Objectively Assessing Intraoperative Arthroscopic Skills Performance and the Transfer of Simulation Training in Knee Arthroscopy: A Randomized Controlled Trial.

PURPOSE: To objectively investigate the transfer validity of simulation training using wireless elbow-worn motion sensors intraoperatively to assess whether surgical simulation leads to improvements in intraoperative arthroscopic performance. METHODS: In this randomized controlled trial, postgraduate year 2 to 3 trainees in nationally approved orthopaedic surgery posts were randomized to standard junior residency training (control group) or standard training plus additional weekly simulation training (intervention group). Both groups performed a supervised real-life diagnostic knee arthroscopy in the operating room at 13 weeks. Performance was measured using wireless elbow-worn motion sensors recording objective surgical performance metrics: number of hand movements, smoothness, and time taken. A participant-supervisor performance ratio was used to adjust for variation in case mix and difficulty. The study took place in a surgical simulation suite and the orthopaedic operating rooms of a university teaching hospital. RESULTS: The intervention group objectively outperformed the control group in all outcome metrics. Procedures performed by the intervention group required fewer hand movements (544 [interquartile range (IQR), 465-593] vs 893 [IQR, 747-1,242]; P < .001), had smoother movements (25,842 ms-3 [IQR, 20,867-27,468 ms-3] vs 36,846 ms-3 [IQR, 29,840-53,949 ms-3]; P < .001), and took less time (320 seconds [IQR, 294-392 seconds] vs 573 seconds [IQR, 477-860 seconds]; P < .001) than those performed by the control group. The cases were comparable between the groups. Standardized to the supervisor's performance, the intervention group required fewer hand movements (1.9 [IQR, 1.5-2.1] vs 3.3 [IQR, 2.2-4.8]; P = .0091), required less time (1.2 [IQR, 1.1-1.7] vs 2.6 [IQR, 1.6-3.0]; P = .0037), and were smoother (2.1 [IQR, 1.8-2.8] vs 4.3 [IQR, 2.8-5.4]; P = .0037) than the control group, but they did not perform as well as their supervisors. CONCLUSIONS: This study uses intraoperative motion-analysis technology to objectively show that surgical simulation training improves actual intraoperative technical skills performance. CLINICAL RELEVANCE: The described wireless objective assessment method complements the subjective observational performance assessments commonly used. Further studies are required to assess how these measures of intraoperative performance correlate to patient outcomes. Intraoperative motion analysis is translatable across surgical specialties, offering potential for objective assessment of progression through competency-based training, revalidation, and talent selection for specialist training.

Simulation-Based Training Platforms for Arthroscopy: A Randomized Comparison of Virtual Reality Learning to Benchtop Learning.

PURPOSE: To determine whether a virtual reality (VR) arthroscopy simulator or benchtop (BT) arthroscopy simulator showed superiority as a training tool. METHODS: Arthroscopic novices were randomized to a training program on a BT or a VR knee arthroscopy simulator. The VR simulator provided user performance feedback. Individuals performed a diagnostic arthroscopy on both simulators before and after the training program. Performance was assessed using wireless objective motion analysis and a global rating scale. RESULTS: The groups (8 in the VR group, 9 in the BT group) were well matched at baseline across all parameters (P > .05). Training on each simulator resulted in significant performance improvements across all parameters (P < .05). BT training conferred a significant improvement in all parameters when trainees were reassessed on the VR simulator (P < .05). In contrast, VR training did not confer improvement in performance when trainees were reassessed on the BT simulator (P > .05). BT-trained subjects outperformed VR-trained subjects in all parameters during final assessments on the BT simulator (P < .05). There was no difference in objective performance between VR-trained and BT-trained subjects on final VR simulator wireless objective motion analysis assessment (P > .05). CONCLUSIONS: Both simulators delivered improvements in arthroscopic skills. BT training led to skills that readily transferred to the VR simulator. Skills acquired after VR training did not transfer as readily to the BT simulator. Despite trainees receiving automated metric feedback from the VR simulator, the results suggest a greater gain in psychomotor skills for BT training. Further work is required to determine if this finding persists in the operating room. CLINICAL RELEVANCE: This study suggests that there are differences in skills acquired on different simulators and skills learnt on some simulators may be more transferable. Further work in identifying user feedback metrics that enhance learning is also required.

Validation of the updated ArthroS simulator: face and construct validity of a passive haptic virtual reality simulator with novel performance metrics.

