Knee Arthroscopy Simulator Research Articles

KNEE ARTHROSCOPY: SHOULD KNEE ARTHROSCOPY SIMULATION BE PART OF THE TRAINING CURRICULUM IN THE UK?

IntroductionKnee arthroscopy can be used for ligamentous repair, reconstruction and to reduce burden of infection. Understanding and feeling confident with knee arthroscopy is therefore a highly important skillset for the orthopaedic surgeon. However, with limited training or experience, furthered by reduced practical education due to COVID-19, this skill can be under-developed amongst trainee surgeons.MethodsAt a single institution, ten junior doctors (FY1 to CT2), were recruited as a part of a five, two-hour session, training programme utilising the Simbionix® ARTHRO Mentor knee arthroscopy simulator, supplemented alongside educational guidance with a consultant orthopaedic knee surgeon. All students had minimal to no levels of prior arthroscopic experience. Exercises completed included maintaining steadiness, image centring and orientation, probe triangulation, arthroscopic knee examination, removal of loose bodies and meniscectomy. Pre and post experience questionnaires and quantitative repeat analysis on simulation exercises were undertaken to identify levels of improvement.ResultsComparing pre and post experience questionnaires significant improvements in levels of confidence were noted in the following domains: naming arthroscopic instruments, port positioning and insertion, recognising normal anatomy arthroscopically, holding and using arthroscopic instruments and assisting in a live theatre setting (p<0.05). Significant improvements were also noted in time taken to complete and distance covered in metres, of the simulated exercises on repeat performance (p<0.05).ConclusionOverall, with only five sessions under senior guidance, using a simulator such as the ARTHRO Mentor, significant improvements in both levels of confidence and skill can be developed even among individuals with no prior experience.

KNEE ARTHROSCOPY: SHOULD KNEE ARTHROSCOPY SIMULATION BE PART OF THE TRAINING CURRICULUM IN THE UK?

AbstractIntroductionKnee arthroscopy can be used for ligamentous repair, reconstruction and to reduce burden of infection. Understanding and feeling confident with knee arthroscopy is therefore a highly important skillset for the orthopaedic surgeon. However, with limited training or experience, furthered by reduced practical education due to COVID-19, this skill can be under-developed amongst trainee surgeons.MethodsAt a single institution, ten junior doctors (FY1 to CT2), were recruited as a part of a five, two-hour session, training programme utilising the Simbionix® ARTHRO Mentor knee arthroscopy simulator, supplemented alongside educational guidance with a consultant orthopaedic knee surgeon. All students had minimal to no levels of prior arthroscopic experience. Exercises completed included maintaining steadiness, image centering and orientation, probe triangulation, arthroscopic knee examination, removal of loose bodies, and meniscectomy. Pre and post-experience questionnaires and quantitative repeat analysis on simulation exercises were undertaken to identify levels of improvement.ResultsComparing pre and post-experience questionnaires significant improvements in levels of confidence were noted in the following domains: naming arthroscopic instruments, port positioning and insertion, recognising normal anatomy arthroscopically, holding and using arthroscopic instruments and assisting in a live theatre setting (p<0.05). Significant improvements were noted in time taken to complete, distance covered in metres and roughness of instruments used on the simulated exercises on repeat performance (p<0.05).ConclusionWith only five sessions under senior guidance, using a simulator such as the ARTHRO Mentor, significant improvements in both levels of confidence and skill can be developed even among individuals with no prior experience.

Virtual reality simulation training improve diagnostic knee arthroscopy and meniscectomy skills: a prospective transfer validity study

