Utility of Modern Arthroscopic Simulator Training Models

doi:10.1016/j.arthro.2013.09.084

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 30, Issue 1, January 2014, Pages 121-133

https://doi.org/10.1016/j.arthro.2013.09.084 Get rights and content

Purpose

The purpose of this study was to review the published literature on modern arthroscopic simulator training models to (1) determine the ability to transfer skills learned on the model to the operating room and (2) determine the learning curve required to translate such skills.

Methods

A systematic review of all studies using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. Two independent reviewers then analyzed studies deemed appropriate for inclusion. Study data collected included participant demographic characteristics, simulator model, type and number of tasks, method of analysis, and results of training, when available. Given the different methods used in each study, descriptive analysis was performed.

Results

Nineteen studies met the inclusion criteria (9 shoulder, 9 knee, and 1 hip). A total of 465 participants with a mean age of 30 years were evaluated. Twelve studies (63%) compared task performance among participants of different experience levels, with 100% reporting a positive correlation between experience level and simulator performance. Eight studies (42%) evaluated task performance before and after simulator training, with 6 studies showing improvement after training; 1 study noted no difference in performance after 1 hour of training. One study commented on improved operating room performance after simulator training. No studies commented on the number of training sessions needed to translate skills learned on the models to the operating room.

Conclusions

This review suggests that practice on arthroscopic simulators improves performance on arthroscopic simulators. We cannot, however, definitively comment on whether simulator training correlates to an improved skill set in the operating room. Further work is needed to determine the type and number of training sessions needed to translate arthroscopic skills learned on the models to the operating room.

Level of Evidence

Level IV, systematic review of studies with Level I through IV evidence.

Section snippets

Methods

We conducted a systematic review of publicly available evidence using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with a PRISMA checklist.16, 17 Three independent reviewers completed the search. The search was performed on August 5, 2013. The following databases were used: Medline (PubMed), CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane Central Register of Controlled Trials. The following terms were searched:

Results

Sixty-two studies were identified with the initial search. One additional study was identified by cross-referencing the references within the studies from the initial search. A total of 44 studies were excluded, including non–English-language articles (n = 2), an abstract-only listing (n = 1, which was also on an unrelated topic), review articles (n = 6), biomechanical studies (n = 12), studies analyzing novel techniques (n = 4), studies analyzing the validity of simulator models (n = 2),

Discussion

The principal findings of this study include the following: (1) training on arthroscopic simulators improves performance on arthroscopic simulators, (2) more experienced subjects perform better on arthroscopic simulators than less experienced subjects, and (3) there is little evidence to correlate performance on simulators with performance in the operating room. A summary of the key findings is presented in Table 4.

Since the popularization of arthroscopy in the United States in the late 1960s,³⁷

Conclusions

Arthroscopic simulators have the potential to enable residents and surgeons to further develop their skills in a safe environment. This review supports the belief that practice on arthroscopic simulators improves performance on arthroscopic simulators. We cannot, however, definitively comment on whether simulator training correlates to an improved arthroscopic skill set in the operating room. Further work is needed to determine the type and number of training sessions needed to translate

