Rapid Blueprinting: An Efficient Method for Designing Content of Assessments.

Problem: Many assessments in medical education involve measuring proficiency in a content area. Thus, proper content development (blueprinting) of tests in this field is of primary importance. Prior efforts to conduct content review as part of assessment development have been time- and resource-intensive, relying on practice analysis and then on linking methods. This monograph explores a "rapid, cost-effective" approach to blueprinting that allows efficient assessment development with rigor. Our investigation seeks to explore an efficient and effective alternate method for creating a content design (blueprint) for medical credentialing and evaluation examinations by focusing directly on assessment requirements. Approach: We employed a two-phase process to propose a rapid blueprinting method. Phase 1 involved a 1-day direct meeting of content experts/practitioners. Phase 2 involved a corroboration survey sent to a wider group of content experts/practitioners. The rapid blueprinting method was applied to developing eleven blueprints (five for medical specialty certification; five for health professions certification; and one for in-training assessment). Outcomes: The methods we used resulted in effective, well-balanced, operational examinations that successfully implemented the resulting blueprints in item writing assignments and test development. Assessments resulting from the use of the rapid blueprinting method also generated psychometrically sound inferences from the scores. For example, the assessments resulting from this methodology of test construction had KR-20 reliability coefficients ranging from .87 to .92. Next Steps: This approach leveraged the effectiveness and feasibility of the rapid blueprinting method and demonstrated successful examination designs (blueprints) that are cost- and time-effective. The rapid blueprinting method may be explored for further implementation in local assessment settings beyond medical credentialing examinations.

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.

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.

Severity of Overuse Injury Impacts Self-Efficacy and Quality of Life in Runners: A 2-Year Prospective Cohort Study.

CONTEXT: While 55 million Americans incorporate running into their exercise routines, up to 65% of runners sustain an overuse injury annually. It has been consistently shown that regular physical activity positively impacts quality of life (QOL), an essential public health indicator; however, the impact of running-related injuries on QOL is unknown. This study seeks to determine whether overuse injury severity impacts QOL in recreational runners, and if self-efficacy mediates this relationship. DESIGN: Community-based prospective cohort study of 300 runners who had been running injury free for at least 5 miles/wk in the past 6 months. METHODS: Self-efficacy for running and QOL measures (Short Form-12 Physical Component and Mental Component, Satisfaction with Life, Positive Affect and Negative Affect) were assessed at baseline, time of injury, and follow-up visits. Over 2 years of observation, overuse injuries were diagnosed by an orthopedic surgeon and injured runners were referred to a physical therapist. RESULTS: Injury severity was significantly (P < .01) related with 2 indices of QOL, such that the effect of injury severity was -2.28 units on the Short Form-12 physical component and -0.73 units on positive affect. Self-efficacy accounted for 19% and 48% of the indirect effects on Short Form-12 physical component and positive affect, respectively. CONCLUSIONS: Since self-efficacy is a modifiable factor related to decreased QOL, these findings have important clinical implications for rehabilitation interventions.

Long-term National Trends of Arthroscopic Meniscal Repair and Debridement.

