Acquisition Of Surgical Skills Research Articles

Surgical Skill Acquisition in Medical Students on the Virtual Platform: Is it as Effective as Conventional Proctoring Methods?

Surgical Skill Acquisition in Medical Students on the Virtual Platform: Is it as Effective as Conventional Proctoring Methods?

1005 Acquisition of Surgical Skills in Medical Students Via Telementoring: A Randomised Control Trial

Abstract Aim To evaluate the use of telementoring in acquisition of basic suturing skills in medical students. Method This was a single blinded two- armed randomised control trial. Medical students undergoing clinical rotations in their penultimate and final years were invited to participate in this study. Informed consent was obtained. The control group underwent conventional suturing training, with the interventional group undergoing the tutorial in a remote learning setting via live streaming. Pre- and post-test assessment was carried out using validated Global Rating Scale tool. Results Eleven students were enrolled in this study. Participants were comparable at baseline (p=.18) and following the tutorial (p=.29). Participants improved to a statistically significant degree in both the virtual group (p=.02) and the in-person group (p=.001). Conclusions Telementoring is an effective tool in the provision of teaching basic suturing skills in medical students. Research on its use in more complex practical skills is warranted.

Hybrid Workshops During the COVID-19 Pandemic—Dawn of a New Era in Neurosurgical Learning Platforms

BackgroundDuring the COVID-19 pandemic, disruption of surgical hands-on training has hampered the skills acquisition by budding neurosurgeons. Online and virtual classrooms have not been able to substitute the hands-on experience and learning via direct interaction with senior colleagues. To overcome these challenges, we organized a hybrid workshop where simulation-based learning modules, and direct and virtual interaction with surgeons during live surgeries or didactic lectures were utilized to help delegates in understanding the nuances of neurosurgery.MethodsA 3-day hybrid workshop was held in March 2021, which was attended by 133 delegates. A structured questionnaire was utilized to record their feedback.ResultsAn overwhelming majority of the respondents (94.1%, n = 64) found hybrid conferences to be better than an online conference. Most of the respondents (88.3%, n = 60) rated the utility of direct face-to-face interaction to be more satisfying as compared with online interaction with faculty during a webinar. Again, many the respondents (86.8%, n = 59) believed that similar hybrid events will be the new normal given the current situation of COVID-19 pandemic. A large majority (88.2%, n = 60) of the respondents reported that they will prefer a hybrid event over an online conference.ConclusionsIn this era of the COVID-19 pandemic, “hybrid” microneurosurgery workshops offer unique opportunities to enhance surgical skills acquisition by hands-on simulation-based learning and observing live surgical demonstrations, apart from 2-way interactions with experts under one roof. This may be a stepping stone for what lies ahead in the future of neurosurgical training.

The effects of unilateral transcranial direct current stimulation on unimanual laparoscopic peg-transfer task

IntroductionEfficient training methods are required for laparoscopic surgical skills training to reduce the time needed for proficiency. Transcranial direct current stimulation (tDCS) is widely used to enhance motor skill acquisition and can be used to supplement the training of laparoscopic surgical skill acquisition. The aim of this study was to investigate the effect of anodal tDCS over the primary motor cortex (M1) on the performance of a unimanual variant of the laparoscopic peg-transfer task. MethodsFifteen healthy subjects participated in this randomized, double-blinded crossover study involving an anodal tDCS and a sham tDCS intervention separated by 48 h. On each intervention day, subjects performed a unimanual variant of laparoscopic peg-transfer task in three sessions (baseline, tDCS, post-tDCS). The tDCS session consisted of 10 min of offline tDCS followed by 10 min of online tDCS. The scores based on the task completion time and the number of errors in each session were used as a primary outcome measure. A linear mixed-effects model was used for the analysis. ResultsWe found that the scores increased over sessions (p < 0.01). However, we found no effects of stimulation (anodal tDCS vs. sham tDCS) and no interaction of stimulation and sessions. ConclusionThis study suggests that irrespective of the type of current stimulation (anodal and sham) over M1, there was an improvement in the performance of the unimanual peg-transfer task, implying that there was motor learning over time. The results would be useful in designing efficient training paradigms and further investigating the effects of tDCS on laparoscopic peg-transfer tasks.

Training and mentoring of the congenital heart surgeon for India.

