The Efficacy of Arthroscopic Simulation Training on Clinical Ability: A Systematic Review

doi:10.1016/j.arthro.2020.09.018

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 37, Issue 3, March 2021, Pages 1000-1007.e1

https://doi.org/10.1016/j.arthro.2020.09.018 Get rights and content

Purpose

To examine the effect of arthroscopic simulator training on technical performance in a human model.

Methods

A systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Literature searches of PubMed, Embase, and Cochrane Library were conducted using combinations of the terms virtual, digital, computer, reality, simulation, arthroscopy, training, learning, and education. Studies were considered for inclusion if they tested the effect of arthroscopic simulator training in a randomized controlled fashion, performed testing in a cadaver or live patient, and used explicit outcome measures of technical skill. Data from studies were extracted and study characteristics and outcomes were reviewed. The primary outcome measure was the number of studies in which the simulation trained group had significantly improved performance results relative to the control group in ≥50% of all measured outcomes. Risk of bias was assessed with Cochrane’s Collaboration Tool.

Results

Twelve studies, including 340 total study participants, were included for review. Eight studies showed improved performance of the simulation trained group relative to the control group in ≥50% of assessed outcomes. Six of ten studies reporting completion time, three of six studies reporting task checklist completion, 3 of 7 studies reporting global rating scales, and 1 of 4 studies reporting Arthroscopic Surgical Skill Evaluation Tool scores showed improved performance of the simulation group relative to the control group for the respective outcome measures.

Conclusions

The literature is limited due to heterogeneity, both in type and merit, of the outcome measures that have been used to assess the transfer validity of arthroscopic simulator training to clinical performance. Despite the limitations of the literature, this review demonstrates that arthroscopic simulator training has potential to improve clinical performance.

Level of Evidence

II, systematic review of Level II studies.

Section snippets

Study Eligibility

Studies were considered for inclusion if they tested the effect of arthroscopic simulator training in a randomized controlled fashion, performed testing on a cadaver or live patient, and reported explicit outcome measures of technical skill. Reviews, abstracts, and expert opinions were excluded.

Literature Search

This systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Independent literature searches were conducted by 2 of the

Eligibility

The initial literature searches performed by both reviewers produced 312 and 498 results, respectively (Fig 3). Following combination and subsequent elimination of duplicates, 284 articles remained. The inclusion and exclusion criteria were applied to these articles, following which 76 remained after screening based on abstracts and 12 remained after screening based on full text.²³^,26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36

Participant Characteristics

Of the 12 included studies, 9 studies used orthopaedic surgery residents

Discussion

The potential of arthroscopic simulation training to improve clinical performance is demonstrated by the primary outcome of the review, as 8 of the 12 studies showed improved results in the simulation trained group relative to the control group in ≥50% of the assessed outcome measures.²³^,²⁷^,²⁹^,³⁰^,³²^,³³^,³⁵^,³⁶ While, at face value, this representation of the included papers seems to strongly support the notion that arthroscopic simulation training improves clinical performance, the validity of

