Clinical Practice Patterns in Facelift Surgery: A 15-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery.

BACKGROUND: This study evaluates change in practice patterns in facelift surgery based on a 15-year review of tracer data collected by the American Board of Plastic Surgery as part of the Continuous Certification process. METHODS: Tracer data for facelift was reviewed from 2006 to 2021. The 15-year collection period was divided into an "early cohort (EC)" from 2006 to 2014 and a "recent cohort (RC)" from 2015 to 2021. RESULTS: Of 3400 facelifts (1710 EC/1690 RC) performed, 18% were done in hospital and 76% were done in an accredited office facility. Ninety one percent of patients were female with an average age of 61 years. There was an increase in the number of secondary facelifts (4% EC vs 18% RC; p < 0.001) and an increased number of patients concerned about volume loss/deflation (25% EC vs 37% RC; p < 0.001). The surgical approach to the SMAS involved plication (40%), flaps (35%), SMASectomy (22%) and MACS lift (6%). One percent of facelifts were subperiosteal and 8% skin-only. Significantly more surgeons used the lateral SMAS flap (14% EC vs 18% RC, p < 0.005), while less used an extended SMAS flap (21% vs 18%; p = 0.001) and MACS lift (10% EC vs 6% RC; p = 0.021) techniques. The concomitant use of facial fat grafting is becoming more common (15% EC vs 24% RC, p = 0.0001). CONCLUSIONS: A 15-year review of ABPS tracer data provides an excellent venue for the objective assessment of the current status of facelift surgery, and key changes in practice patterns during that time. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clinical Practice Patterns in Abdominoplasty: 16-Year Analysis of Continuous Certification Data from the American Board of Plastic Surgery.

BACKGROUND: The authors evaluated trends in practice patterns for abdominoplasty based on a 16-year review of tracer data collected by the American Board of Plastic Surgery as part of the continuous certification process. METHODS: To facilitate comparison of an equal number of patients over time, tracer data from 2005 to 2021 were split into an early cohort (EC) (from 2005 to 2014) and a recent cohort (RC) (from 2015 to 2021). Fisher exact tests and two-sample t tests were used to compare patient demographics, surgical techniques, and complication rates. RESULTS: Data from 8990 abdominoplasties (EC, n = 4740; RC, n = 4250) were analyzed. RC abdominoplasties report a lower rate of complications (RC, 19%; EC, 22%; P < 0.001) and a lower rate of revision surgery (RC 8%; EC, 10%; P < 0.001). This has occurred despite the increased use of abdominal flap liposuction (RC, 25%; EC, 18%; P < 0.001). There has been a decline in the use of wide undermining (81% versus 75%; P < 0.001), vertical plication of the abdomen (89% versus 86%; P < 0.001), and surgical drains (93% versus 89%; P < 0.001). Abdominoplasty surgery is increasingly performed in an outpatient setting, with increased use of chemoprophylaxis for thrombosis prevention. CONCLUSIONS: Analysis of these American Board of Plastic Surgery tracer data highlights important trends in clinical practice over the past 16 years. Abdominoplasty continues to be a safe and effective procedure with similar complication and revision rates over the 16-year period.

Clinical Practice Patterns and Evidence-Based Medicine in Rhinoplasty: A 10-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery.

BACKGROUND: The American Board of Plastic Surgery (ABPS) has collected data on cosmetic surgery from member surgeons since 2003. These data offer valuable information on national trends in clinical practice. OBJECTIVES: The present study was performed to analyze trends in rhinoplasty over the last decade. METHODS: Tracer data were compared between two cohorts 2012-2016 (early cohort "EC") and 2017-2021 (recent cohort "RC"). Data included patient demographics and surgical techniques. Results were considered in the context of current EBM-based guidance in the plastic surgery literature. RESULTS: Data from 730 rhinoplasties (270 EC and 460 RC) were analyzed. The median age was 30 years, and the most common patient concern was the nasal dorsum (79%). In the RC group, fewer patients voiced concerns about tip projection (58% vs 43%, p = 0.0002) and more complained of functional airway problems (38% vs 49%, p = 0.004). An open approach was most common (83%). Septoplasty (47% vs 52%, p = 0.005), caudal septum repositioning (14% vs 23%, p = 0.002), and tip rotation maneuvers (32% vs 49%, p < 0.0001) became more popular. There was also an increase in the use of spreader grafts (35% vs 45%, p = 0.01) and columellar strut grafts (42% vs 50%, p = 0.04), while there has been a decrease in alar base resection (17% vs 10%, p = 0.007) and non-cartilaginous dorsum/radix augmentation (9% vs 4%, p = 0.02). CONCLUSIONS: ABPS tracer data provide an excellent resource for the objective assessment of procedures in plastic surgery. The present study is the first to highlight evolving trends in rhinoplasty over the last 10 years. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Practice Patterns in Primary Breast Augmentation: A 16-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery.

