Training effect of using Touch Surgery for intramedullary femoral nailing

Comparison of multimodal active learning and single-modality procedural simulation for central venous catheter insertion for incoming residents in anesthesiology: a prospective and randomized study

BACKGROUND

Active learning methods, including low-fidelity simulation, are useful but the incremental learning effect of each method is however limited. We designed this study to assess if combining flipped classroom and the modified Peyton's « 4-steps» method during procedural simulation (intervention group [IG]) would provide better learning results than simulation alone (control group [CG]) in the context of central venous catheter insertion training.

METHODS

This prospective, single-center, and randomized study took place in 2017 in a single simulation center. All first year Anesthesiology residents of Ile de France area at the start of their residency were randomly included either in the IG or CG during a seminar aimed at providing initial procedural skills with low-fidelity simulation. A composite learning score which included knowledge MCQ and a questionnaire assessing satisfaction and value of the training session was recorded after training (primary outcome, /100). A randomized sub-group of learners of each group were video-recorded during central venous catheter insertion at the end of training and their skills were evaluated with validated tools, including a specific checklist and a global rating scale (GRS).

RESULTS

Among 89 anesthesiology residents, 48 and 41 learners were randomized in the intervention and control groups respectively. Of the IG residents, 40/48 (83%) had read the learning material prior to the session. There was no significant difference regarding the composite outcome ([IG]= 81.1 vs [CG] = 80.5 /100 (p = 0.68)). Results of the post-session MCQ knowledge questionnaire were also non-significantly different. Residents were similarly satisfied and described a significant improvement of their knowledge and skills after training. Learners highly valued the training session as a mean to improve their future practice. No significant differences regarding checklist and GRS scores were observed.

CONCLUSIONS

A multimodal active learning strategy of procedural learning did not provide better learning outcomes when compared to a traditional simulation method. In both groups, satisfaction was high and perception of the acquired theoretical and practical knowledge was improved after training.

Virtual Reality in Medical Students' Education: Scoping Review

BACKGROUND

Virtual reality (VR) produces a virtual manifestation of the real world and has been shown to be useful as a digital education modality. As VR encompasses different modalities, tools, and applications, there is a need to explore how VR has been used in medical education.

OBJECTIVE

The objective of this scoping review is to map existing research on the use of VR in undergraduate medical education and to identify areas of future research.

METHODS

We performed a search of 4 bibliographic databases in December 2020. Data were extracted using a standardized data extraction form. The study was conducted according to the Joanna Briggs Institute methodology for scoping reviews and reported in line with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines.

RESULTS

Of the 114 included studies, 69 (60.5%) reported the use of commercially available surgical VR simulators. Other VR modalities included 3D models (15/114, 13.2%) and virtual worlds (20/114, 17.5%), which were mainly used for anatomy education. Most of the VR modalities included were semi-immersive (68/114, 59.6%) and were of high interactivity (79/114, 69.3%). There is limited evidence on the use of more novel VR modalities, such as mobile VR and virtual dissection tables (8/114, 7%), as well as the use of VR for nonsurgical and nonpsychomotor skills training (20/114, 17.5%) or in a group setting (16/114, 14%). Only 2.6% (3/114) of the studies reported the use of conceptual frameworks or theories in the design of VR.

CONCLUSIONS

Despite the extensive research available on VR in medical education, there continue to be important gaps in the evidence. Future studies should explore the use of VR for the development of nonpsychomotor skills and in areas other than surgery and anatomy.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2020-046986.

Cognitive task analysis-based training in surgery: a meta-analysis

BACKGROUND

Reduced hands-on operating experience has challenged the development of complex decision-making skills for modern surgical trainees. Cognitive task analysis- (CTA-)based training is a methodical solution to extract the intricate cognitive processes of experts and impart this information to novices. Its use has been successful in high-risk industries such as the military and aviation, though its application for learning surgery is more recent. This systematic review aims to synthesize the evidence evaluating the efficacy of CTA-based training to enable surgeons to acquire procedural skills and knowledge.

METHODS

The PRISMA guidelines were followed. Four databases, including MEDLINE, EMBASE, Web of Science and Cochrane CENTRAL, were searched from inception to February 2021. Randomized controlled trials and observational studies evaluating the training effect of CTA-based interventions on novices' procedural knowledge or technical performance were included. Meta-analyses were performed using a random-effects model.

