Can Repetition-based Training in a High-fidelity Model Enhance Critical Trauma Surgical Skills Among Trainees and Attending Surgeons Equally?

BACKGROUND: The evolution of warfare has resulted in a surge of high-energy blast injuries predominantly involving the lower extremities. Once thought to impact only forward-deployed military, such mechanisms of injury are becoming a harsh reality even in civilian territory. Proficiency in surgical techniques for extremity damage control is vital for surgeons, regardless of specialty. To evaluate and train surgical residents and attending surgeons in critical limb-salvage techniques, Theater Hospital Operations Replication (THOR) has been proposed as a high-fidelity training platform to enhance extremity surgery teaching practices and assess proficiency in fasciotomy, vascular shunting, and knee-spanning external fixation in a simulated, resource-limited environment. QUESTIONS/PURPOSES: Given the importance of proficiency and efficiency in surgeon ability to perform fasciotomies, vascular shunting, and placement of external fixators, in this study, we proposed two research questions: (1) Does repetition-based training within the THOR model improve surgeon knowledge and technical skill? (2) Are there differences in skill outcome when utilizing the THOR model based on surgical specialty (orthopaedic versus general) and/or level in training (attending versus resident)? METHODS: This was an observational learning outcome study performed in the bioskills lab at a single institution, the Naval Medical Center Portsmouth, in which 26 surgeons completed a same-day course consisting of pretraining assessment, cadaver training on three damage-control surgery techniques in a high-fidelity THOR environment, and post-training assessment. The surgeons were either general surgeons or orthopaedic surgeons and consisted of both residents and attending surgeons. Subjects underwent a pretraining knowledge assessment, followed by two rounds of performing simulated surgery. The first round of surgery included guidance and instruction from board-certified orthopaedic surgeons. After a short break for the subjects to review the material, the second round was completed without instruction. To answer our first question of how repetition-based training impacts surgical skill, our metrics included: Objective Structured Assessment of Technical Skills (OSATS) scores (range 1 to 5, scored lowest to highest, where higher scores represent optimal skill performance), procedural accuracy, a 10-question knowledge assessment administered before and after training (scored 0 to 10, where higher scores represent competency of the anatomy and procedure steps), and total procedure time. To address our second question, data on demographic characteristics were collected on all participants, which included surgical specialty, year in training, and gender. RESULTS: The general surgery residents' cohort demonstrated improvement in both mean ± SD OSATS scores (2.4 ± 0.7 before training versus 3.6 ± 0.6 after training, mean difference 1.2 [95% CI 0.4 to 2.0]; p = 0.01) and procedure duration (23 ± 7 minutes before training versus 16 ± 5 minutes after training, mean difference 6 minutes [95% CI 4 to 9]; p = 0.001) for external fixator procedures after THOR. Similar results were seen in fasciotomies after THOR. The orthopaedic surgery residents' cohort showed similar improvements in reducing procedure duration when performing knee-spanning external fixator surgery, as well as exhibited improvements during vascular shunting procedures in both mean ± SD OSATS scores (previously 3.3 ± 0.9 versus 4.0 ± 0.9, mean difference 0.7 [95% CI 0.2 to 1.2]; p = 0.01) and procedure duration (23 ± 5 minutes versus 14 ± 8 minutes, mean difference 10 minutes [95% CI 4 to 15]; p = 0.003) after THOR. When we compared the cohorts, general surgery attending surgeons demonstrated an improvement in vascular shunting procedure duration after instruction with the THOR model (19 ± 3 minutes versus 12 ± 4 minutes, mean difference 7 minutes [95% CI 1 to 13]; p = 0.03) and in overall knowledge scores (4.3 + 0.5 versus 8.0 ± 1.6, mean difference 3.8 [95% CI 0.5 to 7.0]; p = 0.04). The orthopaedic surgery attending surgeons yielded no improvement for any metric, pretraining and post-training. Using the prescores as a covariate, for almost all metrics analyzed, there were no differences between surgeon groups based on specialty after completing the repeated training. CONCLUSION: Use of the high-fidelity THOR training model improved proficiency in the examined sample of extremity damage-control procedures, thus demonstrating its efficacy in enhancing surgical skills and short-interval knowledge retention while simultaneously highlighting the importance of cadaver simulation training in enhancing surgical preparedness for complex trauma. CLINICAL RELEVANCE: The high-fidelity THOR training model represents a promising modality for preparing surgeons for extremity combat trauma management in resource-limited, high-stress environments. Whether in a wartime environment or in the civilian sector, efficient and skilled intervention are crucial in managing patient morbidity. Differences of a few minutes per procedure can mean all the difference in damage control, especially when compounded in situations where vascular shunting, knee-spanning external fixation, and lower leg four-compartment fasciotomy have to be performed together by both orthopaedic and general surgeons. The observational period in this study spanned 1 day and thus does not provide information on retention of long-term skills or knowledge. A follow-on study can assess how time from initial training to final evaluation impacts overall skill competency and knowledge.

Proportion of Navy Recruits Diagnosed With Symptomatic Stress Fractures During Training and Monetary Impact of These Injuries.

