Objective Assessment of Knot-Tying Proficiency With the Fundamentals of Arthroscopic Surgery Training Program Workstation and Knot Tester

Abstract

Purpose: To assess a new method for biomechanical assessment of arthroscopic knots and to establish proficiency benchmarks using the Fundamentals of Arthroscopic Surgery Training (FAST) Program workstation and knot tester.

Methods: The first study group included 20 faculty at an Arthroscopy Association of North America resident arthroscopy course (19.9 ± 8.25 years in practice). The second group comprised 30 experienced surgeons attending an Arthroscopy Association of North America fall course (17.1 ± 19.3 years in practice). The training group included 44 postgraduate year 4 or 5 orthopaedic residents in a randomized, prospective study of proficiency-based training, with 3 subgroups: group A, standard training (n = 14); group B, workstation practice (n = 14); and group C, proficiency-based progression using the knot tester (n = 16). Each subject tied 5 arthroscopic knots backed up by 3 reversed hitches on alternating posts. Knots were tied under video control around a metal mandrel through a cannula within an opaque dome (FAST workstation). Each suture loop was stressed statically at 15 lb for 15 seconds. A calibrated sizer measured loop expansion. Knot failure was defined as 3 mm of loop expansion or greater.

Results: In the faculty group, 24% of knots "failed" under load. Performance was inconsistent: 12 faculty had all knots pass, whereas 2 had all knots fail. In the second group of practicing surgeons, 21% of the knots failed under load. Overall, 56 of 250 knots (22%) tied by experienced surgeons failed. For the postgraduate year 4 or 5 residents, the aggregate knot failure rate was 26% for the 220 knots tied. Group C residents had an 11% knot failure rate (half the overall faculty rate, P = .013).

Conclusions: The FAST workstation and knot tester offer a simple and reproducible educational approach for enhancement of arthroscopic knot-tying skills. Our data suggest that there is significant room for improvement in the quality and consistency of these important arthroscopic skills, even for experienced arthroscopic surgeons.

Level of evidence: Level II, prospective comparative study.