BACKGROUND: Optimal treatment of meniscal pathology continues to evolve in orthopaedic surgery, with a growing understanding of which patients benefit from which procedure and which patients might be best treated nonsurgically. In 2002, Moseley et al found no difference between arthroscopic procedures, including meniscal debridement and sham surgery, in patients with osteoarthritis of the knee. This called into question the role of routine arthroscopic debridement in these patients. Additionally, an increased interest in understanding and maintaining the function of the meniscus has more recently resulted in a greater focus on meniscal preservation procedures. STUDY DESIGN: Descriptive epidemiology study. PURPOSE/HYPOTHESIS: The purpose was to evaluate the trends of arthroscopic meniscal debridement and repair and the characteristics of the patients receiving these treatments, compare the differences in practice between newly trained orthopaedic sports medicine specialists and those of other specialties, and analyze if there are differences in practice by region. It was hypothesized that the American Board of Orthopaedic Surgery (ABOS) database would evaluate practice patterns of recent graduates as a surrogate for current treatment and training and, consequently, demonstrate a decreased rate of meniscal debridement. METHODS: Data from ABOS Part II examinees from 2001 to 2017 were obtained from the ABOS Case List. Current Procedure Terminology (CPT) codes related to arthroscopic meniscal treatment were selected. The examination year, age of the patient, practice region, and examinee subspecialty were analyzed. Patient age was stratified into 4 groups: <30, 30 to 50, 51 to 65, and >65 years. Examinee subspecialty was stratified into sports medicine and non-sports medicine. Statistical regression analysis was performed. RESULTS: Between 2001 and 2017, ABOS Part II examinees submitted 131,047 cases with CPT codes 29880 to 29883. Meniscal debridement volume decreased for all age groups during the study period, while repair increased. Sports medicine subspecialists were more likely than their counterparts to perform repair over debridement in patients aged younger than 30 years (P = .0004) and between 30 and 50 years (P = .0005). CONCLUSION: This study provides insights into arthroscopic meniscal debridement and repair practice trends among ABOS Part II examinees. Meniscal debridement is decreasing and meniscal repair is increasing. Younger patient age and treatment by a sports medicine subspecialty examinee are associated with a higher likelihood of repair over debridement.

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 (

The American Board of Orthopaedic Surgery Response to COVID-19.

The COVID-19 pandemic has disrupted every aspect of society in a way never previously experienced by our nation's orthopaedic surgeons. In response to the challenges the American Board of Orthopaedic Surgery has taken steps to adapt our Board Certification and Continuous Certification processes. These changes were made to provide flexibility for as many Candidates and Diplomates as possible to participate while maintaining our high standards. The American Board of Orthopaedic Surgery is first and foremost committed to the safety and well-being of our patients, physicians, and families while striving to remain responsive to the changing circumstances affecting our Candidates and Diplomates.

A 2-Year Prospective Cohort Study of Overuse Running Injuries: The Runners and Injury Longitudinal Study (TRAILS).

BACKGROUND: The National Center for Injury Prevention and Control, noting flaws in previous running injury research, called for more rigorous prospective designs and comprehensive analyses to define the origin of running injuries. PURPOSE: To determine the risk factors that differentiate recreational runners who remain uninjured from those diagnosed with an overuse running injury during a 2-year observational period. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Inclusion criteria were running a minimum of 5 miles per week and being injury free for at least the past 6 months. Data were collected at baseline on training, medical and injury histories, demographics, anthropometrics, strength, gait biomechanics, and psychosocial variables. Injuries occurring over the 2-year observation period were diagnosed by an orthopaedic surgeon on the basis of predetermined definitions. RESULTS: Of the 300 runners who entered the study, 199 (66%) sustained at least 1 injury, including 73% of women and 62% of men. Of the injured runners, 111 (56%) sustained injuries more than once. In bivariate analyses, significant ( P ≤ .05) factors at baseline that predicted injury were as follows: Short Form Health Survey-12 mental component score (lower mental health-related quality of life), Positive and Negative Affect Scale negative affect score (more negative emotions), sex (higher percentage of women were injured), and knee stiffness (greater stiffness was associated with injury); subsequently, knee stiffness was the lone significant predictor of injury (odds ratio = 1.18) in a multivariable analysis. Flexibility, quadriceps angle, arch height, rearfoot motion, strength, footwear, and previous injury were not significant risk factors for injury. CONCLUSION: The results of this study indicate the following: (1) among recreational runners, women sustain injuries at a higher rate than men; (2) greater knee stiffness, more common in runners with higher body weights (≥80 kg), significantly increases the odds of sustaining an overuse running injury; and (3) contrary to several long-held beliefs, flexibility, arch height, quadriceps angle, rearfoot motion, lower extremity strength, weekly mileage, footwear, and previous injury are not significant etiologic factors across all overuse running injuries.

An Analysis of Orthopaedic Job Trends in the United States Over the Past 30 years.

