A surgical skills training curriculum for PGY-1 residents: AAOS exhibit selection

A Surgical Skills Rotation for Mid-Level Residents

Introduction

The University of Iowa orthopaedic residency previously designed a month-long surgical skill rotation for postgraduate year (PGY)-1 residents. This successful initiative has become a model of interest for other teaching institutions. In addition to the intern year, an important phase in residency occurs during the transition from PGY2 to PGY3, when residents assume greater responsibility and autonomy in leading surgical procedures.

Methods

To directly address this transition and assess residents' readiness, our residency program established a week-long PGY2 surgical skills rotation. This rotation serves as a training checkpoint and focuses on both training and evaluation of level-appropriate skills in joint arthroplasty, trauma, arthroscopy, and wire navigation. The primary objective of the PGY2 surgical skills rotation is to enhance orthopaedic residents' operative skills and experience by providing increased exposure and practice of requisite technical skills. Similar to the Orthopedic In-Training Examinations that assess residents' knowledge, this week-long program, aimed at assessing residents' proficiency in fundamental orthopaedic technical skills, occurs before their PGY3 year.

Results

Faculty-led training and assessment sessions in each area offer residents many opportunities for dedicated practice and improvement. Transferring these acquired skills from the laboratory to the operating room is essential for a training program. To confirm improvement, the final day of the surgical skills rotation was exclusively dedicated to structured performance evaluations, with a specific emphasis on establishing proficiency benchmarks.

Conclusion

We herein describe the University of Iowa's PGY2 surgical skills rotation, providing insights into its development, implementation, and outcomes. By sharing our experience, we offer a framework for other academic departments seeking to optimize surgical skills education and ensure the successful transition of mid-level residents.

A Video Teaching Tool Is Effective for Training Residents in Hip Arthroplasty Templating

Work hour restrictions imposed on orthopedic surgery residents since the early 2000s have reduced educational opportunities at the workplace and encouraged alternative strategies for teaching outside the clinical setting. Preoperative templating is essential for safe and effective total hip arthroplasty (THA) and is accurate in predicting final implants. We sought to determine the effectiveness of a video tool for teaching orthopedic residents basic THA templating skills. We developed a video-based teaching tool with instructions on proper THA templating techniques. Ten cases were selected for testing, after excluding patients with severe hip deformities and poor-quality radiographs and only retaining those with concordance between templating by the senior authors and implanted components. The study subjects included three postgraduate year 1 (PGY-1), three PGY-2, and three PGY-5 residents, and three adult reconstruction fellows (PGY-6). Templating skills were assessed before and after watching the instructional video. The evaluation included the size and positioning of femoral and acetabular components, as well as the restoration of leg length. Each templating session was repeated twice. Variance was measured to evaluate consistency in measurements. A linear mixed model and F-test were used for statistical analyses. The number of years in training significantly affected performance prior to exposure to the instructional video. Post-exposure, there was a significant improvement in the accuracy of sizing and positioning of acetabular and femoral components for PGY-1, PGY-2, and PGY-5 residents. The results achieved were comparable to PGY-6 examiners, who did not gain substantial performance benefits from the instructional video. Limb length restoration was less affected by experience or exposure to the video. Component positioning and sizing, as well as leg length discrepancy (LLD), showed a significant decrease in variance after the intervention in all study groups. Video learning is reliable in teaching invaluable skills to orthopedic surgery residents without encroaching on work hours. We conceived a concise video to train orthopedic residents to perform THA templating with proper technique and demonstrated its efficiency and reproducibility.

Success of Surgical Simulation in Orthopedic Training and Applications in Spine Surgery

STUDY DESIGN

This was a narrative review.

OBJECTIVE

This study aimed to review the current literature on surgical simulation in orthopedics and its application to spine surgery.

SUMMARY OF BACKGROUND DATA

As orthopedic surgery increases in complexity, training becomes more relevant. There have been mandates in the United States for training orthopedic residents the fundamentals of surgical skills; however, few studies have examined the various training options available. Lack of funding, availability, and time are major constraints to surgical simulation options.

METHODS

A PubMed review of the current literature was performed on all relevant articles that examined orthopedic trainees using surgical simulation options. Studies were examined for their thoroughness and application of simulation options to orthopedic surgery.

RESULTS

Twenty-three studies have explored orthopedic surgical simulation in a setting that objectively assessed trainee performance, most in the field of trauma and arthroscopy. However, there was a lack of consistency in measurements made and skills tested by these simulators. There has only been one study exploring surgical simulation in spine surgery.

