Orthopedic Surgical Residents Research Articles

Preoperative Planning for Your Career

Surgical residents face significant demands to obtain the requisite skills and knowledge for their specialty by the time they graduate. Structured, guided, deliberate learning in a manner that is reproducible is crucial for surgical resident success and for ensuring residents will be able to meet the increasing demands of clinical practice. Use of an organized surgical planning tool, such as the PERFECT (Position, Exposure, Reduction, Fixation, Evaluation, Closure, and Therapy) model described in this article, is fundamental and indispensable to not only resident education, but to ones’ future career and to orthopaedic practice more broadly. This tool helps to emphasize important elements of a case, allows for mental rehearsal, serves as a custom educational resource for the resident, provides a framework for focused and intentional communication between the resident and attending surgeon, helps to encourage a critical appraisal of a procedure by all participants, and provides the resident guidance for future practice. Broadly instituting teaching frameworks such as the PERFECT model has demonstrated the potential to improve the standardization and overall learning experience for orthopaedic surgical residents, who continue to be tasked with learning more efficiently in a changing healthcare and education landscape.

Austere Lower Extremity Splinting: A Head-To-Head Comparison of A New Novel 1-Step Spray-On Splint Verse Standard Splinting

Category:TraumaIntroduction/Purpose:Fracture immobilization in low resource environments is a critical and common aspect of austere medical care. However, there are few studies that critically investigate the efficacy and consistency of current practices. The purpose of this study was to compare austere immobilization techniques for lower extremity fractures while validating a splint application evlauation score sheet.Methods:Six orthopaedic surgical residents and 2 medical students participated in a prospective analysis of austere splinting techniques that utilized a cadaveric model with a distal third tibia-fibula fracture. Each participant was observed and scored by 3 Orthopaedic surgeons. All scoring was independent using a Likert scale based on 10 splinting criteria, including quality of radiographic reduction and time to completion. The participants utilized standard equipment that included structural aluminum malleable (SAM) splints and 6-inch ACE wraps in their first attempt. A second immobilization attempt was done with a 1-step spray-on foam splint. After each splinting attempt the reduction was verified with radiographic imaging.Results:The 1-step spray-on foam splinting technique was significantly superior (P <.05) in all parameters. Respectively yielding a mean score of 42.3 (range: 38-50), safety 4.7 (range: 3-5), longitudinal traction 4.5 (range: 3-5), time 136 seconds (range: 99-162). The standard splinting resulted in a mean score of 34.2 (22 - 46), safety 2.8 (range: 1- 5), longitudinal traction 4.1 (range: 3-5), time 169.5 seconds (range: 94-254). No catastrophic failures were noted in either group. A strong interobserver reliability was established.Conclusion:A 1-step spray-on foam splinting technique demonstrated consistent superiority in reducing fracture motion, potential soft-tissue damage, and sustained longitudinal traction as compared to the standard technique. Secondly, our results validate our splinting evaluation criteria allowing for further utilization in training austere splinting.

Awareness of Hazard Risks and Prevention Among Orthopaedic Surgery Residents in South East Nigeria.

