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Background: A preliminary validation study on a computer-based force-feedback simulation platform demonstrated the ability of the simulator to distinguish between novice and experienced users during a simulated hip-pinning procedure. The purpose of the present study was to further investigate whether the simulator and associated training modules are effective for improving user performance during simulated percutaneous hip-pinning procedures., Methods: With institutional review board approval, 24 medical students at our institution were randomized to "Trained" and "Untrained" groups. After a basic introduction, the Untrained group placed 3 guidewires in a valgus-impacted femoral neck fracture with use of the simulator. The Trained group completed 9 simulator-based training modules before performing the same task. Measured outcomes included an overall performance score and the distance from the pin to various ideals on the femoral neck, femoral head articular surface, and lateral cortex. Performance parameters were compared between groups with the Mann-Whitney U test., Results: The Trained group achieved a significantly higher overall score (median, 29) compared with the Untrained group (median, 6) (p < 0.01), outperformed the Untrained group in 4 specific performance metrics, and trended toward improvement over the Untrained group in 4 pin placement measures (p < 0.2)., Conclusions: Completion of novel training modules for percutaneous hip pinning on this fluoroscopic surgery simulator improves skill performance on simulator-based objective measurements and a simulated orthopaedic procedure compared with non-simulator-trained surgically inexperienced users. Improvement in the overall score and on 4 of 13 specific performance parameters implies that the training modules more effectively teach only certain motor and 3-dimensional spatial skills., Clinical Relevance: A valid platform such as the one described here has the potential to improve surgical education in orthopaedic trauma.

Background: The Accreditation Council for Graduate Medical Education and the American Board of Orthopaedic Surgery have implemented "milestones" to evaluate residents during their progression in medical education. The purpose of this study was to determine whether a validated evaluation tool correlates with surgical experience, year in training, and progression over time., Design: This was a retrospective study of already collected curriculum assessment data where 2 unbiased, blinded orthopedic surgeons evaluated resident performance on basic diagnostic knee arthroscopy using the Arthroscopic Surgical Skills Evaluation Tool (ASSET) over 3 years. Residents also gained arthroscopy experience through a structured arthroscopy curriculum and clinical experience., Setting: The study was conducted at the TRIA Orthopaedic Center (Bloomington, Minnesota, USA), an institutional site for The University of Minnesota orthopedic surgery residency program., Participants: Eleven orthopedic surgery residents at postgraduate years 2 to 5 were evaluated using the ASSET., Results: The Pearson's Correlation Coefficient was used to validate both the number of arthroscopic procedures performed by residents (r = 0.946) and their level in training (r = 0.89). Residents who were re-evaluated after undergoing the arthroscopy curriculum throughout the year displayed significant increases in total ASSET scores (p < 0.01)., Conclusion: Resident performance on the ASSET correlated with arthroscopic experience based on year-in training. More importantly, performance improved with additional years of training, demonstrating validity over time. The data also demonstrates interobserver reliability. Due to these correlations between exposure to surgery and score on the ASSET, we believe the tool could serve as a suitable means for assessing residents' technical proficiency as required by The Accreditation Council for Graduate Medical Education program guidelines., (Copyright © 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: To test the face validity of the hip diagnostics module of a virtual reality hip arthroscopy simulator., Methods: A total of 25 orthopaedic surgeons, 7 faculty members and 18 orthopaedic residents, performed diagnostic supine hip arthroscopies of a healthy virtual reality hip joint using a 70° arthroscope. Twelve specific targets were visualised within the central compartment; six via the anterior portal, three via the anterolateral portal and three via the posterolateral portal. This task was immediately followed by a questionnaire regarding the realism and training capability of the system. This consisted of seven questions addressing the verisimilitude of the simulator and five questions addressing the training environment of the simulator. Each question consisted of a statement stem and 10-point Likert scale. Following similar work in surgical simulators, a rating of 7 or above was considered an acceptable level of realism., Results: The diagnostic hip arthroscopy module was found to have an acceptable level of realism in all domains apart from the tactile feedback received from the soft tissue. 23 out of 25 participants (92%) felt the simulator provided a non-threatening learning environment and 22 participants (88%) stated they enjoyed using the simulator. It was most frequently agreed that the level of trainees who would benefit most from the simulator were registrars and fellows (22 participants; 88%). Additionally, 21 of the participants (84%) agreed that this would be a beneficial training modality for foundation and core trainees, and 20 participants (80%) agreed that his would be beneficial for consultants., Conclusions: This VR hip arthroscopy simulator was demonstrated to have a sufficient level of realism, thus establishing its face validity. These results suggest this simulator has sufficient realism for use in the acquisition of basic arthroscopic skills and supports its use in orthopaedics surgical training., Level of Evidence: I.

We came in with high expectations, yet the Arthroscopy Association of North America (AANA) Traveling Fellowship far exceeded them. The 4 traveling fellows came from different backgrounds, different parts of North America, and different practice settings, including an independent private practice, a hybrid private-academic practice, the military, and academia. We were lucky to have been ushered along the way by our godfather, the distinguished John Richmond, M.D., Past-President of AANA and Associate Editor Emeritus of Arthroscopy, who was gracious enough to give his time to the expedition. Over the course of the journey, this gang came together quickly and forged relationships that will last a lifetime. We are extremely grateful to AANA for the privilege and will cherish the memories for years to come., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To analyze the learning curves of 5 experienced, fellowship-trained shoulder surgeons and their respective 25 first arthroscopic Latarjet cases in regard to surgical time, graft placement, complication rates, and recurrent instability., Methods: The first 25 arthroscopic Latarjet procedures of 5 surgeons were retrospectively analyzed in an international multicenter setting, and thus 125 patients were included in this study. The surgical time, intraoperative and postoperative events out of the ordinary, and graft positioning were examined., Results: The 125 patients consisted of 16 women (12.8%) and 109 men (87.2%). In 81.6% (n = 102), surgery was undertaken as a first-line procedure, whereas 18.4% (n = 23) were revisions. Surgical time decreased significantly from an average of 123.8 minutes (range 70 to 210) to 92.6 minutes (range 50 to 160) from the first 5 cases to the last 5 cases of each surgeon within a period of <2 years. Overall, 22 events in 21 patients requiring additional treatment were reported (17.6%). Five (4%) were unlikely to affect final outcome and did not require revision surgery. Twelve (9.6%) required revision surgery that was not trauma related yet was prone to affect outcomes. Five events were trauma-related (4%), 4 requiring revision surgery and 1 treated conservatively. Overall, 6 patients (4.8%) had recurrent shoulder instability, 3 as a result of a traumatic event. Conventional radiology showed the bone-block in ideal positioning in 93 cases (74.4%), flush with the glenoid in a true anteroposterior view. In 3 cases (2.4%), it was considered too high, 15 too low (12%), 5 too lateral (4%), and 15 too medial (12%). Some patients had combinations of the above., Conclusion: This analysis shows that surgical time in arthroscopic Latarjet can be significantly reduced after only 20 cases. However, complication rates did not decrease over this time. The authors believe that the arthroscopic Latarjet is a challenging yet viable technique to treat anterior shoulder instability, achieving results equal to the open technique with advantages of the arthroscopic setting., Level of Evidence: Level IV, retrospective cohort study., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: This study’s aim was to evaluate the performance of senior orthopedic residents during simulated arthroscopic anterior stabilization (Bankart repair) before and after a national shoulder review course., Methods: Participants were assessed before and after the Annual Shoulder Review Course over a 3-day period, using a multiple-choice examination and surgery performance assessment. The surgical evaluation was completed by fellowship-trained surgeons using a standardized procedure checklist and a global rating scale. All Canadian senior orthopedic residents were invited to participate in the course., Results: The 57 participants showed improvement following the course. The written knowledge evaluation mean score increased, and all 3 surgical performance measurements improved: surgical task time improved from 4:40 min to 2:53 min (p < 0.001), surgical technique evaluation increased from 56% to 67% after the procedure checklist (p < 0.001), and anchor placement improved for all 3 aspects. Anchor entry point was the sole measure not to improve enough to reach statistical significance (p = 0.37)., Conclusion: Our data support the inclusion of dry model surgical simulation as part of a surgical skills course for both training and assessment of orthopedic surgery residents., Competing Interests: D. Rouleau is a consultant for Bioventus and Wright Medical. V. Godbout has received speaker fees from Arthrex., (© 2019 Joule Inc. or its licensors)