BACKGROUND: Lower extremity stress fractures result in lost time from work and sport and incur costs in the military when they occur in service members. Hypovitaminosis D has been identified as key risk factor in these injuries. An estimated 33% to 90% of collegiate and professional athletes have deficient vitamin D levels. Other branches of the United States military have evaluated the risk factors for stress fractures during basic training, including vitamin D deficiency. To the best of our knowledge, a study evaluating the correlation between these injuries and vitamin D deficiency in US Navy recruits and a cost analysis of these injuries has not been performed. Cutbacks in military medical staffing mean more active-duty personnel are being deferred for care to civilian providers. Consequently, data that previously were only pertinent to military medical providers have now expanded to the nonmilitary medical community. QUESTIONS/PURPOSES: We therefore asked: (1) What proportion of US Navy recruits experience symptomatic lower extremity stress fractures, and what proportion of those recruits had hypovitaminosis vitamin D on laboratory testing? (2) What are the rehabilitation costs involved in the treatment of lower extremity stress fractures, including the associated costs of lost training time? (3) Is there a cost difference in the treatment of stress fractures between recruits with lower extremity stress fractures who have vitamin D deficiency and those without vitamin D deficiency? METHODS: We retrospectively evaluated the electronic medical record at Naval Recruit Training Command in Great Lakes, IL, USA, of all active-duty males and females trained from 2009 until 2015. We used ICD-9 and ICD-10 diagnosis codes to identify those diagnosed with symptomatic lower extremity stress fractures. Data collected included geographic region of birth, preexisting vitamin D deficiency, vitamin D level at the time of diagnosis, medical history, BMI, age, sex, self-reported race or ethnicity, hospitalization days, days lost from training, and the number of physical therapy, primary care, and specialty visits. To ascertain the proportion of recruits who developed symptomatic stress fractures, we divided the number of recruits who were diagnosed with a stress fracture by the total number who trained over that span of time, which was 204,774 individuals. During the span of this study, 45% (494 of 1098) of recruits diagnosed with a symptomatic stress fracture were female and 55% (604 of 1098) were male, with a mean ± SD age of 24 ± 4 years. We defined hypovitaminosis D as a vitamin D level lower than 40 ng/mL. Levels less than 40 ng/mL were defined as low normal and levels less than 30 ng/mL as deficient. Vitamin D levels were obtained at the discretion of the individual treating provider without standardization of protocol. Cost was defined as physical therapy visits, primary care visits, orthopaedic visits, diagnostic imaging costs, laboratory costs, hospitalizations, if applicable, and days lost from training. Diagnostic studies and laboratory tests were incorporated as indirect costs into initial and follow-up physical therapy visits. Evaluation and management code fee schedules for initial visits and follow-up visits were used as direct costs. We obtained these data from the Centers for Medicare & Medicaid Services website. Per capita cost was calculated by taking the total cost and dividing it by the study population. Days lost from training is based on a standardized government military salary of recruits to include room and board. RESULTS: We found that 0.5% (1098 of 204,774) of recruits developed a symptomatic lower extremity stress fracture. Of the recruits who had vitamin D levels drawn at the time of stress fracture, 95% (416 of 437 [95% confidence interval (CI) 94% to 98%]; p > 0.99) had hypovitaminosis D (≤ 40 ng/mL) and 82% (360 of 437 [95% CI 79% to 86%]; p > 0.99) had deficient levels (≤ 30 ng/mL) on laboratory testing, when evaluated. The total treatment cost was USD 9506 per recruit. Days lost in training was a median of 56 days (4 to 108) for a per capita cost of USD 5447 per recruit. Recruits with deficient vitamin D levels (levels ≤ 30 ng/mL) incurred more physical therapy treatment costs than did those with low-normal vitamin D levels (levels 31 to 40 ng/mL) (mean difference USD 965 [95% CI 2 to 1928]; p = 0.049). CONCLUSION: The cost of lost training and rehabilitation associated with symptomatic lower extremity stress fractures represents a major financial burden. Screening for and treatment of vitamin D deficiencies before recruit training could offer a cost-effective solution to decreasing the stress fracture risk. Recognition and treatment of these deficiencies has a role beyond the military, as hypovitaminosis and stress fractures are common in collegiate or professional athletes. LEVEL OF EVIDENCE: Level III, prognostic study.

Infantile Myofibromatosis of the Femoral Neck: A Case Report.

CASE: A 15-month-old boy who was being followed for developmental dysplasia of the hip because of breech presentation was discovered to have a solitary infantile myofibroma in the left femoral neck. The patient was avoiding weight-bearing on the affected extremity; thus, stabilization of the femoral neck was performed using a proximal femur locking plate. Postoperatively, he achieved all gross motor developmental milestones. CONCLUSION: This report is the first to describe a solitary infantile myofibroma in the femoral neck and demonstrates the utility of operative stabilization of these lesions.

Teaching of anterior cruciate ligament function in osteopathic medical education.

The anterior cruciate ligament (ACL) of the knee and the function of its anteromedial (AM) and posterolateral (PL) bundles are a focus of orthopedic research. Because of the probability that third-year and fourth-year osteopathic medical students will encounter ACL injuries during clinical rotations, it is of paramount importance that students fully understand the functions of the AM and PL bundles as 2 distinct functional components of the ACL. The authors assess the degree to which the AM and PL bundles are discussed within basic science curricula at colleges of osteopathic medicine (COMs). In September 2008, a 6-question survey addressing various aspects of ACL education was mailed to instructors of lower-extremity anatomy at all 28 COMs that existed at that time. Nine of the 21 responding institutions (42.9%) indicated that both the AM and PL bundles of the ACL are discussed within their basic science curricula. Four of these 9 COMs indicated that their instruction mentions that the bundles are parallel in extension and crossed in flexion. Nine of the 21 responding COMs (42.9%) indicated that they instruct students that the AM bundle is a major anterior-posterior restrictor, and 12 (57.1%) indicated that they instruct students that the PL bundle is the major rotational stabilizer of the ACL. In 7 of the 21 responding COMs (33.3%), the AM and PL bundles are identified via direct visualization during anatomic dissection of the ACL. The authors conclude that their findings suggest the need for enhanced presentation of the AM and PL bundles within the basic science curricula at COMs to provide osteopathic medical students with a more comprehensive education in anatomy.