BACKGROUND: As part of the continuous certification process, the American Board of Plastic Surgery collects case data for specific tracer procedures in aesthetic surgery to assess practice improvement by the diplomates. These case-based data provide valuable information on national trends in clinical practice. The current study was performed to analyze practice patterns in aesthetic primary breast augmentation. METHODS: Breast augmentation tracer data were reviewed from 2005 to 2021 and grouped into an early cohort (EC), from 2005 through 2014, and a recent cohort (RC), from 2015 through 2021. Fisher exact tests and two-sample t tests compared demographic characteristics of the patients, surgical techniques, and complication rates. RESULTS: Patients in the RC were slightly older (34 versus 35 years; P < 0.001), more likely to have ptosis greater than 22 cm (20% versus 23%; P < 0.0001), less likely to smoke (12% versus 8%; P < 0.0001), and less likely to undergo a preoperative mammogram (29% versus 24%; P < 0.0001). From a technical standpoint, inframammary incisions have become more common (68% versus 80%; P < 0.0001), whereas periareolar incision use has decreased (24% versus 14%; P < 0.0001). Submuscular plane placement has increased (22% versus 56%; P < 0.0001), while subglandular placement has decreased (19% versus 7%; P < 0.0001). Silicone implants are most popular (58% versus 82%; P < 0.0001). Textured implant use increased from 2011 (2%) to 2016 (16%), followed by a sharp decline to 0% by 2021. Trends follow U.S. Food and Drug Administration approvals and warnings. CONCLUSIONS: This study highlights evolving trends in aesthetic breast augmentation over the past 16 years. The most common technique remains a smooth silicone prosthesis placed in the subpectoral plane through an inframammary incision.

A 16-Year Review of Clinical Practice Patterns in Liposuction Based on Continuous Certification by the American Board of Plastic Surgery.

BACKGROUND: The American Board of Plastic Surgery has collected data on cosmetic surgery tracers as part of the Continuous Certification process since 2005. The current study was performed to analyze evolving trends in liposuction from the American Board of Plastic Surgery database. METHODS: Tracer data from 2005 through 2021 were reviewed and grouped into an early cohort (EC) (2005-2014) and a recent cohort (RC) (2015-2021). Fisher exact tests and two-sample t tests were used to compare patient demographics, techniques, and complications. RESULTS: A total of 2810 suction-assisted liposuction cases were included (1150 EC, 1660 RC). In-office procedures increased (36% EC versus 41% RC). The use of general anesthesia remained the same (63% EC versus 62% RC). The use of power-assisted liposuction increased (24% EC versus 40% RC) and use of ultrasound-assisted liposuction decreased (5% versus 2%). With respect to body areas treated, liposuction of the abdomen (64% EC versus 69% RC), flanks (60% EC versus 64% RC), and back (22% EC versus 34% RC) increased; treatments of thighs (36% EC versus 23% RC), and knees (8% EC versus 5% RC) decreased. Intraoperative position changes are more common (30% EC versus 37% RC), as is liposuction of multiple areas in one case (28% EC versus 36% RC). The volume of lipoaspirate also increased (1150 cc EC versus 1660 cc RC). CONCLUSIONS: This study highlights evolving trends in liposuction over 16 years. Liposuction is becoming more common as an outpatient procedure performed concomitantly with other procedures. Despite multiple emerging technologies, the popularity of power-assisted liposuction is increasing. Although adverse events have not significantly increased with these changes, the authors stress careful preoperative evaluation of patients to identify factors that increase the risk of complications.

American Board of Orthopaedic Surgery's Initiatives Toward Competency-Based Education.

The American Board of Orthopaedic Surgery (ABOS) is the national organization charged with defining education standards for graduate medical education in orthopaedic surgery. The purpose of this article is to describe initiatives taken by the ABOS to develop assessments of competency of residents to document their progress toward the independent practice of orthopaedic surgery and provide feedback for improved performance during training. These initiatives are called the ABOS Knowledge, Skills, and Behavior Program. Web-based assessment tools have been developed and validated to measure competence. These assessments guide resident progress through residency education and better define the competency level by the end of training. The background and rationale for these initiatives and how they serve as steps toward competency-based education in orthopaedic residency education in the United States will be reviewed with a vision of a hybrid of time and competency-based orthopaedic residency education that will remain 5 years in length, with residents assessed using standardized tools.

