Arthroscopic Skills Research Articles

Validity Evidence for a Low-Cost Shoulder Arthroscopy Partial Task Trainer (L-CASTT)

Objectives: To develop and validate a novel, low-cost shoulder arthroscopy partial task trainer. Study Design: Cross-sectional study Methods: A low-cost arthroscopy model was created to simulate navigation and triangulation skills in conjunction with ABOS-certified Orthopaedic surgeons' input. Each participant performed three trials of simulated labral repair and performance data was compared between experienced surgeons and novice medical students. Results: A total of 8 orthopaedic surgeons in the experienced group and 18 medical students in the novice group participated in the study. The average age of the experienced group was 43.1 years old, with 8.3 years of post-residency experience. The average age of the novice group was 24.3 years. The experienced group completed the simulation task faster than the novice group (16.6±7.6 vs. 96.4 ±102.2 seconds; p<0.001). Conclusion: The shoulder arthroscopy model demonstrated significant differences in performance between experienced orthopaedic surgeons and novices when used to assess a standardized basic arthroscopic technical skill. This low-cost trainer discriminates between varying skill levels and may be an effective option for simulation training of arthroscopic fundamentals to novice learners. Level of Evidence: III, Case Control Keywords: Arthroscopy, Simulation, Validity Evidence, Orthopaedics, Graduate Medical Education (J Ortho Business 2022; Volume 2, Issue 4:pages 1-4)

Meditation Using a Mobile App Improves Surgery Trainee Performance: A Simulation-Based Randomized Controlled Trial

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.

Learning and Short-Term Retention of Simulation-Based Arthroscopic Skills

The study aimed to examine the learning curve and short-term retention of arthroscopic skills acquired on a simulator. Cohort study. Clinical Skills Training Center of Zhujiang Hospital of Southern Medical University PARTICIPANT AND METHODS: Orthopaedic residents (n = 14) without previous arthroscopy experience were included. After basic information was collected and an initial arthroscopy knowledge level test was administered, the subjects received standardised training on the simulator (day 1); then, they completed tasks on the simulator, including guided diagnostics (4 times), triangulation (5 times) and loose body removal (7 times). A learning curve for each skill was generated based on the total scores. The score of the last repetition of each task was the training level. A total of 14 orthopedic residents were enrolled. All participants completed the training and testing. There was a learning curve over the course of training for all 3 arthroscopic skills (p < 0.001). On day 8 after the training, the mean score for guided diagnostics decreased from 49.9 to 48.9 (p = 0.001), and the retention rate was 97.8%. For triangulation, the mean total score decreased from 58.9 to 53.6 (p < 0.001), and the retention rate was 90.8%. For loose body removal, the mean total score decreased from 87.1 to 80.7 (p < 0.001), and the retention rate was 92.7%. Orthopaedic residents' arthroscopic skills learned through simulator training declined significantly in 1 week after the training, especially more difficult skills.

A three-dimensional (3D) printed simulator as a feasible assessment tool for evaluating hip arthroscopy skills

PurposeThe aims of this study were (1) to develop a three-dimensional (3D) printed simulator that facilitates the simulation of surgical skills for portal placement, intra-articular identification of anatomical structures and arthroscope navigation for hip arthroscopy and (2) to concurrently examine the feasibility of using this simulator as an assessment tool to evaluate trainees’ surgical competencies.MethodsA simulator was developed using a combination of medical imaging, computer-aided design, and 3D printing. A cross-sectional study was conducted with 29 participants divided into 3 subgroups (novice, intermediate and experienced). All participants performed related skills on the simulator, and their performance was evaluated using different assessment parameters. The participants’ qualitative feedback regarding the simulator was also collected. The data collated from each group of participants were subsequently compared.ResultsSignificant differences were observed between the three subgroups of participants with regard to the total checklist score (F2,26 = 11.3), total Arthroscopic Surgical Skill Evaluation score (F2,26 = 92.1), overall final global rating scale score (F2,26 = 49), number of times the participants used fluoroscopy (F2,26 = 7.4), and task completion times (F2,26 = 23.5). The participants’ performance in the simulated operation was correlated with their prior clinical experience. There was mainly positive feedback with regard to the fidelity and utility of the simulator in relation to the surgeons’ prior clinical experience.ConclusionsThis study demonstrated that a reliable hip arthroscopic simulator can be developed for use by orthopedic surgeons to evaluate their hip arthroscopic skills before performing actual surgical operations.Level of evidenceLevel III.