Background:Orthopaedic surgery is a specialty that deals with a lot of complex and delicate procedures which involve the use of power tools as well as handling of sharp tools and bony spicules, which, among other things, expose trainees to day-to-day hazards which can predispose them to an array of health challenges and burden the health sector. Knowledge of different measures in minimizing some of these risks can go a long way to saving lives and resources.Objectives:This study aims to determine the level of awareness among orthopaedic surgical residents about various hazards and risks and to ascertain their views on the prevention thereof to guide certain decision-making concerning surgical hazard risk reduction.Materials and Methods:A cross-sectional survey of orthopaedic surgery residents in South East Nigeria was conducted using a structured questionnaire designed using the free software Google® Form and was electronically distributed randomly to orthopaedic surgery residents in southern Nigeria using platforms including WhatsApp and Telegram. The data obtained were analysed using Statistical Package for the Social Sciences (SPSS) statistical software version 26. Consent was obtained from all respondents by outlining a clear statement of consent at the beginning of the form.Results:At the end of the study period, 49 surgical residents completed and submitted the questionnaire. There was a significant level of awareness of surgical hazard risks among the surgical residents, with over 90% agreeing to radiation exposure, needlestick injury, and inhalation of smoke being the major surgical hazard risks encountered in orthopaedic surgery practice. Over 95.9% of the respondents agreed that the use of sharp collection devices can help reduce needlestick injuries. All respondents agreed that the provision of adequate personal protective equipment (PPE) can help reduce surgical hazards. It was noted that the majority of the respondents (65.3%) had their preliminary knowledge about exposure to surgical hazard risks and appropriate safety measures during their undergraduate education. About 30.6% were aware of a surgery hazard risk safety guideline in their training centres, whereas only 65.3% of those people have studied the guidelines. There was no statistically significant associations between the level of training and marital status and those who had studied the surgical hazard risk guidelines available in their centres (P = 0.086, χ2= 2.942; P = 0.715, χ2=0.133, respectively). All of the residents know that immunization can help reduce the impact of disease risk among the surgery staff, but only 73.5% have completed a hepatitis B immunization and 55.1% have completed the tetanus immunization.Conclusion:Surgical hazards risks are important issues that need to be addressed and measures regularly reviewed appropriately to ensure and maintain the safety and health of the orthopaedic surgical and all other health personnel. There is a significant level of awareness of surgical hazard risks and prevention measures among orthopaedic residents, but the level of compliance to safety guidelines is not yet optimal.Recommendation:PPEs and sharp collection boxes should always be available in theatres and measures should be taken to encourage residents’ adherence to studying and practicing established surgical safety guidelines in their hospitals and also completing their immunization schedules.

Lower Extremity Splinting: A Head-to-Head Comparison of A Novel One-Step Spray-on Splint Versus Standard Splinting.

Splinting is an essential component of treating many lower extremity musculoskeletal injuries; however, little development has been made in splinting technology. The purpose of this study is to evaluate the efficacy of current immobilization equipment for lower extremity fractures by testing a novel one-step spray-on foam splint (Fast Cast) against structural aluminum malleable (SAM) lower extremity musculoskeletal injuries and 6-inch ACE (3M Corp., Minneapolis, MN, USA) bandage splints. Six orthopedic surgical residents and two medical students participated in a prospective analysis of austere splinting techniques and equipment that utilized a cadaveric model with a distal third tibia-fibula shaft fracture. Each participant was observed and scored by three fellowship trained attending orthopedic surgeons. All scoring was independent using a 5-point Likert scale based on 10 splinting criteria (50 total points possible), including quality of radiographic reduction, time to completion, safety, and sustain longitudinal traction. The Likert scale is a set of questions that reflects the respondent's degree of agreement or disagreement with a statement. Each of the 10 questions has a range of 1-5. A score of 50 means the splint performed perfectly. The lowest possible score is a 10. The participants utilized standard equipment that included SAM splints and 6-inch ACE wraps (3M Corp., Minneapolis, MN, USA) in their first attempt. A second immobilization attempt was done with a one-step spray-on foam splint (Fast Cast). After each splinting attempt, the reduction was verified with radiographic imaging. Data analysis was performed using standard descriptive statistics, Student's t-tests, and inter-rater reliability was calculated using Cronbach's alpha scores. This project is Institutional Review Board (IRB) exempt. The one-step spray-on foam splinting technique was superior (P < .05) in all parameters of the Likert scale, yielding a mean overall score of 45.1 points (±3.8), safety 4.7 points, longitudinal traction 4.5 points, and time 136 seconds (±23). The SAM resulted in a mean overall score of 33.8 points (±7.3), safety 2.8 points, longitudinal traction 4.1 points, and time 170 seconds (±52). Radiographic rating was 4.1 points (±0.7) for the SAM splint and 4.5 (±0.6) for Fast Cast. The differences in time to completion and radiograph rating did not reach statistical significance (P = .12 and P = .07, respectively). A one-step spray-on foam splinting technique demonstrated consistent superiority in reducing fracture motion, potential soft-tissue damage, and sustained longitudinal traction as compared to the standard technique.

