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Ankle Arthroscopy Procedural Volume Is Low Among Graduating Orthopaedic Surgery Residents

Open AccessPublished:August 03, 2022DOI:https://doi.org/10.1016/j.asmr.2022.06.003

      Purpose

      To evaluate graduating orthopaedic resident case volume and variability for ankle arthroscopy from 2016 to 2020.

      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 leg/ankle 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

      There was no significant change in the average number of leg/ankle arthroscopy cases from 2016 to 2020 (6.2 ± 5 [range 0-35] vs 6.1 ± 6 [range 0-76] P = .732), despite a 19% increase in the average number of total leg/ankle procedures performed over time (168.4 ± 47 [range 55-414] in 2016; 200.8 ± 57 in 2020 [range 67-601], P < .001). There was wide variability in ankle arthroscopy case volume among residents. The 90th percentile of residents performed 13 cases in 2020, compared with 5 in 50th percentile, and 1 in the 10th percentile.

      Conclusions

      Orthopaedic surgery resident exposure to ankle arthroscopy has remained low and highly variable overtime, despite an overall increase in the total number of leg/ankle procedures performed.

      Clinical Relevance

      Understanding ankle arthroscopy in case volume and variability is important for programs to ensure that orthopaedic residents are gaining adequate exposure to increasingly popular procedures. Orthopaedic surgery residency programs should explore methods to increase resident exposure to ankle arthroscopy.
      Profound changes in orthopaedic surgery residency education have occurred in the last decade. In 2013, the Accreditation Council for Graduate Medical Education (ACGME) implemented a new accreditation system for graduate medical education in the United States,
      • Kirk L.M.
      The next accreditation system.
      which shifted focus to the monitoring of measurable outcomes of resident training.
      • Kirk L.M.
      The next accreditation system.
      ,
      • Marsh J.L.
      • Potts 3rd, J.R.
      • Levine W.N.
      Challenges in resident education: Is the Next Accreditation System (NAS) the answer? AOA critical issues.
      Since then, orthopaedic surgery residents have been mandated to perform at least 1,000 surgical cases before graduation and specified case minimum requirements for 15 core procedural categories.
      • Sabharwal S.
      • Toci G.R.
      • D'Sa A.A.
      • Nayar S.K.
      • LaPorte D.M.
      Impact of 2013 ACGME minimum case requirements on orthopedic resident operative volume.
      Assessment of resident case logs have become an important measure of procedural experience and are frequently monitored by the ACGME to ensure adequate procedural volume and case variety among residents for their given year of training.
      • Gordon A.M.
      • Flanigan D.C.
      • Malik A.T.
      • Vasileff W.
      Orthopaedic surgery sports medicine fellows see substantial increase in hip arthroscopy procedural volume with high variability from 2011 to 2016.
      While overall case volume among orthopaedic surgery residents has increased by 17% upon implementation of case minimum requirements, wide variability was present.
      • Sabharwal S.
      • Toci G.R.
      • D'Sa A.A.
      • Nayar S.K.
      • LaPorte D.M.
      Impact of 2013 ACGME minimum case requirements on orthopedic resident operative volume.
      Specifically, residents performing at the 90th percentile logged twice as many cases as residents performing at the 10th percentile.
      • Sabharwal S.
      • Toci G.R.
      • D'Sa A.A.
      • Nayar S.K.
      • LaPorte D.M.
      Impact of 2013 ACGME minimum case requirements on orthopedic resident operative volume.