PurposeLimited data exist on the actual transfer of skills learned using a virtual reality (VR) simulator for arthroscopy training because studies mainly focused on VR performance improvement and not on transfer to real word (transfer validity). The purpose of this single-blinded, controlled trial was to objectively investigate transfer validity in the context of initial knee arthroscopy training.MethodsFor this study, 36 junior resident orthopaedic surgeons (postgraduate year one and year two) without prior experience in arthroscopic surgery were enrolled to receive standard knee arthroscopy surgery training (NON-VR group) or standard training plus training on a hybrid virtual reality knee arthroscopy simulator (1 h/month) (VR group). At inclusion, all participants completed a questionnaire on their current arthroscopic technical skills. After 6 months of training, both groups performed three exercises that were evaluated independently by two blinded trainers: i) arthroscopic partial meniscectomy on a bench-top knee simulator; ii) supervised diagnostic knee arthroscopy on a cadaveric knee; and iii) supervised knee partial meniscectomy on a cadaveric knee. Training level was determined with the Arthroscopic Surgical Skill Evaluation Tool (ASSET) score.ResultsOverall, performance (ASSET scores) was better in the VR group than NON-VR group (difference in the global scores: p < 0.001, in bench-top meniscectomy scores: p = 0.03, in diagnostic knee arthroscopy on a cadaveric knee scores: p = 0.04, and in partial meniscectomy on a cadaveric knee scores: p = 0.02). Subgroup analysis by postgraduate year showed that the year-one NON-VR subgroup performed worse than the other subgroups, regardless of the exercise.ConclusionThis study showed the transferability of the technical skills acquired by novice residents on a hybrid virtual reality simulator to the bench-top and cadaveric models. Surgical skill acquired with a VR arthroscopy surgical simulator might safely improve arthroscopy competences in the operating room, also helping to standardise resident training and follow their progress.Level of evidence2

Practicing Procedural Skills Is More Effective Than Basic Psychomotor Training in Knee Arthroscopy: A Randomized Study.

Background:Simulator-assisted arthroscopy education traditionally consists of initial training of basic psychomotor skills before advancing to more complex procedural tasks.Purpose:To explore and compare the effects of basic psychomotor skills training versus procedural skills training on novice surgeons’ subsequent simulated knee arthroscopy performance.Study Design:Controlled laboratory study.Methods:Overall, 22 novice orthopaedic surgeons and 11 experienced arthroscopic surgeons participated in this study, conducted from September 2015 to January 2017. Novices received a standardized introductory lesson on knee arthroscopy before being randomized into a basic skills training group or a procedural skills training group. Each group performed 2 sessions on a computer-assisted knee arthroscopy simulator: The basic skills training group completed 1 session consisting of basic psychomotor skills modules and 1 session of procedural modules (diagnostic knee arthroscopy and meniscal resection), whereas the procedural skills training group completed 2 sessions of procedural modules. Performance of the novices was compared with that of the experienced surgeons to explore evidence of validity for the basic psychomotor training skills modules and the procedural modules. The effect of prior basic psychomotor skills training and procedural skills training was explored by comparing pre- and posttraining performances of the randomized groups using a mixed-effects regression model.Results:Validity evidence was found for the procedural modules, as test results were reliable and experienced surgeons significantly outperformed novices. We found no evidence of validity for the basic psychomotor skills modules, as test scores were unreliable and there was no difference in performance between the experienced surgeons and novices. We found no statistical effect of basic psychomotor skills training as compared with no training (P = .49). We found a statistically significant effect of prior procedural skills training (P < .001) and a significantly larger effect of procedural skills training as compared with basic psychomotor skills training (P = .019).Conclusion:Procedural skills training was significantly more effective than basic psychomotor skills training regarding improved performance in diagnostic knee arthroscopy and meniscal resection on a knee arthroscopy simulator. Furthermore, the basic psychomotor skills modules lacked validity evidence.Clinical Relevance:On the basis of these results, we suggest that future competency-based curricula focus their training on full knee arthroscopy procedures. This could improve future education programs.

Surgical Games: A Simulation-Based Structured Assessment of Orthopedic Surgery Resident Technical Skill

Simulation-based education and objective evaluation of surgical skill have been incorporated into many surgical training programs. We describe the development and implementation of a timed, multitask, station-based Surgical Games to evaluate orthopedic resident surgical skills. Participants in the study were postgraduate-year 2 to 5 orthopedic surgery residents from a single institution. Residents completed 4-timed simulated tasks: cadaveric carpal tunnel release (CTR), Sawbones model of total knee arthroplasty (TKA), Sawbones model of ankle fracture open reduction internal fixation (ORIF), and knee arthroscopy simulator (KAS) of removal of loose body. Evaluations were performed using standardized score sheets by attending surgeons. Resident performance was analyzed by postgraduate-year and number of weeks of prior task-related residency training. A total of 32 residents were assessed at the 4 stations. Total scores were significantly different for CTR (p = 0.006), TKA (p = 0.05), and the KAS (p = 0.004) by year of training, but not for the ankle ORIF task. Residents with more task-specific experience performed significantly better on the KAS (p < 0.001), TKA (p = 0.002), and CTR (p = 0.02) tasks but not on the ankle ORIF task (p = 0.1). Overall, residents rated the exercise valuable to their education with mean scores of 3.9 ± 0.54 on a 5-point Likert Scale. This Surgical Games exercise provided an objective evaluation of surgical skill that correlated with year-in-training and prior experience in skill-specific rotations for the KAS, TKA, and CTR tasks. This surgical skills assessment provided an opportunity for effective structured feedback and identification of areas for improvement.

