The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 13

Topics in Training | July 03, 2012

Simple Visual Parameters for Objective Assessment of Arthroscopic Skill

A. Alvand, BSc(Hons), MBBS, MRCS(Eng)¹; T. Khan, BSc(Hons), MBBS, MRCS(Eng)¹; S. Al-Ali, MBBS, MRCS¹; W.F. Jackson, FRCS(Orth)¹; A.J. Price, DPhil, FRCS(Orth)¹; J.L. Rees, MD, FRCS(Orth)¹

¹ Oxford Orthopaedic Simulation and Education Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, NIHR Biomedical Research Unit, Nuffield Orthopaedic Centre, University of Oxford, 150 Windmill Road, Oxford OX3 7LD, United Kingdom. E-mail address for T. Khan: tanvir.khan@ndorms.ox.ac.uk

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Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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J Bone Joint Surg Am, 2012 Jul 03;94(13):e97 1-7. doi: 10.2106/JBJS.K.01437

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Abstract

Background:

Restrictions placed on the working hours of doctors over the past decade have resulted in substantial changes to the training and assessment of orthopaedic surgical residents. Many who are responsible for training the surgeons of the future have become concerned that this reduced clinical exposure is having a detrimental impact on technical skill acquisition. Consequently, there is a need for surgical educators to develop more objective methods for assessing surgical skill. The primary aim of this study was to determine whether a novel set of visual parameters assessing visuospatial ability, fine motor dexterity, and gaze control could objectively discriminate among various levels of arthroscopic experience. The secondary aim was to evaluate the correlations between these new parameters and previously established technical skill assessment methods.

Methods:

Twenty-seven subjects were divided into a novice group (n = 7), a resident group (n = 15), and an expert group (n = 5) on the basis of arthroscopic experience. All subjects performed a diagnostic knee arthroscopy task on a simulator. Their performance was assessed with use of novel simple visual parameters that included the prevalence of instrument loss, triangulation time, and prevalence of lookdowns. Performance was also evaluated with use of previously validated technical skill assessment methods (a global rating scale and motion analysis).

Results:

A significant difference in performance among the groups was demonstrated with use of all three novel visual parameters, the global rating scale, and motion analysis (p < 0.05). There were strong and highly significant correlations (p < 0.0001) between each of the novel parameters and the previously validated skill assessment methods.

Conclusions:

This study demonstrates the construct validity of three novel visual parameters for objectively assessing arthroscopic performance. These parameters are simple, can be used easily in the operating room, and are strongly correlated with current validated methods of technical skill assessment.

Clinical Relevance:

The identification of objective methods for evaluating technical skill in arthroscopic surgery is of paramount importance. The generic nature of the simple visual parameters in this study makes them a powerful and user-friendly objective assessment tool that may offer an alternative to existing assessment methods.

Figures in this Article

Introduction

There have been substantial changes in postgraduate surgical education and assessment in the United States and Europe. Restrictions placed on the working hours of doctors in training^1,2 have led to increasing time pressures on surgical training^3,4. In addition, rising peer and public scrutiny⁵ has prompted the need for surgeons to demonstrate their technical competence. The shift from a traditional time-based apprenticeship to a competency-driven model of training has led to the development of new approaches for assessing surgical skill. Consequently, there is growing interest in the use of objective methods of assessing surgical skills, such as global rating scales^6,7 and motion analysis⁸.

Global rating scales developed from the Objective Structured Assessment of Technical Skill (OSATS) system⁹ have been successfully applied for evaluating surgical skill. Although initially designed and validated for open general surgical procedures⁹, global rating scales have since been adapted for use in many surgical subspecialties^10-14. A specific global rating scale has been validated to objectively evaluate technical performance in arthroscopic surgery⁶. The use of motion analysis for assessing surgical skill in orthopaedics and other surgical subspecialties has also been studied extensively, and its construct validity is well documented^8,15,16.

Despite the availability of such validated assessment methods for evaluating arthroscopic performance, it is important to highlight some of their limitations. Although global rating scales can be used intraoperatively to directly assess a trainee’s skill, they are subjective measures of performance and can be assessed only by experts or trained observers. Motion analysis, on the other hand, is an objective assessment tool but it remains costly, may not be widely available, and is logistically difficult to use in an actual operating room environment.

