Orthopaedic Surgical Training Research Articles

Orthopaedic Sport Medicine Surgeons and Fellows Value Immersive Virtual Reality for Improving Surgical Training, Procedural Planning, and Distance Learning

BackgroundOverall, the potential utility of iVR technology in orthopaedic surgery is promising. The attitudes of medical students and surgical trainees on VR simulated surgical training have been overwhelmingly positive. However, further research and understanding of the attitudes of practicing orthopaedic surgeons and Fellows are needed to appreciate its benefits for clinical practice. PurposeThe purpose of this study was to assess the attitudes of Canadian orthopaedic surgeons and Fellows on the value of iVR for surgical training, clinical practice, and distance learning. MethodsForty-three orthopedic surgeons and Fellows attended a VRthrscopy™ Knee Module (Conmed Corporation, Largo, USA) demonstration. The view and audio from the lead headset were cast to a large screen so the audience could follow the procedure in real-time. Immediately after the presentation, the audience members were given a paper questionnaire assessing their perceptions and attitudes toward iVR or use in orthopaedic learning, clinical practice and distance education and mentoring. ResultsiVR was perceived to be valuable for the field of orthopaedic surgery. All 13 questions were rated with mean Likert scores of five or greater indicating observed value for all 13 questions. The respondents indicated that iVR had value (score of 5 or greater) in each questionnaire domain, with agreement ranging from 78-98% for teaching and learning, 66-97% for clinical practice, and 88-100% for distance education and mentoring questions. ConclusionThis study has demonstrated that a group of Canadian sport medicine orthopedic surgeons and Fellows had favourable attitudes towards, and perceived that iVR has value in, orthopaedic surgical training, clinical practice, and distance learning and mentorship. The potential for utilizing iVR technology for distance learning, mentorship and global education appears promising.

Virtual Reality and Surgical Simulation Training for Orthopaedic Surgery Residents: A Qualitative Assessment of Trainee Perspectives.

The demonstrated benefits of virtual reality (VR) in orthopaedic surgical training are numerous. However, it is relatively unknown how best to implement VR into an already established orthopaedic resident education curriculum and how trainees will engage and use these technologies longitudinally. This was an exploratory, qualitative research study performed in accordance with Consolidated Criteria for Reporting Qualitative Research guidelines. Orthopaedic surgery residents at a single institution were recruited during the 2022 to 2023 academic year. Semistructured interviews were conducted. Data were analyzed through grounded theory methodology, beginning with open coding, followed by axial coding, and concluding with selective coding that describes orthopaedic surgery residents' current perceptions of VR as a training tool. Six residents participated in interviews before thematic saturation was achieved. Average interview length was 13:27 (±2:59) minutes. Residents felt that currently, VR is most useful for interns and junior residents as an educational adjunct for learning anatomy, surgical exposures, and the steps of a procedure in a risk- and judgment-free arena. There seems to be a "ceiling effect" with VR given current technological limitations, and residents remarked that there is an associated "opportunity cost" with using VR technology. Some residents may find it more time-efficient to study texts, videos, or surgical guides rather than use VR. Cost (limited number of headsets) and technological barriers (i.e., hardware, software, and Wi-Fi issues) were some of the described barriers to VR utilization. Residents felt that there needs to be dedicated technological support to help with these issues. At this time, given these limitations of VR, many preferred VR as an optional educational adjunct rather than as a required curricular tool or assessment of surgical competency. There is current utility for VR in orthopaedic surgical training. Future technological advances may make VR more central to resident education. This study describes resident perceptions about the technology and best use practices for the technology. Qualitative Study, Level V Evidence.

Orthopaedic trauma residency programs: Perspectives from different countries across the world

The ability to manage the myriad of musculoskeletal conditions successfully requires multiple years of training. Access to and completion of orthopaedic surgical training entails an often grueling, highly regulated path to certification to practice. Although the world is more connected than ever, the question is whether the local certification criteria for medical specialists leads to a generic residency program and a similar training in all countries. This report from eight nations on five continents details the distinctive features of that training, including the number of positions available, the examinations required, the gender distribution of residents, and available possibilities once the residence period is complete. This analysis shows a wide variation in the orthopaedic trauma training program worldwide, with emphasis on different skills per country.