Distal biceps tendon injection.

BackgroundInjection therapy around the distal biceps tendon insertion is challenging. This therapy may be indicated in patients with a partial distal biceps tendon tear, bicipitoradial bursitis and tendinopathy. The primary goal of this study was to determine the accuracy of manually performed injections without ultrasound guidance around the biceps tendon.MethodsSeven upper limb specialists, two general orthopedic specialists, and three orthopedic surgical residents manually injected a cadaver elbow with acrylic dye using an anterior and a lateral infiltration approach. After infiltration the cadaveric elbows were dissected to determine the location of the acrylic dye.ResultsIn total, 79% of the injections were localized near the biceps tendon. Of these injections, 20% were localized on the radius near the bicipitoradial bursa. In total, 53% of the performed infiltrations were injected by anterior and 47% by lateral approaches. Of the injections near the distal biceps (79%), 47% were injected by an anterior and 53% by a lateral approach. Of the injections on the radius (20%), 33% were injected by anterior and 67% by lateral approach. Of the inaccurate injections (21%), 75% were injected anterior and 25% lateral. ConclusionsManual infiltration without ultrasound guidance for distal biceps pathology lacks accuracy. We therefore recommend ultrasound guidance for more accurate infiltration.

Surgical Ergonomics and Musculoskeletal Pain in Orthopaedic Surgery Residents: A Multicenter Survey Study.

Purpose:Owing to the nature of orthopaedic surgery, occupational hazards and musculoskeletal pain (MSP) are inherent. These hazards have been well-documented among practicing orthopaedic surgeons, but there remains a paucity of data regarding MSP among orthopaedic surgery residents. The purpose of this study was to identify the prevalence and quantify the extent of work-related MSP among orthopaedic surgical residents. We also sought to analyze resident attitudes, beliefs, and behaviors regarding surgical ergonomics.Methods:An online survey was sent to 78 orthopaedic surgery resident program directors to be distributed to residents within their programs. The survey included three main sections: symptoms by body part, attitudes/beliefs/behaviors regarding surgical ergonomics, and finally demographics. Pain was reported as using the 0 to 10 Numeric Rating Scale, with 0 = no pain and 10 = maximum pain. Several questions about resident well-being were assessed using the Maslach Burnout Inventory.Results:Seventy-six orthopaedic surgery residents completed the survey, 72% men and 28% women. Most residents (97%) experience procedural-related MSP. Average pain scores of all residents was 3.52/10. Notable levels of MSP (≥4/10) were most common in the lower back (35%), neck (29.7%), and feet (25.7%). A positive association exists between higher MSP and lower work satisfaction (P = 0.005), burnout (P = 0.04), and callousness toward others (P < 0.0001). MSP has notable impact on resident behaviors including over-the-counter medication use, stamina, concentration, and degree of irritability.Conclusion:The prevalence of MSP among orthopaedic surgical residents is extremely high. Our study demonstrates that MSP has a notable impact on resident concentration, degree of irritability, and other burnout symptoms. The results of this study highlight the importance of limiting compromising procedural positions, ergonomic optimization, and increasing the awareness of the importance of ergonomics among residents. This could have future implications on productivity and career longevity.