Objective: To determine the effectiveness of simulator training on basic arthroscopic skills utilizing a novel, low-cost arthroscopic triangulation training system., Design: A randomized controlled trial of subjects without prior arthroscopy training was conducted, with participants randomized to receive either a fixed protocol of simulation training on a triangulation simulation model (30 minutes of training for 4 consecutive days), or no training. On Days 1 and 5, all participants were evaluated on 3 simulated arthroscopic tasks by an independent observer. Variables analyzed included how many times portals were changed, the time it took to complete the tasks, and the task completion rate., Setting: Arthrex Inc., Naples, FL., Participants: Thirty-six participants (92% male, average 28 ± 5 years) with no prior arthroscopy training were randomized into 2 groups, with 17 in the training group (T) and 19 in the no-training group (NT)., Results: On Day 1, there was no difference in rate of task completion between the T group and NT groups (41% versus 53%, p = 0.52). On Day 5, significantly more participants in the T group completed all tasks compared to the NT group (100% versus 63%, p = 0.008). Participants in the T group had significantly improved task completion times on Day 5 versus Day 1 (p < 0.05). Participants in the NT group had a significantly improved task completion time for Task 1 on Day 5 versus Day 1 (p = 0.037); no differences were found for Tasks 2 or 3. On Day 5, participants in the T group required significantly fewer portal changes compared to the NT group (2.35 ± 2.29 versus 6.95 ± 8.55, p = 0.039)., Conclusions: Simulation training on a simple, low-cost arthroscopic triangulation training system resulted in an overall improvement in arthroscopic probing and triangulation skills within 1 week of training, with significantly decreased task completion times and increased efficiency of movement., (Copyright © 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Arthroscopy is a technically challenging surgical procedure with a relatively shallow learning curve compared to open procedures. To become an expert special cognitive and manual abilities have to be acquired and trained. The current situation in further medical education combined with the increasing economic pressure in the medical field does not leave enough room for a time-consuming training in arthroscopic techniques. A structured simulation training could be an alternative solution to this problem. The benefits of arthroscopic simulation training are meanwhile well documented. The complex tasks that an expert carries out during arthroscopy can be fragmented into more simple and elementary exercises and can be trained in a stress-free environment outside the operation room. An essential advantage of simulation training is the assessment of objective measurement parameters during the individual exercises. These parameters can be used to evaluate the learning process and performance of arthroscopic tasks. The aim of this review is to reflect the current state of simulation technology in arthroscopy and to show how simulator training can be meaningfully and effectively integrated into arthroscopic further training, exemplified by a modern medical further education concept.

Objective: To assess the face, content and construct validity of a virtual reality hip arthroscopy simulator (Arthros™, VirtaMed AG, Schlieren, Switzerland)., Design: Participants were divided into Expert and Novice groups depending on whether or not they had assisted with or performed more than 50 hip arthroscopy procedures. Participants were given a standardized introduction and shown a video on how to use the simulator. To familiarise themselves with the equipment, they were then given a 5-minute diagnostic task to complete. Participants then performed a therapeutic task. On completion, the simulator produced a summary of performance metrics for the following domains: Operation Time, Safety, Economy, Detailed Visualization and Overall Score. Participants completed a 7-point Likert-scale questionnaire to assess the face and content validity of the simulator., Setting: University lab or exhibition stand at an orthopaedic conference., Participants: Clinicians from a hospital orthopaedic department and attendees at a UK orthopaedic conference with varying levels of experience in hip arthroscopy surgery., Results: Twenty-two participants were recruited. Six were classified as Expert and 16 as Novice. Statistically significant differences were found between the Expert and Novice groups for Overall Score (p=0.001), Safety (p=0.002) and Economy (p=0.033), but not Detailed Visualization (p=0.097). Questionnaire responses were positive for all items related to face and content validity., Conclusion: This study suggests that training on the ArthroS™ VR hip arthroscopy simulator has construct, face and content validity. It expands the evidence base for VR simulator training and is the first study to evaluate this hip arthroscopy module.

Purpose: The purpose of this study is to evaluate the trends in labral repair in American Board of Orthopaedic Surgery Part II candidates performing hip arthroscopy., Methods: Candidates who performed arthroscopic hip surgery between 2011 and 2015 during their American Board of Orthopaedic Surgery Part II board collection period were identified using Current Procedural Terminology codes (29860, 29861, 29862, 29863, 29914, 29915, 29916). The proportion of hip arthroscopy cases including labral repair (Current Procedural Terminology code 29916) were calculated for each year and analyzed by fellowship training experience. Trends in labral repair utilization were calculated using univariate and regression analyses, with significance set at P < .05., Results: During the study period, 1,606 hip labral repair cases were performed, with a 35% increase in utilization between 2011 and 2015. Overall, labral repair was performed in 64.8% (1,606/2,480) of hip arthroscopy cases, with a significant increase between 2011 and 2015 (47.4% vs 79.2%; P < .001). Of the hip arthroscopy cases including labral repair, 80.4% (1,291/1,606) were performed by candidates with sports medicine fellowship training. The proportion of hip arthroscopy cases including labral repair was highest for surgeons with sports medicine fellowship training compared with those without sports medicine fellowship training (66.1% vs 59.8%; P = .007). Candidates with sports medicine training performing at least 1 labral repair each year increased from 68% to 89% over the study period (P = .0007). The average number of labral repairs per candidate increased significantly over the duration of the study period (P = .0072)., Conclusions: Labral repair utilization during hip arthroscopy procedures nearly doubled from 2011 to 2015 for American Board of Orthopaedic Surgery Part II candidates, reflecting a significant change in practice. Current data suggest that nearly 80% of hip arthroscopy procedures include labral repair. These trends may reflect the current practice patterns at academic institutions with sports medicine fellowships., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To objectively investigate the transfer validity of simulation training using wireless elbow-worn motion sensors intraoperatively to assess whether surgical simulation leads to improvements in intraoperative arthroscopic performance., Methods: In this randomized controlled trial, postgraduate year 2 to 3 trainees in nationally approved orthopaedic surgery posts were randomized to standard junior residency training (control group) or standard training plus additional weekly simulation training (intervention group). Both groups performed a supervised real-life diagnostic knee arthroscopy in the operating room at 13 weeks. Performance was measured using wireless elbow-worn motion sensors recording objective surgical performance metrics: number of hand movements, smoothness, and time taken. A participant-supervisor performance ratio was used to adjust for variation in case mix and difficulty. The study took place in a surgical simulation suite and the orthopaedic operating rooms of a university teaching hospital., Results: The intervention group objectively outperformed the control group in all outcome metrics. Procedures performed by the intervention group required fewer hand movements (544 [interquartile range (IQR), 465-593] vs 893 [IQR, 747-1,242]; P < .001), had smoother movements (25,842 ms -3 [IQR, 20,867-27,468 ms -3 ] vs 36,846 ms -3 [IQR, 29,840-53,949 ms -3 ]; P < .001), and took less time (320 seconds [IQR, 294-392 seconds] vs 573 seconds [IQR, 477-860 seconds]; P < .001) than those performed by the control group. The cases were comparable between the groups. Standardized to the supervisor's performance, the intervention group required fewer hand movements (1.9 [IQR, 1.5-2.1] vs 3.3 [IQR, 2.2-4.8]; P = .0091), required less time (1.2 [IQR, 1.1-1.7] vs 2.6 [IQR, 1.6-3.0]; P = .0037), and were smoother (2.1 [IQR, 1.8-2.8] vs 4.3 [IQR, 2.8-5.4]; P = .0037) than the control group, but they did not perform as well as their supervisors., Conclusions: This study uses intraoperative motion-analysis technology to objectively show that surgical simulation training improves actual intraoperative technical skills performance., Clinical Relevance: The described wireless objective assessment method complements the subjective observational performance assessments commonly used. Further studies are required to assess how these measures of intraoperative performance correlate to patient outcomes. Intraoperative motion analysis is translatable across surgical specialties, offering potential for objective assessment of progression through competency-based training, revalidation, and talent selection for specialist training., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: We have developed a new arthroscope with a field of view of 150°. This arthroscope requires less motion to maneuver and exhibits reduced optical error. It also improves how novices learn arthroscopy. We hypothesized that the surgical performance with this arthroscope is superior to that with a conventional arthroscope. This study tested the hypothesis by using motion analysis and a new validated parameter, "dimensionless squared jerk" (DSJ)., Methods: We compared the surgical performance between the use of the wide-angle arthroscope and that of the conventional arthroscope among 14 novice orthopedic residents who performed 3 standardized tasks 3 times with each arthroscope. The tasks simulated the surgical skills in arthroscopic rotator cuff repair. The arthroscope motion was analyzed using an optical tracking system. The differences in performance parameters, such as the time taken to complete the tasks, average acceleration of the hands (m/s2), number of movements, and total path length (m) including DSJ between the 2 arthroscopes were investigated using paired t-tests., Results: All estimated values for the tasks using the 150° arthroscope were lower than those for the tasks using the 105° arthroscope. Statistically significant differences in performance between the 2 arthroscopes were observed only for DSJ (p = 0.014) and average acceleration (p = 0.039)., Conclusions: DSJ and average acceleration are reliable parameters for representing hand-eye coordination. The surgical performance of novice arthroscopists was better with the new wide-angle arthroscope than with the conventional arthroscope., Competing Interests: The authors have declared that no competing interests exist.

