Can Surgical Trainees Achieve Arthroscopic Competence at the End of Training Programs? A Cross-sectional Study Highlighting the Impact of Working Time Directives

Virtual and Augmented Reality Simulators Show Intraoperative, Surgical Training, and Athletic Training Applications: A Scoping Review

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

CLINICAL RELEVANCE

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.

Resident Perceptions of Virtual Reality Versus Dry Lab Simulation for Advanced Shoulder Arthroscopy Resident Training

INTRODUCTION

Surgical training using simulation can fill gaps in traditional surgical residency learning. We hypothesize that arthroscopy training conducted on a virtual reality simulator will be preferred by orthopaedic surgery residents over a traditional dry lab simulation model.

METHODS

38 orthopaedic surgery residents at a single U.S. residency program were randomized to train for a shoulder arthroscopy procedure using either a virtual reality simulator or a table-top dry lab simulator. Training and learning preferences were then asked of the resident participants.

RESULTS

Junior residents were likely to report training preference for the virtual reality simulator compared to senior residents [15/24 (62.5%) v. 8/14 (57.1%); P = .043]. Simulator preference was not influenced by subspecialty interest, prior arthroscopy experience, or simulator experience. Virtual reality simulation was associated with positive attitude towards arthroscopy and high chance of reporting learning gains on general arthroscopic understanding. Senior residents were 4.7 times more likely than juniors to report learning gains via staff discussion pre- and post-operatively. A majority of residents [34/38 (89.5%)] reported, however, wanting more simulation for training surgical skills.

CONCLUSION

Simulation is a desired and potentially valuable adjunct to training orthopaedic residents in arthroscopy. Training needs do evolve; and junior arthroscopists may benefit more from virtual reality platforms for general skills. Senior residents preferred dry lab simulation, possibly because it allowed for handling of actual instruments and implants.

Resident Involvement in Shoulder-Stabilization Procedures Is Not Associated With an Increased Risk of 30-Day Postoperative Complications

Purpose

To examine the 30-day postoperative outcomes of resident involvement in shoulder-stabilization surgical procedures using the American College of Surgeons National Surgical Quality Improvement database.

Methods

We conducted a retrospective review of the National Surgical Quality Improvement database for all shoulder-stabilization procedures from 2010 to 2018. Procedures included arthroscopic Bankart, arthroscopic Bankart with SLAP repair, arthroscopic Bankart with Remplissage, open Bankart, anterior bone block, posterior bone block, Latarjet coracoid process transfer, and capsular shift/capsulorrhaphy for multidirectional instability. Data included preoperative demographics, comorbidities, and 30-day postoperative outcomes. Cases were categorized into 2 groups: "attending alone" and "attending and resident." Statistical analysis comparing groups on demographics and comorbidities included independent t-test for continuous variables and Pearson χ2 or Fischer exact for categorical variables. A logistic regression model including propensity score was used to calculate adjusted odds ratio for outcomes.

Results

A total of 3,954 patients undergoing shoulder-stabilization procedures were included in the study and 28.8% of patients had a resident involved in their procedure. Residents were more likely to be involved in procedure for patients who were of minority ethnicity (P < .001), a lower body mass index (P < .001) and less likely to have a history of chronic obstructive pulmonary disease (P = .029). Resident involvement resulted in statistically significant longer total operation time (91 vs 85 minutes, P < .001). In terms of postsurgical outcomes, complication rates were low for both groups (∼0.8%). Resident involvement was not associated with any significant increase in 30-day postsurgical complications.

Conclusions

Our results show that resident involvement in shoulder-stabilization surgery is associated with a significant increase in operative time without any significant increase in 30-day postsurgical complications.

Level of Evidence

Level III, retrospective comparative study.

Low-Fidelity Arthroscopic Simulation Training in Trauma and Orthopaedic Surgery: A Systematic Review of Experimental Studies

PURPOSE

To identify and appraise evidence assessing the effectiveness of low-fidelity arthroscopic simulation in the acquisition of arthroscopic surgical skills in a novice population.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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 OF EVIDENCE

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

Purpose

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.

Methods

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.

Results

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).

Conclusions

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.

