The anatomy of anatomy: a review for its modernization

Anatomy has historically been a cornerstone in medical education regardless of nation or specialty. Until recently, dissection and didactic lectures were its sole pedagogy. Teaching methodology has been revolutionized with more reliance on models, imaging, simulation, and the Internet to further consolidate and enhance the learning experience. Moreover, modern medical curricula are giving less importance to anatomy education and to the acknowledged value of dissection. Universities have even abandoned dissection completely in favor of user-friendly multimedia, alternative teaching approaches, and newly defined priorities in clinical practice. Anatomy curriculum is undergoing international reformation but the current framework lacks uniformity among institutions. Optimal learning content can be categorized into the following modalities: (1) dissection/prosection, (2) interactive multimedia, (3) procedural anatomy, (4) surface and clinical anatomy, and (5) imaging. The importance of multimodal teaching, with examples suggested in this article, has been widely recognized and assessed. Nevertheless, there are still ongoing limitations in anatomy teaching. Substantial problems consist of diminished allotted dissection time and the number of qualified anatomy instructors, which will eventually deteriorate the quality of education. Alternative resources and strategies are discussed in an attempt to tackle these genuine concerns. The challenges are to reinstate more effective teaching and learning tools while maintaining the beneficial values of orthodox dissection. The UK has a reputable medical education but its quality could be improved by observing international frameworks. The heavy penalty of not concentrating on sufficient anatomy education will inevitably lead to incompetent anatomists and healthcare professionals, leaving patients to face dire repercussions.

Impact of the COVID-19 pandemic on orthopedic trauma workload in a London level 1 trauma center: the "golden month"

Background and purpose - The COVID-19 pandemic has been recognized as an unprecedented global health crisis. This is the first observational study to evaluate its impact on the orthopedic workload in a London level 1 trauma center (i.e., a major trauma center [MTC]) before (2019) and during (2020) the "golden month" post-COVID-19 lockdown.Patients and methods - We performed a longitudinal observational prevalence study of both acute orthopedic trauma referrals, operative and anesthetic casemix for the first "golden" month from March 17, 2020. We compared the data with the same period in 2019. Statistical analyses included median (median absolute deviation), risk and odds ratios, as well as Fisher's exact test to calculate the statistical significance, set at p ≤ 0.05.Results - Acute trauma referrals in the post-COVID period were almost halved compared with 2019, with similar distribution between pediatric and adult patients, requiring a significant 19% more admissions (RR 1.3, OR 2.6, p = 0.003). Hip fractures and polytrauma cases accounted for an additional 11% of the modal number of injuries in 2020, but with 19% reduction in isolated limb injuries that were modal in 2019. Total operative cases fell by a third during the COVID-19 outbreak. There was a decrease of 14% (RR 0.85, OR 0.20, p = 0.006) in aerosol-generating anesthetic techniques used.Interpretation - The impact of the COVID-19 pandemic has led to a decline in the number of acute trauma referrals, admissions (but increased risk and odds ratio), operations, and aerosolizing anesthetic procedures since implementing social distancing and lockdown measures during the "golden month."

Training safer orthopedic surgeons. Construct validation of a virtual-reality simulator for hip fracture surgery

BACKGROUND AND PURPOSE

Virtual-reality (VR) simulation in orthopedic training is still in its infancy, and much of the work has been focused on arthroscopy. We evaluated the construct validity of a new VR trauma simulator for performing dynamic hip screw (DHS) fixation of a trochanteric femoral fracture.

PATIENTS AND METHODS

30 volunteers were divided into 3 groups according to the number of postgraduate (PG) years and the amount of clinical experience: novice (1-4 PG years; less than 10 DHS procedures); intermediate (5-12 PG years; 10-100 procedures); expert (> 12 PG years; > 100 procedures). Each participant performed a DHS procedure and objective performance metrics were recorded. These data were analyzed with each performance metric taken as the dependent variable in 3 regression models.

RESULTS

There were statistically significant differences in performance between groups for (1) number of attempts at guide-wire insertion, (2) total fluoroscopy time, (3) tip-apex distance, (4) probability of screw cutout, and (5) overall simulator score. The intermediate group performed the procedure most quickly, with the lowest fluoroscopy time, the lowest tip-apex distance, the lowest probability of cutout, and the highest simulator score, which correlated with their frequency of exposure to running the trauma lists for hip fracture surgery.

INTERPRETATION

This study demonstrates the construct validity of a haptic VR trauma simulator with surgeons undertaking the procedure most frequently performing best on the simulator. VR simulation may be a means of addressing restrictions on working hours and allows trainees to practice technical tasks without putting patients at risk. The VR DHS simulator evaluated in this study may provide valid assessment of technical skill.

