Current practice of orthopaedic surgical skills training raises performance of supervised residents in total knee arthroplasty to levels equal to those of orthopaedic surgeons

Impact of Resident Involvement on 30-Day Postoperative Outcomes in Orthopedic Shoulder Surgery

The literature concerning resident involvement in shoulder surgery is limited. The purpose of this study was to examine whether resident involvement across all orthopedic shoulder surgeries is associated with adverse 30-day outcomes. Utilizing the American College of Surgeons National Surgical Quality Improvement Program database, patients who underwent shoulder surgery with or without a resident present were analyzed. Independent t-test and chi-square or Fischer's exact test were used appropriately. A logistic regression model was used to calculate adjusted odds ratios. This study examined 5,648 patients: 3,455 patients in the "Attending alone" group and 2,193 in the "Attending and resident in the operating room" group. Resident presence in the operating room was not associated with increased complications, except for bleeding transfusions (OR 1.71, CI 1.32-2.21, P ≤ 0.001). This study demonstrates that resident involvement in orthopedic shoulder surgery does not present an increased risk for 30-day complications when compared to surgeries performed with the attending surgeon alone.

Effectiveness of virtual reality compared to video training on acetabular cup and femoral stem implantation accuracy in total hip arthroplasty among medical students: a randomised controlled trial

PURPOSE

Virtual reality (VR) training effectiveness in improving hip arthroplasty surgical skills requires further evaluation. We hypothesised VR training could improve accuracy and the time taken by medical students compared to a control group with only video teaching.

METHODS

This single-centre randomized controlled clinical trial collected data from March to June 2023. Surgically naïve volunteer undergraduate medical students performed three sessions on a VR training platform, either cup (VR-Cup=Control-Stem) or stem (VR-Stem=Control-Cup) implantation. The primary outcome was the mean difference between predefined cup inclination (60°) and stem anteversion (20°) compared to the actual implanted values in sawbones between VR and control groups. Secondary outcomes were task completion time and mistake number between the groups.

RESULTS

A total of 101 students participated (VR-Cup 47, VR-Stem 54). Groups did not significantly differ concerning age (p = 0.879), gender (p = 0.408), study year (p = 0.938), previous VR use (p = 0.269) and baseline medical and procedural knowledge. The VR-Cup implanted the cup closer to the intended target (p < 0.001) and faster than the Control-Cup group (p = 0.113). The VR-Stem implanted the stem closer to the intended target (p = 0.008) but not faster than the Control-Cup group (p = 0.661). Stem retroversion was commoner in the Control-Stem than in the VR-Stem group (p = 0.016).

CONCLUSIONS

VR training resulted in higher rates of accurate procedure completion, reduced time and fewer errors compared to video teaching. VR training is an effective method for improving skill acquisition in THA.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05807828.

Resident Impact on Primary Total Knee Arthroplasty: A Consecutive Series Under a Single Surgeon

Background

The literature has displayed conflicting evidence on resident involvement in surgical procedures. The goal of this study was to assess the impact of resident involvement on primary total knee arthroplasty (TKA) under a single fellowship-trained adult reconstruction surgeon.

Methods

Two hundred sequential patients were retrospectively reviewed by a single surgeon: the first cohort represented the final 100 TKAs performed by the surgeon without resident involvement (NRI), serving as the control group, and the second cohort represented the initial 100 TKAs performed by the same surgeon with resident involvement (RI), serving as the experimental group. Perioperative variables such as number of people in operating room (OR), surgical time, and tourniquet time, and postoperative variables such as infection, minor complications, medial distal femoral angle, medial proximal tibia angle, and total angulation were assessed.

Results

The rate of infection was significantly lower in the RI group (0%) compared to the NRI group (1%) (P = .043). The number of staff in the OR (P < .001), the tourniquet time (P < .001), and OR time (P < .001) were significantly higher in the RI group compared to the NRI group. There was no difference in coronal plane radiographic measurements: medial distal femoral angle (P = .10), medial proximal tibia angle (P = .19), or total angulation (P = .27).

Conclusions

Resident involvement in primary TKA neither demonstrated any significant difference in coronal plane radiographic alignment of the prosthesis nor an increased risk of infection despite increased operative time, tourniquet time, and number of people in OR.