An Affordable Knee Arthroscopy Simulator

Abstract: Introduction: The objective of this study is to describe a model of knee arthroscopy simulator that is affordable, low-cost and easily reproducible, aiming to enable the diffusion of more effective active teaching and training methodologies. Methods: For the creation of the arthroscopic camera, an endoscopic camera for mobile phones and computers model SXT-5.0M manufactured by KKMOON were used. The camera was introduced in a metal tube, which was coupled to a set of three 20 mm PVC hydraulic connectors to simulate the handle and sleeve of the arthroscope. The camera has a resolution of 1280 x 720 pixels and is equipped with six built-in white LED lamps, simulating and eliminating the need to use an additional light source. The knee model was developed using a PVC pipe fixed on a wooden support, to which synthetic femur and tibia models were affixed. Four three-centimeter diameter holes, compatible with the standard arthroscopic portals, were made in the body of the PVC pipe. For the menisci, a model was made out of modeling clay (Corfix®), until the anatomical structures were close to the real ones. The model consists of both menisci and the intercondylar eminence, simulating the proximal tibial articular surface. The model made out of modeling clay was the basis for the production of a thin Crystal Polyester Resin mold. Using the resin mold, the meniscal models were made of Silicone Rubber Type II, widely used in industry and crafts. Results: A functional and reproducible simulator was obtained, consisting of a knee model and an arthroscopic camera. The simulator works adequately adapted to a TV, monitor or computer, and allows the simulation of diagnostic procedures, meniscectomy and meniscoplasty. Conclusion: It is possible to develop a knee arthroscopy simulator, with components available in local and electronic commerce, at a cost of approximately R$ 300.

An Affordable Knee Arthroscopy Simulator

Abstract: Introduction: The objective of this study is to describe a model of knee arthroscopy simulator that is affordable, low-cost and easily reproducible, aiming to enable the diffusion of more effective active teaching and training methodologies. Methods: For the creation of the arthroscopic camera, an endoscopic camera for mobile phones and computers model SXT-5.0M manufactured by KKMOON were used. The camera was introduced in a metal tube, which was coupled to a set of three 20 mm PVC hydraulic connectors to simulate the handle and sleeve of the arthroscope. The camera has a resolution of 1280 x 720 pixels and is equipped with six built-in white LED lamps, simulating and eliminating the need to use an additional light source. The knee model was developed using a PVC pipe fixed on a wooden support, to which synthetic femur and tibia models were affixed. Four three-centimeter diameter holes, compatible with the standard arthroscopic portals, were made in the body of the PVC pipe. For the menisci, a model was made out of modeling clay (Corfix®), until the anatomical structures were close to the real ones. The model consists of both menisci and the intercondylar eminence, simulating the proximal tibial articular surface. The model made out of modeling clay was the basis for the production of a thin Crystal Polyester Resin mold. Using the resin mold, the meniscal models were made of Silicone Rubber Type II, widely used in industry and crafts. Results: A functional and reproducible simulator was obtained, consisting of a knee model and an arthroscopic camera. The simulator works adequately adapted to a TV, monitor or computer, and allows the simulation of diagnostic procedures, meniscectomy and meniscoplasty. Conclusion: It is possible to develop a knee arthroscopy simulator, with components available in local and electronic commerce, at a cost of approximately R$ 300.

