The impact of COVID-19 on the future of orthopaedic training in the UK

RSTN COVID-19 Hand Recovery: Two years on, where are we now?

Hand surgery services were required to rapidly adapt to the coronavirus disease 2019 (COVID-19). Two years following the initial wave, hand surgery units continue to adapt and recover from the pandemic. The aim of the RSTN COVID-19 Hand Recovery survey was to evaluate what adaptions made to hand surgery services during COVID-19 have been maintained in the COVID recovery phase. A survey was distributed to hand surgery units, across the UK and Ireland. The survey was completed by consultant hand surgeons across 39 hospitals. Most practices returned to pre-pandemic standards. The main changes that endured were the increase in consultant-led triaging for referrals and utilisation of video conferencing platforms for teaching and meetings. Changes made during the pandemic, such as increased use of WALANT, out of theatre operating and use of telemedicine were not sustained during the recovery period. The COVID-19 pandemic allowed the opportunity for hand surgery services to adapt their services. Several changes that were implemented have since been proven to be more efficient and equally effective for patients. However, these changes have not been sustained and the barriers preventing permanent implementation should be scrutinised. We call on hand surgery units to evaluate their current practice to ensure that patients are provided a streamlined and sustainable service.

Dose-response of virtual reality training of paediatric emergencies in a randomised simulation-based setting

AIM

To determine the effect of different virtual reality training intervals on individual performance to facilitate the optimal implementation of medical virtual reality training.

METHODS

Emergency scenarios in virtual reality were performed by 36 medical students from the Medical University of Vienna. After baseline training, the participants were randomised into three groups of equal size and underwent virtual reality training at different time intervals (monthly, one training after 3 months, and no further training) before undergoing final assessment training after 6 months.

RESULTS

Group A, with monthly training exercises, improved their performance score significantly by 1.75 mean score points compared with Group B, who repeated baseline training after 3 months. Statistically significant difference was indicated when comparing Group A with Group C, which was not further trained and served as the control group.

CONCLUSION

One-month intervals are associated with statistically significant performance improvements compared with additional training after 3 months and to a control group without regular training. The results show that training intervals of 3 months or longer are insufficient to achieve high performance scores. Virtual reality training is a cost-effective alternative to conventional simulation-based training for regular practice.

The role of Gender in Operative Autonomy in orthopaedic Surgical Trainees (GOAST)

Aims

Global literature suggests that female surgical trainees have lower rates of independent operating (operative autonomy) than their male counterparts. The objective of this study was to identify any association between gender and lead/independent operating in speciality orthopaedic trainees within the UK national training programme.

Methods

This was a retrospective case-control study using electronic surgical logbook data from 2009 to 2021 for 274 UK orthopaedic trainees. Total operative numbers and level of supervision were compared between male and female trainees, with correction for less than full-time training (LTFT), prior experience, and time out during training (OOP). The primary outcome was the percentage of cases undertaken as lead surgeon (supervised and unsupervised) by UK orthopaedic trainees by gender.

Results

All participants gave permission for their data to be used. In total, 274 UK orthopaedic trainees submitted data (65% men (n = 177) and 33% women (n = 91)), with a total of 285,915 surgical procedures logged over 1,364 trainee-years. Males were lead surgeon (under supervision) on 3% more cases than females (61% (115,948/189,378) to 58% (50,285/86,375), respectively; p < 0.001), and independent operator (unsupervised) on 1% more cases. A similar trend of higher operative numbers in male trainees was seen for senior (ST6 to 8) trainees (+5% and +1%; p < 0.001), those with no time OOP (+6% and +8%; p < 0.001), and those with orthopaedic experience prior to orthopaedic specialty training (+7% and +3% for lead surgeon and independent operator, respectively; p < 0.001). The gender difference was less marked for those on LTFT training, those who took time OOP, and those with no prior orthopaedic experience.

Conclusion

This study showed that males perform 3% more cases as the lead surgeon than females during UK orthopaedic training (p < 0.001). This may be due to differences in how cases are recorded, but must engender further research to ensure that all surgeons are treated equitably during their training.

