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Purpose To assess orthopaedic trainees performing diagnostic knee arthroscopies and evaluate procedural competence using a novel statistical method, the Cumulative Summation Test for Learning Curve (LC-CUSUM). Methods Twenty orthopaedic trainees in postgraduate year (PGY) 1 through 5 performed diagnostic knee arthroscopy and were evaluated intraoperatively with a validated 10-point knee task-specific checklist (TSCL) and 50-point global rating scale (GRS). A score of 40 points or greater (of 50 points) for the GRS and 8 points or greater (of 10 points) for the knee TSCL was considered to indicate a successful procedure. For the LC-CUSUM analysis, adequate performance was defined as a 10% failure rate, inadequate performance was defined as a 30% failure rate, and an acceptable deviation from adequate performance was defined as 10%. A limit h equal to 1.6 was selected to give a true-discovery rate of 90% and a false-discovery rate of 10% over 50 procedures. Results A total of 340 consecutive procedures were performed by 20 trainees during the 12-month study period. The cumulative number of arthroscopic procedures performed by trainees before study start increased with increasing PGY. The median number of arthroscopic procedures performed per trainee was 16.5 (interquartile range, 14 to 21.75). Competency in knee arthroscopy for the TSCL was achieved by 8 trainees (40%), after a median of 16 procedures (interquartile range, 13 to 20), and for the GRS by only a single trainee (5%), after 14 procedures. Threshold-adjusted curves stratified by PGY level enabled multiple trainees to achieve competency for both the TSCL and GRS. Conclusions The LC-CUSUM can be successfully applied to knee arthroscopy to provide an individualized assessment of performance and quantitatively demonstrate competency for basic arthroscopic tasks. Clinical Relevance The LC-CUSUM is an effective method to evaluate procedure competence in arthroscopic training and can provide objective feedback and benchmarks in the learning phase.

Purpose The objective of our study was to summarize the available clinical evidence pertaining to the combined arthroscopic Bankart repair and remplissage procedure (BRR) for the management of recurrent anterior glenohumeral instability. Methods We searched Medline (1946 to the third week of November, 2012), the Cochrane Central Register of Controlled Trials, Embase (1947 to the 50th week of 2012), and PubMed for studies that reported clinical outcome data at a minimum of 1 year after BRR. Two independent reviewers selected studies for inclusion, assessed methodological quality, and extracted relevant data. Clinical outcome data were pooled and summarized. Results Seven clinical studies with a total of 220 patients met the inclusion criteria. Mean patient age was 29 years and mean follow-up was 26 months. Among all studies, the pooled rate of recurrent dislocation after BRR was 3.4%. Compared with preoperative range of motion (ROM) and ROM after Bankart repair (BR) for similar pathologic conditions, there were no clinically significant losses in glenohumeral motion after BRR. Moreover, BRR resulted in favorable functional outcome scores and high patient satisfaction. Four studies reported on postoperative imaging and found high rates of healing and tissue fill-in at the site of infraspinatus tenodesis. Conclusions After BRR, the rate of recurrent dislocation is low and there are no clinically significant losses in glenohumeral ROM. Moreover, functional outcome scores are good and there is a high rate of patient satisfaction. Going forward, there is a need for high-level clinical studies to support the findings of this systematic review and to develop an evidence-based approach to the management of patients with recurrent glenohumeral instability in the setting of a Hill-Sachs defect (HSD). Level of Evidence Level IV, systematic review of Level II, III, and IV studies.

Purpose Failed anterior shoulder stabilization procedures have traditionally been treated with open procedures. Recent advances in arthroscopic techniques have allowed for certain failed stabilization procedures to be treated by arthroscopic surgery. The aim of this systematic review was to determine the outcomes of revision arthroscopic Bankart repair. Methods We searched Medline, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) for articles on revision arthroscopic Bankart repairs. Key words included shoulder dislocation, anterior shoulder instability, revision surgery, and arthroscopic Bankart repair. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Results We included 16 studies comprising 349 patients. All studies were retrospective (1 Level II study and 15 Level IV studies). The mean incidence of recurrent instability after revision arthroscopic Bankart repair was 12.7%, and the mean follow-up period was 35.4 months. The most common cause for failure of the primary surgeries was a traumatic injury (62.1%), and 85.1% of patients returned to playing sports. The reasons for failure of revision cases included glenohumeral bone loss, hyperlaxity, and return to contact sports. Conclusions With proper patient selection, the outcomes of revision arthroscopic Bankart repair appear similar to those of revision open Bankart repair. Prospective, randomized clinical trials are required to confirm these findings. Level of Evidence Level IV, systematic review of Level II and Level IV studies.