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

The purpose of this study was to develop and perform the initial validation for the Surgical Training and Educational Platform (STEP), a cost-effective psychomotor training and assessment instrument designed to teach and evaluate fundamental skills considered critical to competency in hand surgery. An American Society for Surgery of the Hand (ASSH) taskforce of 13 board-certified hand surgeons developed 8 skills considered fundamental to competency in hand surgery including: (1) lag screw fixation of an oblique fracture, (2) depth of plunge during bicortical drilling, (3) central axis scaphoid fixation, (4) phalangeal fracture pinning, (5) flexor tendon repair, (6) microsurgical suturing, (7) full-thickness skin graft harvest, and (8) wrist arthroscopy. The tasks were developed from commercially available, nonclinical supplies at low cost. The startup cost for the entire system was less than $600 USD, with a cost-per-trainee-assessment of approximately $25 USD. After the tasks were finalized, 2 examiners traveled to 8 sites around the country to evaluate 93 surgeons, including 57 board-certified hand surgeons and 36 first-year orthopedic and plastic surgical residents. Scoring criteria for each task were based on a combination of time and clinically relevant quality metrics. Board-certified hand surgeons significantly outperformed surgical trainees on all 8 tasks, demonstrating that the STEP appropriately differentiates the skill level of expert and novice hand surgeons. The STEP is an effective simulator that encompasses a wide range of fundamental psychomotor skills considered critical to competency in hand surgery. Although the STEP tasks are a valuable surgical training tool, further work is required to evaluate and refine the scoring system prior to using it as a critical evaluation of performance. The STEP simulator is a valuable, validated instrument for resident and fellow education and evaluation in hand surgery outside of the operating room.

Assessing Pressure Ulcer Knowledge of General and Orthopedic Surgical Residents Using the Pieper Pressure Ulcer Knowledge Test

Objective To determine the knowledge of postgraduate and non-postgraduate general and orthopedic surgical residents regarding pressure ulcer (PU) prevention, staging and wound description. Study Design Cross sectional, descriptive survey. Place and Duration of Study Six major tertiary care hospitals in India, from Sep-2018 to Nov-2018. Methodology All consenting postgraduate and non-postgraduate general and orthopedic surgical residents were included in the study using convenience sampling. An adapted version of Pressure Ulcer Knowledge Test (PUKT) comprising of 47-true/false items was used as a research tool. For every correct response, 1 point was awarded. Whereas, an incorrect or NK response was scored as 0. All the data was entered and analyzed using SPSS version 21. Results A total of 126 trainees comprising 120 (95.23%) males and 6 (4.76%) females participated in the study. The average PUKT score obtained by the surgical residents was 30.2+3.7 (65.65%), thus indicating a “low” level of knowledge. Conclusion The current levels of knowledge regarding PU prevention among the surgical residents in our study was “low”. The authors recommend continuous education for PU prevention in a hospital care setting.

Pre-education Enhances the Success of Manual Training for Orthopedic Surgery Residents

Surgical skill training is difficult due to limited resources and the associated risks in the clinical setting. There have been many studies that have looked at optimizing resident skill techniques out of the operating room to optimize intraoperative teaching. Specifically, as seen in spine surgery performing a laminectomy with a high-speed drill is difficult and requires many hours of training and guidance before a resident can feel comfortable to adequately complete the laminectomy with minimal risk of adverse effects. The objective of this study is to assess if pre-education of residents prior to using the high-speed drill will significantly increase their comfort level, as well as increase the success of laminectomy. This was done by a prospective cohort study in evaluating 20 orthopedic surgical residents via the objective structured assessment of technical skills and global rating scale. Results showed that residents who had pre-education were in fact more successful in completing the laminectomy with the high-speed drill. Pre-education, whether via a didactic or simulator-based model are both beneficial to resident's knowledge and surgical skill attainment however the simulator based model did not deem the group more successful in completing the laminectomy with the high-speed drill. Certain technical skills still require unreplaceable hands-on practice to become proficient.

Educational Resource Utilization by Current Orthopaedic Surgical Residents: A Nation-wide Survey

Background:More than 150 accredited orthopaedic residency programs exist in the United States with more than 3,300 residents. Every year, between 600 and 800 orthopaedic surgeons complete board certification. However, little is known about what residents use and prefer of the many resources available to them. The purpose of this study is to understand how orthopaedic residents across the country prioritize educational resources.Methods:An 18-question survey with subqueries was compiled on the REDCap (Research Electronic Data Capture) platform. Residents were reached through program coordinators, program directors, and word of mouth. There were 374 total respondents. Responses were summarized for the total population and stratified separately by sex, location, and year of training. P values were adjusted for multiple comparisons using the Bonferroni method.Results:Respondents were 83.4% male and 16.6% female. Orthobullets was the single most valued resource and general review articles were the single most valued journal resource. The average time spent studying was 10.7 hr/wk (SD = 7.6), with no notable differences by program location or sex. A significantly larger percentage of female residents placed more importance on specialty-specific journals (32.8% rated as very important versus 19.9% from males, P = 0.016) and research-related journals (P = 0.004). VuMedi use significantly increased until postgraduate year-4 (P < 0.001), whereas residents earlier in training used YouTube more often (P = 0.026). There were differences in journal prioritization by program region, with the Midwest, Northeast, and South preferring primary, focused articles and the Northeast, South, and West emphasizing systematic review articles (P = 0.032). Industry-sponsored events were used by 67.4% of residents as an educational adjunct.Conclusions:Current residents—regardless of sex, location, and year in training—use Orthobullets and other electronic resources. There continues to be utilization of industry-sponsored resources, although they are not the primary focus for those in training.