Thank you AANA for allowing us to participate in one of the most educational and transformative pieces of our careers to date. It was a great honor to be selected to participate in the 2018 Advanced Arthroscopy Training Fellowship. We journeyed to New York City, New Orleans, and Columbus, Ohio. This was a life-changing experience full of remarkable Friendship and Mentorship., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Elements of competency-based training are being incorporated into surgical training. The primary objective of this study was to determine how the orientation of the arthroscope and the instruments relative to the standing position of the surgeon affects basic arthroscopic performance. The secondary objective was to determine how arthroscopic level of training affects performance., Methods: Participants from a single academic institution were recruited and divided by level of training into 2 groups: novice and advanced. The Fundamentals of Arthroscopic Surgery Training (FAST) Workstation (Sawbones) was used in this study. Performance on the ring transfer module was evaluated based on the total number of ring transfers that were completed and the errors that were made in timed sessions. All participants performed the task with the arthroscope facing away from (position A) and facing toward (position B) their standing position. Two trials were completed for each position, followed by a survey., Results: Fifty-seven subjects participated in this study. Overall, position A showed 2.7 times the amount of transfers compared with position B (p < 0.001). The advanced group had 1.6 times more transfers in position A than the novice group (p = 0.007), and there was no significant difference in transfers between training level in position B. The advanced group had 3.6 times more transfers in position A compared with position B (p < 0.001), while the novice group had 2.0 times more transfers in position A than in position B (p < 0.001)., Conclusions: Performing an arthroscopic simulator task with the arthroscope directed toward the operator was found to be more difficult. An understanding of how the orientation of the operator, the arthroscope, and the instruments can strongly influence performance may be important for the primary surgeon, trainees, or assistants who may be standing opposite the arthroscope, and to optimize training to overcome this discrepancy.

Purpose: To assess the effectiveness of a low-cost self-made arthroscopic camera (LAC) in basic arthroscopic skills training compared with a commercial arthroscopic camera (CAC)., Methods: One hundred fifty-three orthopaedic residents were recruited and randomly assigned to either the LAC or CAC. They were allocated 2 practice sessions, with 20 minutes each, to practice 4 given arthroscopic tasks: task 1, transferring objects; task 2, stacking objects; task 3, probing numbers; and task 4, stretching rubber bands. The time taken for participants to complete the given tasks was recorded in 3 separate tests; before practice, immediately after practice, and after a period of 3 months. A comparison of the time taken between both groups to complete the given tasks in each test was measured as the primary outcome., Results: Significant improvements in time completion were seen in the post-practice test for both groups in all given arthroscopic tasks, each with P < .001. However, there was no significant difference between the groups for task 1 (P = .743), task 2 (P = .940), task 3 (P = .932), task 4 (P = .929), and total (P = .944). The outcomes of the tests (before practice, after practice, and at 3 months) according to repeated measures analysis of variance did not differ significantly between the groups in task 1 (P = .475), task 2 (P = .558), task 3 (P = .850), task 4 (P = .965), and total (P = .865)., Conclusions: The LAC is equally as effective as the CAC in basic arthroscopic skills training with the advantage of being cost-effective., Clinical Relevance: In view of the scarcity in commercial arthroscopic devices for trainees, this low-cost device, which trainees can personally own and use, may provide a less expensive and easily available way for trainees to improve their arthroscopic skills. This might also cultivate more interest in arthroscopic surgery among junior surgeons., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Constructing a durable arthroscopic knot is critical for secure tissue fixation. The effect of various arthroscopic base knot configurations paired with various overhand/underhand stacking combinations of three reversing half-hitches on alternating posts (RHAPs) on knot strength and integrity remains unanswered., Methods: Three common base knots (Surgeon's, Weston and, Tennessee Slider) followed by different overhand/underhand stacking combinations of three RHAPs were evaluated. Ten knots of each combination were tied by four subjects with varying levels of experience, resulting in the analysis of 480 total knots. A single load-to-failure test was performed to evaluate knot strength and integrity. The ultimate clinical failure load and mode of failure were recorded., Results: All knots created surpassed the estimated minimum required load per suture. There was, however, statistically large inter-subject variability for each base knot configuration. The Surgeon's base knot was found to vary the least in knot strength, while the Tennessee base knot was found to vary the most. Knot security was mostly influenced by the base knot configuration than the different overhand/underhand RHAP stacking combinations. Knot slippage failure mode was higher with knots tied with the Weston base knot compared to the other two configurations., Conclusions: Arthroscopic base knot configurations paired with different overhand/underhand stacking combinations of RHAPs yielded knot capable of secure tissue fixation. A short instructional training period appears to be sufficient for inexperienced individuals to learn easier base knot configurations, more challenging and complicated knots, however, may require training in a more gradual fashion., Clinical Relevance: The findings of this study provide information that the importance of hands-on experience for inexperienced individuals, such as residents, in performing arthroscopic knot tying, and that can lead to improving the securely constructed arthroscopic knots, which increase positive outcomes related to strengthened soft tissue to bone fixation of post-operative patients. Level of Evidence: V., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study.

Background: Arthroscopy is one of the cornerstone skills learned during orthopaedic residency training. Previous studies have attempted to identify characteristics of arthroscopy naive individuals leading to superior initial arthroscopic performance with conflicting findings. Furthermore, other virtual reality simulator studies consisting of beginner trainees, have noted that certain individuals fail to progress at the rate of their peers despite rigorous training. Therefore the purpose of this study was to 1) identify trainee characteristics that may have an impact on initial arthroscopy skill and performance and 2) identify trainee characteristics affecting their ability to improve through training on an arthroscopy simulator., Methods: Forty-three medical students with no prior arthroscopy experience performed a diagnostic knee arthroscopy using an anatomic virtual reality simulator. Prior to the procedure, information was collected about each participant regarding various demographics, sports involvement, hand dominance, specialty interest, 3-D video game use and experience assisting in the operating room. Their baseline performance was measured using the following outcomes: time (seconds), camera path length (CPL) (centimeters), and an overall composite score. A subgroup consisting of 22 students underwent training with a non-anatomic virtual arthroscopy simulator consisting of a series of 5 self-guided modules after their initial knee scope. This group was retested using the same diagnostic knee scope one to two weeks later. Participant background characteristics were correlated with initial performance on the knee scope and the change from the first to second knee scope in the sub-group that completed the training., Results: At the time of the initial diagnostic knee arthroscopy, performance was most strongly correlated with how often an applicant currently plays video games and how often they have played video games in the past. However, this was only a weak correlation (r= 0.29 and 0.24, respectively). Interestingly, students pursuing a non-surgical residency outperformed those interested in a surgical specialty in all outcome measurements at baseline, although this did not reach a level of significance. Year of training in medical school, age, hand dominance, current or past participation in sports requiring hand-eye coordination, and number of surgical cases they have assisted in for did not influence initial performance. Participants that have operated another type of scope (e.g. bronchoscopy, laparoscopy) in the past showed a trend towards higher performance in composite score (21.6 vs 14.9, p = 0.07), although this did not reach a level of significance. Regarding the change in performance of those that completed the non-anatomic training prior to the second knee scope, change in time to complete the procedure was significantly different between participants in different years of medical school. Fourth year medical students improved by an average of 421 seconds compared to 98 seconds, 127, and 140 seconds for the other classes, p = 0.02. Those who have regularly participated in sports requiring hand eye coordination in the past improved their time (182 vs 78 seconds, p = 0.0245) and camera path length (96 vs 31 cm, p = 0.0372) significantly more than those were not involved in sports., Discussion and Conclusions: Our study demonstrates that baseline arthroscopy performance correlates most highly with 3D video game experience. The ability of trainees to learn arthroscopy using a virtual reality simulator appears to be influenced more by those who have regularly participated in sports requiring hand eye coordination rather than video game use. Level of Evidence: III., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study.