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Virtual and Augmented Reality Simulators Show Intraoperative, Surgical Training, and Athletic Training Applications: A Scoping Review
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To review published literature to identify and evaluate the effect of virtual reality (complete immersion) and augmented reality (overlay of digital information onto the physical world) simulators on intraoperative use for orthopaedic surgeons, orthopaedic surgical education, and athletic training.
A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies, published since 2014, that evaluated the role of augmented/virtual reality on intraoperative use for orthopaedic surgeons, orthopaedic surgical education, and athletic training.
Virtual reality (VR) simulators provide 3-dimensional graphical simulation of the physical world, and augmented reality (AR) simulators overlay digital information onto the physical world. Simulators can include interactive features (i.e., replication of intraoperative bleeding), haptic feedback, and unrestricted task repetition, and they can record, compare, and analyze performance while being easily accessible and eliminating the need for the presence of a mentor or coach. Four studies reported on VR for intraoperative use, 47 studies on surgical education, and 10 studies on athletic training. Two studies revealed the advantages of using VR simulation during intraoperative procedures, specifically showcasing its benefits for elbow arthroscopy, while 2 studies demonstrated similar positive outcomes for hip arthroscopy. Seventeen studies demonstrated that a VR simulator could be a beneficial tool to assist in surgical education for the knee, while 12 studies found that VR simulation is a valuable tool for aiding in surgical education of shoulder arthroscopy. Ten studies demonstrated that VR simulation improves skills in the operating room. Three studies revealed that individuals with more experience exhibit superior performance on these simulators compared to those with less experience. In the realm of athletic training, 10 studies showcased the potential of VR simulation to play a significant role in athletic performance and injury rehabilitation.
VR simulation shows benefits in the operating room, is a valuable tool for surgical education resulting in improved skills, and can be used to enhance athletic performance and injury rehabilitation.
Understanding that VR simulators can improve surgical outcomes, surgical skill training, and athletic training and rehabilitation could facilitate development and adoption of this advanced technology.
Low-Fidelity Arthroscopic Simulation Training in Trauma and Orthopaedic Surgery: A Systematic Review of Experimental Studies
2022, Arthroscopy - Journal of Arthroscopic and Related Surgery
To identify and appraise evidence assessing the effectiveness of low-fidelity arthroscopic simulation in the acquisition of arthroscopic surgical skills in a novice population.
Four databases were electronically searched in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) algorithm. Studies from any year that described the use of orthopaedic, low-fidelity arthroscopic training models in novice populations were included. Questionnaires, case studies, and review studies were excluded. Risk of bias assessment was conducted using the Cochrane Collaboration’s Risk of Bias Tool or the Cochrane Risk of Bias in Non-Randomised Studies of Interventions (ROBINS-I) checklist.
Sixteen studies were identified. Using the PRISMA algorithm, 6 studies were included with a total of 131 novice participants. Individual studies ranged from 8 to 40 novices and were of Level I to II evidence. Outcome measurements varied between studies (total 16 different outcomes used). Various outcome measures used for assessing arthroscopic surgical skills within all 6 studies demonstrated significant improvement. A cross-study subjective outcome synthesis revealed low-fidelity arthroscopic simulators reduced time to completion outcomes (2 studies, P < .05), increased Arthroscopic Surgical Skill Evaluation Tool scores (2 studies, P < .01), and confirmed face validity (2 studies) and transfer of skills to cadavers (2 studies) or live patients (1 study). Cost data were under-reported in all studies apart from one.
Arthroscopic training using low-fidelity simulators likely improves the performance of novice participants in completing basic arthroscopic procedures. These simulators may also be more cost effective and thus more implementable than their high-fidelity counterparts.
Level II, systematic review of Level I-II studies.
Arthroscopic Versus Open Rotator Cuff Repair: Fellowship-Trained Orthopaedic Surgeons Prefer Arthroscopy and Self-Report a Lower Complication Rate
2021, Arthroscopy, Sports Medicine, and Rehabilitation
To evaluate whether fellowship training had an effect on the practice pattern and complication rates among Part II examinees of the American Board of Orthopaedic Surgery (ABOS) for rotator cuff repair (RCR) from 2007-2017.
The ABOS database was queried for arthroscopic (Current Procedural Terminology [CPT] code 29827) and open/mini-open (CPT codes: 23410, 23412) RCR performed from 2007-2017. Excluded were procedures that did not included CPT codes 29827, 23410, 23412. A comparison between arthroscopic and open/mini-open use as well as self-reported complications were assessed based on recorded fellowship training.
A total of 31,907 RCR were reported over the past 10 years (2007-2017). The percentage of RCR procedures performed using arthroscopic technique vs open/mini-open varied among surgeons who completed one fellowship: Sports Medicine (92.5 % arthroscopy; 7.5 % mini/open), Shoulder & Elbow (91.3 % arthroscopy; 8.7% mini/open), and Hand & Upper Extremity (69.6 % arthroscopy; 30.4 % open). Total complication rates varied among surgeons who completed one fellowship: Sports Medicine (11.5 %), Shoulder & Elbow (13.5 %), and Hand & Upper Extremity (13.4 %). Surgeons completing one fellowship in either Sports Medicine, Shoulder & Elbow, Hand & Upper Extremity all reported significantly lower complication rates using arthroscopic over mini/open technique (P < .001).
Among ABOS Part II examinees completing a Sports Medicine, Shoulder and Elbow or Hand and Upper Extremity fellowship, Sports Medicine trained surgeons had significantly greater rates of performing arthroscopic over open RCR and significantly lower self-reported intraoperative complication rates.
Understanding the effects of fellowship training may guide mentors and future trainees.
A Portable Hip Arthroscopy Simulator Demonstrates Good Face and Content Validity with Incomplete Construct Validity
2021, Arthroscopy, Sports Medicine, and Rehabilitation
We evaluate the face, content, and construct validity of a portable hip arthroscopy module in a regional orthopaedic unit.
Participants were recruited from a regional orthopaedic centre, and categorized into novice (0 arthroscopies), intermediate (1-29 arthroscopies), and expert (>50 arthroscopies) groups based on reported experience in arthroscopy. Face and content validity was evaluated by feedback from users immediately following completion of modules. Objective measurements, including time taken and subjective measurements consisting of simulation software metrics including, cam lesion locations attempts, scope strikes on bone, healthy bone burred, and cam lesion burred. Scores achieved by experts were recorded, and the median score was set at the level at which proficiency was demonstrated. Participant feedback on perceived educational use was collected following completion.
In total, 20 participant results were included for analysis. Good face and content validity was expressed by participants with previous arthroscopic experience. Number of scope strikes within the simulator-derived metrics accurately discerned between levels of experience. Novices had a mean of 5 strikes per attempt (SD $\pm 5), intermediates$ a mean of 5.8 strikes (SD $\pm$ 4.1). There was a significant difference between expert and novice groups (P = .01), and expert and intermediate groups (P = .002). No significant difference between overall performance scores achieved by participants in expert, intermediate, and novice groups (62% $\pm 19$ vs 55% $\pm 22$ vs 50% $\pm 23,$ P = .15). This demonstrates incomplete construct validity of the simulator software-derived metrics.
This hip arthroscopy simulator demonstrated acceptable face and content validity, with incomplete construct validity of simulator software metrics. Participants reported high levels of satisfaction with the module, highlighting that the addition of haptic feedback would be beneficial to improve procedural steps. Incorporation of tactile feedback to the modulator components would likely enable the software to accurately delineate between levels of experience.
This study demonstrates good face and content validity. The addition of haptic feedback in a hip arthroscopy simulator may improve learning.
The FAST Workstation Shows Construct Validity and Participant Endorsement
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To determine in what way the proposed simulation-based intervention (SBI) is an effective intervention for use in basic arthroscopic skills training.
Twenty candidates were recruited and grouped according to experience. Performance metrics included the time to activity completion, errors made, and Global Rating Scale score. Qualitative data were collected using a structured questionnaire.
Performance on the SBI differed depending on previous arthroscopic training received. Performance on the simulator differed between groups to a statistically significant level regarding time to completion. A difference was also present between participants with no previous training and those with previous training when assessed using the Global Rating Scale. The SBI was deemed acceptable, user-friendly, and realistic. Participants practicing at the expert level believe that such an SBI would be beneficial in developing basic arthroscopic skills.
The results of this study provide evidence that the use of an SBI consisting of a benchtop workstation, laptop viewing platform, 30° arthroscope, and defined performance metrics can detect differences in the level of arthroscopic experience. This format of SBI has been deemed acceptable and useful to the intended user, increasing the feasibility of introducing it into surgical training.
This study adds to the existing body of evidence supporting the potential benefits of benchtop SBIs in arthroscopic skills training. Improved performance on such an SBI may be beneficial for the purpose of basic arthroscopic skills training, and we would support the inclusion of this system in surgical training programs such as those developed by the Arthroscopy Association of North America and American Board of Orthopaedic Surgery.
Novice Surgeon Portal Preference to Visualize the Femoral Anterior Cruciate Ligament Footprint: The Accessory Medial Portal Offers Improved Visualization
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To evaluate participant opinions on the appropriateness of different viewing angles by asking 8 questions, using visual content techniques.
Survey information from participants was used in this study. We used images of a patient who was operated on for symptomatic knee instability. Participants were asked whether the visual angle could determine the femoral tunnel entry point or evaluate anterior cruciate ligament (ACL) integrity.
Questionnaires were completed by 40 participants. When all responses were evaluated, participant opinions on the accessory medial portal (AMP) were more positive than opinions on images taken from the anterolateral portal (ALP). These observations were statistically significant (P < .005). Both ACL integrity assessments and femoral tunnel entry site questions were evaluated, we observed that participant opinions on the AMP for both types of evaluation were more positive than opinions on the ALP. This observation was statistically significant (P < .005). When evaluations with photos and video transcripts were compared, no significant differences in terms of participant opinions were observed (P < .005).
AMP use may be a valuable tool for assistant and postgraduate education, as it offers a more suitable view angle for ACL reconstruction.
Level V, survey study.