Congenital heart surgery is one of the most demanding subspecialities in surgery. To become a competent surgeon, a lot of investment of time, in-depth study, training under a committed mentor, acquisition of the necessary fine surgical skills, and development of a three-dimensional appreciation of corrections are needed to be cultivated. These make it not only a speciality of skills, but also a cerebral speciality. It is commonly felt amongst the residents training in cardiovascular and thoracic surgery that they perform far less operative work to make them even "somewhat" confident of doing procedures independently towards the end of their residency. If this young cardiac surgeon needs to subspecialize in congenital heart surgery, more exposure to newer concepts and a much higher level of skill-based training become mandatory for achieving competence. Taking all this into consideration, this article will dwell on some of the traits and abilities that are desired in the candidates choosing to train incongenital heart surgery(CHS), the requirements of the speciality, and some tips to the trainers/mentors to help in effective devolution of thoughts, principles, and skills. Salient points of the mentoring process have also been discussed. A modular plan for staged acquisition and transmission of surgical skills, as well as surgical management of common congenital cases, has been outlined. Finally, a note is added to sensitize the young congenital heart surgeon to learn to embrace the nuances of practicing this speciality in India. This could also apply to many other developing and low- and middle-income countries.

Simulation in surgical education: mentors’ point of view

: Simulation allows surgical trainees to practice in a safe and standardized setting. Reduction of working hours, financial need of efficiency, and ethical dilemmas over patient’s safety have motivated the development of surgical simulation. Currently, a wide variety of surgical simulators are available with a broad range from simple and economic models to highly sophisticated and expensive ones. Some of them are used to train basic surgical skills, and others offer realism and opportunities to train entire surgical procedures. Acquisition of surgical skills and improvement of intraoperative performance are main advantages associated with simulation. High-fidelity simulated operating rooms also allow for training teamwork technical and non-technical skills such as response to intraoperative crisis scenarios or communication skills among team members. In addition, simulation is very useful for practicing surgeons who want to embrace new technologies in their practice. On the other hand, costs, limited manpower resources, and lack of standardized simulation curricula are significant challenges of surgical simulation. While in some countries surgical simulation is already well-established, in others simulation is not yet formally included in the training curricula. As simulation is a key component of surgical education, further efforts are needed to formally incorporate simulation in every surgical residency program.

Neuroimaging Guided Transcranial Electrical Stimulation in Enhancing Surgical Skill Acquisition. Comment on Hung et al. The Efficacy of Transcranial Direct Current Stimulation in Enhancing Surgical Skill Acquisition: A Preliminary Meta-Analysis of Randomized Controlled Trials. Brain Sci. 2021, 11, 707.

Surgical skill acquisition may be facilitated with a safe application of transcranial direct current stimulation (tDCS). A preliminary meta-analysis of randomized control trials showed that tDCS was associated with significantly better improvement in surgical performance than the sham control; however, meta-analysis does not address the mechanistic understanding. It is known from skill learning studies that the hierarchy of cognitive control shows a rostrocaudal axis in the frontal lobe where a shift from posterior to anterior is postulated to mediate progressively abstract, higher-order control. Therefore, optimizing the transcranial electrical stimulation to target surgical task-related brain activation at different stages of motor learning may provide the causal link to the learning behavior. This comment paper presents the computational approach for neuroimaging guided tDCS based on open-source software pipelines and an open-data of functional near-infrared spectroscopy (fNIRS) for complex motor tasks. We performed an fNIRS-based cortical activation analysis using AtlasViewer software that was used as the target for tDCS of the motor complexity-related brain regions using ROAST software. For future studies on surgical skill training, it is postulated that the higher complexity laparoscopic suturing with intracorporeal knot tying task may result in more robust activation of the motor complexity-related brain areas when compared to the lower complexity laparoscopic tasks.

Cochlear implant surgery: Learning curve in virtual reality simulation training and transfer of skills to a 3D-printed temporal bone – A prospective trial

