Rehabilitation outcomes based on service provision and geographical location for patients with multiple trauma: A mixed-method systematic review.

INTRODUCTION: Previous research has highlighted the benefit of regionalised trauma networks in relation to decreased mortality. However, patients who now survive increasingly complex injuries continue to navigate the challenges of recovery, often with a poor view of their experiences of the rehabilitation journey. Geographical location, unclear rehabilitation outcomes and limited access to the provision of care are increasingly noted by patients as negatively influencing their view of recovery. STUDY DESIGN: This mixed-methods systematic review included research that addresses the impact of service provision and geographical location of rehabilitation services for multiple trauma patients. The primary aim of the study was to analyse functional independence measure (FIM) outcomes. The secondary aim of the research was to examine the rehabilitation needs and experiences of multiple trauma patients by identifying themes around the barriers and challenges to rehabilitation provision. Finally, the study aimed to contribute to the gap in literature around the rehabilitation patient experience. METHODS: An electronic search of seven databases was undertaken against pre-determined inclusion/exclusion criteria. The Mixed Methods Appraisal Tool was utilised for quality appraisal. Following data extraction, both quantitative and qualitative analysis methods were utilised. In total, 17,700 studies were identified and screened against the inclusion/exclusion criteria. Eleven studies met the inclusion criteria (five quantitative, four qualitative, two mixed method). RESULTS: FIM scores showed no significant difference in all studies after long-term follow-up. However, statistically significantly less FIM improvement was noted in those with unmet needs. Patients with physiotherapist assessed unmet rehabilitation needs were statistically less likely to improve than patients whose needs were reportedly met. In contrast, there was a differing opinion regarding the success of structured therapy input, communication and coordination, long-term support and planning for home. Common qualitative themes revealed lack of rehabilitation post-discharge, often with long waiting times. CONCLUSION: Stronger communication pathways and coordination within a trauma network, particularly when repatriating outside of a network catchment area is recommended. This review has exposed the many rehabilitation variations and complexities a patient may experience following trauma. Furthermore, this highlights the importance of arming clinicians with the tools and expertise to improve patient outcomes.

Covid-19 and orthopaedic trauma: Quantification of orthopaedic trauma workload and staff resource allocation during a global pandemic-related lockdown.

Introduction: Healthcare systems across the world have struggled as a result of the Covid-19 pandemic. Most specialties have redeployed their staff and resources to deal with the pandemic whilst ceasing their planned elective activity. However acute specialties such as Trauma and Orthopaedics still have a significant emergency caseload that must be safely managed, even in a pandemic. The aim of this study was to investigate the change in Orthopaedic Trauma caseload in a Trauma Unit and a Major Trauma Centre during a pandemic compared to pre-pandemic levels and the associated staffing requirements. Methods: The data presented was collected from a Trauma Unit and a Major Trauma Centre in the United Kingdom. We compared the number of accident and emergency referrals, fracture clinic appointments, inpatient admissions and operations during the six weeks of the first lockdown from 23rd March to May 3, 2020, to the same time period in 2019. Results: The results showed that the orthopaedic trauma caseload was approximately half that of pre-pandemic levels, reducing by an average of 54.2%. Conclusion: A significant orthopaedic trauma caseload still remains to be safely managed during a pandemic and appropriate resources must be allocated. Staff allocation must take into account sick cover and staff wellbeing. A proportion of staff may need to be ring fenced from redeployment to facilitate this.

Platelet-Rich Plasma Augmentation of Arthroscopic Rotator Cuff Repair Lowers Retear Rates and Improves Short-Term Postoperative Functional Outcome Scores: A Systematic Review of Meta-Analyses.

