What skills should simulation training in arthroscopy teach residents?

Training surgical skills on hip arthroscopy by simulation: a survey on surgeon's perspectives

Purpose

The purpose of this study is to investigate the importance of general and specific surgical skills for hip arthroscopy from the perspective of surgeons in China. Concurrently, we intend to identify the preferred type of simulation that would facilitate competency of surgical trainees in performing arthroscopy and reinforce their preparation for carrying out the actual surgical procedure.

Methods

An online survey comprising 42 questions was developed by experts in hip arthroscopy and sent to 3 online communities whose members are arthroscopic surgeons in China. The responses collected were based on a 5-point Likert scale, with an open-ended comment section. Data were analyzed using one-way AVOVA and post hoc Tukey’s test.

Results

A total of 159 valid responses from 66 junior specialist surgeons, 68 consultant surgeons, and 25 senior consultant surgeons (from 130 institutions in 27 out of 34 provincial administrative districts in China) were collected. Cognitive ability was identified as the overall most important attribute for hip arthroscopic trainees to possess, while skills relevant to the treatment of femoroacetabular impingement (FAI) were considered as the most important specific skills by the surgeons surveyed. In addition, simulation using cadaveric specimens was considered the most favorable method for surgeons to practice their surgical skills.

Conclusion

In designing a training program for hip arthroscopy, it is essential to incorporate features that evaluate cognitive skills. It would be helpful for trainees to specifically practice skills that are often used in the treatment of some very common diseases of the hip joint, such as FAI. Using high-fidelity physical models for simulation to train skills of hip arthroscopy could be an ideal alternative and effective way to overcome problems arising from the lack of accessibility to cadaveric specimens.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11548-022-02708-x.

Resident Involvement in Posterior Lumbar Interbody Fusion is Associated With Increased Readmissions and Operative Time, But No Increased Short-term Risks

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim was to compare rates of adverse events and additional posterior lumbar interbody fusion (PLIF) cases assisted by residents versus cases performed solely by an orthopedic attending.

SUMMARY OF BACKGROUND DATA

PLIF is a widely accepted surgical technique for the management of a variety of spinal conditions requiring spinal stabilization and fusion. However, no published studies have assessed the effects of resident involvement on intraoperative and postoperative outcomes in PLIF.

METHODS

This retrospective study utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry from 2007 to 2012 to identify patients who underwent PLIF procedures. A propensity score matching model was utilized to reduce patient cohort variances. The perioperative data and outcomes in the matched population were analyzed using paired t test and the McNemar test in order to assess, based on resident presence, the rates of postoperative adverse events, readmission, reoperation within 30 days, and operative time.

RESULTS

In total, 1633 patients undergoing PLIF were included in the study, with 24.62% involving resident participation. The propensity score matching algorithm yielded 396 well-matched resident and nonresident pairs. Patients undergoing PLIF involving a resident were associated with a higher rate of readmission (1.77% vs. 0.00%; P=0.008), and longer operative time (245.7 vs. 197.7 min; P<0.001). However, these procedures were not associated with any significant difference in minor or severe adverse events.

CONCLUSIONS

Resident involvement in PLIF was associated with an increased rate of readmissions, and operative time; however, was not associated with an increase in minor or severe adverse events. Further investigation is needed to characterize the role of resident involvement based on level of training experience, as well as methods to improve the learning curve to independence while reducing postoperative hospital length of stay.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Validation of Simendo Knee Arthroscopy Virtual Reality Simulator

PURPOSE

To determine the face and construct validity as well as educational value and user-friendliness of the Simendo knee arthroscopy virtual reality simulator.

METHODS

Sixty participants were recruited and equally divided into novices (0 arthroscopic procedures), intermediates (1-59 arthroscopic procedures), and experts (60 or more arthroscopic procedures). Participants were excluded if they had previously trained with the studied simulator. Construct validity, that is, the ability to discriminate between different levels of expertise, was examined by a navigation task. All participants were asked to perform 5 navigation trials within 10 minutes. Face validity, educational value, and user-friendliness were examined by questionnaires before and after the navigation trials. Face validity is the subjective impression of how closely the simulation replicates the real environment.

RESULTS

The novices were significantly slower than the intermediates in the first (P < .001) and the third (P = .031) trial. The novices were significantly slower than the experts in all trials (P = .016), except for the fifth (P = .054). The experts were significantly faster than the intermediates in every trial except for the fourth (P = .069). Median task time for the fifth trial was 63 seconds (44-80 seconds) for novices, 58 seconds (46-80 seconds) for intermediates, and 41 seconds (33-55 seconds) for experts. Ninety-two percent of all participants agreed that the simulator can be used to train for surgical inspection, and 95% indicated sufficient user-friendliness.

