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1 Simultion Trining Improves Surgicl Proficiency nd Sfety During Dignostic Shoulder Arthroscopy Performed by Residents Brin R. Wtermn, MD; Kevin D. Mrtin, DO; Kenneth L. Cmeron, PhD, MPH, ATC; Brett D. Owens, MD; Philip J. Belmont Jr, MD bstrct Although virtul relity simultors hve estblished construct vlidity, no studies hve proven trnsfer of skills from simultor to improved in vivo surgicl skill. The current uthors hypothesized tht simultion trining would improve residents bsic rthroscopic performnce nd sfety. Twenty-two orthopedic surgery trinees were rndomized into simultion or stndrd prctice groups. At bseline testing, ll of the prticipnts performed simultor-bsed testing nd supervised, in vivo dignostic shoulder rthroscopy with video recording. The simultion group subsequently received 1 hour of totl instruction during 3-month period, nd the stndrd prctice group received no simultor trining. After intervention, both groups were reevluted with simultor testing nd second recorded dignostic shoulder rthroscopy. Two blinded, independent experts evluted rthroscopic performnce using the ntomic checklist, Arthroscopic Surgery Skill Evlution Tool (ASSET) score, nd totl elpsed time. All outcome mesures were compred within nd between groups. After intervention, men time required by the simultion group to complete the simultor tsk (30.64 seconds) ws 8±1.2 seconds fster thn the time required by the control group (38.64 seconds; P=.001). Probe distnce (51.65 mm) ws improved by 41.2±6.08 mm compred with the control (92.83 mm; P=.001). When compring ASSET sfety scores, the simultion group ws competent (3.29) nd significntly better thn the control group (3.00; P=.005) during finl rthroscopic testing. This study estblishes trnsfer vlidity for n rthroscopic shoulder simultor model. Simultor trining for residents in trining cn decrese surgicl times, improve bsic surgicl skills, nd confer greter ptient sfety during shoulder rthroscopy. [Orthopedics.] Grdute medicl eduction in orthopedic surgery nd other surgicl disciplines hs evolved rpidly in the pst decde. With the implementtion of mjor chnges mndted by the Accredittion Council for Grdute Medicl Eduction (ACGME), residents must now comply with significnt work hour restrictions, cse log requirements, nd forml surgicl skills trining progrms. 1,2 These chnges hve prompted residency progrm directors nd orthopedic eductors to criticlly pprise nd further develop their current surgicl skills trining curriculum. Ide- The uthors re from the Deprtment of Orthopedic Surgery nd Rehbilittion (BRW, KDM, PJB), Willim Beumont Army Medicl Center, El Pso, Texs; nd The John A. Fegin Jr Sports Medicine Fellowship (KLC, BDO), Keller Army Hospitl, US Militry Acdemy, West Point, New York. Drs Wtermn, Mrtin, Cmeron, nd Belmont hve no relevnt finncil reltionships to disclose. Dr Owens is pid consultnt for Mitek. The uthors thnk the US Army Centrl Simultion Committee for support with this investigtion. The views expressed in this mnuscript re those of the uthors nd do not reflect the officil policy of the Deprtment of the Army, Deprtment of Defense, or US Government. The uthors re employees of the US Government. This work ws prepred s prt of their officil duties nd s such, there is no copyright to be trnsferred. Correspondence should be ddressed to: Brett D. Owens, MD, The John A. Fegin Jr Sports Medicine Fellowship, Keller Army Hospitl, US Militry Acdemy, 900 Wshington Rd, West Point, NY (owensbrett@gmil.com). Received: April 28, 2015; Accepted: November 11, doi: /

2 Figure: Photogrph of the shoulder simultor model (Arthro VR, 3D Systems, Simbionix Products, Clevelnd, Ohio). lly, these progrms should promote nd ccelerte skill cquisition within sfe nd controlled simultion environment to ultimtely improve surgicl performnce in the operting room. Although the link between technicl bility on simulted models nd ctul surgicl proficiency hs been more firmly estblished in the generl surgicl literture, 3-6 mny of these studies hve not estblished the construct vlidity of the individul trining model with n objective ssessment of surgicl experience, such s ACGME surgicl cse log dt, or used previously vlidted ssessment tools to quntify rthroscopic skill progression. When incorporting the use of simultor model s prt of n orthopedic surgicl skills curriculum, it is prgmtic to objectively ssess its vlue prior to full integrtion. Knee nd shoulder rthroscopy re mong the most commonly performed surgeries in the United Sttes, 7 nd the ACGME Orthopedic Surgery Residency Review Committee hs selected shoulder rthroscopy s 1 of the 15 procedures with minimum cselod requirements. 