Scoring metrics for assessing skills in arthroscopic rotator cuff repair: performance comparison study of novice and expert surgeons.

We aim to develop quantitative performance metrics and a deep learning model to objectively assess surgery skills between the novice and the expert surgeons for arthroscopic rotator cuff surgery. These proposed metrics can be used to give the surgeon an objective and a quantitative self-assessment platform. Ten shoulder arthroscopic rotator cuff surgeries were performed by two novices, and fourteen were performed by two expert surgeons. These surgeries were statistically analyzed. Two existing evaluation systems: Basic Arthroscopic Knee Skill Scoring System (BAKSSS) and the Arthroscopic Surgical Skill Evaluation Tool (ASSET), were used to validate our proposed metrics. In addition, a deep learning-based model called Automated Arthroscopic Video Evaluation Tool (AAVET) was developed toward automating quantitative assessments. The results revealed that novice surgeons used surgical tools approximately 10% less effectively and identified and stopped bleeding less swiftly. Our results showed a notable difference in the performance score between the experts and novices, and our metrics successfully identified these at the task level. Moreover, the F1-scores of each class are found as 78%, 87%, and 77% for classifying cases with no-tool, electrocautery, and shaver tool, respectively. We have constructed quantitative metrics that identified differences in the performances of expert and novice surgeons. Our ultimate goal is to validate metrics further and incorporate these into our virtual rotator cuff surgery simulator (ViRCAST), which has been under development. The initial results from AAVET show that the capability of the toolbox can be extended to create a fully automated performance evaluation platform.

Effective Skill Transfer From Fundamentals of Arthroscopic Surgery Training to Shoulder Arthroscopic Simulator in Novices.

To investigate whether novices could improve performance on a shoulder arthroscopic simulator (high-fidelity) through short-term training on a Fundamentals of Arthroscopic Surgery Training (FAST) simulator (low-fidelity). Twenty-eight novices with no experience in arthroscopy were recruited to perform a pre-test on a shoulder arthroscopic simulator. Then they were randomized into two groups: the experimental group practiced five modules on the FAST simulator three times, and the control group did nothing. The experimental group performed a post-test immediately after FAST simulator practice. Control group rested for 70minutes after experiencing pre-test before performing post-test. All parameters were recorded by the simulator. The experimental group outperformed the control group in terms of total score, procedure time, camera path length, and grasper path length. However, there was no statistical difference in scratching of humerus cartilage or glenoid cartilage. Significant differences were found in the improvement of both groups in total score, procedure time, and camera path length. Arthroscopic skills gained after short-term training on FAST simulator could be transferred to the shoulder arthroscopic simulator. This research provides important evidence of the benefits of FAST simulator in shoulder arthroscopy training program.