Validating Touch Surgery™: A cognitive task simulation and rehearsal app for intramedullary femoral nailing

BACKGROUND

The role of simulation in orthopaedic surgical training is becoming increasingly evident, as simulation allows repeated sustained practice in an environment that does not harm the patient. Previous studies have shown that the cognitive aspects of surgery are of equal if not greater importance in developing decision making than the practical aspects.

AIM

To observe construct, content and face validity of four IFN modules on a cognitive simulator, Touch Surgery™.

METHODS

39 novices and 10 experts were recruited to complete four simulation modules on surgical decision-making that represented the procedural steps of preparing the patient and equipment, inserting and locking an intramedullary femoral nail. Real-time objective performance metrics were obtained, stored electronically and analysed using median and Bonett-Price 95% confidence intervals from the participant's primary attempt to assess for construct validity. The median score of a post-study questionnaire using 5-point Likert scales assessed face and content validity. Data was confirmed as non-parametric by the Kolmogorov-Smirnov test. Significance was calculated using the Mann-Whitney U test for independent data whilst the Wilcoxon signed ranked test was used for paired data. Significance was set as 2-tailed p-value<0.05.

RESULTS

Experts significantly outperformed novices in all four modules to demonstrate construct validity (p<0.001). Specifically, experts scored 32.5% higher for patient positioning and preparation (p<0.0001), 31.5% higher for femoral canal preparation (p<0.0001), 22.5% higher for proximal locking (p<0.0001) and 17% higher scores for distal locking and closure (p<0.001). Both cohorts either agreed or strongly agreed that the graphics, simulated environment and procedural steps were realistic. Also, both cohorts agreed that the app was useful for surgical training and rehearsal, should be implemented within the curriculum and would want to use it to learn other surgical procedures.

CONCLUSION

IFN on the Touch Surgery app demonstrated construct, face and content validity. Users can demonstrate cognitive competencies prior to performing surgical procedures in the operating room. The application is an effective adjunct to traditional learning methods and has potential for curricular implementation.

Should double lung transplant be performed with or without cardiopulmonary bypass?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether double lung transplantation should be performed with or without cardiopulmonary bypass (CPB) in order to improve postoperative clinical outcomes. Altogether 386 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All 14 papers assessed a range of postoperative outcomes and broadly speaking, six papers found significantly worse outcomes with CPB use, six found no difference and two found a mixture of both depending on the specific outcomes assessed. Dalibon et al. [J Cardiothorac Vasc Anesth 2006;20:668-672] found that mortality was significantly worse in the CPB group at 48 h, one month and one year [P = 0.001, odds ratio (OR) = 246.1; P = 0.083, OR = 2.6; P = 0.001, OR = 5.3, respectively]. Other papers revealed poor outcomes in the CPB group in a range of measures including diffuse alveolar damage (P = 0.009), chest radiograph infiltrate score (P = 0.005), longer intubation time (P = 0.002), longer intensive care unit stay (P = 0.05), and greater incidence of pulmonary reimplantation response (P = 0.03). However, Myles et al. [J Cardiothorac Vasc Anesth 1997;11:177-183] found that only acute postoperative outcomes were significantly worse in their CPB group (P < 0.001); medium- and long-term survival outcomes were not significantly different (P = 0.055). de Boer et al. [Transplantation 2002;73:1621-1627] even found that there was an improved one-year survival rate with CPB use (OR = 0.25, P = 0.038) and that the number of human leukocyte antigen DR (HLA-DR) mismatches influenced this effect. Those papers suggesting no deleterious effects of CPB generally measured similar postoperative outcomes to those mentioned above, with one study also assessing incidence of primary graft failure, which was not significantly different (P = 0.37). We conclude that CPB should continue to be used where clinically indicated for a specific reason (for example, where there is pulmonary hypertension or a requirement for concomitant cardiac repair). However, given that the evidence for using CPB for all elective cases is relatively weak, and the fact that there are strong arguments in the literature for both methods, either approach would be clinically acceptable.

