Effect of Training Modules on Hip Fracture Surgical Skills Simulation Performance: Early Validation of the AAOS/OTA Simulator

Can an Orthopedic Hip Fracture Simulator Advance Orthopedic Residents' Hip Fracture Fixation Skills to an Expert Level?

OBJECTIVE

This study was undertaken to evaluate hip fracture simulator training and orthopedic resident skill attainment. We hypothesized that after 6 training sessions, improvement in post-training scores in junior residents would exceed that of senior residents and that senior residents would attain expert level proficiency sooner.

DESIGN

Thirty orthopedic residents from a single institution completed 6 training sessions. Sessions included a pretest, 9 training modules, and post-test. An expert score was obtained from the average scores of 8 trauma fellows and attending orthopedic traumatologists. The primary outcome measure was overall score.

SETTING

A single academic institution.

PARTICIPANTS

Orthopedic residents (postgraduate years [PGYs] 1-5).

RESULTS

Twenty-six residents completed the study. The mean overall post-training score was 87% of the expert level. Factors associated with post-training score changes were additional training sessions (4.2% improvement [p < 0.01]), time between training sessions (0.3% decrease [p = 0.05]) and PGY5 class (12.1% improvement [p = 0.03]). Fifty-four percent of residents attained the expert overall score. Expert score attainment was not associated with an additional year of training or case log volume. Post-training scores plateaued for the PGY1s and showed linear improvement for the PGY5s.

CONCLUSIONS

Differences in trends between training levels suggest this simulator is a useful adjunct to a 5-year orthopedic residency training program.

Can a Computer-based Force Feedback Hip Fracture Skills Simulator Improve Clinical Task Performance? A Cadaveric Validation Study

BACKGROUND

This cadaveric study seeks to determine whether skills acquired on the simulator translate to improved performance of the clinical task. We hypothesized that completion of simulator training modules would improve performance of percutaneous hip pinning.

METHODS

Eighteen right-handed medical students from two academic institutions were randomized: trained (n = 9) and untrained (n = 9). The trained group completed nine simulator-based modules of increasing difficulty, designed to teach techniques of placing wires in an inverted triangle construct in a valgus-impacted femoral neck fracture. The untrained group had a brief simulator introduction but did not complete the modules. Both groups received a hip fracture lecture, an explanation and pictorial reference of an inverted triangle construct, and instruction on using the wire driver. Participants then placed three 3.2 mm guidewires in cadaveric hips in an inverted triangle construct under fluoroscopy. Wire placement was evaluated with CT at 0.5 mm sections.

RESULTS

The trained group significantly outperformed the untrained group in most parameters (P ≤ 0.05).

CONCLUSIONS

The results suggest that a force feedback simulation platform with simulated fluoroscopic imaging using an established, increasingly difficult series of motor skills training modules has potential to improve clinical performance and might offer an important adjunct to traditional orthopaedic training.

Procedural simulation training in orthopaedics and traumatology: Nationwide survey among surgeon educators and residents in France

BACKGROUND

Simulation is among the tools used in France to train residents specialising in orthopaedic and trauma surgery (OTS). However, implementing simulation-based training (SBT) is complex and poorly reported. The objective of this study was to describe the use of simulation for OTS training in France.

HYPOTHESIS

Nationwide, SBT is not used to its full capacity for teaching OTS in France, and differences in opinions about SBT may exist between surgeon educators and residents.

STUDY DESIGN

Nationwide questionnaire survey in France.

MATERIALS AND METHODS

We built two specific self-questionnaires then e-mailed them between December 2020 and February 2021 to the surgeon educators who were members of the national university council and to the residents specialising in OTS during the current academic year. The questions were about the 2018-2019 academic year, before the COVID-19 pandemic. Two classes of residents who were still medical students during this period were not included, leaving three classes for the analysis.

