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A novel arthroscopy training program based on a 3D printed simulator
∗Corresponding author: J. Ferràs-Tarragó. cotferras@gmail.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Arthroscopy is the most important and exciting contribution to sports medicine of the last 100 years. One of its main limitations, however, is the steep learning curve it requires, which is not easy to beat given the scarcity and the high price of arthroscopy simulators.
To describe and evaluate the effectiveness of an open-access arthroscopy training program based on a 3D-printed simulator.
A model was designed, which was to be printed on a fused filament fabrication (FFF) 3D printer for home use with polylactic acid (PLA) filaments. Fourteen exercises were prepared, each with its timeframe and conceptual goals, arranged from least difficult to most challenging. Exercises were designed to assist subjects in developing the skills of an experienced arthroscopic surgeon through use of the simulator. Twenty subjects from nine hospitals completed the arthroscopy training program. Performance in each exercise was evaluated according to the Arthroscopic Surgical Skill Evaluation Tool (ASSET), taking into account the number of times a student had to repeat each exercise to complete it successfully.
The mean ASSET score for each exercise was 22 points (IQR 19–25) and the mean number of times students had to repeat each exercise was 16 (95% CI 15.27–17.97). Eighty-five percent of subjects completed the program. The device was printed without difficulty by an independent investigator without prior knowledge of 3D printing. The price of the device was under US$ 12.
Subjects exhibited an improvement in their basic arthroscopic skills on the simulator. The number of times each of them had to repeat each exercise was similar, which is indicative of a smooth progression of difficulty along the program. The device proved easy to print, accessible, economical, and effective. This is the first structured program based on an open-access arthroscopic simulator to obtain satisfactory results.
Abstract
Highlights
•This is the first arthroscopy learning program based in a 3D printed simulator. It is not only a device, but a complete program, validated in this article in nine hospitals prospectively.•The model can be downloaded and printed for free in any 3D printer, including low cost and domestic printers.
Keywords
3D printing
Artrhoscopy learning curve
Patient safety
Arthroscopy practise
1 Introduction
Arthroscopy was one of the most important innovations in orthopedic surgery in the 20th century1 and still plays a major role in the 21st century,2,3 with an increasing number of applications and devices being developed and extremely beneficial outcomes being obtained in a large number of conditions.
One of its main limitations is the learning curve it requires.4–6 Indeed, arthroscopy being a minimally invasive technique, the surgeon cannot access the operating field or manipulate instruments directly, which makes for a steep learning curve.1 With the development of video, it became possible for surgeons to monitor what their hands were doing during the procedure but direct instrument manipulation was still out of the question. More recently, arthroscopic simulation systems have been developed to provide prospective arthroscopists with the possibility of rehearsing a procedure before going in for real. These systems have taken the form of grapefruits,7 virtual reality simulators,8–12 and basic13,14 or standard physical simulators.15,16
The main limitation of these simulators has been their high price.17 Simple simulators are around US$ 500 and must be used in conjunction with an arthroscopy tower and arthroscopy materials; the price of virtual simulators ranges between US$ 23,000 and US$ 98,500.18 For that reason, multiple low cost simulators for home use have been proposed to train residents in the basic maneuvers used in arthroscopy.19–21 Such simulators have been faced with limitations such as inconsistencies during their construction process, absence of validation, and the lack of a structured training program.
Widespread adoption of 3D printing has been considered the industrial revolution of the 21st century22,23 as it allows to build and share objects and medicines with high levels of accuracy in a very economical, simple and safe manner. One single click is enough to generate an object that may have been designed thousands of kilometers away with a printer installed in a private home.
The purpose of this study was to evaluate a new open-source arthroscopic simulation project based on a 3D-printed device.
2 Methods
2.1 Description of the simulator
The device was made up of a base (1.1) onto which different practice modules could be assembled (1.5–1.12) and a lid (1.2) that created a closed space where the different exercises could be completed (Fig. 1). The modules were fixed to the base via a thread connection. A mobile device, which acted as a receiving screen for the camera, was attached to a support (1.12), connected to the base via a stop system. The 3.5 mm camera was introduced in a purpose-built handle at an angle ranging from 0° to 30° (1.4). The final appearance of the device is shown in Fig. 1.
