Assigning Medical Students Learning Goals: Do They Do It, and What Happens When They Don't?

Theory: Medical curricula now include more time for trainees to manage their studying independently, yet evidence suggests that time is not well spent without guidance. Social-cognitivist models of self-regulated learning suggest value when guiding learners to set goals related to their performance processes (actions producing outcomes) versus their performance outcomes (products of performance). Hypotheses: We expected participants oriented to set process goals would demonstrate better suturing skill retention compared with participants oriented to set outcome goals. Method: We randomly assigned 41 medical students to two groups: outcome oriented or process oriented. They self-scored their performance using a visual analog scale on every third trial during 25 training trials, and during 10 retention trials 2 weeks later. Two raters assessed participants' suturing performances (process) and final products (outcome). After finding weak support for our hypothesis, we calculated a "self-monitoring calibration coefficient" as the Pearson's correlation between the raters' average score and each participant's self-scores. We used a mixed-effects analysis of variance to compare participants' performance scores as well as t tests and an analysis of variance to compare their self-monitoring calibration coefficients. Results: Analysis of skill retention data revealed a significant Group × Trial interaction, suggesting a benefit for the process group only for the 10th retention trial (p = .03). During training, the process group had significantly better (p = .02) self-monitoring calibration (r = .71 ± .29) than the outcome group (r = .38 ± .55). In retention, participants in both groups were significantly better calibrated (p = .04) with rater's scores of performance processes (r = .39 ± .60) versus performance outcomes (r = .11 ± .63). Conclusions: Our findings provide limited evidence for our original hypothesis. Perhaps more important, however, our self-monitoring calibration data highlighted inconsistencies between our interventions and our participants' apparent preferences. Not all participants adopted their assigned goal setting orientation, showing that researchers and educators must consider the extent to which trainees adopt imposed instructions in any educational intervention.

Negative-pressure wound therapy after fasciotomy reduces muscle-fiber regeneration in a pig model.

BACKGROUND: Negative-pressure wound therapy (NPWT) can improve fasciotomy wound closure, but its effects on skeletal muscle are largely unknown. The purpose of this study was to evaluate NPWT effects on skeletal muscle after fasciotomy for compartment syndrome in an animal model and to assess regional variability in muscle fiber regeneration. METHODS: Compartment syndrome was induced in the hindlimb of twenty-two adult female pigs with use of a continuous intracompartmental serum-infusion model. Fasciotomy was performed after six hours, and animals were randomized to receive either wet-to-dry gauze dressings (control group) or NPWT dressings (-125 mm Hg, continuous suction) for seven days. Delayed primary wound closure was attempted at seven days, and the peroneus tertius was harvested for analysis seven days or twenty-one days after fasciotomy. Muscles were weighed, and hematoxylin and eosin-stained samples from four regions of the muscle (superficial central, deep central, lateral, and proximal) were mapped for different cellular morphologies. RESULTS: Muscle weight was greater in the affected limb at all time points with no difference between treatment groups. At seven days, only the deep central samples in the NPWT group had a significantly greater cross-sectional area containing normal fibers as compared with that found in the controls. By twenty-one days, the deep central, lateral, and proximal regions of the NPWT-treated muscles had a smaller cross-sectional area containing normal fiber morphology and a greater cross-sectional area containing only mononucleated cells as compared with the controls. CONCLUSIONS: NPWT did not decrease muscle weight. At twenty-one days, the extent of muscle fiber regeneration after fasciotomy for compartment syndrome was reduced in muscles treated with NPWT for seven days compared with the values in the control group treated with wet-to-dry gauze dressings. CLINICAL RELEVANCE: NPWT may be harmful to skeletal muscle after compartment syndrome requiring fasciotomy and local wound care.

Toronto orthopaedic boot camp III: examining the efficacy of student-regulated learning during an intensive, laboratory-based surgical skills course.

