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Can a low fidelty simulator teach the same core arthroscopic skills as a high fidelity simulator?

Background:
The development of arthroscopic skills has a longer learning curve than traditional open surgery. Simulation training has become more important for skills acquisition, especially since the introduction of the European Working Time Directive (EWTD) and the competency-based curriculum. High fidelity simulators, such as virtual reality models with haptic feedback, confer realistic core skills and procedural training in a safe environment without compromising patient safety or the EWTD. Unfortunately these simulators are expensive, not easily accessible and require specialist equipment. The arthroscopic skills acquisition tools (ASATs) is a group of low fidelity tools that test hand-eye coordination that were designed to overcome these limitations. The purpose of this study was to see if the performance on the ASATs correlated with core skills performance for shoulder arthroscopy on a validated virtual reality simulator (ArthroVR).

Methods:
49 novice medical students were tested for the baseline performances on core skills for shoulder arthroscopy on the ArthoVR. The 4 ArthroVR tasks were “operating room”, “locate and palpate”, “visualisation” and “pendulum”. ArthroVR performance was measured as units of time, distance movement of camera +/- probe and roughness of camera +/- probe. The ASATs record performance parameters, including time taken for completion of test and accuracy of hand movements. Pearson’s correlation was used to assess the correlation of ASATs parameters with ArthroVR performance parameters. Significance was assumed if p <0.05.

Results:
Significant correlation was observed between time taken to complete “shape match inverted controls” ASAT with ArthroVR performance parameters of time, camera and probe distance during the ArthroVR  tasks of “palpate”, “visualise”, and “pendulum”. Significant correlation was also observed between distances the mouse was moved to complete this ASAT and ArthroVR performance parameters. The same significant correlations were found when this ASAT had dual input and scope view settings turned on. No correlation was found between any of the ASAT parameters and roughness of the camera or probe.

Discussion: 
It is likely the lack of haptic feedback of the control devices of the ASATs contributed to the lack of correlation with roughness of the scope or probe. However, the ASATs do appear to correlate with other desirable core skills on the virtual reality shoulder simulator. This suggests that the core skills of arthroscopy may be learned on easily-accessible tools, reserving high fidelity simulators to learn more procedural-based skills.

Conclusion:
These early results suggest junior trainees could develop core arthroscopic skills remotely and once achieved, be given access to expensive simulators to develop arthroscopic procedural skills before operating on patients. This can help overcome current limitations of simulators by proposing a cheaper and more widely accessible alternative training tool.



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