Lessons taught by a knee arthroscopy simulator about participants in a European arthroscopy training programme

BackgroundArthroscopy simulators offer safe and reproducible training to orthopaedic residents, thereby obviating the need for cadaver specimens. In addition, they collect data that can serve to investigate learning curves and evaluate training programmes with the goal of improving the quality of arthroscopy teaching. In this study, a cohort of surgeons was evaluated before and after a European theoretical and practical training programme that used a knee arthroscopy simulator. The primary objective was to assess whether the overall performance score was improved by the training programme. The secondary objectives were to determine which tasks and skills were improved by the programme, to compare a novice group to an experienced group, and to identify targets for improvement. HypothesisA theoretical and practical training course improves the scores achieved on an arthroscopy simulator task. MethodsA prospective comparative study was performed in 34 surgeons during the advanced arthroscopy training course organised by the European Paediatric Orthopaedic Society (EPOS) in January 2018. All participants performed a diagnostic task on the VirtaMed ArthroS™ simulator before and after the programme. The participants were divided into two groups based on number of knee arthroscopies performed each year, i.e.,>20 (experienced group) vs.≤20 (inexperienced group). The following parameters were compared between the two groups: overall score, operative time, percentage of iatrogenic injuries, camera and hook path lengths, and success in identifying anatomical structures. ResultsThe overall score on the diagnostic task was 199 before and 203 after the training programme (p=0.02). The operative time decreased significantly, from 185 to 115.9seconds (p<0.01). Camera path length decreased from 85.2 to 49.2cm and hook path length from 65.5 to 15.0cm (p<0.05). The mean proportion of arthroscopies with iatrogenic tibial cartilage injuries diminished from 2.7%±1.7% (range, 0–6.7) to 1.8%±1.8% (range, 0–7) (p=0.03); no change occurred in femoral injuries. When each group was assessed separately, the only significant change found in the experienced group was a decrease in operative time, whereas in the inexperienced group all parameters improved significantly. However, visualisation of anatomical structures was unchanged. ConclusionParticipation in the training programme improved overall performance, and the gains were greatest in the inexperienced group. During the post-training evaluation, some of the major anatomical structures were classified by the simulator as incompletely visualised, raising concern about a risk of underdiagnosis during arthroscopic explorations. Level of evidenceIII, prospective comparative study.

Three days of training with a low-fidelity arthroscopy triangulation simulator box improves task performance in a virtual reality high-fidelity virtual knee arthroscopy simulator.

The aim of this work is to evaluate the effectiveness of training with the low-fidelity ArthroBox® regarding performance of different basic arthroscopy tasks using a validated high-fidelity virtual reality simulator of the knee. Nineteen volunteers (14 females and 5 males) without any previous experience in arthroscopy were randomly assigned either to the ArthroBox® training group (n =10) or the non-training group (n =9). The training group underwent a supervised ArthroBox ® training consisting of a daily 60-min session for three consecutive days. Both groups completed the basic and the final assessment using a validated virtual reality-based passive haptic knee arthroscopy simulator (ArthroS, VirtaMed™). The following three factors were measured in different exercises (explained in "Materials and methods"): amount of time to finish the task, length of camera and scope path within the joint. Furthermore, the volunteers' demographics (age, sex, dexterity, video game experience, sport activities and profession) was assessed but showed no differences between the groups. There were no significant differences between the training and non-training group regarding the above-mentioned demographic factors. However, the training group showed significant improvement from baseline to follow-up in most activities (e.g. task performance time in seconds, intra-articular camera and grasp distance in centimetres; see Table1) in comparison to the non-training group. The results from this study demonstrate that training for three consecutive days using a portable and versatile low-fidelity simulator significantly improves arthroscopy performance when using a validated high-fidelity virtual knee simulator. Arthroscopic triangulation training outside the operating theatre with a portable, low-cost simulator has proven to be a valuable educational tool to improve the arthroscopic skills of trainee surgeons. Diagnostic study, Level II.

Progress in Knee Arthroscopy Skills of Residents and Medical Students: A Prospective Assessment of Simulator Exercises and Analysis of Learning Curves

