A Proficiency-Based Progression Simulation Training Curriculum to Acquire the Skills Needed in Performing Arthroscopic Bankart and Rotator Cuff Repairs—Implementation and Impact

Published:December 24, 2020DOI:


      To investigate the impact of a proficiency-based progression (PBP) curriculum employed to teach trainees in the skills needed to demonstrate proficiency for an arthroscopic Bankart repair (ABR) and an arthroscopic rotator cuff repair (ARCR) by objectively comparing pre- and immediate postcourse performances.


      In a prospective study, 16 arthroscopy/sports medicine fellows and 2 senior residents (complete group: N = 18) were randomly assigned to perform a precourse cadaveric ABR (Bankart subgroup: N = 6), ARCR (cuff subgroup: N = 6), or basic skills on a shoulder simulator (N = 6). After completing a PBP training curriculum, all 18 registrants performed both an ABR and ARCR scored in real time by trained raters using previously validated metrics.


      The Bankart subgroup made 58% fewer objectively assessed errors at the completion of the course than at baseline (P = .004, confidence interval –1.449 to –0.281), and performance variability was substantially reduced (standard deviation = 5.89 vs 2.81). The cuff subgroup also made 58% fewer errors (P = .001, confidence interval –1.376 to 0.382) and showed a similar reduction in performance variability (standard deviation = 5.42 vs 2.1). Only one subject’s precourse baseline performance met the proficiency benchmark compared with 89% and 83% of the all registrants on the final ABR and ARCR cadaveric assessments, respectively.


      The results of this study reject the null hypothesis. They demonstrate that the implementation of a PBP simulation curriculum to train the skills necessary to perform arthroscopic Bankart and rotator cuff repairs results in a large and statistically significant improvement in the trainee’s ability to meet the 2 related performance benchmarks. Proficiency was demonstrated by 89% and 83% of the trainees for an ABR and an ARCR, respectively, in a two- and one-half day course.

      Clinical Relevance

      Surgical training employing a PBP curriculum is efficient, effective, and has the potential to improve patient safety.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Asch D.A.
        • Weinstein D.F.
        Innovation in medical education.
        N Engl J Med. 2014; 371: 794-795
        • Angelo R.L.
        Magellan and Copernicus: Arthroscopy Association of North America Seeking Excellence in Education.
        Arthroscopy. 2015; 31: 1428-1429
        • Ahlberg G.
        • Enochsson L.
        • Gallagher A.G.
        • et al.
        Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies.
        Am J Surg. 2007; 193: 797-804
        • Gallagher A.
        Metric-based simulation training to proficiency in medical education: What it is and how to do it.
        Ulster Med J. 2012; 81: 107-113
        • Gallagher A.G.
        • O'Sullivan G.C.
        Fundamentals of surgical simulation: Principles and practices.
        Springer, London2012
        • Van Sickle K.R.
        • Ritter E.M.
        • Baghai M.
        • et al.
        Prospective, randomized, double-blind trial of curriculum-based training for intracorporeal suturing and knot tying.
        J Am Coll Surg. 2008; 207: 560-568
        • Seymour N.E.
        • Gallagher A.G.
        • Roman S.A.
        • et al.
        Virtual reality training improves operating room performance: Results of a randomized, double-blinded study.
        Ann Surg. 2002; 236: 458-464
        • Angelo R.L.
        • Ryu R.K.
        • Pedowitz R.A.
        • Gallagher A.G.
        Metric development for an arthroscopic Bankart procedure: Assessment of face and content validity.
        Arthroscopy. 2015; 31: 1430-1440
        • Angelo R.L.
        • Pedowitz R.A.
        • Ryu R.K.
        • Gallagher A.G.
        The Bankart performance metrics combined with a shoulder model simulator create a precise and accurate training tool for measuring surgeon skill.
        Arthroscopy. 2015; 31: 1639-1654
        • Angelo R.L.
        • Ryu R.K.
        • Pedowitz R.A.
        • Gallagher A.G.
        The Bankart performance metrics combined with a cadaveric shoulder create a precise and accurate assessment tool for measuring surgeon skill.
        Arthroscopy. 2015; 31: 1655-1670
        • Pedowitz R.A.
        • Nicandri G.T.
        • Angelo R.L.
        • Ryu R.K.
        • Gallagher A.G.
        Objective assessment of knot-tying proficiency with the fundamentals of arthroscopic surgery training program workstation and knot tester.
        Arthroscopy. 2015; 31: 1872-1879
        • Angelo R.L.
        • Ryu R.K.
        • Pedowitz R.A.
        • et al.
        A proficiency-based progression training curriculum coupled with a model simulator results in the acquisition of a superior arthroscopic Bankart skill set.
        Arthroscopy. 2015; 31: 1854-1871
        • Cates C.U.
        • Lönn L.
        • Gallagher A.G.
        Prospective, randomised and blinded comparison of proficiency-based progression full-physics virtual reality simulator training versus invasive vascular experience for learning carotid artery angiography by very experienced operators.
        BMJ Simulation Technol Enhanced Learning. 2016; 2: 1-5
        • Srinivasan K.K.
        • Gallagher A.
        • O’Brien N.
        • et al.
        Proficiency-based progression training: an ‘end to end’model for decreasing error applied to achievement of effective epidural analgesia during labour: A randomised control study.
        BMJ Open. 2018; 8e020099
        • Collins J.W.
        • Levy J.
        • Stefanidis D.
        • et al.
        Utilising the Delphi process to develop a proficiency-based progression train-the-trainer course for robotic surgery training.
        Eur Urol. 2019; 75: 775-785
        • Angelo R.L.
        • Tauro J.
        • Pierre P.S.
        • et al.
        Arthroscopic rotator cuff repair metrics: establishing face, content, and construct validity in a cadaveric model.
        Arthroscopy. 2020; 36 (e71): 71-79
        • American Education and Research Association
        Standards for Education and psychological testing.
        AERA, Washington, DC2014
        • StataCorp LLC
        Stata statistical software: Release 16.
        StataCorp LLC, College Station,TX2019
        • Breen D.
        • O’Brien S.
        • McCarthy N.
        • Gallagher A.G.
        • Walshe N.
        Effect of proficiency based progression simulation training and standard simulation training on Isbar performance. A randomized controlled trial.
        BMJ Open. 2019; 2019
        • Gallagher A.G.
        • O'Sullivan G.C.
        • Leonard G.
        • Bunting B.P.
        • McGlade K.J.
        Objective structured assessment of technical skills and checklist scales reliability compared for high stakes assessments.
        ANZ J Surg. 2014; 84: 568-573
        • Kojima K.
        • Graves M.
        • Taha We
        • Cunningham M.
        • Joeris A.
        • Gallagher A.G.
        AO international consensus panel for metrics on a closed reduction and fixation of a 31A2 pertrochanteric fracture.
        Injury. 2018; 49: 2227-2233
        • Ericsson K.A.
        • Krampe R.T.
        • Tesch-Römer C.
        The role of deliberate practice in the acquisition of expert performance.
        Psychol Rev. 1993; 100: 363-406
        • Gallagher A.G.
        • Ryu R.K.
        • Pedowitz R.A.
        • Henn P.
        • Angelo R.L.
        Inter-rater reliability for metrics scored in a binary fashion—performance assessment for an arthroscopic Bankart repair.
        Arthroscopy. 2018; 34: 2191-2198
        • Gallagher A.G.
        • Ritter E.M.
        • Satava R.M.
        Fundamental principles of validation, and reliability: Rigorous science for the assessment of surgical education and training.
        Surg Endosc. 2003; 17: 1525-1529