Robert A. Pedowitz, MD, PhD provides a summary of a strategic and coordinated approach to address simulation and other important concerns in the field of orthopaedic surgery.

Simulation has been used for decades in the field of orthopedic surgery. Although simulation has been used widely in US residency training program, there has been little in the way of structured curriculum or validated performance metrics for orthopaedic simulation technology. Recently, a number of intersecting factors have converged, and these factors will probably transform our surgical training paradigm from the apprenticeship model toward a proficiency-based approach. Simulation technology has advanced dramatically in parallel with the computer and gaming industries. Safety concerns have pushed us to find better educational alternatives, in order to protect patients from the “surgical learning curve”. Recent changes in resident work hour restrictions force us to find more efficient and effective training paradigms. This article provides a summary of a strategic and coordinated approach to address these important concerns in the field of orthopaedic surgery.

“Surgical simulation” is often associated specifically with high tech virtual reality (VR) training devices. But in the most basic sense, medical simulation involves anything that offers educational value outside of the clinical domain. From that perspective, orthopedic surgeons have been using simulation for many years. Examples include dissection of cadavers (to learn and rehearse surgical approaches), performance of partial procedures using task simulators (bone and joint models), and development of arthroscopic knot tying skills (using rope and then practicing with suture). However, orthopedic surgery has had little in the way of structured curriculum for the implementation of these simulation alternatives, and there is a paucity of information regarding useful, quantitative, and validated metrics that can be used to objectively measure surgical skills.

Developments in the Last 15 Years

The American Academy of Orthopaedic Surgery (AAOS), along with the Arthroscopy Association of North America (AANA) and the American Board of Orthopaedic Surgery (ABOS) began investigating virtual reality and surgical simulation around 1997. Five years later, the three organizations entered into an agreement with Touch of Life Technology (ToLTech) to invent a high-tech VR simulator for arthroscopic knee surgery, under the visionary leadership of Dil Cannon, MD. ToLTech currently offers a VR training device for purchase (Figure 1)., Simbionix, Virtamed, and Swemac /Augmented Reality Solutions are among the companies that have also entered this highly competitive business sector. The marketplace has expanded, in part due to the development of a mandate for implementation of simulation in orthopedic training as described below. It is likely that the affordability index for VR technology will increase, as computers, haptic devices, and software proliferate.

Figure 1. Barriers to implementation in orthopedic surgery
Figure 1. Barriers to implementation in orthopedic surgery

Figure 2. Demonstration of ToLTec VR athrocopy simulator - ArthroSim. Image Credit: Robert Pedowitz.
Figure 2. Demonstration of ToLTec VR athrocopy simulator - ArthroSim. Image Credit: Robert Pedowitz.

Looking back at the evolution of simulation in orthopedic surgery during the last 15 years, most of our effort focused upon the educational “gizmos”, with particular emphasis upon high fidelity ultra-realistic surgical simulation. There has been relatively little emphasis upon our fundamental training objectives, as defined by a structured educational curriculum. This is a natural tendency for most surgeons (especially orthopedic surgeons), who especially love their surgical “toys”. But our focus on technology and ultra-realism may have led us slightly astray.

This realization was enhanced by several presentations at the December 2010 Executive Workshop on the Role of Simulation in Surgical Education. This workshop was coordinated by Richard Satava, MD and Jeffrey Levy, MD. It was a precursor to creation of the Alliance for Surgical Simulation in Education and Training (ASSET). Two key observations were presented at that meeting, which strongly influenced subsequent efforts in orthopaedic surgery. First, Dr. Satava remarked, “It’s all about the curriculum.” And in retrospect, Dr. Satava wished that he had coordinated with the Board of Surgery and the Residency Review Committee (RRC) from the start, so the simulation end-products would provide greater value for those key oversight bodies.

We paid attention. Our efforts over the last few years have been directed at development and implementation using a coordinated and strategic approach.

On November 3, 2011, the AAOS sponsored the first Orthopedic Surgery Simulation Summit, Co-Chaired by Robert Pedowitz, MD, PhD and Larry Marsh, MD. The purpose of the Summit was to pull together key stakeholders in the field of orthopedic surgery, in the hopes of developing a mandate for simulation training in the United States (Figure 2). We invited Dr. Satava, Dr. Levy, and Gary Dunnington, MD to share their experiences from general surgery, obstetrics and gynecology, and other medical specialties. Summit participants included senior leadership from the ABOS (which sets the requirements for Board Certification) and from the orthopedic RRC (which sets the requirements for all US orthopaedic residency training programs), in addition to representatives of various orthopedic subspecialty societies.

In retrospect, inclusion of the ABOS and the RRC was a very important factor that influenced our subsequent success. Our objectives were well defined, but in honesty, we were not confident that they would be rapidly achieved. We hoped to; establish a mandate for simulation (if possible); place simulation in the formal orthopaedic curriculum; promote objective proficiency assessment; identify short-term action items, and create a go-forward management plan for simulation within our specialty.

Leading up to the Summit, we performed a “needs assessment”, in order to facilitate and focus subsequent conversations .1 We learned that only 50 percent of orthopaedic residency programs had a motor skills lab or a motor skills program. There was high interest among program directors in a standardized orthopaedic skills curriculum (which did not exist at the time). Most program directors had little knowledge of the department budget for skills training or the cost of running a skills lab, and cost was perceived as a major implementation challenge for surgical simulation in residency training programs (Figure 3).

