BACKGROUND: The purpose of this study was to determine whether low-fidelity arthroscopic simulation training improves basic ankle arthroscopy

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1 Kevin Martin, DO, MC, USA David Patterson, MD *,# (presenting author) Phinit Phisitkul, MD * Kenneth Cameron, PhD, MPH, ATC $ John Femino, MD * Annunziato Amendola, MD * * University of Iowa Hospitals and Clinics, Iowa City, Evans Army Hospital, Fort Carson, CO # Detroit Medical Center Sports Medicine, Detroit, MI $ Keller Army Hospital, West Point, NY

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3 BACKGROUND: The purpose of this study was to determine whether low-fidelity arthroscopic simulation training improves basic ankle arthroscopy performance and efficiency among orthopedic trainees. METHODS: Twenty-nine orthopedic surgery trainees with varying levels of experience in ankle arthroscopy were randomized into either simulation or standard practice groups. At baseline testing, all participants performed simulator-based testing and a cadaveric diagnostic ankle arthroscopy with video recording. The simulation group subsequently received 4 one-on-one, 15-minute simulation training sessions over a 4-month period, while the standard practice group received no additional simulation training or exposure. After intervention, both groups were reevaluated with simulator testing and a second recorded cadaveric diagnostic ankle arthroscopy. Two blinded, independent experts evaluated each randomized arthroscopic performance using the 15-point checklist, Arthroscopic Surgery Skill Evaluation Tool (ASSET), and total elapsed time, and all outcome measures were compared within and between groups. RESULTS: Baseline arthroscopic experience, simulator task performance measures, and ASSET scores were equivalent between the simulation and standard practice groups. After completion of training, the simulation group outscored the control group in total ASSET score (34.9 vs 19.6; P <.001) and checklist score (14.5 vs 8.4; P <.001) and achieved nearly expert ASSET Safety scores (4.7 vs 2.9; P <.001) on the simulator model. Cadaver testing also demonstrated significant improvements in total ASSET score (28.8 vs 16.8; P <.001), checklist score (12.6 vs 7.1; P <.001), and ASSET Safety score (3.9 vs 2.6; P <.001). CONCLUSION: These results demonstrate that low-fidelity ankle arthroscopy simulation training can improve basic surgical skills, efficiency of movement, and anatomic recognition. The results suggest greater patient safety during ankle arthroscopy following simulation training. LEVEL OF EVIDENCE: Level I, prospective comparative study.

4 Orthopedic resident training has undergone substantial changes, with a goal of standardized, outcomes-based curricula. ACGME work hour restrictions, case log minimums and core milestones are just some examples of this drive towards standardization 1 Recently the Resident Review Committee (RRC) has mandated that simulation be incorporated into resident education 2 Large-joint simulator models have been studied, validated, 3,4,5 and show transfer validity 6,7 Most simulators used have a focus on highfidelity virtual reality with sophisticated force feedback haptic arms Cost and availability are sometimes out of reach for some training programs

5 Orthopedic trainees would show improved performance in basic arthroscopic skills following a supplementary arthroscopic simulation training curriculum utilizing a lowfidelity ankle simulator model.

6 Single-blinded, prospective randomized controlled trial with parallel group design 29 residents, baseline data collected including year-in-training, previous ankle arthroscopy experience (ACGME case logs), baseline recorded video arthroscopic exam on both cadaver and sawbones models Arthroscopic exams independently graded by expert ankle arthroscopists using the wellvalidated Arthroscopic Surgery Skill Evaluation Tool (ASSET) 8 Time to completion, and identification of a 15 point anatomic checklist also recorded Residents subsequently randomized within yearin-training to either four 15 minute training sessions on a low-fidelity model (sawbones) or typical experience provided by residency

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9 No differences in baseline characteristics of simulation vs. standard practice groups, nor in number of ankle scopes performed during study period (4 months) Simulation group outscored the control group in total ASSET score on the simulator (34.9 vs. 19.6; p<.001) and cadaver (27.8 vs. 16.8; p<.001) ASSET safety subscore demonstrated expert-level safety scores in simulation group for simulation testing (4.7 vs. 2.9; p<.001) and superior safety scores in the cadaver (3.9 vs. 2.6; p<.001) Simulation group outperformed controls in regard to anatomic identification in the simulator (14.5 vs. 8.4; p<.001) and cadaver (12.6 vs. 7.1; p<.001) Both groups improved mean time to completion but control group significantly faster on the cadaver (171 vs. 219 seconds; p=.005)

10 Transfer validity skills learned on a simulator translating to in vivo surgical skills have not been previously demonstrated utilizing a lowfidelity arthroscopic ankle simulator Previous studies did not have standardized testing, did not rely on orthopedic residents exclusively, and relied on self-reporting of experience 9,7 The simulation group demonstrated superiority in skills, while the control group demonstrated a degradation in their ASSET score Evaluation bias addressed by using independent experts that were blinded to randomization

11 A curriculum that entails training in low-fidelity ankle arthroscopy simulation can improve orthopedic trainees basic surgical skills, efficiency of movement and anatomic recognition These results suggest greater patient safety during ankle arthroscopy following simulation training With as few as four 15-minute training sessions, orthopedic trainees can improve their basic skills as assessed by a validated measurement tool (ASSET score) Future studies should correlate to experience in the OR as well as refining objective measures for proficiency-based progression curricula

12 1. Accreditation Council for Graduate Medical Education. ACGME program requirements for residency education in general surgery. ialties/surgery.aspx, Accessed Oct Accreditation Council for Graduate Medical Education for Orthopaedic Surgery. /OrthopaedicSurgery.aspx 3. Gomoll AH, O Toole RV, Czarnecki J, Warner JJ. Surgical experience correlates with performance on a virtual reality simulator for shoulder arthroscopy. Am J Sports Med. 2007;35: Martin KD, Belmont JPJ Jr, Schoenfeld AJ, Todd M, Cameron KL, Owens BD. Arthroscopic basic task performance in shoulder simulator model correlates with simulator task performance in cadavers. J Bone Joint Surg Am. 2011;93:e127(1-5) 5. Pedowitz RA, Esch J, Snyder S. Evaluation of a virtual reality simulator for arthroscopy skills development. Arthroscopy. 2002;18:E29 6. Henn RF, Shah N, Warner JJ, Gomoll AH. Shoulder arthroscopy simulator training improves shoulder arthroscopy performance in a cadaveric model. Arthroscopy. 2013;29(6): Howells NR, Gill HS, Carr AJ, Price AJ, Rees JL. Transferring simulated arthroscopic skills to the operating theatre: a randomized blinded study. J Bone Joint Surg Br. 2008;90-B: Koehler RJ, Amsdell S, Arendt EA, et al. The Arthroscopic Surgical Skill Evaluation Tool (ASSET). Am J Sports Med. 2013;41: Butler A, Olson T, Koehler R, Nicandri G. Do the skills acquired by novice surgeons using anatomic dry models transfer effectively to the task of diagnostic knee arthroscopy performed on cadaveric specimens? J Bone Joint Surg Am. 2013;95(3):e15(1-8)