Conclusions

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Virtual and Augmented Reality Simulators Show Intraoperative, Surgical Training, and Athletic Training Applications: A Scoping Review
2024, Arthroscopy - Journal of Arthroscopic and Related Surgery
To review published literature to identify and evaluate the effect of virtual reality (complete immersion) and augmented reality (overlay of digital information onto the physical world) simulators on intraoperative use for orthopaedic surgeons, orthopaedic surgical education, and athletic training.
A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies, published since 2014, that evaluated the role of augmented/virtual reality on intraoperative use for orthopaedic surgeons, orthopaedic surgical education, and athletic training.
Virtual reality (VR) simulators provide 3-dimensional graphical simulation of the physical world, and augmented reality (AR) simulators overlay digital information onto the physical world. Simulators can include interactive features (i.e., replication of intraoperative bleeding), haptic feedback, and unrestricted task repetition, and they can record, compare, and analyze performance while being easily accessible and eliminating the need for the presence of a mentor or coach. Four studies reported on VR for intraoperative use, 47 studies on surgical education, and 10 studies on athletic training. Two studies revealed the advantages of using VR simulation during intraoperative procedures, specifically showcasing its benefits for elbow arthroscopy, while 2 studies demonstrated similar positive outcomes for hip arthroscopy. Seventeen studies demonstrated that a VR simulator could be a beneficial tool to assist in surgical education for the knee, while 12 studies found that VR simulation is a valuable tool for aiding in surgical education of shoulder arthroscopy. Ten studies demonstrated that VR simulation improves skills in the operating room. Three studies revealed that individuals with more experience exhibit superior performance on these simulators compared to those with less experience. In the realm of athletic training, 10 studies showcased the potential of VR simulation to play a significant role in athletic performance and injury rehabilitation.
VR simulation shows benefits in the operating room, is a valuable tool for surgical education resulting in improved skills, and can be used to enhance athletic performance and injury rehabilitation.
Understanding that VR simulators can improve surgical outcomes, surgical skill training, and athletic training and rehabilitation could facilitate development and adoption of this advanced technology.
Arthroscopic approach in initial training: Study of a novice cohort using inverse direct and indirect approaches and its implication in the development of training programs
2023, Orthopaedics and Traumatology: Surgery and Research
Arthroscopic training includes successive stages of observation, reproduction and then repetition. Learning through simulation in 2D virtual reality makes it possible to repeat these different stages to enhance the learner's experience in complete safety and a shorter timeframe. Some procedures require inversion of the optical and instrumental approaches in the axial plane, disrupting the existing psychomotor and technical skills. The objective of this study was to compare the degree of difficulty and the distribution of results for the same exercise carried out alternately in classical holding and inverted holding of the instruments in a cohort of novice learners.
Twenty-two medical students, novices in arthroscopic surgery, participated in the study. Each performed an exercise consisting of grasping ten targets with arthroscopic forceps and placing them in a basket on the VirtaMed ArthroS™ simulator. The exercise was performed with the scope and grasping instrument pointed away from the operator, “catch the stars front” (CTSF), then directed towards the operator, “catch the stars back” (CTSB). The simulator recorded several parameters making up an overall composite score (“overall performance score”, OPS) out of 120 points. Voluntary abandonment of the exercise was also collected.
All students completed the CTSF exercise but 6 dropped out of the CTSB exercise (27%, p = 0.01). In the CTSF exercise, the average OPS was higher with 45.9 points versus 22.8 points in the CTSB exercise (p < 0.001). By detailing the components of the OPS score, the parameters of interest on the Fundamentals of Arthroscopic Training (FAST) module of the simulator included: the distance traveled by the scope and the grasping forceps was significantly greater in the CTSB group (p < 0.001), the duration of the exercise was significantly greater in the CTSB group (p < 0.001), the time spent with the instruments in the videoscopic field was significantly lower in the CTSB group (p = 0.001) and finally the absence of a significant difference in the camera alignment compared to the horizontal plane between the two groups.
The exercise with the instruments directed towards the operator is more difficult with a greater distribution for all the secondary criteria except for the camera alignment, which suggests that it could be more discriminating. The dropout rate is also higher. It would therefore be interesting to introduce CTSB type training in initial training programs in arthroscopy.
III, comparative prospective study.
Arthroscopic approach in initial training: study of a novice cohort using inverse direct and indirect approaches and its implication in the development of training programs
2023, Revue de Chirurgie Orthopedique et Traumatologique
L’apprentissage de l’arthroscopie comprend des étapes successives d’observation, de reproduction puis de répétition. L’apprentissage par simulation en réalité virtuelle 2D permet de répéter ces différents temps pour accroître l’expérience de l’apprenant en toute sécurité et dans un laps de temps plus réduit. Certaines procédures nécessitent une inversion des voies d’abord optique et instrumental dans le plan axial, perturbant les aptitudes psychotechniques déjà acquises. L’objectif de cette étude est de comparer la difficulté et la distribution des résultats d’un même exercice réalisé alternativement en tenue classique et en tenue inversée des instruments dans une cohorte d’apprenants novices.
Vingt-deux étudiants en médecine, novices en chirurgie arthroscopique ont participé à l’étude. Chacun réalisait un exercice consistant à saisir dix cibles avec une pince arthroscopique et à les déposer dans un panier sur le simulateur VirtaMed ArthroS™. L’exercice a été réalisé avec le scope et la pince dirigés vers l’opposé de l’opérateur, « catch the stars front » (CTSF), puis dirigés vers l’opérateur, « catch the stars back » (CTSB). Le simulateur relevait plusieurs paramètres composant un score global composite (« overall performance score », OPS) sur 120 points. L’abandon volontaire de l’exercice a également été colligé.