RESULTS

The initial search yielded 2205 articles, with 12 meeting the full inclusion criteria. Seven studies used surgical trainees as study subjects, four used medical students and one study used a combination. Surgical trainees enrolled into CTA-based training groups had enhanced procedural knowledge (standardized mean difference (SMD) 1.36 (95 per cent c.i. 0.67 to 2.05), P < 0.001) and superior technical performance (SMD 2.06 (95 per cent c.i. 1.17 to 2.96), P < 0.001) in comparison with groups that used conventional training methods.

CONCLUSION

CTA-based training is an effective way to learn the cognitive skills of a surgical procedure, making it a useful adjunct to current surgical training.

A virtual reality simulator for training the surgical reduction of patient-specific supracondylar humerus fractures

PURPOSE

Virtual reality has been used as a training platform in medicine, allowing the repetition of a situation/scenario as many times as needed and making it patient-specific prior to an operation. Of special interest is the minimally invasive plate osteosynthesis (MIPO). It represents a novel technique for orthopedic trauma surgery, but requires intensive training to acquire the required skills. In this paper, we propose a virtual reality platform for training the surgical reduction of supracondylar fractures of the humerus using MIPO. The system presents a detailed surgical theater where the surgeon has to place the bone fragments properly.

METHODS

Seven experienced users were selected to perform a surgical reduction using our proposal. Two paired humeri were scanned from a dataset obtained from the Complejo Hospitalario de Jaén. A virtual fracture was performed in one side of the pair, using the other as contralateral part. Users have to simulate a reduction for each case and fill out a survey about usability, using a five-option Likert scale.

RESULTS

The subjects have obtained excellent scores in both simulations. The users have notably reduced the time employed in the second experiment, being 60% less in average. Subjects have valued the usability (5.0), the intuitiveness (4.6), comfort (4.5), and realism (4.9) in a 1-5 Likert scale. The mean score of the usability survey was 4.66.

CONCLUSION

The system has shown a high learning rate, and it is expected that the trainees will reach an expert level after additional runs. By focusing on the movement of bone fragments, specialists acquire motor skills to avoid the malrotation of MIPO-treated fractures. A future study can fulfill the requirements needed to include this training system into the protocol of real surgeries. Therefore, we expect the system to increase the confidence of the trainees as well as to improve their decision making.

A review of participant recruitment transparency for sound validation of hip surgery simulators: a novel umbrella approach

Malposition of implants is associated with complications, higher wear and increased revision rates in total hip replacement (THR) along with surgeon inexperience. Training THR residents to reach expert proficiency is affected by the high cost and resource limitations of traditional training techniques. Research in extended reality (XR) technologies can overcome such barriers. These offer a platform for learning, objective skill-monitoring and, potentially, for automated certification. Prior to their incorporation into curricula however, thorough validation must be undertaken. As validity is heavily dependent on the participants recruited, there is a need to review, scrutinise and define recruitment criteria in the absence of pre-defined standards, for sound simulator validation. A systematic review on PubMed and IEEE databases was conducted. Training simulator validation research in fracture, arthroscopy and arthroplasty relating to the hip was included. 46 validation studies were reviewed. It was observed that there was no uniformity in reporting or recruitment criteria, rendering cross-comparison challenging. This work developed Umbrella categories to help prioritise recruitment, and has formulated a detailed template of fields and guidelines for reporting criteria so that, in future, research may come to a consensus as to recruitment criteria for a hip "expert" or "novice".

Effect of Smartphone Laparoscopy Simulator on Laparoscopic Performance in Medical Students

BACKGROUND

This study aims to investigate if a smartphone laparoscopy simulator, SimuSurg, is effective in improving laparoscopic skills in surgically inexperienced medical students.

METHODS

This is a single-blinded randomized controlled trial featuring 30 preclinical medical students without prior laparoscopic simulation experience. The students were randomly allocated to a control or intervention group (n = 15 each) and 28 students completed the study (n = 14 each). All participants performed three validated exercises in a laparoscopic box trainer and repeated them after 1 week. The intervention group spent the intervening time completing all levels in SimuSurg, whereas the control group refrained from any laparoscopic activity. A prestudy questionnaire was used to collect data on age, sex, handedness, and experience with gaming.

