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

Learning and Short-Term Retention of Simulation-Based Arthroscopic Skills

OBJECTIVE

The study aimed to examine the learning curve and short-term retention of arthroscopic skills acquired on a simulator.

DESIGN

Cohort study.

SETTING

Clinical Skills Training Center of Zhujiang Hospital of Southern Medical University PARTICIPANT AND METHODS: Orthopaedic residents (n = 14) without previous arthroscopy experience were included. After basic information was collected and an initial arthroscopy knowledge level test was administered, the subjects received standardised training on the simulator (day 1); then, they completed tasks on the simulator, including guided diagnostics (4 times), triangulation (5 times) and loose body removal (7 times). A learning curve for each skill was generated based on the total scores. The score of the last repetition of each task was the training level.

RESULTS

A total of 14 orthopedic residents were enrolled. All participants completed the training and testing. There was a learning curve over the course of training for all 3 arthroscopic skills (p < 0.001). On day 8 after the training, the mean score for guided diagnostics decreased from 49.9 to 48.9 (p = 0.001), and the retention rate was 97.8%. For triangulation, the mean total score decreased from 58.9 to 53.6 (p < 0.001), and the retention rate was 90.8%. For loose body removal, the mean total score decreased from 87.1 to 80.7 (p < 0.001), and the retention rate was 92.7%.

CONCLUSIONS

Orthopaedic residents' arthroscopic skills learned through simulator training declined significantly in 1 week after the training, especially more difficult skills.

Virtual versus jaw simulation in inlay preparation preclinical teaching: a randomised controlled trial

BACKGROUND

To investigate the effect of virtual simulation systems on the teaching of inlay experiments and to guide the experimental teaching of tooth preparation.

METHODS

Participants in their second semester of the junior year were selected to carry out the unified teaching and evaluation of dental preparation theory. The age varied from 18 to 22 years (19.96 ± 0.70) and the participants were randomly divided into four groups (n = 19) with a similar male-to-female ratio following CONSORT guidelines, including a jaw simulation model training group (Group J), a virtual simulation system training group (Group V), a jaw model training first followed by a virtual system training group (Group J-V), and a virtual system followed by a jaw model training group (Group V-J). The inlay tooth preparation assessment was performed on the extracted teeth. The data were analysed according to the assessment scores by a senior clinician. The subjective feelings of the students towards the system were evaluated using questionnaires.

RESULTS

The second theoretical scores of Group V-J (63.5 ± 2.89) and Group J-V (60.5 ± 3.25) were higher than those of Group V (57.5 ± 3.13) and Group J (58.0 ± 3.67). The experimental scores of Groups J-V and V-J (62.79 ± 2.84; 64.00 ± 2.85) were higher than those of Groups V and J (56.05 ± 3.39; 55.74 ± 2.53). The questionnaire survey illustrated that most students preferred the digital virtual simulation system (perfect assessment: 91.3%, accuracy: 82.6%, satisfaction: 52.2%).

CONCLUSION

Virtual simulation training can facilitate the teaching effect of tooth preparation in inlay experiments, and the teaching mode of Group V-J was the best. Therefore, this teaching mode is to be popularised.

Procedural simulation training in orthopaedics and traumatology: Nationwide survey among surgeon educators and residents in France

BACKGROUND

Simulation is among the tools used in France to train residents specialising in orthopaedic and trauma surgery (OTS). However, implementing simulation-based training (SBT) is complex and poorly reported. The objective of this study was to describe the use of simulation for OTS training in France.

HYPOTHESIS

Nationwide, SBT is not used to its full capacity for teaching OTS in France, and differences in opinions about SBT may exist between surgeon educators and residents.

STUDY DESIGN

Nationwide questionnaire survey in France.

MATERIALS AND METHODS

We built two specific self-questionnaires then e-mailed them between December 2020 and February 2021 to the surgeon educators who were members of the national university council and to the residents specialising in OTS during the current academic year. The questions were about the 2018-2019 academic year, before the COVID-19 pandemic. Two classes of residents who were still medical students during this period were not included, leaving three classes for the analysis.