Impact of the COVID-19 pandemic on paediatric orthopaedic trauma workload in central London: a multi-centre longitudinal observational study over the "golden weeks"

Background and purpose - The COVID-19 pandemic has been recognised as an unprecedented global health crisis. This study assesses the impact on a large acute paediatric hospital service in London, evaluating the trends in the acute paediatric orthopaedic trauma referral caseload and operative casemix before (2019) and during (2020) COVID-19 lockdown. Patients and methods - A longitudinal retrospective observational prevalence study of both acute paediatric orthopaedic trauma referrals and operative caseload was performed for the first 6 "golden weeks" of lockdown. These data were compared with the same period in 2019. Statistical analyses included median (± median absolute deviation), risk and odds ratios as well as Fisher's exact test to calculate the statistical significance, set at p ≤ 0.05. Results - Acute paediatric trauma referrals in 2020 were reduced by two-thirds compared with 2019 (n = 302 vs. 97) with a halving risk (RR 0.55) and odds ratios (OR 0.43) of sporting-related mechanism of injuries (p = 0.002). There was a greater use of outpatient telemedicine in the COVID-19 period with more Virtual Fracture Clinic use (OR 97, RR 84, p < 0.001), and fewer patients being seen for consultation and followed up face to face (OR 0.55, RR 0.05, p < 0.001). Interpretation - The impact of the COVID-19 pandemic has led to a decline in the number of acute paediatric trauma referrals, admissions, and operations during the COVID period. There has also been a significant change in the patient pathway with more being reviewed via the means of telemedicine to reduce the risk of COVID-19 transmission and exposure. More work is required to observe for similar trends nationwide and globally as the pandemic has permanently affected the entire healthcare infrastructure.

Training effect of using Touch Surgery for intramedullary femoral nailing

BACKGROUND

Simulation in orthopaedic training is becoming increasingly popular and has been widely used in formal curricula. However, these resources are expensive and not easily accessible to every trainee. Other means of disseminating surgical education through virtual reality (VR) multimedia can act as useful adjunct to traditional methods of teaching. One validated VR platform is Touch Surgery, a cognitive task simulation and rehearsal app.

OBJECTIVES

The primary objective of this study was to identify the training effect of Touch Surgery intramedullary femoral nailing (IFN) modules using objective performance metrics over six consecutive attempts. Secondary objectives consisted of validated multiple choice questions (MCQ) testing before the first (pre) and after the sixth (post) attempts.

METHODS

27 medical undergraduates were recruited to complete the decision-making process six consecutive times for four modules on the procedural steps of IFN. The modules consisted of (i) preparing the patient and equipment, (ii) femoral canal preparation, (iii) nail insertion and proximal locking, and (iv) distal locking and closure. Real-time objective performance metrics were obtained, stored electronically and analysed using the median and Bonett-Price 95% confidence intervals from the participants' attempts to assess training effect. Significance was calculated using the Mann-Whitney U test for independent data whilst the Wilcoxon signed ranked test was used for paired data. Significance was set as 2-tailed p-value <0.05.

RESULTS

Median performance scores per attempt for all four modules demonstrated a significant improvement ranging from 58 to 115%. Scoring variability and distribution was reduced and more predictable per attempt. Logarithmic learning curves elicited strong positive correlations between the number of attempts and scoring. Mean scores for pre and post-study MCQs tests significantly improved from 83 to 94% in all modules.

CONCLUSION

IFN modules on Touch Surgery app demonstrated a significant training effect with practice. Novices demonstrated cognitive competencies to ensure patient safety prior to operating. The app is an effective adjunct to traditional learning methods and has the potential for curricular implementation.

Training effect of a virtual reality haptics-enabled dynamic hip screw simulator

BACKGROUND AND PURPOSE

Virtual reality (VR) simulation offers a safe, controlled, and effective environment to complement training but requires extensive validation before it can be implemented within the curriculum. The main objective was to assess whether VR dynamic hip screw (DHS) simulation has a training effect to improve objective performance metrics.

PATIENTS AND METHODS

52 surgical trainees who were naïve to DHS procedures were randomized to 2 groups: the training group, which had 5 attempts, and the control group, which had only one attempt. After 1 week, both cohorts repeated the same number of attempts. Objective performance metrics included total procedural time (sec), fluoroscopy time (sec), number of radiographs (n), tip-apex distance (TAD; mm), attempts at guide-wire insertion (n), and probability of cut-out (%). Mean scores (with SD) and learning curves were calculated. Significance was set as p < 0.05.

RESULTS

The training group was 68% quicker than the control group, used 75% less fluoroscopy, took 66% fewer radiographs, had 82% less retries at guide-wire insertion, achieved a reduced TAD (by 41%), had lower probability of cut-out (by 85%), and obtained an increased global score (by 63%). All these results were statistically significant (p < 0.001). The participants agreed that the simulator provided a realistic learning environment, they stated that they had enjoyed using the simulator, and they recognized the need for the simulator in formal training.

INTERPRETATION

We found a significant training effect on the VR DHS simulator in improving objective performance metrics of naïve surgical trainees. Patient safety, an important priority, was not compromised.