RESULTS

The total score improved significantly between the two testing sessions for the intervention group (n = 14, median change [MC] = 182.00, P = 0.009) but not for the control group (n = 14, MC = 161.50, P = 0.08). Scores for the nondominant hand improved significantly in the intervention group (MC = 66.50, P = 0.008) but not in the control group (MC = 9.00, P = 0.98). There was no improvement in dominant hand scores for either the intervention (MC = 62.00, P = 0.08) or control (MC = 26.00, P = 0.32) groups. Interest in surgery (β = -234.30, P = 0.02) was positively correlated with the baseline total scores; however, age, sex, and experience with video games were not.

CONCLUSIONS

The results suggest that smartphone applications improve laparoscopic skills in medical students, especially for the nondominant hand. These simulators may be a cost-effective and accessible adjunct for laparoscopic training among surgically inexperienced students and clinicians.

Virtual Reality and Augmented Reality-Translating Surgical Training into Surgical Technique

PURPOSE OF REVIEW

As immersive learning outside of the operating room is increasingly recognized as a valuable method of surgical training, virtual reality (VR) and augmented reality (AR) are increasingly utilized in orthopedic surgical training. This article reviews the evolving nature of these training tools and provides examples of their use and efficacy. The practical and ethical implications of incorporating this technology and its impact on both orthopedic surgeons and their patients are also discussed.

RECENT FINDINGS

Head-mounted displays (HMDs) represent a possible adjunct to surgical accuracy and education. While the hardware is advanced, there is still much work to be done in developing software that allows for seamless, reliable, useful integration into clinical practice and training. Surgical training is changing: AR and VR will become mainstays of future training efforts. More evidence is needed to determine which training technology translates to improved clinical performance. Volatility within the HMD industry will likely delay advances in surgical training.

Simulation Training in Fracture Surgery

The current surgical training environment has sparked a paradigm shift toward the use of surgical training simulation. An apprentice-based model has historically been used in surgical education, but current financial and practical constraints have led to a more variable training experience. Surgical simulation has demonstrated efficacy in many facets of orthopaedic training and has most recently been implemented to fine-tune surgical skill in reconstruction of traumatic skeletal injuries. Although some surgical skills learned during residency training are not fully used in later practice, most surgeons require a baseline level of competence in managing skeletal trauma. Fracture surgery is heavily dependent on technical skill. Trainee simulation use in skill acquisition has potential to improve proficiency during actual surgery. Furthermore, in a specialty where the standard axiom has been repetition matters, education augmentation with simulation provides overall benefit. Work remains to maximize the effectiveness of surgical simulation in fracture treatment through improved model integration and access.

Using Cognitive Task Analysis to train Orthopaedic Surgeons - Is it time to think differently? A systematic review

Background

Working time restraints; senior led care; and a reduction in 'out of hours' operating has resulted in less operating time for orthopaedic trainees in the United Kingdom. Therefore, there has been an attempt to overcome these challenges by implementing novel techniques. Cognitive Task Analysis (CTA) focuses on the mental steps required to complete complex procedures. It has been used in training athletes and in general surgery but is new to orthopaedic training.

Aim

To undertake a systematic review to analyse if CTA is beneficial to train novice surgeons in common orthopaedic and trauma procedures.

Materials and methods

A systematic review was performed evaluating CTA in trauma and orthopaedic surgery on MEDLINE and EMBASE. Search terms used were: 'Cognitive task', 'mental rehearsal' and 'Orthop*'']. 33 studies were originally identified. Duplicate studies were excluded (11). Articles not relating to Orthopaedic surgery were excluded (15). The CTA research ranking scale was used to evaluate the impact of the studies included.

Results

7 studies were identified as appropriate for inclusion. 264 participants. 178 M, 86F. All studies showed objective or subjective benefits from CTA in orthopaedic training when compared to traditional methods. The majority of the participants highlighted high subjective satisfaction with the use of the CTA tools and reported that they proved to be excellent adjuncts to the traditional apprenticeship model.

Conclusion

CTA learning tools have demonstrated significant objective and subjective benefits in trauma and orthopaedic training. It is cost effective, easily accessible and allows repeated practice which is key in simulation training.

Virtual Reality and Physical Models in Undergraduate Orthopaedic Education: A Modified Randomised Crossover Trial

Background

Orthopaedic surgery is underrepresented in the United Kingdom medical school curriculum, with an average of less than 3 weeks of exposure over the five-year degree. This study evaluates the effectiveness of high-fidelity virtual reality (VR) and physical model simulation in teaching undergraduate orthopaedic concepts.