A novel arthroscopy training program based on a 3D printed simulator

BackgroundArthroscopy is the most important and exciting contribution to sports medicine of the last 100 years. One of its main limitations, however, is the steep learning curve it requires, which is not easy to beat given the scarcity and the high price of arthroscopy simulators. Hypothesis/purposeTo describe and evaluate the effectiveness of an open-access arthroscopy training program based on a 3D-printed simulator. MethodsA model was designed, which was to be printed on a fused filament fabrication (FFF) 3D printer for home use with polylactic acid (PLA) filaments. Fourteen exercises were prepared, each with its timeframe and conceptual goals, arranged from least difficult to most challenging. Exercises were designed to assist subjects in developing the skills of an experienced arthroscopic surgeon through use of the simulator. Twenty subjects from nine hospitals completed the arthroscopy training program. Performance in each exercise was evaluated according to the Arthroscopic Surgical Skill Evaluation Tool (ASSET), taking into account the number of times a student had to repeat each exercise to complete it successfully. ResultsThe mean ASSET score for each exercise was 22 points (IQR 19–25) and the mean number of times students had to repeat each exercise was 16 (95% CI 15.27–17.97). Eighty-five percent of subjects completed the program. The device was printed without difficulty by an independent investigator without prior knowledge of 3D printing. The price of the device was under US$ 12. ConclusionSubjects exhibited an improvement in their basic arthroscopic skills on the simulator. The number of times each of them had to repeat each exercise was similar, which is indicative of a smooth progression of difficulty along the program. The device proved easy to print, accessible, economical, and effective. This is the first structured program based on an open-access arthroscopic simulator to obtain satisfactory results.

Use of a Dry Surgical Simulator Improves Orthopaedic Residents’ Competency and Technical Skills for Arthroscopic Rotator Cuff Repair

PurposeTo evaluate whether an anatomic dry shoulder Dexter training model surgical simulator would be effective in augmenting orthopaedic residents’ skills for arthroscopic rotator cuff repair.MethodsNine 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.ResultsThe 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).Clinical RelevanceIn order to provide as many training opportunities as possible, an arthroscopy simulator could be used to supplement clinical arthroscopy skills training for orthopaedic residents.

Validating low-fidelity arthroscopic simulation in medical students: a feasibility trial.

With surgical opportunities becoming increasingly restricted for orthopaedic trainees, simulation training is a valuable alternative at providing sufficient practice. This pilot study aims to assess the potential effectiveness of low-fidelity simulation in teaching medical students basic arthroscopic skills and the feasibility of its incorporation into formal student training programmes. Twenty-two medical students completed pre- and post-training tests on the Probing (Task 1) and Maze (Task 2) exercises from the Sawbones 'Fundamentals of Arthroscopy Surgery Training' (FAST) programme. Training consisted of practising horizon control, deliberate linear motion and probing within 25min over a period of days. Completion time and error frequency were measured. The difference in performance was assessed using a paired two-tailed t-test. Qualitative data were collected. Test completion time decreased significantly by a mean of 83s (±46s, 95% confidence intervals [CI] 37 to 129) for Task 1 (p=0.001) and 105s (±55s, 95% CI 50 to 160) for Task 2 (p=0.0007). Frequency of direct visualisation errors decreased significantly by a mean of 1.0 errors (±1.0 errors, 95% CI 0.1 to 2.0) for Task 1 (p = 0.04) and 0.8 errors (±0.8 errors, 95% CI 0.1 to 1.6) for Task 2 (p = 0.04). At post-training, 82% of participants were willing to incorporate FAST into formal training. Low-fidelity simulators such as FAST can potentially teach basic arthroscopic skills to medical students and are feasible for incorporation into formal training. They also give students a cost-effective and safe basic surgical training experience.

The Use of Telesurgery Mentoring and Augmented Reality to Teach Arthroscopy

Surgical teaching methods may be enhanced with telesurgery mentoring technology through virtual, visual, and audio interactions in the operating room, irrespective of geographic restrictions. The use of telesurgery mentoring carries the potential for accelerated learning in arthroscopic and surgical education. A telesurgery platform enables the establishment of a global network of surgeons with the goal of bridging gaps in surgical training via an accessible, cost-effective communication pathway. Specifically, such a platform allows a local surgeon to deliver real-time and live virtual assistance to a remote surgeon over a standard internet connection and removes the geographic barriers that prevent the practice of high-quality surgical care, thereby expanding virtual surgical collaboration. The purpose of our study is to describe our technique of telesurgery mentoring using a telesurgery internet platform (SurgTime; www.surgtime.com) and its applicability to teaching arthroscopic surgery skills both within the United States and in developing countries across the globe.

