Orthopaedic residents at WBAMC use virtual reality simulators such as this shoulder model to gain proficiency in arthroscopic surgical skills.
Courtesy of Kevin D. Martin, DO


Published 3/1/2013
Maureen Leahy

Army Applies Simulation Tactics to Surgical Education

Standardized training puts military ahead of the curve

Orthopaedic surgical techniques are evolving rapidly. To keep pace, many ­orthopaedic residency programs are integrating simulation-based surgical skills training into their education processes, enabling residents to refine their skills and become proficient in procedures outside of the operating room (OR). One program that’s ahead of the curve is William Beaumont Army Medical Center (WBAMC) in El Paso, Texas, where orthopaedic residents have been training on high-fidelity simulators for more than 4 years.

WBAMC is one of the U.S. Army Central Simulation Committee’s (CSC) 10 medical treatment facilities that offer simulation training in 12 specialties, including orthopaedics. Funded through the Army Surgeon General’s Office, CSC was established in 2007 to standardize simulation-based training in Army graduate medical education (GME) programs, assist in redeployment training of physicians returning from war, and improve patient safety.

“The Army has taken the lead in medical simulation training and physician GME,” said Kevin D. Martin, DO, assistant to the CSC chief of orthopaedics at WBAMC. “CSC has integrated high-fidelity shoulder and knee arthroscopy simulators into all the Army’s orthopaedic residency teaching programs. At WBAMC, we have more than tripled our hours of resident training on the simulators and have integrated simulation training into our residency curriculum.”

Gaining proficiency in ­arthroscopic surgical skills—such as triangulation, spatial relationships, and eye-hand control—involves a lot of practice. At WBAMC, residents hone their skills on virtual reality simulators that mimic a realistic surgical environment. The simulators feature high-definition monitors that provide high-fidelity resolution and two robotic arms equipped with force-reflective technology for tactile, interactive feedback. Simulated procedures are performed with a realistic probe and arthroscopic camera.

Simulation research
Based on data they have collected over the last 4 years, Dr. Martin and his colleagues have published two articles—and are currently working on a third—that support the educational advantages of surgical simulation. They’ve also presented their research at several orthopaedic conferences including the annual meetings of the AAOS, Arthroscopy Association of North America (AANA), and the Western Orthopaedic Society.

“Simulation has been used by the military for decades, across a very broad spectrum of applications. Our military colleagues are ahead of the curve in the implementation of innovative simulation methods for medical training, and they are doing solid developmental research in El Paso and at other programs around the country,” said Robert A. Pedowitz, MD, PhD, chair of the Fundamentals of Arthroscopic Surgery Training (FAST) program, a collaborative venture between AANA, the AAOS, and the American Board of Orthopaedic Surgery (ABOS). (See “Using Simulation, Metrics to Improve Orthopaedic Surgical Skills,” AAOS Now, February 2012.)

Dr. Pedowitz recently visited the orthopaedic simulation training program at WBAMC. “The purpose of my visit was to facilitate simulation research collaboration. The associated information will help us to develop efficient and cost-effective simulation strategies to enhance resident education and to improve patient safety,” he said.

During his day-long visit, Dr. Pedowitz also presented information on the changes to training for PGY1 residents in orthopaedic programs. Under a mandate from the ABOS and the Orthopaedic Residency Review Committee, beginning in the 2013–2014 academic year, programs will have to provide surgical skills training, including instruction in basic surgical skills and basic skills required to manage an injured patient. The instruction can be provided either longitudinally during the year or as a dedicated 4-week skills rotation.

Validating the data
WBAMC plans to continue its simulation research and has applied for an educational grant from AANA to support it.

“We are working on a simulation validation study—similar to the AANA Copernicus project—in which half of our residents will be trained on an arthroscopy simulator and the other half will receive standard training,” said Dr. Martin. “The residents will then be videotaped in the OR and the videos will be sent to experts for blind grading. The purpose of the study is to see if residents make fewer technical errors during surgery following simulation training. That’s really the bottom line—to determine if simulation training makes surgeons perform better in the OR.”

Disclosures: Dr. Pedowitz—DJ Orthopaedics; Stryker; Arthroscopy; Wolters Kluwer Health–Lippincott Williams & Wilkins; AAOS; AANA. Dr. Martin—no disclosures.

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

Bottom Line

  • Simulation-based surgical training enables residents to refine their skills and become proficient in procedures outside of the OR.
  • The Army has integrated standardized simulation training into all of its orthopaedic residency teaching programs.
  • WBAMC is performing developmental research on the educational advantages of surgical simulation.


  1. “Arthroscopic Basic Task Performance in Shoulder Simulator Model Correlates with Similar Task Performance in Cadavers.” Kevin D. Martin, DO; Philip J. Belmont, MD; Andrew J. Schoenfeld, MD; Michael Todd, DO; Kenneth L. Cameron, PhD, ATC; Brett D. Owens, MD. J Bone Joint Surg Am, 2011 Nov 02;93(21):e127 1-5. doi: 10.2106/JBJS.J.01368
  2. “Shoulder Arthroscopy Simulator Performance Correlates with Resident and Shoulder Arthroscopy Experience. Kevin D. Martin, DO; Kenneth Caeron, PhD, MPH, ATC; Philip J. Belmont Jr, MD; Andrew Schoenfeld, MD; and Brett D. Owens, MD. J Bone Joint Surg Am, 2012 Nov 07;94(21):e160 1-5. doi: 10.2106/JBJS.L.00072