Methods

A modified randomised crossover trial was used. Forty-nine students were randomly allocated to two groups, with thirty-three finishing the six-week follow-up assessment. All undergraduate medical students were eligible for inclusion. Both groups were given introductory lectures, before completing a pre-test with questions on the principles of fracture fixation and osteotomy. Each group then received a lecture on these topics with the same content, but one was delivered with VR and the other with physical models. Both groups completed the post-course assessments. Knowledge was assessed by way of questionnaire immediately before, immediately after, and six-weeks after.

Results

In the VR group, participants improved their post-training score by 192.1% (U=32; p<0.00001). In the physical models group, participants improved their post-training scores by 163.1% (U=8.5; p<0.00001). Overall, there was no statistically significant difference in the total means of post-training test scores between the VR and the physical models study groups (U=260.5; p=0.4354).

Conclusion

Both VR and physical models represent valuable educational adjuncts for the undergraduate medical curriculum. Both have demonstrated improvements in immediate and long-term knowledge retention of key orthopaedic concepts.

Finding NEEMO: towards organizing smart digital solutions in orthopaedic trauma surgery

There are many digital solutions which assist the orthopaedic trauma surgeon. This already broad field is rapidly expanding, making a complete overview of the existing solutions difficult.The AO Foundation has established a task force to address the need for an overview of digital solutions in the field of orthopaedic trauma surgery.Areas of new technology which will help the surgeon gain a greater understanding of these possible solutions are reviewed.We propose a categorization of the current needs in orthopaedic trauma surgery matched with available or potential digital solutions, and provide a narrative overview of this broad topic, including the needs, solutions and basic rules to ensure adequate use in orthopaedic trauma surgery. We seek to make this field more accessible, allowing for technological solutions to be clearly matched to trauma surgeons' needs. Cite this article: EFORT Open Rev 2020;5:408-420. DOI: 10.1302/2058-5241.5.200021.

Face, content, construct validity and training effect of touch surgery™ as a surgical decision-making trainer for novices in open appendicectomy

BACKGROUND

Laparoscopic surgery has become the gold standard for many operations with significant benefits in morbidity and hospital recovery time. One such procedure is appendicectomy, which is overwhelmingly performed using the laparoscopic approach in the modern era. This has also meant that the number of cases involving traditional open appendicectomy has declined despite surgeons being expected to be able to convert to the open technique if required. One method to rehearse for theatre is the use of software applications. This paper investigates the validity of Touch Surgery™ as an education tool for surgical decision-making for novices, as well as its training effect in open appendicectomy.

METHOD

70 participants will be recruited, consisting of 60 medical students (novices) and 10 surgical consultants (experts). For face, content, and construct validity, first attempt scores on the Touch Surgery™ Open Appendicectomy Test Module will be compared between novices and experts. For the training effect and knowledge decline elements of the study, novices will be further randomised into either the low intervention (control) group who will complete the simulation once, or to the high intervention group who will complete the simulation six times, with both novice groups asked to repeat the test one week later. All participants will also be requested to complete questionnaires regarding the stimulation.

Assessing validity evidence for a serious game dedicated to patient clinical deterioration and communication

Background

A serious game (SG) is a useful tool for nurse training. The objectives of this study were to assess validity evidence of a new SG designed to improve nurses’ ability to detect patient clinical deterioration.

Methods

The SG (LabForGames Warning) was developed through interaction between clinical and pedagogical experts and one developer. For the game study, consenting nurses were divided into three groups: nursing students (pre-graduate) (group S), recently graduated nurses (graduated < 2 years before the study) (group R) and expert nurses (graduated > 4 years before the study and working in an ICU) (group E). Each volunteer played three cases of the game (haemorrhage, brain trauma and obstructed intestinal tract). The validity evidence was assessed following Messick’s framework: content, response process (questionnaire, observational analysis), internal structure, relations to other variables (by scoring each case and measuring playing time) and consequences (a posteriori analysis).