The popularity of arthroscopic surgery has surged in recent years, with widening indications for its use as both a diagnostic and a therapeutic tool. It requires a particular subset of skills and attributes that are generally not required during open surgery. Visuospatial awareness and fine motor dexterity are essential in minimally invasive surgery¹⁷. There is also some evidence that a correlation exists between the experience of surgeons and control of their gaze during laparoscopy¹⁸. However, to our knowledge, the relationships between these three skill domains and arthroscopic performance have not been previously investigated.

The primary aim of this study was to determine whether a novel set of visual parameters assessing visuospatial ability, fine motor dexterity, and gaze control could objectively discriminate among various levels of experience. The secondary aim was to evaluate the correlations between these new parameters and previously established technical skill assessment methods.

Materials and Methods

Setting and Subjects

Institutional review board approval was obtained for this study, and all subjects gave informed consent to participate. The study took place in the surgical skills laboratory of a university teaching hospital. We recruited twenty-seven subjects from within our institution. The subjects were divided into a novice group (n = 7), a resident group (n = 15), and an expert group (n = 5). The novice group consisted of medical students in their penultimate year who were undertaking their orthopaedic rotation, which is a compulsory rotation undertaken by all medical undergraduates at our university. However, participation in the current study was entirely voluntary. None of the novice group had any previous experience with arthroscopic surgery. The residents were orthopaedic trainees who had each personally performed between fifty and 150 arthroscopic procedures. The experts were consultant orthopaedic surgeons who had each performed a minimum of 700 arthroscopic procedures.

Simulated Knee Arthroscopy Task

A benchtop knee arthroscopy simulator (model 1401; Sawbones, Malmö, Sweden) and a standard 30° arthroscope, arthroscopic camera, and display system (Smith & Nephew Endoscopy, Huntingdon, United Kingdom) were used during all trials. Each subject performed a single diagnostic arthroscopy task on the knee simulator. Commencing from a standardized position, the camera was inserted from the anterolateral portal and an arthroscopy probe (ACUFEX Straight Probe; Smith & Nephew Endoscopy) was inserted from the anteromedial portal. Four randomly marked points within the knee joint (two in the lateral and two in the medial compartment) were then identified and probed. Prior to performing the task, subjects viewed an instructional video outlining the procedure and were then allowed five minutes to familiarize themselves with the equipment.

Data Acquisition for Assessment of Arthroscopic Skill

During each arthroscopic task, three sets of data were acquired (Fig. 1): (1) the video stream from the arthroscope; (2) an external video of the subject performing the task, captured with use of a high-resolution webcam; and (3) motion analysis of the subject’s hands performed with use of a validated three-dimensional motion tracking system⁸.

Fig. 1

Setup of the arthroscopy equipment, knee simulator, webcam, and motion analysis system.

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Outcome Measures

Global Rating Scale

One of the outcome measures utilized was a global rating scale that had been previously developed and validated for assessment of basic arthroscopic skills⁶. Since the latter study had been conducted on cadavers, some of the skill domains such as dissection were not relevant to a simple diagnostic task on a knee simulator. Consequently, only the domains relevant to a simulated diagnostic arthroscopy were used in the current study. The arthroscopy videos were assessed in a blinded fashion by two of the authors (A.A. and S.A.-A.) who had been trained in use of the global rating scale for assessment of arthroscopic procedures.

Motion Analysis

Arthroscopic performance was evaluated objectively with use of a previously validated three-dimensional motion tracking system⁸. The hand motion data were analyzed with custom software developed in MATLAB (version 6.5; MathWorks, Natick, Massachusetts) that produced three outcome parameters: the number of hand movements, path length (traveled by the subject’s hands), and time taken. Previous studies involving motion analysis in orthopaedic surgery and other surgical subspecialties have demonstrated that individuals with greater surgical ability perform tasks with fewer hand movements, a shorter path length, and a shorter time^8,16.