Objectives: This study aims to compare the efficacy of existing training models for acquisition of arthroscopic skills and to investigate the most effective training method or combination of methods for residents., Materials and Methods: A total of 100 fifth-year students from medical school (40 males, 60 females; mean age 23.7 years; range, 22 to 33 years) volunteered to participate in the study and were randomly divided into five education groups (E1-5): group E1 (trained on bench-top simulator), group E2 (read surgical technique), group E3 (read surgical technique and watched surgical video), group E4 (watched surgical video only), and group E5 (control group). After completion of the pre-training, each student was individually asked to perform an arthroscopy practice. A checklist containing the tasks to be performed was given to students and students were asked to complete the tasks on the checklist in five minutes., Results: In group E1, the mean rate of successful achievement of tasks was significantly higher than other groups in both knee and shoulder arthroscopy models. Rate of each task was statistically similar for groups E2, E3, E4 and E5. In group E1, mean durations for completion of tasks in both arthroscopy models were significantly shorter than other groups. There was no statistically significant difference in terms of gender between those who successfully completed the tasks in both arthroscopy models., Conclusion: A basic arthroscopic bench-top simulator may be a low-cost and effective training method to increase arthroscopic skill levels in resident training compared to traditional methods.

Purpose: This study aimed to determine the effect of a simulation course on gaze fixation strategies of participants performing arthroscopy., Methods: Participants (n = 16) were recruited from two one-day simulation-based knee arthroscopy courses, and were asked to undergo a task before and after the course, which involved identifying a series of arthroscopic landmarks. The gaze fixation of the participants was recorded with a wearable eye-tracking system. The time taken to complete the task and proportion of time participants spent with their gaze fixated on the arthroscopic stack, the knee model, and away from the stack or knee model were recorded., Results: Participants demonstrated a statistically decreased completion time in their second attempt compared to the first attempt (P = 0.001). In their second attempt, they also demonstrated improved gaze fixation strategies, with a significantly increased amount (P = 0.008) and proportion of time (P = 0.003) spent fixated on the screen vs. knee model., Conclusion: Simulation improved arthroscopic skills in orthopaedic surgeons, specifically by improving their gaze control strategies and decreasing the amount of time taken to identify and mark landmarks in an arthroscopic task., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: Wrist arthroscopy is a challenging discipline with limited training exposure during residency. The purpose of this study was to evaluate the effectiveness of virtual knee arthroscopy simulation training for gaining proficiency in wrist arthroscopy., Design: Participants were recorded performing a cadaveric wrist arthroscopy simulation. The residents then practiced knee arthroscopy on a virtual reality simulator and repeated the wrist arthroscopy simulation. All videos were blinded prior to assessment. Proficiency was graded using the Arthroscopic Surgery Skill Evaluation Tool global rating scale. In addition, participants were asked to complete a survey assessing the value of the virtual reality knee arthroscopy simulator for wrist arthroscopy., Setting: Orthopaedic Surgery Residency Program, Carolinas Medical Center, a large, public, nonprofit hospital located in Charlotte, North Carolina., Participants: Orthopaedic residents at our center were asked to participate in the simulation training. Participation was voluntary and nonincentivized. All orthopaedic residents at our institution (N = 27) agreed to participate. In total, there were 10 Intern (PGY-0 and PGY-1), 10 Junior (PGY-2 and PGY-3), and 7 Senior (PGY-4 and PGY-5) residents. In addition, a fellowship-trained hand surgeon was recruited to participate in the study, performing the wrist arthoscopy simulation. Two additional fellowship-trained hand surgeons, for a total of 3, assessed the blinded videos., Results: There was a trend toward better wrist Arthroscopic Surgery Skill Evaluation Tool scores by training level, although the difference was not statistically significant. Interns improved by an average of 1.8 points between baseline and postknee simulation tests. Junior and senior residents decreased by 1.6 and 5.0 points, respectively., Conclusions: Knee arthroscopy simulation training did not objectively improve wrist arthroscopy proficiency among residents. A wrist-specific arthroscopy simulation program is needed if measurable competence through simulation is desired., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Knee arthroscopies are very common orthopedic procedures. For a number of reasons, including increased public awareness for medical errors, patient safety, strict regulations governing duty-hours for residents, surgeons' liability, and an increasing emphasis on the efficient use of operating room time, interest in simulator training is on the rise. It was the purpose of this study to analyze learning curves of medical students and orthopedic resident surgeons using a virtual knee arthroscopy simulator., Design: Learning curves of medical students and orthopedic residents were measured perspective using an arthroscopic training simulator for 2 different exercises. Time, camera and probe movement as well as camera and probe roughness were the parameters to be compared. Mean and standard deviation of the initial and the final score for the consecutively performed exercises as well as their slope were reported., Setting: The study was performed at the Medical University of Innsbruck, Department of Orthopaedic Surgery. Level of clinical care: institutional., Participants: A Students Group (n = 10) consisting of medical students at the Medical University of Innsbruck with no prior knowledge of arthroscopy but interest in orthopedic surgery was selected. The group was compared to a Residents Group (n = 9) which was comprised of orthopedic resident surgeons who had learned arthroscopy in operation courses. All participants involved in the study did several repetitions of the described exercises., Results: Both groups improved their skills after several repetitions. Residents were on average faster, moved the camera less, and touched the cortical tissue less than the students. For certain parameters students showed a steeper improvement curve than did residents, because the students started from a different experience level., Conclusions: In conclusion, our results demonstrate the usefulness of virtual knee arthroscopy simulators as an important tool for improving surgical and arthroscopic skills in orthopedic resident surgeons, and medical students., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To determine current methods of arthroscopic skills training and proficiency assessment, identify skills considered fundamental to arthroscopy, and evaluate desire for a formal training and assessment program., Study Design: Anonymized electronic survey., Sample Population: Diplomates and residents of the American College of Veterinary Surgeons (ACVS) and European College of Veterinary Surgeons (ECVS)., Methods: An electronic survey was distributed in commercial software (Qualtrics, Provo, Utah). Questions were divided into 4 categories: (1) demographics, (2) arthroscopy experience, (3) teaching, and (4) proficiency assessment. Descriptive statistical analysis was performed. Comparisons between groups were performed by using χ 2 , t tests, and 1-way ANOVA (P ≤ .05)., Results: In total, 429 diplomates and 149 residents responded (response rate 28%). Overall, 80% of respondents trained using clinical cases. Barriers to simulator training included cadaver/simulator availability and time. Skills deemed most fundamental included anatomic knowledge, precise portal placement, triangulation, and image orientation. Overall, 90% of respondents supported a formal training program with requirement to demonstrate proficiency; 80% believed this should be part of standard ACVS/ECVS residency training., Conclusion: Arthroscopic skills are taught by using clinical cases, with subjective proficiency assessment. Fundamental skills are those that may be taught using simulators. There is enthusiasm for formal arthroscopic skills training and assessment., Clinical Significance: Improved acquisition and assessment of fundamental arthroscopic skills is indicated. A validated methodology for formal training using simulators, minimizing morbidity, and facilitating objective evaluation is warranted. This is the first phase of a project to develop and validate a simulator program., (© 2018 The American College of Veterinary Surgeons.)

Background: Arthroscopy is one of the most common procedures performed by orthopedic surgeons. Virtual reality (VR) simulation in general surgery residency training has been increasing over the past decade, but it has seen little use in the field of orthopedic surgery., Objective: To determine osteopathic orthopedic surgery residents' perceived value of having access to a VR simulator before performing an arthroscopic procedure on a live patient., Methods: A survey was developed and sent to all US osteopathic orthopedic surgery residency programs to be disseminated to all of their current residents. The survey consisted of 12 questions, which included Likert-type scale responses and yes or no responses., Results: Fifty-eight residents out of approximately 507 responded. Forty-one of 57 respondents (72%) were in year 1 of residency when they performed their first arthroscopy, and 53 of 57 (93%) were not very comfortable when they performed their first arthroscopy. With respect to VR simulator exposure, approximately 31of 51 (61%) reported no exposure to a VR simulator, and 40 of 50 (80%) reported that their program did not provide a skills laboratory where they could practice arthroscopy. Of 50 respondents, 37 (74%) believed that a skills laboratory was important, 28 (56%) believed that a resident should perform 1 to 10 arthroscopies in a skills laboratory before performing one in the operating room, 34 (60%) believed that skills acquired in a skills laboratory would transfer to the operating room, and 33 (66%) agreed that every residency program should provide a skills laboratory. However, 29 (58%) believed that a skills laboratory would not improve patient safety., Conclusion: Osteopathic orthopedic surgery residents indicated that they would benefit from the addition of an arthroscopic skills laboratory with a VR simulator. Furthermore, they believed that the skills learned in the skills laboratory would transfer to the operating room and would increase their comfort level with the procedure.