Results

The content validity was supported by the game design produced by clinical, pedagogical and interprofessional experts in accordance with the French nurse training curriculum, literature review and pilot testing. Seventy-one nurses participated in the study: S (n = 25), R (n = 25) and E (n = 21). The content validity in all three cases was highly valued by group E. The response process evidence was supported by good security control. There was no significant difference in the three groups’ high rating of the game’s realism, satisfaction and educational value. All participants stated that their knowledge of the different steps of the clinical reasoning process had improved. Regarding the internal structure, the factor analysis showed a common source of variance between the steps of the clinical reasoning process and communication or the situational awareness errors made predominantly by students. No statistical difference was observed between groups regarding scores and playing time. A posteriori analysis of the results of final examinations assessing study-related topics found no significant difference between group S participants and students who did not participate in the study.

Conclusion

While it appears that this SG cannot be used for summative assessment (score validity undemonstrated), it is positively valued as an educational tool.

Trial registration

ClinicalTrials.gov ID: NCT03092440

The learning curves of a validated virtual reality hip arthroscopy simulator

INTRODUCTION

Decreases in trainees' working hours, coupled with evidence of worse outcomes when hip arthroscopies are performed by inexperienced surgeons, mandate an additional means of training. Though virtual reality simulation has been adopted by other surgical specialities, its slow uptake in arthroscopic training is due to a lack of evidence as to its benefits. These benefits can be demonstrated through learning curves associated with simulator training-with practice reflecting increases in validated performance metrics.

METHODS

Twenty-five medical students with no previous experience of hip arthroscopy completed seven weekly simulated arthroscopies of a healthy virtual hip joint using a 70° arthroscope in the supine position. Twelve targets were visualised within the central compartment, six via the anterior portal, three via the anterolateral portal and three via the posterolateral portal. Task duration, number of collisions (bone and soft-tissue), and distance travelled by arthroscope were measured by the simulator for every session of each student.

RESULTS

Learning curves were demonstrated by the students, with improvements in time taken, number of collisions (bone and soft-tissue), collision length and efficiency of movement (all p < 0.01). Improvements in time taken, efficiency of movement and number of collisions with soft-tissue were first seen in session 3 and improvements in all other parameters were seen in session 4. No differences were found after session 5 for time taken and length of soft-tissue collision. No differences in number of collisions (bone and soft-tissue), length of collisions with bone, and efficiency of movement were found after session 6.

CONCLUSIONS

The results of this study demonstrate learning curves for a hip arthroscopy simulator, with significant improvements seen after three sessions. All performance metrics were found to improved, demonstrating sufficient visuo-haptic consistency within the virtual environment, enabling individuals to develop basic arthroscopic skills.

Profile of Educational Technology Use by Medical Students and Evaluation of a New Mobile Application Designed for the Study of Human Physiology

Nowadays, smartphones represent an invaluable tool to access educational material; however, the available information is not always accurate or evidence-based. Therefore, we aimed to evaluate the use of technology by medical students and assess the effect of a newly developed mobile app for the study of human physiology. We used a standardised questionnaire to assess the profile of educational technology use, from which a mobile app (PhysioQuiz) was developed. The effectiveness and user opinion were assessed in a randomised controlled study (n = 110). Of 1022 students enrolled in medical school, 489 (47.9%) participated in the study. Of the respondents, 96.7% used mobile applications, with the main purpose being entertainment (94.7%) and study (81.9%). Only 6.1% reported use of physiology apps. PhysioQuiz use did not yield higher average grades (p = 0.48); however, user opinion demonstrated that it was useful for assisted learning (82.1%) and identification of non-learned content (78.6%) and considered a tool for self-assessment (89.3%). Mobile app use is widespread among medical students but there is a lack of human physiology education apps. A newly developed app for the study of human physiology was useful for assisted learning and considered a tool for self-assessment.

Touch Surgery: Analysis and Assessment of Validity of a Hand Surgery Simulation "App"

BACKGROUND

Surgical educators are increasingly exploring surgical simulation and other nonclinical teaching adjuncts in the education of trainees. The simulators range from purpose-built machines to inexpensive smartphone or tablet-based applications (apps). This study evaluates a free surgery module from one such app, Touch Surgery, in an effort to evaluate its validity and usefulness in training for hand surgery procedures across varied levels of surgical experience.