PURPOSE: To assess the construct and face validity of ArthroS, a passive haptic VR simulator. A secondary aim was to evaluate the novel performance metrics produced by this simulator. METHODS: Two groups of 30 participants, each divided into novice, intermediate or expert based on arthroscopic experience, completed three separate tasks on either the knee or shoulder module of the simulator. Performance was recorded using 12 automatically generated performance metrics and video footage of the arthroscopic procedures. The videos were blindly assessed using a validated global rating scale (GRS). Participants completed a survey about the simulator's realism and training utility. RESULTS: This new simulator demonstrated construct validity of its tasks when evaluated against a GRS (p ≤ 0.003 in all cases). Regarding it's automatically generated performance metrics, established outputs such as time taken (p ≤ 0.001) and instrument path length (p ≤ 0.007) also demonstrated good construct validity. However, two-thirds of the proposed 'novel metrics' the simulator reports could not distinguish participants based on arthroscopic experience. Face validity assessment rated the simulator as a realistic and useful tool for trainees, but the passive haptic feedback (a key feature of this simulator) is rated as less realistic. CONCLUSION: The ArthroS simulator has good task construct validity based on established objective outputs, but some of the novel performance metrics could not distinguish between surgical experience. The passive haptic feedback of the simulator also needs improvement. If simulators could offer automated and validated performance feedback, this would facilitate improvements in the delivery of training by allowing trainees to practise and self-assess.

The John Charnley Award: Highly crosslinked polyethylene in total hip arthroplasty decreases long-term wear: a double-blind randomized trial.

BACKGROUND: The use of highly crosslinked polyethylene (HXLPE) is now commonplace for total hip arthroplasty. Hip simulator studies and short-term in vivo measurements suggest that the wear rate of some types of HXLPE is significantly less than conventional ultrahigh-molecular-weight polyethylene (UHMWPE). However, there are few long-term data to support its use. QUESTIONS/PURPOSES: The aim of this study was to measure the long-term steady-state wear of HXLPE compared with UHMWPE liners in a prospective, double-blind, randomized controlled trial using radiostereometric analysis. METHODS: Fifty-four patients were randomized to receive hip arthroplasties with either UHMWPE liners or HXLPE liners. Complete followup was available on 39 of these patients (72%). All patients received the same cemented stem and an uncemented acetabular component. Three-dimensional penetration of the head into the socket was determined at 10 years using a radiostereometric analysis system, which has an in vivo accuracy of <0.1 mm. Oxford Hip Scores were compared between the groups. RESULTS: At 10 years there was significantly less wear of HXLPE (0.003 mm/year; 95% confidence interval [CI], ±0.010; SD 0.023; range, -0.057 to 0.074) compared with UHMWPE (0.030 mm/year; 95% CI, ±0.012; p<0.001; SD 0.0.27; range, -0.001 to 0.164). The volumetric penetration from 1 to 10 years for the UHMWPE group was 98 mm3 (95% CI, ±46 mm3; SD 102 mm3; range, -4 to 430 mm3) compared with 14 mm3 (95% CI, ±40 mm3; SD 91 mm3; range, -189 to 242 mm3) for the HXLPE group (p=0.01). CONCLUSIONS: This study demonstrates that HXLPE has little detectable steady-state in vivo wear. This may result in fewer reoperations from loosening; however, careful clinical followup into the second decade still needs to be performed. LEVEL OF EVIDENCE: Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Evidence in managing traumatic anterior shoulder instability: a scoping review.

BACKGROUND: Traumatic anterior shoulder instability (TASI) accounts for 95% of glenohumeral dislocations and is associated with soft tissue and bony pathoanatomies. Non-operative treatments include slings, bracing and physiotherapy. Operative treatment is common, including bony and soft-tissue reconstructions performed through open or arthroscopic approaches. There is management variation in patient pathways for TASI including when to refer and when to operate. METHODS: A scoping review of systematic reviews, randomised controlled trials, comparing operative with non-operative treatments and different operative treatments were the methods followed. Search was conducted for online bibliographic databases and reference lists of relevant articles from 2002 to 2012. Systematic reviews were appraised using AMSTAR (assessment of multiple systematic reviews) criteria. Controlled trials were appraised using the CONSORT (consolidation of standards of reporting trials) tool. RESULTS: Analysis of the reviews did not offer strong evidence for a best treatment option for TASI. No studies directly compare open, arthroscopic and structured rehabilitation programmes. Evaluation of arthroscopic studies and comparison to open procedures was difficult, as many of the arthroscopic techniques included are no longer used. Recurrence rate was generally considered the best measure of operative success, but was poorly documented throughout all studies. There was conflicting evidence on the optimal timing of intervention and no consensus on any scoring system or outcome measure. CONCLUSIONS: There is no agreement about which validated outcome tool should be used for assessing shoulder instability in patients. There is limited evidence regarding the comparative effectiveness of surgical and non-surgical treatment of TASI, including a lack of evidence regarding the optimal timing of such treatments. There is a need for a well-structured randomised control trial to assess the efficacy of surgical and non-surgical interventions for this common type of shoulder instability.