View all citing articles on Scopus

: The authors report that they have no conflicts of interest in the authorship and publication of this article.

View full text

Systematic ReviewUtility of Modern Arthroscopic Simulator Training Models

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Methods

Results

Discussion

Conclusions

Curr Surg

J Am Coll Surg

J Thorac Cardiovasc Surg

Int J Surg

Arthroscopy

J Shoulder Elbow Surg

Arthroscopy

Arthroscopy

Orthopaedic resident and program director opinions of resident duty hours: A national survey

J Bone Joint Surg Am

The effect of work hour restrictions on the education of orthopaedic surgery residents

Clin Orthop Relat Res

Resident duty-hour restrictions—Who are we protecting?: AOA critical issues

J Bone Joint Surg Am

The early effects of code 405 work rules on attitudes of orthopaedic residents and attending surgeons

J Bone Joint Surg Am

Resident work-hour rules: A survey of residents' and program directors' opinions and attitudes

Am J Orthop

Current and future use of surgical skills training laboratories in orthopaedic resident education: A national survey

J Bone Joint Surg Am

Motor skills training in orthopaedic surgery: A paradigm shift toward a simulation-based educational curriculum

J Am Acad Orthop Surg

Surgical simulation in orthopaedic skills training

J Am Acad Orthop Surg

Prospective, randomized assessment of transfer of training (ToT) and transfer effectiveness ratio (TER) of virtual reality simulation training for laparoscopic skill acquisition

Ann Surg

Virtual reality training improves operating room performance: Results of a randomized, double-blinded study

Ann Surg

Simulator training to automaticity leads to improved skill transfer compared with traditional proficiency-based training: A randomized controlled trial

Ann Surg

Level of evidence in orthopaedic journals

J Bone Joint Surg Am

Surgical experience correlates with performance on a virtual reality simulator for shoulder arthroscopy

Am J Sports Med

Systematic Review
Utility of Modern Arthroscopic Simulator Training Models