METHODS

Participants were divided into 3 cohorts: fellowship-trained hand surgeons, orthopedic surgery residents, and medical students. Participants were trained in the use of the Touch Surgery app. Each participant completed the Carpal Tunnel Release module 3 times, and participants' score was recorded for each trial. Participants also completed a customized Likert survey regarding their opinions on the usefulness and accuracy of the app. Statistical analysis using a 2-tailed t test and analysis of variance was performed to evaluate for performance within and between cohorts.

RESULTS

All cohorts performed better on average with each subsequent simulation attempt. For all attempts, the experts outperformed the novice and intermediate participants, while the intermediate cohort outperformed the novice cohort. Novice users consistently gave the app better scores for usefulness as a training tool, and demonstrated more willingness to use the product.

CONCLUSIONS

The study confirms app validity and usefulness by demonstrating that every cohort's simulator performance improved with consecutive use, and participants with higher levels of training performed better. Also, user confidence in this app's veracity and utility increased with lower levels of training experience.

A Randomized Controlled Trial of Skills Transfer: From Touch Surgery to Laparoscopic Cholecystectomy

BACKGROUND

Surgical training has traditionally involved teaching trainees in the operating room. However, intraoperative training is time-intensive and exposes patients to greater risks. Touch Surgery (TS) is an application that uses animation to provide simulation training via cognitive task analysis as an adjunct to intraoperative training.

METHODS

Forty students were recruited and randomly allocated to either a control or intervention group. Each group received the same preparation before intervention, including a 10-min introduction to laparoscopic equipment and a 15-min educational tutorial on laparoscopic cholecystectomies. The participants then received training via either TS (intervention) or written information (control). Their performance was compared using a validated scoring tool on a porcine laparoscopic cholecystectomy model. Significance was defined as P < 0.050.

RESULTS

In total, n = 22 and n = 18 participants were randomly assigned to intervention and control groups, respectively. There was no significant difference between age (P = 0.320), year of medical school (P = 0.322), handedness (P = 1.000), or gender (P = 0.360) of the groups. The overall mean performance score was higher for intervention (mean ± SD = 41.9 ± 22.5) than control (mean ± SD = 24.7 ± 19.6; P = 0.016). There was no significant difference between scores for each intraoperative segment between the intervention and control group (P > 0.050).

CONCLUSIONS

This study demonstrates that TS is effective for providing cognitive training in laparoscopic cholecystectomies to medical students. It is likely that this effect will be seen across modules and other platforms that use cognitive task analysis alongside high-fidelity animation. Further work is necessary to extend this to other surgical procedures for evaluating its longitudinal effectiveness.

Evaluation of App-Based Serious Gaming as a Training Method in Teaching Chest Tube Insertion to Medical Students: Randomized Controlled Trial

BACKGROUND

The insertion of a chest tube should be as quick and accurate as possible to maximize the benefit and minimize possible complications for the patient. Therefore, comprehensive training and assessment before an emergency situation are essential for proficiency in chest tube insertion. Serious games have become more prevalent in surgical training because they enable students to study and train a procedure independently, and errors made have no effect on patients. However, up-to-date evidence regarding the effect of serious games on performance in procedures in emergency medicine remains scarce.

OBJECTIVE

The aim of this study was to investigate the serious gaming approach in teaching medical students an emergency procedure (chest tube insertion) using the app Touch Surgery and a modified objective structural assessment of technical skills (OSATS).

METHODS

In a prospective, rater-blinded, randomized controlled trial, medical students were randomized into two groups: intervention group or control group. Touch Surgery has been established as an innovative and cost-free app for mobile devices. The fully automatic software enables users to train medical procedures and afterwards self-assess their training effort. The module chest tube insertion teaches each key step in the insertion of a chest tube and enables users the meticulous application of a chest tube. In contrast, the module "Thoracocentesis" discusses a basic thoracocentesis. All students attended a lecture regarding chest tube insertion (regular curriculum) and afterwards received a Touch Surgery training lesson: intervention group used the module chest tube insertion and the control group used Thoracocentesis as control training. Participants' performance in chest tube insertion on a porcine model was rated on-site via blinded face-to-face rating and via video recordings using a modified OSATS tool. Afterwards, every participant received an individual questionnaire for self-evaluation. Here, trainees gave information about their individual training level, as well as previous experiences, gender, and hobbies. Primary end point was operative performance during chest tube insertion by direct observance.

