Abstract
Although previous chapters indicated the potential and benefits of training arthroscopic skills in simulated environments, training needs to be continued in the operating room to achieve the necessary proficiency. Based on the theory on learning strategies in Chap. 4, it is posed that if residents indeed acquire the basic skills before they enter the operating room, the focus in the operating room can be on more complex tasks. This requires the formulation of guidelines that determine the level that qualifies proficiency. For the actual cases in the operating room, this is a difficult task as the level of complexity of the procedure plays an important role, and proficiency is not necessarily defined as the summation of several part-task skills, but rather requires a holistic approach.
Keywords
- Anterior Cruciate Ligament
- Surgical Performance
- Global Rating Scale
- Video Feedback
- Arthroscopic Rotator Cuff Repair
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
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Appendices
Appendix 13.A Orthopaedic Competence Assessment Project
Skill | Score 1 | Score 2 | Score 3 | Score 4 | Score 5 |
---|---|---|---|---|---|
Follows protocol | Unsatisfactory | Adequate. Occasional need for guidance and help | Excellent adherence to agreed protocol. No prompts. No mistakes | ||
Handles tissue well | Careless. Potential to cause damage | Adequate. No tissue damage. Occasional need for increased care | Excellent tissue handling. Precise and delicate | ||
Appropriate and safe use of instruments | Dangerous. Risk to patient and assistant. Potential for damage to equipment | Adequate use of instruments and scope. Occasional guidance to ensure instruments remain within field of vision | Excellent use of instruments. Good control of arthroscope. Instruments constantly within field of vision | ||
Appropriate pace with economy of movement | Erratic pace and movements. Overly rushing or inappropriately slow | Adequate economy of movement. Majority of movements controlled and careful. Occasional erratic movement | Excellent fluidity and economy of movement. Procedure performed at appropriate pace without erratic movements | ||
Act calmly and effectively with untoward events | Unable to deal with adverse events. Panic and inability to respond | Remains calm. Remains safe. Takes advice from supervisor. Unable to cope independently | Excellent ability to cope with adverse events. Remains calm. Deals with complication independently | ||
Appropriate use of assistant | Fails to involve assistant appropriately. Resultant poor positioning. Poor rapport | Asks for appropriate joint position at appropriate times. Unable to suggest alternative positions to improve view/access | Excellent use of assistant. Good rapport. Able to constantly modify input of assistant to best advantage throughout procedure | ||
Communicates with scrubs nurse | Inappropriate communication resulting in confusion or operative delay | Appropriate communication with scrub nurse. Occasional need for clarification from supervisor | Excellent rapport with scrub nurse. Clear and effective communication, maximising procedural efficiency | ||
Clearly identifies common abnormalities | Unable to identify common abnormalities. Confusion over basic anatomy | Adequate identification of common pathology. Occasional mistake. Unsure of precise classifications | Excellent knowledge of pathology of common abnormalities. Clear understanding of classification of injuries | ||
Protecting the articular surface | Inability to protect articular surface appropriately. Potential to cause damage | Awareness of need to protect articular surface. Adequate care taken. Occasional prompt from supervisor required | Excellent awareness of articular surfaces. High degree of care maintained throughout the procedure |
Appendix 13.B Basic Arthroscopic Knee Skill Scoring System
Skill | Score 1 | Score 2 | Score 3 | Score 4 | Score 5 |
---|---|---|---|---|---|
Dissection | Appeared excessively hesitant, caused trauma to tissues, did not dissect into correct anatomical plan | Controlled and safe dissection into correct anatomical plane, caused minimal trauma to tissues | Superior and atraumatic dissection into the correct anatomical plane | ||
Instrument handling | Repeatedly makes tentative or awkward movements with instruments | Competent use of instruments, although occasionally appeared stuff or awkward | Fluid moves with instruments and no awkwardness | ||
Depth perception | Constantly overshoots target, slow to correct | Some overshooting or missing of target | Accurately directs instruments in the correct plane to target | ||
Bimanual dexterity | Noticeably awkward with non-dominant hand, poor coordination between hands | Uses both hands but does not maximise interaction between hands | Expertly uses both hands in complementary manner to provide optimum performance | ||
Flow of operation and forward planning | Frequently stopped operating or needed to discuss next move | Demonstrated ability for forward planning with steady progression of operative procedure | Obviously planned course of operation with effortless flow from one move to the next | ||
Knowledge of instruments | Frequently asked for the wrong instrument or used inappropriate instrument | Knew the names of most instruments and used appropriate instrument for the task | Obviously familiar with the instruments required and their names | ||
Efficiency | Many unnecessary, inefficient movements. Constantly changing focus or persisting without progress | Slow, but planned movements are reasonably organised with few unnecessary or repetitive movements | Confident, clear economy of movement and maximum efficiency | ||
Knowledge of specific procedure | Deficient knowledge, needed specific instruction at most operative steps | Knew all important aspects of the operation | Demonstrated familiarity with all aspects of the operation | ||
Autonomy | Unable to complete entire task, even with verbal guidance | Able to complete task safely with moderate guidance | Able to complete task independently without prompting | ||
Quality of final product | Very poor | Competent | Clearly superior |
Appendix 13.C Arthroscopic Skills Assessment
Start time | Stop time | Total time |
---|---|---|
Landmark | To be visualised | Score |
Suprapatellar pouch | View all areas of pouch | (3) |
Patella | View medial facet | (3) |