Knee Arthroscopy Simulation: A Randomized Controlled Trial Evaluating the Effectiveness of the Imperial Knee Arthroscopy Cognitive Task Analysis (IKACTA) Tool

BACKGROUND

Virtual-reality and cadaveric simulations are expensive and not readily accessible. Innovative and accessible training adjuncts are required to help to meet training needs. Cognitive task analysis has been used extensively to train pilots and in other surgical specialties. However, the use of cognitive task analyses within orthopaedics is in its infancy. The purpose of this study was to evaluate the effectiveness of a novel cognitive task analysis tool to train novice surgeons in diagnostic knee arthroscopy in high-fidelity, phantom-limb simulation.

METHODS

Three expert knee surgeons were interviewed independently to generate a list of technical steps, decision points, and errors for diagnostic knee arthroscopy. A modified Delphi technique was used to generate the final cognitive task analysis. A video and a voiceover were recorded for each phase of this procedure. These were combined to produce the Imperial Knee Arthroscopy Cognitive Task Analysis (IKACTA) tool that utilizes written and audiovisual stimuli to describe each phase of a diagnostic knee arthroscopy. In this double-blinded, randomized controlled trial, a power calculation was performed prior to recruitment. Sixteen novice orthopaedic trainees who performed ≤10 diagnostic knee arthroscopies were randomized into 2 equal groups. The intervention group (IKACTA group) was given the IKACTA tool and the control group had no additional learning material. They were assessed objectively (validated Arthroscopic Surgical Skill Evaluation Tool [ASSET] global rating scale) on a high-fidelity, phantom-knee simulator. All participants, using the Likert rating scale, subjectively rated the tool.

RESULTS

The mean ASSET score (and standard deviation) was 19.5 ± 3.7 points in the IKACTA group and 10.6 ± 2.3 points in the control group, resulting in an improvement of 8.9 points (95% confidence interval, 7.6 to 10.1 points; p = 0.002); the score was determined as 51.3% (19.5 of 38) for the IKACTA group, 27.9% (10.6 of 38) for the control group, and 23.4% (8.9 of 38) for the improvement. All participants agreed that the cognitive task analysis learning tool was a useful training adjunct to learning in the operating room.

CONCLUSIONS

To our knowledge, this is the first cognitive task analysis in diagnostic knee arthroscopy that is user-friendly and inexpensive and has demonstrated significant benefits in training.

CLINICAL RELEVANCE

The IKACTA will provide trainees with a demonstrably strong foundation in diagnostic knee arthroscopy that will flatten learning curves in both technical skills and decision-making.

Training safer surgeons: How do patients view the role of simulation in orthopaedic training?

Background

Simulation allows training without posing risk to patient safety. It has developed in response to the demand for patient safety and the reduced training times for surgeons. Whilst there is an increasing role of simulation in orthopaedic training, the perception of patients and the general public of this novel method is yet unknown. Patients and the public were given the opportunity to perform a diagnostic knee arthroscopy on a virtual reality ARTHRO Mentor simulator. After their practice session, participants answered a validated questionnaire based on a 5-point Likert Scale assessing their opinions on arthroscopic simulation. Primary objective was observing perception of patients on orthopaedic virtual reality simulation.

Findings

There were a total of 159 respondents, of which 86% were of the opinion that simulators are widely used in surgical training and 94% felt that they should be compulsory. 91% would feel safer having an operation by a surgeon trained on simulators, 87% desired their surgeon to be trained on simulators and 72% believed that additional simulator training resulted in better surgeons. Moreover, none of the respondents would want their operation to be performed by a surgeon who had not trained on a simulator. Cronbach’s alpha was 0.969.

Conclusions

There is also a clear public consensus for this method of training to be more widely utilised and it would enhance public perception of safer training of orthopaedic surgeons. This study of public perception provides a mandate to increase investment and infrastructure in orthopaedic simulation as part of promoting clinical governance.

The Transferability of Generic Minimally Invasive Surgical Skills: Is There Crossover of Core Skills Between Laparoscopy and Arthroscopy?

OBJECTIVE

The primary objective was observing transferability of minimally invasive surgical skills between virtual reality simulators for laparoscopy and arthroscopy. Secondary objectives were to assess face validity and acceptability.

DESIGN

Prospective single-blinded crossover randomized controlled trial.

SETTING

MSk Laboratory, Imperial College London.

PARTICIPANTS

Student doctors naïve to simulation and minimally invasive techniques.

