Abstract
Virtual reality (VR) simulation has enormous potential utility in technically demanding manual activities. Hip arthroscopy is a perfect example of a challenging surgical technique with an extensive learning curve. The literature has recently consistently demonstrated that both career and annual maintenance case volume significantly influences patient-reported outcomes and risk of revision surgery and complications. Current residency and fellowship programs do not sufficiently prepare trainees to meet or exceed experience thresholds, so augmentation of training is necessary. A significant strength of VR simulation includes its ability to practice without limits. Unfortunately, hip models are limited to simple tasks, without full surgery models yet available simulating routine arthroscopic hip preservation procedures like labral repair, cam and pincer correction, capsular repair. Advanced techniques like labral reconstruction or augmentation, protrusio acetabulae, extensive cam morphology, revision surgery, peritrochanteric space endoscopy, and deep gluteal space endoscopy are not yet available for simulation. VR simulation can probably achieve competence for most, if not all, surgeons; possibly achieve proficiency; and unlikely to achieve mastery. The use of machine learning and artificial intelligence can process vast quantities of photo and video data to generate high-fidelity, lifelike surgical simulation. The near future will incorporate and assimilate these technologies cost-effectively for training programs and surgeons. Our patients will benefit.
As a resident at The Ohio State University, one of the first things I was taught by Dr. Ruskin “Rusty” Lawyer were Rusty’s rules: (1) Recognize easy cases, (2) Only do easy cases, and (3) Don’t make easy cases hard. Soon after learning Rusty’s rules, I learned from Dr. Thomas “Tom” Lee that an orthopaedic surgeon’s job has 2 simple requirements: (1) Make clinical decisions, and (2) Operate. These sets of rules are far more complex than their apparent simplicity entails. Learning how to operate and not making easy cases hard—these are largely technical skills first acquired as a trainee and continually indefinitely honed beyond training. As an attending surgeon now, nearly 15 years later, these concepts still hold true. Learning hip arthroscopy is hard (teaching it is not much easier). I wish I had a way to somehow practice back then when I was first learning, when I was in fellowship actually getting to “do something” in the operating room, and especially in the first couple years post-fellowship when I was in the “learning curve.”
This is where virtual reality (VR) simulation comes in—and its utility has potential unique merits for different stages of learning for surgeons-in-training: competence, proficiency, and mastery. “The Arthroscopic Surgery Skill Evaluation Tool Global Rating Scale is a Valid and Reliable Adjunct Measure of Performance on a Virtual Reality Simulator for Hip Arthroscopy” by Bishop, Ode, Hurwit, Zmugg, Rauck, Nguyen, and Ranawat
1
reports on a terrific investigation that expands our understanding of the utility of this essential training modality. While admittedly imperfect, VR simulators generate muscle memory, haptic feedback, and technical skills and hopefully instill the confidence needed to incorporate hip arthroscopy in practice, which we know has one of the more challenging learning curves in arthroscopic and related surgery. A prototypical example of how successful VR simulation can be is the airline industry—how pilots log “flight time” while never leaving the ground.Despite terminology similarities, performing hip arthroscopy and piloting an aircraft are worlds apart in “real-world” application. Looking more closely at the “gold standard” VR simulator industry as an example, a single full-flight simulator for United Airlines costs approximately 20 million US dollars. By 2025, the flight-simulation industry is estimated to be 7.7 billion US dollars.
2
Every possible known thing that can go wrong with a plane can be simulated, e.g., bad weather, landing gear malfunction, bird hits the engine. The complexity of this essential training tool exceeds that of the actual airplane itself! Unfortunately, hip arthroscopy VR simulators are currently limited to simple tasks (e.g., loose body removal, using a probe to navigate and palpate anatomical structures), largely using mostly surrogate measures (e.g., path length for camera and probe) rather than actual intraoperative skills (e.g., drilling a suture anchor, passing a suture, and tying a secure knot), without transferrable relevant outcome metrics.Flight simulators, safety, and the power of AI 2020.