Clinical Relevance

Understanding the effects of fellowship training may guide mentors and future trainees.

The Efficacy of Arthroscopic Simulation Training on Clinical Ability: A Systematic Review

PURPOSE

To examine the effect of arthroscopic simulator training on technical performance in a human model.

METHODS

A systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Literature searches of PubMed, Embase, and Cochrane Library were conducted using combinations of the terms virtual, digital, computer, reality, simulation, arthroscopy, training, learning, and education. Studies were considered for inclusion if they tested the effect of arthroscopic simulator training in a randomized controlled fashion, performed testing in a cadaver or live patient, and used explicit outcome measures of technical skill. Data from studies were extracted and study characteristics and outcomes were reviewed. The primary outcome measure was the number of studies in which the simulation trained group had significantly improved performance results relative to the control group in ≥50% of all measured outcomes. Risk of bias was assessed with Cochrane's Collaboration Tool.

RESULTS

Twelve studies, including 340 total study participants, were included for review. Eight studies showed improved performance of the simulation trained group relative to the control group in ≥50% of assessed outcomes. Six of ten studies reporting completion time, three of six studies reporting task checklist completion, 3 of 7 studies reporting global rating scales, and 1 of 4 studies reporting Arthroscopic Surgical Skill Evaluation Tool scores showed improved performance of the simulation group relative to the control group for the respective outcome measures.

CONCLUSIONS

The literature is limited due to heterogeneity, both in type and merit, of the outcome measures that have been used to assess the transfer validity of arthroscopic simulator training to clinical performance. Despite the limitations of the literature, this review demonstrates that arthroscopic simulator training has potential to improve clinical performance.

LEVEL OF EVIDENCE

II, systematic review of Level II studies.

The Effect of Triangulation Simulator Training on Arthroscopy Skills: A Prospective Randomized Controlled Trial

Purpose

To prospectively evaluate the transferability of skills acquired on a low-cost, at-home, nonanatomic triangulation simulation system to cadaveric models.

Methods

We randomized 28 medical students into either a simulator-training group (n = 14) or group with no training (control, n = 14). All subjects were pretested using a standardized checklist of arthroscopic skills on cadaveric knees and shoulders. Training-group subjects practiced on the triangulation simulator for 90 minutes per week for 4 consecutive weeks. Control subjects received no training. All subjects completed a post-test checklist of arthroscopic skills on cadaveric knees and shoulders, as well as 4 training tasks on the simulator. A blinded orthopaedic surgeon evaluated the arthroscopic videos using the Arthroscopic Surgical Skill Evaluation Tool (ASSET) score.

Results

Training-group knee and shoulder ASSET scores increased from 12.2 ± 1.85 to 14.6 ± 2.76 (P = .02) and from 14.6 ± 3.5 to 17.9 ± 4.5 (P = .29), respectively. In the control group, knee and shoulder ASSET scores increased from 14.3 ± 3.12 to 14.25 ± 4.67 (P = .99) and from 14.2 ± 2.7 to 17.07 ± 6.7 (P = .58), respectively. There were no significant differences in the mean post-test ASSET scores between the training group and control group for either knee or shoulder arthroscopy. The post-test ASSET safety subscore during knee arthroscopy was significantly higher in the training group (P = .03). The training group was able to complete significantly more simulator tasks compared with controls (P = .003) at post-testing. A significant positive correlation was found between knee arthroscopy performance and the number of tasks completed during simulation post-testing (P = .043). There was no significant correlation between shoulder arthroscopy performance and simulation performance (P = .532).

Conclusions

Basic triangulation skills may be acquired by training on a low-cost, at-home, nonanatomic triangulation simulation system, although the degree of transferability and universal joint applicability, as well as the existence of an early ceiling effect in skill development, could not be shown.

Level of Evidence

Level II, randomized controlled trial.

Global Rating Scales for the Assessment of Arthroscopic Surgical Skills: A Systematic Review

PURPOSE

To evaluate whether sufficient validity and reliability evidence exists to support the use of global rating scales (GRS) as evaluation tools in both formative assessment and competency assessment of arthroscopic procedures.