The Changing Environment in Postgraduate Education in Orthopedic Surgery and Neurosurgery and Its Impact on Technology-Driven Targeted Interventional and Surgical Pain Management: Perspectives from Europe, Latin America, Asia, and The United States

Personalized care models are dominating modern medicine. These models are rooted in teaching future physicians the skill set to keep up with innovation. In orthopedic surgery and neurosurgery, education is increasingly influenced by augmented reality, simulation, navigation, robotics, and in some cases, artificial intelligence. The postpandemic learning environment has also changed, emphasizing online learning and skill- and competency-based teaching models incorporating clinical and bench-top research. Attempts to improve work-life balance and minimize physician burnout have led to work-hour restrictions in postgraduate training programs. These restrictions have made it particularly challenging for orthopedic and neurosurgery residents to acquire the knowledge and skill set to meet the requirements for certification. The fast-paced flow of information and the rapid implementation of innovation require higher efficiencies in the modern postgraduate training environment. However, what is taught typically lags several years behind. Examples include minimally invasive tissue-sparing techniques through tubular small-bladed retractor systems, robotic and navigation, endoscopic, patient-specific implants made possible by advances in imaging technology and 3D printing, and regenerative strategies. Currently, the traditional roles of mentee and mentor are being redefined. The future orthopedic surgeons and neurosurgeons involved in personalized surgical pain management will need to be versed in several disciplines ranging from bioengineering, basic research, computer, social and health sciences, clinical study, trial design, public health policy development, and economic accountability. Solutions to the fast-paced innovation cycle in orthopedic surgery and neurosurgery include adaptive learning skills to seize opportunities for innovation with execution and implementation by facilitating translational research and clinical program development across traditional boundaries between clinical and nonclinical specialties. Preparing the future generation of surgeons to have the aptitude to keep up with the rapid technological advances is challenging for postgraduate residency programs and accreditation agencies. However, implementing clinical protocol change when the entrepreneur-investigator surgeon substantiates it with high-grade clinical evidence is at the heart of personalized surgical pain management.

"It's making me think outside the box at times": a qualitative study of dynamic capabilities in surgical training

Craft specialties such as surgery endured widespread disruption to postgraduate education and training during the pandemic. Despite the expansive literature on rapid adaptations and innovations, generalisability of these descriptions is limited by scarce use of theory-driven methods. In this research, we explored UK surgical trainees' (n = 46) and consultant surgeons' (trainers, n = 25) perceptions of how learning in clinical environments changed during a time of extreme uncertainty (2020/2021). Our ultimate goal was to identify new ideas that could shape post-pandemic surgical training. We conducted semi-structured virtual interviews with participants from a range of working/training environments across thirteen Health Boards in Scotland. Initial analysis of interview transcripts was inductive. Dynamic capabilities theory (how effectively an organisation uses its resources to respond to environmental changes) and its micro-foundations (sensing, seizing, reconfiguring) were used for subsequent theory-driven analysis. Findings demonstrate that surgical training responded dynamically and adapted to external and internal environmental uncertainty. Sensing threats and opportunities in the clinical environment prompted trainers' institutions to seize new ways of working. Learners gained from reconfigured training opportunities (e.g., splitting operative cases between trainees), pan-surgical working (e.g., broader surgical exposure), redeployment (e.g., to medical specialties), collaborative working (working with new colleagues and in new ways) and supervision (shifting to online supervision). Our data foreground the human resource and structural reconfigurations, and technological innovations that effectively maintained surgical training during the pandemic, albeit in different ways. These adaptations and innovations could provide the foundations for enhancing surgical education and training in the post-pandemic era.

COVID-19 Did Not Stop the Rising Tide: Trends in Case Volume Logged by Surgical Residents

INTRODUCTION

The coronavirus pandemic has profoundly impacted all facets of surgical care, including surgical residency training. The objective of this study was to assess the operative experience and overall case volume of surgery residents before and during the pandemic.

METHODS

Using data from the Accreditation Council for Graduate Medical Education annual operative log reports, operative volume for 2015 to 2021 graduates of Accreditation Council for Graduate Medical Education -accredited general, orthopedic, neuro- and plastic surgery residency programs was analyzed using nonparametric Kendall-tau correlation analysis. The period before the pandemic was defined as AY14-15 to AY18-19, and the pandemic period was defined as AY19-20 to AY20-21.

