Sixteen orthopaedic residency programs—both in the United States and around the world—now use a knee arthroscopy simulator in training.
Courtesy of TolTech


Published 11/1/2012
Howard Mevis

Virtual Reality and Surgical Simulation Development Continues

AAOS, AANA, OTA moving forward on simulation-based training

Howard Mevis

One year ago, the AAOS conducted a Surgical Simulation Summit for orthopaedic surgery. (See “Using Simulation, Metrics to Improve Orthopaedic Surgical Skills,” AAOS Now, February 2012.) In the intervening year, the AAOS—along with the Arthroscopy Association of North America (AANA) and the Orthopaedic Trauma Association (OTA)—have been engaged in updating the existing knee arthroscopy simulator and developing new simulation devices for training orthopaedic surgeons and residents.

“The Summit led us to a common understanding that new approaches are needed for surgical skills training for orthopaedic surgeons in practice and orthopaedic residents,” said Robert A. Pedowitz, MD, PhD, who cochaired the summit. “Simulation-based training can have a positive impact on both graduate medical education for residents and continuing medical education for all of us in practice.”

Knee arthroscopy simulator
Under the leadership of Dilworth Cannon, MD, and in partnership with AANA, the AAOS continues to work with Touch of Life Technologies (ToLTech) to add new educational modules and simulation training for arthroscopic procedures of the knee.

“Our expansion plans add several new procedures for simulation training, such as loose body removal, partial meniscectomy, mensical repair, and microfracture,” said Dr. Cannon.

“In addition, the base program on diagnostic arthroscopy will include new features requiring the learner to identify and document various pathologies around the knee joint,” he added. The expansion program will be released in 2013.

The knee arthroscopy simulator is now in use at 16 orthopaedic programs worldwide. Residency programs in Canada, Australia, and Saudi Arabia have purchased the simulator, in addition to several programs in the United States. Each sale generates royalties for the AAOS. “We are reinvesting the royalties to support this expansion project and other new projects,” said Edward Akelman, MD, who chairs the AAOS Council on Education.

Recently, attendees of the Fundamentals of Knee and Shoulder Arthroscopy for Orthopaedic Residents course, cosponsored by the AAOS and the American Orthopaedic Society for Sports Medicine, had the opportunity to use the knee arthroscopy simulator. According to Andrew J. Cosgarea, MD, the course director and a member of the AAOS CME Courses Committee, “The residents really enjoyed using the simulator to practice the basic skills that they learned during the didactic portion of the course before they began training on cadaver knees and shoulders.”

Developing a shoulder arthroscopy simulator
Andrew Green, MD, is leading a new project team charged with developing a shoulder arthroscopy simulator. According to Dr. Green, “We are following the same path as the original project team that developed the knee arthroscopy program. Our initial work is focused on the diagnostic arthroscopy of the shoulder as a base program.”

Shoulder arthroscopy presents several unique challenges for simulation development, Dr. Green noted. “We are creating a program that enables orthopaedic surgeons to train using both the lateral decubitus and beach-chair positions,” he explained. “A training sequence that includes 36 different tasks for diagnostic arthroscopy of the shoulder has been developed.”

The shoulder simulator will be available from ToLTech on the same unit as the knee simulator.

Simulation training for basic skills
The Simulation Summit also called for the development of new simulation devices expressly designed for PGY-1 and PGY-2 residents. Two such devices are currently being investigated—one focused on teaching basic arthroscopy skills and the other focused on basic fracture fixation, using hip fracture as the initial diagnosis.

AANA, in partnership with the AAOS, is leading development of the basic arthroscopy simulator. As the project team leader, Dr. Pedo-witz is well aware of the increasing importance of simulation training.

“We have an opportunity, through these new projects, to create training programs that help prepare residents for their initial surgical experiences,” he said. “Each project is beginning with curriculum design as the keystone for simulator development.

“Creating a simulation-based training curriculum requires breaking down a procedure into individual tasks and setting proficiency standards that the trainee must meet,” he continued. “It requires development of unique measurement tools to provide continuous feedback to the trainee as a task is mastered.”

The AANA/AAOS project team is first defining the content delivery options that will integrate with the simulator; content development will follow. As the development process proceeds, the project team will seek a corporate partner to help invent the simulator.

A new simulator focusing on basic fracture fixation training is being developed by an AAOS/OTA partnership, under the direction of Marcus F. Sciadini, MD.

“Our goal is to create an affordable simulation trainer for residents, with the capability for expansion to include multiple fracture fixation procedures,” explained Dr. Sciadini. “Each procedure would be supported by a curriculum requiring the learner to meet certain proficiency requirements. The ideal trainer would incorporate authentic visual images that mimic the fluoroscopic imaging data obtained during routine orthopaedic procedures as well as realistic tactile feedback via a handheld haptic device.”

The project team’s mandate includes designing a curriculum to integrate with the simulator so as to maximize the benefits to residents. The AAOS/OTA Project Team is currently seeking a corporate partner for the project.

Upcoming residency program changes
Attendees at the Simulation Summit recommended that surgical skills training for residents be mandated as a required part of residency training. Since then, both the American Board of Orthopaedic Surgery (ABOS) and the Resident Review Committee in orthopaedic surgery have implemented this mandate with identical requirements.

The Summit also called for development of a basic surgical skills training curriculum for orthopaedic residents with emphasis on the use of simulation prior to operating room experience. The ABOS has convened a project team to plan and organize such a curriculum, under the leadership of J. Lawrence Marsh, MD, and Dr. Pedowitz. Representatives from the ABOS, the AAOS, and the American Orthopaedic Association Council of Orthopaedic Residency Directors (CORD) program are also part of the project team, which is creating a standardized set of modules for all residency programs to use in implementing the required curriculum changes.

Simple, low-cost simulations and new simulation technologies under development will be instrumental in implementing basic skills training, noted Dr. Marsh. “We have already agreed on a module template and a curriculum of 17 modules as surgical skills training exercises for orthopaedic PGY-1s,” he said. “We anticipate a completed product by Spring 2013, in time for the start of the new program requirements.”

Howard Mevis is AAOS director of electronic media, evaluation programs, course operations, and practice management group. He can be reached at