Objective Mastering Cochlear Implant (CI) surgery requires repeated practice, preferably initiated in a safe – i.e. simulated – environment. Mastoidectomy Virtual Reality (VR) simulation-based training (SBT) is effective, but SBT of CI surgery largely uninvestigated. The learning curve is imperative for understanding surgical skills acquisition and developing competency-based training. Here, we explore learning curves in VR SBT of CI surgery and transfer of skills to a 3D-printed model. Methods Prospective, single-arm trial. Twenty-four novice medical students completed a pre-training CI inserting test on a commercially available pre-drilled 3D-printed temporal bone. A training program of 18 VR simulation CI procedures was completed in the Visual Ear Simulator over four sessions. Finally, a post-training test similar to the pre-training test was completed. Two blinded experts rated performances using the validated Cochlear Implant Surgery Assessment Tool (CISAT). Performance scores were analyzed using linear mixed models. Results Learning curves were highly individual with primary performance improvement initially, and small but steady improvements throughout the 18 procedures. CI VR simulation performance improved 33% (p < 0.001). Insertion performance on a 3D-printed temporal bone improved 21% (p < 0.001), demonstrating skills transfer. Discussion VR SBT of CI surgery improves novices’ performance. It is useful for introducing the procedure and acquiring basic skills. CI surgery training should pivot on objective performance assessment for reaching pre-defined competency before cadaver – or real-life surgery. Simulation-based training provides a structured and safe learning environment for initial training. Conclusion CI surgery skills improve from VR SBT, which can be used to learn the fundamentals of CI surgery.

The Efficacy of Transcranial Direct Current Stimulation in Enhancing Surgical Skill Acquisition: A Preliminary Meta-Analysis of Randomized Controlled Trials.

The application of transcranial direct current stimulation (tDCS) to targeted cortices has been found to improve in skill acquisition; however, these beneficial effects remained unclear in fine and complicated skill. The aim of the current meta-analysis was to investigate the association between tDCS application and the efficacy of surgical performance during surgical skill training. We included randomized controlled trials (RCTs) investigating the efficacy of tDCS in enhancing surgical skill acquisition. This meta-analysis was conducted under a random-effect model. Six RCTs with 198 participants were included. The main result revealed that tDCS was associated with significantly better improvement in surgical performance than the sham control (Hedges’ g = 0.659, 95% confidence intervals (95%CIs) = 0.383 to 0.935, p < 0.001). The subgroups of tDCS over the bilateral prefrontal cortex (Hedges’ g = 0.900, 95%CIs = 0.419 to 1.382, p < 0.001) and the primary motor cortex (Hedges’ g = 0.599, 95%CIs = 0.245 to 0.953, p = 0.001) were both associated with significantly better improvements in surgical performance. The tDCS application was not associated with significant differences in error scores or rates of local discomfort compared with a sham control. This meta-analysis supported the rationale for the tDCS application in surgical training programs to improve surgical skill acquisition.

621 Impact Of COVID-19 On Surgical Training at A District General Hospital in London

IntroductionCOVID 19 affected surgical training owing to changes in rotations, moving trusts/departments, surgical skills acquisition and new guidelines/protocols during unprecedented times. Aim was to infer how redeployment impacted surgical skills via an objective and subjective study.MethodA retrospective observational study comparing lead surgeons in Laparotomy and Appendectomies between 23rd March- 31st July (2019/2020). A subjective survey was done to elucidate perspectives on skill, academic advancement and trust/deanery support. A focussed group discussion was also done to gain insight on physical and psychological well-being.ResultsLaparotomy 2019 (n = 75) had 59%; 41%; 0% - Consultants/Registrars/ fellows respectively as lead surgeons. 2020 Laparotomies (n = 50) had 40% consultants; 41% registrars; 20% fellowsSimilarly, Appendectomy 2019 (n = 94) had 8.5% consultants; 71.3% registrars; 3.2% clinical fellows, whereas 2020 Appendectomies (n = 67) had 18% consultants; 71.6% registrars and 10.4% fellows.The Likert questionnaire showed 42.86% had mental exhaustion, less confidence/skills due to lesser opportunities/procedures. 57.14% expressed COVID 19 extremely affected surgical training while 28.14% believed in a reduction of 81-100% operative log book entries from before.ConclusionsAlthough, the results were not significant in number of cases managed by trainees; many reported perceived loss of training( log book/portfolio), less teaching/training opportunities and mental exhaustion.