Cost Analysis of an In-House Arthroscopic Skills Simulator

Objectives: To compare objective costs between an in-house developed arthroscopy simulator and commercially available options. Design: Cost analysis. Setting: Orthopaedic graduate medical education. Patients/Participants: Eight board-certified orthopaedic surgeons and nineteen novice learners. Intervention: Simulation Training. Main outcome measurement: Cost difference between an in-house developed simulator and a commercially available simulator. Results and conclusions: Significant price differences exist between in-house simulator production cost and commercially available simulators. Low-cost, in-house simulators improve access to arthroscopic simulation training for novice learners by reducing up front cost by 29% and reducing recurring costs by over 90% when compared to a similar commercially available option. Level of Evidence: IV; Cost Analysis Keywords: Education; Simulation; Orthopaedics; Arthroscopy; Simulation Based Learning Theory (J Ortho Business Jan 2022;2(1):7-9)

Is the Virtual Reality Fundamentals of Arthroscopic Surgery Training Program a Valid Platform for Resident Arthroscopy Training?

Training in arthroscopy is associated with a steep learning curve for trainees and bears risks for patients. Virtual reality (VR) arthroscopy simulation platforms seek to overcome this and to provide a safe environment for surgical learners. The Fundamentals of Arthroscopic Surgery Training (FAST) program is one such platform. It is currently not known whether the VR FAST program can be employed as a useful teaching or examination tool to assess the basic arthroscopic skills of surgical trainees. (1) Does the VR FAST program differentiate among novice, intermediate, and expert arthroscopists? (2) Does ambidextrous performance in the VR FAST program correlate with arthroscopic experience? We prospectively recruited orthopaedic interns (novices), residents (intermediates), and fellows and attendings (experts) to complete the VR FAST program over a 1-year period from four major orthopaedic training programs on a voluntary basis. Sixty-six of 156 invited orthopaedic surgeons participated: 26 of 50 novices (16 men and 10 women), 27 of 65 intermediates (20 men and seven women), and 13 of 41 experts (10 men and three women). Surgeons of any arthroscopic experience were included, with only those with prior experience on the VR FAST program being excluded. The program consists of eight modules: three basic camera modules (Image Centering, Horizon Control, and Telescoping), three advanced camera modules (Periscoping, Trace the Line, and Trace the Curve), and two instrumented bimanual-dexterity modules (Probe Triangulation and Gather the Stars). Time taken to complete each task and measures of economy of movement (camera and instrument path length, camera alignment) were used as measures of arthroscopic experience. Every participant completed the modules using their dominant and nondominant hands. Equality in proficiency in completing the tasks using the dominant and nondominant hands were determined to be measures of arthroscopic experience. Due to the large number of outcome variables, only p values < 0.01 were considered to be statistically significant. Six of eight VR FAST modules did not discriminate among novice, intermediate, and expert arthroscopy participants. However, two did, and the ones that were most effective at distinguishing participants by level of experience were the Periscoping and Gather the Stars modules. For the Periscoping module using the dominant hand, novices required longer to complete the task with a median time of 231 seconds (IQR 149 to 358) and longer camera path length median of 191 cm (IQR 128 to 273) compared with intermediates who needed 127 seconds (IQR 106 to 233) and 125 cm (IQR 92 to 159) and experts who needed 121 seconds (IQR 93 to 157) and 119 cm (IQR 90 to 134) (p = 0.001 and p = 0.003, respectively). When using the nondominant hand, novices took longer to complete the task with a median time of 231 seconds (IQR 170 to 350) and longer camera path length 204 cm (IQR 169 to 273) compared with intermediates who required 132 seconds (IQR 97 to 162) and 111 cm (IQR 88 to 143) and experts who needed 119 seconds (IQR 104 to 183) and 120 cm (IQR 108 to 166) (p < 0.001 and p < 0.001, respectively). For the Gather the Stars module using the nondominant hand, only the novices needed longer to complete the task at a median of 131 seconds (IQR 112 to 157) and needed a longer grasper path length of 290 cm (IQR 254 to 332) compared with intermediates who needed 84 seconds (IQR 72 to 119) and 232 cm (IQR 195 to 254) and experts who needed 98 seconds (IQR 87 to 107) and 244 cm (IQR 215 to 287) (p < 0.001 and p = 0.001, respectively). Six of eight VR FAST modules did not demonstrate construct validity, and we found no correlation between arthroscopic experience and ambidextrous performance. Two modules demonstrated construct validity; however, refinement and expansion of the modules is needed with further validation in large prospective trials so that pass-fail thresholds can be set for use in high-stakes examinations. Most VR FAST modules were not discriminatory; however, they can form essential conceptual and procedural building blocks in an arthroscopic curriculum that are beneficial for novices when developing key psychomotor skills. In their present format, however, they are unsuitable for assessing arthroscopic proficiency.

