Surgeons explain the trend towards simulation-based training in Arthroscopy

VirtaMed_ArthroS_Basic_Skills_Knee_VirtaMed_web555 2Surgical simulation-based training in arthroscopy: An emerging paradigm shift (Healio)

With advances in medical technology and changes in the health care system, the way residents are being trained has shifted from a traditional master/apprentice model to one of proficiency-based progression training plus simulation.

“The Accreditation Council for Graduate Medical Education in 2013 stated that every orthopedic training institution must incorporate some form of surgical skills training in their curricula, whether it is something as straightforward as a cadaver lab, or low fidelity simulation such as a knot tying board, or, as technology improves and costs come down, high fidelity simulation,” W. Dilworth Cannon, MD, of the University of California, San Francisco Medical Center, told Orthopedics Today.

During the past 3 years, the Arthroscopy Association of North America has focused on evaluating surgical simulation-based training in arthroscopy, which requires proficiency-based progression, and comparing it to the current standard training. According to Anthony G. Gallagher, PhD, DSc, the research, which will be published later this year, showed promising results in favor of simulation-based training.

W. Dilworth Cannon, MD

W. Dilworth Cannon, MD, of the University of California, San Francisco Medical Center, noted that using a surgical simulator to train can help residents reach a predetermined level of high proficiency and allow them to go into the OR and fine-tune their skills starting from a higher level. The result could be fewer surgical errors.

Image: Tingle C, Orthopedics Today

“What the results showed was that proficiency-based progression training on a simulation model produced unambiguously superior skill-sets in comparison to traditional training,” Gallagher, who is the Director of Research at the Application of Science to Simulation, Education and Research on Training (ASSERT) for Health Centre (, College of Medicine and Health at University College Cork in Cork, Ireland, said. “It is the best prospective, randomized and blinded clinical study of simulation-based training anywhere in the world today.”

Similarly, a previously published study by Cannon and his colleagues showed residents who underwent knee arthroscopy training on a simulator to a predetermined proficiency level performed significantly better according to a procedural checklist compared with residents who continued institution-specific orthopedic education training.

“We regard this study as the first to show transfer of training — transfer validity — from a realistic virtual-reality simulator to the operating room,” Cannon said.

Incorporating surgical simulation

Although research has shown promising results with the use of surgical simulation, if not implemented correctly, the technology cannot provide the proper educational benefits, according to Gallagher.

“What simulation should not be, but so frequently is, it should not just be an interesting educational experience. That is where the trainee comes into the training center and trains on simulations for a day or for 2 days and then they go away. All that does is produce variable skill sets,” Gallagher said.

He noted an appropriate benchmark for trainees to work toward can be established by characterizing the procedures residents need to train in and identifying key performance metrics for the optimal performance for that procedure.

“The benchmark is established on the basis of experience and competent operator’s performance and the trainee is not done with their training until they demonstrate that benchmark,” Gallagher said. “The bottom line is they do not progress until they demonstrate the proficiency benchmark, and that is the optimal way for simulation to be used.”

Richard L. Angelo, MD, past president of the Arthroscopy Association of North America, noted residents who trained using surgical simulation coupled with a proficiency-based progression curriculum were five- to seven-times more likely to meet a pre-defined surgical skill benchmark when compared to residents trained with traditional methods.

Richard L. Angelo

Richard L. Angelo

“There is so much focus on the simulator, but the simulator is just a tool,” Angelo told Orthopedics Today. “It is important to establish the curriculum first, identify the skillsets that we need to train, and then validate that those skillsets are what are essential to the success of a particular procedure. Then, you go back and identify how complex of a ‘simulator’ (what fidelity) is needed to train that particular set of skills. Then, the simulator is of great value.”

Advantages and patient safety

When it comes to advantages, training on a surgical simulator allows residents the opportunity for deliberate practice to help become more accurate in performing arthroscopic procedures, Gallagher said.

“If somebody does something wrong on a patient, you are not allowed to go back over it again and again,” Gallagher said. “The simulation offers the opportunity for deliberate rather than repeated practice, and that is what makes simulation so effective.”