INTRODUCTION: Orthopaedic surgery residency training requires 5 clinical years; fellowship subspecialty training requires an additional year. Orthopaedic surgery fellowship training has financial implications regarding potential career earnings and opportunity cost. To evaluate the effect of fellowship training on employment, 30 years of orthopaedic job advertisements were analyzed to determine fellowship requirements for academic centers, private practices, urban areas, and rural areas. It was hypothesized that subspecialty training is an important prerequisite for orthopaedic employment. METHODS: Job advertisements in the Journal of Bone and Joint Surgery (JBJS Am) and Orthopedics were analyzed to determine whether fellowship training versus "generalist" (no subspecialty fellowship) positions were advertised for the years 1984, 1989, 1994, 1999, 2004, 2009, and 2014. Jobs were categorized as academic (defined by the requirement to teach medical students, residents, or fellows); private practice; rural (defined as population under 200,000); and urban. "General" orthopaedic surgery job postings were defined as job advertisements that did not require fellowship training. RESULTS: A total of 4,720 job advertisements were analyzed. From 1984 to 2014, the percentage of advertised jobs requiring fellowship training increased from 5% to 68% (P < 0.05). Conversely, from 1984 to 2014, the percentage of advertised jobs targeting general orthopaedic surgeons decreased from 95% to 32% (P < 0.05). Between 2009 and 2014, advertised jobs requiring fellowship surpassed general orthopaedic surgery jobs. CONCLUSIONS: Over the past 30 years, there was a trend toward fellowship being required as part of the advertised orthopaedic jobs available to graduates of orthopaedic training programs. The reasons for increased orthopaedic training are likely multifactorial, including limited clinical duty hours during orthopaedic residency, advertisement and marketing forces emphasizing super-sub-specialty care in multispecialty orthopaedic groups, and the greater complexity of orthopaedic procedures being performed.

Construct Validity for a Cost-effective Arthroscopic Surgery Simulator for Resident Education.

INTRODUCTION: Arthroscopy is one of the most challenging surgical skills to assess and teach. Although basic psychomotor arthroscopic skills, such as triangulation and object manipulation, are incorporated into many simulation exercises, they are not always individually taught or objectively evaluated. In addition, arthroscopic instruments, arthroscopy cameras, and the cadaver or joint models necessary for practice are costly. METHODS: A low-cost arthroscopic simulator was created to practice triangulation, probing, horizon changes, suture management, and object manipulation. The simulator materials were purchased exclusively from national hardware stores with a total cost averaging $79. The universal serial bus (USB) camera is included in the total cost. Three residency programs accredited by the Accreditation Council for Graduate Medical Education were tested on the simulator. Replica boards were created at each institution. Participants included medical students (20), residents (46), and attending physicians (9). RESULTS: Construct validity-the ability to differentiate between novice, intermediate, and senior level participants-was obtained. On all tasks, junior residents scored at a statistically significant lower rate than senior residents and attending physicians. CONCLUSIONS: This cost-effective arthroscopic surgical simulator objectively demonstrated that attending physicians and senior residents performed at a higher level than junior residents and novice medical students. The results of this study demonstrate that this simulator could be an important training tool for resident education.

Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Part II candidates.

BACKGROUND: Tears of the superior labrum (superior labrum anterior and posterior [SLAP] lesions) of the shoulder are uncommon injuries; however, the incidence of surgical correction seems to be increasing. PURPOSE: To report the findings of a review of a proprietary descriptive database that catalogs cases for the purpose of board certification on the demographics of SLAP lesion repair. It is the authors' impression that the percentage of cases of SLAP lesion repairs reported by young orthopaedic surgeons is high and that complications associated with this are not insignificant. STUDY DESIGN: Cohort study; level of evidence, 3. METHODS: We searched the American Board of Orthopedic Surgery (ABOS) part II database to evaluate changes in treatment over time and to identify available outcomes and associated complications of arthroscopic repair of SLAP lesions. The database was searched for all SLAP lesions (ICD-9 code 840.7) and SLAP repairs (CPT code 29807) for the years 2003 through 2008. Utilization was analyzed by geographic region and was also obtained based on applicant subspecialty declaration. RESULTS: There were 4975 SLAP repairs, representing 9.4% of all applicants' shoulder cases. Mean follow-up was 8.9 weeks because of the time-limited case collection period. There were 78.4% who were men, and 21.6% of patients were women. The percentage of shoulder cases that were SLAP repairs increased over the study period from 9.4% to 10.1% by 2008 (P = .0163). Mean age of male patients was 36.4 ± 13.0 years, with a maximum of 85 years. Mean age of female patients was 40.9 ± 14.0 years, with a maximum of 88 years. Pain was reported as absent in only 26.3% of patients at follow-up and function as normal in only 13.1%. There were 40.1% of applicants who self-reported their patients to have an excellent result. The self-reported complication rate was 4.4%. Declared sports medicine specialists had a higher percentage of SLAP repairs than did general orthopaedic surgeons: 12.4% versus 9.2%. CONCLUSION: The percentage of shoulder cases that are SLAP repairs reported by the candidates is 3 times the published incidence supported by the current literature. The large number of repairs in middle-aged and elderly patients is concerning. Focusing on educating young orthopaedic surgeons to appropriately recognize and treat symptomatic SLAP lesions may bring the rate of SLAP repairs down.