BACKGROUND: Previous studies have presented compelling data that a 1-month "boot-camp"-style course can be a highly effective mechanism for teaching and developing targeted technical skills. In the current study, we examine whether performance of these targeted skills is improved when residents are trained using directed, student-led (SL) learning methods compared with traditional instructor-led (IL) learning methods. METHODS: Twelve first-year orthopedic residents began their training with a 1-month, intensive skills course. Six residents were taught basic surgical skills using a format that focused on deliberate, SL exploration and practice of the skills under instructor supervision (SL group). The remaining residents were taught the same surgical skills using more traditional IL methods that included complete demonstration of the surgical task by an orthopedic surgeon, followed by an extended period of instruction (IL group). Performance on 4 targeted technical skills (sawing, bone drilling, suturing, and plaster splint application) was tested using an objective, structured assessment of technical skills examination for the 2 groups at the beginning and the end of the skills course. RESULTS: Before the start of the skills course, there were no differences in performance scores between the 2 groups. On completion of the skills course, mean global rating scores for the 4 surgical skills tasks were greater for the SL group compared with the IL group: SL, 3.95 ± 0.1; IL, 3.42 ± 0.1; F(1,10) = 7.66 P < .02. A similar pattern of results was revealed by the checklists scores, with the SL group outperforming the IL group: SL, 94.9 ± 2.1; IL, 86.4 ± 2.1; F(1,10) = 8.512; P < .02. CONCLUSION: Previous work has demonstrated the effectiveness of teaching basic surgical skills through an intensive course at the onset of residency. The present study shows that allowing surgical trainees to take a directed, student-regulated approach to learning basic surgical skills can further improve performance of these skills.

Total hip arthroplasty for adult hip dysplasia.

Preoperative planning is essential to define anatomy, clarify the operative approach and exposure, and ensure that suitable implants are available.Concerns exist regarding the long-term effectiveness and safety of hip resurfacing arthroplasty for the young dysplastic hip.In light of current evidence, concerns exist regarding the use of metal-on-metal articulations for hip arthroplasty in the young dysplastic hip.The ideal bearing surface is not known, although the longest data available support the use of metal-on-polyethylene.

Orthopaedic Boot Camp II: examining the retention rates of an intensive surgical skills course.

BACKGROUND: We examined retention rates for basic surgical skills taught through a 1-month intensive laboratory boot camp-style course at the onset of residency. METHODS: We present data from 3 groups, each composed of 6 residents. The first group consisted of residents from a new competency-based curriculum (CBC). They started residency training with the Toronto Orthopaedic Boot Camp course. The other 2 groups were junior (JR) and senior (SR) residents from a traditional program whose residency training included no such course. Performance on targeted technical skills was tested using an objective structured assessment of technical skills examination 7 months after the onset of training for the CBC and JR groups and at least 43 months after the onset of training for the SR group. RESULTS: The mean global rating scale score for the CBC group immediately after the skills course was 4.3, which was maintained 6 months later. There were no significant performance differences between the CBC and SR groups. Both the CBC and SR groups performed significantly better than the JR group (mean global rating scale 3.7; F[2, 15] = 12.269, P < .001). CONCLUSION: We conclude that a surgical skills course at the onset of residency is an effective mechanism for teaching targeted technical skills and that skills taught in this manner can have excellent retention rates. Furthermore, an early focus on technical skills allows junior residents to perform at the same level as senior residents for certain tasks and may privilege later learning.

The use of structural allograft in primary and revision knee arthroplasty with bone loss.

Bone loss around the knee in the setting of total knee arthroplasty remains a difficult and challenging problem for orthopaedic surgeons. There are a number of options for dealing with smaller and contained bone loss; however, massive segmental bone loss has fewer options. Small, contained defects can be treated with cement, morselized autograft/allograft or metal augments. Segmental bone loss cannot be dealt with through simple addition of cement, morselized autograft/allograft, or metal augments. For younger or higher demand patients, the use of allograft is a good option as it provides a durable construct with high rates of union while restoring bone stock for future revisions. Older patients, or those who are low demand, may be better candidates for a tumour prosthesis, which provides immediate ability to weight bear and mobilize.

Distal femoral varus osteotomy: unloading the lateral compartment: long-term follow-up of 45 medial closing wedge osteotomies.

Distal femoral medial closing wedge osteotomy is useful for mechanical axis realignment to unload the lateral compartment of the valgus knee. The primary indication for unloading the lateral compartment is lateral unicompartmental osteoarthritis. Alternative treatment options include lateral unicompartment or total knee arthroplasty (TKA). Prerequisites for the osteotomy include a 90° arc of motion, age younger than 60 years, and an active patient capable of an extensive period of rehabilitation. Surgery is carried out through a midline skin incision and uses a subvastus approach. The medial femoral closing wedge osteotomy is fixed with a 90° dynamic compression blade plate. A critical technical point is the need to insert the blade plate parallel to the joint line. The right angle plate corrects the tibialfemoral angle to 0°. A benefit of the closing wedge over an opening wedge osteotomy is reduced risk of nonunion. Survivorship and functional outcome of 41 patients with 45 distal femoral varus osteotomies at a mean follow-up of 13.3 years were retrospectively analyzed. Survivorship at 10, 15, and 20 years was 90%, 79%, and 21.5% respectively. Mean Modified Knee Society Score was 36.1 preoperatively, 74.4 at 1-year postoperatively, and 60.5 at last follow-up. Distal femoral varus osteotomy is effective at unloading the lateral compartment in unicompartmental arthritis in the valgus knee. It may be indicated in the young, high activity demand, and overweight patient. By 20 years after the osteotomy most patients require conversion to TKA.