Low-Cost, Low-Fidelity, Self-Made Arthroscopic Surgical Simulators: A Systematic Review

Purpose: To systematically review the literature regarding low-cost, low-fidelity, self-made arthroscopic surgical simulators and provide an overview of their use in the teaching of arthroscopic surgical skills. Methods: Systematic review of the literature following PRISMA (Preferred Reporting Items for Systematic Reviews and MetaAnalyses) guidelines. Results: A total of 10 studies met inclusion criteria. All studies utilized low-cost, low-fidelity, self-made arthroscopic simulators of varying designs. Five studies (50%) utilized low-cost, self-made arthroscopic cameras and three (30%) utilized commercial surgical arthroscopic cameras. One study (10%) demonstrated face validity, five (50%) demonstrated construct validity, and three (30%) demonstrated transfer validity. The assessed arthroscopic tasks varied, but generally consisted of a combination of triangulation, object grasping, and tissue manipulation. Seven (70%) studies evaluated total simulator construction costs, with six (60%) studies achieving total construction costs of &lt; $80 US Dollars. Conclusions: A growing body of literature supports the use of low-cost, low-fidelity, self-made arthroscopic surgical simulators. The cost-effectiveness and practicality of these simulators remains a major benefit to their overall utility when compared to their commercially available and high-fidelity counterparts. Furthermore, studies utilizing low-fidelity arthroscopic simulators are beginning to place a large importance on the achievement of face, construct, and transfer validity. Evidence suggests that the true utility of low-cost, low-fidelity arthroscopic surgical simulators stem not from their ability to replicate operating room conditions, but rather from their ability to provide practical training in basic and essential arthroscopic skills that will then be further refined through possible additional simulation and future surgical training.

Validation of virtual reality arthroscopy simulator relevance in characterising experienced surgeons

