Trauma and Orthopedic Surgery Curriculum Concordance: An Operative Learning Curve Trajectory Perspective

INTRODUCTION

Certification of completion of training in Trauma and Orthopedic (T&O) surgery in the UK requires the demonstration of operative competence in 12 index procedures, achieved through attaining a level 4 consultant-validated procedure-based assessment (PBA). The aim of this study was to evaluate the trajectory of operative learning curves related to PBA performance with respect to operative caseload and training time.

DESIGN

Logbook data from consecutive 24 higher T&O trainees were compared with PBA evaluations to determine the relationship between PBA level, operative experience, training time, and indicative numbers. Learning curve gradients were calculated using trigonometry related to operative experience and training time.

SETTING

A higher surgical orthopedic training program serving a single UK (Wales) Deanery.

PARTICIPANTS

Twenty-four consecutive higher T&O surgery trainees.

RESULTS

Median caseload to achieve level 4 competences ranged from 9 (interquartile range 6-12) for tension band wiring (olecranon or patella) to 101 (61-127) for arthroscopy, with significant variation between all 12 procedures (p < 0.001). Median number of PBAs to reach level 4 competences was 4 (2-6) with significant variation between procedures (p < 0.001). Median learning curve gradients to achieve level 4 competence for tension band wiring were 68.2° and 33.7° by caseload and training time respectively, compared with 12.2° and 45° for arthroscopy, with significant learning curve variation for all procedures related to caseload between first level 3 and first level 4 PBA (p < 0.001). Competence ratios were <1 (median 0.99, range 0.70-2.53) for 6 of the 12 indicative procedures.

CONCLUSIONS

Significant learning curve trajectory variance was observed, with discrepancies between indicative operative numbers and the point at which competence was judged achieved. Numbers of index operations to achieve certification of completion of training warrant further examination.

Influence of Trainer Role, Subspecialty and Hospital Status on Consultant Workplace-based Assessment Completion

OBJECTIVE

Performance assessment is challenging to administer and validate, yet remains central to patient safety and quality of care. The aim of this study was to evaluate Consultant Surgeon trainer performance with respect to Workplace Based Assessment (WBA) completion.

DESIGN

All WBAs for 60 Core Surgical Trainees (n = 2932) recorded in one academic year were analyzed using the Intercollegiate Surgical Curriculum Progamme. Primary outcome measures were numbers of WBAs performed related to trainer role (Assigned Educational Supervisor vs. Clinical Supervisor vs. No Training Role), gender, surgical subspecialty, hospital status (teaching vs. district general), and trainer RCSEng. TrACE course accreditation.

SETTING

A core surgical training program serving a single UK (Wales) deanery.

PARTICIPANTS

Sixty consecutively appointed core surgical trainees.

RESULTS

Median WBA number performed irrespective of trainer role was 6 (range 0-51), consisting of CBD 2 (0-18), mini-CEX 2 (0-22), DOPS 2 (0-32), and PBA 0 (0-10). Assigned Educational Supervisor trainers were more likely to complete the full range of WBAs compared with Clinical Supervisor and No Training Role assessors; WBA 17 vs. 6 vs. 3; CBD 5 vs. 2 vs. 1; mini-CEX 5 vs. 2 vs. 1; DOPS 4 vs. 2 vs. 1; and PBA 0 vs. 0 vs. 0 (p < 0.001). WBAs completed varied by subspecialty; first quartile performance: ENT, Plastic Surgery, (median 12, interquartile range 13), compared with fourth quartile: OMFS, Urology, T&O, and Cardiothoracic Surgery (median 5, interquartile range 11, p = 0.016). Hospital status, gender, and TrACE accreditation were not associated with WBA performance.

CONCLUSIONS

Important variations in trainer WBA completion were apparent; training programme directors and trainees alike should be aware of this when agreeing educational contracts.

Rural Rotations at Core: Rarefied Exposure or Real Experience?

OBJECTIVE

Surgical rotations involving rural General Hospitals (rGH) are frequently associated with recruitment challenges, partly because of adverse perceptions regarding distances from social support networks and training opportunities. The aim of this study was to determine the outcomes of core surgical training rotations involving rGHs when compared with urban hospitals in a single UK Deanery.