To our very pleasant surprise, within a year of the Summit, both the ABOS and the Orthopaedic RRC approved mandates for surgical simulation in all US orthopaedic training programs. These mandates were strongly facilitated by Larry Marsh, MD (who served both bodies), and by Shep Hurwitz, MD, Executive Director of the ABOS. This was a fortuitous lesson re-emphasized: We had the right leaders with the right influence at the right time, and they were able to manage and coordinate what otherwise could have been a divisive and slow conversation. As a result, the ABOS and RRC approved mandates that defined rapid programmatic implementation requirements with a July 2013 start date. Initial implementation required basic motor skills training for all orthopedic surgery training programs, as part of a major structural overhaul of the Post-Graduate Year 1 (PGY1 year). The mandate indicated that basic motor skills training must include dedicated time, dedicated space, a structured educational curriculum, and the PGY1 skills program should be integrated with subsequent training years. The next challenge became immediately obvious: How could we help residency training programs meet these substantial implementation requirements, given the short and demanding timeline?

To this end, the ABOS sponsored a workgroup, Co-Chaired by Larry Marsh, MD, and Robert Pedowitz, MD, PhD, to develop examples of curriculum-based motor skills training modules. The workgroup defined basic motor skills modules that could be offered during the PGY1 year and provide continuity into subsequent training years. We agreed to use a standardized curriculum template, which was derived in part from curriculum templates developed by the American College of Surgeons and by the ASSET consortium. We defined very specific and achievable goals, and adhered to an ambitious timeline. Prior to the start date for the new simulation mandates, we posted the skills curriculum on-line. The modules were offered open access, without charge, for any orthopaedic program that wished to utilize the program in whole or in part (https://www.abos.org/abos-surgical-skills-modules-for-pgy-1-residents.aspx).

FAST and Other Initiatives 

In parallel to these efforts, other initiatives were underway to provide practical and relevant simulation training alternatives for orthopedic surgery programs. The Fundamentals of Arthroscopic Surgery Training (FAST) Program is a collaborative project of AANA, AAOS, and ABOS that offers core motor skills training in the field of arthroscopic surgery. Arthroscopy is one of the most common orthopedic procedures done today, it is technically demanding, and it is hard to learn. The arthroscopic image is presented on a two dimensional video screen, which makes it suitable for VR simulation. Arthroscopy requires ambidextrous use of all instruments, which can be quite difficult for many learners.

Figure 4a Knot tying mandrel
Figure 4a Knot tying mandrel

Figure 4b FAST workstation with lucent dome
Figure 4b FAST workstation with lucent dome

Figure 4c FAST workstation with opaque dome
Figure 4c FAST workstation with opaque dome

The FAST project team deconstructed arthroscopic skills into six specific sub-modules (using the common curriculum template described previously), which were then incorporated into the ABOS basic skills program.

Once the curriculum was well-defined, the project team created the FAST workstation, which was designed specifically for training of these fundamental arthroscopic motor skills (Figure 4).

Another collaborative project, between the AAOS and the Orthopaedic Trauma Association (OTA), focuses upon basic fluoroscopy skills and associated radiation safety. Fluoroscopy is used commonly in orthopedic surgery, and the associated radiation risks are not trivial, both for patients and for surgeons and other operating room personnel. Since the image is projected on a two-dimensional screen, fluoroscopy is also well-suited for haptic-based VR simulation training.

Our hope is that training programs will refine, expand, and share these simulation alternatives. Additional information must be collected in order to create relevant and reliable performance metrics. We anticipate that more orthopaedic sub-specialties will get involved, as they seek opportunities to develop their own simulation training solutions. And we expect that most programs will struggle with financial issues as they assess between low-tech / low-expense simulation compared to high-tech / high- expense VR alternatives. These assessments will naturally change over time, as the marketplace responds to increasing demand for simulation alternatives in orthopedic surgery.

Simulation Summit Participants
Simulation Summit Participants

To this end, the AAOS will sponsor the Second Orthopedic Surgery Simulation Summit, which will be held at the Westin O’Hare, Rosemont, Illinois on November 22, 2013. The purpose of Summit II is to bring together program directors, department chairs, residency coordinators, and interested faculty, in order to help them better define their simulation training objectives and to provide information about what is available from a practical implementation perspective. This Summit will include a number of companies from the VR domain, in addition to vendors that offer lower-cost training alternatives, so program leaders can make informed decisions about expenditures that affect their bottom line. We will also discuss opportunities for collaborative validation research for emerging simulation technologies in orthopedic surgery. The Second Simulation Summit is no longer about the mandate. Now we are talking about efficient solutions that facilitate the shift toward proficiency-based simulation training.

A lot has been happening with simulation training in orthopedic surgery. We’ve seen rapid acceleration, remarkable buy-in, deliberate leadership, and a lot of hard work. In the future, we will probably appreciate the insightful advice that we got a few years ago: it’s all about the curriculum, and if possible, key stakeholder organizations should create a coordinated and strategic mandate for the shift to simulation based surgical skills training.

About the Author

Robert A. Pedowitz, MD, PhD is a Professor of Orthopaedic Surgery at the David Geffen School of Medicine at UCLA.

Dr. Pedowitz received his MD from UC San Diego School of Medicine, his PhD from the University of Gothenburg, Sweden and Fellowship in Sports Medicine, Duke University Medical Center.

He has extensive clinical and research experience in the field of orthopaedic sports medicine and arthroscopic surgery of the knee and shoulder, including many years of experience caring for athletes at the recreational, collegiate, and professional levels.

REFERENCES

Karam, MD, Pedowitz RA, Mevis H, Marsh JL: Current and Future use of Surgical Skills Training Laboratories in Orthopedic Resident Education - A National Survey. Journal of Bone and Joint Surgery (Am), 95(1):e4, 2013.