RESULTS

The participation rates were 57% (67/117) for the educators and 24% (87/369) for the three classes of residents. Of the 67 educators, 47 (70%) reported being involved in SBT and identified the university (70%) and industry (53%) as the main funders of this teaching modality. The educators indicated that the mean number of SBT laboratories in their region was 1.4±0.9 (range, 0-4). The main types of simulators were saw bones (77%); cadavers (85%); and commercial simulators (74%), notably for the knee (87%) and shoulder (78%). The educators estimated that they had achieved a mean of 33%±23% (range, 0%-100%) of the teaching objectives set out in the OTS curriculum and that the main obstacles were insufficient funding (81%) and lack of time (67%). Only 21% of educators reported conducting SBT research. The residents reported that they accessed SBT via the OTS teaching module (28/87, 32%), local university degrees (23/87, 26%), their hospital department (17/87, 18%), or the industry (15/87, 17%); 25/87 (29%) had never received SBT. On a 0-10 scale (0, completely disagrees; 10, completely agrees), the mean score for SBT effectiveness was 8.6±2.1 for residents and 7.1±3.0 for educators (p<0.001); the corresponding values for the quality of SBT integration in the region were 1.5±1.8 and 3.8±2.6, respectively (p<0.001).

CONCLUSION

SBT is not yet used to its full potential for teaching OTS in France. Insufficient funding and lack of time were identified by the educators as the main obstacles to greater use of SBT. Both the residents and the educators felt that SBT mightbe beneficial for training.

LEVEL OF EVIDENCE

IV, nationwide survey.

A Review of Orthopaedic Resident Case Logs to Identify Fluctuations in Exposure to Adult Orthopaedic Procedures

INTRODUCTION

Orthopaedic surgery resident case exposure is an important component of surgical training and is monitored by the Accreditation Council for Graduate Medical Education (ACGME) to ensure resident readiness for graduation. The purpose of this study was to investigate trends in exposure to adult orthopaedic surgical procedures and analyze the impact of the 2013 update in ACGME case logging expectations.

METHODS

A retrospective review of ACGME case log data was conducted for adult orthopaedic procedures performed by graduating orthopaedic surgery residents from 2012 to 2020. Trends in the number of cases logged and the case share by anatomical location were investigated. Linear regression analysis was performed to analyze changes in case number over the 9-year period.

RESULTS

For all surgical categories, there was stability in the average case number per resident from 2012 to 2013, followed by a precipitous decrease from 2013 to 2014. From 2014 to 2020, there has been a gradual increase in case number for all categories except "other musculoskeletal (MSK)," resulting in a total 46% recovery since the 2014 decline. Concomitant with the decline, there was a relative increase in pelvis/hip and femur/knee procedures and decrease in shoulder, other MSK, and spine procedures. From 2014 to 2020, shoulder, humerus/elbow, pelvis/hip, leg/ankle, foot/toes, and spine cases have gradually accounted for a larger proportion of total cases while femur/knee and "other MSK" cases have accounted for less.

CONCLUSIONS

The 2013 update in ACGME case logging expectations was associated with a significant decrease in case number. This is likely a reflection of residents correctly entering 1 primary Current Procedural Terminology code for each surgical case. Programs should be aware of a general increase in case number since 2014 and acknowledge the fact that some procedure types may be given priority from a logging standpoint when multiple Current Procedural Terminology codes apply.

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".

Life Long Learning: The Attending and Educator in Orthopedic Trauma

As effective surgeon educators, we must seek continual improvement, to be "better today than I was yesterday." This pursuit of personal and professional development requires self-awareness of a guiding purpose, and grit, the passion and perseverance to achieve long-term goals. Surgical training draws on an apprenticeship model, where progressive transfer of knowledge, responsibility, and autonomy occurs over time as trainees work with experienced surgeons. Educators should model personal responsibility and technical excellence and require both of their trainees. While training programs shift towards competency-based learning, educators must remember that we shape learners with the "hidden curriculum" and not just the facts we teach them.

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.