Novel Visual Parameters

The purpose of this portion of the study was to evaluate the use of three simple parameters designed to provide an objective assessment of arthroscopic skill (visuospatial awareness, fine motor dexterity, and gaze control) while being applicable to any joint and potentially transferable to the operating room. “Prevalence of instrument loss,” which assessed visuospatial awareness and fine motor dexterity, was defined as the number of instances during which the tip of the arthroscopy probe was not visible on the arthroscopy display unit. “Triangulation time,” which also assessed visuospatial awareness and fine motor dexterity, was defined as the mean duration of the instrument loss episodes during the entire task (total duration of instrument loss in seconds divided by the number of instances of instrument loss). “Prevalence of lookdowns,” which assessed gaze control, was defined as the number of instances during which the subject looked away from the arthroscopy display unit to look at his or her hands while holding the arthroscope.

Statistical Analyses

As the data were not normally distributed, nonparametric tests were used and data are presented as medians and interquartile ranges (IQRs). The interobserver reliability of the global rating scale assessment was calculated with use of the Cronbach α value. The Kruskal-Wallis test was used to determine the presence of a difference in performance between the groups. Where a significant difference in performance was found, pairwise comparisons between the groups were made with use of the Mann-Whitney U test. Correlations between the previously validated assessment methods (global rating scale scores and motion analysis parameters) and the novel visual parameters were calculated with use of the Spearman rank correlation coefficient. All data analyses were performed with use of SPSS software (version 18.0; SPSS, Chicago, Illinois). A p value of <0.05 was considered significant.

Source of Funding

Support for this study was received from the National Institute for Health Research (NIHR) Biomedical Research Unit into Musculoskeletal Disease and from the National Health Service (NHS) Education South Central.

Results

Performance Assessed with the Global Rating Scale and Motion Analysis

There were significant differences in performance across the three groups (p < 0.05, Kruskal-Wallis test) as assessed with use of the global rating scale and all three motion analysis parameters (Table I). Pairwise comparisons between the groups also demonstrated that the performance of the resident group was significantly better than that of the novice group and that the performance of the expert group was significantly better than that of the resident group for all of the previously validated technical assessment tools (p < 0.05 for all, Mann-Whitney U test). The interobserver reliability for the global rating scale was excellent (Cronbach α = 0.90).

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TABLE I Performance of the Three Groups Based on the Previously Validated Technical Skill Assessment Methods

Assessment Method	Novice Group (N = 7)*	P Value, Novice vs. Resident†	Resident Group (N = 15)*	P Value, Resident vs. Expert†	Expert Group (N = 5)*	P Value Across All Three Groups‡
Global rating scale	5 (5-7)	0.001	18 (15-20)	0.001	25 (24-25)	<0.0001
No. of hand movements	118 (96-156)	0.041	90 (77-108)	0.001	36 (19-45)	0.001
Path length (cm)	2001 (1540-2185)	0.045	1403 (1269-1720)	0.002	604 (560-1037)	0.001
Time taken (s)	239 (176-307)	0.022	117 (96-145)	0.001	49.5 (42-66)	0.001

*The values are given as the median, with the interquartile range (IQR) in parentheses.
†Mann-Whitney U test. All differences were significant.
‡Kruskal-Wallis test. All differences were significant.

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TABLE I Performance of the Three Groups Based on the Previously Validated Technical Skill Assessment Methods

Assessment Method	Novice Group (N = 7)*	P Value, Novice vs. Resident†	Resident Group (N = 15)*	P Value, Resident vs. Expert†	Expert Group (N = 5)*	P Value Across All Three Groups‡
Global rating scale	5 (5-7)	0.001	18 (15-20)	0.001	25 (24-25)	<0.0001
No. of hand movements	118 (96-156)	0.041	90 (77-108)	0.001	36 (19-45)	0.001
Path length (cm)	2001 (1540-2185)	0.045	1403 (1269-1720)	0.002	604 (560-1037)	0.001
Time taken (s)	239 (176-307)	0.022	117 (96-145)	0.001	49.5 (42-66)	0.001

Performance Assessed with the Novel Visual Parameters

Prevalence of Instrument Loss

The median number of instrument loss episodes was fourteen (IQR, 13 to 15.5) for the novice group, nine (IQR, 6.5 to 10.0) for the resident group, and two (IQR, 1.0 to 3.0) for the expert group (Fig. 2). The resident group performed significantly better than the novice group on the basis of the prevalence of instrument loss, and the expert group performed significantly better than the resident group (p < 0.05 for both, Mann-Whitney U test).

