Simulation-Based Educational Module Improves Intern and Medical Student Performance of Closed Reduction and Percutaneous Pinning of Pediatric Supracondylar Humeral Fractures

Ponseti Clubfoot Casting: Factors That Affect Trainee Competency (Retrospective Observational Study)

Introduction:

This study investigates how previous simulation training and clinical experience affects trainee performance when manipulating a foot, applying a Ponseti clubfoot cast, and performing an Achilles tenotomy on a clubfoot simulator.

Methods:

Sixty-four Accreditation Council for Graduate Medical Education orthopaedic trainees participated in the 2017 to 2018 Top Gun (TG) skills competition at the International Pediatric Orthopaedic Symposium. Trainees were judged by expert pediatric orthopaedic surgeons on how they manipulated a clubfoot model, applied a cast, and performed a simulated tendoachilles tenotomy (TAT). An analysis was done to correlate the test variables with a contestant's TG Ponseti score.

Results:

Twenty-one contestants with previous residency training using synthetic clubfoot models scored higher (P = 0.007) than those trainees without training. Trainees who had applied >10 clubfoot casts and who participated in >10 TATs in training also scored higher (P = 0.038 and P = 0.01, respectively). Thirteen contestants who had previously attended an International Pediatric Orthopaedic Symposium meeting and seven contestants who attended a American Academy of Orthopaedic Surgery clubfoot workshop scored higher (P = 0.012 and P = 0.017 respectively).

Discussion:

Clinical and previous simulation experience related to the Ponseti method correlated with improved performance on our Ponseti simulation. Trainees who had previous experience with >10 clubfoot casts and >10 TATs scored higher during TG than less experienced trainees.

Validation of a Cost-effective Cast Saw Simulation-based Educational Module to Improve Cast Removal Safety

BACKGROUND

Inexperience in cast removal in the pediatric population can lead to a range of cast saw-related injuries. The purpose of this study is to validate a simple simulation-based wax model that is both reproducible and economical while providing a valuable tool that can be used to grade cast saw use performance in trainees.

METHODS

Cylindrical wax models were used as an analog for a pediatric upper extremity. The wax models were casted in a proscribed reproducible fashion for consistency. Two groups, the first consisting of 15 experienced cast saw users and the second consisting of 15 inexperienced individuals, completed 4 sequential longitudinal cuts in the casted wax models. After removal of the cast material, marks left by the cast saw in the wax were counted and measured. Indentation length, maximum depth, and maximum width were measured on each wax model. The total length of the cast saw indentations per cast saw user was also calculated.

RESULTS

For the inexperienced cast saw users, the average total length of the cast saw indentations was 526.56 mm, average maximum depth was 1.91 mm, and average maximum width was 3.24 mm. For experienced cast saw users, the average total length of the cast saw indentations was 156.57 mm with an average maximum depth of 1.06 mm and average maximum width of 2.19 mm. Receiver operating characteristic curves of the total number of errors, total error length, maximum error depth, and maximum error width show effective discrimination of experienced from inexperienced trainees.

CONCLUSIONS

This study provides valid evidence supporting a cost-effective, time-efficient, and easily reproducible educational simulation module that can objectively measure cast saw the performance in trainees. This model demonstrates construct validity and can distinguish novice from experienced cast saw users. It is sensitive enough to identify mistakes even in the most experienced cast saw users, creating a platform that can provide performance-based feedback to cast saw users of all experience levels.

LEVEL OF EVIDENCE

Level III-diagnostic test.

Analysis of Tools Used in Assessing Technical Skills and Operative Competence in Trauma and Orthopaedic Surgical Training: A Systematic Review

BACKGROUND

Robust assessment of skills acquisition and surgical performance during training is vital to ensuring operative competence among orthopaedic surgeons. A move to competency-based surgical training requires the use of tools that can assess surgical skills objectively and systematically. The aim of this systematic review was to describe the evidence for the utility of assessment tools used in evaluating operative performance in trauma and orthopaedic surgical training.

METHODS

We performed a comprehensive literature search of MEDLINE, Embase, and Google Scholar databases to June 2019. From eligible studies we abstracted data on study aim, assessment format (live theater or simulated setting), skills assessed, and tools or metrics used to assess surgical performance. The strengths, limitations, and psychometric properties of the assessment tools are reported on the basis of previously defined utility criteria.

RESULTS

One hundred and five studies published between 1990 and 2019 were included. Forty-two studies involved open orthopaedic surgical procedures, and 63 involved arthroscopy. The majority (85%) were used in the simulated environment. There was wide variation in the type of assessment tools in used, the strengths and weaknesses of which are assessor and setting-dependent.

