Setting proficiency standards for simulation-based mastery learning of short antegrade femoral nail osteosynthesis: a multicenter study.

BACKGROUND AND PURPOSE: Orthopedic trainees frequently perform short antegrade femoral nail osteosynthesis of trochanteric fractures, but virtual reality simulation-based training (SBT) with haptic feedback has been unavailable. We explored a novel simulator, with the aim of gathering validity evidence for an embedded test and setting a credible pass/fail standard allowing trainees to practice to proficiency. PATIENTS AND METHODS: The research, conducted from May to September 2020 across 3 Danish simulation centers, utilized the Swemac TraumaVision simulator for short antegrade femoral nail osteosynthesis. The validation process adhered to Messick's framework, covering all 5 sources of validity evidence. Participants included novice groups, categorized by training to plateau (n = 14) or to mastery (n = 10), and experts (n = 9), focusing on their performance metrics and training duration. RESULTS: The novices in the plateau group and experts had hands-on training for 77 (95% confidence interval [CI] 59-95) and 52 (CI 36-69) minutes while the plateau test score, defined as the average of the last 4 scores, was 75% (CI 65-86) and 96% (CI 94-98) respectively. The pass/fail standard was established at the average expert plateau test score of 96%. All novices in the mastery group could meet this standard and interestingly without increased hands-on training time (65 [CI 46-84] minutes). CONCLUSION: Our study provides supporting validity evidence from all sources of Messick's framework for a simulation-based test in short antegrade nail osteosynthesis of intertrochanteric hip fracture and establishes a defensible pass/fail standard for mastery learning of SBT. Novices who practiced using mastery learning were able to reach the pre-defined pass/fail standard and outperformed novices without a set goal for external motivation.

Does Virtual Reality Improve Procedural Completion and Accuracy in an Intramedullary Tibial Nail Procedure? A Randomized Control Trial.

BACKGROUND: Artificial reality technologies are currently being explored as potential options to improve surgical education. Previous studies have primarily examined the efficacy of artificial reality in laparoscopic procedures, but to our knowledge, none have been performed in orthopaedically relevant procedures such as intramedullary tibial nailing, which calls for more versatile large-scale movements. QUESTIONS/PURPOSES: Does a virtual reality simulator with or without a standard technique guide result in (1) a higher proportion of participants who completed the insertion of an intramedullary tibial nail in a synthetic bones model and (2) greater procedural accuracy than does training with a technique guide alone? METHODS: Twenty-five first- and second-year medical students without prior exposure to intramedullary tibial nail insertion were recruited. Participants were randomly assigned to the technique guide control group (n = 8), the virtual reality group (n = 8), or the virtual reality and technique guide group (n = 9). The technique guide was adapted from a commercially available technique guide, which participants in the assigned groups could use to prepare as much as desired. The virtual reality simulation was based on the same procedure, and we used a commercially available virtual reality simulator that we purchased for this task. Participants in the virtual reality experimental groups completed the simulation on three separate sessions, at a set interval of 3 to 4 days apart. After 10 to 14 days of preparation, all participants attempted to insert an intramedullary nail into an intact, compact bone-model tibia that lacked surrounding soft tissue. Participants were given written hints if requested, but no other assistance was given. A procedure was considered complete if the nail and screw were properly placed. Procedural accuracy was defined as the number of incorrect steps normalized out of the 16 possible performed. After the procedure, one orthopaedic surgeon assessed a blinded video of the participant performing it so the assessor could not recognize the individual or that individual's gender. Additionally, the assessor was unaware of which group each participant had been randomized to during the evaluation. RESULTS: A higher proportion of participants in the virtual reality group (6 of 8) and the virtual reality and technique guide group (7 of 9) completed the intramedullary nail than did participants in the technique guide group (2 of 8; p = 0.01). There was no difference in completion between the virtual reality groups (p = 0.89). Participants in the virtual reality and virtual reality and technique guide had fewer normalized incorrect steps than did participants in the technique guide group (3.2 ± 0.1 of 16 and 3.1 ± 0.1 of 16 versus 5.7 ± 0.2 of 16, respectively; p = 0.02 for comparisons of virtual reality groups to technique guide, p = 0.63 between the virtual reality group). CONCLUSIONS: Virtual reality increased both procedural accuracy and the completion proportion compared with a technique guide in medical students. Based on our findings, virtual reality may help residents learn the procedural workflow and movements required to perform surgical procedures. Future studies should examine how and when exactly the technology can be applied to residencies and its impact on residents. LEVEL OF EVIDENCE: Level I, therapeutic study.