2 As the number nd complexity of shoulder rthroscopic procedures hs incresed with concomitnt decrese in resident work hours, rthroscopic shoulder simultion my better fcilitte the development of bsic shoulder rthroscopy skills during residency trining. In previous study, the performnce of bsic rthroscopic exercises on shoulder simultor model hs shown strong correltion with similr tsks in cdveric model. 8 In ddition, technicl performnce on the sme shoulder simultor model hd significnt reltionship with surgicl experience s mesured by totl number of rthroscopic cses nd yer in trining, thus estblishing the construct vlidity of the rthroscopic shoulder simultor under study. 9 Bsed on these findings, the im of the current study ws to evlute the trnsfer vlidity of this rthroscopic shoulder simultor model to ctul shoulder rthroscopy. To this end, the current investigtion evluted orthopedic surgery residents performnce before nd fter rthroscopic shoulder simultion trining in comprison to control group to determine whether the simultion trining improved bsic rthroscopic shoulder tsk performnce in the operting room. The current uthors hypothesized tht orthopedic residents would show improved performnce in bsic shoulder rthroscopic skills following supplementry rthroscopic simultion trining curriculum. Mterils nd Methods Prticipnts After receiving institutionl review bord pprovl, ll orthopedic trinees (N=22) from within single progrm with vrying postgrdute yer trining were enrolled for this study between October 2012 nd Jnury All prticipnts were recruited voluntrily to prticipte, nd cdemic stnding ws not ffected by study involvement or individul performnce. Previous rthroscopic experience vried by the individul resident s postgrdute yer in trining nd clinicl rottion schedule. All residents hd prticipted in dignostic simultion testing, but no forml rthroscopic simultion trining hd been undertken previously. Demogrphic informtion nd rthroscopy experience were collected t the onset of testing nd included ge, sex, postgrdute yer in trining, nd ACGME surgicl cse log dt. Ech resident s cse log previously ws reviewed qurterly by the senior uthor (P.J.B.) to ensure ccurcy of totl rthroscopic surgicl cses. Study Design The study ws single-blinded, prospective rndomized control tril using prllel group design in which prticipnts were rndomized to either simultion curriculum or stndrd prctice curriculum fter strtifiction by yer in trining. Following rndomiztion, both groups continued ll rottion-specific clinicl nd surgicl duties, which were uncontrolled but ccounted for using ACGME cse log dt. Initilly, both groups were briefed on the study design nd shown smple video recording of 14-point dignostic shoulder rthroscopy performed by n expert surgeon. In ddition, ll of the prticipnts viewed slide show presenttion of designted ntomic structures nd correltive rthroscopic imges for lter testing purposes. Simultor Testing All prticipnts underwent stndrdized evlution on the Arthro VR shoulder simultor (Simbionix Products, Clevelnd, Ohio) (Figure). This simultor is rrnged with 2 robotic rms tht re equipped with force reflective technology to provide hptic feedbck to the prticipnt nd produce high-fidelity rthroscopic model. 10 The simultor llows prticipnts to mnipulte tissue nd perform bsic rthroscopic tsks using highdefinition monitors nd stte-of-the-rt simultion technology. 2 Copyright SLACK Incorported

3 For the purposes of this study, prend postintervention simultor ssessments were performed using vlidted blue-sphere progrm, 8 which plces blue spheres t ntomic loctions within the joint tht the prticipnt must locte nd plpte. The simultor objectively recorded tsk performnce outcomes tht included time to completion (in seconds), cmer distnce (in mm), nd probe distnce (in mm). In previous vlidtion study, shorter time to completion, cmer distnce, nd probe distnce were ssocited with prticipnts expert performnce, indicting higher level of proficiency. 8 Arthroscopic Testing After orienttion, both simultion nd stndrd prctice curriculum prticipnts performed bseline dignostic shoulder rthroscopy in the operting room. All surgeries were performed in the bech chir position under stff supervision using hooked probe, 30 rthroscope, nd highdefinition rthroscopic cmer (Stryker Inc, Klmzoo, Michign) with video recording. Stndrd nterior working nd posterior viewing portls were estblished by n unblinded, ttending orthopedic surgeon, nd prticipnts performed stndrd 14-point dignostic rthroscopy until completion (Tble 1). All surgeries were performed without coching or ssistnce from the ttending surgeon, nd testing could be terminted erly if deemed unsfe. All video recordings were viewed by 2 blinded, independent rthroscopy experts, which is prctice tht hs been proven to llow multiple rters to relibly nd objectively ssess surgicl performnce. 