Tous les étudiants ont complété l’exercice CTSF mais 6 ont abandonné l’exercice CTSB (27 %, p = 0,01). Dans l’exercice CTSF, l’OPS moyen est plus élevé avec 45,9 points vs 22,8 points dans l’exercice CTSB (p < 0,001). En détaillant les composantes du score OPS, les paramètres d’intérêts sur le module FAST du simulateur étaient la distance parcourue par le scope et la pince significativement supérieure dans le groupe CTSB (p < 0,001), la durée de l’exercice significativement supérieure dans le groupe CTSB (p < 0,001), le temps passé avec les instruments dans le champ vidéoscopique significativement inférieur dans le groupe CTSB (p = 0,001) et enfin l’absence de différence significative dans l’alignement de la caméra par rapport à l’horizon entre les 2 groupes.
L’exercice par voies avec les instruments dirigés vers l’opérateur est plus difficile avec une distribution plus importante pour tous les critères secondaires sauf pour l’alignement de la caméra ce qui suggère qu’il pourrait être plus discriminant. Le taux d’abandon est également plus élevé. Il serait donc intéressant d’introduire des entraînements type CTSB dans les programmes de formation initiale en arthroscopie.
III, étude prospective comparative.
Meditation Using a Mobile App Improves Surgery Trainee Performance: A Simulation-Based Randomized Controlled Trial
2023, Arthroscopy - Journal of Arthroscopic and Related Surgery
To primarily investigate: (1) whether a 10-minute instant meditation practice using a mobile app could enhance arthroscopy performance and (2) whether a 10-day app-based meditation could reduce short-term arthroscopic skills deterioration.
Orthopaedic residents with no previous experience in arthroscopy and meditation were randomly assigned to groups A, B, and C. After initial standard competency-based arthroscopy training on the simulator on day 1, a pretest was performed via the simulator by all participants to assess their initial level of performance, then groups A and B were required to practice app-based mindfulness meditation 10 min/day for 10 consecutive days while group C did nothing. On day 11, all participants returned to perform a posttest. Before the posttest, the participants in group A practiced app-based meditation (10 minutes), whereas groups B and C had no intervention.
In total, 43 participants were included and reached similar level of performance after initial training phase in day 1. On day 11, participants in group A had statistically a better instant arthroscopy performance than group B, with greater total score (mean difference [MD] 3.57; P < .001), less completion time (MD –42.89 seconds; P = .001), shorter camera (MD –23.38 cm; P < .001) and grasper (MD –15.23 cm; P = .002) path length, and less cartilage injury (MD –1.07%; P = .012). Participants in group B had less skills deterioration than group C, with better total score (MD –5.42; P < .001), less completion time (MD 51.96s; P = .002), camera path length (MD 28.41 cm; P = .007), and cartilage injury (MD 1.19%; P = .038).
Meditation training using a mobile app enhanced instant simulation-based arthroscopy performance and reduced short-term skills deterioration of orthopaedic residents with no arthroscopy hands-on experience.
A meditation using mobile app for clinicians and educators should be incorporated into simulation-based arthroscopy curriculums and perhaps clinical settings to improve arthroscopy performance and mental health of orthopaedic residents without any previous arthroscopy experience.
Use of a Dry Surgical Simulator Improves Orthopaedic Residents’ Competency and Technical Skills for Arthroscopic Rotator Cuff Repair
2022, Arthroscopy, Sports Medicine, and Rehabilitation
Citation Excerpt :
All surgical skills have a learning curve and require dedicated practice to obtain mastery; arthroscopic techniques present additional challenges to the learning curve.3 The master-apprentice approach has dominated surgical training for more than 100 years,4 but specifically regarding minimally invasive surgery, it has been shown that operating during the period of initial skill acquisition can lead to increased rates of complications.5 New methods and new criterion standards for the training of surgeons must be developed.
To evaluate whether an anatomic dry shoulder Dexter training model surgical simulator would be effective in augmenting orthopaedic residents’ skills for arthroscopic rotator cuff repair.
Nine residents, enrolled for this prospective study, watched a video presentation about transosseus equivalent (TOE) double-row, rotator cuff repair technique, repeating the aforementioned technique twice on the simulator. The time to complete all steps to final repair, as well as the quality of the final repair, were measured.
The data for repair completion time showed a statistically significant difference in the total duration time of performing the procedure, when comparing the timing in tests 1 and 2, demonstrating a reduced operative time. The qualitative data collected show an increase in the final score in 100% (9 out of 9) of the participants between the first and second tests, with an improvement in the average score of 16.4% (3.22 points with a standard deviation of 2.64). Hence, there is a statistically significant difference (P = .006) between the total scores obtained by the participants at the end of tests 1 and 2, presenting an improvement of the quality score, shifting from the first (average score 19.7) to the second (average score 22.9) test. Conclusion: The dry simulator may be a valuable device to improve arthroscopic technical skills. This improvement was observed both in the resulting reduced operative time required to carry out the surgical procedure and the increased quality score (established to evaluate the quality of the required tasks).
In order to provide as many training opportunities as possible, an arthroscopy simulator could be used to supplement clinical arthroscopy skills training for orthopaedic residents.
Editorial Commentary: Assistive Technologies for Hip Arthroscopic Cam Resection Will Improve Diagnostic and Surgical Accuracy: Desperately Needed and Here to Stay
2021, Arthroscopy - Journal of Arthroscopic and Related Surgery
Hip arthroscopy is technically demanding and presents a steep learning curve. Joint access and maneuverability of surgical tools are impeded by a large soft-tissue envelope. Furthermore, cam resection is challenging owing to the small size of the lesion and the difficulty in delineating what is normal and where the cam starts. Thus, the number of incomplete resections is high and represents the bulk of indications for revision hip arthroscopy. The search for assistive technologies to improve on diagnostics and surgical accuracy is consequently substantial and unquestionably needed. Intraoperative feedback will improve our resection accuracy while decreasing the learning efforts of both expert and novice surgeons.