Suprapatellar tibial nailing: a learning curve analysis.

PURPOSE: The suprapatellar approach for intramedullary nailing of tibial fractures is gaining popularity with reported improved patient outcomes when compared to infrapatellar techniques. The aim of this study was to investigate the learning curve of the suprapatellar technique using radiation exposure as an outcome measure. METHODS: Data were analysed from a prospectively collected database over a 3-year period at a Major Trauma Centre in the United Kingdom. 83 study patients with an acute isolated extra-articular fracture of the tibia treated with intramedullary tibial nailing were included. Cases requiring additional intra-operative procedures were excluded. Four consultant trauma surgeons with no previous experience of the suprapatellar technique used this approach for 40 consecutive operations. Six consultant trauma surgeons used the infrapatellar approach for 43 patients and acted as a control group. Patient demographics, fluoroscopy time and radiation dose area product (DAP) were collected for each operation. A segmented linear regression modelling method was employed to analyse learning. RESULTS: Fluoroscopy time and DAP per surgeon showed no evidence of a learning curve when using a suprapatellar tibial nailing technique in group or individual analysis. Fluoroscopy time and DAP were stationary in the infrapatellar group analysis, confirming the absence of time-dependent trends over the study period. CONCLUSIONS: Consultant trauma surgeons experienced no significant learning-related increase in radiation exposure when introducing a suprapatellar technique for intramedullary nailing of uncomplicated tibial fractures. Future work is required to investigate the effects of learning on other outcome measures.

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.

Is it safe to assist proximal humeral nailing to residents? An analysis of 1134 cases.

INTRODUCTION: Intramedullary nailing is a common procedure for the treatment of proximal humeral fractures. In practical resident training this standardized operation plays an important role in the introduction to osteosynthesis. Our aim was to investigate whether assisting this operation to residents influences the surgical complication rate both in-house and on re-admission. METHODS: All 1134 patients who received a proximal humeral Targon PH nail (Aesculap) for proximal humeral fractures were included between 2000 and 2013. Several age groups (≤60 years, 61-70 years, 71-80 years, 80-90 years, and over 90 years) were analyzed separately. Complications including screw/nail protrusion, displacement, infection, humeral head necrosis, nonunion, stiffness, hematoma, impingement, screw loosening, implant failure, dislocation were recorded. 803 (70.7%) of the patients were female. Mean patient age was 71.7 years (standard deviation: 14.0 years). For detection of significantly different complication frequencies between operations performed by residents or attending physicians, we used the χ2 test in cases with all expected values greater than five, otherwise we used the two-sided Fisher's exact test. RESULTS: Supervised residents performed 204 operations. Overall complication rate was 12.6% (95% CI: 10.7-14.5%). The complication rate of the attending operations was 13.2% while it was 9.8% for resident operations. The difference was not significant. No statistically significant relation between age group and complication rate was found. In all patients older than 80 years the complication rate was higher when operated by residents compared to those operated by consultants, whereas in younger patients it was lower. Whereas the difference was not significant in patients younger than 60 and older than 80, we found significantly less complications in the group of patients between 61 and 80 years of age. On the other hand patients between 81 and 90 years displayed a 1.46 fold higher risk after training operations. No significant differences in the frequency of the different complications were found. CONCLUSION: We conclude that proximal humeral nailing is an operation suitable for teaching purposes. However, patients between 81 and 90 years of age seem to be at an increased risk for complications if operated by a resident.

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.

Interlocked Intramedullary Nail Without Fluoroscopy.

Surgical Implant Generation Network (SIGN) was founded 15 years ago to create equality of fracture care throughout the world. This is done by education and supply of the appropriate implants and instruments to implement the education. SIGN implants have been used in 150,000 long bone fractures in developing countries. The same implants and instruments are used to provide intramedullary nail interlocking screw fixation in the tibia, femur, and humerus. The design of SIGN implants and the surgical technique are described.

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.

[Pertrochanteric fracture - operation for beginners?]. / Pertrochantäre Femurfraktur - eine Anfängeraufgabe?