CONCLUSIONS

While there has been a growing number of surgical simulators to train orthopedic residents the fundamentals of surgical skills, most of these simulators are not feasible, reproducible, or available to the majority of training centers. Furthermore, the lack of consistency in the objective measurements of these studies makes interpretation of their results difficult. There is a need for more simulation in spine surgery, and future simulators and their respective studies should be reproducible, affordable, applicable to the surgical setting, and easily assembled by various programs across the world.

"Virtual" Boot Camp: Orthopaedic Intern Education in the Time of COVID-19 and Beyond

The emergence of COVID-19 as a viral pandemic in early 2020 resulted in notable changes to the daily practice, workflow, and education of orthopaedic residencies internationally. In particular, social distancing, residency restructuring, and redeployment to other services has increased heterogeneity in schedules and made the in-person gathering of trainees for education increasingly challenging. These changes may last until 2024 based on some mathematical models, resulting in notable disruptions to orthopaedic education, especially for junior residents. Therefore, in this study, we describe how we converted our in-person PGY-1 skills course into a "virtual" boot camp based on validated training modules and existing American Board of Orthopaedic Surgeons guidelines. Lessons learned from the experience and potential areas for improvement in the use of newer technology to teach cognitive knowledge and skills modules are highlighted with the hope that this can be useful to other orthopaedic residency programs, during the pandemic and also beyond.

Validity of a Novel Free-Hand Pedicle Screw Placement Training Tool

INTRODUCTION

This study establishes the construct validity of a low-cost training platform designed for high-repetition training of the skills required for fluent use of the five specific tools described for free-hand pedicle screw placement and breach avoidance.

METHODS

A total of 19 participants were included and divided into three groups based on spine surgery experience. Participants were asked to place five pedicle screws into the model. The performance was assessed by recording breaches, technical criteria (0 to 44 points), time to completion, and angulation of the screws. Success (no breaches, no protrusions) frequency (success/time) was calculated and analyzed.

RESULTS

Participants included three spine surgeons, seven advanced trainees (who had placed >10 pedicle screws), and nine inexperienced trainees. None of the screws placed by the spine surgeons breached the pedicle wall. Eight of 35 screws placed by advanced trainees (22.9%) and 31 of 45 screws placed by inexperienced trainees (68.9%) had a pedicle breach. Spine surgeons had a higher median success frequency compared with inexperienced trainees and advanced trainees (P = 0.015). The time needed to place a screw decreased over time (P < 0.0001). There was a trend toward an association between increased training level and decreased time to place five screws (P = 0.076). Increased training level was associated with greater total points scored (P < 0.0001). More screws placed by inexperienced trainees were further away from the ideal pedicle axis compared with those placed by advanced trainees or spine surgeons.

CONCLUSION

An association exists between training level and performance on the pedicle screw model, which suggests construct validity when evaluating our model's use for teaching surgeon learners. The model is easily assembled and is an alternative spine surgery training tool that overcomes limited availability and considerable costs of other training platforms. It can be used in high repetition to establish tool-skill fluency.

LEVEL OF EVIDENCE

Level I.

Identifying Technical Procedures in Orthopaedic Surgery and Traumatology That Should Be Integrated in a Simulation-Based Curriculum: A National General Needs Assessment in Denmark

BACKGROUND

Simulation-based training is emerging within the orthopaedic field to alleviate the challenges that trainees face such as work-hour restrictions, limited exposure to procedures, and increasing pressures to reduce risk to patients. This training modality has grown increasingly popular over the last 2 decades. However, integration into the curriculum often fails to follow a structured educational plan. The development of simulation-based curricula should follow a structured and stepwise approach that starts with a general needs assessment. This study aimed to identify and prioritize procedures within orthopaedic surgery to be included in a simulation-based curriculum on a national basis.

METHODS

A national needs assessment was conducted using the Delphi method. Ninety-five experts who are involved in the training of orthopaedic surgeons from all orthopaedic departments in Denmark were selected to participate in the assessment. Round 1 was a brainstorming phase to identify technical procedures that are relevant for orthopaedic surgeons in training. Round 2 was performed on a departmental basis; it explored the frequency of procedures, the number of surgeons performing each procedure, the risk and/or discomfort to patients, and the feasibility for simulation-based training to prioritize and eliminate some of the procedures that were determined in round 1. During round 3, the experts eliminated and reprioritized procedures from round 2 to produce a final prioritized list.

