Establishing Validity of a Comprehensive Hand Surgical Training and Educational Platform (STEP)

A Systematic Review of Hand Surgery Simulation

BACKGROUND

The COVID-19 pandemic and duty hour restrictions illuminated a role for surgical simulation in hand surgery training that permits meaningful technical experience outside the operating room. Implementation of surgical simulation infrastructure alongside clinical training accounting for complexity and cost should be considered. This systematic review analyzes cadaveric, benchtop, 3D-printed, augmented/virtual reality, and animal models that may effectively simulate hand surgical techniques and procedures with subjective or objective competence assessment.

METHODS

A systematic review was conducted according to PRISMA-P guidelines using the following databases: PubMed, Medline, Scopus, Embase, Web of Science, and Cochrane. Selected search terms included procedures relevant to hand surgery and various simulation training modalities. Inclusion criteria were English-language peer-reviewed articles about surgical simulation techniques or hand surgery-related training. Abstracts, conference proceedings, non-English literature, and reviews were excluded. Data, including skills and techniques taught and assessed, model type, equipment, cost, and emphasis placed in training for each article, were entered into an electronic database. Additional articles were identified through references from the initial search.

RESULTS

Our search criteria identified 2745 articles, 39 of which met the inclusion criteria. Models were described with the following frequency: synthetic benchtop/3D printed (41.0%), animal (25.6%), cadaveric (17.9%), augmented and virtual reality (AR/VR; 10.3%), and other computer simulation (10.3%). Three models incorporated both a physical benchtop and AR/VR components. The procedures most represented by the simulation tools assessed include tendon repair (30.8%), fracture fixation (25.6%), wrist arthroscopy (15.4%), and carpal tunnel release (15.4%). Of all articles, 51.3% evaluated the efficacy of the educational tool. Of these, 40.0% were evaluated via subjective methods only, 10.0% via objective methods, and 50% via both. Eighty-seven percent of articles emphasized the importance of surgical simulation in a surgeon's training.

CONCLUSIONS

A diverse collection of hand surgical simulation models exists for the practice of various aspects of hand surgery. The existing literature demonstrates their utility for increasing expertise with surgical techniques and procedures in a low-risk setting. Integration into surgical training will depend on program time and budget constraints.

Implementation of a Hand Training Curriculum in Junior Resident Education: Experience at a Military Orthopedic Residency Program

Purpose

The American Society for Surgery of the Hand developed the Surgery Training and Educational Platform (STEP) in order to assess essential skills in hand surgery. The American Society for Surgery of the Hand designed modules spanning both osseous and soft tissue skills aimed to be cost effective for the purpose of orthopedic surgical education. The STEP curriculum was adapted and implemented at a single military orthopedic residency program.

Methods

The following six modules were implemented: (1) depth of plunge, (2) scaphoid pinning, (3) phalangeal fracture pinning, (4) microsurgery, (5) full-thickness skin graft harvest, and (6) wrist arthroscopy. Both first- (PGY1) and second-year (PGY2) residents participated. Scores were calculated according to the original STEP curriculum criteria and were compared with historic data from the previous year. All residents responded to an evaluation questionnaire following the performance of the tasks.

Results

The PGY2 cohort outperformed PGY1 cohorts across all modules except for the depth of plunge and scaphoid fixation modules. In the phalangeal pinning module, PGY2s did significantly better when compared with pooled PGY1 performance and their own PGY1 performance (P < .05). In the microsurgery module, PGY2s scored better than pooled PGY1s. In the full-thickness skin grafting module, PGY2s outperformed PGY1s (P < .05). On the post-task evaluation, residents unanimously responded that this was a valuable exercise, but the time required to complete all the modules was significant, similar to that of the previous year survey.

Conclusions

The STEP simulation is a cost effective and reliable program to engage residents in hand surgery-related skills. However, adaptations should be encouraged according to institutional resources to provide the most inclusive training platform possible per institutional constraints. The STEP simulation is interpreted by residents as a valuable exercise but requires a significant time commitment that could be a barrier to implementation and regular use.

Type of study/level of evidence

Therapeutic IV.