O57: GREATER USE OF NON-TECHNOLOGICAL SIMULATION METHODS IMPROVES SKILL ACQUISITION IN SURGICAL TEACHING

Abstract Introduction Studies that have reviewed technologies including haptic feedback and virtual reality indicate the usefulness of simulation. However, these technologies are not universally available. Less technologically innovative simulation methods that utilise the learning environment, equipment and presentation can still effectively support surgical teaching. A review was undertaken to assess the effect of these lower fidelity simulation methods on surgical skill acquisition. Method Two courses enrolled 12 and 14 respectively, with trainees ranging in seniority from Foundation Year 1 to Core Trainee Year 2. Four basic surgical skills (suturing, hand tying, local anaesthetic and surgical instruments) were taught in 20 and 30 minute stations. These skills were used to assess trainee confidence before and after teaching, using a 5 point qualitative data collection scale ranging from Not Very to Very Confident. The faculty received a pre-course lecture on teaching methods to ensure standardisation. Result Mean confidence increased following participation in simulation teaching; 1st course demonstrated a post-teaching increase of 42%, 2nd a 60% increase. Individual skill confidence increased more following simulation-based course in hand tying (57% p=0.002, v 89% p=0.00007), local anaesthetic (30% p=0.001, v 41% p=0.005) and surgical instruments (44% p=0.005, v 89% p=0.0001). Suturing was not associated with increased mean confidence, but median confidence score increased more (33% p=0.005, v 60% p=0.0001). Conclusion Greater incorporation of simulation in training is generally associated with increased confidence with surgical skills. This is likely due to better contextualisation, leading to improved understanding of the place of the skills in the clinical setting. Take-home message Greater incorporation of simulation techniques, not necessarily of a technological nature, leads to increased confidence with surgical skills.

P1: THE VITAL STUDY: A FEASIBILITY STUDY OF A RANDOMISED CONTROLLED TRIAL TO EXAMINE IF VIRTUAL REALITY TECHNOLOGY CAN IMPROVE SURGICAL TRAINING IN SIERRA LEONE

Abstract Introduction Training surgeons is expensive and relies on expert supervision. Virtual reality (VR) may enhance acquisition of knowledge and skills. There is limited evidence on the effectiveness of VR in low and middle-income countries (LMICs). The purpose of this study was to evaluate the technical feasibility of mobile phone VR in LMICs and the feasibility of conducting a full-scale randomised controlled trial. Method A prospective randomised controlled feasibility study was conducted. Surgical trainees were recruited from a government teaching hospital in Freetown in November 2019. Participants were randomised 1:1 VR vs non-VR. These were given one-week prior to a two-day hands-on course on lower limb amputation. The VR training involved two 30-minute modules consisting of narrated live surgery videos. Feasibility outcomes included recruitment rates and VR intervention fidelity and acceptability. Result Thirty participants were randomised to the VR group (n=15) or control group (n=15). Of these, 29 (96.7%) participants completed the course. The recruitment period required was two days. Intervention adherence exceeded defined success rates with 100% of participants completing the intervention. There was no unblinding. Compared to controls, the VR group rated statistically significantly higher engagement during the course in 4/6 domains, increased perceived learning in 5/5 domains and increased engagement with pre-course learning in in 4/6 domains. Conclusion VR is technically feasible in an LMIC setting and improves engagement and perceived learning. With minor modifications to the intervention and assessments, a full-scale trial is feasible. Further exploration is required to determine the best outcome measures to demonstrate effect. Take-home message VR is technically feasible in an LMIC setting and improves engagement and perceived learning. Now we need to explore if it can improve surgical knowledge and skill acquisition on a large scale.

AB049. SOH21AS067. Use of virtual reality simulation in surgical training: a systematic review on predictive validity and current use in surgical curricula

Background: Use of simulated surgical learning is an evolving training modality within surgical trainees. Its use in transferring simulation based skill to the operating room is an integral aspect of its use as a pedagogical tool for surgical trainees in an era of reduced working hours and fewer intraoperative opportunities. These systems may allow trainees to upskill in simulated scenarios leading to improved skillsets and patient safety. The aim of this review was to evaluate if acquisition of surgical skills developed in simulated procedures result in improved intra-operative performance and whether this be integrated into current surgical curriculums.

AB155. SOH21AS124. Investigating the receptivity to virtual reality in surgical training: a survey based analysis in the Department of Surgery in Midland Regional Hospital Tullamore (MRHT)

Background: In surgical training, virtual reality (VR) has the potential to expedite acquisition of surgical skills and prepare surgical trainees for independent practice—especially in the COVID-19 era. While research has shown that VR can increase efficiency and improve patient safety, the receptivity of surgical consultants and trainees must continue to be explored in order to better understand how it can be integrated into current medical education. This study aims to investigate attitudes, prior experience and barriers to use of virtual reality simulation across surgical specialities in MRHT.