Key performance and training parameters in primary total hip arthroplasty - an expert consensus using the Delphi technique.

AIMS: Primary total hip arthroplasty (THA) is a commonly performed and successful operation which orthopaedic trainees must demonstrate competence in prior to completion of surgical training. An assessment of agreement between surgical trainers regarding the critical steps of a primary THA has never been undertaken. The aim of this study was to define and rank the key steps of a primary THA regards ease of teaching and their importance in achieving the best patient outcome. MATERIALS AND METHODS: The Delphi technique with 3 iterative rounds was used to establish expert group consensus. The benchmark for consensus was set at an 80% agreement in any category for each step of a THR. The intra-class correlation coefficient (ICC) was used to report on the inter- and intra-rater reliabilities between and within participants responses respectively in rounds 2 and 3. RESULTS: 50 consultant orthopaedic hip surgeons completed round 2, and 28 completed round 3. Overall, 27 steps (54 parameters) were identified, with 16 parameters achieving consensus agreement for their impact on patient outcome, and 17 for ease of teaching. The inter-rater ICC for patient outcome parameters was 0.89 and 0.92 in rounds 2 and 3 respectively while for teaching parameters it was 0.82 and 0.73. 50% of surgeons agreed that acetabular reaming, assessing and accurately restoring leg length, and acetabular cup anteversion were the 3 most difficult steps to teach trainees, while 90% agreed these 3 steps were substantially important to patient outcome. Another 5 steps achieved consensus for their substantial impact on patient outcome but failed to achieve consensus for ease of teaching. CONCLUSIONS: The results of this expert consensus have produced a rank-order list of the key steps in primary THA, which may be used for orthopaedic curriculum development and guiding focused improvements for surgical training in primary THR including simulation.

Development of a surgical trainer assessment questionnaire.

BACKGROUND: The assessment of surgical trainees has become well-established in practice; however, this is not yet the case for surgical trainers. The aim of this study was to develop a trainer assessment questionnaire (OxTrAQ) based on the 12 key trainer attributes identified by a previous systematic review, to then explore this questionnaire's potential domains and test its reliability. METHODS: The OxTrAQ was piloted at two surgical training centres in two surgical sub-specialities. At each centre, every trainee assessed every trainer while under their clinical supervision. RESULTS: Internal consistency (Cronbach's alpha) was calculated for this 12-item questionnaire as 0.958. Factor analysis revealed two domains which accounted for 77.997% of the variance; these were the general domain (nine items) and the independence domain (three items). Inter-observer reliability was shown by the intraclass correlation coefficients (ICCs) (average measures) for the overall OxTrAQ score, general domain score and independence domain score which were 0.951, 0.945 and 0.955 for centre 1 and 0.857, 0.819 and 0.883 for centre 2, respectively. Intra-observer reliability was shown by the ICCs (average measures) for the overall OxTrAQ score, general domain score and independence domain score which were 0.925, 0.913 and 0.940, respectively. Construct validity was demonstrated by a high correlation (Spearman rho = 0.886, P = 0.019) between trainer scores and the scores predicted by the trainers themselves. CONCLUSIONS: The OxTrAQ is a simple trainer assessment questionnaire which has demonstrated both high inter- and intra-observer reliability.

What is Known About the Attributes of a Successful Surgical Trainer? A Systematic Review.

BACKGROUND: Surgical training has been subject to significant upheaval in recent years with an increasingly rigorous assessment regimen for trainees. The assessment of surgical trainers is less well evolved by comparison. Recent proposals from the Royal College of Surgeons of England recommend "professionalising the trainers." However, they do not suggest any accepted or validated methods of trainer assessment, nor do they indicate how these might be implemented and monitored in a real-world training program to determine their effect on trainee outcomes. AIM: To determine what is known about the attributes of successful surgical trainers. METHODS: We conducted a systematic review of the scientific literature using the preferred reporting items for systematic reviews and meta-analyses and Cochrane guidelines of the Medline database using specific search criteria. The qualitative analysis involved grouping trainer attributes together into "themes" within 4 "super-themes." Each theme needed to be mentioned by a minimum of 5 studies. RESULTS: After review of the full study texts a total of 14 studies met the inclusion criteria. Thirteen studies involved the views of trainees, whereas only 1 study solely assessed the views of trainers. There was a wide variety of study designs and types of participants. The attribute themes are listed in brackets after each super-theme: "character" (approachability, patience, enthusiasm, encouraging/supportiveness), "procedural" (willingness to let trainee operate, balance between supervision and independence), "teamwork and communication" (sets educational aims and objectives, ability to use appropriate feedback, communication skills, and time availability to train) and "clinical" (capable, good relationships with patients, and the health care team). CONCLUSIONS: This detailed review describes several perceived important themes for the positive attributes of surgical trainers. The identification of these key attributes is only of value if their presence is confirmed by effective and feasible evaluation, and if the possession of such attributes in trainers is proven to have a positive effect on training. In times of reduced training opportunities, exploring the topics raised by this review through future education research is warranted.

