Shoulder Surgery: Training the Residents, Fellows

The training of orthopedic surgery residents is a responsibility that many of us share. When residents complete their training they should be proficient in a wide range of orthopedic procedures, some of which involve the shoulder. Over the past 10 years, there has been a significant increase in the number of shoulder fellowship programs. As the variety and complexity of shoulder surgery increases, it becomes reasonable to ask these questions: “Which surgical procedures about the shoulder should be considered part of the standard training of orthopedic residents, and which procedures require advanced (ie, fellowship) training”? To provide some insight, we have posed this question to some of the leaders of shoulder surgery who are also involved in the training of residents and fellows.

— Joseph D. Zuckerman, MD
Moderator

MODERATOR Joseph D. Zuckerman, MD, Professor and Chairman of Orthopaedic Surgery, New York University Hospital for Joint Diseases, Member of Orthopedics Today’s Shoulder and Elbow section PARTICIPANTS Robert H. Cofield, MD, Professor of Orthopedics, Mayo Clinic College of Medicine, Rochester, MN Andrew Green, MD, Assistant Professor of Orthopedic Surgery, Brown University, Providence, RI Joseph Ianotti, MD, PhD Chair, Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland Editor of Orthopedics Today’s Shoulder and Elbow section James Tibone, MD, Clinical Associate Professor, Department of Orthopaedic Surgery, University of Southern California, Los Angeles

Joseph D. Zuckerman, MD: Are you currently involved in a shoulder fellowship program?

Robert Cofield, MD: I am currently involved in a shoulder fellowship program and am actually program director for the fellowship.

Andrew Green, MD: I am not currently in a shoulder fellowship program; however, I am involved in an orthopedic residency program.

Joseph Iannotti, MD: Yes.

James Tibone, MD: Yes, my fellowship is a combination of sports medicine and shoulder and elbow. There is a large focus on the shoulder and elbow outside of sports medicine.

Zuckerman: What arthroscopic procedures do you feel every orthopedic resident should be able to perform at the end of their residency training and which ones should be performed by those with advanced training? Consider the following procedures:

• Diagnostic glenohumeral arthroscopy
• Subacromial decompression
• Lateral clavicle resection
• Anterior shoulder repair
• Posterior shoulder repair
• Repair of a SLAP lesion
• Arthroscopic rotator cuff repair
• Revision anterior shoulder repair
• Revision rotator cuff repair
• Removal of calcium deposits

The panel said that total shoulder arthroplasty should be performed by those with fellowship training. COURTESY OF JOSEPH D. ZUCKERMAN

Cofield: Every orthopedic resident should be able to perform diagnostic glenohumeral arthroscopy, subacromial decompression, SLAP lesion repair and anterior shoulder repair. Lateral clavicle resection could also be included in that list. I doubt that many residents would feel comfortable with posterior shoulder repairs, arthroscopic rotator cuff repair except for very simple tears, or revision surgery. They, of course, should feel comfortable with removal of calcium deposits; however, in some instances this may require a small rotator cuff repair.

Those with advanced training would be able to do all the arthroscopic repair methods listed.

Green: In general, every orthopedic resident should be able to perform the following arthroscopic procedures: diagnostic glenohumeral and subacromial arthroscopy, acromioplasty and subacromial decompression, distal clavicle resection, superior labral repair, rotator cuff repair (small and medium-sized tears), revision rotator cuff repair (small and medium-sized tears), removal of calcium deposits, irrigation and debridement of infected shoulder.

In general, advanced training is required for anterior instability repairs, posterior instability repairs, capsular plication and shift, and capsular release.

Iannotti: Residents should be able to perform diagnostic glenohumeral arthroscopy, subacromial decompression, lateral clavicle resection, anterior shoulder repair, SLAP lesion repair, arthroscopic rotator cuff repair (1 cm to 3 cm), removal of calcium deposits.

Fellows with greater skill should be able to perform these procedures, as well as the others listed.

Tibone: Residents should be able to perform diagnostic glenohumeral arthroscopy, subacromial decompression, lateral clavicle resection and removal of calcium deposits.

Fellows should be able to execute anterior and posterior shoulder repairs, SLAP lesion repair, arthroscopic rotator cuff repair, revision anterior shoulder repair and revision rotator cuff repair.

Zuckerman: What specific fractures about the shoulder should residents be able to treat operatively at the conclusion of residency training? Which procedures require advanced training?

• Open reduction internal fixation
• (ORIF) of two- and three-part proximal humeral fractures
• Proximal humeral replacement for acute four-part fractures
• ORIF of clavicle fractures (midshaft and lateral)
• ORIF of clavicle nonunions
• ORIF of scapular body/glenoid fractures

Cofield: I would think that residents should be able to do ORIF of proximal humeral fractures, clavicle fractures and clavicle nonunions. In addition, they should be able to do proximal humeral replacement for the acute four-part fracture. Special training is probably needed for fixation of scapular fractures.