Development and Validation of a Low-Cost Drilling Model

Background: Simulation models enable learners to have repeated practise at their own time, to master the psycho-motor and sensory acuity aspects of surgery and build their confidence in the procedure. The study aims to develop and evaluate the feasibility of a low-cost drilling model to train surgeons in the drilling task. The model targets three aspects of drilling - (1) Reduce plunge depth, (2) Ability to differentiate between bone and medullary canal and (3) Increase accuracy drilling in various angles. Methods: This cross-sectional study was conducted after obtaining ethics approval. We invited Consultants in the field of Orthopaedic or Hand Surgery to form the 'expert' group, and the 'novice' group consisted of participants who had no prior experience in bone drilling. We developed a drilling simulator model made from a polyvinyl chloride (PVC) pipe filled with liquid silicone. This model cost less than US$5. An electric Bosch drill (model GBM 10 RE) with a 1.4 mm K-wire 10 cm in length (6.5 cm outside the drill) was used for drilling. The main outcomes of the study were time taken for drilling, plunge depth, ability to penetrate the far cortex and accuracy. Results: Thirty-one participants were recruited into the study, of which 15 were experts and 16 were novices. The experts performed significantly better for plunge depth (t = -3.65, p = 0.0003) and accuracy (t = -2.07, p = 0.04). The experts required 20% less time to complete the drilling tasks, but it was not statistically significant (t = -0.79, p = 0.43). Conclusions: The low-cost drilling model could be useful in training Residents in the drilling task. It will allow Residents to practise independently at their own time and assess their own performance.

Validation of Two Novel and Complementary Training Platforms for Small Joint Arthroscopy

PURPOSE

We developed 2 complementary low-fidelity models to be used to create the tool skills needed to perform small joint arthroscopy. The purpose of the study was to establish the face and construct validity of the 2 models.

METHODS

The "foundation model" was constructed from lemon and radish sections, and the "advanced model" was constructed from a chicken knee. Using both models, novice, intermediate, and experienced participants were asked to perform specific tasks and were timed and scored on their performance. The experienced surgeons were given a 16-item survey to rate how closely each model emulated reality to determine face validity.

RESULTS

For the foundation model, the mean total time for the completion of tasks was 1,138 seconds for novices, 1,059 seconds for intermediates, and 631 seconds for experienced, with significant differences between the groups for time to complete 2 of the tasks. With a maximum possible score of 50 points for the correct performance of all tasks, the mean total performance score was 23 for novices, 31.8 for intermediates, and 42.2 for experienced operators. For the advanced model, the mean total time for completion was 266 seconds for novices, 147 seconds for intermediates, and 72 seconds for experienced participants. With a maximum possible score of 31 points for the correct performance of all tasks, the mean total performance score was 1.9 for novices, 15.0 for intermediates, and 24.3 for experienced participants. The average scores for the face validity surveys using a 5-point Likert scale were 4.2 and 4.5 of 5 possible points for the foundation and advanced models, respectively.

CONCLUSIONS

Experienced operators completed the tasks more quickly and had higher performance scores than the operators in other groups. This correlation between experience and performance suggests that both models have construct validity. The face validity scores were on the upper end of the scale, suggesting that both models emulate reality for experienced operators.

CLINICAL RELEVANCE

These novel models provide low-cost, available and valid simulations conducive to high-repetition training.

Simulation training to retool practicing orthopedic surgeons is rare

Purpose

Modern surgical practice is continuously changing as technology develops. New techniques are often implemented after a surgeon has made the transition to independent clinical practice. There is therefore a need to 'retool' technical skills. Additionally, practicing surgeons must maintain and develop skills such as leadership, communication, critical thinking, teaching, and mentoring. Our aim was to perform a scoping review to assess the current status of simulation education for practicing Orthopedic Surgeons (OS).

Methods

A 10 year search of PubMed, ERIC, and Web of Science was performed with a medical librarian. Controlled vocabulary Medical Subject Headings terms and natural language were developed with subject matter experts describing simulation, training and OS. Two trained reviewers evaluated all abstracts for inclusion. Exclusion criteria were articles that did not assess simulation education involving practicing OS. Data were extracted from the included full text articles by two reviewers: details of study design, type of participants, type of simulation and role of OS in the educational event.