Background: Following the introduction of worktime regulations across the world along with existing concerns over the nonuniform nature of the traditional apprenticeship model, an alternative method for teaching surgical skills is being sought. Simulation training offers a safe and standardized environment to develop and improve surgical skills. The purpose of the present study was to review the existing and most recent research into the utility of arthroscopic simulators in training and the teaching of surgical skills., Methods: A systematic review of the MEDLINE, Embase, and Cochrane Library databases for English-language articles published between 2014 and November 2017 was conducted. Search terms included arthroscopy or arthroscopic with simulation or simulator., Results: We identified a total of 27 relevant studies involving simulated ankle, knee, shoulder, hip, and simple box arthroscopic environments. The majority of these studies demonstrated construct validity, while a few demonstrated transfer, face, and content validity., Conclusions: Our review suggests that there is a considerable evidence base regarding the use of arthroscopic simulators for training purposes. Further work should focus on the development of a standardized simulator training course that can be contrasted against current intraoperative training in large-scale multicenter trials with long-term follow-up.

Background: There are less and fewer opportunities for residents to learn and develop surgical skills in the operating room. In some parts of the world, the development and adaptation of technology for the teaching of psychomotor skills in surgical specialties appears. Arthroscopy is a surgical technique that lends itself to simulation. So far there is no such thing as a structured and validated arthroscopy training program for orthopaedic residents in Mexico., Objective: To propose a structured arthroscopy training plan that incorporates the simulation for orthopaedic residents., Method: A review of the literature on teaching with simulation in orthopaedics and arthroscopy was performed, a study was conducted to establish reference values for arthroscopy exercises in a virtual reality simulator and a training plan was developed with Arthroscopy simulation for orthopaedic residents., Results: A seven-stage program was developed with theoretical classes and simulation to improve motor skills. The complexity of the procedures increases through the practical modules. It is complemented by a semester evaluation., Discussion: Currently most of the efforts in teaching with simulators focus on medical students and first-and second-year residents. I believe that efforts should be focused to include residents of higher ranks and surgeons. This design will be proposed to the orthopaedic Unique Medical Education Program (PUEM in Spanish). It is important to develop validated curricula that incorporate the simulation for the development of motor skills in orthopaedic residents.

Purpose: To determine the inter-rater reliability (IRR) of a procedure-specific checklist scored in a binary fashion for the evaluation of surgical skill and whether it meets a minimum level of agreement (≥0.8 between 2 raters) required for high-stakes assessment., Methods: In a prospective randomized and blinded fashion, and after detailed assessment training, 10 Arthroscopy Association of North America Master/Associate Master faculty arthroscopic surgeons (in 5 pairs) with an average of 21 years of surgical experience assessed the video-recorded 3-anchor arthroscopic Bankart repair performance of 44 postgraduate year 4 or 5 residents from 21 Accreditation Council for Graduate Medical Education orthopaedic residency training programs from across the United States., Results: No paired scores of resident surgeon performance evaluated by the 5 teams of faculty assessors dropped below the 0.8 IRR level (mean = 0.93; range 0.84-0.99; standard deviation = 0.035). A comparison between the 5 assessor groups with 1 factor analysis of variance showed that there was no significant difference between the groups (P = .205). Pearson's product-moment correlation coefficient revealed a strong and statistically significant negative correlation, that is, -0.856 (P < .000), indicating that as intra-operative error rate scores increased, the IRR decreased., Conclusions: Arthroscopy Association of North America shoulder faculty raters from across the United States showed high levels of IRR in the assessment of an arthroscopic 3-anchor Bankart repair procedure. All paired assessments were above the 0.8 level and the mean IRR of all resident assessments was 0.93, indicating that they could be used for high-stakes decisions., Clinical Relevance: With the move toward outcomes-based performance evaluation for graduate medical education, high-stakes assessments of surgical skill will require robust, reliable measurement tools that are able to withstand challenge. Surgical checklists employing metrics scored in a binary fashion meet the need and can show a high (>80%) IRR., (Copyright © 2018 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Most studies demonstrated, that training on a virtual reality based arthroscopy simulator leads to an improvement of technical skills in orthopaedic surgery. However, how long and what kind of training is optimal for young residents is unknown. In this study we tested the efficacy of a standardized, competency based training protocol on a validated virtual reality based knee- and shoulder arthroscopy simulator., Methods: Twenty residents and five experts in arthroscopy were included. All participants performed a test including knee -and shoulder arthroscopy tasks on a virtual reality knee- and shoulder arthroscopy simulator. The residents had to complete a competency based training program. Thereafter, the previously completed test was retaken. We evaluated the metric data of the simulator using a z-score and the Arthroscopic Surgery Skill Evaluation Tool (ASSET) to assess training effects in residents and performance levels in experts., Results: The residents significantly improved from pre- to post training in the overall z-score: - 9.82 (range, - 20.35 to - 1.64) to - 2.61 (range, - 6.25 to 1.5); p < 0.001. The overall ASSET score improved from 55 (27 to 84) percent to 75 (48 to 92) percent; p < 0.001. The experts, however, achieved a significantly higher z-score in the shoulder tasks (p < 0.001 and a statistically insignificantly higher z-score in the knee tasks with a p = 0.921. The experts mean overall ASSET score (knee and shoulder) was significantly higher in the therapeutic tasks (p < 0.001) compared to the residents post training result., Conclusions: The use of a competency based simulator training with this specific device for 3-5 h is an effective tool to advance basic arthroscopic skills of resident in training from 0 to 5 years based on simulator measures and simulator based ASSET testing. Therefore, we conclude that this sort of training method appears useful to learn the handling of the camera, basic anatomy and the triangulation with instruments.

Purpose: To determine the effectiveness of a nonanatomic simulator in developing basic arthroscopy motor skills transferable to an anatomic model., Methods: Forty-three arthroscopy novice individuals currently enrolled in medical school were recruited to perform a diagnostic knee arthroscopy using a high-fidelity virtual reality arthroscopic simulator providing haptic feedback after viewing a video of an expert performing an identical procedure. Students were then randomized into an experimental or control group. The experimental group then completed a series of self-guided training modules using the fundamentals of arthroscopy simulator training nonanatomic modules including camera centering, tracking, periscoping, palpation, and collecting stars in a three-dimensional space. Both groups completed another diagnostic knee arthroscopy between 1 and 2 weeks later. Camera path length, time, tibia and femur cartilage damage, as well as a composite score were recorded by the simulator on each attempt., Results: The experimental group (n = 22) showed superior performance in composite score (30.09 vs 24, P = .046) and camera path length (71.51 cm vs 109.07 cm, P = .0274) at the time of the second diagnostic knee arthroscope compared with the control group (n = 21). The experimental group also showed significantly greater improvement in composite score between the first and second arthroscopes compared with the control group (14.27 vs 4.95, P < .01). Femoral and tibial cartilage damage were not significantly improved between arthroscopy attempts (-0.86% vs -1.45%, P = .40) and (-1.10 vs -1.27%, P = .83), respectively., Conclusions: The virtual reality-based fundamentals of arthroscopy simulator training nonanatomic simulator is beneficial in developing basic motor skills in arthroscopy novice individuals resulting in significantly greater composite performance in an anatomic knee model. Based on the results of this study, it appears that there may be benefit from nonanatomic simulators in general as part of an arthroscopy training program., Level of Evidence: Level II, randomized trial., (Published by Elsevier Inc.)

Aims: The aim of this study was to assess the current evidence relating to the benefits of virtual reality (VR) simulation in orthopaedic surgical training, and to identify areas of future research., Materials and Methods: A literature search using the MEDLINE, Embase, and Google Scholar databases was performed. The results' titles, abstracts, and references were examined for relevance., Results: A total of 31 articles published between 2004 and 2016 and relating to the objective validity and efficacy of specific virtual reality orthopaedic surgical simulators were identified. We found 18 studies demonstrating the construct validity of 16 different orthopaedic virtual reality simulators by comparing expert and novice performance. Eight studies have demonstrated skill acquisition on a simulator by showing improvements in performance with repeated use. A further five studies have demonstrated measurable improvements in operating theatre performance following a period of virtual reality simulator training., Conclusion: The demonstration of 'real-world' benefits from the use of VR simulation in knee and shoulder arthroscopy is promising. However, evidence supporting its utility in other forms of orthopaedic surgery is lacking. Further studies of validity and utility should be combined with robust analyses of the cost efficiency of validated simulators to justify the financial investment required for their use in orthopaedic training. Cite this article: Bone Joint J 2018;100-B:559-65.