      Similar inconsistencies have been reported in studies assessing case volume and variability of specific orthopaedic procedures.
      • Carender C.N.
      • Shamrock A.G.
      • An Q.
      • Karam M.D.
      Variability in experience performing lower extremity amputations between surgical residents: An examination of ACGME case logs.
      • DeFroda S.F.
      • Gil J.A.
      • Blankenhorn B.D.
      • Daniels A.H.
      Variability in foot and ankle case volume in orthopaedic residency training.
      • Blood T.D.
      • Gil J.A.
      • Born C.T.
      • Daniels A.H.
      Variability in trauma case volume in orthopedic surgery residents.
      • Gil J.A.
      • Waryasz G.R.
      • Owens B.D.
      • Daniels A.H.
      Variability of arthroscopy case volume in orthopaedic surgery residency.
      • Hinds R.M.
      • Klifto C.S.
      • Guss M.S.
      • Capo J.T.
      Microsurgery case volume during orthopedic surgery residency: A 7-year assessment.
      • Hinds R.M.
      • Gottschalk M.B.
      • Capo J.T.
      National trends in carpal tunnel release and hand fracture procedures performed during orthopaedic residency: An analysis of ACGME case logs.
      • Hinds R.M.
      • Rapp T.B.
      • Capo J.T.
      Orthopedic oncology caseload among orthopedic surgery residents.
      Continued analyses are critical for identifying procedures with growing public demand to which graduating orthopaedic residents may have limited exposure.
      • Sudah S.Y.
      • Michel C.R.
      • Nasra M.H.
      • et al.
      Hip Arthroscopy procedural volume is low among graduating orthopaedic surgery residents.
      The incidence of ankle arthroscopy has risen considerably in recent years.
      • Best M.J.
      • Buller L.T.
      • Miranda A.
      United States national trends in ankle arthroscopy: Analysis of the national survey of ambulatory surgery and national hospital discharge survey.
      ,
      • Werner B.C.
      • Burrus M.T.
      • Park J.S.
      • Perumal V.
      • Gwathmey F.W.
      Trends in ankle arthroscopy and its use in the management of pathologic conditions of the lateral ankle in the United States: A national database study.
      From 2007 to 2011, the number of ankle arthroscopy cases increased by 11.8%, which outpaced the growth of shoulder, knee, and elbow arthroscopy.
      • Werner B.C.
      • Burrus M.T.
      • Park J.S.
      • Perumal V.
      • Gwathmey F.W.
      Trends in ankle arthroscopy and its use in the management of pathologic conditions of the lateral ankle in the United States: A national database study.
      However, unlike shoulder and knee arthroscopy, a case minimum requirement for ankle arthroscopy among orthopaedic residents does not exist.
      Accreditation Council for Graduate Medical Education
      ACGME program requirements for graduate medical education in orthopaedic surgery.
      While previous studies have reported trends in ankle arthroscopy case volume among orthopaedic residents, these analyses were performed more than a decade ago.
      • DeFroda S.F.
      • Gil J.A.
      • Blankenhorn B.D.
      • Daniels A.H.
      Variability in foot and ankle case volume in orthopaedic residency training.
      ,
      • Hinds R.M.
      • Gottschalk M.B.
      • Strauss E.J.
      • Capo J.T.
      Trends in arthroscopic procedures performed during orthopaedic residency: An analysis of accreditation council for graduate medical education case log data.
      The purpose of this study was to evaluate graduating orthopaedic resident case volume and variability for ankle arthroscopy from 2016 to 2020. We hypothesized that case volume would remain low during this time, despite an overall increase in the number of ankle procedures performed. We also hypothesized wide variability in case volume among the 10th and 90th percentile of graduating residents.