Green: Residency training prepares physicians for ORIF of two- and three-part proximal humeral fractures, ORIF of clavicle fractures, ORIF of clavicle nonunions.

Advanced training is needed for ORIF and proximal humeral replacement for complex four-part fractures, ORIF of scapular body/glenoid fractures.

Iannotti: Both residents and fellows should be able to perform all of the above procedures; however, fellows should possess greater skill.

Tibone: Residents should have the ability to perform ORIF two- and three-part proximal humeral fractures, ORIF of clavicle fractures and midshaft and lateral and ORIF clavicle nonunions.

Fellows are better suited for proximal humeral replacement for acute four-part fractures and ORIF of scapular body/glenoid neck fractures.

Zuckerman: Which of the following open procedures should residents be able to perform at the end of residency training? Which require advanced/fellowship training?

• Open acromioplasty and rotator cuff repair
• Open anterior shoulder repair
• Open posterior shoulder repair
• Revision anterior shoulder repair
• Revision posterior shoulder repair
• Suprascapular nerve exploration and decompression

Cofield: Certainly, residents should be able to do open acromioplasty and rotator cuff repair and anterior shoulder repair.

Advanced training is probably useful for the posterior open repair and revision repair. Also, suprascapular nerve exploration and decompression might be left to the specialist.

Green: Residents should be able to perform acromioplasty and rotator cuff repair, open anterior instability repair, suprascapular nerve compression, irrigation and debridement for infection.

Advanced training is required for open posterior instability repair, revision of any instability repair.

Iannotti: Residents should be able to perform open acromioplasty and rotator cuff repair, open anterior shoulder repair and open posterior shoulder repair.

Fellows should be able to perform all of the procedures listed.

Tibone: Residents should be well versed in open acromioplasty and rotator cuff repair. Fellows should be skilled in revision anterior and posterior shoulder repair, suprascapular nerve exploration and decompression.

Zuckerman: Which of the reconstructive procedures should residents be able to perform at the completion of residency training, and which require additional training?

• Proximal humeral replacement for osteonecrosis
• Total shoulder replacement
• Total shoulder replacement with glenoid bone grafting
• Revision of a loose glenoid component
• Revision of a loose humeral component
• Revision of a loose total shoulder replacement
• Resection arthroplasty for infected shoulder replacement
• Repair of nonunion surgical neck fracture
• Glenohumeral arthrodesis
• Scapulothoracic arthrodesis

Arthroscopic rotator cuff repairs, particularly larger, more complex tears, require advanced clinical training. COURTESY OF JOSEPH D. ZUCKERMAN

Cofield: Residents should be able to perform proximal humeral replacement for osteonecrosis. In our program, they should be able to perform total shoulder replacement and repair of a nonunion.

People with special training would probably do better with glenoid bone grafting, revision surgery, resections for infected implants and the various arthrodesis procedures.

Green: They should be proficient in proximal humerus replacement for osteonecrosis (atraumatic).

Advanced training is necessary for total shoulder replacement, total shoulder replacement with glenoid bone grafting, revision of loose glenoid or humeral components, revision of a loose total replacement, resection arthroplasty for infected shoulder replacement, repair of nonunion of surgical neck fracture, glenohumeral arthrodesis and scapulothoracic arthrodesis.

Iannotti: At the conclusion of residency, residents should be competent in proximal humeral replacement for osteonecrosis, total shoulder replacement and total shoulder replacement with glenoid bone grafting.

Fellows should be able to perform all of the above.

Tibone: Fellows ought to be able to perform all of the procedures listed.

Zuckerman: It is recognized that a resident’s experience in shoulder surgery will vary from program to another, based upon the volume and variety of cases they are exposed to. What are the essential procedures each resident must learn by the completion of their training? Please describe arthroscopic procedures and open procedures.

Cofield: Residents should be able to do basic internal fixation of various fractures, uncomplicated shoulder prosthesis implantation, first-line arthroscopic procedures and arthroplasty for straightforward arthritis. In addition, they would be able to handle rotator cuff problems of the usual type and instability problems, too.

“I believe that the most important qualities are diagnostic abilities, motor skills and the ability to learn from experience. Repetition enhances learning and ability. ” — Andrew Green

Green: There are a number of factors that determine what procedures a practicing surgeon should be able to perform after completion of an orthopedic residency. These include factors related to the individual surgeon, such as their inherent intellectual capacity and technical abilities, and factors related to training.

