Simulation Training Improves Surgical Proficiency and Safety During Diagnostic Shoulder Arthroscopy Performed by Residents

Abstract

Although virtual reality simulators have established construct validity, no studies have proven transfer of skills from a simulator to improved in vivo surgical skill. The current authors hypothesized that simulation training would improve residents' basic arthroscopic performance and safety. Twenty-two orthopedic surgery trainees were randomized into simulation or standard practice groups. At baseline testing, all of the participants performed simulator-based testing and a supervised, in vivo diagnostic shoulder arthroscopy with video recording. The simulation group subsequently received 1 hour of total instruction during a 3-month period, and the standard practice group received no simulator training. After intervention, both groups were reevaluated with simulator testing and a second recorded diagnostic shoulder arthroscopy. Two blinded, independent experts evaluated arthroscopic performance using the anatomic checklist, Arthroscopic Surgery Skill Evaluation Tool (ASSET) score, and total elapsed time. All outcome measures were compared within and between groups. After intervention, mean time required by the simulation group to complete the simulator task (30.64 seconds) was 8±1.2 seconds faster than the time required by the control group (38.64 seconds; P=.001). Probe distance (51.65 mm) was improved by 41.2±6.08 mm compared with the control (92.83 mm; P=.001). When comparing ASSET safety scores, the simulation group was competent (3.29) and significantly better than the control group (3.00; P=.005) during final arthroscopic testing. This study establishes transfer validity for an arthroscopic shoulder simulator model. Simulator training for residents in training can decrease surgical times, improve basic surgical skills, and confer greater patient safety during shoulder arthroscopy. [Orthopedics. 2016; 39(3):e479-e485.].

Impact of Simulation Training on Diagnostic Arthroscopy Performance: A Randomized Controlled Trial

“…5,6 Previous investigations have generally supported some degree of skill transfer from practice on arthroscopic simulator models to performance on either cadaveric models or live arthroscopy. [7][8][9][10][11][12][13][14][15][16][17][18] However, some investigations have challenged the idea that simulator training provides generalizable skill acquisition. 19,20 In addition, the questions of how much simulator training is necessary and if there is an upper limit to the benefits of simulator training hold particular importance as new simulator technologies are being integrated into residency training programs.…”

Does virtual reality simulation have a role in training trauma and orthopaedic surgeons?

“…A small number of studies have attempted to assess the concurrent validity of several VR simulators, with positive results (Table IV). [43][44][45][46][47] Cannon et al 43 showed orthopaedic residents who had undergone VR simulator training outperformed their control group counterparts at probing scale scores and self-defined global rating scale scores during diagnostic knee arthroscopy in vivo. However, procedural checklist scores were not shown to be significantly different, which has been attributed to the influence of an extreme outlier.…”

“…However, procedural checklist scores were not shown to be significantly different, which has been attributed to the influence of an extreme outlier. These benefits in knee arthroscopy were also assessed by Camp et al, 45 who compared the improvements in performance to those seen in another group trained on cadaveric specimens. Contrary to these promising results, Rebolledo et al 46 reported no significant benefit derived from two and a half hours of knee arthroscopy simulation training in orthopaedic residents whose performance was subsequently assessed on cadaveric models.…”

“…To date, while those studies that have examined the effect of simulator training on performance in the operating theatre support the use of simulation, they are few in number. [43][44][45][46] It is in this area of transferability that supportive evidence is lacking when compared to other surgical specialties. Multiple studies have demonstrated a 'real-world' benefit from the use of Knee arthroscopic ability on a cadaver knee in a simulated intra-operative environment using the validated Global Rating Scale, 49 arthroscopic checklist, and procedural time -for both diagnostic examination and probing examination; additionally, participants were given an untrained task (partial medial meniscectomy) to assess skill transfer, which was assessed using the same metrics as above VR-trained participants outperformed both lowfidelity trained and control groups when assessed with the GRS, for diagnostic examination, probe examination, and partial medial meniscectomy; no difference was observed between arthroscopic checklist completion between the VR and lowfidelity trained groups for the diagnostic and probe examinations, although both groups outperformed the untrained controls; 31% of participants were able to complete the partial meniscectomy vs 0% in the low-fidelity and control groups; VR-trained and low-fidelity groups showed significantly lower procedural times vs controls, but were not significantly different from each other.…”

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

“…Ó Tool (ASSET) 3,9 and patient-reported outcomes in the study design, it may actually be possible to prove what simulator enthusiasts have postulated all alongdthat simulator training does have the potential to improve surgical outcomes. [10][11][12] 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!…”