Christopher L. Camp, Aaron J. Krych, Michael J. Stuart, Terry D. Regnier

Karen M. Mills, Norman S. Turner

The use of simulation as an adjunctive educational tool for orthopaedic surgery residents is on the rise. This may be due in part to the desire for orthopaedic residencies to continue to produce skilled surgeons in an era of restricted work hours and economic constraint. The importance of surgical skills training is also supported by The American Board of Orthopaedic Surgeons (ABOS), who, starting in 2013, have required all residency programs to have formal surgical skills education incorporated into their curricula. Both residents and program directors think that deliberate practice of surgical skills outside of the operating room should become a larger part of current training. Accordingly, a number of simulation techniques have been developed, which vary widely in terms of cost, accessibility, and sophistication. Examples range from dry models and modified hardware tools to fully equipped cadaveric skills laboratories and high-fidelity virtual reality simulators.

Research regarding surgical skills acquisition in orthopaedic surgery is rapidly expanding. A number of measures and scoring systems have been proposed in an effort to provide objective, valid assessment of residents’ performance in the operating room and on simulators. These tools have demonstrated that it is often possible to distinguish between novice and experienced surgeons by assessing their performance on surgical simulators. Although the body of research is growing, less is known about the transfer validity of surgical simulation in orthopaedics. Studies of simulated training in general surgery have demonstrated improvements in performance in the operating room, and it appears that this holds true for orthopaedic learners as well. Despite these encouraging trends, barriers to widespread implementation of surgical simulation persist. Currently, approximately 25% of residency programs do not have a dedicated area for surgical skills training at their institution, and 87% of program directors cited a lack of funding as the largest barrier. In order to merit widespread implementation, simulation needs to provide measurable performance improvement in a cost-efficient manner.

Two of the most common training modalities utilized outside of the operating room to improve residents’ arthroscopy performance are cadaveric skills laboratories and virtual reality arthroscopy simulators. Residents traditionally have used cadaveric specimens to hone their skills, but newly developed virtual reality simulation is gaining popularity. In this prospective randomized trial, a validated performance measure was used to carry out a head-to-head comparison of the educational values of practicing knee arthroscopy on cadavera and practicing it with virtual reality simulation. Specifically, we sought (1) to determine if residents demonstrate measurable improvement in arthroscopic performance after a defined period of deliberate practice on cadaveric specimens and with a high-fidelity simulator compared with controls and (2) to determine which simulated training modality allows maximal performance gains.