Assessing Pressure Ulcer Knowledge of General and Orthopedic Surgical Residents Using the Pieper Pressure Ulcer Knowledge Test

Objective To determine the knowledge of postgraduate and non-postgraduate general and orthopedic surgical residents regarding pressure ulcer (PU) prevention, staging and wound description. Study Design Cross sectional, descriptive survey. Place and Duration of Study Six major tertiary care hospitals in India, from Sep-2018 to Nov-2018. Methodology All consenting postgraduate and non-postgraduate general and orthopedic surgical residents were included in the study using convenience sampling. An adapted version of Pressure Ulcer Knowledge Test (PUKT) comprising of 47-true/false items was used as a research tool. For every correct response, 1 point was awarded. Whereas, an incorrect or NK response was scored as 0. All the data was entered and analyzed using SPSS version 21. Results A total of 126 trainees comprising 120 (95.23%) males and 6 (4.76%) females participated in the study. The average PUKT score obtained by the surgical residents was 30.2+3.7 (65.65%), thus indicating a “low” level of knowledge. Conclusion The current levels of knowledge regarding PU prevention among the surgical residents in our study was “low”. The authors recommend continuous education for PU prevention in a hospital care setting.

Impact of Trauma Hospital Ransomware Attack on Surgical Residency Training

BackgroundA recent ransomware attack led to the shutdown of the electronic health information system (HIS) at our trauma center for 2 mo. We investigated its impact on residency training during the downtime. Material and methodsGeneral and orthopedic surgical residents who rotated at the hospital were invited to participate in a survey regarding their patient care and residency training experiences during the downtime. Attending surgeons from both the specialties were invited to participate in a semistructured interview regarding their attitude toward residency training during the downtime. ResultsTwenty-nine residents responded to the survey with a response rate of 78.4%. Residents acknowledged significant increases in face-to-face communication and decreases in use of online educational resources during the downtime (P < 0.01). Residents were significantly stressed by the dearth of online resources (P < 0.0001) and by paper-based orders and outpatient clinic (P < 0.05). A multivariate analysis demonstrated an inverse relationship between postgraduate year and stress from paper orders (P = 0.003). Attending surgeon's interviews revealed that they recognized residents' unpreparedness and strove harder to teach more effectively. ConclusionsOur study demonstrated that an unexpected shutdown of the hospital HIS imposed significant stress upon surgical residents providing trauma patient care and made attending surgeons take greater efforts to be more effective teachers. Residents who are digital natives lack adaptability to handle a paper-based workflow. With cyber security threats increasing in health care, preparedness should be included in the graduate medical education curriculum.

The hidden cost of training orthopaedic surgery residents to perform an open carpal tunnel release