View lateral facets | (3) | |
Trochlea | View trochlear surface | (4) |
Medical recess | View medial gutter/assess meniscal synovial junction | (4) |
Lateral recess | View lateral gutter/assess meniscal junction/popliteus | (4) |
Medial compartment | Assess condyle for chondral lesions | (5) |
Meniscus/view anterior, middle, posterior | (5) | |
Probe superior and inferior surface | (10) | |
Intercondylar notch | View and inspect ACL | (5) |
View and inspect PCL | (5) | |
Lateral compartment | Assess condyle for chondral lesions | (5) |
Meniscus/view anterior, middle, posterior | (5) | |
Probe superior and inferior surface | (10) | |
View popliteus tendon | (4) |
Missed items | Scope score | |
---|---|---|
Time | Time penalty | Total time score |
Total score |
Appendix 13.D Objective Assessment of Arthroscopic Skills
Skill | Novice | Advanced beginner | Competent | Proficient | Expert |
---|---|---|---|---|---|
Examining/manipulating joint | Did not examine joint or position to give improved visualisation during procedure | Examined joint without diagnostic abilities and lacked ability to facilitate view by positioning | Positioned knee appropriately after some difficulty with visualisation | Used common positioning to facilitate view during arthroscopy | Used accepted and novel positioning to perform the arthroscopy effortlessly |
Triangulating instruments | Could not insert instruments into ports and maintain them in view. Unable to locate instrument tips without difficulty | Unable to maintain instrument in field of view consistently | Found instruments with delay. Field of view wandered from operative site but returned | Found instruments quickly and began work. Occasionally delayed in orienting camera to afford better visualisation | Immediately located instruments and began work without delay. Kept instrument in field of view at all times |
Controlling fluid flow and joint distension | Under-/overdistended joint consistently due to inappropriate matching of suction and flow. | Achieved proper distension after delays. Some extravasation into tissue due to overdistension | Distended joint adequately after initial loss of pressure during suction | Joint distended appropriately through control of flow and suction | Minimal fluid extravasated with constantly maintained field of view |
Maintaining field of view | Often disoriented. Was unable to adjust scope to improve visualisation | Maintained field of view part of the time | Maintained and adjusted arthroscope to provide maximal view with some difficulty | Maintained field of view in same portal | Changed portals quickly to improve visualisation |
Controlling instruments | Was unable to perform tasks with provided instruments. Caused cartilage damage | Repeatedly made tentative or awkward moves with instruments | Competently used instruments although occasionally appeared stiff or awkward | Used instruments appropriately and efficiently | Made fluid moves with instruments and used some instruments in novel ways to increase efficiency |
Economising time and planning forward | Was unable to complete any portion of the procedure | Was able to complete components of the procedure, but needed to discuss next move | Completed all components of the operation with some unnecessary moves | Was efficient, but continued discovering new time saving motions | Showed economy of movement and maximum efficiency |
Overall | Possessed rudimentary arthroscopic skills with only basic anatomical and mechanical understanding | Knew basic steps of procedure and performed some independently | Performed the procedure independently | Performed procedure with changes to improve efficiency | Performed the procedure with minimal chance to improve efficiency |
Complexity | No difficulties | Slightly difficult | Moderately difficult | Considerable difficulty | Critical |
Appendix 13.E Arthroscopic Surgical Skill Evaluation Tool
Skill | Score 1 | Score 2 | Score 3 | Score 4 | Score 5 |
---|---|---|---|---|---|
Safety | Significant damage to articular cartilage or soft tissue | Insignificant damage to articular cartilage or soft tissue | No damage to articular cartilage or soft tissue | ||
Field of view | Narrow field of view, inadequate arthroscope or light source positioning | Moderate field of view, adequate arthroscope and light source positioning | Expansive field of view, optimal arthroscope and light source positioning | ||
Camera dexterity | Awkward or graceless movements, fails to keep camera centred and correctly oriented | Appropriate use of camera, occasionally needs to reposition | Graceful and dexterous throughout procedure with camera always centred and correctly | ||
Instrument dexterity | Overly tentative or awkward with instruments, unable to consistently direct instruments to targets | Careful, controlled use of instruments, occasionally misses targets | Confident and accurate use of all instruments | ||
Bimanual dexterity | Unable to use both hands or no coordination between hands | Uses both hands but occasionally fails to coordinate movement of camera and instruments | Uses both hands to coordinate camera and instrument positioning for optimal performance | ||
Flow of procedure | Frequently stops operating or persists without progress, multiple unsuccessful attempts prior to completing tasks | Steady progression of operative procedure with few unsuccessful attempts prior to completing tasks | Obviously planned course of procedure, fluid transition from one task to the next with no unsuccessful attempts | ||
Quality of procedure | Inadequate or incomplete final product | Adequate final product with only minor flaws that do not require correction | Optimal final product with no flaws | ||
Autonomy | Unable to complete procedure even with intervention(s) | Able to complete procedure but required intervention(s) | Able to complete procedure without intervention | ||
Complexity | No difficulty | Moderate difficulty (mild inflammation or scarring) | Extreme difficulty (severe inflammation or scarring, abnormal anatomy) |
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Tuijthof, G.J.M., Sierevelt, I.N. (2015). Monitoring Performance and Progression in the Operating Theatre. In: Karahan, M., Kerkhoffs, G., Randelli, P., Tuijthof, G. (eds) Effective Training of Arthroscopic Skills. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-44943-1_13
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