By using a surgical simulator to train until residents reach a predetermined level of high proficiency instead of being assigned a predetermined number of hours to train, Cannon told Orthopedics Today residents will be able to go into the OR and fine-tune their skills starting from a higher level.

“Rather than the attending surgeon spending considerable time on the basics of arthroscopic surgery, he or she can continue the resident’s surgical training at a higher level,” he said. “This should mean fewer surgical errors, such as scuffing articular cartilage, and reduced operating room time for arthroscopic cases.”

Unlike in an OR where a mistake could injure the patient, training on the simulator allows residents to make mistakes without consequences.

“Errors can be made prior to any actual patient contact,” Eric J. Strauss, MD, associate residency program director at New York University’s Hospital for Joint Diseases, said. “The number of studies evaluating the impact of simulation are rapidly increasing and showing that residents who are exposed to simulation training are faster, are more efficient with these procedures and the error commission rate is dramatically decreased. So when they are helping out on a surgical procedure, they are further along the steep learning curve.”

Cannon also noted that at the end of the training session, the simulator itself can provide the resident with feedback, which can help residents become more proficient and reduce any possible errors.

“There are advantages of virtual reality simulation because of the instantaneous feedback to the trainee regarding progression in proficiency and possible errors in technique,” Cannon said.

Along with the opportunity for mistakes and instantaneous feedback, Richard Satava, MD, professor of the department of surgery at the University of Washington, told Orthopedics Today that regular training, preoperative planning and surgical rehearsal on a surgical simulator all contribute to overall patient safety by improving surgical outcomes.

“It is a given that one of the major foundations of improving surgical outcomes is improving the training so they make less errors,” Satava said. “This is where simulation comes in because it allows you to measure resident performance in the laboratory before they are allowed to actually do it on patients [and] training, preoperative planning and surgical rehearsal contribute incrementally to the ability to reduce errors and, therefore, become much more patient safety.”

Disadvantages and limitations

Whatever the type of simulator, whether it is a medium-fidelity model or a high-fidelity virtual reality computer system, if it does not mimic how the surgery will be performed on a real patient, Angelo noted, it will not be an accurate representation and will be less valuable to the resident as a training tool. The risk is that you may have an expensive simulator that is ineffective in training the needed skills. “If [the simulator] accurately emulates the touch, the feel and what you need to do [in the operating room] then it is going to provide a true ‘synthetic experience’ and be very effective,” Angelo said.

Gallagher noted the reasons for discrepancies with simulator models lies with the manufacturer and how it was designed.

“The reason for discrepancy between the anatomical structure or surgical problem in the simulation model is the manufacturer either does not ask surgeons who are experienced in performing that procedure or were very familiar with the anatomy or they were badly advised,” he said. “The simulation needs to be derived from the clinical procedure and from surgeons who actually are good or experienced at performing those procedures.”

Another disadvantage that may hinder residents in training is the lack of variety presented by the surgical simulators.

“The disadvantages of simulation is, in contrast to real patients, the variety of the simulation models is discreet,” Gallagher said. “The variety of anatomical structures that you will give residents will be similar and that is a disadvantage because the trainee, whether it is a doctor or surgeon, they need to be exposed to that variety because anatomical presentation is different from patient to patient and the trainee needs to be able to recognize core structures, pathology and so on.”

However, Gallagher noted that more complex simulations should not be presented to residents until they have excelled at the basic surgeries.

“You want to present residents with reasonably straightforward surgical problems. It is only later in the training that you want them to see variance,” Gallagher added. “When they become good at the standard surgical problem, then you start giving them slightly more difficult and more complex issues.”

Sometimes the visuals or the tools of a simulator may come across as not realistic and may not produce the right physical characteristics, creating an unreal feel to the procedure.

“Despite how good the technology is becoming, it is still not perfect,” Strauss, who is also assistant professor in the department of orthopedic surgery at New York University’s Langone Medical Center, said. “There is still a lack of realism that the technology is working to improve, but there is still no denying that the simulated computer generated image of a meniscus tear and the virtual instrument that is trimming the meniscus is not exactly what is experienced in real life.”