https://airfactsjournal.com/2020/04/flight-simulators-safety-and-the-power-of-ai/
Date accessed: March 1, 2021
3
A very compelling argument for the necessity of VR simulators, based on what we currently know and where we need to go, was recently written by Dr. Angelo, past president of the Arthroscopy Association of North America (AANA).3
There may be very few, if any, people on Earth better equipped to discuss “the most effective methods being used to educate and train those individuals working in highly-skilled technical professions.” Leading the AANA’s Magellan Project and Copernicus Initiative, Dr. Angelo has been working on teaching arthroscopy for more than a decade.4
Together with Dr. Felix (Buddy) Savoie, Dr. Angelo communicated with the National Aeronautics and Space Administration (NASA) and asked how they assessed whether astronauts had mastered the skills necessary to dock a lunar landing module—“an exhaustive document was returned” and used to develop an Arthroscopic Bankart Skills Assessment tool. The skill set assessment in this tool, derived from a Magellan subcommittee, represented a “paradigm shift from the apprenticeship model to proficiency-based progression (PBP).”5
In consultation and collaboration with Dr. Anthony Gallagher, “likely the world’s authority on PBP training for procedural skills,” a relationship fostered from the first World Congress on Surgical Skills Training, the arthroscopic Bankart repair is now the template for PBP training.6
,7
It is this model that Bishop et al.1
have modeled in their analysis of the ASSET Global Rating Scale in hip arthroscopy.Upon further analysis of VR flight simulation, as of November, 2018, the United Airlines’ Flight Training Center (one of the world’s largest) has at least 31 flight simulators.
8
Pilots use this training environment upon their initial hire, but also every 9 months that they are employed with the company. Becoming a pilot requires both book knowledge and practical knowledge, simulator and real flight training, taking and passing examinations, obtaining certifications, and maintaining continuing education and training. This training progression is not significantly dissimilar from that of becoming a hip arthroscopist. However, arthroscopic hip preservation surgery VR simulation has a long way to go to truly replicate all the possible events that can occur with the major and minor technical steps in the routine operation, as that which can be simulated in a trans-Atlantic 747 jumbo jet landing in a blizzard in New York. Thus, as a hip arthroscopy profession, we must devote this same level of commitment if we want the proven success of the airline industry, which entails: (1) time, (2) effort, (3) financial resources, (4) access, and (5) objective metrics for assessment. Pilots routinely report the high fidelity, or “realness,” of full flight VR simulators, as opposed to Bauer et al.,9
who said participants’ overall impression in terms of realism was “completely realistic” by only 17% of expert and nonexpert hip arthroscopy VR simulator participants. Further, transfer validity from the VR simulator to successful actual airplane flight is strong, as opposed to most VR simulator arthroscopy studies. The latter consistently show that high simulator scores only translate to successful simulator performance, and not necessarily actual in vivo surgical performance and patient outcomes.10
Further, the complexity of VR flight simulation is currently already enhanced and augmented by machine learning and artificial intelligence algorithms, with the ability to adapt to the simulation user.2
Although arthroscopy simulation is not there, this is likely the field that will generate high fidelity and transfer validity of hip arthroscopy VR simulation to the operating room for our trainees and practicing surgeons.Flight simulators, safety, and the power of AI 2020.
https://airfactsjournal.com/2020/04/flight-simulators-safety-and-the-power-of-ai/
Date accessed: March 1, 2021
As a hip arthroscopist, it’s not just your skill in the operating room that determines your patients’ success or failure, but determining who belongs there, which is just as important. Dr. Thomas Byrd has said “even the best operation will fail if performed for the wrong reason.”
