MEASURING SURGICAL SKILL OBJECTIVELY IN ORTHOPAEDIC TRAINEES

Abstract

Recent studies have assessed operative skill in surgical trainees “objectively” based on patient outcomes by attempting to statistically separate many contributory variables. Compression hip screw fixation (CHS) for neck of femur fracture (#NOF) is a standard operation commonly performed by orthopaedic trainees of varying experience. Our aim was to determine if trainees could be assessed objectively on their efficiency and aptitude in performance of this operation. A secondary aim was to evaluate the predictors of fixation failure for CHS described in the literature.

Records and radiographs for all CHS performed by trainees of all levels for acute adult #NOF were examined retrospectively for 2 calendar years. Preoperative patient and fracture variables were scored. Outcome measures included operative time, scores of accuracy of fracture reduction and fixation, blood loss and complications. Failure of fixation was compared to the scores given to radiographs. Multivariate analysis was used to apportion variance between multiple contributing factors.

Three hundred and eight two eligible operations were performed by 26 trainees. Operative time was effected by fracture complexity, trainee level and trainee operator (all p< 0.05). “Tip apex distance”, a measure of depth and centrality of screw placement in the femoral head, known to predict screw cut out was associated with trainee operator. Other outcome scores of fixation on radiographs were not correlated with fracture, patient or operator variables. Blood loss and complications were not associated with operator. The rate of failure of fixation was low and associated with scores of reduction quality only (p< 0.05).

Trainees of variable experience perform CHS with a low overall complication rate and the most noticeable performance difference seems to be in speed of surgery.