Abstract
Purpose
To evaluate orthopaedic resident case volume and case log variability for wrist and hand arthroscopy.
Methods
The Accreditation Council for Graduate Medical Education surgical case log data from 2016 to 2020 for graduating United States orthopaedic surgery residents was assessed. Arthroscopy procedures of the wrist and hand were categorized. The average number of cases performed per resident was compared from 2016 to 2020 to determine the percent change in case volume. The 10th, 30th, 50th, 70th, and 90th percentiles of case volumes from 2016 to 2020 were presented to demonstrate case volume variability.
Results
The average number of total arthroscopic wrist and hand procedures performed per resident was 4.6 ± 5 (3, 0-44) in 2016, which decreased to 3 ± 3 in 2020 (2, 0-25), representing a 34.8% decrease (P < .001). The average number of total arthroscopic wrist and hand procedures performed by the 10th and 90th percentile of residents was 0 and 10 in 2016 and 0 and 7 in 2020, representing a large degree of case log variability. About 1 in 10 graduating orthopaedic surgery residents performed only a single wrist and hand arthroscopy case each year, and half performed 3 cases or fewer.
Conclusions
Orthopaedic graduate medical education exposure to wrist and hand arthroscopy remains low and highly variable, despite increasing use of arthroscopy in wrist procedures.
Clinical Relevance
It is important to evaluate the procedural case volume for wrist and hand arthroscopy among orthopaedic surgery residents. With information from this study, we may be able to suggest changes, such as the implementation of case minimums, that provide better opportunities for orthopaedic trainees to enhance proficiency and improve patient care in this area.
Graduate medical education remains a central milestone in the professional development of nascent orthopaedic surgeons. However, this critical development period is complicated by rapidly evolving surgical technologies, variability in procedural volume, and continually evolving performance measures. In 2013, the Accreditation Council for Graduate Medical Education (ACGME) in the United States established a new accreditation structure that focused on a competency-based monitoring system.1 Orthopaedic resident cases must now be tracked in the ACGME case log system with residents completing between 1,000 and 3,000 surgical cases prior to graduation within 15 core procedural categories. Residents log their surgical procedures using Current Procedural Terminology (CPT) codes. These codes are standardized and categorized into various anatomic categories groups by the ACGME. The ACGME groups CPT codes into anatomic categories, such as shoulder, humerus/elbow, wrist, hand/fingers, pelvis/hip, femur/knee, leg/ankle, and foot/toes. This allows for the tracking of specific types of procedures within each category. The case log system tracks orthopaedic residents’ cases throughout all 5 years.
Resident case logs have evolved to become a key benchmark in ensuring adequate procedural volume and variety among orthopaedic trainees. Since case log implementation, overall case volume among orthopaedic surgery residents has increased 17% from 2014 to 2019.2 However, despite these case minimums, there continues to be variability in overall case volume and the number of procedures performed within orthopaedic subspecialities.3, 4, 5, 6, 7, 8 Additionally, arthroscopic procedures, which traditionally have been thought to require a high degree of technical proficiency, have been found to have low procedural volumes and a high degree of procedure variability in several orthopaedic subspecialties.2, 3, 4,9, 10, 11, 12 A study by Sabharwal et al.2 revealed that after implementation of case log minimums, there was a decrease in arthroscopic case volume among the 2014 to 2019 cohort of orthopaedic residents as compared to the 2007 to 2013 cohort.
Over the past decade, wrist arthroscopy has advanced from a distinctly diagnostic intervention into an alternative to open surgery. Utilization of arthroscopic techniques in fracture fixation, ligament reconstruction, and carpal tunnel decompression has led to increased utilization of wrist arthroscopy and an increase in arthroscopic wrist procedural volume.13, 14, 15, 16 In contrast to ACGME-established knee and shoulder arthroscopy minimum case requirements, wrist arthroscopy lacks any required minimum exposure at the resident level of graduate medical education.