RESULTS

During the first round, 194 procedures were identified. These were reduced to 62 in round 2, and the final list after round 3 consisted of 33 prioritized procedures that are relevant for simulation-based training in orthopaedic surgery. The response rates were 63 of 95 physicians for round 1, 26 of 26 departments for round 2, and 64 of 97 physicians for round 3. The highest prioritized procedures were basic surgical techniques and principles for osteosynthesis, osteosynthesis of proximal femoral fracture, and surgical exposure of the upper and lower extremities.

CONCLUSIONS

The prioritized list of technical procedures in orthopaedic surgery that are suitable for simulation-based training can aid in the development of a simulation-based curriculum.

CLINICAL RELEVANCE

This article offers insights into needs assessment and curriculum development of simulation-based training in orthopaedic surgery and traumatology.

Evaluating Internal Fixation Skills Using Surgical Simulation

BACKGROUND

Open reduction and internal fixation (ORIF) is an essential skill for an orthopaedic surgeon, yet teaching its components to surgical residents poses challenges in both complexity and cost. Surgical simulation has demonstrated efficacy and is now a mandated component of residency programs, but the techniques and resources required for effective simulation vary greatly. We hypothesized that simulation of ORIF skills could be accomplished in a cost-effective, quantifiable, and reproducible manner and that this experience coupled with didactic learning would increase skill proficiency and enhance ORIF performance.

METHODS

Sixteen postgraduate-year-1 orthopaedic surgery interns were assessed on performance of ORIF simulation tasks before and after attending a module designed to introduce and practice internal fixation techniques. Simulation tasks addressed drilling accuracy via oblique drilling through polyvinyl chloride (PVC) cylinders and bisecting wooden dowels and plunge control via drilling through layered boards of varying densities. Fracture fixation simulation involved fixing oblique fractures on synthetic ulnae. Task performance was assessed at 3 time points: immediately before the module, 1 week after the module, and 3 months after the module. Fracture fixation was assessed before and after the module via load-to-failure testing. Success rates for the tasks were analyzed using a repeated-measures analysis of variance, and mechanical properties of the fixed ulnar constructs were compared using paired t tests.

RESULTS

In all ORIF simulation tasks, pre-module to post-module improvement in success rates was significant (p < 0.001) and improvements were maintained between the post-module assessment and the 3-month follow-up. The interns also achieved significantly greater strengths in their ulnar fixation constructs, with a mean improvement of 256 N (p = 0.01) after the module.

CONCLUSIONS

These results indicate that the technical and sensorimotor skills relevant to internal fixation (with emphasis on the specific skill of using a drill) can be significantly augmented and retained in the short term in surgical residents after exposure to faculty-led lecture and hands-on skills practice using low-cost materials.

CLINICAL RELEVANCE

This study provides evidence for an effective, accessible method of enhancing and assessing surgical skills in training.

A Comprehensive, High-Quality Orthopedic Intern Surgical Skills Program

OBJECTIVES

To design and implement a month-long, low-cost, comprehensive surgical skills curriculum built to address the needs of orthopedic surgery interns with high satisfaction among both interns and faculty.

DESIGN

The study design was retrospective and descriptive.

SETTING

The study was conducted at tertiary care referral center with a medium sized orthopedic residency surgery program (5 residents/year).

PARTICIPANTS

Totally 5 orthopedic surgery residents and 16 orthopedic surgery faculty participated.

RESULTS

A general mission was established-to orient the resident to the postgraduate year 1 and prepare them for success in residency. The basic tenets of the American Board of Orthopaedic Surgeons surgical skills program framework were built. Curricular additions included anatomic study, surgical approaches, joint-specific physical examination, radiographic interpretation, preoperative planning, reduction techniques, basic emergency and operating room procedures, cadaveric procedure practice, and introduction to arthroplasty. The program was held in August during protected time for intern participants. In total, 16 orthopedic surgeons instructed 85% of the educational sessions. One faculty member did most of the preparation and organization to facilitate the program. The program ran for a cumulative 89 hours, including 14.5 hours working with cadaveric specimens. The program cost a total of $8100. The average module received a 4.15 rating on a 5-point scale, with 4 representing "good" and 5 representing "excellent."

CONCLUSIONS

The program was appropriately timed and addressed topics relevant to the intern without sacrificing clinical experience or burdening inpatient services with interns' absence. The program received high satisfaction ratings from both the interns as well as the faculty. Additionally, the program fostered early relationships between interns and faculty-an unforeseen benefit. In the future, our program plans to better integrate validated learning metrics and improve instruction pertaining to both fluoroscopic examination and arthrocentesis.