Purpose: To determine the utility of modern arthroscopic simulators in transferring skills learned on the model to the operating room., Methods: A meta-analysis and systematic review of all English-language studies relevant to validated arthroscopic simulation models using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines from 1999 to 2016 was performed. Data collected included the specific simulator model, the joint used, participant demographic characteristics, participant level of training, training session information, type and number of tasks, pre- and post-training assessments, and overall outcomes of simulator performance. Three independent reviewers analyzed all studies., Results: Fifty-seven studies with 1,698 participants met the study criteria and were included. Of the studies, 25 (44%) incorporated an arthroscopic training program into the study methods whereas 32 (56%) did not. In 46 studies (81%), the studies' respective simulator models were used to assess arthroscopic performance, whereas 9 studies (16%) used Sawbones models, 8 (14%) used cadaveric models, and 4 (7%) evaluated subject performance on a live patient in the operating room. In 21 studies (37%), simulator performance was compared with experience level, with 20 of these (95%) showing that clinical experience correlated with simulator performance. In 25 studies (44%), task performance was evaluated before and after simulator training, with 24 of these (96%) showing improvement after training. All 4 studies that included live-patient arthroscopy reported improved operating room performance after simulator training compared with the performance of subjects not participating in a training program., Conclusions: This review suggests that (1) training on arthroscopic simulators improves performance on arthroscopic simulators and (2) performance on simulators for basic diagnostic arthroscopy correlates with experience level. Limited data suggest that simulator training can improve basic diagnostic arthroscopy skills in vivo., Level of Evidence: Level IV, systematic review of Level I through IV studies., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: Arthroscopy of the hip joint is considered a demanding procedure with long learning curve. There are only a few studies that concentrate on this topic. This prospective clinical study evaluates the learning curve of the hip arthroscopy based on clinical outcomes, surgical time, and complication rate., Materials: In this study, we first evaluated 150 hip arthroscopy procedures performed by a single surgeon. The patient group consisted of 86 females and 64 males with mean age 37 years (range 16-69). Study cohorts were divided into groups of 50 patients. Surgical time, complication rate and clinical results based on NAHS score were recorded for each group. Statistical analysis of differences between groups was performed using the ANOVA method and paired t-test., Results: We found a statistically significant decrease of complication rate with more procedures performed. There were significantly better clinical outcomes after at least 100 procedures. No difference in surgical time was found, but towards the end of the learning curve, more complex procedures were performed. The only statistical difference was the portal setup time. The learning curves were constructed based on these results., Conclusions: Hip arthroscopy provides very good clinical outcomes if precisely indicated and performed. It is, however, a demanding procedure with many possible pitfalls and complications. According to our study, at least 100 procedures are needed to gain basic technical and indication skills. The presence of a more skilled surgeon in the beginning of the learning curve is advised to reduce the complication rate.

A survey of 67 experienced orthopedic surgeons indicated that precise portal placement was the most important skill in arthroscopic surgery. However, none of the currently available virtual reality simulators include simulation / training in portal placement, including haptic feedback of the necessary puncture force. This study aimed to: (1) measure the in vivo force and stiffness during a portal placement procedure in an actual operating room and (2) implement active haptic simulation of a portal placement procedure using the measured in vivo data. We measured the force required for port placement and the stiffness of the joint capsule during portal placement procedures performed by an experienced arthroscopic surgeon. Based on the acquired mechanical property values, we developed a cable-driven active haptic simulator designed to train the portal placement skill and evaluated the validity of the simulated haptics. Ten patients diagnosed with rotator cuff tears were enrolled in this experiment. The maximum peak force and joint capsule stiffness during posterior portal placement procedures were 66.46 (±10.76N) and 2560.82(±252.92) N/m, respectively. We then designed an active haptic simulator using the acquired data. Our cable-driven mechanism structure had a friction force of 3.763 ± 0.341 N, less than 6% of the mean puncture force. Simulator performance was evaluated by comparing the target stiffness and force with the stiffness and force reproduced by the device. R-squared values were 0.998 for puncture force replication and 0.902 for stiffness replication, indicating that the in vivo data can be used to implement a realistic haptic simulator.

Background: Orthopaedic training programs are incorporating arthroscopic simulations into their residency curricula. There is a need for a physical shoulder simulator that accommodates lateral decubitus and beach chair positions, has realistic anatomy, allows for an objective measure of performance and provides feedback to trainees., Methods: A physical shoulder simulator was developed for training basic arthroscopic skills. Sensors were embedded in the simulator to provide a means to assess performance. Subjects of varying skill level were invited to use the simulator and their performance was objectively assessed., Results: Novice subjects improved their performance after practice with the simulator. A survey completed by experts recognized the simulator as a valuable tool for training basic arthroscopic skills., Conclusions: The physical shoulder simulator helps train novices in basic arthroscopic skills and provides objective measures of performance. By using the physical shoulder simulator, residents could improve their basic arthroscopic skills, resulting in improved patient safety., (Copyright © 2017 John Wiley & Sons, Ltd.)

Background: Changing trends in surgical education and patient expectation are leading to proficiency models of progression and the use of simulators. Hip arthroscopy is increasingly performed and has a steep learning curve mainly addressed during fellowship training. The aim of this study was to assess the impact of previous generic arthroscopic experience on performance at a simulated hip arthroscopy task to both estimate the minimum case numbers that correlate with expert proficiency levels and help to guide selection for hip arthroscopy fellowships., Methods: Fifty-two participants were recruited to a cross-sectional study. Four consultants (expert hip arthroscopists), 28 trainees (residents and fellows), and 20 novices (interns and medical students) performed a standardized bench-top simulated hip arthroscopy task. A validated global rating scale (GRS) score and motion analysis were used to assess surgical performance. Prior arthroscopic experience was recorded from surgical electronic logbooks. Receiver operating characteristic (ROC) curve analyses were conducted to identify optimum cut-points for task proficiency at both expert and competent GRS levels., Results: There were significant differences (p < 0.05) between the arthroscopic ability of all experience groups based on GRS assessment and for all motion analysis metrics. There was a significant positive correlation between logbook numbers and GRS scores (p < 0.0001). ROC curve analysis demonstrated that a minimum of 610 prior arthroscopic procedures were necessary to achieve an expert GRS score, and 78 prior arthroscopic procedures were necessary for a competent score., Conclusions: Performing a basic hip arthroscopy task competently requires substantial previous generic arthroscopic experience. The numbers identified in this study provide targets for residents. Program directors appointing to hip arthroscopy fellowship training posts may find these results useful as a guide during the selection process.

Objective: Observing experts constitutes an important and common learning experience for surgical residents before operating under direct guidance. However, studies suggest that exclusively observing experts may induce suboptimal motor learning, and watching errors from non-experts performing simple motor tasks may generate better performance. We investigated whether observational learning is transferrable to arthroscopy learning using virtual reality (VR) simulation., Setting/design: In our surgical simulation laboratory, we compared students learning basic skills on a VR arthroscopy simulator after watching an expert video demonstration of VR arthroscopy tasks or a non-expert video demonstration of the same tasks to a Control group without video demonstration. Ninety students in 3 observing groups (expert, non-expert, and Control) subsequently completed the same procedure on a VR arthroscopy simulator. We hypothesized the non-expert-watching group would outperform the expert-watching group, and both groups to outperform the Control group. We examined performance pretest, posttest, and 1 week later., Participants: Participants were recruited from the final year of medical school and the very early first year of surgical residency training programs (orthopaedic surgery, urology, plastic surgery, and general surgery) at Western University (Ontario, Canada)., Results: All participants improved their overall performance from pretest to retention (p < 0.001). At initial retention testing, non-expert-watching group outperformed the other groups in camera path length p < 0.05 and time to completion, p < 0.05, and both the expert/non-expert groups surpassed the Control group in camera path length (p < 0.05)., Conclusion: We suggest that error-observation may contribute to skills improvement in the non-expert-watching group. Allowing novices to observe techniques/errors of other novices may assist internalization of specific movements/skills required for effective motor performances. This study highlights the potential effect of observational learning on surgical skills acquisition and offers preliminary evidence for peer-based practice (combined non-experts and experts) as a complementary surgical motor skills training strategy., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Hip arthroscopy utilization has increased dramatically over the last decade. However, the lack of a formal training curriculum raises concern that inconsistent technical performance may be an issue for early-career hip arthroscopists. The purpose of the present study was to investigate hip arthroscopy utilization by early-career orthopaedic surgeons while focusing on fellowship training status to better guide future development of a hip arthroscopy training curriculum., Methods: The American Board of Orthopaedic Surgery (ABOS) Part-II database was used to identify candidates who had performed ≥1 hip arthroscopy procedures between 2006 and 2015. Procedures were categorized using Common Procedural Terminology (CPT) codes, and candidates were categorized by fellowship training experience. Trends in hip arthroscopy utilization were evaluated using univariate and regression analyses while stratifying by fellowship training experience., Results: Overall, 9.2% (643) of 6,987 ABOS candidates had performed ≥1 hip arthroscopy procedures. Over the study period, both the proportion of candidates performing hip arthroscopy and the proportion of hip arthroscopy procedures performed (relative to all procedures performed, of any type) increased (p < 0.001). Candidates performing hip arthroscopy most frequently reported sports medicine fellowship training (74.5%; 479 of 643). Also, among the candidates who performed hip arthroscopy, the proportion who had sports medicine fellowship training increased over the study period (p = 0.001). The majority of candidates performing hip arthroscopy (67.2%; 432 of 643) performed ≤5 hip arthroscopy procedures, while a small number of high-volume hip arthroscopists (6.5%; 42 of 643) performed 34.6% (1,403 of 4,054) of all hip arthroscopy procedures., Conclusions: The increase in hip arthroscopy utilization in this cohort appears to have been driven primarily by the increased number of candidates performing hip arthroscopy and less by an increasing number of hip arthroscopy procedures being performed by individual candidates. The majority of candidates performing hip arthroscopy were sports-medicine-fellowship trained. This information is valuable for both trainees and educators interested in improving education and defining a curriculum for future hip arthroscopy training.

