New technologies, along with increasing concern over patient safety, are driving changes in surgical education. Nowadays, virtual reality, robotics, and computer simulations are being used to teach a range of surgical techniques, allowing surgeons to practice and refine their skills in a nonclinical environment. Although orthopaedics has lagged behind some other specialties in developing and adapting simulation techniques, that may be changing, based on a recent summit on the issue sponsored by the AAOS.

The goal of the 2011 Orthopaedic Surgery Simulation Summit was to develop a working plan to improve education in orthopaedic surgical skills through simulation and virtual reality. The Summit included representatives from AAOS, the American Board of Orthopaedic Surgery (ABOS), the Residency Review Committee for Orthopaedic Surgery, the American Orthopaedic Association/Council of Orthopaedic Residency Directors (AOA/CORD), and various subspecialty societies.

Among the topics of the day-long summit were discussions of ongoing initiatives for the development of cost-effective simulations for basic orthopaedic surgery skills, such as arthroscopy and fracture management techniques in trauma.

The FAST program
According to Robert A. Pedowitz, MD, PhD, because a structured curriculum for sequential development of basic knowledge and motor skills for arthroscopy currently does not exist, orthopaedic residents must learn the technique in the operating room on real patients.

“We need to change the way we teach and assess these surgical skills,” he said, to address both patient safety and work-hours issues.

Cochair of the Summit, Dr. Pedowitz is also the chair of the Fundamentals of Arthroscopic Surgery Training (FAST) program, a collaborative venture between the Arthroscopy Association of North America (AANA), the AAOS, and the ABOS.

“As we’ve envisioned it, the FAST program will teach arthroscopic skills progressively via a curriculum-based, hands-on, cost-effective education program,” Dr. Pedowitz said. “Beginning with the basics, students will learn arthroscopic skills sequentially, before they are taught the full surgical procedure.”

The FAST program has the following specific goals:

• Teach arthroscopy skills in a step-wise manner
• Train across cognitive, psychomotor, and affective domains
• Allow students to learn and practice at their own pace
  (advance via proficiency)
• Create a flexible platform to be used for advanced arthroscopy skills training
• Integrate with existing educational programs
• Develop opportunities for online CME and, possibly, Maintenance of Certification programs
• Leverage existing educational content, expertise, and organizational resources
• Develop simple metrics to monitor learning progress and confirm proficiency
• Integrate FAST with virtual reality trainers and competency testers
• Place the deliverables into the hands of the end-users in a cost-effective manner

To help achieve these goals, Dr. Pedowitz believes that training programs should take advantage of alternatives to expensive, high-definition virtual reality systems for teaching and assessing basic orthopaedic skills. For example, he noted, a Swedish company offers a fluoroscopy training system that, when combined with a USB connector and commercial-grade haptic arm, could serve as an inexpensive simulator for practicing placing pins. When combined with two haptic arms, the device could be used as an in-home arthroscopy trainer, according to Dr. Pedowitz.

“That is my vision,” he said. “To have a set of teaching tools that enables residents to practice arthroscopy skills at home, with more expensive simulation devices available at the residency program and hospital levels, and ultimately, state-of-the-art and highly sophisticated virtual reality equipment at regional centers where testing is performed.”

The Copernicus Initiative
The AANA Copernicus Initiative—a pilot project to develop metrics for an arthroscopic Bankart procedure—recognizes the value in changing the culture of surgical training programs. “A paradigm shift is evolving in surgical training, from the apprenticeship model to a proficiency-based progression training model,” said Richard L. Angelo, MD, president of AANA. A fundamental aspect of this new approach is that “trainees acquire and demonstrate skills from basic to complex in a sequential manner.”

“We’re using an arthroscopic Bankart procedure to better understand and validate how this new process works,” said Dr. Angelo. “The metric development and validation process is challenging—we began 18 months ago to identify what steps should and what events really should not occur during a Bankart procedure. Rather than just describing these events, we have explicitly defined them and will use these tools as the foundation of our training program.”