Level of evidence

Level 3 - Therapeutic retrospective cohort study.

The impact of surgical trainee involvement in total knee arthroplasty: a systematic review of surgical efficacy, patient safety, and outcomes

PURPOSE

Trainee involvement in patient care has raised concerns about the potential risk of adverse outcomes and harming patients. We sought to analyze the impact and potential consequence of surgical trainee involvement in total knee arthroplasty (TKA) procedures in terms of surgical efficacy, patient safety, and functional outcomes.

METHODS

We systematically reviewed Medline/PubMed, EMBASE, the Cochrane library, and Scopus databases in April 2021. Eligible studies reported on the impact of trainee participation in TKA procedures performed with and without such involvement.

RESULTS

Twenty-three publications met our eligibility criteria and were included in our study. These studies reported on 132,624 surgeries completed on 132,416 patients. Specifically, 23,988 and 108,636 TKAs were performed with and without trainee involvement, respectively. The mean operative times for procedures with (n = 19,573) and without (n = 94,581) trainee involvement were 99.77 and 85.05 min, respectively. Both studies that reported data on cost of TKAs indicated a significant increase (p < 0.001) associated with procedures completed by teaching hospitals compared to private practices. Mean overall complication rates were 7.20% and 7.36% for TKAs performed with (n = 9,386) and without (n = 31,406) trainees. Lastly, the mean Knee Society Scale (KSS) knee scores for TKAs with (n = 478) and without (n = 806) trainee involvement were similar; 82.81 and 82.71, respectively.

CONCLUSION

Our systematic review concurred with previous studies that reported trainee involvement during TKAs increases the mean operative time. However, the overall complication rates and functional outcomes were similar. Larger studies with a better methodology and higher level of evidence are still needed for a resolute conclusion.

Validity of an immersive virtual reality training system for orthognathic surgical education

Virtual reality (VR) has been proven an important supplement for surgical education in medical students. However, studies on immersive VR (iVR) simulation in orthognathic surgical education are limited. This study aimed to assess the validity of the iVR surgical training system for orthognathic surgery. Participants completed questionnaires at the end of the course to assess the validity of the training system. The questionnaires included questions on the experience of using the iVR system and surgical authenticity. Seven experienced surgeons and seven inexperienced students were recruited in this study to use our self-developed iVR training system for orthognathic surgery. The participants showed strong agreement to the fidelity of our training system (4.35 out of 5), including the virtual environment, instruments, anatomy structures, and surgical procedures. The participants also strongly agreed that the iVR technique was essential in imparting surgical education. However, most of the participants experienced some degree of dizziness or fatigue after 1 h of using the system. The iVR training system is a new method for imparting education about orthognathic surgery. The iVR training system can act as a supplement and potential substitute of the traditional surgical training method.

Predicting robotic-assisted total knee arthroplasty operating time

Aims

No predictive model has been published to forecast operating time for total knee arthroplasty (TKA). The aims of this study were to design and validate a predictive model to estimate operating time for robotic-assisted TKA based on demographic data, and evaluate the added predictive power of CT scan-based predictors and their impact on the accuracy of the predictive model.

Methods

A retrospective study was conducted on 1,061 TKAs performed from January 2016 to December 2019 with an image-based robotic-assisted system. Demographic data included age, sex, height, and weight. The femoral and tibial mechanical axis and the osteophyte volume were calculated from CT scans. These inputs were used to develop a predictive model aimed to predict operating time based on demographic data only, and demographic and 3D patient anatomy data.

Results

The key factors for predicting operating time were the surgeon and patient weight, followed by 12 anatomical parameters derived from CT scans. The predictive model based only on demographic data showed that 90% of predictions were within 15 minutes of actual operating time, with 73% within ten minutes. The predictive model including demographic data and CT scans showed that 94% of predictions were within 15 minutes of actual operating time and 88% within ten minutes.

Conclusion

The primary factors for predicting robotic-assisted TKA operating time were surgeon, patient weight, and osteophyte volume. This study demonstrates that incorporating 3D patient-specific data can improve operating time predictions models, which may lead to improved operating room planning and efficiency.

