Is the Virtual Reality Fundamentals of Arthroscopic Surgery Training Program a Valid Platform for Resident Arthroscopy Training?

BACKGROUND: Training in arthroscopy is associated with a steep learning curve for trainees and bears risks for patients. Virtual reality (VR) arthroscopy simulation platforms seek to overcome this and to provide a safe environment for surgical learners. The Fundamentals of Arthroscopic Surgery Training (FAST) program is one such platform. It is currently not known whether the VR FAST program can be employed as a useful teaching or examination tool to assess the basic arthroscopic skills of surgical trainees. QUESTIONS/PURPOSES: (1) Does the VR FAST program differentiate among novice, intermediate, and expert arthroscopists? (2) Does ambidextrous performance in the VR FAST program correlate with arthroscopic experience? METHODS: We prospectively recruited orthopaedic interns (novices), residents (intermediates), and fellows and attendings (experts) to complete the VR FAST program over a 1-year period from four major orthopaedic training programs on a voluntary basis. Sixty-six of 156 invited orthopaedic surgeons participated: 26 of 50 novices (16 men and 10 women), 27 of 65 intermediates (20 men and seven women), and 13 of 41 experts (10 men and three women). Surgeons of any arthroscopic experience were included, with only those with prior experience on the VR FAST program being excluded. The program consists of eight modules: three basic camera modules (Image Centering, Horizon Control, and Telescoping), three advanced camera modules (Periscoping, Trace the Line, and Trace the Curve), and two instrumented bimanual-dexterity modules (Probe Triangulation and Gather the Stars). Time taken to complete each task and measures of economy of movement (camera and instrument path length, camera alignment) were used as measures of arthroscopic experience. Every participant completed the modules using their dominant and nondominant hands. Equality in proficiency in completing the tasks using the dominant and nondominant hands were determined to be measures of arthroscopic experience. Due to the large number of outcome variables, only p values < 0.01 were considered to be statistically significant. RESULTS: Six of eight VR FAST modules did not discriminate among novice, intermediate, and expert arthroscopy participants. However, two did, and the ones that were most effective at distinguishing participants by level of experience were the Periscoping and Gather the Stars modules. For the Periscoping module using the dominant hand, novices required longer to complete the task with a median time of 231 seconds (IQR 149 to 358) and longer camera path length median of 191 cm (IQR 128 to 273) compared with intermediates who needed 127 seconds (IQR 106 to 233) and 125 cm (IQR 92 to 159) and experts who needed 121 seconds (IQR 93 to 157) and 119 cm (IQR 90 to 134) (p = 0.001 and p = 0.003, respectively). When using the nondominant hand, novices took longer to complete the task with a median time of 231 seconds (IQR 170 to 350) and longer camera path length 204 cm (IQR 169 to 273) compared with intermediates who required 132 seconds (IQR 97 to 162) and 111 cm (IQR 88 to 143) and experts who needed 119 seconds (IQR 104 to 183) and 120 cm (IQR 108 to 166) (p < 0.001 and p < 0.001, respectively). For the Gather the Stars module using the nondominant hand, only the novices needed longer to complete the task at a median of 131 seconds (IQR 112 to 157) and needed a longer grasper path length of 290 cm (IQR 254 to 332) compared with intermediates who needed 84 seconds (IQR 72 to 119) and 232 cm (IQR 195 to 254) and experts who needed 98 seconds (IQR 87 to 107) and 244 cm (IQR 215 to 287) (p < 0.001 and p = 0.001, respectively). CONCLUSION: Six of eight VR FAST modules did not demonstrate construct validity, and we found no correlation between arthroscopic experience and ambidextrous performance. Two modules demonstrated construct validity; however, refinement and expansion of the modules is needed with further validation in large prospective trials so that pass-fail thresholds can be set for use in high-stakes examinations. CLINICAL RELEVANCE: Most VR FAST modules were not discriminatory; however, they can form essential conceptual and procedural building blocks in an arthroscopic curriculum that are beneficial for novices when developing key psychomotor skills. In their present format, however, they are unsuitable for assessing arthroscopic proficiency.

Active vs passive haptic feedback technology in virtual reality arthroscopy simulation: Which is most realistic?

BACKGROUND: Virtual Reality (VR) simulators are playing an increasingly prominent role in orthopaedic training and education. Face-validity - the degree to which reality is accurately represented - underpins the value of a VR simulator as a learning tool for trainees. Despite the importance of tactile feedback in arthroscopy, there is a paucity for evidence regarding the role of haptics in VR arthroscopy simulator realism. PURPOSE: To assess the difference in face validity between two high fidelity VR simulators employing passive and active haptic feedback technology respectively. METHOD: 38 participants were recruited and divided into intermediate and expert groups based on orthopaedic training grade. Each participant completed a 12-point diagnostic knee arthroscopy VR module using the active haptic Simbionix ARTHRO Mentor and passive haptic VirtaMed ArthroS simulators. Subsequently, each participant completed a validated simulator face validity questionnaire. RESULTS: The ARTHRO Mentor active haptic system failed to achieve face validity with mean scores for external appearance (6.61), intra-articular appearance (4.78) and instrumentation (4.36) falling below the acceptable threshold (≥7.0). The ArthroS passive haptic simulator demonstrated satisfactory scores in all domains: external appearance (8.42), intra-articular appearance (7.65), instrumentation (7.21) and was significantly (p < 0.001) more realistic than ARTHRO Mentor for all metrics. 61% of participants gave scores ≥7.0 for questions pertaining to haptic feedback realism from intra-articular structures such as menisci and ACL/PCL for the ArthroS vs. 12% for ARTHRO Mentor. There was no difference in face-validity perception between intermediate and expert groups for either simulator (p > 0.05). CONCLUSION: Current active haptic technology which employs motors to simulate tactile feedback fails to demonstrate sufficient face-validity or match the sophistication of passive haptic systems in high fidelity arthroscopy simulators. Textured rubber phantoms that mirror the anatomy and haptic properties of the knee joint provide a significantly more realistic training experience for both intermediate and expert arthroscopists.