Do Orthopaedic In-Training Examination Scores Predict the Likelihood of Passing the American Board of Orthopaedic Surgery Part I Examination? An Update With 2014 to 2018 Data.

INTRODUCTION: Previous research shows a correlation in performance between the Orthopaedic In-Training Examination (OITE) and the American Board of Orthopaedic Surgery (ABOS) Certifying Examination Part I; however, these studies are not current, with the most recent data from 2009. The purpose of this study was to update the relationship between the OITE and ABOS Part I scores with the five most recent nationwide cohorts of Part I scores and their corresponding OITE scores. METHODS: The American Academy of Orthopaedic Surgeons provided the results for each resident taking the OITE from 2013 to 2017. The ABOS provided the results for each resident taking the Part I examination from 2014 to 2018. These two datasets were matched at the individual level and analyzed. RESULTS: Between 2014 and 2018, 3,502 first-time test-takers were present for the ABOS Part I Examination. A 96.6% pass rate was noted (3,383 of 3,502). A statistically significant correlation between the OITE score and ABOS Part I score was observed at all levels of training: postgraduate year (PGY) 1 r = 0.380, PGY2 r = 0.463, PGY3 r = 0.498, PGY4 r = 0.504, and PGY5 r = 0.504 (P < 0.001 for all correlations). CONCLUSION: The OITE scores continue to correlate with the ABOS scores and the pass rate for the ABOS with moderate strength correlation. However, although a correlation of the examinations exists when evaluated as a group, the predictive value of the OITE for passing the Part I examination for any specific individual is far from perfect. Individuals with PGY5 OITE percentile scores less than 10 pass the Part I examination, and individuals with PGY5 OITE percentile scores greater than 90 fail the Part I examination.

Complications of Hardware Removal.

BACKGROUND: While hardware removal may improve patient function, the procedure carries risks of unexpected outcomes. Despite being among the most commonly performed orthopaedic procedures, scant attention has been given to its complication profile. METHODS: We queried the American Board of Orthopaedic Surgery (ABOS) de-identified database of Part II surgical case lists from 2013 through 2019 for American Medical Association Current Procedural Terminology (CPT) implant-removal codes (20680, 20670, 22850, 22852, 22855, 26320). Hardware removal procedures that were performed without any other concurrent procedure ("HR-only procedures") were examined for associated complications. RESULTS: In the 7 years analyzed, 13,089 HR-only procedures were performed, representing 2.1% (95% confidence interval [CI], 2.1% to 2.2%) of the total of 609,150 surgical procedures during that period. A complication was reported to have occurred in association with 1,256 procedures (9.6% [95% CI, 9.1% to 10.1%]), with surgical complications reported in association with 1,151 procedures (8.8% [95% CI, 8.3% to 9.3%]) and medical/anesthetic complications reported in association with 196 procedures (1.5% [95% CI, 1.3% to 1.7%]). Wound-healing delay/failure (2.1% [95% CI, 1.8% to 2.3%]) and infection (1.6% [95% CI, 1.4% to 1.8%]) were among the most commonly reported complications after HR-only procedures, but other serious events were reported as well, including unexpected reoperations (2.5% [95% CI, 2.2% to 2.7%]), unexpected readmissions (1.6% [95% CI, 1.4% to 1.8%]), continuing pain (95% CI, 1.2% [1.0% to 1.4%]), nerve injury (0.6% [95% CI, 0.4% to 0.7%]), bone fracture (0.5% [95% CI, 0.4% to 0.6%]), and life-threatening complications (0.4% [95% CI, 0.3% to 0.5%]). CONCLUSIONS: Hardware removal is one of the most commonly performed orthopaedic procedures and was associated with an overall complication rate of 9.6% (95% CI, 9.1% to 10.1%) in a cohort of recently trained orthopaedic surgeons in the United States. Although specific complications such as infection, refractures, and nerve damage were reported to have relatively low rates of occurrence, and associated life-threatening complications occurred rarely, surgeons and patients should be aware that hardware removal carries a definite risk. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Use of the Behavior Assessment Tool in 18 Pilot Residency Programs.