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: See commentary on page 1008

: The authors report the following potential conflicts of interest or sources of funding: A.L., J.H., M.O., C.C., and T.S.L. report grants from Orthopedic Surgery Research Foundation, during the conduct of the study. T.S.L. report grants from the Orthopaedic Scientific Research Foundation, Inc., during the conduct of the study. T.S.L. also reports other from Smith & Nephew, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.

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Systematic ReviewThe Efficacy of Arthroscopic Simulation Training on Clinical Ability: A Systematic Review

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Study Eligibility

Literature Search

Eligibility

Participant Characteristics

Discussion

Conclusions

Arthroscopy

Lancet

Am J Surg

Arthroscopy

Arthroscopy

Arthroscopy

J Surg Educ

Int J Surg

Arthroscopy

J Surg Educ

Arthroscopy

J Surg Educ

Hip arthroscopy utilization and associated complications: A population-based analysis

J Hip Preserv Surg

Practice patterns for subacromial decompression and rotator cuff repair: An analysis of the American Board of Orthopaedic Surgery database

J Bone Joint Surg Am

American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II, certification examination case mix

J Bone Joint Surg Am

Assessment of arthroscopic training in U.S. orthopedic surgery residency programs—a resident self-assessment

Bull NYU Hosp Jt Dis

Surgical training, duty-hour restrictions, and implications for meeting the Accreditation Council for Graduate Medical Education core competencies: Views of surgical interns compared with program directors

Arch Surg

A systematic review of the effects of resident duty hour restrictions in surgery: Impact on resident wellness, training, and patient outcomes

Ann Surg

Complications of arthroscopy of the knee

J Bone Joint Surg Br

Systematic Review
The Efficacy of Arthroscopic Simulation Training on Clinical Ability: A Systematic Review