METHODS

A total of 72 medical students were randomized into 4 groups (2 control groups and 2 training groups), and tested on haptic virtual reality simulators. Group 1 (control; n = 16) performed a partial laparoscopic cholecystectomy and Group 2 (control; n = 16) performed a diagnostic knee arthroscopy. Both groups then repeated the same task a week later. Group 3 (training; n = 20) completed a partial laparoscopic cholecystectomy, followed by an arthroscopic training program, and repeated the laparoscopic cholecystectomy a week later. Group 4 (training; n = 20) performed a diagnostic knee arthroscopy, followed by a laparoscopic training program, and then repeated the initial arthroscopic test a week later. The time taken, instrument path length, and speed were recorded for each participant and analyzed.

RESULTS

Time taken for task: All 4 cohorts were significantly quicker on their second attempt but the 2 training groups outperformed the 2 control groups, with the laparoscopy-trained group improving the most (p < 0.05). Economy of movement: All cohorts had a significant improvement in left hand path length (p < 0.01) but there was no difference for right hand path length. Left hand speed: Only the 2 training groups showed significant improvement with the laparoscopy-trained group improving the most (p < 0.05). Right hand speed: All cohorts improved significantly with the laparoscopy-trained group improving the most (p < 0.05). Face validity and acceptability were established for both simulators.

CONCLUSION

This study showed that minimally invasive surgical skills learnt on a laparoscopy simulator are transferable to arthroscopy and vice versa, with greater effect after training on the laparoscopy simulator.

Trauma simulation training: a randomized controlled trial -evaluating the effectiveness of the Imperial Femoral Intramedullary Nailing Cognitive Task Analysis (IFINCTA) tool

Background and purpose - Cognitive task analysis (CTA) has been used extensively to train pilots and in other surgical specialties. However, the use of CTA within orthopedics is in its infancy. We evaluated the effectiveness of a novel CTA tool to improve understanding of the procedural steps in antegrade femoral intramedullary nailing. Material and methods - Design: A modified Delphi technique was used to generate a CTA from 3 expert orthopedic trauma surgeons for antegrade femoral intramedullary nailing. The written and audiovisual information was combined to describe the technical steps, decision points, and errors for each phase of this procedure Validation: A randomized double-blind controlled trial was undertaken with 22 medical students (novices) randomized into 2 equal groups. The intervention group were given the CTA tool and the control group were given a standard operative technique manual. They were assessed using the validated "Touch Surgery™" application assessment tool on femoral intramedullary nailing. Results - The pre-test scores between the two groups were similar. However, the post-test scores were statistically significantly better in the intervention group compared with the control group. The improvement (post-test median scores) in the intervention group compared with the control group was 20% for patient positioning and preparation, 21% for femoral preparation, 10% for proximal locking, and 19% for distal locking respectively (p < 0.001 for all comparisons). Interpretation - This is the first multimedia CTA tool in femoral intramedullary nailing that is easily accessible, user-friendly, and has demonstrated significant benefits in training novices over the traditional use of operative technique manuals.

Training and Transfer Effect of FluoroSim, an Augmented Reality Fluoroscopic Simulator for Dynamic Hip Screw Guidewire Insertion: A Single-Blinded Randomized Controlled Trial

BACKGROUND

FluoroSim, a novel fluoroscopic simulator, can be used to practice dynamic hip screw (DHS) guidewire insertion in a high-fidelity clinical scenario. Our aim was to demonstrate a training effect in undergraduate medical students who are not familiar with this operation and its simulation.

METHODS

Forty-five undergraduate medical students were recruited and randomized to either training (n = 23) or control (n = 22) cohorts. The training cohort had more exposure to FluoroSim (5 attempts each week) over a 2-week period (with a 1-week washout period in between) compared with the control cohort (a single attempt 1 week apart) over a 2-week period. Five real-time objective performance metrics were recorded: (1) tip-apex distance (TAD) (mm), (2) predicted cut-out rate (%), (3) total procedural time (sec), (4) total number of radiographs (n), and (5) total number of guidewire retries (n).

RESULTS

At baseline, there was no significant difference in the performance metrics, which confirmed the absence of a selection bias. The intragroup training effect demonstrated a significant improvement in all metrics for the training cohort only. A significant difference between groups was demonstrated as the training cohort significantly outperformed the control cohort in 3 metrics (procedural time [25%], number of radiographs [57%], and number of guidewire retries [100%]; p < 0.001). A learning curve showed an inversely proportional correlation between frequency of attempts and procedural time as well as the number of digital fluoroscopic radiographs that were made, indicating the development of psychomotor skills. There was also an improved baseline of the learning curve after the 1-week washout period, suggesting skill retention.