The purpose of our study is to evaluate orthopaedic resident case volume and variability for wrist and hand arthroscopy. We hypothesize that case volume has remained low during this time and anticipate wide variability in case volume among graduating residents.
Methods
Data Collection and Study Design
ACGME case log reports from 2016 to 2021 for all graduating orthopaedic surgery residents were reviewed in June 2022 by a group of the study authors. The ACGME case log reports are available to residency program faculty and residents, and the study team received permission to analyze these data. Residents log surgical procedures using CPT. The ACGME groups CPT codes into anatomic categories and provides national averages for several resident-performed procedures. Procedures include incision, excision, intro or removal, repair/revision/reconstruction, trauma, fracture/dislocation, manipulation, arthrodesis, amputation, arthroscopy, and others. Anatomic categories include shoulder, humerus/elbow, forearm/wrist, hand/fingers, pelvis/hip, femur/knee, leg/ankle, and foot/toes. In this study, the mean number of total (adult and pediatric) arthroscopy cases performed per resident under the wrist ACGME case category from 2016 to 2020 was assessed to determine a percent change in case volume. The specific CPT codes and definitions for each arthroscopy procedure under the wrist ACGME case category are listed in Table 1. Additionally, 10th, 30th, 50th, 70th, and 90th percentiles of case volumes from 2016 to 2020 were presented to examine case volume variability.
Table 1.
CPT Codes With Description of Arthroscopy Procedures for Wrist and Hand
| CPT Codes | Description of Arthroscopy Procedures | Category |
|---|---|---|
| 29840 | Arthroscopy, wrist, diagnostic, with or without synovial biopsy (separate procedure) | Wrist |
| 29843 | Arthroscopy, wrist, surgical; for infection, lavage and drainage | Wrist |
| 29844 | Arthroscopy, wrist, surgical; synovectomy, partial | Wrist |
| 29845 | Arthroscopy, wrist, surgical; synovectomy, complete | Wrist |
| 29846 | Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement | Wrist |
| 29847 | Arthroscopy, wrist, surgical; internal fixation for fracture or instability | Wrist |
| 29900 | Arthroscopy, metacarpophalangeal joint, diagnostic, includes synovial biopsy | Wrist |
| 29901 | Arthroscopy, metacarpophalangeal joint, surgical; with debridement | Wrist |
| 29902 | Arthroscopy, metacarpophalangeal joint, surgical; with reduction of displaced ulnar collateral ligament (e.g., Stener lesion) | Wrist |
CPT, Current Procedural Terminology.
Statistical Analysis
Comparisons of mean case volume reported per resident were examined using unpaired 2-tailed t tests. Statistical significance was designated a P < .05. Excel software, version 16.0 (Microsoft) was used for data input and statistical tests.
Results
The total number of orthopaedic surgery residency programs was 153 (705 residents) in 2016, 156 (709 residents) in 2017, 154 (729 residents) in 2018, 154 (725 residents) in 2019, and 154 (724 residents) in 2020 (Table 2).
Table 2.
The Demographics of Orthopaedic Surgery Accreditation Council for Graduate Medical Education Case Log Respondents
| Year | Total Number of Residency Programs | Total Number of Residents |
|---|---|---|
| 2016 | 153 | 705 |
| 2017 | 156 | 709 |
| 2018 | 154 | 729 |
| 2019 | 154 | 725 |
| 2020 | 154 | 724 |
The average number of total wrist and hand arthroscopy procedures performed per resident was 4.6 ± 5 (3; range, 0-44) in 2016, which decreased to 3 ± 3 in 2020 (2; range, 0-25), representing a 34.8% decrease (P < .001) (Table 3). The average number of adult wrist and hand arthroscopy procedures performed per resident was 4.5 ± 5 (range, 0-44) in 2016, which decreased to 2.8 ± 3 in 2020 (2; range, 0-20), representing a 37.8% decrease (P < .001) (Table 3). Case volume for the mean number of total wrist and hand arthroscopy procedures performed per resident from 2016 to 2020 is depicted in Figure 1.