BACKGROUND: The purpose of this study was to determine the feasibility and evaluate the effectiveness of the American Board of Orthopaedic Surgery Behavior Tool (ABOSBT) for measuring professionalism. METHODS: Through collaboration between the American Board of Orthopaedic Surgery and American Orthopaedic Association's Council of Residency Directors, 18 residency programs piloted the use of the ABOSBT. Residents requested assessments from faculty at the end of their clinical rotations, and a 360° request was performed near the end of the academic year. Program Directors (PDs) rated individual resident professionalism (based on historical observation) at the outset of the study, for comparison to the ABOSBT results. RESULTS: Nine thousand eight hundred ninety-two evaluations were completed using the ABOSBT for 449 different residents by 1,012 evaluators. 97.6% of all evaluations were scored level 4 or 5 (high levels of professional behavior) across all of the 5 domains. In total, 2.4% of all evaluations scored level 3 or below reflecting poorer performance. Of 431 residents, the ABOSBT identified 26 of 32 residents who were low performers (2 or more < level 3 scores in a domain) and who also scored "below expectations" by the PD at the start of the pilot project (81% sensitivity and 57% specificity), including 13 of these residents scoring poorly in all 5 domains. Evaluators found the ABOSBT was easy to use (96%) and that it was an effective tool to assess resident professional behavior (81%). CONCLUSIONS: The ABOSBT was able to identify 2.4% low score evaluations (

Resident Independence Performing Common Orthopaedic Procedures at the End of Training: Perspective of the Graduated Resident.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) has established minimum exposure rates for specific orthopaedic procedures during residency but has not established the achievement of competence at the end of training. The determination of independence performing surgical procedures remains undefined and may depend on the perspective of the observer. The purpose of this study was to understand the perceptions of recently graduated orthopaedic residents on the number of cases needed to achieve independence and on the ability to perform common orthopaedic procedures at the end of training. METHODS: We conducted a web survey of all 727 recently graduated U.S. orthopaedic residents sitting for the 2018 American Board of Orthopaedic Surgery Part I Examination in July 2018. The surveyed participants were asked to assess the ability to independently perform 26 common adult and pediatric orthopaedic procedures as well as to recommend the number of cases to achieve independence at the end of training. We compared these data to the ACGME Minimum Numbers and the average ACGME resident experience data for residents who graduated from 2010 to 2012. RESULTS: For 14 (78%) of the 18 adult procedures, >80% of respondents reported the ability to perform independently, and for 7 (88%) of the 8 pediatric procedures, >90% reported the ability to perform independently. The resident-recommended number of cases for independence was greater than the ACGME Minimum Numbers for all but 1 adult procedure. For 18 of the 26 adult and pediatric procedures, the mean 2010 to 2012 graduated resident exposure was significantly less than the mean number recommended for independence by 2018 graduates (p < 0.05). CONCLUSIONS: Overall, recently graduated residents reported high self-perceived independence in performing the majority of the common adult and pediatric orthopaedic surgical procedures included in this study. In general, recently graduated residents recommended a greater number of case exposures to achieve independence than the ACGME Minimum Numbers.

Early Practice Patterns of Hand Surgeons: An American Board of Orthopaedic Surgery Database Study.

PURPOSE: To investigate the variety of cases that are performed by newly graduated fellowship-trained orthopedic hand surgeons. METHODS: All cases submitted by board-eligible orthopedic surgeons taking part II of their board examination between 2004 and 2013 were obtained from the database of the American Board of Orthopaedic Surgery (ABOS). Each case was then categorized based on the fellowship training of the treating surgeon and whether it was a hand surgery case. Each hand surgery case was then further categorized into 1 of the 8 surgical categories used by the ABOS to determine eligibility for the Subspecialty Certificate in Orthopaedic Surgery of the Hand (SCOSH). RESULTS: During our study period, 6,854 orthopedic surgeons submitted 858,146 cases to the ABOS. Fellowship-trained hand surgeons made up 13% of all surgeons, and 24% of all submitted cases were hand surgery cases. Based on the cases submitted, 44% of hand surgeons were not on track to become eligible for the SCOSH. The most common reason for not reaching eligibility was failure to meet the minimum requirements in 1 of either the congenital, the skin and wound problems, the contracture and joint stiffness, the microvascular, or the tumor categories. CONCLUSIONS: A large proportion of fellowship-trained orthopedic hand surgeons are not on track to meet the minimum eligibility requirements for the ABOS SCOSH during their part II case collections. Their case profile is not sufficiently diverse to be considered an active hand surgery practice for the purpose of SCOSH eligibility. CLINICAL RELEVANCE: This study highlights 1 possible reason why over one-third of young hand surgeons do not obtain their subspecialty certification.

Perceptions of the Recommended Resident Experience with Common Orthopaedic Procedures: A Survey of Program Directors and Early Practice Surgeons.