11 The shoulder rthroscopy performnces were grded ccording to the Arthroscopic Surgery Skill Evlution Tool (ASSET). 12 The ASSET globl rting scle hs 8 seprte skill domins nd hs been shown to hve cceptble vlidity s well s interobserver nd testretest relibility for ssessing surgicl performnce during dignostic rthroscopy. 12 The primry dignostic shoulder rthroscopy outcome mesures included composite ASSET nd individul domin scores, performnce on the 14-point dignostic rthroscopy ntomic checklist, nd time to completion. Simultor Trining All prticipnts ssigned to the simultion curriculum received 4 supplementry, one-on-one simultion trining sessions lsting pproximtely 15 minutes with 1 senior resident during 3-month period. Instruction emphsized cmer orienttion, probe mnipultion, tringultion, nd further psychomotor skill development. One hour of cumultive trining ws chosen bsed on previous study demonstrting tht residents improved 12 seconds on the simultor per 50 rthroscopic cses completed. 9 Thus, the current uthors estimted tht prticipting residents could perform pproximtely 12 to 15 dignostic exmintions in ech simultor session to rech criticl threshold for performnce evlution. Trining ws concluded fter totl of t lest 60 minutes of supervised simultor ctivity. Finl Simultor nd Arthroscopic Testing After the simultion trining intervention, both groups performed second simultion exmintion using the blue-sphere progrm. In ddition, second dignostic shoulder rthroscopy ws performed, nd postintervention blinded ASSET score ws generted from the video recording. Simultion testing, ASSET globl score nd individul domin scores, 14-point dignostic rthroscopy ntomic checklist, nd time to completion were compred within nd between simultion nd stndrd prctice groups before nd fter the intervention. No. Tble 1 14-Point Antomic Checklist Tsk 1 Inspect nd probe long hed of the biceps tendon 2 Pull biceps from the intertuberculr groove into the joint 3 Inspect the biceps sling 4 Inspect nd probe the superior lbrum 5 Inspect nd probe the glenoid rticulr surfce 6 Inspect nd probe the humerl hed rticulr surfce 7 Inspect the rticulr surfce of the suprspintus muscle 8 Inspect the rticulr surfce of the infrspintus muscle 9 Inspect the posterior humerl hed nd bre re 10 Inspect the cpsulr ttchment to the humerus (HAGL) 11 Inspect the inferior pouch of the humerus 12 Inspect nd probe the posterior lbrum 13 Inspect nd probe the nterior lbrum 14 Inspect the subscpulris recess nd insertion Abbrevition: HAGL, humerl vulsion glenohumerl ligment. Prticipnts were video recorded completing the 14-point ntomic checklist (unssisted) rthroscopiclly, nd the recording then ws grded by 2 independent blinded experts. Sttisticl Anlysis Mthemticl mens nd stndrd devitions were clculted for continuous vribles, nd frequencies nd proportions were clculted for ctegoricl vribles by group (simultion vs stndrd prctice curriculum) nd time points (pre- vs postintervention). For continuous vribles, independent t tests were used to evlute between-group differences t bseline nd t follow-up for ll outcomes of interest. If the ssumptions for the independent t test were not met, the nonprmetric equivlent Kruskl- Wllis test ws used for inter-group com- 3

4 prisons. Dependent t tests were used to evlute within group differences from pre- to postintervention for continuous vribles. If the ssumptions for the dependent t test were not met, the nonprmetric equivlent Wilcoxon rnk sum test ws used for within-group comprisons over time. All sttisticl nlyses were completed using STATA/SE softwre version 10.1 (SttCorp, College Sttion, Texs), nd type I error rte of Tble 2 Demogrphic Dt for the Simultion nd Stndrd Prctice Groups Stndrd Prctice Group Simultion Group Prmeter Medin IQR Medin IQR P Age, y Sex, mle:femle 10:0-11:1 - Postgrdute yer Arthroscopies performed Bseline Follow-up Abbrevition: IQR, interqurtile rnge. Number of reported shoulder rthroscopy current procedurl terminology (CPT) codes. P<.05 ws used to ssess sttisticl significnce. Results Of the 22 residents who greed to prticipte in the study, 12 were rndomized to the simultion intervention group nd 10 were rndomized to the control or stndrd prctice group. Both groups were similr in terms of postgrdute yer in trining, number of shoulder rthroscopy cses performed t bseline testing (ie, preintervention), nd number of shoulder rthroscopy cses performed t the time of postintervention testing (Tble 2). There were no preintervention differences between the simultion nd stndrd prctice groups on ny of the rthroscopic shoulder simultor tsk performnce mesures (Tble 3). Following the intervention, prticipnts in the simultion group hd significntly better ASSET sfety