METHODS

A search of PubMed, Embase, and Scopus was conducted for articles published between 1990 and 2018. Studies reporting measures of validity and reliability of GRS relating to arthroscopic skills were included. Procedural checklists and other assessment tools were excluded.

RESULTS

A total of 39 articles met the inclusion criteria. In total, 7 de novo GRS specific for arthroscopic education and 3 pre-existing GRS repurposed 4 times for arthroscopic education were identified in the literature. The 11 GRS were used to assess 1175 surgeons 3890 times. Three GRS tools explicitly defined an arbitrary minimum competency threshold, 6 of 11 tools demonstrated construct validity-the ability to significantly discriminate between groups of differing experience-and 5 of 11 tools assessed inter-rater reliability, but only the Arthroscopic Surgical Skills Evaluation Tool demonstrated excellent inter-rater reliability. The Arthroscopic Surgical Skills Evaluation Tool was validated by 16 articles for a total of 537 surgeons for hip, knee, shoulder, and ankle arthroscopy in both simulated and clinical environments but was found to be invalid in wrist arthroscopy. The Basic Arthroscopic Knee Skill Scoring System was validated by 15 articles for a total of 497 surgeons for knee, hip, and shoulder in both clinical and simulated environments. The remaining 9 GRS were validated by 2 or fewer studies.

CONCLUSIONS

Overall, GRS have contributed to training, feedback, and formative assessment practices. The GRS reviewed demonstrate both construct and concurrent validity as well as reliability in multiple arthroscopic procedures in multiple joints. Currently, there is sufficient evidence to use GRS as a feedback tool. However, there is insufficient evidence for its use in high-stakes examinations or as a minimum competency assessment.

LEVEL OF EVIDENCE

Level III, systematic review of level I to III studies.

Editorial Commentary: The Arthroscopist's Baton-Can Minimizing Motion Lead to Better Outcomes?

Unlike an orchestra conductor, whose fundamental goal is to bring a written score to life through exaggerated arm and body motion, the arthroscopist's goal is to enhance his or her surgical procedure by minimizing wasteful motion. So, the next time you are in the operating room observing or assisting with an arthroscopic procedure, do not just watch the monitor. Look at the surgeon's arm motion and see if you can distinguish between the maestro and the novice!

Efficacy of a Virtual Arthroscopic Simulator for Orthopaedic Surgery Residents by Year in Training

BACKGROUND

Virtual reality arthroscopic simulators are an attractive option for resident training and are increasingly used across training programs. However, no study has analyzed the utility of simulators for trainees based on their level of training/postgraduate year (PGY).

PURPOSE/HYPOTHESIS

The primary aim of this study was to determine the utility of the ArthroS arthroscopic simulator for orthopaedic trainees based on their level of training. We hypothesized that residents at all levels would show similar improvements in performance after completion of the training modules.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Eighteen orthopaedic surgery residents performed diagnostic knee and shoulder tasks on the ArthroS simulator. Participants completed a series of training modules and then repeated the diagnostic tasks. Correlation coefficients (r 2) were calculated for improvements in the mean composite score (based on the Imperial Global Arthroscopy Rating Scale [IGARS]) as a function of PGY.

RESULTS

The mean improvement in the composite score for participants as a whole was 11.2 ± 10.0 points (P = .0003) for the knee simulator and 14.9 ± 10.9 points (P = .0352) for the shoulder simulator. When broken down by PGY, all groups showed improvement, with greater improvements seen for junior-level residents in the knee simulator and greater improvements seen for senior-level residents in the shoulder simulator. Analysis of variance for the score improvement variable among the different PGY groups yielded an f value of 1.640 (P = .2258) for the knee simulator data and an f value of 0.2292 (P = .917) for the shoulder simulator data. The correlation coefficient (r 2) was -0.866 for the knee score improvement and 0.887 for the shoulder score improvement.

CONCLUSION

Residents training on a virtual arthroscopic simulator made significant improvements in both knee and shoulder arthroscopic surgery skills.

CLINICAL RELEVANCE

The current study adds to mounting evidence supporting virtual arthroscopic simulator-based training for orthopaedic residents. Most significantly, this study also provides a baseline for evidence-based targeted use of arthroscopic simulators based on resident training level.