Utility assessment of virtual reality technology in orthopaedic surgical training.

Virtual reality (VR) has proved to be a useful technology beyond the field of surgery in areas that are highly dependent on consolidating motor tasks. Despite being reliant on these skills, the uptake of VR in orthopaedics has been extremely limited. Therefore, this study's purpose was to help assess the utility of applying this technology in teaching different experience levels of orthopaedic training. Secondary objectives were to assess enjoyability and feasibility to complete modules prior to surgery. The study explored which experience level of orthopaedic trainee benefits the most from the proposed haptic VR package. Participants completed a total hip arthroplasty module using the Fundamental Surgery package. Qualitative data was collected in the form of a post completion survey of 24 participants. Quantitative data was collected in the form of module completion time and percentage of skills completed. 37.5% of participants rated non-training orthopaedic registrars as the experience level that would benefit the most from using VR. 88% of participants would recommend this module to a colleague and found the module very enjoyable (4.2 out of 5). 50% of participants took between 25 and 31.5 min to finish and completed between 80% and 95% of tasks in the module. The study demonstrated that non-training orthopaedic registrars were most likely to benefit using this particular VR package. Most users found the experience to be enjoyable and would recommend it to a colleague. It was also deemed feasible to complete the module prior to performing an operation.

The Effects of COVID-19 on Orthopaedic Surgery Training Programs in the United States

This study investigates the effects of the COVID-19 pandemic on medical education, research opportunities, and mental health in orthopaedic surgical training programs. A survey was sent to the 177 Electronic Residency Application Service-participating orthopaedic surgery training programs. The survey contained 26 questions covering demographics, examinations, research, academic activities, work settings, mental health, and educational communication. Participants were asked to assess their difficulty in performing activities relative to COVID-19. One hundred twenty-two responses were used for data analysis. Difficulties were experienced in collaborating with others (49%), learning through online web platforms (49%), maintaining the attention span of others through online web platforms (75%), and in gaining knowledge as a presenter or participating through online web platforms (56%). Eighty percent reported that managing time to study was the same or easier. There was no reported change in difficulty for performing activities in the clinic, emergency department, or operating room. Most respondents reported greater difficulty in socializing with others (74%), participating in social activities with coresidents (82%), and seeing their family (66%). Coronavirus disease 2019 has had a significant effect on the socialization of orthopaedic surgery trainees. Clinical exposure and engagement were marginally affected for most respondents, whereas academic and research activities were more greatly affected by the transition from in-person to online web platforms. These conclusions merit investigation of support systems for trainees and evaluating best practices moving forward.

A Comparative Study of Traditional Technique Guide versus Virtual Reality in Orthopedic Trauma Training.

Medical and surgical education is an expansive field fraught with many challenges. Technology such as virtual reality could be a new venue that can offer a solution to improve surgical training. The objective of this prospective, blinded study was to evaluate virtual reality as a training model for orthopedic surgery and surgical training at large. Fourth-year medical students with novice skills volunteered to participate in this observer-blinded 1:1 randomized controlled trial. They had no prior experience in tibia intramedullary nail (IMN) surgery. They were randomized into traditional technique guide education and virtual reality. The participants were timed on their mock surgery, and a blinded observer was utilized to subjectively grade their performance throughout the procedure using the Global Assessment 5-point Rating Scale and Procedure-Specific Checklist. Thirty-eight participants were recruited and randomized into virtual reality (19) and traditional (19) groups. There were trends in all categories favoring the virtual reality group. The VR group had improved time to completion (9.6 minutes vs 12.2 minutes, P = 0.034) and reduced need for corrections within the mock procedure (2.2 vs 2.5; P = 0.05). Virtual reality training was more effective than traditional training in learning and completing the steps of the tibia IMN surgery for novice medical students. Virtual reality training may be a useful method to augment orthopedic education and surgical training.

Orthopaedic Surgery Training and Education During COVID-19: A Systematic Review.