scores (P=.005) during the dignostic rthroscopy nd performed better on the ASSET (P=.061) compred with prticipnts in the stndrd prctice group (Tble 3). Prticipnts in the simultion group lso completed the simultion testing significntly fster (P=.001) nd were much more efficient in using the probe (P=.001) during the simultion test following the intervention compred with the prticipnts in the stndrd prctice group. Prticipnts in the simultion group lso were more efficient in using the cmer following the intervention compred with prticipnts in the stndrd prctice group; however, the difference between the 2 groups ws not sttisticlly significnt (P=.07). Tble 3 Between-Group Comprisons for the ASSET Score nd Simultion Vribles Pre- nd Postintervention Pre Stndrd Prctice Group Simultion Group Stndrd Prctice Group Simultion Group Vrible Men SD Men SD P Men SD Men SD P Dignostic exmintion ASSET totl score Sfety score Antomic checklist b Time, sec Simultion exmintion Time, sec Probe, c mm Cmer, c mm Abbrevition: ASSET, Arthroscopic Surgery Skill Evlution Tool. Sfety score: n objective evlution within the ASSET score. b Antomic checklist: number of ntomic loctions identified during dignostic exmintion. c Simultion probe nd cmer indicte the distnce the instrument trveled to complete dignostic exmintion. Post 4 Copyright SLACK Incorported

5 Tble 4 Pre- to Postintervention Within-Group Comprisons for the ASSET Score nd Simultion Vribles Stndrd Prctice Group Simultion Group Pre Post Pre Post Vrible Men SD Men SD P Men SD Men SD P Dignostic exmintion ASSET totl score Sfety score Antomic checklist b Time, sec Simultion exmintion Time to completion, sec Probe distnce c, mm Cmer distnce c, mm Abbrevition: ASSET, Arthroscopic Surgery Skill Evlution Tool. Sfety score: n objective evlution within the ASSET score. b Antomic checklist: number of ntomic loctions identified during dignostic exmintion. c Simultion probe nd cmer indicte the distnce the instrument trveled to complete dignostic exmintion. Both groups demonstrted significnt improvements on the ASSET during the second dignostic rthroscopy compred with the preintervention bseline ssessments (Tble 4). In ddition, prticipnts in the simultion group lso performed the second dignostic rthroscopy significntly fster following the intervention (P=.026). Finlly, prticipnts in the simultion group demonstrted significnt improvements from pre- to postintervention for the time required to complete the simultor ssessment (P=.03) nd both probe (P=.04) nd cmer (P=.049) efficiency during the tsk, wheres none of the improvements observed in the stndrd prctice group over time were sttisticlly significnt for the simultor tsk ssessment (P>.05). When exmining performnce on the 14-point dignostic rthroscopy ntomic checklist in both the simultion nd stndrd prctice pre- nd postintervention s well s between the 2 groups, no significnt differences were found. On verge, the residents completed ech point of the 14-point dignostic rthroscopic shoulder exmintion more thn 70% of the time, except when evluting the subscpulris recess nd insertion (56%) nd the cpsuloligmentous ttchments on the humerus (27%). Discussion The current study reveled tht dditionl simultion trining improved technicl performnce nd ptient sfety mesures mong orthopedic surgery residents during shoulder rthroscopy compred with stndrd teching curriculum. Similrly, strong correltion between improved simultion mesures nd greter rthroscopic surgicl proficiency ws demonstrted. After high-fidelity simultion trining intervention, the simultion group ws ble to perform designted rthroscopic tsks fster nd more efficiently thn the stndrd prctice group, lthough comprtively higher overll ASSET score mong the simultion cohort filed to chieve sttisticl significnce. This study is the first investigtion to estblish trnsfer vlidity, or the trnsltion of technicl skill cquired from simultion trining to improved performnce during rel-time rthroscopic surgery, in shoulder simultor model. Trditionl surgicl trining curricul hve long scribed to n pprenticeship model, in which residents ssume incresing levels of hnds-on involvement during surgery with subjective feedbck bout surgicl competency. However, with strict resident work hour restrictions nd possibly indequte rthroscopic trining, 13 orthopedic surgicl trining progrms hve sought lterntive trining opportunities outside the operting room to respond to the incresing scope nd complexity of rthroscopic surgery. Similrly, the implictions of grdute medicl trining on ptient sfety nd finncil helth cre costs, prticulrly those relted to incresed opertive time, lso hve been considered in developing simultion trining progrms. 14,15 Despite the impetus for resident simultion-bsed lerning, erly concerns bout the incresed cost nd vlidity of rthroscopic simultor trining hve persisted. 16 Construct vlidity, or the bility for simultor to reflect reltive rthroscopic experience, previously hs been n re of focus in shoulder simultor models, including investigtions t the current 5