Knee arthroscopies are very common orthopedic procedures. For a number of reasons, including increased public awareness for medical errors, patient safety, strict regulations governing duty-hours for residents, surgeons' liability, and an increasing emphasis on the efficient use of operating room time, interest in simulator training is on the rise. It was the purpose of this study to analyze learning curves of medical students and orthopedic resident surgeons using a virtual knee arthroscopy simulator. Learning curves of medical students and orthopedic residents were measured perspective using an arthroscopic training simulator for 2 different exercises. Time, camera and probe movement as well as camera and probe roughness were the parameters to be compared. Mean and standard deviation of the initial and the final score for the consecutively performed exercises as well as their slope were reported. The study was performed at the Medical University of Innsbruck, Department of Orthopaedic Surgery. Level of clinical care: institutional. A Students Group (n = 10) consisting of medical students at the Medical University of Innsbruck with no prior knowledge of arthroscopy but interest in orthopedic surgery was selected. The group was compared to a Residents Group (n = 9) which was comprised of orthopedic resident surgeons who had learned arthroscopy in operation courses. All participants involved in the study did several repetitions of the described exercises. Both groups improved their skills after several repetitions. Residents were on average faster, moved the camera less, and touched the cortical tissue less than the students. For certain parameters students showed a steeper improvement curve than did residents, because the students started from a different experience level. In conclusion, our results demonstrate the usefulness of virtual knee arthroscopy simulators as an important tool for improving surgical and arthroscopic skills in orthopedic resident surgeons, and medical students.

Wrist Arthroscopy: Can We Gain Proficiency Through Knee Arthroscopy Simulation?

Wrist arthroscopy is a challenging discipline with limited training exposure during residency. The purpose of this study was to evaluate the effectiveness of virtual knee arthroscopy simulation training for gaining proficiency in wrist arthroscopy. Participants were recorded performing a cadaveric wrist arthroscopy simulation. The residents then practiced knee arthroscopy on a virtual reality simulator and repeated the wrist arthroscopy simulation. All videos were blinded prior to assessment. Proficiency was graded using the Arthroscopic Surgery Skill Evaluation Tool global rating scale. In addition, participants were asked to complete a survey assessing the value of the virtual reality knee arthroscopy simulator for wrist arthroscopy. Orthopaedic Surgery Residency Program, Carolinas Medical Center, a large, public, nonprofit hospital located in Charlotte, North Carolina. Orthopaedic residents at our center were asked to participate in the simulation training. Participation was voluntary and nonincentivized. All orthopaedic residents at our institution (N = 27) agreed to participate. In total, there were 10 Intern (PGY-0 and PGY-1), 10 Junior (PGY-2 and PGY-3), and 7 Senior (PGY-4 and PGY-5) residents. In addition, a fellowship-trained hand surgeon was recruited to participate in the study, performing the wrist arthoscopy simulation. Two additional fellowship-trained hand surgeons, for a total of 3, assessed the blinded videos. There was a trend toward better wrist Arthroscopic Surgery Skill Evaluation Tool scores by training level, although the difference was not statistically significant. Interns improved by an average of 1.8 points between baseline and postknee simulation tests. Junior and senior residents decreased by 1.6 and 5.0 points, respectively. Knee arthroscopy simulation training did not objectively improve wrist arthroscopy proficiency among residents. A wrist-specific arthroscopy simulation program is needed if measurable competence through simulation is desired.

Fundamentals of Arthroscopic Surgery Training Program Improves Knee Arthroscopy Simulator Performance in Arthroscopic Trainees

To determine the effectiveness of a nonanatomic simulator in developing basic arthroscopy motor skills transferable to an anatomic model. Forty-three arthroscopy novice individuals currently enrolled in medical school were recruited to perform a diagnostic knee arthroscopy using a high-fidelity virtual reality arthroscopic simulator providing haptic feedback after viewing a video of an expert performing an identical procedure. Students were then randomized into an experimental or control group. The experimental group then completed a series of self-guided training modules using the fundamentals of arthroscopy simulator training nonanatomic modules including camera centering, tracking, periscoping, palpation, and collecting stars in a three-dimensional space. Both groups completed another diagnostic knee arthroscopy between 1 and 2weeks later. Camera path length, time, tibia and femur cartilage damage, as well as a composite score were recorded by the simulator on each attempt. The experimental group (n= 22) showed superior performance in composite score (30.09 vs 24, P= .046) and camera path length (71.51cm vs 109.07cm, P= .0274) at the time of the second diagnostic knee arthroscope compared with the control group (n= 21). The experimental group also showed significantly greater improvement in composite score between the first and second arthroscopes compared with the control group (14.27 vs 4.95, P < .01). Femoral and tibial cartilage damage were not significantly improved between arthroscopy attempts (-0.86% vs-1.45%, P= .40) and (-1.10 vs-1.27%, P= .83), respectively. The virtual reality-based fundamentals of arthroscopy simulator training nonanatomic simulator is beneficial in developing basic motor skills in arthroscopy novice individuals resulting in significantly greater composite performance in an anatomic knee model. Based on the results of this study, it appears that there may be benefit from nonanatomic simulators in general as part of an arthroscopy training program. Level II, randomized trial.

