Three-year experience with training courses using a TKA simulator - clinical impact and lessons learned

Introduction of robotic systems and personalized alignment workflows have brought new challenges to Total Knee Arthroplasty (TKA) training. Simulator training is one promising option to reduce decision errors and increase efficiency. The aims of this study were (1) to analyse the effect of simulator training on quality and efficiency at different training courses using a TKA simulator, and (2) to measure the acceptance of simulator training.

Over the last 3 years 35 training courses were performed and 638 surgeons trained on the Knee-CAT simulator (SOS GmbH; Regensburg; Germany). Twenty basic courses and 15 advanced alignment courses were included. All exercises were analysed for decision quality of all bone cuts, soft tissue management and balancing steps as well as for alignment. Every decision within 1 mm/degree of an optimal reference bone cut was rated as green, every decision deviating more than 1 and less than 2mm/degree was rated as yellow and every decision deviating more than 2mm/degree was rated as red. A single red decision was rated as failed exercise. Efficiency was measured by measuring time for each surgical step as well as for the entire procedure. Effect of training was measured by comparing exercise outcome data at the beginning and at the end of the training. Compliance was measured as the number of exercises performed by delegates.

Significant improvements for decision quality (51 %) and efficiency (62 %) were found. This positive effect was found in basic as well as in advanced TKA alignment courses. Only 36-51 % of delegates performed the training exercises at all, demonstrating a rather low compliance rate. However, delegates who completed at least one case, completed all cases in more than 85.

Simulator training is a promising option for robotic and alignment training showing significant increase of decision quality and efficiency. However, a low compliance rate in the training courses has been observed. Future concepts may need to integrate additional training options such as video tutorials and virtual reality (VR) environment. However, proper trainee selection will remain crucial to achieve a higher compliance, as not every conventional TKA surgeon appears to be motivated in transitioning towards personalized robotic TKA surgery.