Purpose: The purpose of this study is to conduct a systematic review of meta-analyses of rotator cuff repair using platelet-rich plasma (PRP) to identify whether PRP improves clinical function and rate of tendon retears. We will (1) conduct a systematic review of the current meta-analyses of rotator cuff repair using platelet-rich plasma available in the literature, (2) evaluate the quality of these meta-analyses using the Preferred Reporting Items for Systematic Review (PRISMA) methodology, (3) identify whether PRP improves clinical function and rate of tendon retears, and develop guidance to improve future studies in this area. Methods: We carried out a systematic review of previous meta-analyses published on the clinical outcomes of PRP used in the treatment of rotator cuff tears. We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase databases, using various combinations of the commercial names of each PRP preparation and "rotator cuff" (with its associated terms), looking specifically at human meta-analysis studies involving the repair of the rotator cuff tendon surgically in the English language. Data validity was assessed and collected on clinical outcomes. Following this, a meta-analysis was undertaken. Results: Thirteen meta-analyses met the inclusion and exclusion criteria. All were considered of similar quality with Oxman-Guyatt index of 9 and PRISMA score of more than 24. A total of 1,800 patients with an average follow up of 12 to 36 months. The use of PRP for arthroscopic rotator cuff tear, when compared with controls, leads to a lower number of retears, improved short-term postoperative scores, and functional outcome. The following postoperative scores were reported: Constant: 12, Simple Shoulder Test: 10, ASES (American Shoulder and Elbow Surgeons): 9, UCLA (University of California, Los Angeles) 11, SANE (Single Assessment Numeric Evaluation) 1, VAS (visual analog scale): 6, and Retears: 13. Subgroup analysis showed that leukocyte content and gel application make no difference in the effectiveness of PRP. VAS score subgroup analysis showed short-term pain relief. Conclusions: Our study shows that PRP is effective in reducing retears after rotator cuff repair and improving functional outcome scores and reducing short-term pain. Level of Evidence: Level III, systematic review of Level I-III studies.

Emotional Intelligence and Good Medical Practice: Is There a Relationship?

Emotional intelligence (EI) is defined as the ability to perceive and manage the emotions of oneself and others. Despite being one of the most highly used psychological terms in popular nomenclature, its understanding in the context of clinicians remains poor. There is a dearth of literature on this topic, and this submission examines the relationship between a clinicians' EI and the key domains of "Good Medical Practice" guidelines from the General Medical Council, United Kingdom. It aims to review and critically analyse the existing literature on EI and Good Medical Practice while attempting to establish a relationship between the two. This submission thus examines the relationship between emotional intelligence and a clinician's on-the-job performance. The findings demonstrate how emotional intelligence can aid the clinician in all aspects of their working life in the context of practising in line with General Medical Council (GMC) guidance. The authors also recommend exploring the possibility of inclusion of EI within a modern medical curriculum, as it may lead to improved practice in clinicians.

Is the Virtual Reality Fundamentals of Arthroscopic Surgery Training Program a Valid Platform for Resident Arthroscopy Training?