The published literature was queried using search strategies devised by a medical librarian, according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Studies eligible for inclusion were studies related to COVID-19, orthopaedic surgical training, and medical education. Studies were excluded if they (1) were abstracts, conference proceedings, letters, perspective pieces, reviews, or editorials; (2) evaluated medical student education; (3) included other specialties; or (4) were unrelated to COVID-19 and/or orthopaedic training. Eighty-three (n = 83) studies were included. Five themes emerged including (I) Fellowship Application, Interview, and Match Processes; (II) Social Media and Websites for Program Information; (III) Changes in Trainee Surgical Volume; (IV) Trainee Mental Health and Well-being; and (V) Innovations in Education. The pandemic decreased opportunities for medical students to gain exposure to orthopaedic surgery. Social media use, particularly Instagram, among orthopaedic residencies increased during the pandemic. Between the cancellation of away rotations and in-person interviews, applicants saved over $6,000; however, both residency applicants and interviewers preferred in-person interviews. The pandemic led to decreased surgical volume and in-person didactics for trainees, thus relying more on virtual learning. Orthopaedic trainees had mixed feelings regarding online virtual education. Although some respondents reported that they preferred the convenience of online learning, others expressed dissatisfaction with the quality of virtual education. The shift to virtual learning affected how applicants learned about residency programs, with many relying on virtual away rotations and social media to compare different programs. The pandemic also highlighted issues of diversity and accessibility within orthopaedic surgery, with cost savings from virtual interviews and canceled away rotations potentially benefiting applicants from lower socioeconomic backgrounds. Although some innovative approaches and adaptations to orthopaedic education and training have shown promise and may continue to be used in the future after the COVID-19 pandemic, the role of others, such as virtual interviews, is less clear.

Surgery Training and Simulation Using Virtual and Augmented Reality for Knee Arthroplasty.

A range of extended reality technology integration, including immersive virtual reality (IVR), augmented reality (AR), as well as mixed reality, has lately acquired favour in orthopaedics. The utilization of extended reality machinery in knee arthroplasty is examined in this review study. Virtual reality (VR) and AR are usually exercised together in orthopaedic surgical training as alluring training outside of the operation theatre is acknowledged as a good surgical training tool. The use of this technology, its consequences for orthopaedic surgeons and their patients, and its moral and practical issues are also covered. Head-mounted displays (HMDs) are a potential addition directed toward improving surgical precision along with instruction. Although the hardware is cutting-edge, substantial effort needs to be done to develop software that enables seamless, trustworthy integration into clinical practice and training. Remote virtual rehabilitation has drawn increasing attention in recent years, and its significance has increased in light of the recent outbreak of the COVID-19 epidemic. Numerous medical sectors have shown the benefits of telerehabilitation, gamification, VR, and AR. Given the rising demand for orthopaedic therapy and its rising costs, this is a requirement. A remote surgeon can impart knowledge without being present, by virtually placing his or her hands in the visual field of a local surgeon using AR technology. With the use of this innovation, orthopaedic surgery seems to have been able to participate in the telemedicine revolution. This technology may also have an impact on how surgeons collaborate and train for orthopaedic residencies in the future. Volatility in the HMD market will probably stall improvements in surgical education.

941 The Effect of COVID-19 on Orthopaedic Trauma Theatre Efficiency and Surgical Training in the North and East of Scotland Major Trauma Centres – a Year On

Abstract Aim To determine the orthopaedic trauma theatre efficiency in two large major trauma centres (MTCs) in Scotland before and after the outbreak of Coronavirus disease (COVID-19) pandemic. Method All trauma patients presented to the North and East of Scotland's MTCs prior to the outbreak of COVID-19 (7th May to 7th June 2019), during the first peak of COVID-19 (7th May to 7th June 2020), after Aerosol Generating Procedures updates (7th November to 7th December 2020) and the ‘new normal’ (7th May to 7th June 2021) were retrospectively reviewed. Training opportunities and theatre time were compared. The Kruskall-Wallis test was used. Results There were no significant differences in the length of hospital stay (p=0.117, 0.065) and time from injuries and surgery within groups in both MTCs (p=0.508, 0.384). The pandemic has negatively affected the anaesthetic and surgical preparation time, time between end of procedure and send for next case, and turnover time, with more profound effect on the North of Scotland's MTC. The trainee's involvement as main surgeon had decreased with the outbreak of the pandemic, with the junior trainees being affected most severely in North of Scotland. The time taken for patient to arrive to theatre after sending and total downtime were twice as long in the North of Scotland. Conclusion The COVID-19 pandemic has negatively impacted the orthopaedic trauma theatre efficiency and training opportunities. Actions should be taken to improve the turnover time to maximise theatre efficiency while prioritizing training opportunities.