All practice modules and instructional videos have been developed in the author's institution and printed in a domestic 3D printer, being an example of how the 3D printing technologies are useful to resolve clinical and educational problems.
2.2 Description of the program
The skills to be trained were segmented as follows (1) two-dimensional transportation of objects; (2) two-dimensional manipulation of objects; (3) three-dimensional manipulation of objects; (4) control of elastic forces in three-dimensional movements; (5) arthroscopic knot tying; (6) simulation and repair of tendon injuries (Table 1).
| Object | Time (mins) | Grams of filament | Meters of filament | Skill rehearsed/Purpose |
| Base (Fig. 1.1) | 499 | 90 | 30.07 | Used to secure the different working modules |
| Lid (Fig. 1.2) | 1235 | 185 | 61.86 | Creates a closed space where the different exercises can be completed. It features a series of holes that can be used as the visualization and working portals |
| Module 1 (Fig. 1.5) | 61 | 10 | 3.52 | Two-dimensional transportation of objects. The cradles are in the same coronal plane and the rings are simply transported, they are not rotated or reoriented. (Video 1) |
| Module 2 (Fig. 1.6) | 63 | 9 | 2.95 | Two-dimensional manipulation of objects. The different posts are oriented in the direction of the three planes of space, but they are kept in the same coronal plane as the cradle. The ring must be displaced so that it can be introduced into the posts. (Video 2) |
| Module 3 (Fig. 1.11) | 126 | 17 | 5.55 | Three-dimensional manipulation of objects. The three posts are at different depths, which requires three-dimensional manipulation of the rings so that they can be inserted into the posts. (Video 3) |
| Module 4 (Fig. 1.7) | 68 | 8 | 2.54 | Sliding knot tying and knot-pusher practice. (Video 4) |
| Module 5 (Fig. 1.9) | 235 | 27 | 9.12 | Simulation of the glenohumeral joint. Planning for rotator cuff tears. Arthroscopic sutures and anchor placement (together with module 10) (Videos 5 and 6) |
| Module 6 (Fig. 1.10) | 199 | 25 | 8.53 | Used with module 5 |
| Rings (Fig. 1.5) | 6 | 1 | 0.22 | Used with modules 1, 2 and 3 |
| Arthroscopic camera adapter (Fig. 1.4) | 72 | 9 | 2.94 | Device used to convert a conventional camera to an arthroscopic camera |
| Mobile support (Fig. 1.12) | 104 | 17 | 5.7 | Device used to secure the Smartphone screen |
| Fasteners (Fig. 1.12) | 80 | 10 | 3.5 | Devices used to secure the base, the lid and the mobile support. |
| Knot pusher (Fig. 1.8) | 42 | 6 | 2 | Device used together with modules 4, 5 and 6 to tie arthroscopic knots |
| Total | 2790 | 414 | 138.5 |
Supplementary video related to this article can be found at https://doi.org/10.1016/j.jor.2022.04.006.
The following are the supplementary data related to this article:Video 1Video 1Video 2Video 2Video 3Video 3Video 4Video 4Video 5Video 5Video 6Video 6
Each of the skills was planned to be practiced with the working and visualization portals in three different distributions: (A) both portals on the same frontal plane, simulating the clinical position of portals 2 and 3 in shoulder arthroscopy or the anteromedial and anterolateral portals in knee arthroscopy.24,25 (Table 2.1). (B) both portals oriented toward the lateral plane (one in front of the other), with the anterior visualization portal and the posterior working portal simulating the position of portal 2 and 7 in shoulder arthroscopy24,25 (Table 2.2) (C) both portals with a 90° position between them, with the lateral visualization portal and the anterior working portal simulating portals 2 and 10 in shoulder arthroscopy24,25 (Table 2.3) (Table 2). Scenario A was considered the simplest while scenario C was considered the most complex.
Table 2 describes the exercises included and the time assigned to each of them. To determine the time to be assigned to each exercise, two surgeons with experience in arthroscopy (over 100 arthroscopic procedures a year) were asked to perform each of them twice after having become familiar with the device. The time to be assigned was determined by working out the mean of the time employed by the surgeons to complete the four attempts (two each). (Table 2).