I suspect that there is substantial variation in the shoulder experiences available in residency programs. Some might be quite extensive and border on fellowship-level training; others may offer no more than the general orthopedist’s perspective. In addition, even within a specific residency program, individual residents may have different shoulder experiences. This undoubtedly affects one’s ability to perform specific procedures after residency training.

I believe that the most important qualities are diagnostic abilities, motor skills and the ability to learn from experience. Repetition enhances learning and ability. Consequently, it is difficult to specify the procedures that all residents should be able to perform after they complete their training.

The fundamentals of residency training should provide the background and foundations for general orthopedic practice including the ability to perform some shoulder surgery. Residents must acquire knowledge of shoulder pathology, have the ability to evaluate patients with shoulder disorders, have basic surgical skills (open and arthroscopic), and be very familiar with anatomy and operative approaches. The actual clinical exposure will then dictate the specific procedures that a practicing orthopedic surgeon can perform without requiring advanced training.

Foremost, the surgeon must know his or her own limitations and what is best for the patients. Uncommon problems and low volume procedures are best treated by more experienced physicians. This presents a paradox: How does one become more experienced if it is inappropriate to perform surgery when inexperienced? Fellowship training and continuing education are the answer. After residency an orthopedic surgeon can obtain advanced training in a number of settings not just through a fellowship. The following are essential procedures for residents to master by the completion of their training:

• Diagnostic glenohumeral and subacromial arthroscopy
• Arthroscopic acromioplasty and subacromial decompression
• Distal clavicle resection
• Open and arthroscopic irrigation and debridement of infected shoulder
• ORIF of two- and three-part fractures
• Open acromioplasty and rotator cuff repair
• Open anterior instability repair
• Suprascapular nerve decompression

Iannotti: I think that every resident who completes training and goes into general practice should be comfortable with doing an open and arthroscopic anterior stabilization; all fracture work for acute fractures, including hemiarthroplasty; open rotator cuff repair; all acromioclavicular joint fixations; arthroscopic acromioplasty and distal clavicle resections; and arthroscopic repair of small non-retracted rotator cuff tears. Also, most residents should be able to do a primary hemi or total shoulder arthroplasty for arthritis.

Tibone: Residents should be capable of open and arthroscopic decompressions and resection of distal clavicle, open Bankart repair, open rotator cuff repair, ORIF of most shoulder and clavicle fractures.

Zuckerman: Do you feel that shoulder fellowship programs have the potential to detract from a resident’s experience during training? If so, in what ways can this occur? How do you address these issues in your own programs?

Cofield: Advanced fellowship training is probably better for the more complicated things, as mentioned above, and for revision activities. Of course, it goes without saying that advanced training often allows people to perform even the basic procedures better, so it has that role, too. Fellowship programs also allow one to focus on research activities involved in this area and create new knowledge. Residents often do not have the luxury of doing that to any degree.

Fellowship programs could have the potential to detract from the residents’ experience if the scheduling is not organized to avoid this. We address this in our program by having enough faculty in shoulder and elbow surgery so that the fellow rotates with each of us only one quarter of the year; the other three-quarters of the year, residents have that opportunity, and this seems to work just right.

Green: Shoulder fellowship programs have the potential to enhance as well as detract from a resident’s experience during training. If there is enough clinical volume, then the fellow will not detract from the surgical experience. If there is insufficient volume, then a fellow might detract from the resident’s surgical experience. Fellows with greater experience during their residency may feel less compelled or pressured to do surgical cases. In the proper setting a fellow can enhance the residence experience. The fellow can be an effective teacher and enhance the learning experience through greater interaction with the residents.

Iannotti: All fellowship programs have the potential to detract from resident training. The way to prevent this is not having the fellows scrub on the same cases as a senior resident. If it happens and it is one of the cases listed above, it must be clear that the senior resident is the surgeon with the greater participation in the case; the fellow is there as a second assist or for observation. If a junior resident is involved, then the fellow is the first person in training to participate in most cases. For simple nonrevision cases, the junior resident may be the first person in training.

Under ideal circumstances, there should be about 500 cases per fellow on a service and the two staff shoulder surgeons per fellow. This can be achieved where the fellows are rarely in the same place as the fellows. Fellows can often add to resident education, particularly at the junior resident level, through lectures, patient rounds and in the operating room.

In our program, we have two shoulder surgeons on the rotation. The fellows are with one staff at a time, and the residents are assigned to the staff not having fellows. When there is a surgeon with two operating rooms, the surgeon may have one fellow and one resident. Conflicts arise when there are too few surgeons or cases per trainee.

Tibone: Most shoulder procedures, including arthroscopic stabilization and arthroscopic rotator cuff and arthroplasty are too difficult for residents. Seeing a fellow being taught to perform these procedures is better than watching an attending do them.