Purpose: To evaluate the clinical results of an arthroscopy-assisted latissimus dorsi tendon transfer (aLD) for irreparable posterosuperior cuff tears as a primary surgery. The secondary aim of this study was to quantify the learning curve using the log-linear model. We hypothesized that aLD significantly improved shoulder function and that there was consistent reduction of the operative time in support of a learning-curve effect., Methods: After the arthroscopic partial repair was completed, the latissimus dorsi tendon was harvested via axillary mini-open incision and fixed with a knotless anchor arthroscopically. All patients were evaluated preoperatively and postoperatively using a modified University of California Los Angeles (UCLA) scoring system, active range of motion, and the visual analog scale (VAS) for pain. The operative time was recorded to quantify the learning curve using a log-linear model., Results: Thirty patients with a mean age of 67.4 years who underwent aLD were included. At a mean of 34 months after an aLD, the mean UCLA score increased from 15.7 preoperatively to 28.8 postoperatively (P < .001). The mean active forward elevation increased from 105° preoperatively to 149° postoperatively (P < .001). The mean active external rotation increased from 22° preoperatively to 32° postoperatively (P < .001). The VAS improved from 58 mm to 18 mm (P < .001). In all but 2 cases (93%), the preoperative osteoarthritis grade was maintained. The mean operative time was 145 minutes. A significant linear correlation was observed between the operative time and cumulative volume of cases after performing a logarithmic transformation. The learning rate was calculated as 84%., Conclusions: Arthroscopy-assisted latissimus dorsi tendon transfer is a technically demanding procedure; however, it can lead to significant improvements in overall shoulder pain and function. This study also confirmed a learning-curve effect for the aLD. The learning rate was 84%, indicating the existence of a long learning period., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Arthroscopic subscapularis (SSC) repair is a technically demanding procedure with a long learning curve. As effective completion of resident's practical experience remains controversial, a prospective clinical study was performed to assess the functional and anatomical outcomes of subscapularis (SSC) arthroscopic repair by orthopedic residents. The pathological anatomy of the tears, the surgical approach and the difficulties encountered at the beginning of the learning curve were reported., Materials and Methods: Between June 2009 and June 2010, 30 patients with rotator cuff tear were preoperatively evaluated with clinical exam, Constant and UCLA scores. Surgery was performed under arthroscopy by a team of three orthopedic surgeons in training. A SSC tear, if present, was recorded and treated. The same clinical exam and functional scores were repeated at minimum 6 months of follow-up. Subscapularis strength recovery and tendon healing were investigated with arthromagnetic resonance imaging., Results: A SSC tear was observed in 11 cases out of 30 and treated arthroscopically. The clinical scores improved in all patients: the average Constant score increased from 34 ± 14 to 77 ± 11 and the UCLA score from 11 ± 5 to 29 ± 3. The SSC tests were negative in all patients with the exception of one. Tendon healing was observed in 10 out of 11 cases., Conclusions: Arthroscopic SSC repair performed by educated residents is possible and leads to good clinical and anatomical results. Surgery duration progressively improved as the learning curve advanced., Level of Evidence: Level 2.

Purpose: To develop a model using wearable inertial sensors to assess the performance of orthopaedic residents while performing a diagnostic knee arthroscopy., Methods: Fourteen subjects performed a diagnostic arthroscopy on a cadaveric right knee. Participants were divided into novices (5 postgraduate year 3 residents), intermediates (5 postgraduate year 4 residents), and experts (4 faculty) based on experience. Arm movement data were collected by inertial measurement units (Opal sensors) by securing 2 sensors to each upper extremity (dorsal forearm and lateral arm) and 2 sensors to the trunk (sternum and lumbar spine). Kinematics of the elbow and shoulder joints were calculated from the inertial data by biomechanical modeling based on a sequence of links connected by joints. Range of motion required to complete the procedure was calculated for each group. Histograms were used to compare the distribution of joint positions for an expert, intermediate, and novice., Results: For both the right and left upper extremities, skill level corresponded well with shoulder abduction-adduction and elbow prono-supination. Novices required on average 17.2° more motion in the right shoulder abduction-adduction plane than experts to complete the diagnostic arthroscopy (P = .03). For right elbow prono-supination (probe hand), novices required on average 23.7° more motion than experts to complete the procedure (P = .03). Histogram data showed novices had markedly more variability in shoulder abduction-adduction and elbow prono-supination compared with the other groups., Conclusions: Our data show wearable inertial sensors can measure joint kinematics during diagnostic knee arthroscopy. Range-of-motion data in the shoulder and elbow correlated inversely with arthroscopic experience. Motion pattern-based analysis shows promise as a metric of resident skill acquisition and development in arthroscopy., Clinical Relevance: Wearable inertial sensors show promise as metrics of arthroscopic skill acquisition among residents., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: The goal of this study was to validate the cigar box arthroscopy trainer (CBAT) as a training tool and then compare its effectiveness to didactic training and to another previously validated low-fidelity but anatomic model, the anatomic knee arthroscopy trainer (AKAT)., Methods: A nonanatomic knee arthroscopy training module was developed at our institution. Twenty-four medical students with no prior arthroscopic or laparoscopic experience were enrolled as subjects. Eight subjects served as controls. The remaining 16 subjects were randomized to participate in 4 hours of either the CBAT or a previously validated AKAT. Subjects' skills were assessed by 1 of 2 faculty members through repeated attempts at performing a diagnostic knee arthroscopy on a cadaveric specimen. Objective scores were given using a minimally adapted version of the Basic Arthroscopic Knee Skill Scoring System. Total cost differences were calculated., Results: Seventy-five percent of subjects in the CBAT and AKAT groups succeeded in reaching minimum proficiency in the allotted time compared with 25% in the control group (P < .05). There was no significant difference in the number of attempts to reach proficiency between the CBAT and AKAT groups. The cost to build the CBAT was $44.12, whereas the cost was $324.33 for the AKAT., Conclusions: This pilot study suggests the CBAT is an effective knee arthroscopy trainer that may decrease the learning curve of residents without significant cost to a residency program. This study demonstrates the need for an agreed-upon objective scoring system to properly evaluate residents and compare the effectiveness of different training tools., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Virtual-reality and cadaveric simulations are expensive and not readily accessible. Innovative and accessible training adjuncts are required to help to meet training needs. Cognitive task analysis has been used extensively to train pilots and in other surgical specialties. However, the use of cognitive task analyses within orthopaedics is in its infancy. The purpose of this study was to evaluate the effectiveness of a novel cognitive task analysis tool to train novice surgeons in diagnostic knee arthroscopy in high-fidelity, phantom-limb simulation., Methods: Three expert knee surgeons were interviewed independently to generate a list of technical steps, decision points, and errors for diagnostic knee arthroscopy. A modified Delphi technique was used to generate the final cognitive task analysis. A video and a voiceover were recorded for each phase of this procedure. These were combined to produce the Imperial Knee Arthroscopy Cognitive Task Analysis (IKACTA) tool that utilizes written and audiovisual stimuli to describe each phase of a diagnostic knee arthroscopy. In this double-blinded, randomized controlled trial, a power calculation was performed prior to recruitment. Sixteen novice orthopaedic trainees who performed ≤10 diagnostic knee arthroscopies were randomized into 2 equal groups. The intervention group (IKACTA group) was given the IKACTA tool and the control group had no additional learning material. They were assessed objectively (validated Arthroscopic Surgical Skill Evaluation Tool [ASSET] global rating scale) on a high-fidelity, phantom-knee simulator. All participants, using the Likert rating scale, subjectively rated the tool., Results: The mean ASSET score (and standard deviation) was 19.5 ± 3.7 points in the IKACTA group and 10.6 ± 2.3 points in the control group, resulting in an improvement of 8.9 points (95% confidence interval, 7.6 to 10.1 points; p = 0.002); the score was determined as 51.3% (19.5 of 38) for the IKACTA group, 27.9% (10.6 of 38) for the control group, and 23.4% (8.9 of 38) for the improvement. All participants agreed that the cognitive task analysis learning tool was a useful training adjunct to learning in the operating room., Conclusions: To our knowledge, this is the first cognitive task analysis in diagnostic knee arthroscopy that is user-friendly and inexpensive and has demonstrated significant benefits in training., Clinical Relevance: The IKACTA will provide trainees with a demonstrably strong foundation in diagnostic knee arthroscopy that will flatten learning curves in both technical skills and decision-making.