CONCLUSIONS

Based on the results, this knee simulator can be applied to train the basic arthroscopic hand-eye coordination skills at the start of resident education programs. Further testing is necessary to determine whether the skills are retained.

CLINICAL RELEVANCE

The simulator is partly validated, which contributes to training of basic arthroscopic skills without compromising patient safety.

Development of a physical shoulder simulator for the training of basic arthroscopic skills

BACKGROUND

Orthopaedic training programs are incorporating arthroscopic simulations into their residency curricula. There is a need for a physical shoulder simulator that accommodates lateral decubitus and beach chair positions, has realistic anatomy, allows for an objective measure of performance and provides feedback to trainees.

METHODS

A physical shoulder simulator was developed for training basic arthroscopic skills. Sensors were embedded in the simulator to provide a means to assess performance. Subjects of varying skill level were invited to use the simulator and their performance was objectively assessed.

RESULTS

Novice subjects improved their performance after practice with the simulator. A survey completed by experts recognized the simulator as a valuable tool for training basic arthroscopic skills.

CONCLUSIONS

The physical shoulder simulator helps train novices in basic arthroscopic skills and provides objective measures of performance. By using the physical shoulder simulator, residents could improve their basic arthroscopic skills, resulting in improved patient safety.

How to Build Your Simple and Cost-effective Arthroscopic Skills Simulator

Acquisition of arthroscopic skills is not always easy and can be time-consuming. Simulation in arthroscopy improves surgical skills and can bridge the gap between reduced surgical exposure and training time and the need to reach a required level of competency. We propose a method to create a simple and cost-effective arthroscopic skills simulator using readily available materials and a low-cost Web camera available from online shops. This arthroscopic simulation device can be used to improve skills of all levels of trainees at home, in a bioskills laboratory, or in the theater. It can also be used by experienced surgeons to train with instruments and devices before using them for the first time in theaters, thus ensuring safe use and improving patient safety. Further validation as a training tool is needed and should be the focus of additional research, but early results are very promising.

Validation of the PASSPORT V2 training environment for arthroscopic skills

PURPOSE

Virtual reality simulators used in the education of orthopaedic residents often lack realistic haptic feedback. To solve this, the (Practice Arthroscopic Surgical Skills for Perfect Operative Real-life Treatment) PASSPORT simulator was developed, which was subjected to fundamental changes: improved realism and user interface. The purpose was to demonstrate its face and construct validity.

METHODS

Thirty-one participants were divided into three groups having different levels of arthroscopic experience. Participants answered questions regarding general information and the outer appearance of the simulator for face validity. Construct validity was assessed with one standardized navigation task, which was timed. Face validity, educational value and user-friendliness were determined with two representative exercises and by asking participants to fill out the questionnaire. A value of 7 or greater was considered sufficient.

RESULTS

Construct validity was demonstrated between experts and novices. Median task time for the fifth trial was 55 s (range 17-139 s) for the novices, 33 s (range 17-59 s) for the intermediates, and 26 s (range 14-52 s) for the experts. Median task times of three trials were not significantly different between the novices and intermediates, and none of the trials between intermediates and experts. Face validity, educational value and user-friendliness were perceived as sufficient (median >7). The presence of realistic tactile feedback was considered the biggest asset of the simulator.

CONCLUSION

Proper preparation for arthroscopic operations will increase the quality of real-life surgery and patients' safety. The PASSPORT simulator can assist in achieving this, as it showed construct and face validity, and its physical nature offered adequate haptic feedback during training. This indicates that PASSPORT has potential to evolve as a valuable training modality.

Arthroscopic Skills Acquisition Tools: An Online Simulator for Arthroscopy Training

PURPOSE

To evaluate correlations between objective performances measured by a new online arthroscopic skills acquisition tool (ASAT, in which "shape match" with inverted controls requires lifting shapes and releasing them into their corresponding silhouettes) and a validated virtual reality (VR) shoulder arthroscopy simulator (Insight Arthro VR; GMV, Madrid, Spain).

METHODS

Forty-nine medical students familiarized themselves with 5 ASATs. They were then assessed using a sixth ASAT (shape match with inverted controls) and 4 VR tasks (operating room, visualize, locate and palpate, and pendulum) on the VR simulator. Correlations were assessed between 11 ASAT measures and 15 VR measures using Pearson correlation coefficients.