Background: Training orthopaedic surgery residents is time consuming and expensive. The objective of the current study was to determine the time and costs associated with teaching orthopaedic residents to perform an open carpal tunnel release (CTR). Methods: A retrospective chart review of a single orthopaedic hand surgeon’s outpatient surgical cases over 18 mo was performed. One hundred-six isolated open carpal tunnel releases were identified. Seventy-seven were performed while training orthopaedic surgery residents, and 29 were performed by the attending surgeon alone. Standard demographics, post-graduate year (PGY) of training, and surgical times were abstracted from the charts. Results: The time (minutes) required to perform a CTR for PGY-2, 3, and 4 when compared to the attending surgeon was 13.8±3.5 (P=0.012), 16.4±4.9 (P&lt;0.001) and 13.1±4.2 (P=0.044), respectively, with a resident average of 13.7±4.2 min. The attending surgeon required 10.4±4.2 min, which is 3.3 min less than the average resident time (P&lt;0.001). There was no statistically significant difference when comparing surgical times between resident years of training. Conclusions: Orthopaedic surgical residents on average required 32% more surgical time to perform an open CTR. Total ambulatory operating room and anesthesia charge was approximately $137/min at our institution with a collection rate of 27% resulting in a per minute cost equal to $37/min. The 77 cases performed while training residents added an additional $34,811.70 in charges with a resultant $9,401.70 in reimbursement. Level of Evidence: Level IV, retrospective review.

DESIGN OF A PERCUTANEOUS ARTICULAR FRACTURE REDUCTION SIMULATOR.

The American Board of Orthopaedic Surgery has mandated dedicated skills training for first-year orthopedic surgical residents.1 Most residency programs address this requirement with training exercises with cadavers and plastic foam bones. Some programs incorporate one or more simulators in their skills training, including several sophisticated virtual reality simulators and a variety of low-tech simulators. Simulators are helpful because they can provide repeatable educational experiences and quantitative performance assessment. Unfortunately, few simulators have been developed for orthopedic trauma skills training. Even fewer simulators have been developed and validated with more advanced students, such as residents in their 3rd or 4th year of training, and for more complex surgeries. In contrast to the completely virtual surgical simulation using haptic feedback devices and sophisticated renderings of soft tissue deformation, our group has chosen to use physical models, real surgical instruments and position tracking in conjunction with virtual reality.2–4 The physical models provide experience with the surgical tools, and enable more realistic hand movements and haptic cue feedback.

Improved Safety and Cost Savings from Reductions in Cast-Saw Burns After Simulation-Based Education for Orthopaedic Surgery Residents.

The purpose of this investigation was to characterize the clinical efficacy and cost-effectiveness of simulation training aimed at reducing cast-saw injuries. Third-year orthopaedic residents underwent simulation-based instruction on distal radial fracture reduction, casting, and cast removal using an oscillating saw. The analysis compared incidences of cast-saw injuries and associated costs before and after the implementation of the simulation curriculum. Actual and potential costs associated with cast-saw injuries included wound care, extra clinical visits, and potential total payment (indemnity and expense payments). Curriculum costs were calculated through time-derived, activity-based accounting methods. The researchers compared the costs of cast-saw injuries and the simulation curriculum to determine overall savings and return on investment. In the 2.5 years prior to simulation, cast-saw injuries occurred in approximately 4.3 per 100 casts cut by orthopaedic residents. For the 2.5-year period post-simulation, the injury rate decreased significantly to approximately 0.7 per 100 casts cut (p = 0.002). The total cost to implement the casting simulation was $2,465.31 per 6-month resident rotation. On the basis of historical data related to cast-saw burns (n = 6), total payments ranged from $2,995 to $25,000 per claim. The anticipated savings from averted cast-saw injuries and associated medicolegal payments in the 2.5 years post-simulation was $27,131, representing an 11-to-1 return on investment. Simulation-based training for orthopaedic surgical residents was effective in reducing cast-saw injuries and had a high theoretical return on investment. These results support further investment in simulation-based training as cost-effective means of improving patient safety and clinical outcomes. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Effectiveness of Bioskills Training for Simulated Open Lumbar Laminectomy.