The Urgent Need for Evidence in Arthroscopic Meniscal Surgery.

BACKGROUND: Arthroscopic surgery of the knee is one of the most frequently performed orthopaedic procedures. One-third of these procedures are performed for meniscal injuries. It is essential that this commonly performed surgery be supported by robust evidence. PURPOSE: To compare the effectiveness of arthroscopic surgery for meniscal injuries in all populations. STUDY DESIGN: Systematic review. METHODS: An online search was conducted for randomized controlled trials (RCTs) and systematic reviews (SRs) that compared treatment options for meniscal injury. The following databases (inception to April 2015) were included in the search: CENTRAL; MEDLINE; EMBASE; NHS Evidence; National Guideline Clearing House, Database of Abstracts of Reviews of Effects, Health Technology Assessment; ISRCTN; Clinicaltrials.gov ; WHO trials platform. Only studies whose participants were selected on the basis of meniscal injury were included; no restrictions were placed on patient demographics. Two independent reviewers applied AMSTAR (A Measurement Tool to Assess Systematic Reviews) criteria for SRs and the Cochrane Collaboration risk-of-bias tool for RCTs. RESULTS: Nine RCTs and 8 SRs were included in the review. No difference was found between arthroscopic meniscal debridement compared with nonoperative management as a first-line treatment strategy for patients with knee pain and a degenerative meniscal tear (mean difference: Knee injury and Osteoarthritis Outcome Score, 1.6 [95% CI, -2.2 to 5.2], pain visual analog scale, -0.06 [95% CI, -0.28 to 0.15]). Some evidence was found to indicate that patients with resistant mechanical symptoms who initially fail nonoperative management may benefit from meniscal debridement No studies compared meniscal repair with meniscectomy or nonoperative management. Initial evidence suggested that meniscal transplant might be favorable in certain patient groups. CONCLUSION: Further evidence is required to determine which patient groups have good outcomes from each intervention. Given the current widespread use of arthroscopic meniscal surgeries, more research is urgently needed to support evidence-based practice in meniscal surgery in order to reduce the numbers of ineffective interventions and support potentially beneficial surgery.

Is cold or warm blood cardioplegia superior for myocardial protection?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the use of warm or cold blood cardioplegia has superior myocardial protection. More than 192 papers were found using the reported search, of which 20 represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. A good breadth of high-level evidence addressing this clinical dilemma is available, including a recent meta-analysis and multiple large randomized clinical trials. Yet despite this level of evidence, no clear significant clinical benefit has been demonstrated by warm or cold blood cardioplegia. This suggests that neither method is significantly superior and that both provide similar efficacy of myocardial protection. The meta-analysis, including 41 randomized control trials (5879 patients in total), concluded that although a lower cardiac enzyme release and improved postoperative cardiac index was demonstrated in the warm cardioplegia group, this benefit was not reflected in clinical outcomes, which were similar in both groups. This theme of benefit in biochemical markers, physiological metrics and non-fatal postoperative events in the warm cardioplegia group ran throughout the literature, in particular the 'Warm Heart investigators' who conducted a randomized trial of 1732 patients, demonstrated a reduction in postoperative low output syndrome (6.1 versus 9.3%, P = 0.01) in the warm cardioplegia group, but no significant drop in 30-day all-cause mortality (1.4 versus 2.5%, P = 0.12). However, their later follow-up indicates non-fatal postoperative events predict reduced late survival, independent of cardioplegia. A minority of studies suggested a benefit of cold cardioplegia over warm in particular patient subgroups: One group conducted a retrospective study of 520 patients who required prolonged aortic cross-clamp times, results demonstrated less myocardial damage and reduced postoperative cardiac mortality and morbidity in the cold group. The clinical bottom line is that warm and cold cardioplegia result in similar short-term mortality. However, large studies have shown that warm cardioplegia reduces adverse post-operative events; the significance of which is unclear.