A Randomized Controlled Pilot Study of Educational Techniques in Teaching Basic Arthroscopic Skills in a Low-Income Country

Document Type : RESEARCH PAPER


1 Harvard Combined Orthopaedics Residency Program, Boston, MA, USA

2 Harvard Medical School, Boston, MA, USA

3 Program in Global Surgery and Social Change, Boston Children’s Hospital, Department of Plastic & Oral Surgery, Boston, MA, USA

4 Brigham and Women’s Hospital, Department of Orthopaedic Surgery, Boston, MA, USA


Background: Little is known about how to introduce complex technologies like arthroscopy into low-income countries. Thus, we compared low- versus high-resource intensive methods of teaching basic arthroscopic skills in a randomized controlled trial in Haiti.
Methods: Forty-eight Haitian orthopaedic surgeons and residents attending an orthopaedic conference in Haiti were block randomized to receive instruction through a composite video (Control) or a composite video plus hands-on teaching with an expert visiting surgeon (Intervention). A low-fidelity surgical simulator tested visualization and triangulation skills. Participants completed a pre- and post-test where the goal was to sequentially tap the most numbers in 2.5 minutes. Outcome metrics included highest tapped number, number of errors, visualization loss, and number of lookdowns.Multivariate linear regression was used to confirm randomization and compare outcomes between groups.
Results: Seventy-five percent of initially randomized attendees participated with similar attrition rates between both groups. All participants who performed a pre-test completed a post-test. In terms of highest tapped number, treatment and control groups significantly improved compared to pre-test scores, with mean improvement of 3.2% (P=0.007) and 2.2% (P=0.03), respectively. Improvement between treatment and control groups was not statistically different (P=0.4). No statistically significant change was seen with regard to other metrics.
Conclusion: We describe a protocol to introduce basic arthroscopic skills in a low-income country using a low-resource intensive teaching method. However, this method of learning may not be optimal given the failure to improve in all outcome measures.


Main Subjects

1. Coughlin RR, Kelly NA, Berry W. Nongovernmental
organizations in musculoskeletal care: Orthopaedics
Overseas. Clin Orthop Relat Res. 2008; 466(10):2438–42.
2. Dormans JP. Orthopaedic surgery in the developing
world--can orthopaedic residents help? J Bone Joint
Surg Am. 2002; 84-A(6):1086–94.
3. Spiegel DA, Gosselin RA, Coughlin RR, Joshipura M,
Browner BD, Dormans JP. The burden of musculoskeletal
injury in low and middle-income countries: challenges
and opportunities. J Bone Joint Surg Am. 2008;
4. Spiegel DA, Gosselin RA, Coughlin RR, Kushner AL,
Bickler SB. Topics in global public health. Clin Orthop
Relat Res. 2008; 466(10):2377–84.
5. Apisarnthanarak A, Wittayachanyapong S, Sitaposa P,
Thongphubeth K, Babcock H, Fraser VJ. Difficulty in
diagnosing surgical site infection after arthroscopy in
developing countries. Infect Control Hosp Epidemiol.
2009; 30(6):609–10.
6. Azubuike SO, Okojie OH. An epidemiological study of
football (soccer) injuries in Benin City, Nigeria. Br J
Sports Med. 2008; 43(5):382–6.
7. Emami Meybodi MK, Ladani MJ, Emami Meybodi
T, Rahimnia A, Dorostegan A, Abrisham J, et al.
Concomitant ligamentous and meniscal knee injuries
in femoral shaft fracture. J Orthop Traumatol. 2013;
8. Chen XZ, Liu CG, Chen Y, Wang LQ, Zhu QZ, Lin P.
Arthroscopy-assisted surgery for tibial plateau
fractures. Arthroscopy. 2015; 31(1):143–53.
9. Sabat D, Jain A, Kumar V. Displaced posterior
cruciate ligament avulsion fractures: a retrospective
comparative study between open posterior approach
and arthroscopic single-tunnel. Arthroscopy. 2016;
10. Parkkinen M, Madanat R, Mäkinen TJ, Mustonen A,
Koskinen SK, Lindahl J. The usefulness of MRI and
arthroscopy in the diagnosis and treatment of softtissue
injuries associated with split-depression
fractures of the lateral tibial condyle. Bone Joint J.2014; 96-B(12):1631–6.
11. Desai MJ, Kamal RN, Richard MJ. Management of
intercarpal ligament injuries associated with distal
radius fractures. Hand Clin. 2015; 31(3):409–16.
12. Yamazaki H, Uchiyama S, Komatsu M, Hashimoto S,
Kobayashi Y, Sakurai T, et al. Arthroscopic assistance
does not improve the functional or radiographic
outcome of unstable intra-articular distal radial
fractures treated with a volar locking plate. Bone Joint
J. 2015; 97-B(7):957–62.
13. Tibor LM, Hoenecke HR Jr. Introducing arthroscopy
to a developing nation: when and how to make it
sustainable. J Bone Joint Surg Am. 2012; 94(2):e8.
14. Bhashyam AR, Fils J, Lowell J, Meara JG, Dyer GS. A
novel approach for needs assessment to build global
orthopedic surgical capacity in a low-income country.
J Surg Educ. 2015; 72(4):e2-8.
15. Braman JP, Sweet RM, Hananel DM, Ludewig PM,
Van Heest AE. Development and validation of a basic
arthroscopy skills simulator. Arthroscopy. 2014;
16. Frank RM, Erickson B, Frank JM, Bush-Joseph CA, Bach BR
Jr, Cole BJ, et al. Utility of modern arthroscopic simulator
training models. Arthroscopy. 2013; 30(1):121–33.
17. Leopold SS, Morgan HD, Kadel NJ, Gardner GC, Schaad
DC, Wolf FM. Impact of educational intervention on
confidence and competence in the performance of
a simple surgical task. J Bone Joint Surg Am. 2005;
18. Ström P, Kjellin A, Hedman L, Johnson E, Wredmark
T, Fellander-Tsai L. Validation and learning in the
Procedicus KSA virtual reality surgical simulator. Surg
Endosc. 2003; 17(2):227–31.
19. Ström P, Kjellin A, Hedman L, Wredmark T, Fellander-
Tsai L. Training in tasks with different visual-spatial
components does not improve virtual arthroscopy
performance. Surg Endosc. 2004; 18(1):115–20.
20. Howells NR, Auplish S, Hand GC, Gill HS, Carr AJ, Rees
JL. Retention of arthroscopic shoulder skills learned
with use of a simulator. Demonstration of a learning
curve and loss of performance level after a time delay.
J Bone Joint Surg Am. 2009; 91(5):1207–13.