BACKGROUND: U.S. orthopaedic residency training is anchored by the Accreditation Council for Graduate Medical Education (ACGME) requirements, which include minimum numbers for 15 categories of procedures. The face validity of these recommendations and expectations for exposure to other common procedures has not been rigorously investigated. The main goals of this investigation were to understand the perceptions of program directors and early practice surgeons regarding the number of cases needed in residency training and to report which of the most commonly performed procedures residents should be able to perform independently upon graduation. METHODS: We sent surveys to 157 current program directors of ACMGE-approved orthopaedic surgery residency programs and to all examinees sitting for the American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination in 2017, requesting that they estimate the minimum number of exposures for the 22 adult and 24 pediatric procedures that are most commonly performed during residency and the first 2 years in practice. Where applicable, we compared these with the ACGME "Minimum Numbers" and the average ACGME resident experience data from 2010 to 2012 for resident graduates. For each of the 46 procedures, participants were asked if every orthopaedic resident should be able to independently perform the procedure upon graduation. We compared the percent for independence between the early practice surgeons and the program directors. RESULTS: For the majority of adult and pediatric procedures, the early practitioners reported significantly higher numbers of cases needing to be performed during residency than the program directors. ACGME Minimum Numbers were always lower than the case numbers that were recommended by the early practice surgeons and the program directors. Overall we found good-to-excellent agreement for independence at graduation between program directors and early practitioners for adult cases (intraclass correlation coefficient [ICC], 0.98; 95% confidence interval [CI], 0.82 to 0.99) and moderate-to-good agreement for pediatric cases (ICC, 0.96; 95% CI, 0.74, 0.99). CONCLUSIONS: The program directors frequently perceived the need for resident operative case exposure to common orthopaedic procedures to be lower than that estimated by the early practice surgeons. Both program directors and early practice surgeons generally agreed on which common cases residents should be able to perform independently by graduation.

Resident Surgical Skills Web-Based Evaluation: A Comparison of 2 Assessment Tools.

BACKGROUND: Evaluation of surgical skill competency is necessary as graduate medical education moves toward a competency-based curriculum. This study by the American Board of Orthopaedic Surgery (ABOS) and the Council of Orthopaedic Residency Directors (CORD) compares 2 web-based evaluation tools that assess the level of autonomy that is demonstrated by residents during surgical procedures in the operating room as measured by faculty. METHODS: Two hundred and ninety-four residents from 16 orthopaedic surgery residency programs were evaluated by 370 faculty using 2 web-based evaluation tools in a crossover design in which residents requested faculty review of their surgical skills before starting a case. One thousand, one hundred and fifty Ottawa Surgical Competency Operating Room Evaluation (O-Score) assessments, which included a 9-question evaluation of 8 steps of the surgical procedure, were compared with 1,186 P-score evaluations, which included a single-question summative evaluation. Twenty-five different surgical procedures were evaluated. RESULTS: There were no significant differences in rates of resident requests or faculty completion of the 2 scores. The most common surgical procedures that were assessed were total knee arthroplasty (n = 254, 11%), carpal tunnel release (n = 191, 8%), open reduction and internal fixation (ORIF) of stable hip fractures (n = 170, 7%), ORIF of simple ankle fractures (n = 169, 7%), and total hip arthroplasty (n = 166, 7%). Both instruments disclosed significant differences in competency among entry, intermediate, and advanced-level residents. The findings support the construct validity of the evaluation method. The survey results indicated that >70% of the faculty were confident that use of either the P-score or the O-score allowed them to distinguish a resident who can perform the surgery independently from one who needs additional training. CONCLUSIONS: This research has led to the modification of the O-score and the P-score into a combined OP-score instrument. The ABOS envisions that the OP-score instrument can be used with an expanded number of surgical procedures as a required element of residency training in the near future. CLINICAL RELEVANCE: This study allows the profession of orthopaedic surgery education to take a leadership role in the measurement of competence for surgical skills for orthopaedic surgeons in residency training, an important clinically relevant topic to the practice of orthopaedic surgery.

Cartilage Restoration Surgery: Incidence Rates, Complications, and Trends as Reported by the American Board of Orthopaedic Surgery Part II Candidates.