The Copernicus project team, which includes Richard K. N. Ryu, MD, Dr. Pedowitz, and consultant Anthony Gallagher, PhD, plans to use these events (or metrics) to train surgeons to perform an arthroscopic Bankart procedure. Simulation models (ie, an online didactic module and shoulder simulation model) will be harnessed to facilitate the delivery of a proficiency-based curriculum centered around these specific metrics.

The project also involves quantitatively validating the entire training process. “We must demonstrate that the identified metrics capture the ‘essence’ of an experienced and skilled operator and that a curriculum constructed around these events leads to superior operative skills,” explained Dr. Angelo. “These training techniques must be grounded in prospective, randomized (and blinded) evidence.”

One of the first steps in the validation process was to seek the consensus of a group of experienced shoulder surgeons. This “Delphi Panel” met at the 2011 AANA Fall Meeting to reach consensus on identifying and defining the metric events for arthroscopic Bankart repair.

“By offering proficiency-based training that meets certain objectively defined standards, AANA believes it will be able to offer courses that provide trainees with a higher level of education and skills transfer. That’s really the intent of the Copernicus Initiative,” said Dr. Angelo.

AAOS/OTA hip fracture simulation
Charged with developing an educational curriculum designed for PGY-1 and PGY-2 residents, the AAOS/Orthopaedic Trauma Association (OTA) simulation project team chose hip fractures as their starting point.

“So far, we have established the concept of a progressive curriculum that begins with very basic procedures—the junior resident-level type things—but has the potential to incorporate increasingly complex cases applicable for upper-level residents or even fellows,” said Marcus F. Sciadini, MD, a member of the project team.

The project team has identified femoral neck fractures, iliosacral screw positioning, anterior column screw placement, retrograde and antegrade femoral nailing, and interlocking and blocking screw placement as the core group of procedures for simulation training.

“The nice thing about these simulation models is that they provide quantifiable performance goals in terms of time, pin accuracy, and even radiation exposure equivalency, without actually having to experience it,” said Dr. Sciadini. “Radiation safety and fluoroscopy exposure are important; orthopaedists frequently use fluoroscopy, particularly in trauma.”

Dr. Sciadini noted that, according to the literature, 90 percent of physicians underestimate the risk associated with pediatric radiographs and computed tomography, and that orthopaedists have limited understanding of radiation physics. As a result, the AAOS/OTA project team is hoping to incorporate the concept of decreasing radiation exposure into its education curriculum.

“Although we are still in the preliminary stages, the possibility of being able to incorporate fluoroscopy training into the simulation realm is very exciting,” said Dr. Sciadini. “I think it lends itself well to using the simulator in a very effective educational mode.”

Disclosures: Dr. Pedowitz: Stryker; Arthroscopy; Wolters Kluwer Health – Lippincott Williams & Wilkins; AAOS; AANA. Dr. Angelo: DePuy, A Johnson & Johnson Co.; AANA; Dr. Sciadini: Stryker.

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

References

1. Giordano BD, Grauer JN, Miller CP, Morgan TL, Rechtine GR: Radiation exposure issues in orthopaedics. J Bone Joint Surg–A. 2011; 93:e69 1-10 doi:10.2106/JBJS.J.01328.

Simulation project teams

FAST Project Team Members
Robert A. Pedowitz, MD, PhD

(chair)

Christopher Geary, MD

Robert Hunter, MD

Mark Hutchinson, MD

Keith Nord, MD

Howard Sweeney, MD

Ed Goss (AANA)

Howard Mevis (AAOS)

Copernicus Project Team Members
Richard K. N. Ryu, MD

Robert A. Pedowitz, MD, PhD

Anthony Gallagher, PhD

AAOS-OTA Hip Fracture Simulation Team Members
Robert A. Probe, MD (chair)

Matthew R. Camuso, MD

Brett D. Crist, MD

Brett R. Levine, MD

Marcus F. Sciadini, MD

Howard Mevis (AAOS)