Improving residency training in arthroscopic knee surgery with use of a virtual-reality simulator. A randomized blinded study.
BACKGROUND
There is a paucity of articles in the surgical literature demonstrating transfer validity (transfer of training). The purpose of this study was to assess whether skills learned on the ArthroSim virtual-reality arthroscopic knee simulator transferred to greater skill levels in the operating room.


METHODS
Postgraduate year-3 orthopaedic residents were randomized into simulator-trained and control groups at seven academic institutions. The experimental group trained on the simulator, performing a knee diagnostic arthroscopy procedure to a predetermined proficiency level based on the average proficiency of five community-based orthopaedic surgeons performing the same procedure on the simulator. The residents in the control group continued their institution-specific orthopaedic education and training. Both groups then performed a diagnostic knee arthroscopy procedure on a live patient. Video recordings of the arthroscopic surgery were analyzed by five pairs of expert arthroscopic surgeons blinded to the identity of the residents. A proprietary global rating scale and a procedural checklist, which included visualization and probing scales, were used for rating.


RESULTS
Forty-eight (89%) of the fifty-four postgraduate year-3 residents from seven academic institutions completed the study. The simulator-trained group averaged eleven hours of training on the simulator to reach proficiency. The simulator-trained group performed significantly better when rated according to our procedural checklist (p = 0.031), including probing skills (p = 0.016) but not visualization skills (p = 0.34), compared with the control group. The procedural checklist weighted probing skills double the weight of visualization skills. The global rating scale failed to reach significance (p = 0.061) because of one extreme outlier. The duration of the procedure was not significant. This lack of a significant difference seemed to be related to the fact that residents in the control group were less thorough, which shortened their time to completion of the arthroscopic procedure.


CONCLUSIONS
We have demonstrated transfer validity (transfer of training) that residents trained to proficiency on a high-fidelity realistic virtual-reality arthroscopic knee simulator showed a greater skill level in the operating room compared with the control group.


CONCLUSIONS
We believe that the results of our study will stimulate residency program directors to incorporate surgical simulation into the core curriculum of their residency programs.
Department of Orthopaedic Surgery, University of California, San Francisco, 1500 Owens Street, San Francisco, CA 94158. E-mail address: cannond@orthosurg.ucsf.edu.
W Dilworth
WD
Cannon
Duke Medical Center, Box 3338, Durham, NC 27710.
William E
WE
Garrett
Orthopedic Sports Medicine Center, Heart of the Rockies Regional Medical Center, 550 West U.S. Highway 50, Salida, CO 81201.
Robert E
RE
Hunter
Walgreen Building, Room 2505, 2650 Ridge Avenue, Evanston, IL 60201.
Howard J
HJ
Sweeney
1635 Aurora Court, Mail Stop F722, Aurora, CO 80045.
Donald G
DG
Eckhoff
Department of Orthopaedic Surgery, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642.
Gregg T
GT
Nicandri
Department of Orthopaedics, University of Illinois at Chicago, 835 South Wolcott, 270 Medical Sciences Building, Chicago, IL 60612.
Mark R
MR
Hutchinson
Sports Medicine Clinic, Carleton University, 1025 Col By Drive, Ottawa ON, Canada K1S5B6.
Donald D
DD
Johnson
Department of Orthopaedics, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, 462 Grider Street, Buffalo, NY 14215.
Leslie J
LJ
Bisson
Department of Orthopaedic Surgery, MedSport, Domino's Farms, Lobby A, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48105.
Asheesh
A
Bedi
Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, Suite 1350, Chicago, IL 60611.
James A
JA
Hill
Walgreen Building, Room 2505, 2650 Ridge Avenue, Evanston, IL 60201.
Jason L
JL
Koh
Touch of Life Technology, 12635 East Montview Boulevard, Aurora, CO 80045.
Karl D
KD
Reinig
D001182:Arthroscopy / Q000193:education*; D002983:Clinical Competence; D006801:Humans; D007396:Internship and Residency; D007719:Knee Joint / Q000601:surgery*; D019637:Orthopedic Procedures / Q000193:education*; D014584:User-Computer Interface