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Fig. 1 Four components of the FAST workstation. A, Base element and knot tying module; B, Close-up of the arthroscopic knot tying mandrel, which is used initially to develop knot tying skills without working through portals; C, Clear dome for practice of arthroscopic knot tying skills under direct visualization, working through portals; D, Opaque dome for practice of arthroscopic knot tying skills under video control. A USB video camera mounted on a stand (D, upper left) is connected to a laptop computer, which simulates the arthroscopy video monitor system.
Courtesy of Robert A. Pedowitz, MD, PhD

AAOS Now

Published 2/1/2014
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Jennie McKee

“Rebooting” Orthopaedic Resident Education

AAOS sponsors second summit on orthopaedic surgery training through simulation

Virtual reality, robotics, and computer simulation are becoming increasingly popular ways for orthopaedic residents to learn and practice surgical skills in a nonclinical environment. In fact, these new technologies have become so integrated into training efforts that the American Board of Orthopaedic Surgery (ABOS) and the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee (RRC) for Orthopaedic Surgery implemented simulation and motor skills requirements for resident education in July 2013, making it clear that resident education is undergoing a “reboot.”

These new education requirements were some of the many topics discussed by participants of the Orthopaedic Surgery Simulation Summit II, held in Rosemont in November 2013. Attendees of the summit—including orthopaedic residency directors, program coordinators, department chairs, program faculty, and others responsible for guiding resident education—had the opportunity to meet with orthopaedic simulation companies to explore various educational approaches, from low-cost practice models to high-tech virtual reality computer simulation.

The summit included representatives from the AAOS, ABOS, RRC, the American Orthopaedic Association/Council of Orthopaedic Residency Directors (AOA/CORD), and various orthopaedic specialty societies. Robert A. Pedowitz, MD, PhD; J.L. Marsh, MD; and Terrance D. Peabody, MD, served as cochairs.

Meeting new mandates
According to Dr. Marsh, the demand for incorporating skills training, simulation, and assessment of proficiency into surgical education is increasing. He noted that the ABOS and the RRC began requiring a laboratory-based surgical skills training program with the start of the 2013–2014 academic year. The program includes the following requirements:

  • a curriculum with goals and objectives
  • assessment metrics
  • a dedicated space for skills training
  • training in basic skills for emergency care and for future participation in surgical procedures

“General surgery has already made important steps in using surgical simulation to train residents,” said Dr. Marsh. “The ABOS and the RRC for Orthopaedic Surgery have now prompted orthopaedic surgery to develop similar programs by requiring surgical simulation skills training for PGY-1 orthopaedic residents.”

The ABOS also helped support simulation training by convening the Surgical Skills Task Force. As noted by David F. Martin, MD, past president of the ABOS, the task force—which included representatives of the ABOS, AAOS, and AOA/CORD—developed surgical skills modules to help program directors with the new training mandates. The curriculum of 17 modules (see listing on page 7) is designed to teach a wide spectrum of skills for PGY-1 residents and to do the following:

  • assist program directors in the planning of skills exercises
  • assist PGY-1 residents in performing these exercises while minimizing faculty time
  • offer low-tech/low-cost options for surgical simulation training

Each of the modules includes background materials and references, a description of a hands-on skills teaching program, and an evaluation technique. To assess mastery of the skills, some of the modules evaluate residents using the demonstration of skills, while others require observation of tasks. In addition, some of the modules use checklists, while one module uses a written quiz that residents must complete. The 17 modules are available at no cost to residency programs.

Real-life experience
According to M. Daniel Wongworawat, MD, the Loma Linda University School of Medicine used the ABOS Surgical Skills modules as a framework to incorporate simulation training into its orthopaedic resident education program for 2013–2014. The program used low-tech, low-budget options and involved all core faculty members.

“For Part One of the training, which occurred in July 2013 at the beginning of the PGY-1 year, we conducted skills training in the afternoon,” said Dr. Wongworawat. “These faculty-led sessions had presession reading and video assignments, followed by discussion of reading materials and hands-on sessions with faculty members.”

