Retention of Arthroscopic Shoulder Skills Learned with Use of a Simulator

N.R. Howells,
S. Auplish,
G.C. Hand,
H.S. Gill,
A.J. Carr,
J.L. Rees

Nuffield Department of Orthopaedic Surgery, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom

J Bone Joint Surg Am. 2009:91:1207-1213

Demonstration of a Learning Curve and Loss of Performance Level After a Time Delay

Background: In orthopaedic surgery, arthroscopy is an irreplaceable diagnostic and interventional tool, and its breadth of use is increasing. The aim of this study was to investigate the surgeon’s capacity for retention of an unfamiliar arthroscopic skill.

Methods: Six fellowship-trained lower-limb surgeons were given standardized instruction regarding the performance of an arthroscopic Bankart suture on a laboratory-based simulator. They performed three single Bankart sutures on each of four occasions, one to two weeks apart. Six months later, the same surgeons repeated the study. They received no further instruction or guidance. Their performance was objectively assessed with use of validated motion-analysis equipment to record the total path length of the surgeon’s hands, number of hand movements, and time taken to perform the sutures.

Results: A learning curve showing significant and objective improvement in performance was demonstrated for all outcome parameters in both experiments (p < 0.005). The learning curve at six months was a repeated learning curve showing no significant difference from the initial learning curve.

Conclusions: This study objectively demonstrated a loss of all of the initial improvement in the performance of an arthroscopic Bankart suture following a six-month interval in which the surgeons did not do the procedure.

Clinical Relevance: The results indicate a need for regular repetition of some surgical tasks in order to maintain optimum performance levels and to consolidate the skills needed for newly learned procedures. It is hoped that the development of appropriately validated simulators may provide a useful tool with which trainees and established surgeons alike can acquire and maintain certain surgical skills.

Modern surgical practice is subject to increasing peer and public scrutiny. High-profile cases of adverse clinical events have led to improvements in systems for risk management, incident reporting, and monitoring of clinical practice and of patient outcomes1. In some countries, consultant surgeons are now required to obtain recertification to demonstrate their continuing capability to practice2,3. Some studies have demonstrated that surgeons who perform high volumes of a particular procedure achieve better outcomes, and some insurance companies have begun restricting their list of surgeons on the basis of volume of practice. This has raised awareness about the need to maintain appropriate skills, especially for rarely performed procedures4-6.

Trainee surgeons in Europe face reductions in training time and the implementation of working-hour restrictions. This is leading to the development of methods of surgical skills training outside of the operating theater. The role of simulation in medical education has become well established in general surgery and is being increasingly recognized across other specialties7-14.

In orthopaedics, arthroscopy is an irreplaceable diagnostic and interventional tool. Its breadth of use is increasing, and many advanced procedures have now been developed. Arthroscopic laboratory simulators have been used in training courses worldwide, and some studies have recently demonstrated validity, objective improvement in performance with training, and transferability of these learned skills to the operating theater15,16.

The aim of this study was to investigate the ability of experienced orthopaedic surgeons to acquire the appropriate skills to perform an unfamiliar arthroscopic procedure learned in a simulated environment and to assess their capacity to retain these learned skills.