Table 3.
Mean Number of Adult and Pediatric Wrist and Hand Arthroscopy Procedures for Graduating Orthopaedic Surgery Residents in 2016 and 2020
| Demographic | 2016 | 2020 | % Change | P Value | |||
|---|---|---|---|---|---|---|---|
| Mean ± SD Median (Range) | Mean ± SD Median (Range) | ||||||
| Total | 4.6 ± 5 | 3 (0-44) | 3 ± 3 | 2 (0-25) | –34.8 | <.001∗ | |
| Adult | 4.5 ± 5 | 3 (0-44) | 2.8 ± 3 | 2 (0-20) | –37.8 | <.001∗ | |
| Pediatric | 0.2 ± 0 | 0 (0-3) | 0.2 ± 0 | 0 (0-5) | — | — | |
Indicates statistical significance (P < .05).
Fig 1.
Wrist and hand national case volume trends for total wrist and hand procedures in blue and total wrist and hand arthroscopic procedures labeled in gray. A 2-sided scaled y-axis was utilized to compare yearly trends of total logged wrist and hand cases.
There was a low level of variability in total case volume pertaining to the wrist/hand and a wide level of variability in the number of wrist arthroscopy cases performed per resident over the study period (Table 4). The average number of total wrist and hand arthroscopic procedures performed by the 10th and 90th percentile of residents was 0 and 10 in 2016, representing a 10-fold difference, compared to 0 and 7 in 2020, representing a 7-fold difference (Table 4).
Table 4.
Difference in Adult and Pediatric Wrist and Hand Arthroscopy Procedures Between the 10th and 90th Percentiles of Residents
| Demographic | Year | 10th | 30th | 50th | 70th | 90th |
|---|---|---|---|---|---|---|
| Total | 2016 | 0 | 1 | 3 | 5 | 10 |
| 2017 | 0 | 1 | 3 | 5 | 10 | |
| 2018 | 0 | 1 | 3 | 4 | 8 | |
| 2019 | 0 | 1 | 2 | 4 | 8 | |
| 2020 | 0 | 1 | 2 | 4 | 7 | |
| Adults | 2016 | 0 | 1 | 3 | 5 | 10 |
| 2017 | 0 | 1 | 3 | 5 | 9 | |
| 2018 | 0 | 1 | 2 | 4 | 8 | |
| 2019 | 0 | 1 | 2 | 4 | 8 | |
| 2020 | 0 | 1 | 2 | 4 | 6 | |
| Pediatrics | 2016 | 0 | 0 | 0 | 0 | 1 |
| 2017 | 0 | 0 | 0 | 0 | 1 | |
| 2018 | 0 | 0 | 0 | 0 | 1 | |
| 2019 | 0 | 0 | 0 | 0 | 1 | |
| 2020 | 0 | 0 | 0 | 0 | 1 |
The average number of adult wrist and hand arthroscopy procedures performed by the 10th and 90th percentile of residents was 0 and 10 in both 2016, again representing a 10-fold difference, compared to 0 and 6 in 2020, representing a 6-fold difference, respectively (Table 4). The average number of pediatric wrist and hand arthroscopy procedures performed by the 10th and 90th percentile of residents was 0 and 1 in both 2016 and 2020. About 1 in 10 graduating orthopaedic surgery residents performed only a single wrist and hand arthroscopy case each year, and half performed 3 cases or fewer (Table 4).