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

To determine whether a virtual reality (VR) arthroscopy simulator or benchtop (BT) arthroscopy simulator showed superiority as a training tool. 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. 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). 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. 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.

Performance of medical students on a virtual reality simulator for knee arthroscopy: an analysis of learning curves and predictors of performance.

BackgroundEthical concerns for surgical training on patients, limited working hours with fewer cases per trainee and the potential to better select talented persons for arthroscopic surgery raise the interest in simulator training for arthroscopic surgery. It was the purpose of this study to analyze learning curves of novices using a knee arthroscopy simulator and to correlate their performance with potentially predictive factors.MethodsTwenty medical students completed visuospatial tests and were then subjected to a simulator training program of eight 30 min sessions. Their test results were quantitatively correlated with their simulator performance at initiation, during and at the end of the program.ResultsThe mean arthroscopic performance score (z-score in points) at the eight test sessions were 1. -35 (range, -126 to -5) points, 2. -16 (range, -30 to -2), 3. -11 (range, -35 to 4), 4. -3 (range, -16 to 5), 5. -2 (range, -28 to 7), 6. 1 (range, -18 to 8), 7. 2 (range, -9 to 8), 8. 2 (range, -4 to 7). Scores improved significantly from sessions 1 to 2 (p = 0.001), 2 to 3 (p = 0.052) and 3 to 4 (p = 0.001) but not thereafter. None of the investigated parameters predicted performance or development of arthroscopic performance.ConclusionNovices improve significantly within four 30 min test virtual arthroscopy knee simulator training but not thereafter within the setting studied. No factors, predicting talent or speed and magnitude of improvement of skills could be identified.

Correlation Between Arthroscopy Simulator and Video Game Performance: A Cross-Sectional Study of 30 Volunteers Comparing 2- and 3-Dimensional Video Games

To investigate the association between arthroscopy simulator performance and video game skills. This study compared the performances of 30 volunteers without experience performing arthroscopies in 3 different tasks of a validated virtual reality knee arthroscopy simulator with the video game experience using a questionnaire and actual performances in 5 different 2- and 3-dimensional (D) video games of varying genres on 2 different platforms. Positive correlations between knee arthroscopy simulator and video game performances (ρ= 0.63, P< .001) as well as experiences (ρ= 0.50, P= .005) were found. The strongest correlations were found for the task of catching (hooking) 6 foreign bodies (virtual rings; "triangulation") and the dribbling performance in a sports game and a first-person shooter game, as well as the meniscus resection and a tile-matching puzzle game (all ρ ≥ 0.60, P < .001). No correlations were found for any of the knee arthroscopy simulator tasks and a strategy game. Although knee arthroscopy performances do not correlate with 2-D strategy video game skills, they show a correlation with 2-D tile-matching puzzle games only for easier tasks with a rather limited focus, and highly correlate with 3-D sports and first-person shooter video games. These findings show that experienced and good 3-D gamers are better arthroscopists than nonexperienced and poor 3-D gamers. Level II, observational cross-sectional study.

Transfer of arthroscopic skills from computer simulation training to the operating theatre: a review of evidence from two randomised controlled studies

Introduction: There is paucity in the research on transfer validity of arthroscopic simulator training. The aim of this article is to determine whether skills derived from arthroscopic simulation are transferrable to the operating theatre and retained over time. Methods: A systematic review with rigorous criteria to identify the highest level of evidence available was carried out. The studies were critically appraised with narrative data synthesis. Results: Twenty-one studies on arthroscopic simulation were identified. Only two studies were randomised controlled trials. The first article demonstrated improved performance of basic knee arthroscopic tasks following a fixed period of training. The second article showed improved performance of arthroscopic tasks and no deterioration in the levels of skills following a period of six months. In addition, the two studies succeeded in demonstrating the importance of 3D motion analysis using computer simulators in the assessment of technical skills. Components of evaluation such as time to task completion, distance travelled by instruments and incidence of instruments collisions were associated with the highest validity and reliability of assessment. This systematic review highlighted the limitations of these two randomised studies. Discussion: Evidence from the two trials suggests that knee arthroscopy simulator training can result in improved performance. This review helped highlight the contribution of the two studies in terms of internal validity and consistency of using arthroscopic skills training. Further level I studies are however required to demonstrate the evidence for transfer and predictive validity of computer simulation as a training instrument.