11
This concept was reiterated by Dr. Bryan Kelly, speaking about the 2 parts for a successful hip arthroscopy outcome: (1) Appropriate patient selection, and (2) Skillful technical execution. “Patient selection” entails a highly complex clinical evaluation, including corroborating symptoms, physical examination, imaging, and determining if the surgical technique the surgeon can offer will meet or exceed the patient’s expectations.12
Technique is but one component, albeit a critical one, in a patient’s postoperative clinical outcome. It is well-known that hip arthroscopy has a substantial learning curve, with career volume (>518 cases)13
and annual maintenance volume (>164, or even >340, cases per year)14
significantly impacting reoperation rate. It is likely impossible for trainees (e.g., medical students, orthopaedic surgery residents, hip preservation surgery fellows, orthopaedic sports medicine fellows, orthopaedic adult reconstruction fellows, pediatric orthopaedics fellows, or orthopaedic trauma fellows) to obtain a sufficient career volume and assuredly impossible to obtain a sufficient annual maintenance volume to enter practice post-training at a level of proficiency in technical skill. Further, given how a typical orthopaedic surgery early-career practice begins, even in the ideal situation (e.g., surgeon recruited out of fellowship to be the “hip doc”), it would likely take a few years to achieve these minimum thresholds to achieve proficiency. Thus, extra training is absolutely necessary—this is where VR simulation comes in.“A journey of a thousand miles begins with a single step”
15
—every surgeon does their first case. All the preparation that goes into that first case (or first ten, or first hundred, or first thousand) influences how that/those case(s) go(es). Getting through as much of the learning curve as possible before the first case in practice will help dampen the potential pitfalls and complications that can occur during that significant period of time. Surgeons who learned hip arthroscopy with minimal experience during residency or fellowship likely sought training through a combination of means—society-sponsored (e.g., AANA courses at the Orthopedic Learning Center) and industry-sponsored events. Mini-fellowships also exist that permit surgeons a variable amount of time traveling to different hip-preservation surgery centers across the United States and the globe to observe, and in select unique situations participate with, experienced surgeons performing hip arthroscopy. Surgeons with minimal “hands-on” past experience likely encounter a variety of challenging intraoperative situations—perhaps some they have seen from a mentor, like a technique to circumvent (or reverse) a complication, and perhaps some they have never seen (or even heard of). If the frequency of these situations, some avoidable and some unavoidable, is unacceptably high, surgeons may be dissuaded to actually get through the learning curve. Thus, to get through the hip arthroscopy learning curve, the surgeon must “Be naïve enough to start, but stubborn enough to finish.”16
Adventurer completes epic solo marathon swim around circumference of Great Britain. Evening Standard,
2018
https://www.standard.co.uk/news/uk/swimmer-completes-epic-solo-marathon-swim-around-circumference-of-great-britain-a3980061.html
Date accessed: February 28, 2021
Given what we know of the learning curve, I, among many others,
17
would argue that “hip arthroscopy is not for dabblers.” Even basic or “routine” hip arthroscopy requires distraction, joint entry, variable sizes of capsulotomy, labral management, abnormal morphology correction (e.g., cam, pincer, subspine), and appropriate capsular management—all critical, or key, steps that could: (1) avoid complications, (2) reduce the risk of revision arthroscopy, (3) reduce risk of total hip arthroplasty conversion, and (4) optimize patient-reported outcomes.18
VR simulators may currently best help for “the basics”—in other words, learning competency. As progress through the learning curve occurs, basic skills may not be enough (e.g., labral reconstruction/augmentation, protrusio acetabulae, far lateral/posterolateral cam morphology, revision surgery). The evolution of case complexity across the learning curve leads likely to multiple apogees of surgeon skill, confidence, and patient outcomes, potentially never truly peaking, only parabolically “plateauing,” pending substantial changes in indications and/or techniques in the field of hip preservation. This is where I see VR playing a big role for more experienced surgeons, once proficiency has been achieved. The difference between proficiency and competence is not semantics and truly does warrant discussion.While other joints (e.g., routine diagnostic knee or shoulder arthroscopy) may exhibit a “Dunning–Kruger effect” as surgeons progress through a learning curve, I cannot see this happening as frequently or as early with hip arthroscopy. Although it is unknown if hip arthroscopy truly follows a Dunning–Kruger model, it can be conceived that the threshold of achievement of just “the basics” of diagnostic hip arthroscopy may delude surgeons into an “unskilled and unaware” situation.
