A, A virtual reality arthroscopy simulator. The mentor screen shows the instructions step by step, with the animated view of each step. The scope monitor reflects the simulated procedure as in an actual arthroscopic procedure. The scope and probe can be used for triangulation (B) while the replica leg is manipulated as necessary (C). Reprinted with permission from Atesok K, Mabrey JD, Jazrawi LM, Egol KA: Surgical simulation in orthopaedic skills training. J Am Acad Orthop Surg 2012;20(7):410-422.


Published 8/1/2012
Maureen Leahy

Simulation Training in Orthopaedic Surgical Education

New methods for developing surgical skills are on the rise

Orthopaedic surgical education is undergoing a paradigm shift. Traditionally, residents honed their surgical skills in the operating room (OR) under the tutelage of senior orthopaedic surgeons. Due in part, however, to the rapid evolution of orthopaedic surgical techniques, today’s residents are expected to acquire more complex and diverse surgical skills in less time than their predecessors. As a result, alternative teaching methods—such as simulation training—are increasingly becoming a part of resident training.

A review of simulation-based orthopaedic surgical skills training—from cadaver models and synthetic bones to software tools and computerized simulators—appeared in the July issue of the Journal of the AAOS. To learn how these methods are being used in orthopaedic surgical education, AAOS Now spoke with principal author Kivanc I. Atesok, MD.

AAOS Now: Why is orthopaedic surgical education transitioning from the master-apprentice model to alternative teaching methods?

Dr. Atesok: Orthopaedic surgical techniques have evolved rapidly, but on-the-job learning opportunities for residents have decreased due to an increased emphasis on patient safety, work-hour restrictions, cost pressures, and policies aimed at decreasing patient wait times. Modern trainees are expected to learn more complex and diverse technical skills in less time. Alternative teaching methods, such as surgical skills laboratories with cadaver models and synthetic bones, software tools, and computerized simulators, give residents the opportunity to acquire necessary skills outside the OR and before they attempt them on patients.

All orthopaedic residents should have the opportunity to be trained to proficiency. It used to be that a resident was considered proficient in a certain type of procedure after completing a set number of cases. However, not all residents have the same psychomotor abilities. With simulation-based training, every resident can practice a procedure until he or she gains proficiency. The concept is similar to using flight simulators in aeronautics: Pilots crash the plane in a simulator until they get it right!

AAOS Now: What are some areas of orthopaedics in which simulation-based training is especially beneficial?

Dr. Atesok: Simulation-based training is ideal for arthroscopy, where it is difficult to teach and assess skill level during real surgery. Residents need to learn how to use their hands when performing arthroscopic procedures—acquiring triangulation skills takes a lot of practice. In addition, many advanced arthroscopic procedures have a steep learning curve. Virtual reality simulators that mimic the look and feel of the surgical environment enable orthopaedic surgeons to practice and refine their arthroscopic skills outside of the OR.

Computer software simulators are an excellent learning tool for fracture fixation and preoperative planning. Fracture fixation uses a lot of plates, screws, and nails. These tools require hours of hands-on practice to gain proficiency. Simulation software enables surgeons to perform all steps of a proposed surgical procedure in a virtual three-dimensional (3D) environment. Similarly, computerized preoperative planning software enables surgeons to construct 3D digital models of complex fractures, such as the pelvis or acetabulum, from data based on computed tomography scans of patients. This enables trainees to visualize and practice on these fracture patterns before performing the actual surgery.

Cadaver models and synthetic bones are an important part of hands-on skills training in orthopaedic surgery, particularly in fracture management, because skeletal anatomy is consistent among humans. Animal cadavers can also be efficiently used in the laboratory environment to improve trainees’ surgical skills and familiarity with a variety of surgical tools.

AAOS Now: How can simulation-based training improve patient safety?

Dr. Atesok: Simulated environments enable orthopaedic surgeons to practice and refine their skills before operating on patients, thereby shortening the learning curve without sacrificing patient safety. Simulation-based training can also lead to decreases in soft-tissue injuries and surgical duration. Shorter surgical durations are directly correlated with a reduced risk for infection in orthopaedic surgical procedures.

AAOS Now: Do you believe surgical simulators should be a standard training tool for all orthopaedic residents?

Dr. Atesok: Orthopaedic surgical training is moving toward a competency-based medical education model where residents must learn and demonstrate basic knowledge and surgical skills sequentially before moving on to the next level. Simulation-based training fosters this by providing realistic environments in which residents can practice their skills to proficiency.

Simulation-based training will inevitably become a mandatory component of the orthopaedic resident curriculum. It should be incorporated into resident training from the very beginning because that is when residents need to improve their psychomotor skills the most. More advanced training, such as arthroscopy simulation, could be introduced in the second or third year of residency.

AAOS Now: What needs to occur before this can happen?

Dr. Atesok: Surgical simulation in orthopaedics is fairly new; therefore, we don’t have enough tools to measure it objectively. In addition, the objective structured assessment of technical skills checklists and global rating scales, which are used for measuring learned technical skills outside the OR, do not exist in a single universally standardized format.

Before simulation-based surgical training can be integrated into resident training, good evidence is needed to justify its effectiveness. Prospective randomized trials that support the educational advantages of surgical simulation in orthopaedic skills training are needed. For this purpose, the AAOS is sponsoring a multicenter randomized controlled trial comparing traditional arthroscopic training with that done by an arthroscopy simulator known as the Knee Arthroscopy Surgical Trainer (KAST). After this trial, the performance of the residents who practiced on the simulator will be compared in the OR to the performance of the residents who received traditional training.

AAOS Now: General surgery has been using simulation-based training successfully for some time now. However, you note that orthopaedic surgery, not general surgery, should lead the way in simulation-based training. Why?

Dr. Atesok: General surgery has integrated only one simulated procedure—laparoscopy—into their residency curriculum. Orthopaedic surgery, on the other hand, involves the greatest number of complex surgical tools and diverse applications. It has several areas where simulators could be used, such as arthroscopy of all major joints (shoulder, elbow, wrist, hip, knee, and ankle) plus the spine, fracture fixation, plaster application, and preoperative planning. As a result, more than any other specialty, orthopaedic surgery requires integration of simulator-based training into its curriculum.

Dr. Atesok’s coauthors of “Surgical Simulation in Orthopaedic Skills Training,” are Jay D. Mabrey, MD; Laith M. Jazrawi, MD; and Kenneth A. Egol, MD.

Disclosure information: Dr. Atesok: International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; Dr. Mabrey: Exactech; Dr. Jazrawi: Ferring Pharmaceuticals; ConMed Linvatec; Knee Creations; Core Essence Orthopaedics; and DePuy Mitek; Dr. Egol: Exactech; Johnson & Johnson; Stryker; Synthes.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

Bottom Line

  • Learning opportunities in the OR for residents have decreased due to increased emphasis on patient safety, work-hour restrictions, cost pressures, and policies aimed at decreasing patient waiting times.
  • As a result, alternative training methods to help residents and practicing orthopaedic surgeons master rapidly evolving orthopaedic surgical techniques in nonclinical environments have been developed.
  • Simulation-based training methods in orthopaedics include hands-on training in surgical skills laboratories using synthetic or cadaver bones, software tools, and computerized simulators.
  • Despite current limited evidence to support the educational advantages of surgical simulation in orthopaedic skills training, the authors believe it will inevitably become a mandatory component of the orthopaedic resident curriculum and have a positive effect on the overall education of orthopaedic residents.