RESULTS

The participation rates were 57% (67/117) for the educators and 24% (87/369) for the three classes of residents. Of the 67 educators, 47 (70%) reported being involved in SBT and identified the university (70%) and industry (53%) as the main funders of this teaching modality. The educators indicated that the mean number of SBT laboratories in their region was 1.4±0.9 (range, 0-4). The main types of simulators were saw bones (77%); cadavers (85%); and commercial simulators (74%), notably for the knee (87%) and shoulder (78%). The educators estimated that they had achieved a mean of 33%±23% (range, 0%-100%) of the teaching objectives set out in the OTS curriculum and that the main obstacles were insufficient funding (81%) and lack of time (67%). Only 21% of educators reported conducting SBT research. The residents reported that they accessed SBT via the OTS teaching module (28/87, 32%), local university degrees (23/87, 26%), their hospital department (17/87, 18%), or the industry (15/87, 17%); 25/87 (29%) had never received SBT. On a 0-10 scale (0, completely disagrees; 10, completely agrees), the mean score for SBT effectiveness was 8.6±2.1 for residents and 7.1±3.0 for educators (p<0.001); the corresponding values for the quality of SBT integration in the region were 1.5±1.8 and 3.8±2.6, respectively (p<0.001).

CONCLUSION

SBT is not yet used to its full potential for teaching OTS in France. Insufficient funding and lack of time were identified by the educators as the main obstacles to greater use of SBT. Both the residents and the educators felt that SBT mightbe beneficial for training.

LEVEL OF EVIDENCE

IV, nationwide survey.

Arthroscopic anatomy of the posterolateral corner of the knee: anatomic relations and arthroscopic approaches

INTRODUCTION

Although open-surgical techniques for the reconstruction of the posterolateral corner (PLC) are well established, the use of arthroscopic procedures has recently increased. When compared with open surgical preparation, arthroscopic orientation in the PLC is challenging and anatomic relations may not be familiar. Nevertheless, a profound knowledge of anatomic key structures and possible structures at risk as well as technical variations of arthroscopic approaches are mandatory to allow a precise and safe surgical intervention.

MATERIALS AND METHODS

In a cadaveric video demonstration, an anterolateral (AL), anteromedial (AM), posteromedial (PM) and posterolateral (PL) portal, as well as a transseptal approach (TSA) were developed. Key structures of the PLC were defined and sequentially exposed during posterolateral arthroscopy. Finally, anatomic relations of all key structures were demonstrated.

RESULTS

All key structures of the PLC can be visualized during arthroscopy. Thereby, careful portal placement is crucial in order to allow an effective exposure. Two alternatives of the TSA were described, depending on the region of interest. The peroneal nerve can be visualized dorsal to the biceps femoris tendon (BT), lateral to the soleus muscle (SM) and about 3 cm distal to the fibular styloid (FS). The distal attachment of the fibular collateral ligament (FCL) can be exposed on the lateral side of the fibular head (FH). The fibular attachment of the popliteofibular ligament (PFL) is exposed at the tip of the FS.

CONCLUSION

Arthroscopy of the posterolateral recessus allows full visualization of all key structures of the posterolateral corner, which provides the basis for anatomic and safe drill channel placement in PLC reconstruction. A sufficient exposure of relevant anatomic landmarks and precise portal preparation reduce the risk of iatrogenic vascular and peroneal nerve injury.

A Prospective Assessment of Knee Arthroscopy Skills Between Medical Students and Residents-Simulator Exercises for Partial Meniscectomy and Analysis of Learning Curves

Background

The Covid-19 pandemic has created the largest disruption of education in history. In a response to this, we aimed to evaluate the knee arthroscopy learning curve among medical students and orthopaedic residents.

Methods

An arthroscopy simulator was used to compare the learning curves of two groups. Medical students with any prior knowledge of arthroscopy (n=24) were compared to a residents group (n=16). Analyzed parameters were “time to complete a task,” assessment of the movement of tools and values scoring damage to the surrounding tissues.

Results

After several repetitions, both groups improved their skills in terms of time and movement. Residents were on average faster, had less camera movement, and touched the cartilage tissue less often than did students. Students showed a steeper improvement curve than residents for certain parameters, as they started from a different experience level.

Conclusion

The participants were able to reduce the time to complete a task. There was also a decrease in possible damage to the virtual surrounding tissues. In general, the residents had better mean values, but the students had the steeper learning curve. Particularly less experienced surgeons can especially train their hand–eye coordination skills required for arthroscopy surgery. Training simulators are an important training tool that supplements cadaveric training and participation in arthroscopic operations and should be included in training.