BACKGROUND: Training in arthroscopy is associated with a steep learning curve for trainees and bears risks for patients. Virtual reality (VR) arthroscopy simulation platforms seek to overcome this and to provide a safe environment for surgical learners. The Fundamentals of Arthroscopic Surgery Training (FAST) program is one such platform. It is currently not known whether the VR FAST program can be employed as a useful teaching or examination tool to assess the basic arthroscopic skills of surgical trainees. QUESTIONS/PURPOSES: (1) Does the VR FAST program differentiate among novice, intermediate, and expert arthroscopists? (2) Does ambidextrous performance in the VR FAST program correlate with arthroscopic experience? METHODS: We prospectively recruited orthopaedic interns (novices), residents (intermediates), and fellows and attendings (experts) to complete the VR FAST program over a 1-year period from four major orthopaedic training programs on a voluntary basis. Sixty-six of 156 invited orthopaedic surgeons participated: 26 of 50 novices (16 men and 10 women), 27 of 65 intermediates (20 men and seven women), and 13 of 41 experts (10 men and three women). Surgeons of any arthroscopic experience were included, with only those with prior experience on the VR FAST program being excluded. The program consists of eight modules: three basic camera modules (Image Centering, Horizon Control, and Telescoping), three advanced camera modules (Periscoping, Trace the Line, and Trace the Curve), and two instrumented bimanual-dexterity modules (Probe Triangulation and Gather the Stars). Time taken to complete each task and measures of economy of movement (camera and instrument path length, camera alignment) were used as measures of arthroscopic experience. Every participant completed the modules using their dominant and nondominant hands. Equality in proficiency in completing the tasks using the dominant and nondominant hands were determined to be measures of arthroscopic experience. Due to the large number of outcome variables, only p values < 0.01 were considered to be statistically significant. RESULTS: Six of eight VR FAST modules did not discriminate among novice, intermediate, and expert arthroscopy participants. However, two did, and the ones that were most effective at distinguishing participants by level of experience were the Periscoping and Gather the Stars modules. For the Periscoping module using the dominant hand, novices required longer to complete the task with a median time of 231 seconds (IQR 149 to 358) and longer camera path length median of 191 cm (IQR 128 to 273) compared with intermediates who needed 127 seconds (IQR 106 to 233) and 125 cm (IQR 92 to 159) and experts who needed 121 seconds (IQR 93 to 157) and 119 cm (IQR 90 to 134) (p = 0.001 and p = 0.003, respectively). When using the nondominant hand, novices took longer to complete the task with a median time of 231 seconds (IQR 170 to 350) and longer camera path length 204 cm (IQR 169 to 273) compared with intermediates who required 132 seconds (IQR 97 to 162) and 111 cm (IQR 88 to 143) and experts who needed 119 seconds (IQR 104 to 183) and 120 cm (IQR 108 to 166) (p < 0.001 and p < 0.001, respectively). For the Gather the Stars module using the nondominant hand, only the novices needed longer to complete the task at a median of 131 seconds (IQR 112 to 157) and needed a longer grasper path length of 290 cm (IQR 254 to 332) compared with intermediates who needed 84 seconds (IQR 72 to 119) and 232 cm (IQR 195 to 254) and experts who needed 98 seconds (IQR 87 to 107) and 244 cm (IQR 215 to 287) (p < 0.001 and p = 0.001, respectively). CONCLUSION: Six of eight VR FAST modules did not demonstrate construct validity, and we found no correlation between arthroscopic experience and ambidextrous performance. Two modules demonstrated construct validity; however, refinement and expansion of the modules is needed with further validation in large prospective trials so that pass-fail thresholds can be set for use in high-stakes examinations. CLINICAL RELEVANCE: Most VR FAST modules were not discriminatory; however, they can form essential conceptual and procedural building blocks in an arthroscopic curriculum that are beneficial for novices when developing key psychomotor skills. In their present format, however, they are unsuitable for assessing arthroscopic proficiency.

Transferable Global Rating Scales in the Validation of the ArthroSim™ Virtual Reality Arthroscopy Simulator.

INTRODUCTION: Virtual reality arthroscopic simulators are becoming increasingly prevalent in the orthopaedic training environment. The construct validity of the ArthroSim virtual reality simulator (TolTech Touch of Life Technologies, Aurora, Colorado) has been established based on time to completion comparison between candidates of differing levels of surgical experience. This study aims to establish the construct validity of the ArthroSim virtual reality simulator using validated global rating scales that allow direct comparison with intraoperative performance. MATERIALS AND METHODS: Eight novices (medical students), eight intermediates (registrars), and seven experts (consultants) were assessed using the Imperial Global Arthroscopy Rating Scale (IGARS) and the Arthroscopic Surgical Skills Evaluation Tool (ASSET) scoring systems while carrying out a standardised basic diagnostic knee arthroscopy using linked and anonymised recordings of both the arthroscopy video output and candidate's hand posture and position. Time to completion was recorded and the expert group also filled out questionnaires assessing the face and content validity of the simulator. RESULTS: The mean IGARS/ASSET scores for the novice, intermediate and expert groups were 14/11, 29/22, and 46/36 respectively. The difference in score between each of the groups was statistically significant (p<0.05). The average time to completion was 257 seconds, 305 seconds, and 204 seconds respectively. The time to completion was not significantly different between the groups (p=0.6). CONCLUSIONS: The ArthroSim virtual reality simulator could effectively distinguish between candidates of differing experience levels using validated global rating scales and therefore demonstrated construct validity.