      Methods

      The ACGME case log reports from 2016 to 2020 for all graduating orthopaedic surgery residents were reviewed in January of 2022. Residents log surgical procedures using Current Procedural Codes (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 other. 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 leg/ankle 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 leg/ankle ACGME case category are listed in Table 1. In addition, 10th, 30th, 50th, 70th, and 90th percentiles of case volumes from 2016 to 2020 were presented to examine case volume variability.
      Table 1CPT Codes With Description of Arthroscopy Procedures for the Leg/Ankle
      29891Arthroscopy, ankle, surgical, excision of osteochondral defect of talus and/or tibia, including drilling of the defect
      29892Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy)
      29894Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with removal of loose body or foreign body
      29895Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial
      29897Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, limited
      29898Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, extensive
      29899Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis
      CPT, Current Procedural Terminology.
      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 Corp., Redmond, WA) 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 2The Demographics of Orthopaedic Surgery ACGME Case Log Respondents
      YearTotal Number of Residency ProgramsTotal Number of Residents
      2016153705
      2017156709
      2018154729
      2019154725
      2020154724
      ACGME, Accreditation Council for Graduate Medical Education.
      The average number of total leg/ankle procedures performed per resident was 168.4 ± 47 (median 163; range 55-414) in 2016, which increased to 200.8 ± 57 in 2020 (median 195; range 67-601), representing a 19.2% increase (P < .001) (Table 3). The average number of leg/ankle arthroscopy procedures performed per resident was 6.2 ± 5 (median 5; range 0-35) in 2016, which decreased to 6.1 ± 6 in 2020 (median 5; range 0-76), representing a 1.6% decrease (P = .732) (Table 3). Case volume for the mean and median number of total leg/ankle procedures and the number of leg/ankle arthroscopy procedures performed per resident from 2016 to 2020 are depicted in Figure 1.
      Table 3Mean Number of Leg/Ankle Arthroscopy Procedures per Graduating Orthopaedic Surgery Resident From 2016 to 2020
      Procedure (Area)20162017201820192020% changeP Value
      Mean ± SDMedian (Range)Mean ± SDMedian (Range)Mean ± SDMedian (Range)Mean ± SDMedian (Range)Mean ± SDMedian (Range)
      Arthroscopy (leg/ankle)6.2 ± 55 (0-35)6 ± 55 (0-31)6.5 ± 65 (0-40)6.5 ± 65 (0-38)6.1 ± 65 (0-76)–1.6%.732
      Total (leg/ankle)168.4 ± 47163 (55-414)176.5 ± 47170 (55-388)187.3 ± 54181 (74-452)195.3 ± 60189 (63-527)200.8 ± 57195 (67-601)19.2%<.001
      SD, standard deviation.
      Figure thumbnail gr1
      Fig 1Trends in the mean and median orthopaedic resident case volumes. for leg/ankle arthroscopy and total leg/ankle procedures from 2016 to 2020.
      There was a low level of variability in total case volume pertaining to the leg/ankle and a wide level of variability in the number of leg/ankle arthroscopy cases performed per resident over the study period (Figure 2). The average number of total leg/ankle procedures performed by the 10th and 90th percentile of residents was 113 and 228 in 2016, representing a 1.16-fold difference, compared with 130 and 270 in 2020, representing a 1.18-fold difference (Table 4).
      Figure thumbnail gr2
      Fig 2Trends in the mean case volume for leg/ankle arthroscopy procedures among the 10th through 90th percentiles of graduating orthopaedic residents from 2016 to 2020.
      Table 4Variability in Leg/Ankle Arthroscopy Case Volume Between the 10th and 90th Percentiles of Graduating Orthopaedic Surgery Residents
      Procedure (Area)Year10th30th50th70th90th
      Arthroscopy (leg/ankle)2016135813
      2017135713
      2018135814
      2019135814
      2020135713
      Total (leg/ankle)2016113141163192228
      2017122149170196238
      2018127155181207251
      2019130164189217270
      2020137173195222272
      The average number of leg/ankle arthroscopy procedures performed by the 10th and 90th percentile of residents was 1 and 13 in both 2016 and 2020, representing a 13-fold difference, respectively (Table 4). About 1 in 10 graduating orthopaedic surgery residents performed only a single ankle arthroscopy case each year, and half performed 5 cases or less (Table 4).