19
This is analogous to “unconscious incompetence” (Stage 1) in the Hierarchy of Competence model.20
, This is possibly the reason why the learning curve of hip arthroscopy is as significant as it is. It would be desirable to avoid this if exclusively VR simulation was used in training—it must be augmented with cadaver arthroscopic (and open) skills courses and immersion into as many hip scope operating rooms as possible. The goal of training before independent practice would be to achieve at least stage 2 (conscious incompetence). This at least ensures competence, which should equate to safety. The latter ensures a greater chance of passing Part 2 of the American Board of Orthopaedic Surgery certification examination. Stages 3 (conscious competence) and 4 (unconscious competence) are analogous to surgeon proficiency. The Dreyfus Model of Mental Stages in Skill Acquisition dichotomizes competency and proficiency without overlap.Learning a New Skill is Easier Said Than Done. Gordon Training International.
https://www.gordontraining.com/free-workplace-articles/learning-a-new-skill-is-easier-said-than-done/
Date accessed: February 28, 2021
22
,23
Competence is the minimum, the lowest performance level that meets a threshold of safety and outcome. Competence develops with more experience—“hands-on” training with mentored observation and instruction (which can occur with VR simulation and in a real operating room), in addition to independent practice and learning, sometimes the “hard way.” Proficiency represents consistent high-quality performance, although not necessarily at “master” or “expert” levels (Stage 4). A surgeon exhibits proficiency when using intuition in decision-making, whether planned or on the spot. The latter implies the ability of immediate pattern recognition, with subsequent “getting out of a jam” in the operating room seem simple. This is actually somewhat of a drawback for trainees in an experienced hip arthroscopist’s fellowship—they may never see how to navigate intraoperative complications. In fact, some surgeons may actually be able to prevent problems before they happen, clearly not what will happen when young surgeons are in their early practice. Beyond competence and proficiency, mastery or expertise in surgery is beautiful to observe—it is efficient and fluid performance without wasted moves that happens subconsciously, automatically, with little/no intentional thought. It is hypothesized that VR simulators can probably achieve competence for most, if not all, surgeons; possibly achieve proficiency; and unlikely to achieve mastery.In the quest to achieve mastery through competence and proficiency, pilots view flight simulator training as an integral component of their learning curve. Given that iatrogenic labral and articular cartilage injury is a possibility in every case,
24
one aspect of VR simulation that needs improved is the ability to detect this—the ArthroS, VirtaMed AG (Schlieren, Switzerland) as used in Bishop et al.1
can measure scratches, but cannot measure dents, gouges, penetrating holes or cuts, shears, or collisions.25
While machine learning artificial intelligence algorithms have the potential to generate VR simulation for critical parts of the case (e.g., labral repair, cam correction, capsular closure) based on large volumes of photos and videos, it is unlikely that “iatrogenesis imperfecta”26
can actually be simulated, as typically the occurrence of these complications is less likely to be recorded on video or photo. Further, the pressure necessary to cause these complications in vivo would be highly challenging to accurately simulate.It is clear that VR simulation has an incredible potential upside for technically demanding activities, such as surgery, flying a plane, or being an astronaut. Within arthroscopic and related surgery, hip arthroscopy has a demonstrated track record that requires an extensive case volume to optimize outcomes and avoid problems. VR simulation, although in its surgical infancy, can mitigate this learning curve as surgeons train and adopt this rewarding technique in their practice.