Cite this article: Bone Jt Open 2022;3(5):383–389.

Does Resident Participation Influence Surgical Time and Clinical Outcomes? An Analysis on Primary Bilateral Single-Staged Sequential Total Knee Arthroplasty

Background

Although several studies have indirectly compared teaching and nonteaching hospitals, results are conflicting, and evaluation of the direct impact of trainee involvement is lacking. We investigated the direct impact of resident participation in primary total knee arthroplasties (TKAs).

Material and methods

Fifty patients undergoing single-staged sequential bilateral primary TKAs were evaluated. The more symptomatic side was performed by the attending surgeon first, followed by the contralateral side performed by a chief resident under direct supervision and assistance of the same attending surgeon. Surgery was subdivided into 8 critical steps on both sides. The overall time and critical stepwise surgical time and short-term clinical outcomes were then compared between the 2 sides.

Results

The attending surgeon completed the surgery (skin incision to dressing) significantly faster than the resident (70.2 vs 96.9 minutes) by a mean of 26.7 minutes (P < .05) and was also faster in all steps. The most significant differences in time were in “exposure” (9.5 vs 16.5 minutes) and “closure” steps (13.2 vs 24.9 minites), all P < .001. Adverse events occurred in 7 patients; 5 of these resolved uneventfully. There were no significant differences in surgical complications, objective outcome scores, or patient satisfaction scores between both sides.

Conclusion

Resident participation in TKA increased operative time without jeopardizing short-term patient clinical outcomes, satisfaction, and complications. This may alleviate concerns from patients and policymakers about TKA in an academic setting. Surgical “exposure” and “closure” were the most prolonged steps for the residents, and they may benefit with more focus and/or simulation studies during training.

Virtual Reality as a Learning Tool for Trainees in Unicompartmental Knee Arthroplasty: A Randomized Controlled Trial

INTRODUCTION

The efficacy of virtual reality (VR) as a teaching augment for arthroplasty has not been well examined for unfamiliar multistep procedures such as unicompartmental knee arthroplasty (UKA). This study sought to determine whether VR improves surgical competence over traditional procedural preparation when performing a UKA.

METHODS

Twenty-two orthopaedic surgery trainees were randomized to two surgical preparation cohorts: (1) "Guide" group (control) with access to manufacture's technique guide and surgical video and (2) "VR" group with access to an immersive commercially available VR learning module. Surgical performance of UKA on a SawBone model was assessed through time and the Objective Structured Assessment of Technical Skills (OSATS) validated rating system.

RESULTS

Participants were equally distributed among all training levels and previous exposure to UKA. No difference in mean surgical times was observed between Guide and VR groups (Guide = 42.4 minutes versus VR = 43.0 minutes; P = 0.9) or mean total OSATS (Guide = 15.7 versus VR = 14.2; P = 0.59). Most trainees felt VR would be a useful tool for resident education (77%) and would use VR for case preparation if available (86.4%).

CONCLUSION

In a randomized controlled trial of trainees at a single, large academic center performing a complex, multistep, unfamiliar procedure (UKA), VR training demonstrated equivalent surgical competence compared with the use of traditional technique guides, as measured by surgical time and OSATS scores. Most of the trainees found the VR technology beneficial. This study suggests that VR technology may be considered as an adjunct to traditional surgical preparation/training methods.

Resident Level Involvement Affects Operative Time and Surgical Complications in Lower Extremity Fracture Care

OBJECTIVE

The purpose of this study is to evaluate the effect of resident participation on operative time and surgical complications in isolated lower extremity fracture care.

SETTING

Patients who were treated at teaching hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program database.

PARTICIPANTS

A total of 2,488 patients who underwent surgical fixation of isolated hip fractures, femoral or tibial shaft fractures, and ankle fractures.

DESIGN

Patients were stratified by surgical procedure and post-graduate year (PGY) of the resident involved. Total operative time and surgical complications were analyzed with respect to resident participation and seniority. Multivariable logistic regression analyses were used to adjust for potential confounders including case complexity, wound class, and patient comorbidity burden.