The dynamic crossover in water does not require bulk water.

Many of the anomalous properties of water may be explained by invoking a second critical point that terminates the coexistence line between the low- and high-density amorphous states in the liquid. Direct experimental evidence of this point, and the associated polyamorphic liquid-liquid transition, is elusive as it is necessary for liquid water to be cooled below its homogeneous-nucleation temperature. To avoid crystallization, water in the eutectic LiCl solution has been studied but then it is generally considered that "bulk" water cannot be present. However, recent computational and experimental studies observe cooperative hydration in which case it is possible that sufficient hydrogen-bonded water is present for the essential characteristics of water to be preserved. For femtosecond optical Kerr-effect and nuclear magnetic resonance measurements, we observe in each case a fractional Stokes-Einstein relation with evidence of the dynamic crossover appearing near 220 K and 250 K respectively. Spectra obtained in the glass state also confirm the complex nature of the hydrogen-bonding modes reported for neat room-temperature water and support predictions of anomalous diffusion due to "worm-hole" structure.

Optical Kerr-effect study of trans- and cis-1,2-dichloroethene: liquid-liquid transition or super-Arrhenius relaxation.

The evidence that a molecular liquid in its thermodynamically-stable state can undergo a liquid-liquid transition (LLT) is still uncertain. Therefore, trans-1,2-dichloroethene is of interest due to reports of a LLT above the melting point [S. Kawanishi, T. Sasuga and M. Takehisa, J. Phys. Soc. Jpn., 1982, 51, 1579-1583; S. Rzoska, J. Ziolo, A. Drozd-Rzoska, J. L. Tamarit and N. Veglio, J. Phys.: Condens. Matter, 2008, 20, 244124; K. Merkel, A. Kocot, R. Wrzalik and J. Ziolo, J. Chem. Phys., 2008, 129, 074503-074508]. Ultrafast optical Kerr-effect (OKE) spectroscopy enables accurate measurement of the low-frequency modes arising from interactions in liquids and therefore should be sensitive to the change in liquid structure inherent in such a transition. In the OKE data presented here, no sharp transitions are discernible, nor are there any in calorimetry data. However, the same data do reveal that neither trans- nor cis-1,2-dichloroethene is a simple liquid: in each case, a non-Arrhenius temperature dependence (with a Debye lineshape) is observed for the alpha relaxation. This dependence can be fitted by the Vogel-Fulcher-Tammann (VFT) law over the measurable temperature range suggesting that at low temperature, cooperative relaxation, due to the formation of clusters or structure, is present. Accurate analysis of the OKE spectrum in the terahertz region is generally limited by approximations inherent in the models. Here the diffusional modes are convoluted with librational modes to give a more physically meaningful approximation to the inertial response.

Risk factors and mechanisms of knee injury in runners.