Module-Based Arthroscopic Knee Simulator Training Improves Technical Skills in Naive Learners: A Randomized Trial

Purpose

To compare the effectiveness, in comparison to a control group (C), of module-based training (MBT) and traditional learning (TL) as a means of acquiring arthroscopic skills on an arthroscopic surgery simulator.

Methods

Thirty health sciences students with no previous arthroscopy experience were recruited and randomized into 1 of 3 groups: MBT, TL, or C (1:1:1 ratio). Participants in MBT were required to independently practice on a VirtaMed ArthroS simulator (VirtaMed AG, Zurich, Switzerland) for a minimum of 2 hours per week, whereas TL received one-on-one coaching by a senior orthopaedic resident for 15 minutes per week. The control group received no training. All groups were assessed at baseline and at 4 weeks based on objective measures generated by the surgical simulator (procedure time, camera path length, meniscus cutting score, detailed visualization, safety score and total score), and subjective ratings scales (Objective Assessment of Arthroscopic Skill [OAAS] global assessment form, and Competency-Based Assessment form).

Results

Participants in the MBT group trained on average 113 min/week whereas the TL group trained on average 24 min/week. Three-way repeated-measures analysis of variance showed significant group by time interactions for procedure time (P = .006), camera path length (P = .008), safety score (P = .013), total score (P = .003), OAAS form (P < .001), and Competency-Based Assessment form (P < .001). MBT group was superior to C group for procedure time (P = .02), camera path length (P = .003), total score (P = .004), and OAAS form (P = .021), but there were no significant post-hoc differences between MBT and TL groups, or TL and C groups after Bonferroni correction. Total practice time explained 37.5% of the final simulator total score variance.

Conclusions

Knee arthroscopy simulation training with self-learning modules can improve skills in areas such as procedure time, camera path length, and total score in untrained participants compared with a control group.

Clinical Relevance

Module-based simulation training provides additional training time and improves technical skills in naive health science students. It is hoped that this effect can be preserved and applied to junior resident developing in a busy residency program.

Arthroscopic Simulation: The Future of Surgical Training: A Systematic Review

BACKGROUND

Arthroscopic simulation has rapidly evolved recently with the introduction of higher-fidelity simulation models, such as virtual reality simulators, which provide trainees an environment to practice skills without causing undue harm to patients. Simulation training also offers a uniform approach to learn surgical skills with immediate feedback. The aim of this article is to review the recent research investigating the use of arthroscopy simulators in training and the teaching of surgical skills.

METHODS

A systematic review of the Embase, MEDLINE, and Cochrane Library databases for English-language articles published before December 2019 was conducted. The search terms included arthroscopy or arthroscopic in combination with simulation or simulator.

RESULTS

We identified a total of 44 relevant studies involving benchtop or virtually simulated ankle, knee, shoulder, and hip arthroscopy environments. The majority of these studies demonstrated construct and transfer validity; considerably fewer studies demonstrated content and face validity.

CONCLUSIONS

Our review indicates that there is a considerable evidence base regarding the use of arthroscopy simulators for training purposes. Further work should focus on the development of a more uniform simulator training course that can be compared with current intraoperative training in large-scale trials with long-term follow-up at tertiary centers.

Virtual Reality and Physical Models in Undergraduate Orthopaedic Education: A Modified Randomised Crossover Trial

Background

Orthopaedic surgery is underrepresented in the United Kingdom medical school curriculum, with an average of less than 3 weeks of exposure over the five-year degree. This study evaluates the effectiveness of high-fidelity virtual reality (VR) and physical model simulation in teaching undergraduate orthopaedic concepts.

Methods

A modified randomised crossover trial was used. Forty-nine students were randomly allocated to two groups, with thirty-three finishing the six-week follow-up assessment. All undergraduate medical students were eligible for inclusion. Both groups were given introductory lectures, before completing a pre-test with questions on the principles of fracture fixation and osteotomy. Each group then received a lecture on these topics with the same content, but one was delivered with VR and the other with physical models. Both groups completed the post-course assessments. Knowledge was assessed by way of questionnaire immediately before, immediately after, and six-weeks after.

Results

In the VR group, participants improved their post-training score by 192.1% (U=32; p<0.00001). In the physical models group, participants improved their post-training scores by 163.1% (U=8.5; p<0.00001). Overall, there was no statistically significant difference in the total means of post-training test scores between the VR and the physical models study groups (U=260.5; p=0.4354).