Some of the tasks residents performed during training included suturing and knot tying—first with a knot-tying board, and then with an expired suture from the operating room—followed by soft tissue handling tasks.

Dr. Wongworawat noted that residents used pigs’ feet, which were $3 per specimen, to practice incision, dissection, suturing, and knot tying techniques. Residents practiced K-wire techniques by drilling holes in PVC pipes.

“During Part Two, which will occur in June 2014 at the end of the PGY-1 year, we will complete a review of all the ABOS modules. Specifically, we will assess residents’ abilities regarding suture and closure quality, knot quality and security, fluoroscopic drill accuracy, and the ability to complete arthroscopic tasks. We will also measure residents’ ability to perform tasks related to probes, transfers, sutures, and knot tying,” he said.

The long gap in between Parts One and Two of the training provides time for the residents to review skills, and makes it possible to assess retention of those skills.

FAST program
Summit participants also received an update on the Fundamentals of Arthroscopic Surgery Training (FAST) program, a collaborative venture between the Arthroscopy Association of North America (AANA), the AAOS, and the ABOS. The program has made significant strides since its inception in 2011, according to Dr. Pedowitz.

The FAST program committee, noted Dr. Pedowitz, defined training objectives and curriculum, developed skills modules and a workstation to accompany the modules, and prepared educational videos.

“We used the same approach across these modules so the learner would have a sense of consistency,” he said. Modules cover the following topics:

  • principles of arthroscopy
  • triangulation skills
  • interventional arthroscopy
  • suture anchors
  • suture passage
  • arthroscopic knot tying

“Once we decided on the curriculum and the modules, we had to find a way to deliver,” said Dr. Pedowitz, noting that the FAST program opted to partner with a company that produces bone models to create an affordable and modular workstation.

The workstation contains various elements that can sequentially help educate residents on basic arthroscopic skills (Fig. 1).

Fig. 1 Four components of the FAST workstation. A, Base element and knot tying module; B, Close-up of the arthroscopic knot tying mandrel, which is used initially to develop knot tying skills without working through portals; C, Clear dome for practice of arthroscopic knot tying skills under direct visualization, working through portals; D, Opaque dome for practice of arthroscopic knot tying skills under video control. A USB video camera mounted on a stand (D, upper left) is connected to a laptop computer, which simulates the arthroscopy video monitor system.
Courtesy of Robert A. Pedowitz, MD, PhD
Fig. 2 Simulated fluoroscopic image of inferior guidewire placement on AP view (left) and simulated corresponding clinical view (right) in the computer-based AAOS/OTA hip fracture simulator.
Courtesy of Marcus F. Sciadini, MD

“The FAST program,” he added, “essentially represents our efforts to deconstruct arthroscopy into very basic motor skills elements, followed by construction of training modules that are directed at these specific psychomotor elements.

“I’m happy to say that many virtual reality companies have taken the kinds of task deconstruction principles used in the FAST program and built them into virtual reality platforms,” continued Dr. Pedowitz. “The computer has the advantage of giving objective, immediate feedback, whereas the workstation approach requires us to create metrics that must be measured by faculty members or by the learners themselves.”

AAOS/OTA hip fracture simulation
Marcus F. Sciadini, MD,
provided an update on another simulation program—the AAOS/Orthopaedic Trauma Association (OTA) hip fracture simulation team, which first got underway in April 2011.

“Our mandate was to develop an educational curriculum for PGY-1 and PGY-2 residents, as well as a fluoroscopy simulation platform that would integrate basic fluoro-guided skills to meet the ABOS- and RRC-mandated surgical skills requirements,” stated Dr. Sciadini.

The program begins with a simple valgus impacted femoral neck fracture simulation module, with the goal of expanding the model to teach other fluoroscopically guided procedures. The goal is to complete the simulation program by September 2014.

“The simulation platform had to deliver both visual and haptic (touch) feedback to show the passage of instruments through bone,” he said. “It also needed the capability to create 3-D simulation to mimic a real patient’s anatomy.