CONCLUSIONS

Current technical skills-assessment tools in trauma and orthopaedic surgery are largely procedure-specific and limited to research use in the simulated environment. An objective technical skills-assessment tool that is suitable for use in the live operative theater requires development and validation, to ensure proper competency-based assessment of surgical performance and readiness for unsupervised clinical practice.

CLINICAL RELEVANCE

Trainers and trainees can gain further insight into the technical skills assessment tools that they use in practice through the utility evidence provided.

The future of orthopaedic surgical education: Where do we go now?

INTRODUCTION

COVID-19 will undoubtedly change the future landscape of medical and surgical education. The economic and environmental advantages of virtual learning are clear, while access to a wider range of resources and subject specialists makes the adoption of virtual learning within surgical education an attractive prospect.

AIMS

This literature review aims to evaluate evidence on the effectiveness of virtual education in orthopaedics and how we might implement positive changes to educational practice in the future, as a result of lessons learned during the COVID-19 pandemic.

METHODOLOGY

We performed a review of the literature reporting on efficacy of learning outcomes achieved as a result of virtual education within orthopaedic surgery. Electronic searches were performed using NICE healthcare databases from the date of inception to March 2021. Relevant studies were identified, data extracted, and qualitative synthesis performed.

RESULTS

14 manuscripts with a total of 1548 participants (orthopaedic trainees or medical students) were included for analysis. Nine studies (n = 1109) selected compared e-learning to conventional learning material (control group). All nine studies reported significantly higher outcome scores for e-learning participants compared to control participants (p < 0.001 to p < 0.05). The remaining studies compared blended e-learning approaches or evaluated pre/post intervention improvements in learning outcomes. All studies demonstrated a significant improvement in learning outcomes (p < 0.0001 to p < 0.01). The majority of studies (64%) used a blended approach. No studies were identified reporting efficacy of webinars or videoconferencing within orthopaedic education.

CONCLUSION

A blended approach, combining virtual teaching, face-to-face instruction and distance learning tools, based on the evidence we have provided, would improve the quality of knowledge reception and retention, and learner satisfaction. However, in order to be successful, it is vital that these educational programmes are designed with the needs of the learner in mind, and an awareness of best practice for virtual teaching and learning.

Simulation Training in Fracture Surgery

The current surgical training environment has sparked a paradigm shift toward the use of surgical training simulation. An apprentice-based model has historically been used in surgical education, but current financial and practical constraints have led to a more variable training experience. Surgical simulation has demonstrated efficacy in many facets of orthopaedic training and has most recently been implemented to fine-tune surgical skill in reconstruction of traumatic skeletal injuries. Although some surgical skills learned during residency training are not fully used in later practice, most surgeons require a baseline level of competence in managing skeletal trauma. Fracture surgery is heavily dependent on technical skill. Trainee simulation use in skill acquisition has potential to improve proficiency during actual surgery. Furthermore, in a specialty where the standard axiom has been repetition matters, education augmentation with simulation provides overall benefit. Work remains to maximize the effectiveness of surgical simulation in fracture treatment through improved model integration and access.

A Novel Low-Cost Surgical Simulation Tool for Pinning Supracondylar Humerus Fractures

BACKGROUND

Simulation-based training is one way to improve basic competence for surgical trainees and thus improve patient safety. Closed reduction and percutaneous pinning of a supracondylar humerus fracture is a common procedure that encompasses many basic orthopaedic skills and has been identified as a residency milestone. Despite this, no quantitative tools exist to help learners attain this basic skill. This study seeks to validate a quantitative, low-cost simulation-based training tool for teaching orthopaedic surgery trainees the fundamentals of fracture stabilization with pins.

METHODS

Two low-cost models were developed with simulated cancellous bone blocks and cortical bone sheets: a pinning agility tool to teach pin placement and redirection, and a low-cost construct stability tool to replicate pinning. A high-cost construct stability tool was cut using a pediatric supracondylar humerus model to simulate pinning a real fracture. Construct stability was assessed by adding weight until ∼1.6 mm of displacement was observed. Participants were tested naively on all 3 models and then completed a training session using only the low-cost models. Performance following training was then assessed and compared with fellowship-trained pediatric orthopaedic surgeons. Participants also rated their preintervention and postintervention confidence, skill, and knowledgeability.