Global Rating Scales for the Assessment of Arthroscopic Surgical Skills: A Systematic Review.

PURPOSE: To evaluate whether sufficient validity and reliability evidence exists to support the use of global rating scales (GRS) as evaluation tools in both formative assessment and competency assessment of arthroscopic procedures. METHODS: A search of PubMed, Embase, and Scopus was conducted for articles published between 1990 and 2018. Studies reporting measures of validity and reliability of GRS relating to arthroscopic skills were included. Procedural checklists and other assessment tools were excluded. RESULTS: A total of 39 articles met the inclusion criteria. In total, 7 de novo GRS specific for arthroscopic education and 3 pre-existing GRS repurposed 4 times for arthroscopic education were identified in the literature. The 11 GRS were used to assess 1175 surgeons 3890 times. Three GRS tools explicitly defined an arbitrary minimum competency threshold, 6 of 11 tools demonstrated construct validity-the ability to significantly discriminate between groups of differing experience-and 5 of 11 tools assessed inter-rater reliability, but only the Arthroscopic Surgical Skills Evaluation Tool demonstrated excellent inter-rater reliability. The Arthroscopic Surgical Skills Evaluation Tool was validated by 16 articles for a total of 537 surgeons for hip, knee, shoulder, and ankle arthroscopy in both simulated and clinical environments but was found to be invalid in wrist arthroscopy. The Basic Arthroscopic Knee Skill Scoring System was validated by 15 articles for a total of 497 surgeons for knee, hip, and shoulder in both clinical and simulated environments. The remaining 9 GRS were validated by 2 or fewer studies. CONCLUSIONS: Overall, GRS have contributed to training, feedback, and formative assessment practices. The GRS reviewed demonstrate both construct and concurrent validity as well as reliability in multiple arthroscopic procedures in multiple joints. Currently, there is sufficient evidence to use GRS as a feedback tool. However, there is insufficient evidence for its use in high-stakes examinations or as a minimum competency assessment. LEVEL OF EVIDENCE: Level III, systematic review of level I to III studies.

Performance on a Virtual Reality DHS Simulator Correlates with Performance in the Operating Theatre.

INTRODUCTION: Dynamic Hip Screw (DHS) fixation of neck of femur fractures is one of the most commonly performed orthopaedic trauma operations. Changes in working practices have impacted surgical training and have resulted in fewer opportunities to perform this procedure. Virtual reality (VR) simulation has been shown to be a valid means of gaining competency, efficiently and safely, without compromising patient safety. OBJECTIVE: The aim of this study is to determine whether performance on a VR DHS simulator correlates with performance in the operating theatre. MATERIALS AND METHODS: All episodes of DHS fixation of neck of femur fractures performed at Royal London Hospital, Barts Health NHS Trust, level 1 major trauma centre between January 2014 and December 2015 were identified using the hip fracture database. The primary surgeon was identified using the electronic operative notes. The intraoperative fluoroscopic images were accessed and the tip-apex distance (TAD) was measured, as well as the probability of cut-out. The surgeon then performed DHS fixation on a VR DHS simulator and the TAD achieved in theatre was correlated with the simulated TAD. RESULTS: Twenty-five surgeons, including six novices (core surgical trainees), 12 intermediates (specialist registrars), and seven experts (fellows and consultants), completed the study. There was no overall statistically significant difference in TAD between those achieved in the operating theatre and on the simulator for each participant (p=0.688). CONCLUSION: There is no significant difference between performance on a VR DHS simulator and the operating theatre. This suggests that the simulator is excellent for training in this component of the DHS procedure, but further work is needed to assess whether training on the simulator can improve performance in the operating theatre.