RESULTS

A total of 183 students enrolled, 116 students participated (63.4%), and 21 were excluded because of previous experiences in chest tube insertion. Students were randomized to the intervention group (49/95, 52%) and control group (46/95, 48%). The intervention group performed significantly better than the control group (Intervention group: 38.0 [I₅₀=7.0] points; control group: 30.5 [I₅₀=8.0] points; P<.001). The intervention group showed significantly improved economy of time and motion (P=.004), needed significantly less help (P<.001), and was more confident in handling of instruments (P<.001) than the control group.

CONCLUSIONS

The results from this study show that serious games are a valid and effective tool in education of operative performance in chest tube insertion. We believe that serious games should be implemented in the surgical curriculum, as well as residency programs, in addition to traditional learning methods.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) DRKS00009994; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00009994 (Archived by Webcite at http://www.webcitation.org/6ytWF1CWg).

Does virtual reality simulation have a role in training trauma and orthopaedic surgeons?

Aims

The aim of this study was to assess the current evidence relating to the benefits of virtual reality (VR) simulation in orthopaedic surgical training, and to identify areas of future research.

Materials and Methods

A literature search using the MEDLINE, Embase, and Google Scholar databases was performed. The results' titles, abstracts, and references were examined for relevance.

Results

A total of 31 articles published between 2004 and 2016 and relating to the objective validity and efficacy of specific virtual reality orthopaedic surgical simulators were identified. We found 18 studies demonstrating the construct validity of 16 different orthopaedic virtual reality simulators by comparing expert and novice performance. Eight studies have demonstrated skill acquisition on a simulator by showing improvements in performance with repeated use. A further five studies have demonstrated measurable improvements in operating theatre performance following a period of virtual reality simulator training.

Conclusion

The demonstration of 'real-world' benefits from the use of VR simulation in knee and shoulder arthroscopy is promising. However, evidence supporting its utility in other forms of orthopaedic surgery is lacking. Further studies of validity and utility should be combined with robust analyses of the cost efficiency of validated simulators to justify the financial investment required for their use in orthopaedic training. Cite this article: Bone Joint J 2018;100-B:559-65.

Using Touch Surgery to Improve Surgical Education in Low- and Middle-Income Settings: A Randomized Control Trial

BACKGROUND/OBJECTIVE

There is a severe surgical workforce shortage in Rwanda. Innovative educational tools must be introduced to train more residents and increase surgical capacity. Touch Surgery (TS) is a smartphone application that offers trainees the opportunity to practice operations; however, its effect is unknown in low- and middle-income countries. Our objectives were to determine the training effect of TS and its feasibility for use in surgery education in a low-resource setting.

DESIGN

We performed a randomized control trial of University of Rwanda surgical residents. Participants were blocked by postgraduate year and randomized to textbook or TS for learning tendon repair surgical technique. After the learning period, participants performed a tendon repair simulation, evaluated by blinded expert raters. Presimulation and postsimulation questionnaires tested their knowledge of tendon repair.

SETTING

The study was conducted at the simulation center of the University Teaching Hospital of Kigali, a tertiary referral and teaching hospital.

PARTICIPANTS

The study included University of Rwanda surgery residents. A total 27 of 51 surgery residents (52.94%) were enrolled. Participating residents represented the following specialties: general surgery (51.85%), orthopedics (40.74%), and urology (7.41%).

RESULTS

TS users scored 89.7% on tendon repair simulation, compared to textbook users who scored 63.4% (p < 0.001). Postsimulation questionnaires showed a significant improvement in cognitive scores for TS users (38.6%, p < 0.001), as compared to nonsignificant improvement for textbook users (15.9%, p = 0.304). About 92.3% of TS users reported that TS represents a useful training tool, and 61.5% reported that it would be a good or very good required part of the curriculum.

CONCLUSIONS

TS is a useful tool to improve both technical skills and knowledge of tendon repair procedure steps; however, its role may be limited to a supplemental tool as it does not improve the theoretical knowledge. TS has the potential to be implemented in a surgical academic curriculum in low- and middle-income countries.

A pilot study to assess the utility of a freely downloadable mobile application simulator for undergraduate clinical skills training: a single-blinded, randomised controlled trial

BACKGROUND

Medical simulators offer an invaluable educational resource for medical trainees. However, owing to cost and portability restrictions, they have traditionally been limited to simulation centres. With the advent of sophisticated mobile technology, simulators have become cheaper and more accessible. Touch Surgery is one such freely downloadable mobile application simulator (MAS) used by over one million healthcare professionals worldwide. Nevertheless, to date, it has never been formally validated as an adjunct in undergraduate medical education.