RESULTS

Time taken and delta distance (actual distance minus minimum distance traveled) were the most frequent and correlated ASAT measures. Time taken correlated with the VR locate-and-palpate time (r = 0.596, P < .001), visualize time (r = 0.381, P = .007), and pendulum time (r = 0.646, P < .001), whereas delta distance correlated with the locate-and-palpate camera distance (r = 0.667, P < .001), instrument distance (r = 0.664, P < .001), visualize distance (r = 0.4, P = .004), pendulum camera distance (r = 0.538, P < .001), and instrument distance (r = 0.539, P < .001).

CONCLUSIONS

There were significant correlations between performance measures on the ASAT and a validated arthroscopic VR simulator.

CLINICAL RELEVANCE

Arthroscopic simulators are available but are limited by their high cost and availability. ASATs may overcome these limitations by using widely available Internet-based software and basic input devices.

Variation in joint stressing magnitudes during knee arthroscopy

PURPOSE

When performing knee arthroscopy, joint stressing is essential to increase the operative joint space. Adequate training of joint stressing is important, since high stressing forces can damage knee ligaments, and low stressing might not give sufficient operative space. As forces are difficult to transfer since they cannot be seen, simulators might be suited to train joint stressing as they can visualise the amount of applied stress. This requires the joint stressing thresholds to be validated. The purpose of this study was to measure the variation in the maximum joint stressing forces applied by various surgeons in vivo in a human population and based on that derive thresholds for safe stressing.

METHODS

From studies on ligament failure properties, we inferred a theoretical maximum stressing force of 78 N. Twenty-one patients were included, and knee arthroscopies were performed by five experienced surgeons. Forces solely performed in the varus and in valgus direction were measured. A load sensor was mounted on a belt, which was rotated along the hip to measure both varus and valgus stressing. The measurements started as soon as the interior of the knee joint was visualised using joint stressing.

RESULTS

The average maximum stressing force was 60 N (SD = 28 N). The mean first frame force was 47 N (SD = 34 N). No significant differences were found between varus and valgus stressing.

CONCLUSION

Since variation in stressing forces is high, offering training cases on simulators where the complete range of stressing forces can be experienced is recommended. Abiding to safety levels is essential to increase patient safety.

Cerebrovascular biomodeling for aneurysm surgery: simulation-based training by means of rapid prototyping technologies

OBJECTIVE

Opportunities for developing procedural skills are progressively rare. Therefore, sophisticated educational tools are highly warranted.

METHODS

This study compared stereolithography and 3-dimensional printing for simulating cerebral aneurysm surgery. The latter jets multiple materials simultaneously and thus has the ability to print assemblies of multiple materials with different features. The authors created the solid skull and the cerebral vessels in different materials to simulate the real aneurysm when clipped.

RESULTS

Precise plastic replicas of complex anatomical data provide intuitive tactile views that can be scrutinized from any perspective. Hollowed out vessel sections allow serial clipping efforts, evaluation of different clips, and clip positions. The models can be used for accurate prediction of vascular anatomy, for optimization of teaching surgical skills, for advanced procedural competency training, and for patient counseling.

CONCLUSION

Simultaneous 3-dimensional printing is the most promising rapid prototyping technique to produce biomodels that meet the high demands of neurovascular surgery.

First validation of the PASSPORT training environment for arthroscopic skills

The demand for high quality care is in contrast to reduced training time for residents to develop arthroscopic skills. Thereto, simulators are introduced to train skills away from the operating room. In our clinic, a physical simulation environment to Practice Arthroscopic Surgical Skills for Perfect Operative Real-life Treatment (PASSPORT) is being developed. The PASSPORT concept consists of maintaining the normal arthroscopic equipment, replacing the human knee joint by a phantom, and integrating registration devices to provide performance feedback. The first prototype of the knee phantom allows inspection, treatment of menisci, irrigation, and limb stressing. PASSPORT was evaluated for face and construct validity. Construct validity was assessed by measuring the performance of two groups with different levels of arthroscopic experience (20 surgeons and 8 residents). Participants performed a navigation task five times on PASSPORT. Task times were recorded. Face validity was assessed by completion of a short questionnaire on the participants' impressions and comments for improvements. Construct validity was demonstrated as the surgeons (median task time 19.7 s [8.0-37.6]) were more efficient than the residents (55.2 s [27.9-96.6]) in task completion for each repetition (Mann-Whitney U test, P < 0.05). The prototype of the knee phantom sufficiently imitated limb outer appearance (79%), portal resistance (82%), and arthroscopic view (81%). Improvements are required for the stressing device and the material of cruciate ligaments. Our physical simulation environment (PASSPORT) demonstrates its potential to evolve as a training modality. In future, automated performance feedback is aimed for.