Fig. 2

Box-and-whisker plot comparing the three groups on the basis of the prevalence of instrument loss during the arthroscopy task. Asterisks denote significant differences (p = 0.002 for the novice compared with the resident group, and p = 0.001 for the resident compared with the expert group). The shaded box represents the interquartile range, the bold line in the box represents the median, and the whiskers represent the 2.5 and 97.5 percentiles.

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Triangulation Time

The median triangulation time was nine seconds (IQR, 5.9 to 11.8 seconds) for the novice group, 4.2 seconds (IQR, 3.3 to 5.5 seconds) for the resident group, and 1.3 seconds (IQR, 1.3 to 2.0 seconds) for the expert group (Fig. 3). The triangulation time was significantly longer for the novice group than for the resident group, and the time was significantly longer for the resident group than for the expert group (p < 0.05 for both, Mann-Whitney U test).

Fig. 3

Box-and-whisker plot comparing the three groups on the basis of triangulation time during the arthroscopy task. Circles denote outliers, and asterisks denote significant differences (p = 0.037 for the novice compared with the resident group, and p = 0.003 for the resident compared with the expert group).

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Prevalence of Lookdowns

The median number of lookdowns was sixteen (IQR, 14.5 to 16.5) for the novice group, ten (IQR, 6.5 to 12.0) for the resident group, and one (IQR, 0.0 to 2.0) for the expert group (Fig. 4). The resident group performed significantly better than novice group on the basis of the number of lookdowns, and the expert group performed significantly better than the resident group (p < 0.05 for both, Mann-Whitney U test).

Fig. 4

Box-and-whisker plot comparing the three groups on the basis of the prevalence of lookdowns during the arthroscopy task. Circles denote outliers, and asterisks denote significant differences (p = 0.037 for the novice compared with the resident group, and p = 0.001 for the resident compared with the expert group).

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Association Between the Novel Visual Parameters and Previously Validated Technical Skill Assessment Methods

There were statistically strong and highly significant correlations (p < 0.0001) between each of the three visual parameters (prevalence of instrument loss, triangulation time, and prevalence of lookdowns) and the previously validated technical skill assessment methods (the global rating scale and the three motion analysis parameters) (Table II).

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TABLE II Correlation Between the Novel Visual Parameters and Previously Validated Skill Assessment Methods

Novel Visual Parameter	Global Rating Scale	No. of Hand Movements	Path Length	Time Taken
Prevalence of instrument loss
Rho value*	–0.830	0.778	0.802	0.806
P value	<0.0001	<0.0001	<0.0001	<0.0001
Triangulation time
Rho value*	–0.834	0.692	0.770	0.878
P value	<0.0001	<0.0001	<0.0001	<0.0001
Prevalence of lookdowns
Rho value*	–0.829	0.794	0.727	0.780
P value	<0.0001	<0.0001	<0.0001	<0.0001

*Spearman rho. All corresponding p values were significant.

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TABLE II Correlation Between the Novel Visual Parameters and Previously Validated Skill Assessment Methods

Novel Visual Parameter	Global Rating Scale	No. of Hand Movements	Path Length	Time Taken
Prevalence of instrument loss
Rho value*	–0.830	0.778	0.802	0.806
P value	<0.0001	<0.0001	<0.0001	<0.0001
Triangulation time
Rho value*	–0.834	0.692	0.770	0.878
P value	<0.0001	<0.0001	<0.0001	<0.0001
Prevalence of lookdowns
Rho value*	–0.829	0.794	0.727	0.780
P value	<0.0001	<0.0001	<0.0001	<0.0001

*Spearman rho. All corresponding p values were significant.

Discussion

The findings of the present study indicated that three novel yet simple visual parameters can be used to objectively assess the level of arthroscopic skill on a simulator-based knee task. The construct validity for each of these parameters was demonstrated, and the findings indicated a strong correlation with previously validated technical skill assessment methods involving a global rating scale and motion analysis.