Study Design:Randomized, prospective study within an orthopedic surgery resident program at a large urban academic medical center.Objectives:To develop an inexpensive, user-friendly, and reproducible lumbar laminectomy bioskills training module and evaluation protocol that can be readily implemented into residency training programs to augment the clinical education of orthopedic and neurosurgical physicians-in-training.Methods:Twenty participants comprising senior medical students and orthopedic surgical residents. Participants were randomized to control (n = 9) or intervention (n = 11) groups controlling for level of experience (medical students, junior resident, or senior resident). The intervention group underwent a 40-minute bioskills training module, while the control group spent the same time with self-directed study. Pre- and posttest performance was self-reported by each participant (Physician Performance Diagnostic Inventory Scale [PPDIS]). Objective outcome scores were obtained from a blinded fellowship-trained attending orthopedic spine surgeon using Objective Structured Assessment of Technical Skills (OSATS) and Objective Decompression Score metrics.Results:When compared with the control group, the intervention group yielded a significant mean improvement in OSATS (P = .022) and PPDIS (P = .0001) scores. The Objective Decompression Scores improved in the intervention group with a trend toward significance (P = .058).Conclusions:We conclude that a concise lumbar laminectomy bioskills training session can be a useful educational tool for to augment clinical education. Although no direct clinical correlation can be concluded from this study, the improvement in trainee’s technical and procedural skills suggests that Sawbones training modules can be an efficient and effective tool for teaching fundamental spine surgical skills outside of the operating room.

Microsurgical Simulation Exercise for Surgical Training

Initial training for orthopedic surgical residents (postgraduate years 1-5) in microsurgery using the turkey wing model and evaluation of their proficiency. Residents were given a questionnaire on their comfort level with microsurgery and microsurgical knowledge, followed by a lecture on the subject. They watched a surgical dissection and repair of the turkey wing's neurovasculature. Residents performed the dissection and repairs of the artery, vein, and nerve. A postquestionnaire was administered following the simulation exercise. Their performances on repairs were graded and results compared by academic year. A total of 21 orthopedic surgery residents were recruited from Stony Brook University Medical Center, Stony Brook, NK. This training activity resulted in significant improvements in both microsurgical knowledge (41%) and comfort (37%). Senior residents scored significantly higher than juniors on 6 microsurgical parameters. The largest effect was in nerve repair showing 4 parameters that differed significantly between groups. Microsurgical techniques require extensive training to master. The turkey wing model for repair of the artery, vein, and nerve represents a realistic simulation of a human hand artery, vein, and nerve. It provides an inexpensive method for residents to practice on real tissue for improving microsurgical technique.

Assessing Improvement in Diagnostic Knee Arthroscopic Skill During the AAOS Fundamentals of Knee and Shoulder Arthroscopy Course for Orthopaedic Residents

Objectives:The purpose of the AAOS Fundamentals of Knee and Shoulder Arthroscopy Course for Orthopaedic Residents is to provide an opportunity for orthopaedic trainees to practice and improve basic arthroscopic surgical skills. During the course, residents spend the majority of their time in the Orthopaedic Learning Center laboratory performing basic arthroscopic procedures on cadaveric specimens under the direction of an expert faculty. Residents are also exposed to various didactic lectures during this intensive three-day course. Historically, feedback from the course has been extremely positive from both resident participants and faculty, however no attempt has previously been made to more objectively determine the degree to which improvement in resident skill has occurred. The purpose of this study is to determine whether participation in the AAOS Fundamentals of Arthroscopic Surgery Course for Residents led to improved diagnostic knee arthroscopy performance. We hypothesized that scores on post course assessments of knee arthroscopy skills and confidence would be higher in comparison to scores on the same assessments prior to the course.Methods:46 orthopaedic surgical residents enrolled in the AAOS Fundamentals of Arthroscopic Surgery Course volunteered to participate in the study. Participants were asked to perform a diagnostic knee arthroscopy on a cadaveric knee specimen both before and immediately after the conclusion of the knee portion of the course. Diagnostic knee arthroscopy performance was assessed using the Arthroscopic Surgical Skill Evaluation Tool (ASSET). Residents were also assessed before and after the course using the TolTech virtual reality simulator which enables the objective assessment of several measures that correlate with arthroscopic proficiency. Confidence, before and after the course, for several arthroscopic procedures was also assessed via a self-reported questionnaire.Results:Following the course, residents demonstrated a 9.2% improvement in mean ASSET score (p=0.001). ASSET score improved most (13.2%) for those with less than 20 arthroscopic cases (p=0.007). On the TolTech virtual reality simulator, mean scores demonstrated significant improvements for multiple measures of proficiency including: Time, which improved 18% (p=.01), Arthroscope path distance, which improved 13% (p=.02), Probe path distance, which improved 16% (p=.05), Smoothness, which improved 10% (p=.001), and excessive probe pressure, which improved 440% (p=.02). Overall completeness improved 1.8%, but this was not significant (p=0.11). Confidence in performing arthroscopic partial menisectomy improved 13% (p=.002) and confidence in performing ACL reconstruction improved 9% (p=.01).(Table 1).Conclusion:It was feasible to assess several outcomes related to resident proficiency and confidence within the structure of the AAOS Fundamentals of Arthroscopic Surgery Course. Resident participation in the course resulted in modest improvements for many of the outcomes measured demonstrating the value of this and similar courses. This data will be critically evaluated to determine curricular changes in an effort to maximize course benefit for future participants.