The Utility of Virtual Reality in Orthopedic Surgical Training

To examine the efficacy of virtual reality (VR) to prepare surgical trainees for a pediatric orthopedic surgery procedure: pinning of a slipped capital femoral epiphysis (SCFE). Participants were randomly assigned to a standard, study guide (SG) group or to a VR training group. All participants were provided a technique video and SG; the VR group additionally trained via an Osso VR surgical trainer (ossovr.com) with real-time feedback and coaching from an attending pediatric orthopedic surgeon. Following training, participants performed a SCFE guidewire placement on a SawBones model embedded in a soft-tissue envelope (SawBones model 1161). Participants were asked to achieve "ideal placement" based on the training provided. Participants were evaluated on time, number of pin "in-and outs," penetration of the articular surface, angle between the pin and the physis, distance from pin tip to subchondral bone and distance from the center-center point of the epiphysis. Orthopedic Institute for Children, Los Angeles, CA. Twenty fourth-year medical students, first- and second-year orthopedic residents without experience with the SCFE procedure. Twenty participants were randomized to SG (n = 10) or VR (n = 10). Average time to final pin placement was 19% shorter in VR group (706 vs 573 seconds, p = 0.26). When compared to SG, the VR group had, on average, 70% less pin in-and-outs (1.7 vs 0.5, p = 0.28), 50% less articular surface penetrations (0.4 vs 0.2, p = 0.36), and 18% smaller distance from pin tip to subchondral bone on lateral view (7.1 vs 5.8 mm, p = 0.42). Moreover, the VR group had a lower average angle deviation between pin and line perpendicular to the physis on coronal view (4.9° vs 2.5°, p < 0.05). VR training is potentially more effective than traditional preparatory methods. This pilot study suggests that VR training may be a viable surgical training tool, which may alleviate constraints of time, money, and safety concerns with resultant broad applicability for surgical education.

Challenges and Deficiencies in Orthopaedic Surgical Training in Germany - A Qualitative Study

Surgical training is an essential factor for patient safety and care. Germany is in the process of implementing competency-based training. Before changes are made, it is recommended to analyze the current process and its deficiencies to improve a process accordingly. Without analyzing current deficiency, risks for ineffective changes are high. This research aims to reveal the deficiencies in surgical training perceived by stakeholders and the factors leading to insufficient training in Germany to undertake changes of the system accordingly.

Orthopaedic surgical training exposure at a South African academic hospital - is the experience diverse and in depth?

ABSTRACT BACKGROUND: With increasing pressure on our training hospitals, we undertook to ascertain whether our clinical orthopaedic surgery training platform is providing adequate surgical exposure, both in diversity and the level of trainee participation METHODS: The orthopaedic surgery database was interrogated for theatre procedures logged for the 12-month period 1 January to 31 December 2018. Each theatre case was assessed as to the level of trainee participation, whether it was performed during or after hours, and categorised as being elective or trauma in nature, as well as the orthopaedic subdiscipline RESULTS: A total of 3 147 orthopaedic surgical procedures were logged with an even split of elective (51.1%) and trauma (49.9%) cases. Adults predominated in the trauma group while the paediatric service contributed most to the elective cases, followed by arthroplasty and spine. Overall, 25.5% of procedures were performed by consultants and 74.5% by registrars. Registrars were more frequently the primary surgeon in trauma cases (90%) compared to elective procedures (59%) (p &lt; 0.001). Of the elective cases, 37% were performed by registrars as supervised unscrubbed and 22% as supervised scrubbed operations. In total, 17.5% of cases were performed after hours, with 31.7% of trauma surgeries and only 2.9% of elective surgeries occurring after hours. Registrars were the primary surgeon in 98.7% of after-hours trauma cases and 58% of after-hours elective cases under unscrubbed supervision CONCLUSION: Our study presents the surgical experience and level of participation available to orthopaedic surgical trainees in a South African training hospital where their exposure was an equal number of elective and trauma cases. The vast majority of the cases were performed by the registrars in their supervised unscrubbed capacity although the more complex, elective cases were performed by consultants. Almost all after-hours trauma cases were performed by registrars. This suggests the platform allows for a high level of registrar surgical participation and training despite the challenges. Further review is required to assess achievement of trainee competency and whether in fact the current experience is adequate Level of evidence: Level 4 Keywords: orthopaedic registrar surgical experience, South African orthopaedic training exposure, orthopaedic case exposure