PURPOSE: To evaluate the current status of advanced cartilage restoration procedures among newly trained orthopaedic surgeons in the United States. METHODS: The American Board of Orthopaedic Surgery database was queried to identify all advanced cartilage restoration procedure cases submitted by American Board of Orthopaedic Surgery part II board certification examination candidates from 2003 to 2015. All documented autologous chondrocyte implantation, autologous osteochondral transfer, osteochondral allograft transplantation, and marrow stimulation techniques (MSTs) procedures were analyzed. Analysis was performed to describe trends in annual incidence, types of complications, concomitant procedures, and geographical differences in incidence of advanced cartilage procedures. RESULTS: From 2003 to 2015, a total of 2,827 surgeons submitted 7,522 cartilage restoration procedures, with 7,060 cases documented as MST (80.01%). The number of cartilage cases decreased significantly from 2003 to in 2015 (P <.001), with MST having the largest decline (P < .001). The incidence of open osteochondral allograft transplantation (odds ratio = 1.35; P = .023) and open autologous osteochondral transfer (odds ratio = 0.84; P = .004) increased over the study period. Overall, the majority of patients (57.0%) were male; however, female patients were on average significantly older than male patients (P < .001). Cartilage procedures were performed concomitantly with a realignment osteotomy procedure in 1.7% of cases. The incidence of surgical complications increased throughout the study period from 2.9% in 2003 to 9.5% in 2015 (P < .001). CONCLUSIONS: Cartilage restoration procedures, specifically MSTs, are being decreasingly performed among recently trained orthopaedic surgeons. In contrast, complication rates have been increasing since 2003, demonstrating a possible paradigm shift toward more complex cartilage procedures, specifically osteochondral grafting procedures. CLINICAL RELEVANCE: This study demonstrates a significant decline in the use of MSTs by recently trained orthopaedic surgeons. In addition, an increase in several more complex cartilage restoration procedures was found. Taken in sum, these changes may reflect a shift in residency and fellowship training away from marrow stimulation procedures that elicit a fibrocartilage reparative tissue and toward more complex procedures that provide a more hyaline-like articular cartilage surface.

Operative Experience During Orthopaedic Residency Compared with Early Practice in the U.S.

BACKGROUND: The goal of surgical education is to prepare the trainee for independent practice; however, the relevance of the current residency experience to practice remains uncertain. The purpose of this study was to identify the surgical procedures most frequently performed in orthopaedic residency and in early surgical practice and to identify surgical procedures performed more often or less often in orthopaedic residency compared with early surgical practice. METHODS: This retrospective cohort study included American Medical Association (AMA) Current Procedural Terminology (CPT) codes (n = 4,329,561 procedures) reported by all U.S. orthopaedic surgery residents completing residency between 2010 and 2012 (n = 1,978) and AMA CPT codes for all procedures (n = 413,370) reported by U.S. orthopaedic surgeons who took the American Board of Orthopaedic Surgery Part II certifying examination between 2013 and 2015 (n = 2,205). Relative rates were determined for AMA CPT codes and AMA CPT code categories for adult and pediatric surgeries that had frequencies of ≥0.1% for both practitioners and residents. RESULTS: The top 25 adult AMA CPT code categories contributed 82.1% of the total case volume for residents and 82.4% for practitioners. Knee and shoulder arthroscopy were the most frequently performed procedures in adults in both residency and early practice. Humerus/elbow fracture and/or dislocation procedures and "other musculoskeletal-introduction or removal" procedures were the most frequently performed procedures in pediatric cases in both residency and early practice. Of the total 78 adult and 82 pediatric code categories included in our analysis that had a frequency of >1% in residency or early practice, there were 4 adult and 6 pediatric code categories demonstrating 44% to 1,164% greater frequency in residency than in early practice, and there were 8 adult and 7 pediatric code categories demonstrating 26% to 73% less frequency in residency than in early practice. CONCLUSIONS: Similarity between residency and early practice experience is generally strong. However, we identified several AMA CPT code categories and individual CPT codes for which the level of exposure during residency varied substantially from early practice experience. These findings can help residencies ensure adequate trainee exposure to procedures performed commonly in early practice.

Incidence and Complications of Open Hip Preservation Surgery: An ABOS Database Review.