Supplementary Data
- ICMJE author disclosure forms
References
- The Arthroscopic Surgery Skill Evaluation Tool Global Rating Scale is a valid and reliable adjunct measure of performance on a virtual reality simulator for hip arthroscopy.Arthroscopy. 2021; 37: 1856-1866
- Flight simulators, safety, and the power of AI 2020.https://airfactsjournal.com/2020/04/flight-simulators-safety-and-the-power-of-ai/Date accessed: March 1, 2021
- Editorial Commentary: Harnessing surgical simulation-saddle up for a long and rigorous ride!.Arthroscopy. 2019; 35: 796-799
- Magellan and Copernicus: Arthroscopy Association of North America seeking excellence in education.Arthroscopy. 2015; 31: 1428-1429
- A proficiency-based progression training curriculum coupled with a model simulator results in the acquisition of a superior arthroscopic Bankart skill set.Arthroscopy. 2015; 31: 1854-1871
- The Bankart performance metrics combined with a shoulder model simulator create a precise and accurate training tool for measuring surgeon skill.Arthroscopy. 2015; 31: 1639-1654
- The Bankart performance metrics combined with a cadaveric shoulder create a precise and accurate assessment tool for measuring surgeon skill.Arthroscopy. 2015; 31: 1655-1670
- What It Takes To Become A Pilot—inside United's Simulator.(YouTube:) (Accessed February 28, 2021)
- Validation of a virtual reality-based hip arthroscopy simulator.Arthroscopy. 2019; 35: 789-795
- The efficacy of arthroscopic simulation training on clinical ability: A systematic review.Arthroscopy. 2021; 37: 1000-1007.e1
- Editorial Commentary: Great expectations or "we'll see," said the Zen master-hip arthroscopy patient selection.Arthroscopy. 2019; 35: 1817-1818
- Patients' expectations of hip preservation surgery: A survey study.Arthroscopy. 2019; 35: 1809-1816
- Defining the learning curve for hip arthroscopy: A threshold analysis of the volume-outcomes relationship.Am J Sports Med. 2018; (363546517749219)
- Risk of failure of primary hip arthroscopy—a population-based study.J Hip Preserv Surg. 2017; 4: 214-223
- Chapter 64. Tao Te Ching, 6th Century BC.(Accessed February 28, 2021)
- Adventurer completes epic solo marathon swim around circumference of Great Britain. Evening Standard,
2018https://www.standard.co.uk/news/uk/swimmer-completes-epic-solo-marathon-swim-around-circumference-of-great-britain-a3980061.htmlDate accessed: February 28, 2021
- Editorial Commentary: Expansion of hip arthroscopy in sports medicine fellowship training: The good, bad, and ugly.Arthroscopy. 2021; 37: 528-529
- The key parts of hip arthroscopy for FAI syndrome—implications for the learning curve.Orthop J Sports Med. 2021;
- Unskilled and unaware of it: How difficulties in recognizing one's own incompetence lead to inflated self-assessments.J Pers Soc Psychol. 1999; 77: 1121-1134
- Learning a New Skill is Easier Said Than Done. Gordon Training International.https://www.gordontraining.com/free-workplace-articles/learning-a-new-skill-is-easier-said-than-done/Date accessed: February 28, 2021
- Teaching For Learning (XVI.).The Gospel Guardian. 1969; 20: 1-3a
- The Dreyfus model of clinical problem-solving skills acquisition: A critical perspective.Med Educ Online. 2010; 15
- A five-stage model of the mental activities involved in directed skill acquisition.University of California, Berkeley, Berkeley, CA1980
- Complications and reoperations during and after hip arthroscopy: A systematic review of 92 studies and more than 6,000 patients.Arthroscopy. 2013; 29: 589-595
- Iatrogenic articular cartilage injury in arthroscopic hip and knee videos and the potential for cartilage cell death when simulated in a bovine model.Arthroscopy. 2020; 36: 2114-2121
- Iatrogenic arthroscopic cartilage injury: Arthroscrapes result from iatrogenesis imperfecta.Arthroscopy. 2020; 36: 2041-2042
Article info
Publication history
See related article on page 1856
Footnotes
The author reports the following potential conflicts of interest or sources of funding: personal fees from Arthroscopy, The Journal of Arthroscopic and Related Surgery, Xodus Medical, SLACK, and Smith & Nephew; other from Arthroscopic Association of North America, International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine, American Orthopaedic Society for Sports Medicine, American Academy of Orthopaedic Surgeons, and American Orthopaedic Association; and grants from DePuy Synthes and Smith & Nephew, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Identification
Copyright
© 2021 by the Arthroscopy Association of North America