BackgroundVirtual reality (VR) simulation is particularly suitable for learning arthroscopy skills. Despite significant research, one drawback often outlined is the difficulty in distinguishing performance levels (Construct Validity) in experienced surgeons. Therefore, it seems adequate to search new methods of performance measurements using probe trajectories instead of commonly used metrics. HypothesisIt was hypothesized that a larger experience in surgical shoulder arthroscopy would be correlated with better performance on a VR shoulder arthroscopy simulator and that experienced operators would share similar probe trajectories. Materials & methodsAfter answering to standardized questionnaires, 104 trajectories from 52 surgeons divided into 2 cohorts (26 intermediates and 26 experts) were recorded on a shoulder arthroscopy simulator. The procedure analysed was the “loose body removal” in a right shoulder joint. 10 metrics were computed on the trajectories including procedure duration, overall path length, economy of motion and smoothness. Additionally, Dynamic Time Warping (DTW) was computed on the trajectories for unsupervised hierarchical clustering of the surgeons. ResultsExperts were significantly faster (Median 70.9s Interquartile range [56.4–86.3] vs. 116.1s [82.8–154.2], p<0.01), more fluid (4.6.105mm.s−3 [3.1.105–7.2.105] vs. 1.5.106mm.s−3 [2.6.106–3.5.106], p=0.05), and economical in their motion (19.3mm2 [9.1–25.9] vs. 33.8mm2 [14.8–50.5], p<0.01), but there was no significant difference in performance for path length (671.4mm [503.8–846.1] vs 694.6mm [467.0–1090.1], p=0.62). The DTW clustering differentiates two expertise related groups of trajectories with performance similarities, respectively including 48 expert trajectories for the first group and 52 intermediates and 4 expert trajectories for the second group (Sensitivity of 92%, Specificity of 100%). Hierarchical clustering with DTW significantly identified expert operators from intermediate operators and found trajectory similarities among 24/26 experts. ConclusionThis study demonstrated the Construct Validity of the VR shoulder arthroscopy simulator within groups of experienced surgeons. With new types of metrics simply based on the simulator's raw trajectories, it was possible to significantly distinguish levels of expertise. We demonstrated that clustering analysis with Dynamic Time Warping was able to reliably discriminate between expert operators and intermediate operators. Clinical RelevanceThe results have implications for the future of arthroscopic surgical training or post-graduate accreditation programs using virtual reality simulation. Level of evidenceIII; prospective comparative study.

A Prospective Assessment of Knee Arthroscopy Skills Between Medical Students and Residents-Simulator Exercises for Partial Meniscectomy and Analysis of Learning Curves.

BackgroundThe Covid-19 pandemic has created the largest disruption of education in history. In a response to this, we aimed to evaluate the knee arthroscopy learning curve among medical students and orthopaedic residents.MethodsAn arthroscopy simulator was used to compare the learning curves of two groups. Medical students with any prior knowledge of arthroscopy (n=24) were compared to a residents group (n=16). Analyzed parameters were “time to complete a task,” assessment of the movement of tools and values scoring damage to the surrounding tissues.ResultsAfter several repetitions, both groups improved their skills in terms of time and movement. Residents were on average faster, had less camera movement, and touched the cartilage tissue less often than did students. Students showed a steeper improvement curve than residents for certain parameters, as they started from a different experience level.ConclusionThe participants were able to reduce the time to complete a task. There was also a decrease in possible damage to the virtual surrounding tissues. In general, the residents had better mean values, but the students had the steeper learning curve. Particularly less experienced surgeons can especially train their hand–eye coordination skills required for arthroscopy surgery. Training simulators are an important training tool that supplements cadaveric training and participation in arthroscopic operations and should be included in training.

Mixed-Methods Analysis of a Validated Arthroscopic Knot-Tying Simulator With New Indirect Visualization Condition.

