LAUSR

Editor We read James et al.1 with great interest. The conclusions state: ‘There is an abundance of relatively low-quality evidence showing that cadaveric simulation induces short-term skill acquisition as measured by objective means’. In 2015, The Arthroscopy Association of North America (AANA) published a series of research investigations employing a cadaveric simulation model for arthroscopic skills training2–5. In a prospective, randomized, blinded trial study, a cadaveric shoulder simulator was used for training as well as the final proficiency assessment. An arthroscopic Bankart repair (ABR) was deconstructed to identify clearly defined intraoperative performance metrics which included 45 key operative steps and 77 potential errors that were scored in binary fashion (the specific metric either was or was not observed to occur). Thus, a very detailed, accurate and reliable (mean inter-rater reliability = 0⋅93)3,5 assessment of operative performance (by five pairs of attending arthroscopic surgeons) was afforded by the metric characterization. A proficiency benchmark was established based on the mean performance assessment of a cohort of experienced surgeons. To pass, trainees (in postgraduate years 4–5) from 21 Accreditation Council for Graduate Medical Education (ACGME)-approved orthopaedic residency training centres in the USA had to meet quantitatively defined proficiency benchmarks for arthroscopic knot-tying skill, ABR in the model simulator, and finally in a cadaver shoulder. In the prospective, randomized and blinded study (Clinicaltrials .gov NCT01921621), 68⋅7 per cent of trainees in the proficiency based progression (PBP)-trained group demonstrated the proficiency benchmark in the final assessment in comparison to 36⋅7 per cent in the simulation-trained group and 28⋅6 per cent in the standardtrained group. Furthermore, the PBP group made 56 per cent fewer objectively assessed intraoperative errors than the standard trained group and 41 per cent fewer than the simulation group. This work presents very high-quality evidence that a cadaver shoulder can be used to both train and assess operative skill in a very detailed and objective manner.