Validation of the updated ArthroS simulator: face and construct validity of a passive haptic virtual reality simulator with novel performance metrics.

PURPOSE: To assess the construct and face validity of ArthroS, a passive haptic VR simulator. A secondary aim was to evaluate the novel performance metrics produced by this simulator. METHODS: Two groups of 30 participants, each divided into novice, intermediate or expert based on arthroscopic experience, completed three separate tasks on either the knee or shoulder module of the simulator. Performance was recorded using 12 automatically generated performance metrics and video footage of the arthroscopic procedures. The videos were blindly assessed using a validated global rating scale (GRS). Participants completed a survey about the simulator's realism and training utility. RESULTS: This new simulator demonstrated construct validity of its tasks when evaluated against a GRS (p ≤ 0.003 in all cases). Regarding it's automatically generated performance metrics, established outputs such as time taken (p ≤ 0.001) and instrument path length (p ≤ 0.007) also demonstrated good construct validity. However, two-thirds of the proposed 'novel metrics' the simulator reports could not distinguish participants based on arthroscopic experience. Face validity assessment rated the simulator as a realistic and useful tool for trainees, but the passive haptic feedback (a key feature of this simulator) is rated as less realistic. CONCLUSION: The ArthroS simulator has good task construct validity based on established objective outputs, but some of the novel performance metrics could not distinguish between surgical experience. The passive haptic feedback of the simulator also needs improvement. If simulators could offer automated and validated performance feedback, this would facilitate improvements in the delivery of training by allowing trainees to practise and self-assess.

Using simulation to train orthopaedic trainees in non-technical skills: A pilot study.

AIM: To enhance non-technical skills and to analyse participant's experience of a course tailored for orthopaedic surgeons. METHODS: A Delphi technique was used to develop a course in human factors specific to orthopaedic residents. Twenty-six residents (six per course) participated in total with seven course facilitators all trained in Crisis Resource Management providing structured feedback. Six scenarios recreated challenging real-life situations using high-fidelity mannequins and simulated patients. Environments included a simulated operating suite, clinic room and ward setting. All were undertaken in a purpose built simulation suite utilising actors, mock operating rooms, mock clinical rooms and a high fidelity adult patient simulator organised through a simulation control room. Participants completed a 5-point Likert scale questionnaire (strongly disagree to strongly agree) before and after the course. This assessed their understanding of non-technical skills, scenario validity, relevance to orthopaedic training and predicted impact of the course on future practice. A course evaluation questionnaire was also completed to assess participants' feedback on the value and quality of the course itself. RESULTS: Twenty-six orthopaedic residents participated (24 male, 2 female; post-graduation 5-10 years), mean year of residency program 2.6 out of 6 years required in the United Kingdom. Pre-course questionnaires showed that while the majority of candidates recognised the importance of non-technical (NT) skills in orthopaedic training they demonstrated poor understanding of non-technical skills and their role. This improved significantly after the course (Likert score 3.0-4.2) and the perceived importance of these skills was reported as good or very good in 100%. The course was reported as enjoyable and provided an unthreatening learning environment with the candidates placing particular value on the learning opportunity provided by reflecting on their performance. All agreed that the course achieved its intended aims with realistic simulation scenarios. Participants believed patient care, patient safety and team working would all improve with further human factors training (4.4-4.6). and felt that NT skills learnt through simulation-based training should become an integral component of their training program. CONCLUSION: Participants demonstrated improved understanding of non-technical performance, recognised its relevance to patient safety and expressed a desire for its integration in training.

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.

Which Global Rating Scale? A Comparison of the ASSET, BAKSSS, and IGARS for the Assessment of Simulated Arthroscopic Skills.