6 uthors institution. 8,9,17,18 Gomoll et l 17 confirmed psychomotor skill ssessment using virtul relity shoulder simultor correlted with ctul rthroscopic surgicl experience mong 43 prticipnts, with the most notble differences evident between the lest nd most experienced groups in terms of time to completion, pth length, hook collisions, nd verge probe velocity. Mrtin et l 9 found postgrdute yer in trining nd totl number of rthroscopic shoulder cses independently predicted totl time to completion for simple rthroscopic tsks on shoulder simultor, with decrese of 12 seconds for every dditionl 50 cses performed during residency trining. Conversely, trnsfer vlidity hs not been sufficiently investigted nd is wrrnted to fully estblish shoulder simultors s useful djunct with tngible results in rthroscopic surgicl proficiency. In knee model, Howells et l 19 reported junior orthopedic trinees undergoing 1-week rthroscopic simultion progrm performed better on the Orthopedic Competence Assessment Project score nd on the globl rting scle during ctul knee rthroscopy thn those with trditionl trining. To dte, however, no study hs confirmed trnsfer vlidity for n rthroscopic shoulder simultor model. Although both groups in the current study demonstrted significntly better overll ASSET scores on the second dignostic rthroscopy compred with bseline rthroscopic evlution, the simultion group hd superior performnce on the ASSET sfety domin, mesure of itrogenic rticulr crtilge or soft-tissue injury, reltive to the stndrd prctice group (P=.005). In ddition, the simultion group demonstrted higher men overll ASSET score thn the stndrd prctice group on finl testing (P=.061). Ostensibly, these findings could be ttributed to the sttisticlly significnt improvements on simultor-bsed outcome mesures present only in the intervention group. Within this study, certin limittions must be cknowledged. Only 22 orthopedic trinees were vilble for rndomiztion, which represents ll trinees from within the uthors single progrm. With only 22 prticipnts, the postintervention between group comprisons my hve been underpowered; however, lrge effect size ws observed between groups for the trining intervention in totl ASSET score (Cohen s d=0.853) nd cmer distnce (Cohen s d=0.888), both of which pproched significnce (Tble 3). Post hoc power estimtes suggest 22 prticipnts per group would hve been needed to detect significnt between-group difference in postintervention ASSET score nd 20 prticipnts per group would hve been needed to detect significnt betweengroup difference in postintervention cmer distnce. All of the prticipnts in the simultion trining group were given only 1 hour of rthroscopic shoulder simultion trining ccording to the current protocol, but less experienced surgeons could hve benefitted from further exposure. In ddition, more prolonged rthroscopic simultion trining could hve ccentuted existing findings in the bsence of lrger enrollment. Finlly, surgicl indictions nd concomitnt shoulder pthology were not stndrdized, which my lter norml rthroscopic ntomy nd otherwise ffect individul testing performnce. Conclusion A modified surgicl curriculum with rthroscopic simultion trining my ccelerte the lerning curve for performing bsic tsks during shoulder rthroscopy. More importntly, djunctive simultion trining synergisticlly promotes ptient sfety vis-à-vis trditionl methods, lthough both through improved psychomotor coordintion nd shorter opertive times. Further lrge-scle, well-designed studies re required to better elucidte the merits of simultion-bsed trining in orthopedic surgery residency nd its downstrem effects on rthroscopic proficiency nd ultimtely on clinicl ptient outcomes. As simultion technology becomes more sophisticted, dedicted rthroscopic simultion trining will be impertive for initil surgicl development during orthopedic surgicl residency. However, the cost effectiveness of virtul relity, high-fidelity simultion models lso must be considered reltive to other more lower-priced lterntives such s synthetic joint models or cdveric specimens. References 1. Accredittion Council for Grdute Medicl Eduction. ACGME common progrm requirements. pdf. Accessed October 4, Accredittion Council for Grdute Medicl Eduction. Orthopedic surgery minimum numbers. ProgrmResources/260_ORS_Cse_Log_ Minimum_Numbers.pdf. Accessed October 4, Grntchrov TP, Kristinsen VB, Bendix J, Brdrm L, Rosenberg J, Funch-Jensen P. 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