CONCLUSIONS

Skill acquisition with the FluoroSim system was demonstrated with repeat exposure in a safe, radiation-free high-fidelity clinical simulation with actual operating room equipment. The task of DHS guidewire insertion requires cognitive and psychomotor skills that take a variable number of attempts to acquire, as demonstrated on the learning curve. Additional work is required to demonstrate that the skill tested by the FluoroSim is the same skill that is required for intraoperative DHS guidewire insertion. However, use of the FluoroSim provides improvement in skills with extra-clinical training opportunities for orthopaedic trainees.

CLINICAL RELEVANCE

FluoroSim has demonstrated validity and training effect. It has the potential to be approved for possible use on patients in the operating room to help surgeons with the operation. Consequently, operating time, accuracy of TAD, and surgical outcomes may all be improved.

Does video gaming affect orthopaedic skills acquisition? A prospective cohort-study

INTRODUCTION

Previous studies have suggested that there is a positive correlation between the extent of video gaming and efficiency of surgical skill acquisition on laparoscopic and endovascular surgical simulators amongst trainees. However, the link between video gaming and orthopaedic trauma simulation remains unexamined, in particular dynamic hip screw (DHS) stimulation.

OBJECTIVE

To assess effect of prior video gaming experience on virtual-reality (VR) haptic-enabled DHS simulator performance.

METHODS

38 medical students, naïve to VR surgical simulation, were recruited and stratified relative to their video gaming exposure. Group 1 (n = 19, video-gamers) were defined as those who play more than one hour per day in the last calendar year. Group 2 (n = 19, non-gamers) were defined as those who play video games less than one hour per calendar year. Both cohorts performed five attempts on completing a VR DHS procedure and repeated the task after a week. Metrics assessed included time taken for task, simulated flouroscopy time and screw position. Median and Bonett-Price 95% confidence intervals were calculated for seven real-time objective performance metrics. Data was confirmed as non-parametric by the Kolmogorov-Smirnov test. Analysis was performed using the Mann-Whitney U test for independent data whilst the Wilcoxon signed ranked test was used for paired data. A result was deemed significant when a two-tailed p-value was less than 0.05.

RESULTS

All 38 subjects completed the study. The groups were not significantly different at baseline. After ten attempts, there was no difference between Group 1 and Group 2 in any of the metrics tested. These included time taken for task, simulated fluoroscopy time, number of retries, tip-apex distance, percentage cut-out and global score.

CONCLUSION

Contrary to previous literature findings, there was no correlation between video gaming experience and gaining competency on a VR DHS simulator.

Teaching basic trauma: validating FluoroSim, a digital fluoroscopic simulator for guide-wire insertion in hip surgery

Background and purpose - Simulation is an adjunct to surgical education. However, nothing can accurately simulate fluoroscopic procedures in orthopedic trauma. Current options for training with fluoroscopy are either intraoperative, which risks radiation, or use of expensive and unrealistic virtual reality simulators. We introduce FluoroSim, an inexpensive digital fluoroscopy simulator without the need for radiation. Patients and methods - This was a multicenter study with 26 surgeons in which everyone completed 1 attempt at inserting a guide-wire into a femoral dry bone using surgical equipment and FluoroSim. 5 objective performance metrics were recorded in real-time to assess construct validity. The surgeons were categorized based on the number of dynamic hip screws (DHS) performed: novices (< 10), intermediates (10-39) and experts (≥ 40). A 7-point Likert scale questionnaire assessed the face and content validity of FluoroSim. Results - Construct validity was present for 2 clinically validated metrics in DHS surgery. Experts and intermediates statistically significantly outperformed novices for tip-apex distance and for cut-out rate. Novices took the least number of radiographs. Face and content validity were also observed. Interpretation - FluoroSim discriminated between novice and intermediate or expert surgeons based on tip-apex distance and cut-out rate while demonstrating face and content validity. FluoroSim provides a useful adjunct to orthopedic training. Our findings concur with results from studies using other simulation modalities. FluoroSim can be implemented for education easily and cheaply away from theater in a safe and controlled environment.

Learning Acetabular Fracture Classification using a Three-Dimensional Interactive Software: A Randomized Controlled Trial