BACKGROUND: With the move to competency-based models of surgical training, a number of assessment methods have been developed. Of these, global rating scales have emerged as popular tools, and several are specific to the assessment of arthroscopic skills. Our aim was to determine which one of a group of commonly used global rating scales demonstrated superiority in the assessment of simulated arthroscopic skills. METHODS: Sixty-three individuals of varying surgical experience performed a number of arthroscopic tasks on a virtual reality simulator (VirtaMed ArthroS). Performance was blindly assessed by two observers using three commonly used global rating scales used to assess simulated skills. Performance was also assessed by validated objective motion analysis. RESULTS: All of the global rating scales demonstrated construct validity, with significant differences between each skill level and each arthroscopic task (p < 0.002, Mann-Whitney U test). Interrater reliability was excellent for each global rating scale. Correlations of global rating scale ratings with motion analysis were high and strong for each global rating scale when correlated with time taken (Spearman rho, -0.95 to -0.76; p < 0.001), and correlation with total path length was significant and moderately strong (Spearman rho, -0.94 to -0.64; p < 0.001). CONCLUSIONS: No single global rating scale demonstrated superiority as an assessment tool. CLINICAL RELEVANCE: For these commonly used arthroscopic global rating scales, none was particularly superior and any one score could therefore be used. Agreement on using a single score seems sensible, and it would seem unnecessary to develop further scales with the same domains for these purposes.

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.

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.

Assessing Performance in Shoulder Arthroscopy: The Imperial Global Arthroscopy Rating Scale (IGARS).

BACKGROUND: Surgical training is undergoing major changes with reduced resident work hours and an increasing focus on patient safety and surgical aptitude. The aim of this study was to create a valid, reliable method for an assessment of arthroscopic skills that is independent of time and place and is designed for both real and simulated settings. The validity of the scale was tested using a virtual reality shoulder arthroscopy simulator. METHODS: The study consisted of two parts. In the first part, an Imperial Global Arthroscopy Rating Scale for assessing technical performance was developed using a Delphi method. Application of this scale required installing a dual-camera system to synchronously record the simulator screen and body movements of trainees to allow an assessment that is independent of time and place. The scale includes aspects such as efficient portal positioning, angles of instrument insertion, proficiency in handling the arthroscope and adequately manipulating the camera, and triangulation skills. In the second part of the study, a validation study was conducted. Two experienced arthroscopic surgeons, blinded to the identities and experience of the participants, each assessed forty-nine subjects performing three different tests using the Imperial Global Arthroscopy Rating Scale. Results were analyzed using two-way analysis of variance with measures of absolute agreement. The intraclass correlation coefficient was calculated for each test to assess inter-rater reliability. RESULTS: The scale demonstrated high internal consistency (Cronbach alpha, 0.918). The intraclass correlation coefficient demonstrated high agreement between the assessors: 0.91 (p < 0.001). Construct validity was evaluated using Kruskal-Wallis one-way analysis of variance (chi-square test, 29.826; p < 0.001), demonstrating that the Imperial Global Arthroscopy Rating Scale distinguishes significantly between subjects with different levels of experience utilizing a virtual reality simulator. CONCLUSIONS: The Imperial Global Arthroscopy Rating Scale has a high internal consistency and excellent inter-rater reliability and offers an approach for assessing technical performance in basic arthroscopy on a virtual reality simulator. CLINICAL RELEVANCE: The Imperial Global Arthroscopy Rating Scale provides detailed information on surgical skills. Although it requires further validation in the operating room, this scale, which is independent of time and place, offers a robust and reliable method for assessing arthroscopic technical skills.

Requirements analysis of a 5 degree of freedom haptic simulator for orthopedic trauma surgery.

There are currently few Virtual Reality simulators for orthopedic trauma surgery. The current simulators provide only a basic recreation of the manual skills involved, focusing instead on the procedural and anatomical knowledge required. One factor limiting simulation of the manual skills is the complexity of adding realistic haptic feedback, particularly torques. This paper investigates the requirements, in terms of forces and workspace (linear and rotational), of a haptic interface to simulate placement of a lag screw in the femoral head, such as for fixation of a fracture in the neck of the femur. To measure these requirements, a study has been conducted involving 5 subjects with experience performing this particular procedure. The results gathered are being used to inform the design of a new haptic simulator for orthopedic trauma surgery.