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Improving Residency Training in Arthroscopic Knee Surgery with Use of a Virtual-Reality Simulator: A Randomized Blinded Study

Cannon, W. Dilworth MD; Garrett, William E. Jr. MD, PhD; Hunter, Robert E. MD; Sweeney, Howard J. MD; Eckhoff, Donald G. MD, MS; Nicandri, Gregg T. MD; Hutchinson, Mark R. MD; Johnson, Donald D. MD, FRCS; Bisson, Leslie J. MD; Bedi, Asheesh MD; Hill, James A. MD; Koh, Jason L. MD; Reinig, Karl D. PhD

Journal of Bone & Joint Surgery - American Volume: 5 November 2014 - Volume 96 - Issue 21 - p 1798–1806
doi: 10.2106/JBJS.N.00058
Scientific Articles
Supplementary Content

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.

Clinical Relevance: 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.

1Department of Orthopaedic Surgery, University of California, San Francisco, 1500 Owens Street, San Francisco, CA 94158. E-mail address:

2Duke Medical Center, Box 3338, Durham, NC 27710

3Orthopedic Sports Medicine Center, Heart of the Rockies Regional Medical Center, 550 West U.S. Highway 50, Salida, CO 81201

4Walgreen Building, Room 2505, 2650 Ridge Avenue, Evanston, IL 60201

51635 Aurora Court, Mail Stop F722, Aurora, CO 80045

6Department of Orthopaedic Surgery, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642

7Department of Orthopaedics, University of Illinois at Chicago, 835 South Wolcott, 270 Medical Sciences Building, Chicago, IL 60612

8Sports Medicine Clinic, Carleton University, 1025 Col By Drive, Ottawa ON, Canada K1S5B6

9Department of Orthopaedics, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, 462 Grider Street, Buffalo, NY 14215

10Department of Orthopaedic Surgery, MedSport, Domino’s Farms, Lobby A, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48105

11Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, Suite 1350, Chicago, IL 60611

12Walgreen Building, Room 2505, 2650 Ridge Avenue, Evanston, IL 60201

13Touch of Life Technology, 12635 East Montview Boulevard, Aurora, CO 80045

Copyright 2014 by The Journal of Bone and Joint Surgery, Incorporated
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