Background:Simulation provides low-risk opportunities for surgical trainees to learn and practice fundamental skills. One simulation tool for orthopaedics is the Arthroscopic Knot (ArK) Trainer, which has been validated as an effective simulation tool across multiple methodologies. Previous studies have investigated the ArK Trainer in its basic form using clear plexiglass, which allows direct visualization of tissue anchors.Purpose:Using a mixed-methods approach, we assessed and compared junior and senior trainees’ Seoul Medical Center (SMC) knot–tying performance under direct and indirect visualization.Study Design:Cross-sectional study.Methods:Fourteen orthopaedic surgery postgraduate trainees at a single medical school were recruited to participate. Trainees tied SMC knots using the Ark Trainer under direct and indirect visualization. A mixed-methods approach was used to evaluate knot-tying proficiency and characterize participants’ approach to knot-tying. Knot-tying proficiency was evaluated using validated tools: a task-specific checklist (TSC), a global rating scale (GRS), and a proficiency scale (PS). Participants’ approach to knot-tying was characterized using Likert-type questionnaires and semistructured interviews. An α level of .10 was set a priori owing to the small pool of trainees.Results:The 14 participants included 7 junior residents (postgraduate years [PGYs] 1 and 2) and 7 senior residents (PGY ≥3), of whom 3 were fellows (PGY 6). Senior trainees outperformed junior trainees on both versions of the ArK Trainer: clear (GRS, P = .055; PS, P = .075) and covered (TSC, P = .05). Overall, participants performed better under direct visualization conditions (GRS, P = .05). In semistructured interviews, significantly more senior trainees discussed relying on haptic cues while tying knots under direct visualization (P = .021). The majority of trainees agreed that both versions of the ArK Trainer were realistic and appropriate practice formats for their level of training.Conclusion:Senior trainees were significantly more experienced than were junior trainees in arthroscopic skill and outperformed them on both configurations: direct (PS and GRS) and indirect (TSC) visualization. Experienced trainees were significantly more likely to report using tactile cues to aid knot-tying under indirect visualization. It is likely that inexperienced trainees rely more heavily on direct visualization and that the use of tactile cues may be an indicator of knot-tying proficiency. Trainees recommended progression from direct to indirect visualization configurations for inexperienced learners.

Ten hours of simulator training in arthroscopy are insufficient to reach the target level based on the Diagnostic Arthroscopic Skill Score

Simulator arthroscopy training has gained popularity in recent years. However, it remains unclear what level of competency surgeons may achieve in what time frame using virtual training. It was hypothesized that 10h of training would be sufficient to reach the target level defined by experts based on the Diagnostic Arthroscopic Skill Score (DASS). The training concept was developed by ten instructors affiliated with the German-speaking Society of Arthroscopy and Joint Surgery (AGA). The programme teaches the basics of performing arthroscopy; the main focus is on learning and practicing manual skills using a simulator. The training was based on a structured programme of exercises designed to help users reach defined learning goals. Initially, camera posture, horizon adjustment and control of the direction of view were taught in a virtual room. Based on these skills, further training was performed with a knee model. The learning progress was assessed by quantifying the exercise time, camera path length and instrument path length for selected tasks. At the end of the course, the learners' performance in diagnostic arthroscopy was evaluated using DASS. Participants were classified as novice or competent based on the number of arthroscopies performed prior to the assessment. Except for one surgeon, 131 orthopaedic residents and surgeons (29 women, 102 men) who participated in the seven courses agreed to anonymous data analysis. Fifty-eight of them were competents with more than ten independently performed arthroscopies, and 73 were novices, with fewer than ten independently performed arthroscopies. There were significant reductions in exercise time, camera path length and instrument path length for all participants after the training, indicating a rapid increase in performance. No difference in camera handling between the dominant and non-dominant sides was found in either group. The competents performed better than the novices in various tasks and achieved significantly better DASS values on the final performance test. Our data have demonstrated that arthroscopic skills can be taught effectively on a simulator, but a 10-h course is not sufficient to reach the target level set by experienced arthroscopists. However, learning progress can be monitored more objectively during simulator training than in the operating room, and simulation may partially replace the current practice of arthroscopic training. III.