Management of urological trauma associated with pelvic fractures.

Urological trauma is frequently encountered in patients with high energy pelvic fractures and can have debilitating long-term sequelae for patients without appropriate multidisciplinary management. Anterior pelvic ring disruption causes a high incidence of bladder rupture and urethral injuries, and initial assessment requires urological tract imaging and emergent bladder drainage before subsequent surgical repair. Pelvic ring disruption requires urgent fixation and should be managed as an open fracture in the context of significant bladder and urethral injury with urinary leakage. Long-term outcomes are variable and genitourinary dysfunction is commonly reported among patients with pelvic fractures. Optimisation of patient outcomes relies heavily on collaborative management between orthopaedic and urological specialists and requires an appreciation of the anatomical intricacies of the pelvis. This article provides an overview of the British Orthopaedic Association Standards for Trauma and Orthopaedics management of urological trauma in the context of pelvic fractures.

Outcomes of posterior malleolar fixation in ankle fractures in a major trauma centre.

AIMS: Ongoing controversy exists over the indications and benefits of posterior malleolar fixation in ankle fractures. The aim of this pragmatic study was to evaluate the outcomes of posterior malleolar fracture fixation in ankle fractures in the setting of a major trauma centre. Our hypothesis is that posterior malleolus fixation leads to improved clinical outcomes. METHODS: A total of 320 patients were identified with operatively treated ankle fractures involving a posterior malleolus component, at our institution between January 2012 and January 2018, ensuring a minimum 2 year follow-up. Of these patients, 160 had the posterior malleolus fixed as part of their surgery and 160 did not. Patient demographics, surgical details and complications were assessed. The Manchester-Oxford Foot Questionnaire (MOXFQ) was the primary patient outcome measure. RESULTS: Fixation of the posterior malleolus was associated with a statistically significant improvement in patient outcomes. Mean MOXFQ score in the unfixed posterior malleolus group was 24.03 (0 - 62), compared to 20.10 (0 - 67) in the fixed posterior malleolus group (p = 0.04). Outcomes were worse with increasing size of posterior malleolar fragment. Metalwork-related issues were higher in the posterior malleolus fixed group (24/160 (15%) versus 10/160 (6.2%)) and re-operation rate was double. CONCLUSION: This study demonstrates that in the practical setting of a major trauma unit, fixation of the posterior malleolar fracture leads to improved patient outcomes but with increased metalwork risks and reoperation rates.

Spinal clearance and management of spinal cord injury in the trauma patient.

The British Orthopaedic Association's Standards for Trauma and Orthopaedics outline the essential clinical standards for spinal clearance and management of spinal cord injury in the acute trauma patient. From initial presentation in the hospital setting to long-term rehabilitation, the recommendations for clinical assessment, imaging, treatment priorities and the role of trauma networks are summarised.

Global Rating Scales for the Assessment of Arthroscopic Surgical Skills: A Systematic Review.

PURPOSE: To evaluate whether sufficient validity and reliability evidence exists to support the use of global rating scales (GRS) as evaluation tools in both formative assessment and competency assessment of arthroscopic procedures. METHODS: A search of PubMed, Embase, and Scopus was conducted for articles published between 1990 and 2018. Studies reporting measures of validity and reliability of GRS relating to arthroscopic skills were included. Procedural checklists and other assessment tools were excluded. RESULTS: A total of 39 articles met the inclusion criteria. In total, 7 de novo GRS specific for arthroscopic education and 3 pre-existing GRS repurposed 4 times for arthroscopic education were identified in the literature. The 11 GRS were used to assess 1175 surgeons 3890 times. Three GRS tools explicitly defined an arbitrary minimum competency threshold, 6 of 11 tools demonstrated construct validity-the ability to significantly discriminate between groups of differing experience-and 5 of 11 tools assessed inter-rater reliability, but only the Arthroscopic Surgical Skills Evaluation Tool demonstrated excellent inter-rater reliability. The Arthroscopic Surgical Skills Evaluation Tool was validated by 16 articles for a total of 537 surgeons for hip, knee, shoulder, and ankle arthroscopy in both simulated and clinical environments but was found to be invalid in wrist arthroscopy. The Basic Arthroscopic Knee Skill Scoring System was validated by 15 articles for a total of 497 surgeons for knee, hip, and shoulder in both clinical and simulated environments. The remaining 9 GRS were validated by 2 or fewer studies. CONCLUSIONS: Overall, GRS have contributed to training, feedback, and formative assessment practices. The GRS reviewed demonstrate both construct and concurrent validity as well as reliability in multiple arthroscopic procedures in multiple joints. Currently, there is sufficient evidence to use GRS as a feedback tool. However, there is insufficient evidence for its use in high-stakes examinations or as a minimum competency assessment. LEVEL OF EVIDENCE: Level III, systematic review of level I to III studies.