2.3 Evaluation of the device
The main outcome measures were the score obtained on the ASSET scale in the different exercises and the number of attempts required to successfully complete the exercise with a descriptive target. In accordance with the literature,26 the exercise was considered successfully completed if 15 points or more were obtained on the ASSET scale in each exercise. Students with lower scores were given remedial instruction and advised on how to improve. They were subsequently reevaluated and those who obtained a score in excess of the said 15 points were allowed to move on to the following exercise.
The secondary goals included an evaluation of the subjects' subjective appreciation of each exercise's increasing difficulty and of the following dimensions (rated on a scale from 0 to 10): overall appreciation of the course, whether they would recommend the program, whether they felt their skills had improved, whether they felt this program should be taken before attending a cadaver workshop, and whether they felt that the maneuvers learnt corresponded to those of real-life arthroscopy.
Overall, the participants had to complete 28 different exercises, 14 with the dominant hand and 14 with the non-dominant hand. The design of the exercises allow to practice different arthroscopy skills, showed in Tables 1 and 2. The residents were able to practice as many times as they needed to complete the objectives defined in each exercise. Once they were able to properly complete the exercises, they recorded the video using the app of the wi-fi camera used and they sent the video to the evaluators, who helped them to correct errors and who punctuated the exercises according with the ASSET score.
2.4 Study population
To be included in the study subjects had to be active orthopedic and trauma surgery first year residents performing less than five arthroscopic procedures a year as leading surgeons. In line with similar studies, the sample was limited to 20 subjects as statistical hypothesis testing was not the primary goal of our work.
Subjects who failed to complete at least 85% of exercises were excluded from the study (to be included they had to at least complete exercise 12).
The device was delivered to the home address of all subjects by courier. The package contained all elements required for the program. The information on how the device worked and the explanatory videos for each exercise, including the objectives of and the time assigned to each of theme, could be found on www.artroproject.com.
Subjects were allowed a limited number of attempts in each exercise before they achieved the established goals. Once an exercise was completed, subjects had to submit a video recording of their performance through the web platform. Once received, the recording was evaluated by the project investigators who marked the exercise on the ASSET scale.27 If the score obtained was equal to or higher than 15, the subject was allowed to move to the next exercise.
2.5 Accessibility of the device
The device was designed so that it would be ready to be printed in 3D using a 3D printer for home use (Ender 3 Pro, Creality, Shenzhen Creality 3D Technology Co., Shenzhen, China). Such printers had to meet the following requirements: (A) price ˂ US$ 300 (B) build platform: 200 mm × 200 mm (C) use of FFF technology (D) use of PLA filaments.
To ensure the device was easy to print, a 3D printer (Ender 3 Pro, Creality, Shenzhen Creality 3D Technology Co., Shenzhen, China) and an Eryone White PLA filament (Eryone, Shenzhen, China) were made available to an independent collaborator (C.M.A) with no previous training in 3D printing, who was also e-mailed the relevant printing files as well as written instructions on how to print the device (Annex A). An assessment was made of the feasibility to print the device at a distance of 60 km with no technical assistance.
The camera used in this study was bought in a conventional internet market and its price was 15 US$. This camera can be found with the keywords “wifi endoscope 3.5” in any marketplace.
The statistical analysis was made with the R-statistics software (R Project®) and differences were considered statistically significant if α = 0.05. The study was approved by the ethics committee of the institution (2021/0457).
3 Results
Seventeen of the 20 subjects, from 8 different hospitals, completed the training program and fulfilled the established criteria. The median overall ASSET score obtained for the whole program was 22 points (IQR 19–25). ASSET score data were non-normally distributed (Shapiro-Wilk p value < 0.001). The ASSET scores obtained are broken down by subject in Table 3 and by exercise in Table 4. The mean number of repetitions for each exercise was 16.62 (SD 4.97 95% CI 15.27–17.97). The data per exercise largely exhibited a normal distribution (Shapiro-Wilk > 0.05). Groups showing a non-normal distribution were all the same reported as normal to facilitate qualitative comparisons with the other exercises. The number of attempts required to successfully complete each exercise is shown in Table 5. Fourteen percent (68 out of 476) of the repetitions required to complete the different exercises were not performed correctly by the subjects and were therefore excluded from the analysis.
The overall score for the program was 9.5 points. The question whether subjects would recommend the course was given a score of 9.5 points, while the one asking whether they would recommend taking this course prior to attending cadaveric workshops obtained the maximum score of 10 points. The question on the applicability of the maneuvers learned to real arthroscopy situations obtained a score of 9 points.