Acetabular fractures are a real challenge for junior doctors as well as experienced orthopedic surgeons. Correct fracture classification is crucial for appreciating the fracture type, surgical planning, and predicting prognosis. Although three-dimensional (3D) tutorial is believed to improve the understanding of the complex anatomy structure, there have been few applications and randomized controlled trials to confirm it in orthopedics. This study aims to develop a 3D interactive software system for teaching acetabular fracture classification and evaluate its efficacy. Participants were randomly but evenly allocated into either the experimental group (who learned the acetabular fracture classification using a 3D software) or the control group (who used a traditional two-dimensional [2D] tutorial). Both groups were then tasked to classify 10 acetabular fractures and complete a five-point Likert scale on their satisfaction of each learning modality. To calculate significance (P < 0.05), independent t-test was used for normally distributed data whereas Mann-Whitney U test for non-normally distributed data. The experimental group significantly outperformed the control group (t (28) = 2.526, P = 0.017) with identifying correct acetabular fracture classification. Moreover, Likert scale score in the experimental group was also significantly higher than in the control group (Z = 2.477, P = 0.013). This 3D classification software has objectively and subjectively showed an advantage over the traditional 2D tutorial, resulting in an improved classification accuracy and higher Likert scale score. The 3D software has the potential to improve both clinical knowledge as well as identifying correct patient management in orthopedics.

Singapore's anatomical future: quo vadis?

The disciplines of anatomy and surgery are not dichotomous since one is dependent on the other. Traditionally, surgeons predominantly taught gross and clinical anatomy. In this review, we examine the context of how human anatomy is taught nowadays. In essence, we discovered that there are certain discernable trends consistently observable between the American and British systems. In Singapore, the British Russell Group first influenced its education landscape but now more so by the American Ivy League. Singapore now has three medical schools all offering differing anatomy curricula, which serves as an opportune time for it to consider if there is a best approach given that the practice of surgery is also evolving in parallel. This review discusses the various pedagogies and issues involved, and will serve as a forum and stimulus for discussion. By tweaking the curriculum correctly and the lessons learnt, future doctors and surgeons in training will receive a better anatomical education, not just in Singapore but the world in general. Key recommendations include the use of body painting, clay, plasticine to facilitate the learning of anatomy, and the implementation of a body donation program. Furthermore, strategic mergers with key stakeholders will also ensure the survival of the discipline.

Trends in neck of femur fracture incidence in EU15+ Countries from 1990-2017

BACKGROUND

Neck of femur fractures (NOFF) pose significant socio-economic costs to society with a high degree of morbidity and mortality. Its incidence rate has been collated within the Global Burden of Disease (GBD) database; however, to date, no comparison across countries has been reported.

METHODS

NOFF age-standardised incidence rates (ASIR) per 100,000 population were extracted from the GBD database for European Union (EU) 15+ countries over the period 1990 to 2017. Joinpoint regression analysis of the data identified trends in ASIR and associated estimated annual percentage changes (EAPC). These were analysed by specified timeframe, country and gender.

RESULTS

Of the 19 EU15+ countries, 11 (58%) had overall increases in NOFF ASIRs in 2017 compared to 1990. The median ASIRs were 240/100,000 and 322/100,000 for males and females, respectively, in 1990. By 2017, this had increased to 259/100,000 and 325/100,000, respectively. Females consistently had relatively higher NOFF ASIRs with a median gender fracture gap of 62/100,000 in 2017. Males had a higher percentage change in increasing ASIRs, with a smaller percentage change in decreasing ASIRs for all included countries. The highest national ASIRs was observed in Australia, followed by Finland and Belgium. Conversely the Mediterranean countries demonstrated the lowest ASIRs, closely followed by the USA.

CONCLUSION

Despite significant advances in primary and secondary hip fracture prevention strategies over the 28-year study period, significant increases in NOFF ASIRs among most EU15+ countries were observed, especially with respect to gender.

Has the sanctity of life law 'gone too far'?: analysis of the sanctity of life doctrine and English case law shows that the sanctity of life law has not 'gone too far'

The medical profession consistently strives to uphold patient empowerment, equality and safety. It is ironic that now, at a time where advances in technology and knowledge have given us an increased capacity to preserve and prolong life, we find ourselves increasingly asking questions about the value of the lives we are saving. A recent editorial by Professor Raanan Gillon questions the emphasis that English law places on the sanctity of life doctrine. In what was described by Reverend Nick Donnelly as a "manifesto for killing patients", Professor Gillon argues that the sanctity of life law has gone too far because of its disregard for distributive justice and an incompetent person's previously declared autonomy. This review begins by outlining the stance of the sanctity of life doctrine on decisions about administering, withholding and withdrawing life-prolonging treatment. Using this as a foundation for a rebuttal, a proposal is made that Professor Gillon's assertions do not take the following into account:1) A sanctity of life law does not exist since English Common Law infringes the sanctity doctrine by tolerating quality of life judgements and a doctor's intention to hasten death when withdrawing life-prolonging treatment.2) Even if a true sanctity of life law did exist:a) The sanctity of life doctrine allows for resource considerations in the wider analysis of benefits and burdens.b) The sanctity of life doctrine yields to a competent person's autonomous decision.This review attempts to demonstrate that at present, and with the legal precedent that restricts it, a sanctity of life law cannot go too far.