UNLABELLED: Approximately 36 million Americans participate in running each year, with 10.5 million running at least 100 d x yr(-1). Although running injuries are well understood medically, their potential risk factors are not. Thus, we presently have limited ability to identify individuals at high risk for overuse injuries. PURPOSE: This study aimed to identify behavioral and physiological risk factors that influenced potential knee injury mechanisms, including knee joint forces and knee moments. METHODS: Participants included 20 adults ranging in age from 20 to 55 yr (n = 7 males and n = 13 females). During the first screening visit, quadriceps and hamstring flexibility was assessed, and Q-angle, height, and weight were measured. During the second screening visit, participants completed a series of questionnaires and a gait analysis to calculate knee joint loads. An isokinetic dynamometer was used to measure eccentric and concentric knee extension strength. RESULTS: Body weight (r = 0.48, P = 0.03), weekly mileage (r = 0.62, P = 0.005), and concentric knee extension strength (r=0.68, P = 0.0001) were significantly correlated with tibiofemoral compressive force. Knee extension moment displayed a negative correlation with hamstring flexibility (r = -0.47, P = 0.04). Both weekly mileage (r = 0.50, P = 0.03) and concentric knee extension strength (r = 0.60, P = 0.01) had significant positive correlations with patellofemoral force. CONCLUSION: The results of this study relate larger knee joint loads to poor hamstring flexibility, greater body weight, greater weekly mileage, and greater muscular strength. Most of these risk factors could potentially be modified to reduce joint loads to lower the risk of injury.

Surgical treatment of chronic posteromedial instability using capsular procedures.

Patients with posteromedial corner injuries of the knee present a significant problem to the clinician. Often the symptoms of anteromedial rotatory instability may be overlooked due to concurrent anterior cruciate ligament and/or posterior cruciate ligament injuries. When addressing concurrent ligamentous injuries to the knee, the clinician may fail to isolate anteromedial rotatory instability on physical examination and imaging studies may not specifically identify damage to posteromedial corner structures. This unrecognized and untreated damage results in residual functional laxity and can potentially lead to chronic and progressive instability of the knee. This paper contains descriptions of 2 surgical techniques that address posteromedial instability. Both techniques require an understanding of posteromedial corner knee anatomy, careful preoperative planning, and extensive postoperative rehabilitation.

Initial biomechanical properties of staple-anchor Achilles tendon allograft and interference screw bone-patellar tendon-bone autograft fixation for anterior cruciate ligament reconstruction in a cadaveric model.

PURPOSE: Anterior cruciate ligament (ACL) reconstruction is a common procedure that has a fairly high success rate. Despite such success, controversy exists with regard to fixation and graft type. The purpose of this study was to quantify the maximum load to failure for staple-anchor freeze-dried Achilles tendon allograft fixation compared with interference screw bone-pattelar tendon-bone autograft fixation at the time of insertion for ACL reconstruction. METHODS: Eleven pairs of cadaveric knees were prepared for ACL reconstruction by disarticulation before graft insertion. The tibia and femur were mounted separately onto an MTS machine and were loaded to failure in line with the tunnels. Femoral fixation for the allograft was provided by a staple anchor; tibial fixation was provided by a suture anchor. Titanium interference screws on the femoral and tibial sides provided autograft fixation. A paired t test was performed to compare mechanical testing results in the 2 groups. RESULTS: Mean maximum load to failure for the allograft was 58.7 N (range, 32.3 to 92.6 N) and 119.6 N (range, 82 to 165.9 N) for the femur and the tibia, respectively, compared with 228.2 N (range, 74.2 to 352 N) and 232.9 N (range, 65.1 to 553.1 N) for the autografts. This difference was statistically significant (P < .001) for femoral fixation, but it was not statistically significant for tibial fixation (P = .186). CONCLUSIONS: Soft tissue Achilles tendon allograft with staple fixation is a significantly weaker fixation construct when compared with autograft bone-patellar tendon-bone with interference screw fixation. CLINICAL RELEVANCE: This study shows significantly weaker fixation in the staple-alograft construct and yet this construct has had at least equivalent results over a 5-year time frame, indicating that rigid femoral fixation may not be a critical factor in long-term results.

Propofol-induced seizure-like phenomena.

Procedural sedation is a common practice in Emergency Medicine. Propofol has supplanted benzodiazepines in many centers as the drug of choice for procedural sedation. This article reports a case of seizure-like activity in an elderly man undergoing procedural sedation for a fracture reduction. The seizure-like activity was attributed to propofol. A review of the literature is discussed. When using propofol for sedation one should be aware of the risk of seizure-like activity.