Hip preservation surgery encompasses various surgical procedures that have the goal of decreasing the progression of osteoarthritis, preserving normal hip function, and delaying the need for arthroplasty. These procedures can encompass arthroscopic, open, and combined techniques. This study investigated the trends and complications associated with open hip preservation surgery performed by candidates undergoing Part II of the American Board of Orthopaedic Surgery examination. The American Board of Orthopaedic Surgery Part II surgeon case database was queried from the years 2003 to 2013 for Current Procedural Terminology (CPT) codes related to open hip preservation surgery in patients 10 years and older. Patient demographics, fellowship training, geographic location, and complications were extracted from the database. These data were analyzed to determine the incidence by year of individual procedures and complications. During the study period, 644 cases (352 male, 292 female; mean age, 29.7 years) and 730 CPT codes were reported. The most commonly reported fellowship was pediatric orthopedics. No trend was observed in the overall incidence of these surgeries, but there was an increase in the number of cases performed in the Midwest. There were 212 reported complications, with a rate of 33% per case, or 29% per CPT code (range, 12.5%-100% per CPT code). Complications reported ranged from infection to death. The incidence of complications over time showed no discernible trend. Based on the results of this study, the yearly incidence and complications associated with open hip preservation surgery performed by surgeons undergoing board certification should continue at a predictable rate. [Orthopedics. 2017; 40(1):e109-e116.].

Trends in Primary and Revision Hip Arthroplasty Among Orthopedic Surgeons Who Take the American Board of Orthopedics Part II Examination.

BACKGROUND: A certified list of all operative cases performed within a 6-month period is a required prerequisite for surgeons taking the American Board of Orthopaedic Surgery Part II oral examination. Using the American Board of Orthopaedic Surgery secure Internet database database containing these cases, this study (1) assessed changing trends for primary and revision total hip arthroplasty (THA) and (2) compared practices and early postoperative complications between 2 groups of examinees, those with and without adult reconstruction fellowship training. METHODS: Secure Internet database was searched for all 2003-2013 procedures with a Current Procedural Terminology code for THA, hip resurfacing, hemiarthroplasty, revision hip arthroplasty, conversion to THA, or removal of hip implant (Girdlestone, static, or dynamic spacer). RESULTS: Adult reconstruction fellowship-trained surgeons performed 60% of the more than 33,000 surgeries identified (average 28.1) and nonfellowship-trained surgeons performed 40% (average 5.2) (P < .001). Fellowship-trained surgeons performed significantly more revision surgeries for infection (71% vs 29%)(P < .001). High-volume surgeons had significantly fewer complications in both primary (11.1% vs 19.6%) and revision surgeries (29% vs 35.5%) (P < .001). Those who passed the Part II examination reported higher rates of complications (21.5% vs 19.9%). CONCLUSION: In early practice, primary and revision hip arthroplasties are often performed by surgeons without adult reconstruction fellowship training. Complications are less frequently reported by surgeons with larger volumes of joint replacement surgery who perform either primary or more complex cases. Primary hip arthroplasty is increasingly performed by surgeons early in practice who have completed an adult reconstructive fellowship after residency training. This trend is even more pronounced for more complex cases such as revision or management of infection.

Frequency and complications after operative fixation of clavicular fractures.

BACKGROUND: The purpose of this study was to analyze whether a recent trend in evidence supporting operative treatment of clavicular fractures is matched with an increase in operative fixation and complication rates in the United States. METHODS: The American Board of Orthopaedic Surgery database was reviewed for cases with Current Procedural Terminology (American Medical Association, Chicago, IL, USA) code 23515 (clavicle open reduction internal fixation [ORIF]) from 1999 to 2010. The procedure rate for each year and the number of procedures for each candidate performing clavicle ORIF were calculated to determine if a change had occurred in the frequency of ORIF for clavicular fractures. Complication and outcome data were also reviewed. RESULTS: In 2010 vs, 1999, there were statistically significant increases in the mean number of clavicle ORIF performed among all candidates (0.89 vs. 0.13; P < .0001) and in the mean number of clavicle ORIF per candidate performing clavicle ORIF (2.47 vs. 1.20, P < .0473). The difference in the percentage of part II candidates performing clavicle ORIF from the start to the end of the study (11% vs. 36%) was significant (P < .0001). There was a significant increase in the clavicle ORIF percentage of total cases (0.11% vs. 0.74%, P < .0001). The most common complication was hardware failure (4%). CONCLUSION: The rate of ORIF of clavicular fractures has increased in candidates taking part II of the American Board of Orthopaedic Surgery, with a low complication rate. The increase in operative fixation during this interval may have been influenced by literature suggesting improved outcomes in patients treated with operative stabilization of their clavicular fracture.

Trends in primary and revision knee arthroplasty among orthopaedic surgeons who take the American Board of Orthopaedics part II exam.