The FAST Workstation Shows Construct Validity and Participant Endorsement

PurposeTo determine in what way the proposed simulation-based intervention (SBI) is an effective intervention for use in basic arthroscopic skills training.MethodsTwenty candidates were recruited and grouped according to experience. Performance metrics included the time to activity completion, errors made, and Global Rating Scale score. Qualitative data were collected using a structured questionnaire.ResultsPerformance on the SBI differed depending on previous arthroscopic training received. Performance on the simulator differed between groups to a statistically significant level regarding time to completion. A difference was also present between participants with no previous training and those with previous training when assessed using the Global Rating Scale. The SBI was deemed acceptable, user-friendly, and realistic. Participants practicing at the expert level believe that such an SBI would be beneficial in developing basic arthroscopic skills.ConclusionsThe results of this study provide evidence that the use of an SBI consisting of a benchtop workstation, laptop viewing platform, 30° arthroscope, and defined performance metrics can detect differences in the level of arthroscopic experience. This format of SBI has been deemed acceptable and useful to the intended user, increasing the feasibility of introducing it into surgical training.Clinical RelevanceThis study adds to the existing body of evidence supporting the potential benefits of benchtop SBIs in arthroscopic skills training. Improved performance on such an SBI may be beneficial for the purpose of basic arthroscopic skills training, and we would support the inclusion of this system in surgical training programs such as those developed by the Arthroscopy Association of North America and American Board of Orthopaedic Surgery.

Module-Based Arthroscopic Knee Simulator Training Improves Technical Skills in Naive Learners: A Randomized Trial

PurposeTo compare the effectiveness, in comparison to a control group (C), of module-based training (MBT) and traditional learning (TL) as a means of acquiring arthroscopic skills on an arthroscopic surgery simulator.MethodsThirty health sciences students with no previous arthroscopy experience were recruited and randomized into 1 of 3 groups: MBT, TL, or C (1:1:1 ratio). Participants in MBT were required to independently practice on a VirtaMed ArthroS simulator (VirtaMed AG, Zurich, Switzerland) for a minimum of 2 hours per week, whereas TL received one-on-one coaching by a senior orthopaedic resident for 15 minutes per week. The control group received no training. All groups were assessed at baseline and at 4 weeks based on objective measures generated by the surgical simulator (procedure time, camera path length, meniscus cutting score, detailed visualization, safety score and total score), and subjective ratings scales (Objective Assessment of Arthroscopic Skill [OAAS] global assessment form, and Competency-Based Assessment form).ResultsParticipants in the MBT group trained on average 113 min/week whereas the TL group trained on average 24 min/week. Three-way repeated-measures analysis of variance showed significant group by time interactions for procedure time (P = .006), camera path length (P = .008), safety score (P = .013), total score (P = .003), OAAS form (P < .001), and Competency-Based Assessment form (P < .001). MBT group was superior to C group for procedure time (P = .02), camera path length (P = .003), total score (P = .004), and OAAS form (P = .021), but there were no significant post-hoc differences between MBT and TL groups, or TL and C groups after Bonferroni correction. Total practice time explained 37.5% of the final simulator total score variance.ConclusionsKnee arthroscopy simulation training with self-learning modules can improve skills in areas such as procedure time, camera path length, and total score in untrained participants compared with a control group.Clinical RelevanceModule-based simulation training provides additional training time and improves technical skills in naive health science students. It is hoped that this effect can be preserved and applied to junior resident developing in a busy residency program.

242 Maintaining Surgical Training During the Covid-19 Pandemic; A Novel Use of Surgical Simulators

IntroductionDuring Covid-19 pandemic, operation theatres limit the number of staff during each session, which causes a decrease in training opportunity. To counteract this lapse, the Orthopaedic Research Institute (ORI) designs an innovative training session. During the nationwide lockdown, the closure of the Institute allowed for the transfer of the VirtaMed ArthrosTM (VA), to our NHS facility. VA is a surgical simulator which enables the participant to practise knee arthroscopy.MethodParticipants with little arthroscopic experience were included in the study. Three fellowship-trained surgeons conducted daily teaching sessions. Participants were taught necessary arthroscopic skills before undertaking training modules on diagnostic arthroscopy. 90% of the participants attended the session at least three times.At the end of every module, VA generates a score based on parameters which include procedure duration, visualisation of key structures and iatrogenic chondral damage. Structure questionnaires were also used to analyse feedback.ResultsThe overall confidence and module scores progress with each subsequent session. A keystone of success is the location and ease of access to the simulator.ConclusionsSurgical simulators are a useful tool for surgical education and training. We should encourage their use in the future, especially in the UK surgical training programme.