RESULTS

As PGY level increased, operative time increased for each procedure. The odds for a deep surgical site infection decreased as resident seniority increased, but the odds for wound dehiscence increased as resident seniority increased. We found no difference in the incidences of superficial infections or return to the OR with respect to PGY level. Academic quarter within the academic year did not correlate with any of the surgical complications. Furthermore, when cases performed with residents were compared to those performed without residents, there was no increased risk of superficial infections, deep infections, or return to the OR.

CONCLUSIONS

This nationally representative dataset demonstrates that operative times for lower extremity orthopedic trauma increased as resident seniority increased. Additionally, senior resident participation was associated with increased wound dehiscence, whereas junior resident participation was associated with an increased risk of deep surgical site infections. However, there was no associated "July effect" for residents at any level of training and there was no increased risk for surgical site infections or return to the OR in cases involving resident participation.

Trainee performed total knee arthroplasty is safe and effective: A systematic review and meta-analysis comparing outcomes between trainees and consultants

BACKGROUND

There are concerns that trainee performed knee arthroplasty (KA) may adversely affect patient outcomes. Demand for KA is projected to increase, and trainees must therefore be competent to perform it.

METHODS

A systematic literature search was performed identifying articles comparing outcomes following trainee versus consultant surgeon performed primary KA. Outcomes included rate of revision surgery, rate of infection, operation time, length of stay and functional outcomes. A meta-analysis was conducted using Odds ratios (ORs) and weighted mean differences (WMD). A quality assessment of studies and qualitative analysis was performed.

RESULTS

The analysis included 9 studies of 92,309 arthroplasties, 80,655 were performed by consultants, 11,654 by trainees. The mean age was 69.2. There was no significant difference between the two groups' rate of revision (OR 0.79; 95% CI 0.61-1.02; p = 0.07. Trainees were associated with a lower rate of infection (5 studies; OR 0.75; 95% CI 0.58-0.97; p = 0.03). There was no difference in the rate of neurological deficit, transfusion rate or thrombosis. There was no difference in operation time (5 studies; WMD 3.50; 95% CI -3.9-10.89; p = 0.35). The trainee group had less favourable functional outcome scores (7 studies; WMD -1.26; 95% CI -1.44--1.07; p < 0.01). However, this difference was not clinically significant.

CONCLUSIONS

The study suggests that supervised trainees can achieve similar outcomes to consultant surgeons andin selected cases, trainee performed supervised KA is therefore safe and effective.

Does Virtual Reality Improve Procedural Completion and Accuracy in an Intramedullary Tibial Nail Procedure? A Randomized Control Trial

BACKGROUND

Artificial reality technologies are currently being explored as potential options to improve surgical education. Previous studies have primarily examined the efficacy of artificial reality in laparoscopic procedures, but to our knowledge, none have been performed in orthopaedically relevant procedures such as intramedullary tibial nailing, which calls for more versatile large-scale movements.

QUESTIONS/PURPOSES

Does a virtual reality simulator with or without a standard technique guide result in (1) a higher proportion of participants who completed the insertion of an intramedullary tibial nail in a synthetic bones model and (2) greater procedural accuracy than does training with a technique guide alone?

METHODS

Twenty-five first- and second-year medical students without prior exposure to intramedullary tibial nail insertion were recruited. Participants were randomly assigned to the technique guide control group (n = 8), the virtual reality group (n = 8), or the virtual reality and technique guide group (n = 9). The technique guide was adapted from a commercially available technique guide, which participants in the assigned groups could use to prepare as much as desired. The virtual reality simulation was based on the same procedure, and we used a commercially available virtual reality simulator that we purchased for this task. Participants in the virtual reality experimental groups completed the simulation on three separate sessions, at a set interval of 3 to 4 days apart. After 10 to 14 days of preparation, all participants attempted to insert an intramedullary nail into an intact, compact bone-model tibia that lacked surrounding soft tissue. Participants were given written hints if requested, but no other assistance was given. A procedure was considered complete if the nail and screw were properly placed. Procedural accuracy was defined as the number of incorrect steps normalized out of the 16 possible performed. After the procedure, one orthopaedic surgeon assessed a blinded video of the participant performing it so the assessor could not recognize the individual or that individual's gender. Additionally, the assessor was unaware of which group each participant had been randomized to during the evaluation.

