VAS pain score (4.43 versus 3.90, P = 0.0045), final VAS pain score prior to discharge (3.87 versus 3.03, P < 0.001) and average postoperative pain score (4.60 versus 4.03, P < 0.001), but no difference in VAS pain score on follow-up call following surgery. Gabapentin or ketorolac was not associated with decreased VAS pain scores or time to discharge after hip arthroscopy.

The number of residency applications submitted by medical students has risen at an alarming rate, causing increased cost of applications and subsequent interview travel. These both contribute to increased cost for medical students. In light of these concerns, specialty governing bodies have proposed ideas to fight these trends including, application limits, interview limits, using a preference signaling system, and continuing virtual interviews. During the Covid-19 pandemic, all residency interviews were performed virtually, essentially making travel expenses negligible. However, this created a new concern with regards to assessing program and applicant compatibility, as compared to in-person interactions and did nothing to combat the increases in application numbers. Therefore, we want to critically assess the effects of virtual interviews on number of applications submitted, number of interview invites received, and number of interviews attended. We also aim to analyze how applicants viewed the virtual process. 600 medical students were eligible to participate. 456 students from years 2018-2020 were eligible to be surveyed following the NRMP match. 144 students were eligible to be surveyed following 2021 NRMP match. The survey was distributed to medical school graduates just prior to graduation and asked how many programs each student applied to, how many interview invites they received, and how many interviews they attended. The 2021 survey also asked, “How did virtual interviews affect your interview experience?” The quantitative results were compared with student's t-test and qualitative results are presented below. The average number of programs each applicant applied to increased from 35.4 to 47.7 (p-value=0.002) when residency interviews switched from in-person to virtual. However, interview invites received and interviews attended did not change (16.8 vs 16.3, p-value=0.91, 11.8 vs 12.7, p-value=0.18). There were 188 participants in the in-person interview group (response rate=41.2%) and 128 participants in the virtual interview group (response rate=83.3%). The standard deviation and range also increased for number of applications, number of interview invites received, and number of interviews attended. There were 123 responses to the free response question. 36 had a positive experience, 44 were neutral, 47 were negative. The positive themes included 15 noted less expenses, 18 noted more convenient/less time, and 18 were able to attend more interviews. Negative themes included, 38 noted difficulty assessing program fit, 19 wanted to see the program or city in person, eight had increased interest in home/local programs, six found it difficult to make connections or stand out. Sixty-three percent of students reported a positive or neutral experience with virtual interviews. Students applied to more programs when interviews were virtual, but did not receive more interview invites or attend more interviews. These results suggest that virtual interviews are sufficient to conduct residency interviews, however the number of applications continues to rise with no increase in the number interview invites received or number of interviews attended. The increase in the standard deviation and range for all three variables may point to some applicants being able to get more invites and attend more interviews leaving less available spots for other applicants.