DESIGN

Online Intercollegiate Surgical Curriculum Programme portfolios from 163 core surgical trainees (CST) were examined related to postlocation, operative experience, workplace-based assessments, and academic achievement. Of the 163 CSTs, 27 had completed at least 50% of their 2-year training posts at rGHs and were compared with 136 control CSTs completing rotations in urban general and teaching hospitals (uGH). The primary outcome measures were MRCS pass rate and success at national ST3 selection.

SETTING

A core surgical training program serving a single UK Deanery.

PARTICIPANTS

Consecutive 177 CSTs appointed to a single UK Deanery between 2010 and 2016.

RESULTS

Success at MRCS and national ST3 selection were similar for CSTs from rGH vs uGH rotations-MRCS success: 70.4 vs 72.8% (p = 0.816), and ST3 success: 22.2% vs 27.0% (p = 0.811). Median rGH vs uGH curriculum-based outcomes were operative case load: 378 vs 422 (p = 0.300); workplace-based assessments completed: 79 vs 94 (p = 0.499); audits performed: 4 vs 4 (p = 0.966); learned society communications: 1 vs 2 (p = 0.020); and scientific publications: 0 vs 0 (p = 0.478).

CONCLUSION

CST rotations including rGHs produced a different spectrum of training experience compared with uGH rotations but overall primary outcomes were similar.

Intercavernous portion of internal carotid artery occlusion resulting from snowboarding

A 33-year-old gentleman who was otherwise fit and healthy suffered repetitive low impact head injuries while snowboarding in Austria over a period of one week. During the fall he had several hyperextension injuries and presented with headache, nausea, vomiting, drowsiness (felt ‘drunk’ on Friday night despite not being drunk), diplopia, abnormal pupillary signs. A Horner’s syndrome was diagnosed and on investigation, the left intercavernous portion of internal carotid artery (ICA) was found to be thrombosed. The symptoms gradually settled after conservative treatment for a month. Blunt head trauma is a recognized cause of carotid dissection and thrombosis and many neuromechanics studies have attempted to calculate the wall shear stress involved. Physicians treating snowboarders should be aware of the condition and should look for Horner’s syndrome and consider the possibility of carotid occlusion. With a thorough PubMed, Ovid, EMBASE search using ‘snowboarding’, ‘carotid dissection’, ‘Horner’s syndrome’ no such case was found to be reported. Proper training for such sport activities is essential to avoid serious consequences.

A simple technique for intra-operative radiation protection in trauma and orthopaedic procedures

With the number of orthopaedic surgical techniques using intra-operative radiological imaging, the need for effective methods of radiation protection is increasingly important. We describe a sterile, portable, easy to assemble method of providing adequate protection. This radiation protection shield is cost effective and can potentially reduce the risk of contamination and operating time.

Indirect reduction using a simple quadrilateral frame in the application of distal tibial LCP-technical tips

Minimally invasive percutaneous plate osteosynthesis (MIPPO) has become widely practiced in the operative management of articular, metaphyseal and transitional zone fractures. Early indirect reduction of such fractures of the distal tibia can be achieved easily using a simple quadrilateral frame. This enables CT scanning where required and allows the soft tissues to be assessed with ease. Distal tibial anatomical locking compression plates (LCP Synthes UK) have recently become available. Retrograde insertion of the AO distal tibial anatomical LCP via a distal transverse wound enables the MIPPO to be completed rapidly, with minimal surgical trauma to the zone of injury, with the frame in place until the procedure is completed-a particular advantage in these often highly unstable injuries.

Chronic haematoma as a late complication of cosmetic breast augmentation

To our knowledge, a chronic expanding haematoma has not been reported in a patient who received silicone gel breast prostheses for augmentation and never before at an interval as long as 12 years, as in our case. There have been occasional reports of chronic haematoma as complication of implantation of silicone breast prostheses after mastectomy for cancer, presenting 2.5-8 years later.

Using wound fluid analyses to identify trace element requirements for efficient healing

A series of wound fluid and blood plasma samples from 20 patients with breast cancer were analysed by Potentiometric Stripping Analysis and computer-aided chemical speciation to quantify the concentrations of the trace elements of copper and zinc in the samples and to investigate the individual species of copper and zinc present. Comparisons were made between total concentrations of copper and zinc in wound fluid, pre-operative blood plasma levels and reference values. A wound fluid model constructed using JESS identified the main copper and zinc species present. It was also used to investigate the effects of a change in pH and changes in the total concentrations of certain components on their predominance. The clinical significance of the research is discussed, together with suggestions for a continuation in the research.