BACKGROUND: In patients over 65 years, pertrochanteric proximal femur fractures are very common, with an incidence of 966/100,000. Treatment of choice is nailing or dynamic hip screws. The operative approaches are standardised and easy to learn. QUESTION: Is nail fixation a good procedure for surgical training? PATIENTS: From 1 January 2012 until 31 December 2013, 210 patients with an average age of 80.7 years and pertrochanteric fractures underwent treatment. 139 patients (66%) were treated by surgical trainees, 55 (26%) by staff surgeons, and 16 by the head of the department (8%). RESULTS: Preoperative delay averaged one day. Skin to skin operative time averaged 48 minutes for all patients. For trainees, the procedure averaged 45 minutes, while the more complex cases treated by staff surgeons (multi-fragment, markedly displaced) averaged 67 minutes and thus took significantly longer (p < 0.1). There was no difference in complications. There were 6 misplaced implants and cutouts (2.8%), one infection (0.5%), and 6 operative revisions because of hematoma or seroma (2.8%). Four patients (1.9%) died of cardiovascular failure with ASA 3 and 4 during the inpatient stay (2 in each group). CONCLUSION: Internal fixation with nailing in pertrochanteric femur fractures is a standard operative approach. It is suitable as a "beginner's" procedure, that is quickly and easily performed. Only complex, multifragmented or markedly displaced or long-segment fractures need to be treated by staff physicians. Mortality is not affected by the surgeon's experience, but rather by comorbidity and from the preoperative duration.

The Küntscher Society: the South American perspective.

This paper reviews the beginning of the South American Council of the Küntscher International Society, a group of enthusiastic South American Orthopaedic Surgeons committed to teach the principles and advances of intramedullary nailing technique in this part of the world. The goals, current and future educational activities are highlighted.

Training in the practical application of damage control and early total care operative philosophy--perceptions of UK orthopaedic specialist trainees.

INTRODUCTION: Despite improvements in the outcome of individuals sustaining significant injury, the optimum management of fractures in traumatised patients remains an area of debate and publication. There is, however, a paucity of studies regarding the specifics of acquired experience and training of junior orthopaedic surgeons in the practical application of these skills. Our null hypothesis is that, despite alteration in surgical training, the perceived confidence and adequacy of training of UK orthopaedic specialist trainees in the application of damage control orthopaedics (DCO) and early total care (ETC) philosophy is unaffected. SUBJECTS AND METHODS: A web-based survey was sent to a sample of orthopaedic trainees. From 888 trainees, 222 responses were required to achieve a 5% error rate with 90% confidence. RESULTS: A total of 232 responses were received. Trainees reported a high level of perceived confidence with both external fixation and intramedullary devices. Exposure to cases was sporadic although perceived training adequacy was high. A similar pattern was seen in perceived operative role with the majority of trainees expecting to be performing such operations, albeit under varying levels of supervision. In a more complicated case of spanning external fixation for a 'floating knee, trainees reported a decreased level of perceived confidence and limited exposure. One-third of trainees reported never having been involved in such a case. In contrast to nationally collated logbook data, exposure to and perceived confidence in managing cases involving ETC and DCO were similar. CONCLUSIONS: Despite changes in the training of junior orthopaedic surgeons, trainee-reported confidence and adequacy of training in the practical application of DCO and ETC was high. Exposure to cases overall was, however, seen to be limited and there was a suggestion of disparity between current operative experiences of trainees and that recorded in the national trainee logbook.

Injuries in developing countries--how can we help? The role of orthopaedic surgeons.

Each year nearly 5 million people worldwide die from injuries, approximately the number of deaths caused by HIV/AIDS, malaria, and tuberculosis combined. Ninety percent of these injuries occur in developing countries and that number is growing. Road traffic accidents account for 1.2 million of these 5 million deaths. For each death from trauma, three to eight more are permanently disabled. Orthopaedic surgeons should consider the victims of this epidemic by using their ability and capacity to treat these injuries. SIGN (Surgical Implant Generation Network, Richland, WA, USA) builds local surgical capability in developing countries by providing training and equipment to surgeons for use in treating the poor. It assists in treating long-bone fractures by using an intramedullary nail interlocking screw system. C-arm imaging, unavailable in many of these hospitals, is not necessary to accomplish interlocking. Surgery is performed primarily by local surgeons who record their cases on the SIGN surgical database. Discussion of these reports provides a means of communication and education among surgeons. This database demonstrates the capability of these surgeons. It also demonstrates that the SIGN intramedullary nail is safe for use in the developing world as it has been successful in treating 36,000 trauma patients.