RESULTS

Operative data for 8556 general, 5113 orthopedic, 736 plastic, and 1278 neurosurgery residency graduates were included. Between 2015 and 2021, total case volume increased significantly for general surgery graduates (Kendall's tau-b: 0.905, p = 0.007), orthopedic surgery graduates (Kendall's tau-b: 1.000, p = 0.003), neurosurgery graduates (Kendall's tau-b: 0.905, p = 0.007), and plastic surgery graduates (Kendall's tau-b: 0.810, p = 0.016). Across all specialties, the mean total number of cases performed by residents graduating during the pandemic was higher than among residents graduating before the pandemic, though no formal significance testing was performed. Among general surgery residents, the number of cases performed as surgeon chief among residents graduating in AY19-20 decreased for the first time in 5 years, though the overall volume remained higher than the prior year, and returned to prepandemic trends in AY20-21.

CONCLUSIONS

Over the past 7 years, the case volume of surgical residents steadily increased. Surgical trainees who graduated during the coronavirus pandemic have equal or greater total operative experience compared to trainees who graduated prior to the pandemic.

Effects of the SARS-CoV‑2 pandemic on residency training in orthopedics and traumatology in Germany : A nationwide survey

BACKGROUND

The spread of the coronavirus disease has impacted healthcare systems worldwide; however, restrictions due to the SARS-CoV‑2 (severe acute respiratory syndrome coronavirus 2) pandemic are particularly drastic for physicians in residency training. Imposed restrictions interrupt the standard educational curricula, and consequently limited residents to meet mandatory requirements.

AIM

The aim of this study was to evaluate the effects of the SARS-CoV‑2 pandemic on residency training in orthopedics and trauma surgery in Germany.

METHODOLOGY

An online-based, voluntary, and anonymous survey of physicians in residency training for orthopedics and trauma surgery was conducted. Through email lists of junior physician organizations the survey was sent to 789 physicians. Participation was possible between October and November 2021.

RESULTS

A total of 95 participants (female 41.1%) with a mean age of 31.3 ± 2.8 years were analyzed. In the everyday clinical practice and care 80% of participants thought that they were set back in time of their general training due to the pandemic. There was an average reduction of 25.0% in time spent in the OR and 88.4% agreed that their surgical training was delayed due to the pandemic. Of the respondents 33.6% were able to attend external continuing education courses. Only 4.2% were able to invest more time in research and 55.8% of participants agreed that their residency training will be extended due to the pandemic.

CONCLUSION

The COVID pandemic has had a significant impact on the residency training in orthopedics and trauma surgery in Germany. In almost all areas of training, residents had to accept restrictions due to the imposed restrictions, which potentially negatively affected their training.

Global Impact of the COVID-19 Pandemic on Orthopedics and the Implications of Telemedicine: A Systematic Review of the Literature

This study aimed to systematically review the literature on the impact of the coronavirus disease (COVID-19) pandemic on the orthopedics field by focusing on multiple aspects, including orthopedic training and application, performance, work loading, change of practice, research work, and other psychological factors. Published articles were searched using the PubMed database. Articles were selected in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Of 58 studies published between 1 January 2020 and 1 October 2021, 57 peer-reviewed original articles were included. Nearly 90% of students experienced an impact of the pandemic on application. The impact on training stemmed from redeployment rates of 20.9–23.1%. The rate of emergency or outpatient visits decreased from 18% to 58.6%. The rates of all surgeries or emergency surgeries decreased by 15.6–49.4%, while the rates of elective surgeries decreased by 43.5–100%. The rate of work loading ranged from 33% to 66%. Approximately 50–100% of surgeons had a change of practice. A total of 40.5% of orthopedic surgeons experienced mild psychological pressure. Approximately 64% had stopped research participant recruitment. Most of the included studies were conducted in Europe, followed by Asia and North America. It is suggested orthopedic surgeons prepare more sufficient, flexible, and reservable staffing measures, proper preventive strategies and surgical scheduling algorithms, and set up dedicated venues and equipment for routine telemedicine with staff training for virtual teaching or consultations in case of future impacts on orthopedics.

Impact of the National Lockdown Due to the COVID-19 Pandemic On Upper Limb Trauma Workload in Central London: A Multi-Centre Longitudinal Observational Study During Implementation and Ease of National Lockdown

BACKGROUND

This study assessed the impact of the COVID-19 pandemic on acute upper limb referrals and operative case-mix at the beginning and ease of British lockdown.