Conclusion

Both VR and physical models represent valuable educational adjuncts for the undergraduate medical curriculum. Both have demonstrated improvements in immediate and long-term knowledge retention of key orthopaedic concepts.

Teaching hip surgery to orthopaedic residents: what's new?

PURPOSE

The purpose of this study is to provide an overview of the published literature on the existing educational methods used to teach surgical skills, with a specific focus on hip surgery, to orthopaedic residents.

METHODS

A total of 31 articles were selected from a PubMed literature search on the topic of teaching surgical skills to orthopaedic residents, and 9 articles on hip surgery are included in this review.

RESULTS

Although several methods are included in the published literature to teach orthopaedic residents, only arthroscopy of the knee and shoulder joint is well described. Hip arthroscopy has a steeper learning curve and thus the use of simulation training as a complementary teaching method is even more important.

CONCLUSIONS

Currently, open surgery skills for joint arthroplasty are largely acquired by apprenticeship learning. Simulation training in the form of virtual reality could contribute to better performance of residents, decreasing operation time and improving patient safety.

A review of computer-assisted orthopaedic surgery systems

BACKGROUND

Computer-assisted orthopaedic surgery systems have great potential, but no review has focused on computer-assisted surgery systems for the spine, hip, and knee.

METHODS

A systematic search was performed in Web of Science and PubMed. We searched the literature on computer-assisted orthopaedic surgery systems from 2008 to the present and focused on three aspects of systems: training, planning, and intraoperative navigation.

RESULTS AND DISCUSSION

In this review study, we reviewed 34 surgical training systems, 31 surgical planning systems, and 41 surgical navigation systems. The functions and characteristics of the surgical systems were compared and analysed, and the current concerns about and the impact of the surgical systems on doctors and surgery were clarified.

CONCLUSION

Computer-assisted orthopaedic surgery systems are still in the development stage. Future surgical training systems should include synthetic models with patient anatomy. Surgical planning systems with automatic planning should be developed, and surgical navigation systems with multimodal fusion, robotic assistance and imaging should be developed.

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.

Lessons taught by a knee arthroscopy simulator about participants in a European arthroscopy training programme

BACKGROUND

Arthroscopy simulators offer safe and reproducible training to orthopaedic residents, thereby obviating the need for cadaver specimens. In addition, they collect data that can serve to investigate learning curves and evaluate training programmes with the goal of improving the quality of arthroscopy teaching. In this study, a cohort of surgeons was evaluated before and after a European theoretical and practical training programme that used a knee arthroscopy simulator. The primary objective was to assess whether the overall performance score was improved by the training programme. The secondary objectives were to determine which tasks and skills were improved by the programme, to compare a novice group to an experienced group, and to identify targets for improvement.

HYPOTHESIS

A theoretical and practical training course improves the scores achieved on an arthroscopy simulator task.

METHODS

A prospective comparative study was performed in 34 surgeons during the advanced arthroscopy training course organised by the European Paediatric Orthopaedic Society (EPOS) in January 2018. All participants performed a diagnostic task on the VirtaMed ArthroS™ simulator before and after the programme. The participants were divided into two groups based on number of knee arthroscopies performed each year, i.e.,>20 (experienced group) vs.≤20 (inexperienced group). The following parameters were compared between the two groups: overall score, operative time, percentage of iatrogenic injuries, camera and hook path lengths, and success in identifying anatomical structures.

RESULTS

The overall score on the diagnostic task was 199 before and 203 after the training programme (p=0.02). The operative time decreased significantly, from 185 to 115.9seconds (p<0.01). Camera path length decreased from 85.2 to 49.2cm and hook path length from 65.5 to 15.0cm (p<0.05). The mean proportion of arthroscopies with iatrogenic tibial cartilage injuries diminished from 2.7%±1.7% (range, 0-6.7) to 1.8%±1.8% (range, 0-7) (p=0.03); no change occurred in femoral injuries. When each group was assessed separately, the only significant change found in the experienced group was a decrease in operative time, whereas in the inexperienced group all parameters improved significantly. However, visualisation of anatomical structures was unchanged.

CONCLUSION

Participation in the training programme improved overall performance, and the gains were greatest in the inexperienced group. During the post-training evaluation, some of the major anatomical structures were classified by the simulator as incompletely visualised, raising concern about a risk of underdiagnosis during arthroscopic explorations.

LEVEL OF EVIDENCE

III, prospective comparative study.