RESULTS

A total of 18 novice trainees participated (10 PGY1 and PGY2 orthopaedic surgery residents and 8 medical student members of the orthopaedic surgery interest club), whereas the reference group consisted of 7 orthopaedic surgery attendings. The subjects significantly improved their scores on both the low-cost (P=0.002) and high-cost (P<0.001) construct stability tools after the training with only the low-cost tools. Compared with the attending benchmark, trainee scores improved on the high-fidelity model from 31% preintervention to 86% postintervention and their pinning times decreased by 38%. Trainees reported increased knowledge, skill, and confidence after the intervention (P<0.001).

CONCLUSIONS

A novel, low-cost simulation model and training session for supracondylar humerus fracture pinning resulted in improved performance in stabilizing a supracondylar humerus model and increased trainee knowledgeability, confidence, and skill.

LEVEL OF EVIDENCE

Level II-economic.

Home Surgical Skill Training Resources for Obstetrics and Gynecology Trainees During a Pandemic

Resources are available for remote laparoscopic and basic surgical training, including core skills, psychomotor, visual–spatial, and cognitive, to improve gaps in surgical training during the coronavirus disease 2019 (COVID-19) pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has created a unique educational circumstance in which medical students, residents, and fellows find themselves with a gap in their surgical training. We reviewed the literature, and nine categories of resources were identified that may benefit trainees in preventing skill decay: laparoscopic box trainers, virtual reality trainers, homemade simulation models, video games, online surgical simulations, webinars, surgical videos, smartphone applications, and hobbies including mental imagery. We report data regarding effectiveness, limitations, skills incorporated, cost, accessibility, and feasibility. Although the cost and accessibility of these resources vary, they all may be considered in the design of remote surgical training curricula during this unprecedented time of the COVID-19 pandemic.

Gamma3 nail with U-Blade (RC) lag screw is effective with better surgical outcomes in trochanteric hip fractures

The objective of this retrospective study was to investigate the surgical outcomes of AO/OTA 31 A1-3 trochanteric fractures treated with the new-generation Gamma3 nail with U-Blade (RC) lag screw and to analyze the risk factors related to fixation failure. A total of 318 consecutive patients who underwent cephalomedullary nailing using Gamma3 nail with U-Blade lag screw for trochanteric hip fractures between September 2015 and June 2018 were enrolled. The average age was 80 years and most patients (69%) were women. The mean follow-up was 12.2 months with a minimum of 6 months. 309 (97.2%) showed bony union with a mean time to union of 13.5 ± 8.7 weeks. Cut-out occurred in 2 patients (0.6%) and 7 patients showed excessive collapse (≥15 mm) of the proximal fragment. These 9 patients were assigned to the failure group. The presence of a basicervical fracture component and comminution of the anterior cortex on preoperative 3-D CT showed a significant association with fixation failure, including cut-out, although comminution of the anterior cortex was the only independent risk factor for fixation failure on multivariate logistic regression analysis. Gamma3 nail with U-Blade lag screw showed favorable results for trochanteric hip fractures, with low cut-out rate (0.6%). However, more caution is required in treating trochanteric fractures with a basicervical fracture component and anterior cortex comminution even with this nail.

Advancing Simulation-Based Orthopaedic Surgical Skills Training: An Analysis of the Challenges to Implementation

Simulation-based surgical skills training is recognized as a valuable method to improve trainees' performance and broadly perceived as essential for the establishment of a comprehensive curriculum in surgical education. However, there needs to be improvement in several areas for meaningful integration of simulation into surgical education. The purpose of this focused review is to summarize the obstacles to a comprehensive integration of simulation-based surgical skills training into surgical education and board certification and suggest potential solutions for those obstacles. First and foremost, validated simulators need to be rigorously assessed to ensure their feasibility and cost-effectiveness. All simulation-based courses should include clear objectives and outcome measures (with metrics) for the skills to be practiced by trainees. Furthermore, these courses should address a wide range of issues, including assessment of trainees' problem-solving and decision-making abilities and remediation of poor performance. Finally, which simulation-based surgical skills courses will become a standard part of the curriculum across training programs and which will be of value in board certification should be precisely defined. Sufficient progress in these areas will prevent excessive development of training and assessment tools with duplicative effort and large variability in quality.

Drilling Technique Can Minimize Plunging

PURPOSE

Vibratory and acoustic feedback, drill sharpness, and material density have each been shown to influence the depth of plunging when drilling through bicortical bone. We hypothesized that drilling technique can also influence the depth of plunging.

METHODS

Six subjects of various training levels (PGY1 to 16-year experienced surgeon) were asked to drill through a cortical bone surrogate, third-generation Sawbones tube with similar density and compressive modulus of healthy cortical bone. Using a sharp 4.5-mm drill bit and System 6 drill, each participant drilled 30 holes wearing surgical gloves to mimic tactile feedback and using 3 different techniques (10 holes each). The techniques were single-handed smooth, single-handed bounce, and 2-handed smooth drilling. A 60 frame-per-second high-definition video recorder was placed a standard distance from the model and used to calculate the depth of plunging. Analysis of variance with Fisher PLSD post hoc was used to compare techniques (significance P < 0.05).