Remote printing and assembly of the device were completed successfully without the need of assistance by investigator C.M.A. The price of the filament needed was 12 US$. Due to the design of the device, after its impression no post-processing neither manipulation was needed. The device is ready to be used after the 3D printing, with no modifications.
4 Discussion
This is the first arthroscopy training program to use a 3D-printed simulator and to arrange its exercises in order of difficulty, recreating basic and articular simulation scenarios in one single model.
Arthroscopic simulators are a key component in any arthroscopy training program.28,29 Such simulators should be introduced after the theoretical instruction modules30,31 and before practical training in cadaveric workshops.9 Higher-level evidence studies in the literature do not warrant the superiority of virtual over physical models,18 and lower-evidence ones are positive about both the former32 and the latter.33 Nonetheless, all of them agree that simulator practice is beneficial to master the learning curve associated with arhtroscopy,14,18,26,32–34 constituting a highly-cost effective tool for orthopedic training centers.17,18
Each exercise was designed to ensure subjects would acquire their arthroscopic skills in a gradual way, with the duration of each exercise allowing for the number of attempts required to successfully complete them to be similar. The difficulty of the different exercises was graded to keep the “complexity gaps” between consecutive exercises equal. Moreover, none of the subjects was unable to obtain the 15 ASSET points required in each of the exercises thanks to the exercises' progressive difficulty and the possibility to advise and tutor subjects remotely.
One of the main advantages of this program is that it is an online open-source practical program where subjects can be tutored by a seasoned surgeon from anywhere in the world (Fig. 2). This is made possible by the streamlined design of the model, which allows adaptation of conventional video cameras to an arthroscopic practice scenario and makes it possible to adjust the size of the practical scenarios to the focal distance of a home camera and the dimensions of a conventional 3D printer. At the present time, when so many restrictions are being imposed on face-to-face instruction, this program offers subjects the possibility of maintaining or upgrading their manual skills from home. It also allows surgeons from the most prestigious institutions in the world to train subjects living thousands of miles away from them in the practical skills required for arthroscopic surgery, which represents an unprecedented opportunity for any young surgeon.
The main limitation of the present study is the absence of an evaluation of the effects that using the program model would have on the subjects' arthroscopic skills when dealing with a cadaveric specimen. Such an assessment is absent from the program because of the current restrictions on organizing face-to-face courses that may allow evaluation of this parameter. These evaluations will be made as soon as it becomes possible. Taking into consideration that some studies have correlated the ASSET scale with arthroscopic-specific scales based on real joints and obtained comparable results,34–36 it is to be expected that the skills acquired in this program may result in an improvement in arthroscopic practice in the real world. Further research will nevertheless be required to demonstrate the veracity of this assumption. To facilitate arthroscopic training in the midst of the COVID-19 pandemic, a decision was made to present the device before determining its effect on cadaveric specimen practice. The main limitation of the device is the need for a 3D printer to be available. Although more and more hospitals are acquiring such devices, there is still a large number of them that do not have them. In addition, it should be pointed out that subjectivity is always a limiting factor when evaluating subjects' skills in studies of this kind. The ASSET scale is however the most commonly used scoring tool in the literature and one of the few ways of objectively evaluating basic arthroscopic skills.26,37–39
5 Conclusion
This is the first structured open-source arthroscopic practice program based on an 3D-printed simulator. It unquestionably raises the accuracy, reproducibility, and accessibility standard in the realm of arthroscopic simulation systems for home use. Far from consisting of only a 3D-printed device, the program also contains clearly defined objectives, which have been evaluated and validated to provide subjects with an accessible and progressive training itinerary that teaches them the basic arthroscopic skills. The programm also allows for the training to be monitored remotely and is the first online structured basic arthroscopic practice simulation program.
Author's contribution
Ferràs-Tarragó J: Term, conceptualization, methodology, software, formal analysis, investigation, resources, supervision, project administration and funding acquisition (self-financing).
Miranda-Gómez I: Term, conceptualization, methodology, formal analysis, data curation, writing and visualization.
Jover-Jorge N: Term, conceptualization, investigation, data curation, writing, review & editing, visualization and project administration.
Financial disclosures
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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