Discussion
We found a statistically significant decrease in wrist and hand arthroscopy procedural volume when comparing 2016 graduating orthopaedic residents and 2020 graduating orthopaedic surgical residents (Table 3). The 2020 graduating orthopaedic class had 34.8% less arthroscopic wrist and hand cases logged compared to the 2016 graduating class. Regardless of the year, resident exposure to wrist arthroscopic procedures remained low throughout the study period. Additionally, in this study, the residents categorized in the 90th percentile of case volume only performed 10 adult wrist and hand arthroscopic procedures and 1 pediatric wrist and hand arthroscopic procedure during their graduate medical education. A survey of recent orthopaedic surgery graduates suggested median case numbers to achieve independent proficiency in knee and shoulder arthroscopy to be approximately 25 and 28 cases, indicating that resident exposure to wrist and hand arthroscopy remains variable and low in volume.2,17
Wrist arthroscopy allows surgeons to diagnose intra-articular trauma and cartilage damage and nowadays can be applied to the treatment of wrist pathologies, including synovitis, fibrosis, stiffness, triangular fibrocartilage complex injuries, scapholunate and lunotriquetral ligament injuries, removal of loose bodies, and ulnar styloid impaction syndrome.18, 19, 20, 21, 22 While this is not an all-encompassing list of wrist arthroscopy indications, it demonstrates that wrist arthroscopy continues to grow in its surgical indication in the management of wrist pathology. Advantages of arthroscopic wrist surgery have been demonstrated in the setting of distal radius fracture, with recent evidence suggesting wrist arthroscopy can better detect minor step-offs in articular cartilage not detected by fluoroscopy or plain radiograph.21, 22, 23 One retrospective study compared arthroscopically assisted to fluoroscopically assisted reduction and external fixation of distal radius fracture, finding those who underwent arthroscopically assisted external pinning had significantly improved supination, wrist extension, and wrist flexion than those who underwent fluoroscopically assisted surgery.23 Wrist arthroscopy allows for direct visualization of joint surfaces and, as such, can be used in acute and chronic correction of scapholunate ligament tears and triangular fibrocartilage complex injuries, in which arthroscopy is considered a gold standard in identifying and restoring distal-radial ulnar joint stability.21,24,25 A 2009 study comparing arthroscopic versus open irrigation and debridement of septic arthritis of the wrist found arthroscopic treatment to be more effective with fewer total operations and shorter overall hospital stays.21,26 Lastly, one of the most common applications of endoscopic technique is in carpal tunnel release, with a 2020 meta-analysis of 28 studies demonstrating endoscopic carpal tunnel release having higher satisfaction rates, earlier return to work, lower incidence of scar-related complications, and no difference in permanent nerve injury when compared to open carpal tunnel release.27 The ACGME required orthopaedic residents to complete a minimum of 10 carpal tunnel releases but does not distinguish between those performed endoscopically versus open, despite each surgical approach carrying varying degrees of risk and technical proficiency.
Recent literature has investigated wrist procedural volume after the implementation of ACGME case logs, but none have exclusively investigated procedural volumes for wrist and hand arthroscopy. Klimstra et al.28 examined case volume for closed wrist and forearm fractures, demonstrating a significant increase in the median number of procedural case logs from 2007 to 2013 as compared with 2013 to 2016 in all percentiles of case volumes examined. Another study investigating wrist and hand procedures between plastic surgery residents and orthopaedics residents also demonstrated an increase in total case number in both orthopaedic residents and plastic surgery residents from 2011 and 2019.28 Our study also revealed increasing total wrist and hand case volume from 2016 to 2020 (Fig 1, Table 5). The broadening application of wrist and hand arthroscopy and an increase in wrist and hand procedural volume emphasize the growing need for exposure to wrist and hand arthroscopy in orthopaedic graduate medical education (Table 5).
Table 5.