Development of a Surgical Skills Curriculum for the Training and Assessment of Manual Skills in Orthopedic Surgical Residents

To develop and conduct a pilot study of a curriculum of 4 surrogate bone training modules to assess and track progress in basic orthopedic manual skills outside the operating room. Four training modules were developed with faculty and resident input. The modules include (1) cortical drilling, (2) drill trajectory, (3) oscillating saw, and (4) pedicle probing. Orthopedic resident's performance was evaluated. Validity and reliability results were calculated using standard analysis of variance and multivariate regression analysis accounting for postgraduate year (PGY) level, number of attempts, and specific outcome target results specific to the simulation module. St. Mary's Medical Center in San Francisco, CA. These modules were tested on 15 orthopedic surgery residents ranging from PGY 1 to PGY 5 experience. The cortical drilling module had a mean success rate of 56% ± 5%. There was a statistically significant difference in performance according to the diameter of the drill used from 33% ± 7% with large diameter to 70% ± 6% with small diameter. The drill trajectory module had a success rate of 85% ± 3% with a trend toward improvement across PGY level. The oscillating saw module had a mean success rate of 25% ± 5% (trajectory) and 84% ± 6% (depth). We observed a significant improvement in trajectory performance during the second attempt. The pedicle probing module had a success rate of 46% ± 10%. The results of this pilot study on a small number of residents are promising. The modules were inexpensive and easy to administer. Conclusions of statistical significance include (1) residents who could easily detect changes in surrogate bone thickness with a smaller diameter drill than with a larger diameter drill and (2) residents who significantly improved saw trajectory with an additional attempt at the module.

Simple Visual Parameters for Objective Assessment of Arthroscopic Skill

Restrictions placed on the working hours of doctors over the past decade have resulted in substantial changes to the training and assessment of orthopaedic surgical residents. Many who are responsible for training the surgeons of the future have become concerned that this reduced clinical exposure is having a detrimental impact on technical skill acquisition. Consequently, there is a need for surgical educators to develop more objective methods for assessing surgical skill. The primary aim of this study was to determine whether a novel set of visual parameters assessing visuospatial ability, fine motor dexterity, and gaze control could objectively discriminate among various levels of arthroscopic experience. The secondary aim was to evaluate the correlations between these new parameters and previously established technical skill assessment methods. Twenty-seven subjects were divided into a novice group (n = 7), a resident group (n = 15), and an expert group (n = 5) on the basis of arthroscopic experience. All subjects performed a diagnostic knee arthroscopy task on a simulator. Their performance was assessed with use of novel simple visual parameters that included the prevalence of instrument loss, triangulation time, and prevalence of lookdowns. Performance was also evaluated with use of previously validated technical skill assessment methods (a global rating scale and motion analysis). A significant difference in performance among the groups was demonstrated with use of all three novel visual parameters, the global rating scale, and motion analysis (p < 0.05). There were strong and highly significant correlations (p < 0.0001) between each of the novel parameters and the previously validated skill assessment methods. This study demonstrates the construct validity of three novel visual parameters for objectively assessing arthroscopic performance. These parameters are simple, can be used easily in the operating room, and are strongly correlated with current validated methods of technical skill assessment.