RESULTS

The average ± SD plunge depths were 13.0 ± 4.2 mm (range 6.2-26.8 mm) for single-handed smooth, 17.2 ± 5.0 mm (range 8.0-28.8 mm) for single-handed bounce, and 10.6 ± 3.5 mm (range 5.8-19.2) for 2-handed smooth techniques. Difference among all 3 groups reached statistical significance.

CONCLUSION

Bounce technique had the greatest average depth and variance. The 2-handed technique demonstrated the least plunge and the lowest variance, indicating the highest degree of control. This study supports the use of a 2-handed technique for drilling when intraoperative circumstances permit.

Cognitive Apprenticeship in Orthopaedic Surgery: Updating a Classic Educational Model

OBJECTIVE

To define cognitive apprenticeship and describe how it can be applied to orthopedic education.

DESIGN

Traditional apprenticeships have been used through history as a teaching model for wide variety of skills. These apprenticeships are characterized by practical, on-the-job training in which the apprentice observes and assists a master in the completion of a task, and thereby learns the skills needed to complete that task on his or her own.

RESULTS

Cognitive apprenticeship is differentiated from the traditional apprenticeship model primarily by its educational goals. Cognitive apprenticeships are used to teach skills which require internal though processes which cannot be readily observed externally by the teacher or the student.

CONCLUSION

Here, we review the history of the cognitive apprenticeship concept, its basic principles, its applications to a wide variety of educational circumstances, and its potential use a framework for developing orthopedic curricula.

Development of a Spine Surgical Skills and Written Assessment for Orthopaedic Surgery Residents

OBJECTIVE

The objective of this study was to develop an assessment module for orthopaedic spine surgery residents which is cost-effective and can reliably test knowledge and surgical skills.

DESIGN

A ten-question multiple choice question and hands-on spine sawbones combination assessment was prospectively administered to consenting PGY-3 and PGY-4 residents before and after their 8-week spine rotation. Pre- and postrotation scores were compared using the paired t-test.

SETTING

The Department of Orthopaedics, The Ohio State University Wexner Medical Center, a large academic medical centre providing primary and tertiary care.

PARTICIPANTS

Orthopaedic resident physicians.

RESULTS

A total of 21 residents (15 PGY-3, 6 PGY-4) participated in the study. The mean pre- and postrotation written test score was 7.38 ± 1.53 and 9.24 ± 0.83, respectively (p < 0.001). Corresponding surgical skills assessment scores were 95.4% ± 4.7 and 97.1% ± 2.6, respectively (p = 0.10). Overall, the postrotation written and surgical scores improved and showed less variation about the mean.

CONCLUSIONS

This combination assessment measured improvement in below-average scoring residents and maintenance or improvement in residents with average and above average prerotation scores.

A Cadaver-Based Course for Humanitarian Surgery Improves Manual Skill in Powerless External Fixation

BACKGROUND

General surgery residents interested in humanitarian careers may benefit from supplemental training beyond modern residency. The Colorado Humanitarian Surgical Skills Workshop is a 2-d cadaver-based course for senior surgical residents, teaching low-resource skills across multiple specialties, including orthopedics. We assessed the course's ability to transmit manual competence in a critical humanitarian surgical skill, powerless lower extremity external fixation.

MATERIALS AND METHODS

We created a novel standardized manual skills test of powerless lower extremity external fixation. Course participants had no prior experience with this technique. At course initiation, paired participants attempted to stabilize a proximal tibia-fibula fracture in a cadaver. Subsequently, participants received didactics from orthopedic surgeons followed by hands-on practice. At course completion, paired participants repeated the exercise. Fixator constructs were scored using standardized criteria. Precourse and postcourse surveys measured participants' level of confidence in performing external fixation.

RESULTS

Twelve senior surgical residents were included. Average scores of external fixator constructs improved significantly (23% pre versus 75% post, P < 0.01). On pretesting, none of the participants completed the exercise within 15 min. Only one of six constructs was marginally stable, and none were aligned. On post-testing, five of six teams completed the exercise in an average of 12.4 min. Four of six constructs were stable and two of six were also well aligned. Confidence with external fixation also improved significantly.

CONCLUSIONS

Participants in a short cadaver-based workshop demonstrated significant improvements in manual skill and confidence related to powerless external fixation. However, additional training is likely required to achieve clinical competence.