Mean Total Case Volume for Wrist and Hand and Total Arthroscopy
| Year | National Resident Average Total (Mean ± SD) | National Resident Average Total (Median) | National Resident Average Arthroscopy (Mean) | National Resident Average Arthroscopy (Median) |
|---|---|---|---|---|
| 2016 | 133.4 ± 42 | 129 | 4.6 ± 5 | 3 |
| 2017 | 143.3 ± 44 | 137 | 4.3 ± 5 | 3 |
| 2018 | 148.7 ± 50 | 140 | 3.8 ± 5 | 3 |
| 2019 | 152.2 ± 40 | 145 | 3.3 ± 4 | 2 |
| 2020 | 156.2 ± 50 | 151 | 3.0 ± 3 | 2 |
Arthroscopy is a highly specialized skill that requires extensive training to obtain technical proficiency, and its more recent applications to wrist and hand pathology may offer partial insight into low overall resident case volumes.16,29 Additionally, while wrist and hand arthroscopy has expanded its clinical indication, lack of resident exposure to orthopaedic hand specialists trained in arthroscopy may result in the low overall procedural volume and high variability observed in our study. It may be hypothesized that technical proficiency in more commonly performed arthroscopic techniques, such as hip or knee arthroscopic procedures, may translate into technical proficiency in wrist procedures. However, a 2018 study explored wrist arthroscopy proficiency after knee arthroscopy training and found that knee arthroscopy simulation did not objectively improve wrist arthroscopy proficiency in a quantifiable skill evaluation.16 Additionally, multiple studies suggest that resident exposure to shoulder and elbow, ankle, and hip arthroscopy procedures is generally low in volume and highly variable among orthopaedic residencies, limiting transferable skills among subspecialties.8,9,11,12 While elbow arthroscopy is a common arthroscopic procedure, we did not investigate elbow arthroscopy case log data and cannot comment on that field.
Several possible factors could lead to having low exposure of orthopaedic residents to wrist and hand arthroscopic procedures. For one, wrist and hand arthroscopic procedures can be cost-intensive due to the specialized equipment and prolonged surgical training required. Residency programs may face financial constraints that limit the resources available for training in these advanced techniques. Second, wrist and hand arthroscopic procedures are highly specialized and may be reserved for orthopaedic sports medicine fellows with more extensive training. A recent study by Alvandi et al.3 demonstrated that orthopaedic sports medicine fellows reported 286% more arthroscopic cases in 1 year of fellowship than residents reported in 5 years of residency (554 cases vs 193 cases, P < .0001). As there is no clear explanation why orthopaedic residents have low arthroscopy case volume, further investigation is warranted.
Achieving technical proficiency in specialized arthroscopic procedures is unlikely in most orthopaedic graduate medical educational programs, but early procedural exposure coupled with implementation of an ACGME case minimum requirement may offer an incentive for programs to provide more exposure to highly technical arthroscopic skills earlier in resident training and better prepare them for further subspecialization.
Despite the growing indications for diagnostic and therapeutic wrist and hand arthroscopic procedures, there is no established case log minimum for resident-level graduate medical education. Implementing case minimum requirements for wrist and hand arthroscopy during residency may be helpful in increasing exposure to wrist arthroscopy procedures, increasing provider technical skills, and reducing variability in the graduate medical educational experience. Correlation of resident case volume with other objective measures of performance is necessary to determine the genuine impact of caseload on technical proficiency.
Limitations
The present study is not without limitations. The ACGME case log data do not specify the types of procedures within the wrist and hand category. Therefore, while overall case volume and variability for arthroscopic procedures of the wrist and hand were provided, these findings are not applicable to specific CPT procedural codes. Additionally, case logs do not show the actual procedural experience of orthopaedic residents, and residents may under-record or over-record procedural volume due to poor recall and complicated procedural bundling. Additionally, case logs fail to elucidate between primary or assisting resident surgeons, so true involvement in the execution of cases is difficult to assess.
Conclusions
Orthopaedic surgery resident exposure to wrist and hand arthroscopic procedural volume remains low and highly variable, despite increasing use of arthroscopy in wrist and hand procedures.
Disclosures
All authors (F.J.S., D.K.D., S.Y.S., H.G., J.R.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Supplementary Data
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References
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