Rationale and feasibility assessment of an institution-based virtual reality hub in orthopaedic surgical training: an Australian pilot study.

Virtual reality (VR) has been established as a valuable tool outside of medicine but there has been limited uptake in orthopaedics despite being a specialty heavily dependent on psychomotor skills. The purpose of this study was to assess the feasibility of setting up an on-site virtual reality surgical training hub for an orthopaedic surgery unit. A secondary objective was to document encountered hurdles to assist other institutions with a similar process. The study explored the logistical and organizational considerations in the process of creating a virtual reality training area. This included: review of location, set up management, funding arrangements, set up time, research opportunities and training time. Set up and completion times were recorded during a separate trial of 24 participants ranging from medical students to senior consultant orthopaedic surgeons. A VR training area was successfully established over a period of 3 months. A dedicated area for training where the equipment remains permanently was designated to facilitate ease of use. Average set up took 7.5min to turn the computer on and 25 min for the participants to start the module. Issues identified during set up were recorded. The study demonstrated that it is possible to set up a dedicated area for virtual reality surgical training within a hospital unit. A dedicated lockable area is the most feasible method of establishing such a space and reduces the requirement to recalibrate and transfer equipment around the hospital.

Gender associations with selection into Australian Orthopaedic Surgical Training: 2007-2019.

Communities have better health outcomes when their clinicians reflect the diversity of the communities they serve. More than 50% of Australian medical school graduates are female, yet women represent less than 5% of Australian orthopaedic surgeons. Selection into orthopaedic surgical training in Australia is an annual, nation-wide process, based on curriculum vitae (CV), referee reports and performance in multiple mini-interviews (MMI). The influence of applicant gender on these selection scores was examined. The CV, referee reports and MMI scores used for selection for each year from 2007 to 2019 were analysed from the perspective of the applicant's gender. Over the years of the study, male applicants had higher CV scores and referee report scores, which determined the gender proportions invited to interview. By contrast, the interview process and selection from interview did not demonstrate a gender association. We describe the impact of selection tools, utilized over the past 13 years, on the gender diversity of trainees commencing orthopaedic surgery training in Australia. Leaders in postgraduate training should examine commonly used selection procedures to identify and reduce the unconscious biases that may affect their performance and value.

Virtual Reality in Orthopedic Surgery Training.

One emerging technology with the potential to improve and further transform the field of orthopaedic surgery is virtual reality (VR). VR has been explored and used in many different specialties with clinical applications, such as psychiatric therapy, pain management, rehabilitation, and traumatic brain injury. Recent studies have suggested that the use of VR during the training of orthopaedic surgery residents produces similar or improved surgical performance by residents. This is an area where VR can provide a tremendous benefit to the field of orthopaedic surgery, as it offers a safe and accessible complement to orthopaedic surgical training outside of the operating room (OR) and without involving patients directly. This review will elucidate the current state of virtual reality use in the training of orthopaedic surgeons and highlight key benefits and challenges in its application as a training resource.

