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PURPOSE: To objectively investigate the transfer validity of simulation training using wireless elbow-worn motion sensors intraoperatively to assess whether surgical simulation leads to improvements in intraoperative arthroscopic performance. METHODS: In this randomized controlled trial, postgraduate year 2 to 3 trainees in nationally approved orthopaedic surgery posts were randomized to standard junior residency training (control group) or standard training plus additional weekly simulation training (intervention group). Both groups performed a supervised real-life diagnostic knee arthroscopy in the operating room at 13 weeks. Performance was measured using wireless elbow-worn motion sensors recording objective surgical performance metrics: number of hand movements, smoothness, and time taken. A participant-supervisor performance ratio was used to adjust for variation in case mix and difficulty. The study took place in a surgical simulation suite and the orthopaedic operating rooms of a university teaching hospital. RESULTS: The intervention group objectively outperformed the control group in all outcome metrics. Procedures performed by the intervention group required fewer hand movements (544 [interquartile range (IQR), 465-593] vs 893 [IQR, 747-1,242]; P < .001), had smoother movements (25,842 ms-3 [IQR, 20,867-27,468 ms-3] vs 36,846 ms-3 [IQR, 29,840-53,949 ms-3]; P < .001), and took less time (320 seconds [IQR, 294-392 seconds] vs 573 seconds [IQR, 477-860 seconds]; P < .001) than those performed by the control group. The cases were comparable between the groups. Standardized to the supervisor's performance, the intervention group required fewer hand movements (1.9 [IQR, 1.5-2.1] vs 3.3 [IQR, 2.2-4.8]; P = .0091), required less time (1.2 [IQR, 1.1-1.7] vs 2.6 [IQR, 1.6-3.0]; P = .0037), and were smoother (2.1 [IQR, 1.8-2.8] vs 4.3 [IQR, 2.8-5.4]; P = .0037) than the control group, but they did not perform as well as their supervisors. CONCLUSIONS: This study uses intraoperative motion-analysis technology to objectively show that surgical simulation training improves actual intraoperative technical skills performance. CLINICAL RELEVANCE: The described wireless objective assessment method complements the subjective observational performance assessments commonly used. Further studies are required to assess how these measures of intraoperative performance correlate to patient outcomes. Intraoperative motion analysis is translatable across surgical specialties, offering potential for objective assessment of progression through competency-based training, revalidation, and talent selection for specialist training.

Original publication




Journal article



Publication Date





1197 - 1209.e1