METHODS

A longitudinal multicentre observational cohort study was conducted for both upper limb trauma referrals and operative case-mix over a 12-week period (6 weeks from the beginning and 6 weeks from the ease of the national lockdown). Statistical analysis included median (± median absolute deviation), risk and odds ratios, and Fisher's exact test to calculate the statistical significance, set at p ≤ 0.05.

RESULTS

There was a 158% (n = 456 vs. 177) increase in upper limb referrals and 133% (n = 91 vs. 39) increase in the operative trauma caseload at the ease of lockdown compared with its commencement. An increase in sporting injuries was demonstrated (p=0.02), specifically cycling (p=0.004, OR=2.58). A significant increase in COVID-19 testing was demonstrated during the ease of lockdown (p=0.0001) with more patients having their management changed during the beginning of the pandemic (9.6% vs. 0.7%, p=0.0001). Of these patients, 47% went on to have delayed surgery within 6 months. No patients who underwent surgery tested positive for COVID-19 infection within 14 days post-operatively and no mortalities were recorded at 30 days.

CONCLUSION

The ease of lockdown has seen upper limb referrals and operations more than double compared to early lockdown. With no patients testing positive for COVID-19 within 14 days of the procedure, this demonstrates that having upper limb surgery during the current pandemic is safe.

The impact of the COVID-19 pandemic on Polish orthopedics, in particular on the level of stress among orthopedic surgeons and the education process

The Coronovirus Disease 2019 –(COVID-19) pandemic had a significant impact on the health care system and medical staff around the world. The orthopedic units were also subject to new restrictions and regulations. Therefore, the aim of our research was to assess how the COVID-19 pandemic affected orthopedic wards in the last year in Poland. We created an online survey, which was sent to 273 members of the Polish Society of Orthopedics and Traumatology. The survey contained 51 questions and was divided into main sections: Preparedness, Training, Stress, Reduction, Awareness. A total of 80 responses to the survey were obtained. In Preparedness section the vast majority of respondents (90%) replied, that they used personal protective equipment during the pandemic, however only 50% of the respondents indicated that their facility received a sufficient amount of personal protective equipment. Most of the respondents indicated that the pandemic negatively affected the quality of training of future orthopedists (69.4%) and that pandemic has had a negative impact on their operating skills (66,7%). In Reduction section most of the doctors indicated that the number of patients hospitalized in their departments decreased by 20–60% (61,2% respondents), while the number of operations performed decreased by 60–100% (60% respondents). The negative impact of pandemic on education was noticeable especially in the group of young orthopedic surgeons: 0–5 years of work experience (p = 0,029). Among the respondents, the level of stress increased over the last year from 4.8 to 6.9 (p <0.001). The greatest increase in the level of stress was observed among orthopedists working in country hospitals (p = 0,03). In section Awareness 36,3% of respondents feel well or very well informed about the latest Covid-19 regulations. In addition, most doctors (82.6%) believe that the Polish health care system was not well prepared to fight the pandemic and that the regulations applied so far are not sufficient to effectively fight the pandemic (66.2%). The COVID-19 pandemic has impact on orthopedics departments in Poland and negatively affected the quality of training of orthopedic surgeons and the level of stress.

Chronicling the effect of COVID-19 on orthopedic literature

Background

The novel coronavirus disease (COVID-19) has had a significant impact on orthopedic surgery practice, but there has been little investigation of the effects of COVID-19 on the orthopedic surgery literature. Additionally, because orthopedic research plays a vital role in physician education, changes to the characteristics and content of published literature can have lasting impacts on future teaching and learning. This paper represents the first known analysis of the COVID-19 pandemic's impact on peer-reviewed articles published in orthopedic surgery journals.

Methods

The 20 orthopedic journals with the highest impact factors in 2019, according to the Journal Citation Reports, were included in this study. Using PubMed and COVID-19 related keywords as well as manual screening, a final count of 199 articles were assessed for this study and subsequently sorted by country of origin, orthopedic subspecialty, article type, and general theme. Kruskal Wallis and Pearson's Chi-squared tests were used to analyze continuous and categorical variables, respectively.