RESULTS

A higher proportion of participants in the virtual reality group (6 of 8) and the virtual reality and technique guide group (7 of 9) completed the intramedullary nail than did participants in the technique guide group (2 of 8; p = 0.01). There was no difference in completion between the virtual reality groups (p = 0.89). Participants in the virtual reality and virtual reality and technique guide had fewer normalized incorrect steps than did participants in the technique guide group (3.2 ± 0.1 of 16 and 3.1 ± 0.1 of 16 versus 5.7 ± 0.2 of 16, respectively; p = 0.02 for comparisons of virtual reality groups to technique guide, p = 0.63 between the virtual reality group).

CONCLUSIONS

Virtual reality increased both procedural accuracy and the completion proportion compared with a technique guide in medical students. Based on our findings, virtual reality may help residents learn the procedural workflow and movements required to perform surgical procedures. Future studies should examine how and when exactly the technology can be applied to residencies and its impact on residents.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Teaching hip surgery to orthopaedic residents: what's new?

PURPOSE

The purpose of this study is to provide an overview of the published literature on the existing educational methods used to teach surgical skills, with a specific focus on hip surgery, to orthopaedic residents.

METHODS

A total of 31 articles were selected from a PubMed literature search on the topic of teaching surgical skills to orthopaedic residents, and 9 articles on hip surgery are included in this review.

RESULTS

Although several methods are included in the published literature to teach orthopaedic residents, only arthroscopy of the knee and shoulder joint is well described. Hip arthroscopy has a steeper learning curve and thus the use of simulation training as a complementary teaching method is even more important.

CONCLUSIONS

Currently, open surgery skills for joint arthroplasty are largely acquired by apprenticeship learning. Simulation training in the form of virtual reality could contribute to better performance of residents, decreasing operation time and improving patient safety.

What Factors Influence Operative Time in Total Knee Arthroplasty? A 10-Year Analysis in a National Sample

BACKGROUND

Changes in reimbursement in total knee arthroplasty (TKA) by Centers for Medicare and Medicaid Services (CMS) have been tied to a perceived decrease in the total surgical time required to perform these operations. However, little information is available to CMS about recorded surgical times for TKA across the United States and the variables that drive these values. Therefore, the purpose of our study, is to evaluate (1) changes in operative time over time and (2) factors associated with variations in operative time.

METHODS

The National Surgical Quality Improvement Program database was queried to identify all primary TKAs conducted between January 1, 2008, and December 31, 2017. All TKAs conducted within our study period that had operative time data available were included. Multivariable linear models were created to assess factors that influence operative time over the study period.

RESULTS

Our final analysis included 140,890 TKAs. The mean operative time across the study period was found to be 92.60 minutes. Examining quarterly values, operative time stayed within 5 minutes of this mean (range, 89.80-97.51 minutes). Age, sex, functional status, anesthesia type, body mass index, operative year, transfusion requirements, and preoperative laboratory findings significantly influenced operative time (P < .05 for all).

CONCLUSION

Our analysis indicates that while there are numerous factors that influence procedure duration, operative times have remained stable. This information should be heavily considered in regard to physician reimbursement, because providers are maintaining operative times and work effort while mitigating factors that influence outcomes in the perioperative period.

The presence of residents during orthopedic operation exerts no negative influence on outcome

BACKGROUND

Operative procedural training is a key component of orthopedic surgery residency. It is unclear how and whether residents participation in orthopedic surgical procedures impacts on post-operative outcomes.

SOURCES OF DATA

A systematic search was performed to identify articles in which the presence of a resident in the operating room was certified, and was compared with interventions without the presence of residents.

AREAS OF AGREEMENT

There is a likely beneficial role of residents in the operating room, and there is only a weak association between the presence of a resident and a worse outcome for orthopedic surgical patients.

AREAS OF CONTROVERSY

Most of the studies were undertaken in USA, and this represents a limit from the point of view of comparison with other academic and clinical realities.

GROWING POINT

The data provide support for continued and perhaps increased involvement of resident in orthopedic surgery.

AREAS OF RESEARCH

To clarify the role of residents on clinically relevant outcomes in orthopedic patients, appropriately powered randomized control trials should be planned.