Innovations in Urologic Surgical Training

This review aims to summarize innovations in urologic surgical training in the past 5 years. Many assessment tools have been developed to objectively evaluate surgical skills and provide structured feedback to urologic trainees. A variety of simulation modalities (i.e., virtual/augmented reality, dry-lab, animal, and cadaver) have been utilized to facilitate the acquisition of surgical skills outside the high-stakes operating room environment. Three-dimensional printing has been used to create high-fidelity, immersive dry-lab models at a reasonable cost. Non-technical skills such as teamwork and decision-making have gained more attention. Structured surgical video review has been shown to improve surgical skills not only for trainees but also for qualified surgeons. Research and development in urologic surgical training has been active in the past 5 years. Despite these advances, there is still an unfulfilled need for a standardized surgical training program covering both technical and non-technical skills.

Low versus high level of physical resemblance in simulation for the acquisition of basic surgical skill: a meta-analysis

BackgroundMany studies explored the use of simulation in basic surgical education, with a variety of devices, contexts and outcomes, with sometimes contradictory results.ObjectivesThe objectives of this meta-analysis were to focus...

Glenoid and acetabular reaming force varies in simulation between fellowship trained surgeons

BackgroundThe acquisition of surgical skills required to correctly perform orthopedic procedures varies among different institutions due to the diversity of training curriculums. With its technologic advances, surgical simulation can provide trainees with an accurate, safe, and standardized mean to practice procedures throughout their time in residency. The force utilized by a surgeon while reaming relies on prior experience and muscle memory developed throughout their career. The aim of the present study was to evaluate and compare the average force applied during reaming of an acetabulum vs. a glenoid by fellowship trained orthopedic surgeons in order to provide trainees a standard to use during simulation and in practice and to provide an understanding of the force differentials. MethodsA reaming simulator was created by installing a force transducer onto a reamer which allowed the testing of fellowship trained hip and shoulder orthopedic surgeons from the surrounding communities. Each surgeon was given 6 trials to determine the mean clinical force and their max effort force. Demographic information was surveyed for each participating surgeon to determine their level of experience and personal characteristics. Statistical analysis was performed using a Welch t test for scale variables and a Levene's F test to compare variances between groups via SPSS Statistics 24 software. ResultsA 61% greater mean clinical force was applied while simulating reaming of the acetabulum (90.12 N ± 30.12) than of the glenoid (55.91 N ± 25.65), t (184) = 8.0, P< .001. When shoulder (297.62 N ± 82.25) and hip surgeons (318.11 N ± 112.06) were asked to push the reamer at a maximal effort, there was no significant difference between the max effort force generated by the 2 groups (P = .16). For glenoid reaming, shoulder surgeons applied 19% of their max effort force while for acetabular reaming, hip surgeons applied 28% of their max force. ConclusionThe mean clinical force utilized to ream an acetabulum is greater than that of a glenoid by nearly twofold. Application of this knowledge can be translated into surgical simulation training for residents to help them develop the proper muscle memory for reaming in the 2 different clinical scenarios throughout residency. Reamers with an incorporated force transducer could provide surgeons, in real time, feedback on the force they apply to bone. With the advances in simulations, these tools can be optimized to give trainees tactile feedback when learning crucial steps of surgery. Level of evidenceClinical Science Study; Biomechanics

Influence of musical background on surgical skills acquisition

BackgroundThere is growing interest in identifying trainees with surgical aptitude predictive of eventual technical proficiency. Musical tasks involve complex, cerebral activity, and ambidextrousity, which may have a positive impact on the acquisition of surgical skill sets. The purpose of this study was to investigate the influence of prior musical experience on the performance of basic surgical skills. MethodsThis was a prospective cross-sectional study involving 51 novice undergraduate and medical school trainees with no prior surgical exposure. Musicality was assessed with a detailed survey and objectively with the Mini-Profile of Music Perception Skills test. Dexterity was assessed using the Purdue Pegboard test. Surgical skills were then evaluated by performing 2 timed suturing trials after observing tutorial video, followed by a timed laparoscopic peg transfer test. Outcomes included both speed and quality of performance. ResultsParticipants with prior musical experience performed better than nonmusicians on the Mini-Profile of Music Perception Skills test (P = .015), dominant hand dexterity (P = .05), suture quality (P < .03), and laparoscopic peg transfer speed (P < .01). There was no significant difference in the suturing speed between musicians and nonmusicians. The dexterity and Mini-Profile of Music Perception Skills scores were predictive of suture quality (P < .01). Among musicians, duration of musical training, inactivity, instrument type, and certification levels did not correlate with differences in surgical task performance. ConclusionMusical background is associated with better performance of fundamental surgical skills among surgical novices, particularly technique quality. Although this does not imply superior ultimate surgical ability, musicality may be a marker for basic surgical skill development useful in identifying suitable candidates for surgical training.