Results

Fourteen journals published articles relating to COVID-19, representing 26 countries with the United States (37%) and United Kingdom (13%) publishing the greatest proportion of all COVID-19 articles. Sixty percent of publications discussed COVID-19's impact on the overall field of orthopedic surgery, with the remainder focusing on specific subspecialties. Forty-seven percent of publications were original research articles while 46% were editorials or commentaries. The median time to publication for all COVID-19 related articles was 24.5 days, compared to the 129 days reported for orthopedic journals prior to the COVID-19 pandemic (p < 0.001). In the first 100 articles published, 49% (n = 49) originated exclusively from United States institutions, whereas only 25% (n = 25) of the next ninety-nine articles had US-only institutions (p < 0.001).

Conclusions

The COVID-19 pandemic has significantly impacted the characteristics, content, and time to publication of the orthopedic surgery literature. The data and ideas presented in this paper should help streamline future, formal analysis on the lasting implications of COVID-19 on orthopedic surgery practice, teaching, and learning.

Robotics and AI for Teleoperation, Tele-Assessment, and Tele-Training for Surgery in the Era of COVID-19: Existing Challenges, and Future Vision

The unprecedented shock caused by the COVID-19 pandemic has severely influenced the delivery of regular healthcare services. Most non-urgent medical activities, including elective surgeries, have been paused to mitigate the risk of infection and to dedicate medical resources to managing the pandemic. In this regard, not only surgeries are substantially influenced, but also pre- and post-operative assessment of patients and training for surgical procedures have been significantly impacted due to the pandemic. Many countries are planning a phased reopening, which includes the resumption of some surgical procedures. However, it is not clear how the reopening safe-practice guidelines will impact the quality of healthcare delivery. This perspective article evaluates the use of robotics and AI in 1) robotics-assisted surgery, 2) tele-examination of patients for pre- and post-surgery, and 3) tele-training for surgical procedures. Surgeons interact with a large number of staff and patients on a daily basis. Thus, the risk of infection transmission between them raises concerns. In addition, pre- and post-operative assessment also raises concerns about increasing the risk of disease transmission, in particular, since many patients may have other underlying conditions, which can increase their chances of mortality due to the virus. The pandemic has also limited the time and access that trainee surgeons have for training in the OR and/or in the presence of an expert. In this article, we describe existing challenges and possible solutions and suggest future research directions that may be relevant for robotics and AI in addressing the three tasks mentioned above.

Quantifying the impact of the COVID-19 pandemic on orthopaedic trainees: a national perspective

Aims

We aim to objectively assess the impact of COVID-19 on mean total operative cases for all indicative procedures (as outlined by the Joint Committee on Surgical Training (JCST)) experienced by orthopaedic trainees in the deanery of the Republic of Ireland. Subjective experiences were reported for each trainee using questionnaires.

Methods

During the first four weeks of the nationwide lockdown due to COVID-19, the objective impact of the pandemic on each trainee's surgical caseload exposure was assessed using data from individual trainee logbook profiles in the deanery of the Republic of Ireland. Independent predictor variables included the trainee grade (ST 3 to 8), the individual trainee, the unit that the logbook was reported from, and the year in which the logbook was recorded. We used the analysis of variance (ANOVA) test to assess for any statistically significant predictor variables. The subjective experience of each trainee was captured using an electronic questionnaire.

Results

The mean number of total procedures per trainee over four weeks was 36.8 (7 to 99; standard deviation (SD) 19.67) in 2018, 40.6 (6 to 81; SD 17.90) in 2019, and 18.3 (3 to 65; SD 11.70) during the pandemic of 2020 (p = 0.043). Significant reductions were noted for all elective indicative procedures, including arthroplasty (p = 0.019), osteotomy (p = 0.045), nerve decompression (p = 0.024) and arthroscopy (p = 0.024). In contrast, none of the nine indicative procedures for trauma were reduced. There was a significant inter-unit difference in the mean number of total cases (p = 0.029) and indicative cases (p = 0.0005) per trainee. We noted that 7.69% (n = 3) of trainees contracted COVID-19.

Conclusion

During the COVID-19 pandemic, the mean number of operative cases per trainee has been significantly reduced for four of the 13 indicative procedures, as outlined by the JCST. Reassignment of trainees to high-volume institutions in the future may be a plausible approach to mitigate significant training deficits in those trainees worst impacted by the reduction in operative exposure.