Testing basic competency in knee arthroscopy using a virtual reality simulator: exploring validity and reliability.

Diagnostic knee arthroscopy is a common procedure that orthopaedic residents are expected to learn early in their training. Arthroscopy requires a different skill set from traditional open surgery, and many orthopaedic residents feel less prepared for arthroscopic procedures. Virtual reality simulation training and testing provide an opportunity to ensure basic competency before proceeding to supervised procedures in patients. Twenty-six physicians (thirteen novices and thirteen experienced arthroscopic surgeons) were voluntarily recruited to perform a test consisting of five arthroscopic procedures on a knee arthroscopy simulator. Performance was evaluated by obtaining predefined metrics from the simulator for each procedure, and z-scores, describing suboptimal performance, were calculated from the metrics. The intercase reliability of the simulator metrics was explored by calculating an intraclass correlation coefficient. Finally, a pass-or-fail standard was set with use of the contrasting groups method, and the consequences of the pass-or-fail standard were explored. One procedure was excluded from the final test because of a lack of validity. The total Z-scores for the four procedures included in the final test showed an intercase reliability of 0.87 (95% confidence interval, 0.78 to 0.93). The total mean z-score (and standard deviation) was 38.6 ± 27.3 points for the novices and 0.0 ± 9.1 points for the experienced surgeons (p < 0.0005). The pass-or-fail standard was set at a total z-score of 15.5 points, resulting in two of the novices passing the test and a single experienced surgeon failing the test. By combining four procedures on a virtual reality arthroscopy simulator, it was possible to create a valid, reliable, and feasible test of basic arthroscopic competency and to establish a credible pass-or-fail standard. The simulation-based test and pass-or-fail standard could aid in assessing and ensuring basic competency of future orthopaedic residents before proceeding to supervised procedures in patients.

Validation of a Virtual Reality Knee Arthroscopy Simulator for Surgical Training

Validation of a Virtual Reality Knee Arthroscopy Simulator for Surgical Training

Assessing Skills Decay on a Knee Arthroscopy Simulator

Performance on a VR knee arthroscopy simulator deteriorates over time if the subject does not undertake regular arthroscopy and simulation may provide a safe and effective way of preventing skills decay. We have demonstrated that training in Virtual Reality (VR) knee arthroscopy can significantly improve simulator performance compared to controls. The aim of this study is to assess whether skills decay occurs if subjects stop performing arthroscopy. 16 subjects were recruited (8 orthopaedic surgery trainees and 8 medical students or non-clinicians). All 16 subjects had previously undergone a training programme on the ARTHROMentorTM VR arthroscopy simulator consisting of standardized exercises. They had all made significant improvements in performance based on metrics provided by the simulator (time taken, distance covered by the arthroscope and hook, and roughness). These subjects were recalled after a mean period of 17 months and repeated the initial test 3 times. There was a significant deterioration in the measured parameters for all 16 subjects (p<0.03) and there was no difference between the two cohorts. There was however a significant improvement between their 1st and 3rd attempts (p<0.05) but the best score attained was still short of that achieved previously following the training programme (p=0.09). Performance on a VR knee arthroscopy simulator deteriorates over time as skills decay occurs if the subject does not undertake arthroscopy regularly. Simulation may provide a safe and effective way of preventing skills decay if trainees are unable to undertake regular arthroscopy and efforts should be made to integrate simulation into the orthopaedic curriculum.

Ensuring the usability of a knee arthroscopy simulator.

There is limited research considering the usability of medical virtual environments. Usability evaluation is an essential validation phase that considers the extent to which a product achieves its specific goals, with effectiveness, efficiency and satisfaction. A four-stage iterative approach is adopted to enhance usability in the development of a knee arthroscopy training system. This process has drawn attention to issues that may impede system usability for example non-conformity to platform conventions, and visibility of the system status. The process highlights features that computer scientists can overlook when working closely with a system but that are essential to user acceptance and effective application.