“Ultimately,” continued Dr. Sciadini, “we went with a computer-based simulator with a haptic device (Fig. 2).” The simulator closely mimics the clinical surgical situation, including the two screens that appear on the fluoroscopy monitor. Residents begin by learning basic skills and progress to placing an inverted triangle screw array for a valgus impacted femoral neck fracture.

“The goal is to demonstrate the concepts using short recorded lectures or videos,” he said. “We used presentation software to convey the basic skills and concepts. Those presentations are augmented by videos created in the lab and presented by the simulator itself.”

One benefit of a computer-based platform, noted Dr. Sciadini, is that it can provide real-time metrics that give learners immediate feedback about their performance.

“The computer-based platform also gives us the data necessary to validate the system and to improve its efficacy as a teaching tool,” he said.

“We now face the difficult work of defining the correct metrics to measure, determining what those values need to be, and validating the model,” said Dr. Sciadini. “We also want to expand the educational modules to include more advanced procedures that are appropriate for higher level residents, and even fellows in orthopaedic trauma.”

Knee arthroscopy simulator
Dilworth Cannon, MD,
updated Summit attendees on a scientific study involving the ArthroSim knee arthroscopy simulator. Originally developed through a collaboration of the AAOS, AANA, ABOS, and Touch of Life Technologies (ToLTech), the simulator was recently put to the test at seven academic institutions.

Under Dr. Cannon’s leadership, the Content Development Group (CDG) Project Team, a group of nationally-renowned orthopaedic surgeons, conducted a randomized trial involving PGY-3 residents. The study was designed to determine whether residents who had trained with the knee arthroscopy simulator would exhibit greater accuracy, speed, and thoroughness when performing a diagnostic knee arthroscopy on an actual patient, compared with a control group of residents who had trained using traditional methods to practice arthroscopic skills prior to performing surgery on an actual patient. The results will soon be published. In addition, Dr. Cannon will present a scientific paper on the study at the 2014 AAOS Annual Meeting.

The future of surgical simulation
In summary, noted Dr. Pedowitz, any simulation programs currently being developed—and any that will be designed in the future—must be both effective and affordable, with validated performance metrics, which are “critical for high-stakes proficiency assessment.”

Dr. Pedowitz noted that technology and resident education have reached “a fascinating intersection,” as the demand for integrating technology with surgical education grows.

“I think the changes we are going to see in resident education will be quite profound over the next decade or so,” he added.

Jennie McKee is a senior science writer for AAOS Now. She can be reached at mckee@aaos.org

ABOS Surgical Skills Modules for PGY-1 residents
Visit the ABOS website at www.abos.org to access the educational modules developed by the Surgical Skills Task Force, a group that included representatives from the ABOS, AAOS, and AOA/CORD. The modules, which are designed to teach PGY-1 residents a wide range of skills, include the following:

  1. Sterile Technique—Operating Room Setup
  2. Suturing and Knot Tying
  3. Microsurgical Suturing Technique
  4. Soft Tissue Handling and Dissection
  5. Casting and Splinting: Splints, Casts, and Removal
  6. Traction Techniques
  7. Compartment Syndrome: Diagnosis and Treatment
  8. Bone Handling Techniques—Osteotomy
  9. Fluoroscopic Knowledge and Skills
  10. K-Wire Techniques
  11. Techniques Basic to Internal Fixation of Fractures
  12. Principles and Techniques of Fracture Reduction
  13. Basic Techniques in External Fixation
  14. Basic Arthroscopy Skills
  15. Basic Arthroplasty Skills (total knee arthroplasty & total hip arthroplasty)
  16. Joint Aspiration and Injection
  17. Patient Safety, Team Training, Obtaining Consent

FAST program
Visit the ABOS website to access content from the FAST program, a collaborative venture between AANA, the AAOS, and the ABOS. To do so, go to
www.abos.org and click on “Surgical Skills Modules for PGY-1 Residents.” Then, click on “Module 14: Basic Arthroscopy Skills” to access PDFs of the FAST curriculum as well as 12 videos from the FAST program.