To our knowledge, the three visual parameters have not been formally used for assessing arthroscopic ability and their construct validity has not been previously investigated. Earlier studies in general surgery have suggested a positive correlation between visuospatial ability and technical skill^19,20, and Murdoch et al. objectively demonstrated a relationship between scores on a “space relations test” and performance on microsurgical tasks²¹. More recently, endovascular skill has been shown to correlate strongly with fine motor dexterity²². In the present study, we suggest that two novel parameters, the prevalence of instrument loss and triangulation time, are indicators of both visuospatial awareness and fine motor dexterity. The third novel visual parameter, the prevalence of lookdowns, relates to gaze behavior during arthroscopy. With regard to the latter skill domain, eye-motion monitoring devices have previously been used to show that experienced laparoscopistsdemonstrate less eye motion than novices during simulated laparoscopic tasks¹⁸. Similar to the findings of the present study, Wilson et al. demonstrated (using a laparoscopy model) that although novices frequently shift their gaze between their tools and target, experts are able to remain focused on their target and to locate the positions of their instruments with peripheral vision²³.

The present study has some limitations. It would have been desirable to carry out a subanalysis of the resident group to further demonstrate the sensitivity of the novel visual parameters. Unfortunately, the arthroscopic experience of this group was not broad enough and the sample size was not large enough to allow a meaningful subanalysis to be conducted. Despite this, even the least experienced participants in the resident group had enough arthroscopic experience to set them apart from the novice group. Another limitation is the relative simplicity and short duration of the diagnostic arthroscopy task. It has been demonstrated previously that some laboratory-based tasks performed on inanimate simulators may not be sensitive enough for assessment of subtler technical skill differences among surgical trainees²⁴. However, this theoretical ceiling effect was not observed during the present study, and the lack of previous arthroscopy experience in the novice group meant that it would have been inappropriate to make the task any more complex.

There are several reasons why it is desirable to use the visual parameters identified in the present study to assess arthroscopic skill. First, their generic nature enables them to be used for assessing arthroscopic performance in any joint. Second, they provide an objective measure of arthroscopic ability and have the added advantages of being inexpensive and easily transferable to the operating room. More importantly, the prevalence of instrument loss and prevalence of lookdowns are very simple to calculate in the operating room setting as they can be counted in real time by an observer using a tally counter. The simplicity of assessing these two parameters means that the observer requires no specific training prior to acting as an assessor. Triangulation time can be measured with use of video recordings of the procedures (available on all modern arthroscopy display systems) and offers an alternative method that might be the preference of some trainers as it has the advantage of being evaluated in a remote setting, away from the time constraints of the operating room environment. These three parameters are even easier to assess in the simulation-laboratory setting, as we have demonstrated with the use of a webcam and the arthroscopy video recording. Another valuable feature of obtaining video documentation of these parameters during such procedures is that the recordings can be used to provide constructive feedback to trainees regarding their performance as well as to monitor their progress during the residency program.

Despite the simplicity of these visual parameters, the information obtained is a key reflection of surgical skill because it is closely linked with the occurrence of surgical errors and iatrogenic damage. For example, when an individual loses sight of the arthroscopic probe (or any other instrument), substantial inadvertent damage to the surrounding articular cartilage and other structures within the joint may result. The same rationale applies to instances of prolonged triangulation time and poor gaze control. The aforementioned advantages of these novel parameters mean that they may offer an alternative to use of a global rating scale or motion analysis, but further research involving a larger number of surgical trainees is still necessary to demonstrate their value during both simple and more complex arthroscopic tasks—and, more importantly, the transferability of these parameters to an actual operating room setting.

In conclusion, the present study has demonstrated the construct validity of three novel visual parameters for objectively assessing visuospatial ability, fine motor dexterity, and gaze control during arthroscopy. Two of these parameters (prevalence of instrument loss and prevalence of lookdowns) are particularly useful as objective measures of arthroscopic skill as they are very simple to assess in the operating room. These visual parameters are strongly correlated with existing methods of technical skill assessment and have the potential to provide a powerful and objective means of evaluating arthroscopic performance in any joint.

Acknowledgements

Note: The authors thank Dr. Minsi Chen for technical support with the motion analysis system.

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Topics

arthroscopy ; operating room ; gaze ; mann-whitney u test ; medical residencies ; simulators ; construct validity ; motion analysis

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A. Alvand, T. Khan, S. Al-Ali, W.F. Jackson, A.J. Price, J.L. Rees; Simple Visual Parameters for Objective Assessment of Arthroscopic Skill. The Journal of Bone & Joint Surgery. 2012 Jul;94(13):e97 1-7.

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