Immediate Effect of Mental Practice on Performance of a Neurodynamic Skill in Physiotherapy Students: A Randomized Control Trial

Background: Mental Practice (MP), "the cognitive rehearsal of a task in the absence of overt physical movement," has been used successfully in teaching and rehearsing complex psychomotor tasks in several domains, including sports; music; and recently, in surgical skills acquisition. This study investigates the implementation of MP on performance of a neurodynamic skill in third year undergraduate Physiotherapy students. Method: It was a randomized control trial (single-blind) conducted in a Physiotherapy institute. A convenient sample of 40 III year undergraduate students who were novice for the topic were recruited. Some important preliminary steps involved development and validation of the tools used in the study viz. an audio script to guide mental imagery practice and an OSPE checklist to assess the outcome. The OSPE checklist was procedural specific for ULNT-1 and included stations for cognitive, psychomotor and affective domains. A neurodynamic skill (ULNT-1 Median nerve) was taught to all the students (n = 38, 2 drop outs) by a teacher as a didactic lecture followed by physical practice which was supervised and guided by the same teacher. After randomization, the intervention group (n=19) received MP guided by a structured audio script as a single session for 20 minutes delivered to all the participants together in a group. The control group participants (n=19) intended to serve as a basis of comparison and received no intervention. Pre- and post-intervention assessment was done by a set of examiners who were blinded to the intervention. Comparative analysis was done within the group using Wilcoxon sign rank test and between the groups using unpaired t test. Results: MP group showed significant improvement in cognitive, psychomotor, affective domain and total score of OSPE post intervention whereas the control group did not show significant difference except for the total score. Between group comparison showed significant differences in all the domains and total score in favor of the MP group. Also, the extent of improvement (effect size calculated using Cohen’s d) was more in the mental practice group than in the control group. Conclusion: MP as an adjunct to physical practice is a time-and cost-effective strategy to augment traditional training and enhance performance of a neurodynamic skill in Physiotherapy students. This preliminary evidence supported by robust scientific base and ease of integration should facilitate adoption of MP in Physiotherapy education. We recommend future studies to further explore the potential of this promising tool.

No implant, no solution, lost cases to surgery: orthopedic trauma triage for surgery in an NGO hospital in Sierra Leone

IntroductionIn low-income countries (LIC), international surgeons face the fact that there are patients they cannot treat. The goal of this study was to identify and analyze patients lost to treatment.Material and methodsWe analyzed retrospectively the data of 282 trauma victims from a non-governmental organizational (NGO) hospital in Sierra Leone, Africa. During a 3-month period (10.10.2015–08.01.2016), these patients had 367 injuries and underwent 263 orthopedic surgeries. Despite a clear indication, some patients did not receive surgical treatment. We identified these injuries and the reason why they could not be operated. The anatomic region of the injury was evaluated and if they had a bone or soft tissue defect or were infected.ResultsWe identified 95 (25.89%) injuries in 70 patients (47 males; 23 females) that were not be operated. The reasons were lack of specific implants (no implant group; N = 33), no treatment strategy for the injury (no solution group; N = 29), and patients that were lost (lost patient group; N = 33), almost equally distributed by 1/3. In the no implant group were mainly closed fractures and fractures of the pelvis and the proximal femur. The implants needed were locking plates (N = 19), proximal femoral nails (N = 8), and implants for pelvic surgery (N = 6). In the no solution group were nearly all bone (P < 0.0000), soft tissue defects (P < 0.00001) and infections (P = 0.00003) compared to the rest and more open fractures (P < 0.00001). In the lost patients group, most fractures were closed (24 out of 33, P = 0.033). These fractures were mostly not urgent and were postponed repeatedly.ConclusionOne quarter of the patients did not receive the surgical treatment needed. Besides acquisition of implants, surgical skills and expertise could be a solution for this issue. Nevertheless, these skills must be passed to local surgeons.