      Discussion

      In this study, we found a statistically significant increase in the total number of leg/ankle procedures performed per graduating orthopaedic surgery resident from 2016 to 2020. Despite this, resident exposure to ankle arthroscopy remained low throughout the study period and highly variable, with a 13-fold difference in case volume among the 10th and 90th percentiles of performing residents.
      In 2013, the ACGME mandated case minimum requirements for 15 core procedural categories in attempt to standardize resident procedural experience.
      • Sabharwal S.
      • Toci G.R.
      • D'Sa A.A.
      • Nayar S.K.
      • LaPorte D.M.
      Impact of 2013 ACGME minimum case requirements on orthopedic resident operative volume.
      With respect to the foot and ankle, residents are required to perform at least 5 ankle arthrodesis procedures and 15 ankle fracture open reduction internal fixation (ORIF) procedures.
      Accreditation Council for Graduate Medical Education
      ACGME program requirements for graduate medical education in orthopaedic surgery.
      Interestingly, there has been a recent interest in the concurrent use of ankle arthroscopy at the time of ankle ORIF.
      • Ackermann J.
      • Fraser E.J.
      • Murawski C.D.
      • Desai P.
      • Vig K.
      • Kennedy J.G.
      Trends of concurrent ankle arthroscopy at the time of operative treatment of ankle fracture: A national database review.
      In a retrospective study of 32,307 patients undergoing ankle ORIF from 2007 to 2011, there was a significant increase in the prevalence of simultaneous arthroscopic treatment and significant decrease in the prevalence of arthroscopic ankle treatments occurring after ankle ORIF.
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      Trends of concurrent ankle arthroscopy at the time of operative treatment of ankle fracture: A national database review.
      The authors believe this to be a result of early arthroscopic detection and treatment of cartilaginous injury at the time of acute ankle fracture, as 22.4% of patients received concurrent microfracture treatment. This study suggests that resident exposure to ankle arthroscopically may increase in the near future as more surgeons aim to identify and treat cartilaginous defects at the time of ankle ORIF.
      Similar national rates have been reported for arthroscopic arthrodesis of the ankle. According to a recent 17-year analysis, the incidence of outpatient arthrodesis performed with arthroscopic assistance increased by 858%.
      • Best M.J.
      • Buller L.T.
      • Miranda A.
      National trends in foot and ankle arthrodesis: 17-Year analysis of the national survey of ambulatory surgery and national hospital discharge survey.
      Several advantages have been reported with this technique, including preservation of inherent ankle stability, fewer complications, and faster recovery when compared with open surgery.
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      • Daniels A.H.
      Variability in foot and ankle case volume in orthopaedic residency training.
      previously evaluated foot and ankle case volume among orthopaedic surgery residents from 2009 to 2013. Within this study, a 23% increase in ankle arthroscopy (6 vs 7.4) cases was reported, with a 14.0- to 15.0-fold difference between the 10th and 90th percentile of graduating residents. Our study is unique in that it offers an updated analysis of ankle arthroscopy case volume over the preceding 5 years. We found that residents preformed an average of 6.2 ankle arthroscopy cases in 2016, compared to 6.1 in 2020 (–1.6% change; P = .732). In addition, a 13.0-fold difference in case volume was present among the 10th and 90th percentile of graduating residents. Interestingly, however, the total number of leg/ankle procedures from 2009 to 2013 and 2016 to 2020 significantly increased during both time periods, respectively. These data imply that resident exposure to ankle arthroscopy has remained low and highly variable over the preceding decade, despite a continued increase in the number of leg/ankle procedures being performed.
      Foot and ankle surgery has become a prominent focus of orthopaedic surgery residency curricula.
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      However, within this study, data regarding the case volumes of ankle arthroscopy among academic foot and ankle surgeons were not provided. Therefore, while this increase in academic foot and ankle faculty is likely to explain the increases in total leg/ankle exposure among orthopaedic residents, it is difficult to determine the stagnation in ankle arthroscopy
      Teaching arthroscopic ankle surgery to orthopaedic residents is difficult, given the high level of dexterity, hand–eye coordination, triangulation, and anatomic understanding required.
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      As such, a lack of highly specialized ankle arthroscopists associated with academic institutions may be contributing to the variability in case exposure that we found.
      The addition of a standardized ankle simulation curriculum has been shown to improve arthroscopic proficiency, anatomic recognition, and safety when compared with traditional apprenticeship teaching models.
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      performed a prospective comparative study that randomized trainees into either a simulation or standard practice group. Those in the simulation group received 4 one-on-one, 15-minute simulation training sessions over a 4-month period, whereas the standard practice group received no additional simulation or exposure. After intervention, the simulation group outscored the control group in total Arthroscopic Surgery Skill Evaluation Tool score and achieved nearly expert Arthroscopic Surgery Skill Evaluation Tool Safety scores upon cadaveric testing. While similar studies have reported improved ankle arthroscopy skills among orthopaedic residents with practice on cadaveric and simulator models,
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      Ankle arthroscopy simulation improves basic skills, anatomic recognition, and proficiency during diagnostic examination of residents in training.
      most residents find live surgery to be the most advantageous learning environment.
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      Shoulder arthroscopy simulator performance correlates with resident and shoulder arthroscopy experience.