Results

Initial search identified 1824 articles of which 443 were duplicates, and 1381 articles were further screened. Of these, 1155 were excluded, 226 full text articles were assessed for eligibility and 80 included in analysis. Most were published in the last 6 years and from the United States. The majority (99%) described technical skill simulations (arthroscopy 56%, screw placement 23%, ligament reconstruction 19%). OS were rarely the only learners with 91% studies also having residents participate. OS were the targeted learner in 6% studies. OS provided content validity for 15 (19%) and construct validity in 59 (74%) studies.

Conclusions

Simulation training to educate practicing OS is rare. OS are often used to validate work rather than being the center of an educational endeavor. A refocusing is needed to provide adequate training for practicing surgeons to retool skills as new techniques become available.

Training outside of the operating room improves intern resident psychomotor skills on a validated ASSH tool

Objective

The Surgical Training and Educational Platform (STEP) was developed by the American Society for Surgery of the Hand (ASSH) as a cost-effective set of surgical simulation modules designed to represent critical psychomotor skills in hand surgery. We hypothesize that increased training on these training modules, even with limited supervision, would improve resident performance on psychomotor skills.

Design

Baseline evaluation was conducted on four psychomotor skills to simulate surgical tasks: lag screw fixation, depth of plunge, skin graft harvest, and wrist arthroscopy. One-third of them received limited supervised training for one month and two-thirds did not (control). After the training period both groups were re-evaluated and their performance was analysed.

Setting

Six ACGME accredited orthopaedic surgery residency programs.

Participants

All 26 residents in the intern bootcamp participated and completed the study. Selection to the Trained Group was based on willingness and ability to participate. Others remained in the Control Croup.

Results

Compared to baseline, the Control Group performed worse in depth of plunge while showing no improvement in other tasks in the final assessment. Compared to baseline, the Trained Group improved in lag screw fixation and in total score after training, with the greatest improvement in the half with the lowest pre-training scores. Post-training, the Trained Group outperformed the Control Group in depth of plunge.

Conclusions

Training outside the operating room even with limited supervision improved psychomotor skills in orthopaedic surgery interns as assessed by the STEP modules. The STEP simulator is a validated instrument and may be valuable for resident education and assessment.

Simulation in plastic and reconstructive surgery: a scoping review

Since the origins of surgery, simulation has played an important role in surgical education, particularly in plastic and reconstructive surgery. This has greater relevance in contemporary settings of reduced clinical exposure resulting in limited work-based learning opportunities. With changing surgical curricula, it is prescient to examine the role of simulation in plastic and reconstructive surgery.

A scoping review protocol was used to identify relevant studies, with an iterative process identifying, reviewing and charting the data to derive reported outcomes and themes.

Of the 554 studies identified, 52 studies were included in this review. The themes identified included simulator modalities, curriculum elements targeted and relevant surgical competencies. There was a predominance of synthetically based simulators, targeting technical skills largely associated with microsurgery, paediatric surgery and craniomaxillofacial surgery.

Existing simulators largely address high-complexity procedures. There are multiple under-represented areas, including low-complexity procedures and simulation activities addressing communication, collaboration, management and leadership. There are many opportunities for simulation in surgical education, which requires a contextual appreciation of educational theory. Simulation may be used both as a learning method and as an assessment tool.

This review describes the literature relating to simulation in plastic and reconstructive surgery and proposes opportunities for incorporating simulation in a broader sense, in the surgical curriculum.

Do Resident Surgical Volumes and Level of Training Correlate with Improved Performance on Psychomotor Skills Tasks: Construct Validity Testing of an ASSH Training Platform (STEP)?

The Surgical Training and Educational Platform (STEP) was developed by the American Society for Surgery of the Hand (ASSH) as a cost-effective set of surgical simulation modules designed to assess critical skills in hand surgery. Previous study demonstrated that STEP can differentiate between novice trainees and board-certified, certificate of added qualification hand surgeons. The purpose of this study was to assess construct validity of STEP by testing its ability to differentiate psychomotor skill level among intermediate trainees.