Are multiple views superior to a single view when teaching hip surgery? A single-blinded randomized controlled trial of technical skill acquisition

Purpose

Surgical education videos currently all use a single point of view (POV) with the trainee locked onto a fixed viewpoint, which may not deliver sufficient information for complex procedures. We developed a novel multiple POV video system and evaluated its training outcome compared with traditional single POV.

Methods

We filmed a hip resurfacing procedure performed by an expert attending using 8 cameras in theatre. 30 medical students were randomly and equally allocated to learn the procedure using the multiple POV (experiment group [EG]) versus single POV system (control group [CG]). Participants advanced a pin into the femoral head as demonstrated in the video. We measured the drilling trajectories and compared it with pre-operative plan to evaluate distance of the pin insertion and angular deviations. Two orthopedic attendings expertly evaluated the participants’ performance using a modified global rating scale (GRS). There was a pre-video knowledge test that was repeated post-simulation alongside a Likert-scale questionnaire.

Results

The angular deviation of the pin in EG was significantly less by 29% compared to CG (p = 0.037), with no significant difference in the entry point’s distance between groups (p = 0.204). The GRS scores for EG were 3.5% higher than CG (p = 0.046). There was a 32% higher overall knowledge test score (p<0.001) and 21% improved Likert-scale questionnaire score (p = 0.002) after video-learning in EG than CG, albeit no significant difference in the knowledge test score before video-learning (p = 0.721).

Conclusion

The novel multiple POV provided significant objective and subjective advantages over single POV for acquisition of technical skills in hip surgery.

Does using anatomical models improve patient satisfaction in orthopaedic consenting? Single-blinded randomised controlled trial

BACKGROUND

Patient satisfaction in consenting is a major pillar of clinical governance and healthcare quality assessment. The purpose was to observe the effect of using 3D anatomical models of knee and shoulder joints on patient satisfaction during informed consent in the largest single-blinded randomised controlled trial in this field.

METHODS

52 patients undergoing elective knee or shoulder surgery were randomised into two groups when being consented. The intervention group (n = 26) was shown an anatomical model of the knee/shoulder joint while the control group (n = 26) was given only a verbal explanation without a model. Patients rated their satisfaction on the validated Medical Interview Satisfaction Scale (MISS-26) questionnaire. Semi-structured interviews were analysed for specific themes to determine key factors that influenced patient satisfaction. The mean score ±SD were calculated with significance set at p < 0.05.

RESULTS

There was a significant difference in the overall satisfaction between the control and intervention cohorts (MISS-26 score 4.33 [86.6%] ± 0.646 vs 4.70 [94.0%] ± 0.335 respectively, 7.4% improvement, 8.5% difference, p = 0.01). Behavioural criteria showed a 13% increase in satisfaction (p = 0.02). Semi-structured interviews determined that the factors influencing satisfaction included the surgeon's interpersonal manner, the use of the visual aid and seeing the consultant surgeon in clinic. All patients in the intervention cohort identified factors contributing to their satisfaction, whereas a fifth of the control cohort claimed nothing at all made them feel satisfied.

CONCLUSION

Anatomical models as visual aids significantly increased patient satisfaction during the consenting process and played an integral part of the surgeon's explanation. Patients exposed to anatomical models also claimed to be more satisfied with the surgeon's inter-personal skills. This study recommends the use of anatomical models, which are both cost-effective and easily implementable, during explanation and consent for orthopaedic procedures.

Delayed recognition of diaphragmatic injury caused by penetrating thoraco-abdominal trauma

INTRODUCTION

Penetrating trauma to the thoraco-abdomen may cause diaphragmatic injury (DI). We present a case which highlights the difficulties of recognizing DI and the limited role of multimodal diagnostic imaging.

PRESENTATION OF CASE

A 19 year old male presented with stab wounds to his left lateral chest wall. CT was suspicious for diaphragmatic injury but this could not be confirmed despite ultrasound and serial plain radiographs. He was discharged but re-presented with respiratory compromise and diaphragmatic herniation.

DISCUSSION

We review the clinical features of diaphragmatic injury after penetrating thoraco-abdominal trauma and the various imaging modalities available to clinicians.

CONCLUSION

A high index of suspicion must be employed for DI in the context of penetrating thoraco-abdominal trauma. Inpatient observation and laparoscopy/thoracoscopy should be considered when radiological findings are ambiguous. Front line physicians should also consider diaphragmatic herniation in stab victims who re-present with respiratory, circulatory, or gastrointestinal symptomology.