      As such, it is vital for trainees to achieve intraoperative ankle arthroscopy experience throughout their residency training and residency programs should explore methods to increase exposure to this procedure.
      Resident case volume for ankle arthroscopy don’t seem to reflect the national increases in the incidence of this procedure. According to a recent nationwide database study,
      • Werner B.C.
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      • Park J.S.
      • Perumal V.
      • Gwathmey F.W.
      Trends in ankle arthroscopy and its use in the management of pathologic conditions of the lateral ankle in the United States: A national database study.
      the incidence of ankle arthroscopy has outpaced the use of shoulder, knee, and elbow arthroscopy in recent years. However, upon review of recent ACGME case log studies,
      • Hinds R.M.
      • Gottschalk M.B.
      • Strauss E.J.
      • Capo J.T.
      Trends in arthroscopic procedures performed during orthopaedic residency: An analysis of accreditation council for graduate medical education case log data.
      ,
      • Sudah S.Y.
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      Wide variability of shoulder and elbow case volume in orthopedic surgery residency.
      ,
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      • et al.
      Wide variability of pediatric knee arthroscopy case volume in orthopaedic surgery residency.
      it seems that orthopaedic resident case exposure to ankle arthroscopy is lower than many other areas of arthroscopic surgery. For example, from 2016 to 2020, the average number of shoulder arthroscopy cases performed increased from 69 to 79.7, representing a 15.5% increase.
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      Over this same time period, the average number of knee arthroscopy cases decreased by 2.6%.
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      • et al.
      Wide variability of pediatric knee arthroscopy case volume in orthopaedic surgery residency.
      However, knee arthroscopy appears to be the most commonly performed arthroscopic procedure among residents, as the average number of cases performed in 2020 was 111. Similar to ankle arthroscopy, resident case exposure to elbow arthroscopy and hip arthroscopy is relatively low and stagnant.
      • Sudah S.Y.
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      • et al.
      Hip Arthroscopy procedural volume is low among graduating orthopaedic surgery residents.
      ,
      • Sudah S.Y.
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      Wide variability of shoulder and elbow case volume in orthopedic surgery residency.
      Specifically, the average number of elbow arthroscopy cases performed in 2016 and 2020 was only 1.6, signifying that no change in case volume has occurred over the last 5 years.
      Initially used as a diagnostic tool, this procedure is now widely indicated for the management of intra-articular ankle pathology.
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      While ankle arthroscopy is most commonly used to treat soft tissue and bony impingement,
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      many surgeons now advocate for concomitant or staged arthroscopic intervention during the treatment of lateral ankle instability.
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      For example, the combined use of ankle arthroscopy and peroneal tendon retinacular repair has increased by 50% from 2007 to 2011.
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      • Gwathmey F.W.
      Trends in ankle arthroscopy and its use in the management of pathologic conditions of the lateral ankle in the United States: A national database study.
      In addition, surgeons are now using arthroscopic techniques to perform all-inside ankle ligament reconstruction,
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      • Malagelada F.
      • Cordier G.
      • Dalmau-Pastor M.
      • Vega J.
      Arthroscopic-assisted versus all-arthroscopic ankle stabilization technique.
      • Vega J.
      • Allmendinger J.
      • Malagelada F.
      • Guelfi M.
      • Dalmau-Pastor M.
      Combined arthroscopic all-inside repair of lateral and medial ankle ligaments is an effective treatment for rotational ankle instability.
      arthroscopic-assisted ankle fracture fixation,
      • Ackermann J.
      • Fraser E.J.
      • Murawski C.D.
      • Desai P.
      • Vig K.
      • Kennedy J.G.
      Trends of concurrent ankle arthroscopy at the time of operative treatment of ankle fracture: A national database review.
      ,
      • Bonasia D.E.
      • Rossi R.
      • Saltzman C.L.
      • Amendola A.
      The role of arthroscopy in the management of fractures about the ankle.
      and arthrodesis,
      • Best M.J.
      • Buller L.T.
      • Miranda A.
      National trends in foot and ankle arthrodesis: 17-Year analysis of the national survey of ambulatory surgery and national hospital discharge survey.
      ,
      • Ferkel R.D.
      • Hewitt M.
      Long-term results of arthroscopic ankle arthrodesis.
      with favorable results.
      In addition, multiple studies have demonstrated favorable clinical outcomes when comparing open and arthroscopic ankle procedures. A meta-analysis performed in 2021 found that patients undergoing arthroscopic ankle arthrodesis for the treatment of advanced tibiotalar osteoarthritis experienced a greater fusion rate, lower fusion time, lower intraoperative blood loss, decreased hospital length of stay, and an overall lower rate of postoperative complications when compared to those undergoing open surgery.
      • Bai Z.
      • Yang Y.
      • Chen S.
      • et al.
      Clinical effectiveness of arthroscopic vs open ankle arthrodesis for advanced ankle arthritis: A systematic review and meta-analysis.
      In addition, a separate meta-analysis performed in 2022 comparing outcomes of arthroscopic versus open Brostrom repair showed significantly less time to weight-bearing and decreased pain scores in the arthroscopic groups.
      • Attia A.K.
      • Taha T.A.
      • Khamis K.M.
      • Hunt K.J.
      • Labib S.A.
      • Dhooghe P.
      Outcomes of arthroscopic vs open brostrom surgery for chronic lateral ankle instability: A systematic review and meta-analysis of comparative studies.
      Perhaps the use of ankle arthroscopy within academic settings will rise overtime as the evidence supporting its indications continue to grow.