793 Orthopaedic Surgical Training in The Independent Sector During the COVID 19 Pandemic

IntroductionThe COVID pandemic had led to the cancellation of elective Orthopaedics in the NHS. The aim of this study was to investigate the effect of the independent sector on orthopaedic training and the effect of the COVID pandemic on training locally.MethodA retrospective review of trauma and elective operations was made between April and September of 2019 and 2020 to compare the effects of COVID on training opportunities and the additional capacity provided by the private sector.ResultsThe impact of COVID on Surgical training at GWH has been no decrease in trauma operating experience, but a 53% decrease in elective operating experience and a 74% decrease in joint replacement operative experience during an equivalent six-month period. Use of the independent hospital has enabled 6% of the total elective surgery experience, and 11% of the joint replacement surgery experience.DiscussionThe private sector has provided additional capacity but a productivity of 66 cases from 48 half day lists is low (1.4 cases per list) has proved disappointing. There has been a low impact on elective training. The challenges have been faced on the elective side as trauma cases have remained consistent during the pandemic.ConclusionsUse of the alliance between the private sector and NHS as a resource to provide additional training opportunities needs to be developed further in the future with incentivised guidance. Orthopaedic training will inevitably adapt to the challenges presented for the next generations of surgeons.

572 Virtual Reality Operative Simulation in Orthopaedic Surgical Training During Periods of Restricted Clinical Hours: Systematic Review

IntroductionThe public health response to the coronavirus pandemic-imposed limitations upon orthopaedic surgeon’s scheduled care practice, with a consequential diminution of training time for residents. A potentially viable option for maintenance of operative competency is the use of virtual reality (VR) simulation. This review looks at the effectiveness of (VR) as a pedagogical method of learning for orthopaedic trainees.QuestionCan VR be a viable method of learning and skill retention for orthopaedic trainees during periods of diminished operative time?MethodA systematic search using Google Scholar, EMBASE and PubMed was conducted in July 2020.ResultsFollowing the PRIMSA guidelines; initial search revealed 779 studies. 35 full text articles were analysed by two reviewers with a final total of 30 articles used in this review. A thematic analysis revealed three broad categories: quality and validity of VR teaching simulations studies (n = 8); learning curves and subject performance (n = 14) and VR simulators utility in orthopaedics reviews (n = 8).ConclusionsWe demonstrated that VR has the capacity to help trainees maintain their technical skills, enhance their precision, and retain rudimentary competency during this pandemic. Additional improvements are necessary to ensure its safety as a training tool.

AB206. SOH21AS030. Virtual reality operative simulation in orthopaedic surgical training during periods of restricted clinical hours: systematic review

Background: The public health response to the coronavirus pandemic has imposed limitations upon orthopaedic surgeon’s scheduled care practice, with a consequential diminution of training time for residents within the specialty. A potentially viable option for maintenance of operative competency is the use of virtual reality (VR) surgical simulation. This review looks at the effectiveness of (VR) as a pedagogical method of learning for orthopaedic trainees. Question: Can VR be a viable method of learning and skill retention for orthopaedic trainees during periods of diminished operative time?

Critical Success Factors for Virtual Reality Applications in Orthopaedic Surgical Training: A Systematic Literature Review

There is an increasing pressure to improve the cost-effectiveness of orthopaedic training, both temporally and financially. Accordingly, virtual reality (VR) has been incorporated into a number of surgical training programs, providing trainees a safe yet realistic environment to practice their craft before going into the operating room. Identification of critical success factors (CSFs) for VR integration in the orthopaedic training program, can be beneficial in guiding the focus of healthcare providers and VR designers during the VR platform development stage. The aim of this study is to identify VR-based training CSFs that encourage orthopaedic surgeons to use VR as a method for acquiring, maintaining, and improving skills. A total of 74 studies conducted between 2011 and 2021 were selected and examined. There were 73 CSFs listed as being essential for VR adoption in orthopaedic surgical training. The CSFs were divided into six general categories: HCI/VR Features, Learning Outcome, Usability, Control and Active Learning, Student and Limitation factors. Subsequently, recommendations were made to guide healthcare professionals, researchers, and designers for optimal adoption of VR in orthopaedic surgical training in the future.

Virtual reality simulation in orthopaedic surgical training during periods of restricted clinical hours: a systematic review

Virtual reality simulation in orthopaedic surgical training during periods of restricted clinical hours: a systematic review