PURPOSE: A certified list of all operative cases performed within a six month period is required of surgeons by the American Board of Orthopaedic Surgery (ABOS) as a prerequisite to taking the Part II Oral Examination. Using the data on these cases collected and maintained by ABOS, this study assessed the influence of prior fellowship training in adult reconstruction on the volume and surgeon-reported complication rate of knee joint arthroplasty cases over time. METHODS: All data were self reported to a secure Internet database (SCRIBE) by candidates who applied to take Part II of the ABOS Examination for the first time. This database was searched for all procedures done between 2003 and 2013 with CPT codes for total and revision knee arthroplasty and removal of knee implant (static or dynamic spacer) to determine procedural volumes and early complication rates among Board-eligible orthopaedic surgeons with and without adult reconstructive fellowship training. RESULTS: More than 43,000 knee arthroplasty surgeries were identified. Surgeons who had completed adult reconstruction fellowship training after residency performed 55 % of total knee arthroplasties, averaging 33.5 knee arthroplasties during the six month case-collection period compared to 7.4 procedures by non-fellowship-trained surgeons (p < 0.001). Adult reconstruction fellowship-trained surgeons performed significantly more revisions for infection (average 6.6 versus 2.2 revisions) (p < 0.001). Adult reconstruction fellowship training did not significantly affect complication rates for primary arthroplasty but was associated with an increased complication rate for revisions. Those surgeons who performed more than 100 arthroplasties a year reported significantly fewer complications in primary arthroplasties (12.7 % versus 16.9 %) (p < 0.001). Over time, an increasing percentage of arthroplasties were done by surgeons with adult reconstruction fellowship training. CONCLUSIONS: Adult reconstruction fellowship-trained surgeons performed an increasing number of primary and more complex knee arthroplasties from 2003 to 2013. Surgeons who perform a larger volume of knee arthroplasty surgeries report fewer early complications than surgeons with fewer cases. LEVEL OF EVIDENCE: 4.

High incidence of hemiarthroplasty for shoulder osteoarthritis among recently graduated orthopaedic surgeons.

BACKGROUND: Primary glenohumeral osteoarthritis is a common indication for shoulder arthroplasty. Historically, both total shoulder arthroplasty (TSA) and hemi-shoulder arthroplasty (HSA) have been used to treat primary glenohumeral osteoarthritis. The choice between procedures is a topic of debate, with HSA proponents arguing that it is less invasive, faster, less expensive, and technically less demanding, with quality of life outcomes equivalent to those of TSA. More recent evidence suggests TSA is superior in terms of pain relief, function, ROM, strength, and patient satisfaction. We therefore investigated the practice of recently graduated orthopaedic surgeons pertaining to the surgical treatment of this disease. QUESTIONS/PURPOSES: We hypothesized that (1) recently graduated, board eligible, orthopaedic surgeons with fellowship training in shoulder surgery are more likely to perform TSA than surgeons without this training; (2) younger patients are more likely to receive HSA than TSA; (3) patient sex affects the choice of surgery; (4) US geographic region affects practice patterns; and (5) complication rates for HSA and TSA are not different. METHODS: We queried the American Board of Orthopaedic Surgery's database to identify practice patterns of orthopaedic surgeons taking their board examination. We identified 771 patients with primary glenohumeral osteoarthritis treated with TSA or HSA from 2006 to 2011. The rates of TSA and HSA were compared based on the treating surgeon's fellowship training, patient age and sex, US geographic region, and reported surgical complications. RESULTS: Surgeons with fellowship training in shoulder surgery were more likely (86% versus 72%; OR 2.32; 95% CI, 1.56-3.45, p<0.001) than surgeons without this training to perform TSA rather than HSA. The mean age for patients receiving HSA was not different from that for patients receiving TSA (66 versus 68, years, p=0.057). Men were more likely to receive HSA than TSA when compared to women (RR 1.54; 95% CI, 1.19-2.00, p=0.0012). The proportions of TSA and HSA were similar regardless of US geographic region (Midwest HSA 21%, TSA 79%; Northeast HSA 25%, TSA 75%; Northwest HSA 16%, TSA 84%; South HSA 27%, TSA 73%; Southeast HSA 24%, TSA 76%; Southwest HSA 23%, TSA 77%; overall p=0.708). The overall complication rates were not different with the numbers available: 8.4% (15/179) for HSA and 8.1% (48/592) for TSA (p=0.7555). CONCLUSIONS: The findings of this study are at odds with the recommendations in the current clinical practice guidelines for the treatment of glenohumeral osteoarthritis published by the American Academy of Orthopaedic Surgeons. These guidelines favor using TSA over HSA in the treatment of shoulder arthritis. Further investigation is needed to clarify if these practice patterns are isolated to recently graduated board eligible orthopaedic surgeons or if the use of HSA continues with orthopaedic surgeons applying for recertification. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.