Current Status of Simulation-based Training Tools in Orthopedic Surgery: A Systematic Review

A Simple and Low-cost Drilling Simulator for Training Plunging Distance Among Orthopedic Surgery Residents

OBJECTIVE

Drilling through bone is a complex action that requires precise motor skills of an orthopedic surgeon. In order to minimize plunging and soft tissue damage, the surgeon must halt drill progression precisely following penetration of the far cortex. The purpose of this study was to create a low-cost and easy-to-use drilling simulator to train orthopedic residents in reducing the drill plunging depth.

DESIGN, SETTING, PARTICIPANTS

This prospective observational study was performed in the division of orthopedic surgery of a single tertiary medical center. The participants included 13 residents and 7 orthopedic specialists. The simulator consisted of a synthetic femur bone model and ordinary modeling clay, and the training unit consisted of a disposable plastic tube (∼US$14), clamps (∼US$58), and a power drill + drill bit (standard hospital equipment). Plunging depths were measured by the simulator and compared between orthopedic specialists, the 6 "senior residents" (3+ years) and the 7 "junior residents" during a training session. Measurements were taken again 2 weeks following the training session.

RESULTS

Initially, the plunging depths of the junior residents were significantly greater compared to those of the orthopedic specialists (7.00 mm vs. 5.28 mm, respectively, p < 0.038). There was no similarly significant difference between the senior residents and the orthopedic experts ([6.33 mm vs. 5.28 mm, respectively; p = 0.18). The senior residents achieved plunging depths of 5.17 mm at the end of the training session and 4.7 mm 2 weeks later compared to 7.14 mm at the end of the training session and 6 mm 2 weeks later for the junior residents.

CONCLUSIONS

This study demonstrated the capability of a low-cost drilling simulator as a training model for reducing the plunging depth during the drilling of bone and soft tissue among junior and senior residents.

Progress in Knee Arthroscopy Skills of Residents and Medical Students: A Prospective Assessment of Simulator Exercises and Analysis of Learning Curves

OBJECTIVE

Knee arthroscopies are very common orthopedic procedures. For a number of reasons, including increased public awareness for medical errors, patient safety, strict regulations governing duty-hours for residents, surgeons' liability, and an increasing emphasis on the efficient use of operating room time, interest in simulator training is on the rise. It was the purpose of this study to analyze learning curves of medical students and orthopedic resident surgeons using a virtual knee arthroscopy simulator.

DESIGN

Learning curves of medical students and orthopedic residents were measured perspective using an arthroscopic training simulator for 2 different exercises. Time, camera and probe movement as well as camera and probe roughness were the parameters to be compared. Mean and standard deviation of the initial and the final score for the consecutively performed exercises as well as their slope were reported.

SETTING

The study was performed at the Medical University of Innsbruck, Department of Orthopaedic Surgery. Level of clinical care: institutional.

PARTICIPANTS

A Students Group (n = 10) consisting of medical students at the Medical University of Innsbruck with no prior knowledge of arthroscopy but interest in orthopedic surgery was selected. The group was compared to a Residents Group (n = 9) which was comprised of orthopedic resident surgeons who had learned arthroscopy in operation courses. All participants involved in the study did several repetitions of the described exercises.

RESULTS

Both groups improved their skills after several repetitions. Residents were on average faster, moved the camera less, and touched the cortical tissue less than the students. For certain parameters students showed a steeper improvement curve than did residents, because the students started from a different experience level.

CONCLUSIONS

In conclusion, our results demonstrate the usefulness of virtual knee arthroscopy simulators as an important tool for improving surgical and arthroscopic skills in orthopedic resident surgeons, and medical students.

How to Build a Patient-Specific Hybrid Simulator for Orthopaedic Open Surgery: Benefits and Limits of Mixed-Reality Using the Microsoft HoloLens

Orthopaedic simulators are popular in innovative surgical training programs, where trainees gain procedural experience in a safe and controlled environment. Recent studies suggest that an ideal simulator should combine haptic, visual, and audio technology to create an immersive training environment. This article explores the potentialities of mixed-reality using the HoloLens to develop a hybrid training system for orthopaedic open surgery. Hip arthroplasty, one of the most common orthopaedic procedures, was chosen as a benchmark to evaluate the proposed system. Patient-specific anatomical 3D models were extracted from a patient computed tomography to implement the virtual content and to fabricate the physical components of the simulator. Rapid prototyping was used to create synthetic bones. The Vuforia SDK was utilized to register virtual and physical contents. The Unity3D game engine was employed to develop the software allowing interactions with the virtual content using head movements, gestures, and voice commands. Quantitative tests were performed to estimate the accuracy of the system by evaluating the perceived position of augmented reality targets. Mean and maximum errors matched the requirements of the target application. Qualitative tests were carried out to evaluate workload and usability of the HoloLens for our orthopaedic simulator, considering visual and audio perception and interaction and ergonomics issues. The perceived overall workload was low, and the self-assessed performance was considered satisfactory. Visual and audio perception and gesture and voice interactions obtained a positive feedback. Postural discomfort and visual fatigue obtained a nonnegative evaluation for a simulation session of 40 minutes. These results encourage using mixed-reality to implement a hybrid simulator for orthopaedic open surgery. An optimal design of the simulation tasks and equipment setup is required to minimize the user discomfort. Future works will include Face Validity, Content Validity, and Construct Validity to complete the assessment of the hip arthroplasty simulator.

Utility of Modern Arthroscopic Simulator Training Models: A Meta-analysis and Updated Systematic Review

PURPOSE

To determine the utility of modern arthroscopic simulators in transferring skills learned on the model to the operating room.

METHODS

A meta-analysis and systematic review of all English-language studies relevant to validated arthroscopic simulation models using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines from 1999 to 2016 was performed. Data collected included the specific simulator model, the joint used, participant demographic characteristics, participant level of training, training session information, type and number of tasks, pre- and post-training assessments, and overall outcomes of simulator performance. Three independent reviewers analyzed all studies.

RESULTS

Fifty-seven studies with 1,698 participants met the study criteria and were included. Of the studies, 25 (44%) incorporated an arthroscopic training program into the study methods whereas 32 (56%) did not. In 46 studies (81%), the studies' respective simulator models were used to assess arthroscopic performance, whereas 9 studies (16%) used Sawbones models, 8 (14%) used cadaveric models, and 4 (7%) evaluated subject performance on a live patient in the operating room. In 21 studies (37%), simulator performance was compared with experience level, with 20 of these (95%) showing that clinical experience correlated with simulator performance. In 25 studies (44%), task performance was evaluated before and after simulator training, with 24 of these (96%) showing improvement after training. All 4 studies that included live-patient arthroscopy reported improved operating room performance after simulator training compared with the performance of subjects not participating in a training program.

CONCLUSIONS

This review suggests that (1) training on arthroscopic simulators improves performance on arthroscopic simulators and (2) performance on simulators for basic diagnostic arthroscopy correlates with experience level. Limited data suggest that simulator training can improve basic diagnostic arthroscopy skills in vivo.

LEVEL OF EVIDENCE

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