Wound healing problems in total knee arthroplasty.

It is important to avoid underestimating the significance of wound complications following total knee arthroplasty (TKA). Expedient and aggressive care is recommended. Understanding the blood supply to the skin around the knee and measures to prevent wound complications are fundamental to preventing wound problems. A detailed patient history and physical examination will identify high-risk patients and any modifiable risk factors. Operative techniques such as raising full-thickness skin flaps and judicious placement of skin incisions in the presence of pre-existing scars can greatly reduce the incidence of wound problems. The first step in treating wound problems is recognizing when a problem is present and knowing when a minor problem can turn into a major one. Superficial infections or stitch abscesses can be treated with conservative treatment. However, the surgeon should have a low threshold to revert to surgical management if drainage persists. Skin necrosis or non-viable skin must be excised in the operating room, and the presence of a deep infection must be diagnosed by joint aspiration. The appropriate course of action in dealing with deep infection is dependent on the duration elapsed since the index procedure. The ability to perform a medial gastrocnemius muscle flap and skin graft is an invaluable skill in complex cases where primary wound closure cannot be achieved. Meticulous attention to detail during surgery and aggressive surgical treatment of wound complications can be the difference in saving the knee.

Systematic review of the prevalence of radiographic primary hip osteoarthritis.

Hip osteoarthritis is a common cause of musculoskeletal pain in older adults and may result in decreased mobility and quality of life. Although the presentation of hip osteoarthritis varies, surgical management is required when the disease is severe, longstanding, and unresponsive to nonoperative treatments. For stakeholders to plan for the expected increased demand for surgical procedures related to hip osteoarthritis, including arthroplasty, it is important to first understand its prevalence. We conducted a systematic review by searching MEDLINE and EMBASE to identify recent English language articles reporting on the prevalence of radiographic primary hip osteoarthritis in the general adult population; references including studies and primary studies from previous systematic reviews were also searched. This strategy yielded 23 studies reporting 39 estimates of overall prevalence ranging from 0.9% to 27% with a mean of 8.0% and a standard deviation of 7.0%. Heterogeneity was noted in study populations, eligibility criteria, age and gender distribution, type of radiographs, and method of diagnosis. Although the association between radiographic hip osteoarthritis and the need for eventual surgical management is still unclear, this study supports assertions that hip osteoarthritis is a prevalent condition whose treatment will continue to place important demands on health services.

Juvenile idiopathic scoliosis: the effectiveness of part-time bracing.

STUDY DESIGN: A retrospective review of 34 patients with juvenile idiopathic scoliosis (JIS) treated with a nighttime bending brace. OBJECTIVE: To determine the effectiveness of part-time bracing in JIS. SUMMARY OF BACKGROUND DATA: Although previous bracing studies have focused on adolescent idiopathic scoliosis, no authors have dealt specifically with part-time bracing for JIS. METHODS: Twenty-three patients included in the study met the following criteria: curves greater than 20 degrees and Risser zero at initiation of bracing, brace wear more than 12 months, completion of the bracing program and Risser sign greater than or equal to 4 at final follow-up. Patients were analyzed according to 3 groups: (1) success (progression equal or less than 5 degrees), (2) progression more than 5 degrees (but not requiring surgery and achieving curve stabilization at skeletal maturity), and (3) surgery (curve progressing to greater than 45 degrees ) with failure of bracing treatment during skeletal immaturity. RESULTS: Seven boys and 16 girls with a total of 37 curves were analyzed. The average age at referral and initiation of bracing was 8.3 and 10.3 years, respectively. Average curve magnitude at time of bracing was 30 degrees. Length of bracing averaged 3.7 years with follow-up after brace discontinuation of 2.5 years. Nine patients met the criteria for success, with 7 patients progressing and 7 patients eventually requiring spinal fusion. Of the 37 curves, 19 (51%) were successfully managed in the brace. The magnitude of curvature at initiation of bracing did not relate to a successful outcome, whereas success did correlate with higher radiographic in-brace correction. Given the longer course of treatment for JIS patients, part-time bracing offers potential psychosocial and compliance benefits. CONCLUSION: Part-time bracing in JIS is successful and is better than the natural history.