The use of haptic technology can help make surgical simulators more realistic and, therefore, more effective, according to Cannon. But high level haptic devices are expensive, and many institutions cannot afford them. He noted high level haptic devices can cost anywhere from $10,000 to $13,000 each, making surgical procedures that require multiple portals for instruments more expensive to provide a haptic device for each portal of entry.

“What we are advocating, what a simulation-based training curriculum means is that somebody is going to have to pay for the simulation models that the trainee practices on, whether it is a silicone model, which costs a few hundred dollars, or virtual reality simulation, which can cost hundreds of thousands of dollars,” Gallagher said.

Although the silicone model may sound like the less expensive route, Gallagher noted the silicon model may be just as expensive as the virtual simulation model because a surgeon would need to be hired to help guide and train the resident and provide the performance feedback that is the backbone of deliberate practice training.

“If you have a silicone model you need someone standing over the trainee’s shoulder giving them feedback on their performance,” Gallagher said. “A virtual reality model would give them the feedback automatically and it is computer-generated and scored. So the silicone model may sound less expensive, but when you factor in the person that is supervising and scoring their performance, it is not that inexpensive in comparison to the virtual reality simulation.”

The future

Eric J. StraussEric J. Strauss

As simulator technology improves, not only will more institutions be able to afford to provide surgical simulation laboratories for their residents, but surgical simulation will become more standard in continuing both resident and faculty member education.

“As industry is better able to create simulators that are more realistic with respect to imagery and the feel of normal instrument use, [surgical simulation is] going to become a standard part of education across the country,” Strauss said. “As the technology advances and, hopefully, the cost comes down, any time there is a new procedure out there, whether you are a resident or a faculty member, before you are attempting that new procedure on an actual patient, you are in the lab either performing it on a cadaver or with a simulator. You are developing the skills and understanding the nuances of the technique well in advance of the actual procedure itself.”

New and better simulators will also enable a new way of training for residents, according to Gallagher.

“What you are going to see is more training using simulation, but then applied in a clinical context,” Gallagher said. “You are probably also going to see outcome based assessments in the simulation skills laboratory.”

As surgical simulation continues to be implemented and becomes more of a standard for education, patients should start to become more comfortable with residents helping with their operation.

“Patients will demand more from surgeons and should feel more comfortable that residents have had simulation training reaching a high level of proficiency before going into the operating room,” Cannon said. “The vast majority of patients do not like junior residents doing even a straightforward diagnostic knee arthroscopy if they have not had much experience in the operating room.”

However, according to Angelo, before surgical simulation can have any effect on surgeon education, the orthopedic community needs to accept and adopt the new way of training surgical skills.

“If there is a great deal of resistance because educators are comfortable with traditional methods, then it may be slow to gain traction,” Angelo said. “It is abundantly clear, however, that if you harness simulation appropriately with a validated proficiency-based progression curriculum, the benefits are staggering. If the new paradigm becomes accepted and adopted, then I think that there is the potential that in the not too distant future, certainly for basic skills, simulation will be a routine, essential component of training.” – by Casey Tingle


Cannon WD, et al. J Bone Joint Surg Am. 2014;doi:10.2106/JBJS.N.00058.

For more information:

Richard L. Angelo, MD, can be reached at ProOrtho Clinic, 12911 120th Ave., NE h210, Kirkland, WA 98034;

W. Dilworth Cannon, MD, can be reached at the University of California, San Francisco Medical Center, 505 Parnassus Ave., San Francisco, CA 94143; email:

Anthony Gallagher, PhD, DSc, can be reached at The ASSERT for Health Centre at UCC, School of Medicine, Room 2.49, University College Cork, Brookfield Health Sciences Complex, College Road, Cork, Ireland;

Richard Satava, MD, FACS, can be reached at the University of Washington Medical Center, 1959 NE Pacific St., Seattle, WA 98195; email:

Eric J. Strauss, MD, can be reached at New York University Center for Musculoskeletal Care, 333 East 38th St., 4th Floor, New York, NY 10016; email:

Disclosures: Satava received an unrestrictive educational grant from Intuitive Robotic Surgery and has received numerous individual honoraria. Angelo, Cannon, Gallagher and Strauss report no relevant financial disclosures.