Validity of a Novel Digitally Enhanced Skills Training Station for Freehand Distal Interlocking

Digitally enhanced hands-on surgical training (DEHST) enhances the performance during freehand nail distal interlocking

PURPOSE

Freehand distal interlocking of intramedullary nails remains a challenging task. Recently, a new training device for digitally enhanced hands-on surgical training (DEHST) was introduced, potentially improving surgical skills needed for distal interlocking.

AIM

To evaluate whether training with DEHST enhances the performance of novices (first-year residents without surgical experience in freehand distal nail interlocking).

METHODS

Twenty novices were randomly assigned to two groups and performed distal interlocking of a tibia nail in mock operation under operation-room-like conditions. Participants in Group 1 were trained with DEHST (five distal interlocking attempts, 1 h of training), while those in Group 2 did not receive training. Time, number of X-rays shots, hole roundness in the X-rays projection and hit rates were compared between the groups.

RESULTS

Time to complete the task [414.7 s (range 290-615)] and X-rays exposure [17.8 µGcm2 (range 9.8-26.4)] were significantly lower in Group 1 compared to Group 2 [623.4 s (range 339-1215), p = 0.041 and 32.6 µGcm2 (range 16.1-55.3), p = 0.003]. Hole projections were significantly rounder in Group 1 [95.0% (range 91.1-98.0) vs. 80.8% (range 70.1-88.9), p < 0.001]. In Group 1, 90% of the participants achieved successful completion of the task in contrast to a 60% success rate in Group 2. This difference was not statistically significant (p = 0.121).

CONCLUSIONS

In a mock-operational setting, training with DEHST significantly enhanced the performance of novices without surgical experience in distal interlocking of intramedullary nails and hence carries potential to improve safety and efficacy of this important and demanding surgical task to steepen the learning curve without endangering patients.

LEVEL OF EVIDENCE

II.

Windshield Wiper Effect in Human Bone-Peri-Implant Benign Diaphyseal Expansile Lesion with Humerus Shaft Fracture Non-Union with Implant in situ - Case Report

Introduction

Humerus shaft fractures account for 3% of all adult fractures. Union rate after surgical management is around 84-97% with no difference between compression plating and intramedullary (IM) nailing. Non-union of humeral shaft fracture is not unusual complication of both conservative and operative treatment. IM nailing has been known to have several benefits from its relative stability with minimal soft-tissue dissection but with drawbacks such as less perfect reduction with higher risk of distraction, inability to take down interpositional tissue, risk of radial nerve injury and technical difficulty to pass guide wire and locking of nail. Many methods have been described for nonunion of humeral fracture with good results. However, treatment of a long-standing nonunion of the humerus with bone defect is challenging, as it may be complicated by broken implants. Very less research documented for long standing nonunion of humeral bone with diaphyseal bone defect.

Case Report

We report a case report of middle-aged female who suffered a closed traumatic humeral shaft fracture which was managed with open reduction and fixation with IM nailing with some distraction and distal locking screw missing the nail making it an unstable construct traditionally called Wind shield, wiper effect was noticed in this patient and was the cause of nonunion in this case at some other institute 5 years back lending up in to nonunion with diaphyseal bone defect showing peri-implant expansile benign lesion treated at our institute with implant removal, excision of lytic lesion, and stabilized with extra articular distal humerus locking plate after strut fibular auto bone grafting .

Conclusion

Humerus shaft non-union in a middle-aged patient is heterogeneous entity and has to be managed after ruling out neoplastic (metastasis) as well as infective etiology, and locking plate is the gold standard for its management along with strut grafting being osteoporotic bone with some bony defect.

Application of Virtual Reality Systems in Bone Trauma Procedures

Background and Objectives: Bone fractures contribute significantly to the global disease and disability burden and are associated with a high and escalating incidence and tremendous economic consequences. The increasingly challenging climate of orthopaedic training and practice re-echoes the established potential of leveraging computer-based reality technologies to support patient-specific simulations for procedural teaching and surgical precision. Unfortunately, despite the recognised potential of virtual reality technologies in orthopaedic surgery, its adoption and integration, particularly in fracture procedures, have lagged behind other surgical specialities. We aimed to review the available virtual reality systems adapted for orthopaedic trauma procedures. Materials and Methods: We performed an extensive literature search in Medline (PubMed), Science Direct, SpringerLink, and Google Scholar and presented a narrative synthesis of the state of the art on virtual reality systems for bone trauma procedures. Results: We categorised existing simulation modalities into those for fracture fixation techniques, drilling procedures, and prosthetic design and implantation and described the important technical features, as well as their clinical validity and applications. Conclusions: Over the past decade, an increasing number of high- and low-fidelity virtual reality systems for bone trauma procedures have been introduced, demonstrating important benefits with regard to improving procedural teaching and learning, preoperative planning and rehearsal, intraoperative precision and efficiency, and postoperative outcomes. However, further technical developments in line with industry benchmarks and metrics are needed in addition to more standardised and rigorous clinical validation.

Drill Bone with Both Hands: Plunge Depth and Accuracy with 4 Bracing Positions

Bone drilling is a critical skill honed during orthopaedic surgical education. How a bone drill is held and operated (bracing position) may influence drilling performance.

Methods

A prospective study with randomized crossover was conducted to assess the effect of 4 bracing positions on orthopaedic surgical trainee performance in a simulated bone drilling task. Linear mixed effects models considering participant training level, preferred bracing position, height, weight, and drill hole number were used to estimate pairwise and overall comparisons of the effect of each bracing position on 2 primary outcomes of drilling depth and accuracy.

Results

A total of 42 trainees were screened and 19 were randomized and completed the study. Drill plunge depth with a 1-handed drilling position was significantly greater by pairwise comparison to any of the 3 double handed positions tested: a soft tissue protection sleeve in the other hand (0.41 mm, 95% confidence interval [CI] 0.80-0.03, p = 0.031), a 2-handed position with the contralateral small finger on bone and the thumb on the drill (0.42 mm, 95% CI 0.06-0.79, p = 0.018), and a 2-handed position with the contralateral elbow braced against the table (0.40 mm, 95% CI 0.02-0.78, p = 0.038). No position afforded a significant accuracy advantage (p = 0.227). Interactions of participant height with plunge depth and accuracy as well between drill hole number and plunge depth were observed.

Conclusion

Orthopaedic surgical educators should discourage trainees from operating a bone drill using only 1 hand to reduce the risk of iatrogenic injury due to drill plunging.

Level of Evidence

Therapeutic Level II.