Purpose: Arthroscopy is currently the "gold standard" for various surgeries performed on the knee joint. Therefore, surgeons wishing to operate in this professional field should be able to perform this technique. Arthroscopic training, an experimental laboratory, is important for the surgeons' training, enabling them to increase their skills with the specific instruments and to become familiar with the operating techniques. The aim of this study was to present a new surgical simulator for training in arthroscopic procedures of the knee., Methods: The Kneetrainer 1 is a simulator consisting of a type of thermo-retractile, thermo-sensitive synthetic rubber that has texture, colour, consistency, and mechanical resistance that mimic many human tissues. Nine simulators were used, operated by seventeen expert Brazilian surgeons in knee surgery. The surgeons performed arthroscopy, meniscectomy, and reconstruction of the anterior cruciate ligament (ACL), responded to an electronic questionnaire with several variables, and gave an overall score on the ability of the device to perform realistic simulation for the above procedures., Results: The ability to perform the procedures of meniscectomy and ACL reconstruction was considered adequate by 82 and 100 % of the specialists, respectively. The overall scores for the ability to perform realistic simulation for the procedures meniscectomy and reconstruction of the anterior cruciate ligament by arthroscopy were 64.7 and 82.4 %, respectively. The simulator was therefore considered suitable for practical application with novice surgeons., Conclusion: The Kneetrainer 1 simulator was assessed as an effective tool for recreating accurate arthroscopic knee procedures. In addition, the simulator may be effective as a means of honing the skills of novice surgeons. Future investigations should be performed to validate the reliability of the simulator., Level of Evidence: IV.

Arthroscopic education research recently has been focused on the use of skills labs to facilitate resident education and objective measure development to gauge technical skill. This study evaluates the effectiveness of three different teaching methods. Medical students were randomized into three groups. The first group received only classroom-based lecture. The second group received the same lecture and 28 minutes of lab-based hands-off arthroscopy instruction using a cadaver and arthroscopy setup. The final group received the same lecture and 7 minutes of hands-on arthroscopy instruction in the lab on a cadaver knee. The arthroscopic knee exam that followed simulated a diagnostic knee exam and subjects were measured on task completion and by the number of look downs. The number of look downs and the number of tasks completed did not achieve statistical significance between groups. Posttest survey results revealed that the hands-on group placed significantly more value on their educational experience as compared with the other two groups. (Journal of Surgical Orthopaedic Advances.

The purpose of this study was to generate consensus among experienced surgeons on "what skills a resident should possess before continuing safe training in the operating room (OR)." An online survey of 65 questions was developed and distributed to surgeons in the European community. A total of 216 responded. The survey included 15 questions regarding generic and specific skills; 16 on patient and tissue manipulation, 11 on knowledge of pathology and 6 on inspection of e-anatomical structures; 5 methods to prepare residents; and 12 on specific skills exercises. The importance of each question (arthroscopic skill) was evaluated ranging from 1 (not important at all) to 6 (very important). Chi-square test, respondent agreement, and a qualitative ranking method were determined to identify the top ranked skills ( p  < 0.05). The top four of general skills considered important were "anatomical knowledge," "tissue manipulation," "spatial perception," and "triangulation" (all chi-square test > 134, p  < 0.001, all excellent agreement > 0.85, and all "high priority" level). The top ranked 2 specific arthroscopic skills were "portal placement" and "triangulating the tip of the probe with a 30-degree scope" (chi-square test > 176, p  < 0.001, excellent agreement, and assigned high priority). The online survey identified consensus on skills that are considered important for a trainee to possess before continuing training in the OR. Compared with the Canadian colleagues, the European arthroscopy community demonstrated similar ranking., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Shoulder arthroscopy is a minimally invasive surgical procedure for diagnosis and treatment of a shoulder pathology. The procedure is performed with a fiber optic camera, called arthroscope, and instruments inserted through very tiny incisions made around the shoulder. The confined shoulder space, unintuitive camera orientation and constrained instrument motions complicates the procedure. Therefore, surgical competence in arthroscopy entails extensive training especially for psychomotor skills development. Conventional arthroscopy training methods such as mannequins, cadavers or apprenticeship model have limited use attributed to their low-fidelity in realism, cost inefficiency or incurring high risk. However, virtual reality (VR) based surgical simulators offer a realistic, low cost, risk-free training and assessment platform where the trainees can repeatedly perform arthroscopy and receive quantitative feedback on their performances. Therefore, we are developing a VR based shoulder arthroscopy simulation specifically for the rotator cuff ailments that can quantify the surgery performance. Development of such a VR simulation requires a through task analysis that describes the steps and goals of the procedure, comprehensive metrics for quantitative and objective skills and surgical technique assessment., Methods: We analyzed shoulder arthroscopic rotator cuff surgeries and created a hierarchical task tree. We introduced a novel surgery metrics to reduce the subjectivity of the existing grading metrics and performed video analysis of 14 surgery recordings in the operating room (OR). We also analyzed our video analysis results with respect to the existing proposed metrics in the literature., Results: We used Pearson's correlation tests to find any correlations among the task times, scores and surgery specific information. We determined strong positive correlation between cleaning time vs difficulty in tying suture, cleaning time vs difficulty in passing suture, cleaning time vs scar tissue size, difficulty passing vs difficulty in tying suture, total time and difficulty of the surgery., Conclusion: We have established a hierarchical task analysis and analyzed our performance metrics. We will further use our metrics in our VR simulator for quantitative assessment., (Copyright © 2016 John Wiley & Sons, Ltd.)

Purpose: To establish the construct validity of an arthroscopic training model that teaches arthroscopic tool skills including triangulation, grasping, precision biting, implant delivery and ambidexterity and uses a whole grapefruit for its training platform., Methods: For the grapefruit training model (GTM), an arthroscope and arthroscopic instruments were introduced through portals cut in the grapefruit skin of a whole prepared grapefruit. After institutional review board approval, participants performed a set of tasks inside the grapefruit. Performance for each component was assessed by recording errors, achievement of criteria, and time to completion. A total of 19 medical students, orthopaedic surgery residents, and fellowship-trained orthopaedic surgeons were included in the analysis and were divided into 3 groups based on arthroscopic experience. One-way analysis of variance (ANOVA) and the post hoc Tukey test were used for statistical analysis., Results: One-way ANOVA showed significant differences in both time to completion and errors between groups, F(2, 16) = 16.10, P < .001; F(2, 16) = 17.43, P < .001. Group A had a longer time to completion and more errors than group B (P = .025, P = .019), and group B had a longer time to completion and more errors than group C (P = .023, P = .018)., Conclusions: The GTM is an easily assembled and an alternative arthroscopic training model that bridges the gap between box trainers, cadavers, and virtual reality simulators. Our findings suggest construct validity when evaluating its use for teaching the basic arthroscopic tool skills. As such, it is a useful addition to the arthroscopic training toolbox., Clinical Relevance: There is a need for validated low-cost arthroscopic training models that are easily accessible., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)