METHODS

Medical students in the final 3 years of their programme were recruited and randomised to one of three revision interventions: 1) no formal revision resources, 2) traditional revision resources, or 3) MAS. Students completed pre-test questionnaires and were then assessed on their ability to complete an undisclosed male urinary catheterisation scenario. Following a one-hour quarantined revision period, all students repeated the scenario. Both attempts were scored by allocation-blinded examiners against an objective 46-point mark scheme.

RESULTS

A total of 27 medical students were randomised (n = 9 per group). Mean scores improved between baseline and post-revision attempts by 8.7% (p = 0.003), 19.8% (p = 0.0001), and 15.9% (p = 0.001) for no resources, traditional resources, and MAS, respectively. However, when comparing mean score improvements between groups there were no significant differences.

CONCLUSIONS

Mobile simulators offer an unconventional, yet potentially useful adjunct to enhance undergraduate clinical skills education. Our results indicate that MAS's perform comparably to current gold-standard revision resources; however, they may confer significant advantages in terms of cost-effectiveness and practice flexibility.

TRIAL REGISTRATION

Not applicable.

Current Status of Simulation-based Training Tools in Orthopedic Surgery: A Systematic Review

OBJECTIVE

To conduct a systematic review of orthopedic training and assessment simulators with reference to their level of evidence (LoE) and level of recommendation.

DESIGN

Medline and EMBASE library databases were searched for English language articles published between 1980 and 2016, describing orthopedic simulators or validation studies of these models. All studies were assessed for LoE, and each model was subsequently awarded a level of recommendation using a modified Oxford Centre for Evidence-Based Medicine classification, adapted for education.

RESULTS

A total of 76 articles describing orthopedic simulators met the inclusion criteria, 47 of which described at least 1 validation study. The most commonly identified models (n = 34) and validation studies (n = 26) were for knee arthroscopy. Construct validation was the most frequent validation study attempted by authors. In all, 62% (47 of 76) of the simulator studies described arthroscopy simulators, which also contained validation studies with the highest LoE.

CONCLUSIONS

Orthopedic simulators are increasingly being subjected to validation studies, although the LoE of such studies generally remain low. There remains a lack of focus on nontechnical skills and on cost analyses of orthopedic simulators.

Validation of a Novel Cognitive Simulator for Orbital Floor Reconstruction

PURPOSE

The increasing focus on patient safety in current medical practice has promoted the development of surgical simulation technology in the form of virtual reality (VR) training designed largely to improve technical skills and less so for nontechnical aspects of surgery such as decision making and material knowledge. The present study investigated the validity of a novel cognitive VR simulator called Touch Surgery for a core maxillofacial surgical procedure: orbital floor reconstruction (OFR).

MATERIALS AND METHODS

A cross-sectional study was carried out on 2 groups of participants with different experience levels. Novice graduate dental students and expert surgeons were recruited from a local dental school and academic residency programs, respectively. All participants completed the OFR module on Touch Surgery. The primary outcome variable was simulator performance score. Post-module questionnaires rating specific aspects of the simulation experience were completed by the 2 groups and served as the secondary outcome variables. The age and gender of participants were considered additional predictor variables. From these data, conclusions were made regarding 3 types of validity (face, content, and construct) for the Touch Surgery simulator. Dependent-samples t tests were used to explore the consistency in simulation performance scores across phases 1 and 2 by experience level. Two multivariate ordinary least-squares regression models were fit to estimate the relation between experience and phase 1 and 2 scores.

RESULTS

Thirty-nine novices and 10 experts who were naïve to Touch Surgery were recruited for the study. Experts outperformed novices on phases 1 and 2 of the OFR module (P < .001), which provided the measurement of construct validation. Responses to the questionnaire items used to assess face validity were favorable from the 2 groups. Positive questionnaire responses also were recorded from experts alone on items assessing the content validity for the module. Participant age and gender were not relevant predictors of performance scores.

CONCLUSION

Construct, content, and face validities were observed for the OFR module on a novel cognitive simulator, Touch Surgery. Therefore, OFR simulation on the smart device platform could serve as a useful cognitive training and assessment tool in maxillofacial surgery residency programs.