      Limitations

      The present study is not without limitations. The ACGME case log data does not specify the types of procedures within the leg/ankle category. Therefore, while case volume and variability for arthroscopic procedures of the leg/ankle were provided, these findings are not applicable to specific CPT procedural codes. Next, the ACGME case log data accuracy may be influenced by bias due to underreporting or overreporting among residents Next, the ACGME case log data accuracy for all arthroscopic procedures including hip, ankle, knee, and shoulder may be influenced by bias due to under-reporting or over-reporting among residents due to the fact that there are several unbundled CPT codes that can be included in a single arthroscopic surgical procedure.
      • Salazar D.
      • Schiff A.
      • Mitchell E.
      • Hopkinson W.
      Variability in Accreditation Council for Graduate Medical Education Resident Case Log System practices among orthopaedic surgery residents.
      Finally, the degree of resident participation within each case cannot be determined and may be subject to reporting bias, which may also threaten the accuracy of the data.

      Conclusions

      Orthopaedic surgery resident exposure to ankle arthroscopy has remained low and highly variable overtime, despite an overall increase in the total number of leg/ankle procedures performed. Implementing minimum case requirements for ankle arthroscopy during orthopaedic residency may be helpful to increase exposure to ankle arthroscopy and reduce variability in experience.

      Supplementary Material

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