Improving residency training in arthroscopic knee surgery with use of a virtual-reality simulator. A randomized blinded study.

BACKGROUND: There is a paucity of articles in the surgical literature demonstrating transfer validity (transfer of training). The purpose of this study was to assess whether skills learned on the ArthroSim virtual-reality arthroscopic knee simulator transferred to greater skill levels in the operating room. METHODS: Postgraduate year-3 orthopaedic residents were randomized into simulator-trained and control groups at seven academic institutions. The experimental group trained on the simulator, performing a knee diagnostic arthroscopy procedure to a predetermined proficiency level based on the average proficiency of five community-based orthopaedic surgeons performing the same procedure on the simulator. The residents in the control group continued their institution-specific orthopaedic education and training. Both groups then performed a diagnostic knee arthroscopy procedure on a live patient. Video recordings of the arthroscopic surgery were analyzed by five pairs of expert arthroscopic surgeons blinded to the identity of the residents. A proprietary global rating scale and a procedural checklist, which included visualization and probing scales, were used for rating. RESULTS: Forty-eight (89%) of the fifty-four postgraduate year-3 residents from seven academic institutions completed the study. The simulator-trained group averaged eleven hours of training on the simulator to reach proficiency. The simulator-trained group performed significantly better when rated according to our procedural checklist (p = 0.031), including probing skills (p = 0.016) but not visualization skills (p = 0.34), compared with the control group. The procedural checklist weighted probing skills double the weight of visualization skills. The global rating scale failed to reach significance (p = 0.061) because of one extreme outlier. The duration of the procedure was not significant. This lack of a significant difference seemed to be related to the fact that residents in the control group were less thorough, which shortened their time to completion of the arthroscopic procedure. CONCLUSIONS: We have demonstrated transfer validity (transfer of training) that residents trained to proficiency on a high-fidelity realistic virtual-reality arthroscopic knee simulator showed a greater skill level in the operating room compared with the control group. CLINICAL RELEVANCE: We believe that the results of our study will stimulate residency program directors to incorporate surgical simulation into the core curriculum of their residency programs.

Evaluation of skill level between trainees and community orthopaedic surgeons using a virtual reality arthroscopic knee simulator.

BACKGROUND: Several virtual reality simulators have been developed to assist orthopaedic surgeons in acquiring the skills necessary to perform arthroscopic surgery. The purpose of this study was to assess the construct validity of the ArthroSim virtual reality arthroscopy simulator by evaluating whether skills acquired through increased experience in the operating room lead to improved performance on the simulator. METHODS: Using the simulator, six postgraduate year-1 orthopaedic residents were compared with six postgraduate year-5 residents and with six community-based orthopaedic surgeons when performing diagnostic arthroscopy. The time to perform the procedure was recorded. To ensure that subjects did not sacrifice the quality of the procedure to complete the task in a shorter time, the simulator was programmed to provide a completeness score that indicated whether the surgeon accurately performed all of the steps of diagnostic arthroscopy in the correct sequence. RESULTS: The mean time to perform the procedure by each group was 610 seconds for community-based orthopaedic surgeons, 745 seconds for postgraduate year-5 residents, and 1028 seconds for postgraduate year-1 residents. Both the postgraduate year-5 residents and the community-based orthopaedic surgeons performed the procedure in significantly less time (p = 0.006) than the postgraduate year-1 residents. There was a trend toward significance (p = 0.055) in time to complete the procedure when the postgraduate year-5 residents were compared with the community-based orthopaedic surgeons. The mean level of completeness as assigned by the simulator for each group was 85% for the community-based orthopaedic surgeons, 79% for the postgraduate year-5 residents, and 71% for the postgraduate year-1 residents. As expected, these differences were not significant, indicating that the three groups had achieved an acceptable level of consistency in their performance of the procedure. CONCLUSIONS: Higher levels of surgeon experience resulted in improved efficiency when performing diagnostic knee arthroscopy on the simulator. Further validation studies utilizing the simulator are currently under way and the additional simulated tasks of arthroscopic meniscectomy, meniscal repair, microfracture, and loose body removal are being developed.

Virtual reality in orthopaedics: is it a reality?

BACKGROUND: Virtual reality (VR) simulation has been a requirement for airline and military pilots for decades and is only now being integrated into surgical training programs. Thus far, orthopaedic training programs have been slow to adopt VR training. QUESTIONS/PURPOSES: We therefore asked (1) how VR has worked for other surgical specialties; (2) what VR solutions are available for orthopaedics; and (3) should VR simulation become part of the orthopaedic curriculum? METHODS: An informal literature review was performed, searching for orthopaedically-oriented VR surgical simulators and comparing this to the number of programs available for general surgery teaching programs. An in-depth review of a VR simulator for knee arthroscopy is also presented. WHERE ARE WE NOW?: The number of papers specific to orthopaedics and VR is limited. VR is used effectively in other specialties, especially general surgery. VR simulators are readily available for shoulder and knee arthroscopy but not as well incorporated into training curricula. WHERE DO WE NEED TO GO?: VR technology is available today for training programs. Integration of VR into the orthopaedic curriculum will save time in the OR, reduce operative errors, and improve the resident's overall educational experience. The public will expect their surgeons to train on these simulators. HOW DO WE GET THERE?: Orthopaedic training programs should take advantage of the commercially available VR simulators for orthopaedic procedures and incorporate them into their training curricula. This effort could be led by the American Academy of Orthopaedic Surgeons (AAOS) and the American Board of Orthopaedic Surgery (ABOS), two of the primary sponsors of a major study in the effectiveness of VR simulators for knee arthroscopy.

Variability of landmark identification in total knee arthroplasty.

Virtual reality is new technology that is finding application in many facets of orthopaedics. We will describe an application of virtual reality in orthopaedic research. Component placement in total knee arthroplasty depends on identification of anatomic landmarks about the knee. We surmised significant interobserver variability occurs in the identification of landmarks of the distal femur used in total knee arthroplasty. The results tested in virtual space show that certain anatomic landmarks used in total knee arthroplasty are not reliable. The significance of this observation is that landmark identification, an integral component of computer-assisted surgical navigation in total knee arthroplasty, represents a source of method error in an otherwise accurate and precise computer-assisted technique.